Disparities in Telehealth Uptake for Developmental-Behavioral Pediatric Assessments by Preferred Family Language: A Developmental Behavioral Pediatrics Research Network Study.

OBJECTIVE: Owing to the coronavirus disease 2019 (COVID-19) pandemic, many developmental-behavioral pediatric (DBP) practices adopted telehealth for care delivery. However, telehealth access and use for families with a preferred language other than English (PLOE) is an equity concern. Therefore, our study objective is to compare rates of telehealth utilization and visit completion by preferred family language among patients seen for DBP assessments during the COVID-19 pandemic. METHODS: We completed a descriptive chart review using electronic health record data at 4 academic DBP practices to examine visits for patients up to 5 years seen for new-patient appointments between April 2020 and April 2021. We compared rates of in-person and telehealth visits by preferred family language and visit outcome (completed or missed). RESULTS: A total of 3241 visits were scheduled between April 2020 and April 2021; 48.2% were for in-person and 51.8% for telehealth. Families reported the following languages: 90.5% English, 6.2% Spanish, and 3.3% other language. Missed visits accounted for 7.6% of scheduled visits. The relative percentage of in-person versus telehealth visits varied significantly by site (p < 0.001) and preferred family language (p < 0.001). English-speaking patients had 2.10 times the odds of being scheduled for telehealth compared with patients with PLOE, adjusting for site. Statistically significant differences were not found for visit outcome (completed or missed) by visit type (in-person or telehealth) (p = 0.79), including after accounting for PLOE status (p = 0.83). CONCLUSION: At the height of the pandemic, most English-speaking families were scheduled for new DBP evaluations by telehealth, but fewer families with PLOE were. Attention to language to ensure telehealth access equity is critical.

Increasing Racial and Ethnic Disparities in Ambient Air Pollution-Attributable Morbidity and Mortality in the United States.

BACKGROUND: Ambient nitrogen dioxide (NO2) and fine particulate matter with aerodynamic diameter ≤2.5µm (PM2.5) threaten public health in the US, and systemic racism has led to modern-day disparities in the distribution and associated health impacts of these pollutants. OBJECTIVES: Many studies on environmental injustices related to ambient air pollution focus only on disparities in pollutant concentrations or provide only an assessment of pollution or health disparities at a snapshot in time. In this study, we compare injustices in NO2- and PM2.5-attributable health burdens, considering NO2-attributable health impacts across the entire US; document changing disparities in these health burdens over time (2010-2019); and evaluate how more stringent air quality standards would reduce disparities in health impacts associated with these pollutants. METHODS: Through a health impact assessment, we quantified census tract-level variations in health outcomes attributable to NO2 and PM2.5 using health impact functions that combine demographic data from the US Census Bureau; two spatially resolved pollutant datasets, which fuse satellite data with physical and statistical models; and epidemiologically derived relative risk estimates and incidence rates from the Global Burden of Disease study. RESULTS: Despite overall decreases in the public health damages associated with NO2 and PM2.5, racial and ethnic relative disparities in NO2-attributable pediatric asthma and PM2.5-attributable premature mortality have widened in the US during the last decade. Racial relative disparities in PM2.5-attributable premature mortality and NO2-attributable pediatric asthma have increased by 16% and 19%, respectively, between 2010 and 2019. Similarly, ethnic relative disparities in PM2.5-attributable premature mortality have increased by 40% and NO2-attributable pediatric asthma by 10%. DISCUSSION: Enacting and attaining more stringent air quality standards for both pollutants could preferentially benefit the most marginalized and minoritized communities by greatly reducing racial and ethnic relative disparities in pollution-attributable health burdens in the US. Our methods provide a semi-observational approach to track changes in disparities in air pollution and associated health burdens across the US. https://doi.org/10.1289/EHP11900.

Provider and Caregiver Perspectives on Telehealth Assessments for Autism Spectrum Disorder in Young Children: A Multimethod DBPNet Study Exploring Equity.

BACKGROUND: Telehealth uptake increased dramatically during the COVID-19 pandemic, including for autism spectrum disorder (ASD) assessment by developmental-behavioral pediatric (DBP) clinicians. However, little is known about the acceptability of telehealth or its impact on equity in DBP care. OBJECTIVE: Engage providers and caregivers to glean their perspectives on the use of telehealth for ASD assessment in young children, exploring acceptability, benefits, concerns, and its potential role in ameliorating or exacerbating disparities in access to and quality of DBP care. METHODS: This multimethod study used surveys and semistructured interviews to describe provider and family perspectives around the use of telehealth in DBP evaluation of children younger than 5 years with possible ASD between 3/2020 and 12/2021. Surveys were completed by 13 DBP clinicians and 22 caregivers. Semistructured interviews with 12 DBP clinicians and 14 caregivers were conducted, transcribed, coded, and analyzed thematically. RESULTS: Acceptance of and satisfaction with telehealth for ASD assessments in DBP were high for clinicians and most caregivers. Pros and cons concerning assessment quality and access to care were noted. Providers raised concerns about equity of telehealth access, particularly for families with a preferred language other than English. CONCLUSION: This study's results can inform the adoption of telehealth in DBP in an equitable manner beyond the pandemic. DBP providers and families desire the ability to choose telehealth care for different assessment components. Unique factors related to performing observational assessments of young children with developmental and behavioral concerns make telehealth particularly well-suited for DBP care.

Association of extreme heat events with sleep and cardiovascular health: A scoping review.

