Prevalence and Correlates of Unmet Medical and Social Needs in Virginia's Medicaid Managed Long Term Services and Supports Program.

BACKGROUND: Medicaid Long Term Services and Support (LTSS) programs serve individuals with complex medical and social needs. Increasingly, state Medicaid programs are contracting with managed care organizations to administer LTSS programs. OBJECTIVES: Understand the prevalence of and risk factors for unmet medical and social needs among a sample of patients within a Medicaid managed LTSS program. METHODS: We surveyed a cross-sectional random sample of 798 community-residing individuals over 21 in Virginia who were served by the state Medicaid managed LTSS program. Outcomes of interest include 3 distinct medical needs: medical appointments, medical transportation, and prescriptions; 4 distinct social needs: housing security, food security, utility bills, and nonmedical transportation, and composite measures of unmet social and medical needs. RESULTS: We found that 12.5% of our sample had any unmet medical need, while far more (62.2%) of our sample had any unmet social needs, with food insecurity being the most common. We found that members of color had almost 2 times the odds of having both unmet social and medical needs [social: adjusted odds ratio (aOR): 2.21; 95% confidence Interval (CI): (1.59, 3.09); medical aOR: 2.25 ; 95% CI: (1.34, 3.8)]. CONCLUSION: Medicaid members may not be fully realizing the potential of LTSS programs and would benefit from both Medicaid agency and managed care organizations' strategies aimed at addressing social drivers of health. To achieve health equity for LTSS members of color, Medicaid agencies may consider policies specifically targeting racial disparities.

Patient experiences with outpatient opioid use disorder treatment before and during COVID-19: results from a survey of Medicaid members.

Background: Payers are increasingly interested in quality improvement for opioid use disorder (OUD) treatment, including incorporating patient experiences. Medicaid is the largest payer for OUD treatment, yet we know little about the treatment benefits Medicaid members report, how these vary across members, or changed with the COVID-19 pandemic.Objective: To examine Medicaid members' report of outpatient treatment benefits, employment, and housing outcomes before and during the pandemic.Methods: A representative sample of 1,032 Virginia Medicaid members (52% women) receiving OUD treatment completed a survey of treatment benefits, health status and social needs. A reported treatment benefit index was created based on seven self-reported items. Multivariable linear regression models, pooled and stratified by time (pre-COVID-19/COVID-19), assessed member characteristics associated with reported treatment benefit, employment and housing outcomes.Results: Members reported strong treatment benefit (mean: 21.8 [SD: 5.9] out of 28 points) and improvements in employment (2.4 [1.3] out of 5) and housing (2.8 [1.2] out of 5). After adjustment, mental distress (regression coefficient: -3.00 [95% CI:-3.97;-2.03]), polysubstance use (-1.25 [-1.99;-0.51]), and food insecurity (-1.00 [-1.71;-0.29]), were associated with decreased benefits from treatment. During COVID-19, justice-involved individuals reported decreased benefits (-2.17 [-3.54; -0.80]) compared to before the pandemic (-0.09 [-1.4-;1.24] p < .05).Conclusions: Medicaid members receiving outpatient OUD treatment reported positive treatment benefits, and housing and employment outcomes. However, those with comorbid health and social conditions often benefited the least. As payers move toward quality improvement and value-based purchasing initiatives, collecting and integrating patient reported outcomes into quality metrics is critical.

Taste loss as a distinct symptom of COVID-19: a systematic review and meta-analysis.

Chemosensory scientists have been skeptical that reports of COVID-19 taste loss are genuine, in part because before COVID-19 taste loss was rare and often confused with smell loss. Therefore, to establish the predicted prevalence rate of taste loss in COVID-19 patients, we conducted a systematic review and meta-analysis of 376 papers published in 2020-2021, with 235 meeting all inclusion criteria. Drawing on previous studies and guided by early meta-analyses, we explored how methodological differences (direct vs. self-report measures) may affect these estimates. We hypothesized that direct measures of taste are at least as sensitive as those obtained by self-report and that the preponderance of evidence confirms taste loss is a symptom of COVID-19. The meta-analysis showed that, among 138,015 COVID-19-positive patients, 36.62% reported taste dysfunction (95% confidence interval: 33.02%-40.39%), and the prevalence estimates were slightly but not significantly higher from studies using direct (n = 15) versus self-report (n = 220) methodologies (Q = 1.73, df = 1, P = 0.1889). Generally, males reported lower rates of taste loss than did females, and taste loss was highest among middle-aged adults. Thus, taste loss is likely a bona fide symptom of COVID-19, meriting further research into the most appropriate direct methods to measure it and its underlying mechanisms.

