Hospital Encounters Within 1 Year Postpartum Across Insurance Types, Oregon 2012-2017.

BACKGROUND: Little is known about the timing and frequency of postpartum hospital encounters and postpartum visit attendance and how they may be associated with insurance types. Research on health insurance and its association with postpartum care utilization is often limited to the first 6 weeks. OBJECTIVE: To assess whether postpartum utilization (hospital encounters within 1 year postpartum and postpartum visit attendance within 12 weeks) differs by insurance type at birth (Medicaid, high deductible health plans, and other commercial plans) and whether rates of hospital encounters differ by postpartum visit attendance and insurance status. METHODS: Time-to-event analysis of Oregon hospital births from 2012 to 2017 using All Payer All Claims data. We conducted weighted Cox Proportional Hazard regressions and accounted for differences in insurance type at birth using multinomial propensity scores. RESULTS: Among 202,167 hospital births, 24.9% of births had at least 1 hospital encounter within 1 year postpartum. Births funded by Medicaid had a higher risk of a postpartum emergency department (ED) visit (hazard ratio: 2.05, 95% CI: 1.99, 2.12) and lower postpartum visit attendance (hazard ratio: 0.71, 95% CI: 0.70, 0.72) compared with commercial plans. Among Medicaid beneficiaries, missing the postpartum visit in the first 6 weeks was associated with a lower risk of subsequent readmissions (adjusted hazard ratio 0.77, 95% CI: 0.68, 0.87) and ED visits (adjusted hazard ratio: 0.87 (0.85, 0.88). CONCLUSIONS: Medicaid beneficiaries received more care in the ED within 1 year postpartum compared with those enrolled in other commercial plans. This highlights potential issues in postpartum care access.

Postpartum Hospital Readmissions With and Without Severe Maternal Morbidity Within 1 Year of Birth, Oregon, 2012-2017.

Postpartum readmissions (PPRs) represent a critical marker of maternal morbidity after hospital childbirth. Most severe maternal morbidity (SMM) events result in a hospital admission, but most PPRs do not have evidence of SMM. Little is known about PPR and SMM beyond the first 6 weeks postpartum. We examined the associations of maternal demographic and clinical factors with PPR within 12 months postpartum. We categorized PPR as being with or without evidence of SMM to assess whether risk factors and timing differed. Using the Oregon All Payer All Claims database, we analyzed hospital births from 2012-2017. We used log-binomial regression to estimate associations between maternal factors and PPR. Our final analytical sample included 158,653 births. Overall, 2.6% (n = 4,141) of births involved at least 1 readmission within 12 months postpartum (808 (19.5% of PPRs) with SMM). SMM at delivery was the strongest risk factor for PPR with SMM (risk ratio (RR) = 5.55, 95% confidence interval (CI): 4.14, 7.44). PPR without SMM had numerous risk factors, including any mental health diagnosis (RR = 2.10, 95% CI: 1.91, 2.30), chronic hypertension (RR = 2.17, 95% CI: 1.85, 2.55), and prepregnancy diabetes (RR = 2.85, 95% CI: 2.47, 3.30), all which were on par with SMM at delivery (RR = 1.89, 95% CI: 1.49, 2.40).

Developing patient-refined colorectal cancer screening materials: application of a virtual community engagement approach.

INTRODUCTION: In partnership with a federally qualified health center (FQHC), an adapted virtual version of boot camp translation (BCT) was used to elicit input from Spanish-speaking Latino patients and staff to develop messaging and patient education materials for follow-up colonoscopy after abnormal fecal testing. We describe how we adapted an existing in-person BCT process to be delivered virtually and present evaluations from participants on the virtual format. METHODS: Three virtual BCT sessions were facilitated by bilingual staff and conducted via Zoom. These sessions included introductions and discussions on colorectal cancer (CRC), CRC screening, and gathered feedback from participants on draft materials. Ten adults were recruited from the FQHC. A research team member from the FQHC served as the point of contact (POC) for all participants and offered Zoom introductory sessions and/or technology support before and during the sessions. Following the third session, participants were invited to complete an evaluation form about their virtual BCT experience. Using a 5-point Likert Scale (where 5 = strongly agree), questions focused on session utility, group comfort level, session pacing, and overall sense of accomplishment. RESULTS: Average scores ranged from 4.3 to 5.0 indicating strong support towards the virtual BCT sessions. Additionally, our study emphasized the importance of a POC to provide technical support to participants throughout the process. Using this approach, we successfully incorporated feedback from participants to design culturally relevant materials to promote follow-up colonoscopy. CONCLUSION: We recommend ongoing public health emphasis on the use of virtual platforms for community engaged work.