BACKGROUND: Extreme heat events (EHEs), driven by anthropogenic climate change, exacerbate the risk of cardiovascular disease (CVD), although the underlying mechanisms are unclear. Disturbances in sleep health, caused by excessive heat, may be one way EHEs increase the risk of incident or recurrent CVD. Our objective was to systematically review the empirical peer-reviewed literature on the relationship between EHEs, sleep health, and cardiovascular measures and outcomes, and narratively describe methodologies, evidence, and gaps in this area. METHODS: A comprehensive literature search was performed in the following databases from inception - June 2023: Ovid MEDLINE, Ovid EMBASE, CINAHL, Web of Science and The Cochrane Library. Studies retrieved were then screened for eligibility against predefined inclusion/exclusion criteria. RESULTS: Of the 2035 records screened, three studies met the inclusion criteria. Cardiovascular (CV) measures described included blood pressure (BP), heart rate (HR), and HR variability (no CVD outcomes were described) and objective and subjective measurements of sleep health outcomes included sleep duration, calmness, ease of falling asleep, ease of awakening, freshness after awakening, and sleep satisfaction. Two studies were controlled trials, and one was a cohort study. During EHEs, individuals slept for shorter periods of time and less efficiently, with greater degrees of HR variability in two of the three studies lasting at most 1-2 days; BP (both systolic and diastolic) significantly decreased during EHEs in two of the studies. No formal assessment of a mediating relationship between EHE exposure, sleep outcomes, and the CV measures was undertaken. CONCLUSIONS: There is a paucity of data that examines the link between CVD, sleep, and extreme heat as a possible mechanism of elevated CVD risk during EHEs, despite a strong physiological rationale. Further research is needed to empirically test this relationship rigorously as EHEs become more frequent and their deleterious impacts of health increase.

The Burden of Proof studies: assessing the evidence of risk.

Exposure to risks throughout life results in a wide variety of outcomes. Objectively judging the relative impact of these risks on personal and population health is fundamental to individual survival and societal prosperity. Existing mechanisms to quantify and rank the magnitude of these myriad effects and the uncertainty in their estimation are largely subjective, leaving room for interpretation that can fuel academic controversy and add to confusion when communicating risk. We present a new suite of meta-analyses-termed the Burden of Proof studies-designed specifically to help evaluate these methodological issues objectively and quantitatively. Through this data-driven approach that complements existing systems, including GRADE and Cochrane Reviews, we aim to aggregate evidence across multiple studies and enable a quantitative comparison of risk-outcome pairs. We introduce the burden of proof risk function (BPRF), which estimates the level of risk closest to the null hypothesis that is consistent with available data. Here we illustrate the BPRF methodology for the evaluation of four exemplar risk-outcome pairs: smoking and lung cancer, systolic blood pressure and ischemic heart disease, vegetable consumption and ischemic heart disease, and unprocessed red meat consumption and ischemic heart disease. The strength of evidence for each relationship is assessed by computing and summarizing the BPRF, and then translating the summary to a simple star rating. The Burden of Proof methodology provides a consistent way to understand, evaluate and summarize evidence of risk across different risk-outcome pairs, and informs risk analysis conducted as part of the Global Burden of Diseases, Injuries, and Risk Factors Study.

Long-term trends in urban NO2 concentrations and associated paediatric asthma incidence: estimates from global datasets.

BACKGROUND: Combustion-related nitrogen dioxide (NO2) air pollution is associated with paediatric asthma incidence. We aimed to estimate global surface NO2 concentrations consistent with the Global Burden of Disease study for 1990-2019 at a 1 km resolution, and the concentrations and attributable paediatric asthma incidence trends in 13 189 cities from 2000 to 2019. METHODS: We scaled an existing annual average NO2 concentration dataset for 2010-12 from a land use regression model (based on 5220 NO2 monitors in 58 countries and land use variables) to other years using NO2 column densities from satellite and reanalysis datasets. We applied these concentrations in an epidemiologically derived concentration-response function with population and baseline asthma rates to estimate NO2-attributable paediatric asthma incidence. FINDINGS: We estimated that 1·85 million (95% uncertainty interval [UI] 0·93-2·80 million) new paediatric asthma cases were attributable to NO2 globally in 2019, two thirds of which occurred in urban areas (1·22 million cases; 95% UI 0·60-1·8 million). The proportion of paediatric asthma incidence that is attributable to NO2 in urban areas declined from 19·8% (1·22 million attributable cases of 6·14 million total cases) in 2000 to 16·0% (1·24 million attributable cases of 7·73 million total cases) in 2019. Urban attributable fractions dropped in high-income countries (-41%), Latin America and the Caribbean (-16%), central Europe, eastern Europe, and central Asia (-13%), and southeast Asia, east Asia, and Oceania (-6%), and rose in south Asia (+23%), sub-Saharan Africa (+11%), and north Africa and the Middle East (+5%). The contribution of NO2 concentrations, paediatric population size, and asthma incidence rates to the change in NO2-attributable paediatric asthma incidence differed regionally. INTERPRETATION: Despite improvements in some regions, combustion-related NO2 pollution continues to be an important contributor to paediatric asthma incidence globally, particularly in cities. Mitigating air pollution should be a crucial element of public health strategies for children. FUNDING: Health Effects Institute, NASA.

Correction: Ambient and household PM2.5 pollution and adverse perinatal outcomes: A meta-regression and analysis of attributable global burden for 204 countries and territories.

[This corrects the article DOI: 10.1371/journal.pmed.1003718.].