Associations Between Patient-Reported Experiences with Opioid Use Disorder Treatment and Unmet Treatment Needs and Discontinuation Among Virginia Medicaid Members.

BACKGROUND: Many payers, including Medicaid, the largest payer of opioid use disorder (OUD) treatment, are pursuing treatment-related quality improvement initiatives. Yet, how patient-reported experiences with OUD treatment relate to patient-centered outcomes remains poorly understood. AIM: To examine associations between Medicaid members' OUD treatment experiences, outpatient treatment settings, demographic and social factors, and members' self-report of unmet needs during treatment and treatment discontinuation. METHODS: A sample of Virginia Medicaid members aged 21 years or older with OUD diagnoses who received outpatient OUD treatment completed a mail survey between January 2020 and August 2021 (n = 1042, weighted n = 9244). A treatment experience index was constructed from responses to four items from the Consumer Assessment of Healthcare Providers and Systems (CAHPS) relating to feelings of involvement, safety, and respect and having treatment explained in an understandable way; two additional CAHPS items: "given options for treatment" and "able to refuse treatment" were also assessed. Weighted imputed logistic regressions tested adjusted associations between members' treatment experiences, demographic and social factors, and two outcomes capturing unmet needs during treatment and treatment discontinuation. RESULTS: More positive scores on the treatment experiences index were associated with lower adjusted odds of reporting unmet needs during treatment (aOR: 0.52, 95% CI: 0.41-0.66) and discontinuation (aOR: 0.63, 95% CI: 0.47-0.79). Respondents with serious psychological distress had higher odds of reporting unmet needs during treatment (aOR: 1.69 95% CI: 1.14-2.51) and discontinuation (aOR: 1.84, 95% CI: 1.21-2.82), as did individuals with housing insecurity (unmet needs: (aOR: 1.65, 95% CI: 1.11-2.44); treatment discontinuation: (aOR: 1.56, 95% CI: 1.04-2.36)). CONCLUSION: Using a first-of-its-kind survey of Medicaid members with OUD, we found that members who had more positive treatment experiences were less likely to report unmet treatment needs and discontinue treatment. Care approaches focused on improving patient experience are critical to delivering effective, high-quality OUD treatment.

Taste loss as a distinct symptom of COVID-19: a systematic review and meta-analysis.

Chemosensory scientists have been skeptical that reports of COVID-19 taste loss are genuine, in part because before COVID-19 taste loss was rare and often confused with smell loss. Therefore, to establish the predicted prevalence rate of taste loss in COVID-19 patients, we conducted a systematic review and meta-analysis of 376 papers published in 2020-2021, with 241 meeting all inclusion criteria. Drawing on previous studies and guided by early meta-analyses, we explored how methodological differences (direct vs. self-report measures) may affect these estimates. We hypothesized that direct measures of taste are at least as sensitive as those obtained by self-report and that the preponderance of evidence confirms taste loss is a symptom of COVID-19. The meta-analysis showed that, among 138,897 COVID-19-positive patients, 39.2% reported taste dysfunction (95% confidence interval: 35.34%-43.12%), and the prevalence estimates were slightly but not significantly higher from studies using direct (n = 18) versus self-report (n = 223) methodologies (Q = 0.57, df = 1, P = 0.45). Generally, males reported lower rates of taste loss than did females, and taste loss was highest among middle-aged adults. Thus, taste loss is likely a bona fide symptom of COVID-19, meriting further research into the most appropriate direct methods to measure it and its underlying mechanisms.

Can an Emergency Department-Initiated Intervention Prevent Subsequent Falls and Health Care Use in Older Adults? A Randomized Controlled Trial.