Racial and Ethnic Inequities in Paid Family and Medical Leave: United States, 2011 and 2017-2018.

Objectives. To examine racial and ethnic inequities in paid family and medical leave (PFML) access and the extent to which these inequities are mediated by employment characteristics. Methods. We used data from the 2011 and 2017-2018 American Time Use Survey in the United States to describe paid leave access by race/ethnicity. We present unadjusted models, models stratified by policy-targetable employment characteristics, and adjusted regression models. Results. We found that 54.4% of non-Hispanic White workers reported access to PFML in 2017-2018 but that access was significantly lower among Asian, Black, and Hispanic workers. Inequities were strongest among private-sector and nonunionized workers. Leave access improved slightly between 2011 and 2017-2018, but the inequity patterns were unchanged. Conclusions. We observed large and significant racial and ethnic inequities in access to PFML that were only weakly mediated by job characteristics. PFML has a range of health benefits for workers and their families, but access remains limited and inequitable. Public Health Implications. Our findings suggest that broad PFML mandates (such as those in other high-income countries) may be needed to substantially narrow racial and ethnic gaps in paid leave access. (Am J Public Health. 2022;112(7):1050-1058. https://doi.org/10.2105/AJPH.2022.306825).

Developing Patient-Refined Messaging for Follow-Up Colonoscopy After Abnormal Fecal Testing in Hispanic Communities: Key Learnings from Virtual Boot Camp Translation.

Colorectal cancer (CRC) is a leading cause of cancer death in the US. Screening by fecal immunochemical test (FIT) is a strategy to lower CRC rates. Unfortunately, only half of patients with an abnormal FIT result complete the follow-up colonoscopy, an essential component of screening. We used virtual Boot Camp Translation (BCT), to elicit input from partners to develop messaging/materials to motivate patients to complete a follow-up colonoscopy. Participants were Hispanic, ages 50 to 75 years, and Spanish-speaking. All materials were developed in English and Spanish. The first meeting included expert presentations that addressed colorectal health. The two follow-up sessions obtained feedback on messaging/materials developed based on themes from the first meeting. Ten participants attended the first meeting and eight attended the follow-up sessions. The two key barriers to follow-up colonoscopy after abnormal FIT noted by participants were (a) lack of colonoscopy awareness and (b) fear of the colonoscopy procedure. We learned that participants valued simple messaging to increase knowledge and alleviate concerns, patient-friendly outreach materials, and increased access to health information. Using virtual BCT, we included participant feedback to design culturally relevant health messages to promote follow-up colonoscopy after abnormal fecal testing among Hispanic patients served by community clinics.

Patients' Willingness to Accept Social Needs Navigation After In-Person versus Remote Screening.

BACKGROUND: Social needs screening and referral interventions are increasingly common in health care settings. Although remote screening offers a potentially more practical alternative to traditional in-person screening, there is concern that screening patients remotely could adversely affect patient engagement, including interest in accepting social needs navigation. METHODS: We conducted a cross-sectional study using a multivariable logistic regression analysis and data from the Accountable Health Communities (AHC) model in Oregon. Participants were Medicare and Medicaid beneficiaries in the AHC model from October 2018 through December 2020. The outcome variable was patients' willingness to accept social needs navigation assistance. We included an interaction term (total number of social needs + screening mode) to test whether in-person versus remote screening was an effect modifier. RESULTS: The study included participants who screened positive for ≥1 social need(s); 43% were screened in person and 57% remotely. Overall, 71% of participants were willing to accept help with social needs. Neither screening mode nor interaction term were significantly associated with willingness to accept navigation assistance. CONCLUSIONS: Among patients presenting with similar numbers of social needs, results indicate that type of screening mode may not adversely affect patients' willingness to accept health care-based navigation for social needs.

Neighborhood contexts experienced by young Mexican-American women: enhancing our understanding of risk for early childbearing.

Young Mexican-American women are disproportionately affected by teen pregnancy and early childbearing. While many of the studies that have investigated this population's high risk for early childbearing have focused predominantly on micro-level factors, a growing body of research has demonstrated the importance of neighborhood-level factors in shaping risk for this outcome. In order to elucidate the role of neighborhood context with regards to early childbearing among adolescent Mexican-American women, it is important to understand what these young women consider to be their neighborhood context and how they experience these contexts. This study utilized a mixed-methods design incorporating participatory photography, photo-elicitation, and focus groups in order to gain a more nuanced understanding of how neighborhood context is conceptualized and experienced by Mexican-American young women, and how these experiences may influence risk for early childbearing. Major findings include: (1) participants view the blocks on which they live as their neighborhood, but their exposure to neighborhood context extends beyond these blocks and includes the transient spaces they move through daily; and (2) within their neighborhood contexts, participants are influenced by experiences of discrimination and the presence of gangs and violence. These findings point to the importance of neighborhood-level factors in the lives of adolescent Mexican-American women, and may be used to inform future studies looking at the role of neighborhood context in shaping risk for early childbearing among this population.

Social Needs Resource Connections: A Systematic Review of Barriers, Facilitators, and Evaluation.

INTRODUCTION: Healthcare organizations increasingly are screening patients for social needs (e.g., food, housing) and referring them to community resources. This systematic mixed studies review assesses how studies evaluate social needs resource connections and identifies patient- and caregiver-reported factors that may inhibit or facilitate resource connections. METHODS: Investigators searched PubMed and CINAHL for articles published from October 2015 to December 2020 and used dual review to determine inclusion based on a priori selection criteria. Data related to study design, setting, population of interest, intervention, and outcomes were abstracted. Articles' quality was assessed using the Mixed Methods Appraisal Tool. Data analysis was conducted in 2021. RESULTS: The search identified 34 articles from 32 studies. The authors created a taxonomy of quantitative resource connection measures with 4 categories: whether participants made contact with resources, received resources, had their social needs addressed, or rated some aspect of their experience with resources. Barriers to resource connections were inadequacy, irrelevancy, or restrictiveness; inaccessibility; fears surrounding stigma or discrimination; and factors related to staff training and resource information sharing. Facilitators were referrals' relevancy, the degree of support and simplicity embedded within the interventions, and interventions being comprehensive and inclusive. DISCUSSION: This synthesis of barriers and facilitators indicates areas where healthcare organizations may have agency to improve the efficacy of social needs screening and referral interventions. The authors also recommend that resource connection measures be explicitly defined and focus on whether participants received new resources and whether their social needs were addressed.

"It Made Me Feel like Things Are Starting to Change in Society:" A Qualitative Study to Foster Positive Patient Experiences during Phone-Based Social Needs Interventions.

Many healthcare organizations are screening patients for health-related social needs (HRSN) to improve healthcare quality and outcomes. Due to both the COVID-19 pandemic and limited time during clinical visits, much of this screening is now happening by phone. To promote healing and avoid harm, it is vital to understand patient experiences and recommendations regarding these activities. We conducted a pragmatic qualitative study with patients who had participated in a HRSN intervention. We applied maximum variation sampling, completed recruitment and interviews by phone, and carried out an inductive reflexive thematic analysis. From August to November 2021 we interviewed 34 patients, developed 6 themes, and used these themes to create a framework for generating positive patient experiences during phone-based HRSN interventions. First, we found patients were likely to have initial skepticism or reservations about the intervention. Second, we identified 4 positive intervention components regarding patient experience: transparency and respect for patient autonomy; kind demeanor; genuine intention to help; and attentiveness and responsiveness to patients' situations. Finally, we found patients could be left with feelings of appreciation or hope, regardless of whether they connected with HRSN resources. Healthcare organizations can incorporate our framework into trainings for team members carrying out phone-based HRSN interventions.