STUDY OBJECTIVE: We determine whether an emergency department (ED)-initiated fall-prevention intervention can reduce subsequent fall-related and all-cause ED visits and hospitalizations in older adults. METHODS: The Geriatric Acute and Post-acute Fall Prevention intervention was a randomized controlled trial conducted from January 2018 to October 2019. Participants at 2 urban academic EDs were randomly assigned (1:1) to an intervention or usual care arm. Intervention participants received a brief, tailored, structured, pharmacy and physical therapy consultation in the ED, with automated communication of the recommendations to their primary care physicians. RESULTS: Of 284 study-eligible participants, 110 noninstitutionalized older adults (≥65 years) with a recent fall consented to participate; median age was 81 years, 67% were women, 94% were white, and 16.3% had cognitive impairment. Compared with usual care participants (n=55), intervention participants (n=55) were half as likely to experience a subsequent ED visit (adjusted incidence rate ratio 0.47 [95% CI 0.29 to 0.74]) and one third as likely to have fall-related ED visits (adjusted incidence rate ratio 0.34 [95% CI 0.15 to 0.76]) within 6 months. Intervention participants experienced half the rate of all hospitalizations (adjusted incidence rate ratio 0.57 [95% CI 0.31 to 1.04]), but confidence intervals were wide. There was no difference in fall-related hospitalizations between groups (adjusted incidence rate ratio 0.99 [95% CI 0.31 to 3.27]). Self-reported adherence to pharmacy and physical therapy recommendations was moderate; 73% of pharmacy recommendations were adhered to and 68% of physical therapy recommendations were followed. CONCLUSION: Geriatric Acute and Post-acute Fall Prevention, a postfall, in-ED, multidisciplinary intervention with pharmacists and physical therapists, reduced 6-month ED encounters in 2 urban EDs. The intervention could provide a model of care to other health care systems aiming to reduce costly and burdensome fall-related events in older adults.

Limited Ability of Three Health Literacy Screening Items to Identify Adult English- and Spanish-Speaking Emergency Department Patients With Lower Health Literacy.

STUDY OBJECTIVE: Brief, easily administered, and valid health literacy assessment tools are needed to optimize health care delivery in the emergency medicine setting. Three health literacy screening items have been proposed to assess health literacy in outpatient settings. We investigated their ability to identify English- and Spanish-speaking adult emergency department (ED) patients with lower health literacy. METHODS: Participants were Spanish- or English-speaking adult patients randomly selected from 4 geographically spread, US, urban, safety-net EDs. Participants completed the 3 health literacy screening items, as well as the Short Assessment of Health Literacy-Spanish and English (SAHL-S&E). Test performance characteristics, including receiver operating characteristics area under the curve, of the 3 health literacy screening items were estimated, as compared with the SAHL-S&E. RESULTS: According to the SAHL-S&E, 36% of the 1,165 English speakers and 35% of the 1,605 Spanish speakers had lower health literacy. Areas under the curve for each health literacy screening item individually were: needing others to help read materials (English 0.59, 95% confidence interval [CI] 0.56 to 0.62; Spanish 0.58, 95% CI 0.56 to 0.61), problems learning because of difficulty reading (English 0.63, 95% CI 0.60 to 0.66; Spanish 0.59, 95% CI 0.56 to 0.62), and confidence with completing forms (English 0.62, 95% CI 0.59 to 0.65; Spanish 0.60, 95% CI 0.57 to 0.63). Areas under the curve for the 3 screening items combined were: English 0.66 (95% CI 0.63 to 0.70) and Spanish 0.62 (95% CI 0.59 to 0.64). CONCLUSION: The 3 health literacy screening items performed poorly in identifying adult ED patients with lower health literacy. Higher-validity screening measures are needed to better serve the health care needs of this vulnerable population in the ED setting.

The Restrictive IV Fluid Trial in Severe Sepsis and Septic Shock (RIFTS): A Randomized Pilot Study.

OBJECTIVES: It is unclear if a low- or high-volume IV fluid resuscitation strategy is better for patients with severe sepsis and septic shock. DESIGN: Prospective randomized controlled trial. SETTING: Two adult acute care hospitals within a single academic system. PATIENTS: Patients with severe sepsis and septic shock admitted from the emergency department to the ICU from November 2016 to February 2018. INTERVENTIONS: Patients were randomly assigned to a restrictive IV fluid resuscitation strategy (≤ 60 mL/kg of IV fluid) or usual care for the first 72 hours of care. MEASUREMENTS AND MAIN RESULTS: We enrolled 109 patients, of whom 55 were assigned to the restrictive resuscitation group and 54 to the usual care group. The restrictive group received significantly less resuscitative IV fluid than the usual care group (47.1 vs 61.1 mL/kg; p = 0.01) over 72 hours. By 30 days, there were 12 deaths (21.8%) in the restrictive group and 12 deaths (22.2%) in the usual care group (odds ratio, 1.02; 95% CI, 0.41-2.53). There were no differences between groups in the rate of new organ failure, hospital or ICU length of stay, or serious adverse events. CONCLUSIONS: This pilot study demonstrates that a restrictive resuscitation strategy can successfully reduce the amount of IV fluid administered to patients with severe sepsis and septic shock compared with usual care. Although limited by the sample size, we observed no increase in mortality, organ failure, or adverse events. These findings further support that a restrictive IV fluid strategy should be explored in a larger multicenter trial.