Pregnancy Outcomes and Documentation Status Among Latina Women: A Systematic Review.

Purpose: The impression that Latinas experience paradoxically good pregnancy outcomes in the United States persists, despite evidence showing that these outcomes are not enjoyed by all Latina subgroups. We conducted this systematic literature review to examine the relationship between documentation status and pregnancy outcomes among Latinas. Methods: This review synthesizes empirical evidence on this relationship; examines how these studies define and operationalize documentation status; and makes recommendations of how a more comprehensive methodological approach can guide public health research on the impact of documentation status on Latina immigrants to the United States. We searched the literature within PubMed, Web of Science, Academic Search Premier, and Google Scholar in 2017 for relevant studies. Results: Based on stringent inclusion criteria, we retained nine studies for analysis. Conclusion: We found that evidence for the impact of documentation status on pregnancy outcomes among Latinas is not conclusive. We believe the divergence in our findings is, in part, due to variation in: conceptualization of how documentation status impacts pregnancy outcomes, sample populations, definitions of exposures and outcomes, and contextual factors included in models. Specific analytic challenges around sampling, measurement, and data analysis are identified. Suggestions for future research are offered regarding measurement of documentation status. Findings highlight the need for increased attention to documentation as an influence on Latina pregnancy outcomes.

Employee Experiences with a Newly Adopted Paid Parental Leave Policy: Equity Considerations for Policy Implementation.

Purpose: Paid parental leave (PPL) policies offer immense opportunity to enhance health equity by providing financial stability to workers and promoting the health of families in the United States. Working in partnership with a local county government, which recently adopted a paid leave policy, we engaged in a qualitative substudy to enhance our understanding of how workers perceived and experienced the policy across levels of the socioecological framework. Methods: Working in partnership with Multnomah County, a large public-sector employer in Portland, OR that recently adopted a PPL policy, we collected qualitative data through focus groups with employees. Data were transcribed, coded, and analyzed thematically. Results: We conducted seven focus groups with county employees (N=35) in the fall of 2017. Three major themes emerged from the focus group data: intersectional inequities, disparities by department, and uneven benefits. Conclusions: Our findings highlight the inequities of experience with the PPL policy across employees at individual, organization, and environmental levels. These findings offer insight and guidance for entities considering the adoption and implementation of such policies to consider concrete steps to enhance equity of access and experience.

P2 promoter variants of the hepatocyte nuclear factor 4alpha gene are associated with type 2 diabetes in Mexican Americans.

Common and rare variants of the hepatocyte nuclear factor 4alpha (HNF4A) gene have been associated with type 2 diabetes and related traits in several populations suggesting the involvement of this transcription factor in diabetes pathogenesis. Single nucleotide polymorphisms (SNPs) within a large haplotype block surrounding the alternate P2 promoter, located approximately 45 kb upstream from the coding region, have been investigated in several populations of varying ethnicity with inconsistent results. Additionally, SNPs located within the P1 promoter and coding region have also been inconsistently associated with type 2 diabetes. Characterization of variation across this gene region in Mexican-American populations has not been reported. We therefore examined polymorphisms across the HNF4A gene in a cohort of Mexican-American pedigrees and assessed their association with type 2 diabetes. We observed evidence for association of SNPs in the P2 promoter region with type 2 diabetes (P = 0.003) and its age at diagnosis (P = 0.003). The risk allele frequency (53%) was intermediate to that reported in Caucasian populations (20-27%) and Pima Indians (83%). No other SNPs were associated with either trait. These results support the possibility that a variant in the P2 promoter region of HNF4A, or variants in linkage disequilibrium within this region, contributes to susceptibility to type 2 diabetes in many ethnic populations including Mexican Americans.

Analyzing Policies Through a DOHaD Lens: What Can We Learn?

Social, health, and environmental policies are critical tools for providing the conditions needed for healthy populations. However, current policy analyses fall short of capturing their full potential impacts across the life course and from generation to generation. We argue that the field of Developmental Origins of Health and Disease (DOHaD), a conceptual and research framework positing that early life experiences significantly affect health trajectories across the lifespan and into future generations, provides an important lens through which to analyze social policies. To illustrate this point, we synthesized evidence related to policies from three domains-family leave, nutrition, and housing-to examine the health implications for multiple generations. We selected these policy domains because they represent increasing distance from a reproductive health focus, each with a growing evidence base to support a potential impact on pregnant women and their offspring. Each of these examples represents an opportunity to extend our understanding of policy impact using a DOHaD lens, taking into account the potential life course and intergenerational effects that have previously been overlooked.

Insulin secretion and action in subjects with impaired fasting glucose and impaired glucose tolerance: results from the Veterans Administration Genetic Epidemiology Study.

This study was conducted to observe changes in insulin secretion and insulin action in subjects with impaired fasting glucose (IFG) and/or impaired glucose tolerance (IGT). A total of 319 subjects were studied with an oral glucose tolerance test (OGTT). Fasting plasma glucose and insulin concentrations were measured at baseline and every 30 min during the OGTT. Fifty-eight subjects also received a euglycemic-hyperinsulinemic clamp. Insulin sensitivity was calculated as the total glucose disposal (TGD) during the last 30 min of the clamp. Homeostasis model assessment of insulin resistance (HOMA-IR) was calculated from fasting plasma glucose and insulin concentrations. Subjects with IFG had TGD similar to normal glucose-tolerant subjects, while subjects with IGT and combined IFG/IGT had significantly reduced TGD. HOMA-IR in subjects with IFG was similar to that in subjects with combined IFG/IGT and significantly higher than HOMA-IR in subjects with IGT or NGT. Insulin secretion, measured by the insulinogenic index (DeltaI(0-30)/DeltaG(0-30)) and by the ratio of the incremental area under the curve (AUC) of insulin to the incremental AUC of glucose (0-120 min), was reduced to the same extent in all three glucose-intolerant groups. When both measurements of beta-cell function were adjusted for severity of insulin resistance, subjects with IGT and combined IFG/IGT had a significantly greater reduction in insulin secretion than subjects with IFG. Subjects with IGT and IFG have different metabolic characteristics. Differences in insulin sensitivity and insulin secretion may predict different rates of progression to type 2 diabetes and varying susceptibility to cardiovascular disease.

BUILD EXITO: a multi-level intervention to support diversity in health-focused research.

BACKGROUND AND PURPOSE: As part of the NIH BUILD initiative to diversify the scientific workforce, the EXITO project is a large multi-institutional effort to provide comprehensive support and training for undergraduates from traditionally underrepresented student populations who aspire to health-related research careers. Portland State University, a major public urban university that prioritizes student access and opportunity, and Oregon Health & Science University, a research-intensive academic health center, lead the EXITO network comprised of eleven 2-year and 4-year institutions of higher education spanning Oregon, Washington, Alaska, Hawaii, Guam, American Samoa, and the Northern Mariana Islands. The EXITO project aims for impact in biomedical research by training diverse scholars from indigenous and underserved communities affected by adverse health disparities. PROJECT APPROACH: Guided by socio-ecological theory, the EXITO project is a multi-level intervention offering a three-year research training pathway for scholars in the biomedical, behavioral, health, and social sciences. Fundamental components of the model include student outreach and engagement, integrated curricular enhancements, intensive research experiences, multi-faceted developmental mentoring, supportive community and services, and rigorous evaluation and quality improvement. EXITO also advances faculty and institutional development in these domains by holding curriculum development conferences, creating research learning communities, awarding pilot project research funding, providing mentor training and ongoing support, collaborating with other research equity programs, and developing campus infrastructure and services to support scholars with diverse backgrounds and needs. HIGHLIGHTS: The large and geographically broad network of EXITO institutions engages a range of diverse students, including indigenous populations and students beginning post-secondary education at community colleges. The EXITO model specifically accommodates many students transferring from 2-year partner institutions and facilitates seamless transfer to the 4-year institution. EXITO features several approaches to research training, including supported summer entry into research placements, the incorporation of responsible conduct of research content into general education curriculum, and the intentional matching of scholars with three types of mentors (e.g., peer, career, research). IMPLICATIONS: EXITO provides an example of a comprehensive research training initiative for traditionally underrepresented students that can be implemented across a diverse range of 2-year and 4-year institutions.