Psychotherapy in Europe.

Psychotherapy was an invention of European modernity, but as the 20th century unfolded, and we trace how it crossed national and continental borders, its goals and the particular techniques by which it operated become harder to pin down. This introduction briefly draws together the historical literature on psychotherapy in Europe, asking comparative questions about the role of location and culture, and networks of transmission and transformation. It introduces the six articles in this special issue on Greece, Hungary, Yugoslavia, Russia, Britain and Sweden as well as its parallel special issue of History of Psychology on 'Psychotherapy in the Americas'. It traces what these articles tell us about how therapeutic developments were entangled with the dramatic, and often traumatic, political events across the continent: in the wake of the Second World War, the emergence of Communist and authoritarian regimes, the establishment of welfare states and the advance of neoliberalism.

A new way to estimate disease prevalence from random partial-mouth samples.

AIM: Standard partial-mouth estimators of chronic periodontitis (CP) that define an individual's disease status solely in terms of selected sites underestimate prevalence. This study proposes an improved prevalence estimator based on randomly sampled sites and evaluates its accuracy in a well-characterized population cohort. METHODS: Importantly, this method does not require determination of disease status at the individual level. Instead, it uses a statistical distributional approach to derive a prevalence formula from randomly selected periodontal sites. The approach applies the conditional linear family of distributions for correlated binary data (i.e. the presence or absence of disease at sites within a mouth) with two simple working assumptions: (i) the probability of having disease is the same across all sites; and (ii) the correlation of disease status is the same for all pairs of sites within the mouth. RESULTS: Using oral examination data from 6793 participants in the Arteriolosclerosis Risk in Communities study, the new formula yields CP prevalence estimates that are much closer than standard partial mouth estimates to full mouth estimates. CONCLUSIONS: Resampling of the cohort shows that the proposed estimators give good precision and accuracy for as few as six tooth sites sampled per individual.

Psychotherapy in historical perspective.

This article will briefly explore some of the ways in which the past has been used as a means to talk about psychotherapy as a practice and as a profession, its impact on individuals and society, and the ethical debates at stake. It will show how, despite the multiple and competing claims about psychotherapy's history and its meanings, historians themselves have, to a large degree, not attended to the intellectual and cultural development of many therapeutic approaches. This absence has the potential consequence of implying that therapies have emerged as value-free techniques, outside of a social, economic and political context. The relative neglect of psychotherapy, by contrast with the attention historians have paid to other professions, particularly psychiatry, has also underplayed its societal impact. This article will foreground some of the instances where psychotherapy has become an object of emerging historical interest, including the new research that forms the substance of this special issue of History of the Human Sciences.

Static and moving frontiers: the genetic landscape of Southern African Bantu-speaking populations.

A consensus on Bantu-speaking populations being genetically similar has emerged in the last few years, but the demographic scenarios associated with their dispersal are still a matter of debate. The frontier model proposed by archeologists postulates different degrees of interaction among incoming agropastoralist and resident foraging groups in the presence of "static" and "moving" frontiers. By combining mitochondrial DNA and Y chromosome data collected from several southern African populations, we show that Bantu-speaking populations from regions characterized by a moving frontier developing after a long-term static frontier have larger hunter-gatherer contributions than groups from areas where a static frontier was not followed by further spatial expansion. Differences in the female and male components suggest that the process of assimilation of the long-term resident groups into agropastoralist societies was gender biased. Our results show that the diffusion of Bantu languages and culture in Southern Africa was a process more complex than previously described and suggest that the admixture dynamics between farmers and foragers played an important role in shaping the current patterns of genetic diversity.

Diagnosis and Management of Adnexal Masses.