A Framework to Address Challenges in Communicating the Developmental Origins of Health and Disease.

Findings from the field of Developmental Origins of Health and Disease (DOHaD) suggest that some of the most pressing public health problems facing communities today may begin much earlier than previously understood. In particular, this body of work provides evidence that social, physical, chemical, environmental, and behavioral influences in early life play a significant role in establishing vulnerabilities for chronic disease later in life. Further, because this work points to the importance of adverse environmental exposures that cluster in population groups, it suggests that existing opportunities to intervene at a population level may need to refocus their efforts "upstream" to sufficiently combat the fundamental causes of disease. To translate these findings into improved public health, however, the distance between scientific discovery and population application will need to be bridged by conversations across a breadth of disciplines and social roles. And importantly, those involved will likely begin without a shared vocabulary or conceptual starting point. The purpose of this paper is to support and inform the translation of DOHaD findings from the bench to population-level health promotion and disease prevention, by: (1) discussing the unique communication challenges inherent to translation of DOHaD for broad audiences, (2) introducing the First-hit/Second-hit Framework with an epidemiologic planning matrix as a model for conceptualizing and structuring communication around DOHaD, and (3) discussing the ways in which patterns of communicating DOHaD findings can expand the range of solutions considered and encourage discussion of population-level solutions in relation to one another, rather than in isolation.

The quantitative trait linkage disequilibrium test: a more powerful alternative to the quantitative transmission disequilibrium test for use in the absence of population stratification.

Linkage analysis based on identity-by-descent allele-sharing can be used to identify a chromosomal region harboring a quantitative trait locus (QTL), but lacks the resolution required for gene identification. Consequently, linkage disequilibrium (association) analysis is often employed for fine-mapping. Variance-components based combined linkage and association analysis for quantitative traits in sib pairs, in which association is modeled as a mean effect and linkage is modeled in the covariance structure has been extended to general pedigrees (quantitative transmission disequilibrium test, QTDT). The QTDT approach accommodates data not only from parents and siblings, but also from all available relatives. QTDT is also robust to population stratification. However, when population stratification is absent, it is possible to utilize even more information, namely the additional information contained in the founder genotypes. In this paper, we introduce a simple modification of the allelic transmission scoring method used in the QTDT that results in a more powerful test of linkage disequilibrium, but is only applicable in the absence of population stratification. This test, the quantitative trait linkage disequilibrium (QTLD) test, has been incorporated into a new procedure in the statistical genetics computer package SOLAR. We apply this procedure in a linkage/association analysis of an electrophysiological measurement previously shown to be related to alcoholism. We also demonstrate by simulation the increase in power obtained with the QTLD test, relative to the QTDT, when a true association exists between a marker and a QTL.

Trends and Disparities in Postpartum Sterilization after Cesarean Section, 2000 through 2008.

PURPOSE: Tubal sterilization patterns are influenced by factors including patient race, ethnicity, level of education, method of payment, and hospital size and affiliation. However, less is known about how these factors influence tubal sterilizations performed as secondary procedures after cesarean sections (C-sections). Thus, this study examines variations in the prevalence of postpartum tubal sterilizations after C-sections from 2000 to 2008. METHODS: We used data from the National Hospital Discharge Survey to estimate odds ratios for patient-level (race, marital status, age) and system-level (hospital size, type, region) factors on the likelihood of receiving tubal sterilization after C-section. RESULTS: A disproportionate share of postpartum tubal sterilizations after C-section was covered by Medicaid. The likelihood of undergoing sterilization was increased for Black women, women of older age, and non-single women. Additionally, they were increased in proprietary and government hospitals, smaller hospital settings, and the Southern United States. CONCLUSIONS: Our findings indicate that Black women and those with Medicaid coverage in particular were substantially more likely to undergo postpartum tubal sterilization after C-section. We also found that hospital characteristics and region were significant predictors. This adds to the growing body of evidence that suggests that tubal sterilization may be a disparity issue patterned by multiple factors and calls for greater understanding of the role of patient-, provider-, and system-level characteristics on such outcomes.