Adnexal masses can have gynecologic or nongynecologic etiologies, ranging from normal luteal cysts to ovarian cancer to bowel abscesses. Women who report abdominal or pelvic pain, increased abdominal size or bloating, difficulty eating, or rapid satiety that occurs more than 12 times per month in less than a year should be evaluated for ovarian cancer. Pelvic examination has low sensitivity for detecting an adnexal mass; negative pelvic examination findings in a symptomatic woman should not deter further workup. Ectopic pregnancy must be ruled out in women of reproductive age. A cancer antigen 125 (CA 125) test may assist in the evaluation of an adnexal mass in appropriate patients. CA 125 levels are elevated in conditions other than ovarian cancer. Because substantial overlap in CA 125 levels between pre- and postmenopausal women may occur, this level alone is not recommended for differentiating between a benign and a malignant adnexal mass. Transvaginal ultrasonography is the first choice for imaging of an adnexal mass. Large mass size, complexity, projections, septation, irregularity, or bilaterality may indicate cancer. If disease is suspected outside of the ovary, computed tomography may be indicated; magnetic resonance imaging may better show malignant characteristics in the ovary. Serial ultrasonography and periodic measurement of CA 125 levels may help in differentiating between benign or potentially malignant adnexal masses. If an adnexal mass larger than 6 cm is found on ultrasonography, or if findings persist longer than 12 weeks, referral to a gynecologist or gynecologic oncologist is indicated.

Getting Something out of Nothing: Analyzing Patterns of Null Responses to Improve Data Collection Methods in sub-Saharan Africa.

Careful development and adaptation of assessments is imperative for cultural psychological research. However, despite the best efforts, the use of assessments in new contexts can reveal atypical and/or unexpected patterns of performance. We found this to be the case in the testing of assessments to be used for a larger investigation of Specific Reading Disabilities in Zambia. In a sample of 207 children (100 female) from grades 2 to 7, we illustrated that assessment characteristics (i.e., stimulus type, answer choice, and response type) differentially impact patterns of responsiveness. The number of missing values was highest for assessments that (1) used written stimuli, (2) had an open-ended answer choice, and (3) required an action response. Age and socio-economic status explained some of the variance in responsiveness in selected, but not all assessments. Consideration of the impact of stimulus and response types when adapting assessments cross-linguistically and cross-culturally is essential.

Contribution of brown adipose tissue activity to the control of energy balance by GLP-1 receptor signalling in mice.

AIMS/HYPOTHESIS: We assessed the contribution of glucagon-like peptide-1 (GLP-1) receptor (GLP-1R) signalling to thermogenesis induced by high-fat diet (HFD) consumption. Furthermore, we determined whether brown adipose tissue (BAT) activity contributes to weight loss induced by chronic subcutaneous treatment with the GLP-1R agonist, liraglutide, in a model of diet-induced obesity. METHODS: Metabolic phenotyping was performed using indirect calorimetry in wild-type (WT) and Glp1r-knockout (KO) mice during chow and HFD feeding at room temperature and at thermoneutrality. In a separate study, we investigated the contribution of BAT thermogenic capacity to the weight lowering effect induced by GLP-1 mimetics by administering liraglutide (10 or 30 nmol kg(-1) day(-1) s.c.) to diet-induced obese (DIO) mice for 6 or 4 weeks, respectively. In both studies, animals were subjected to a noradrenaline (norepinephrine)-stimulated oxygen consumption [Formula: see text] test. RESULTS: At thermoneutrality, HFD-fed Glp1r-KO mice had similar energy expenditure (EE) compared with HFD-fed WT controls. However, HFD-fed Glp1r-KO mice exhibited relatively less EE when housed at a cooler standard room temperature, and had relatively lower [Formula: see text] in response to a noradrenaline challenge, which is consistent with impaired BAT thermogenic capacity. In contrast to the loss of function model, chronic peripheral liraglutide treatment did not increase BAT activity as determined by noradrenaline-stimulated [Formula: see text] and BAT gene expression. CONCLUSIONS/INTERPRETATION: These data suggest that although endogenous GLP-1R signalling contributes to increased BAT thermogenesis, this mechanism does not play a significant role in the food intake-independent body weight lowering effect of the GLP-1 mimetic liraglutide in DIO mice.

Exploring the relationship between lifestyles, diets and genetic adaptations in humans.

BACKGROUND: One of the most important dietary shifts underwent by human populations began to occur in the Neolithic, during which new modes of subsistence emerged and new nutrients were introduced in diets. This change might have worked as a selective pressure over the metabolic pathways involved in the breakdown of substances extracted from food. Here we applied a candidate gene approach to investigate whether in populations with different modes of subsistence, diet-related genetic adaptations could be identified in the genes AGXT, PLRP2, MTRR, NAT2 and CYP3A5. RESULTS: At CYP3A5, strong signatures of positive selection were detected, though not connected to any dietary variable, but instead to an environmental factor associated with the Tropic of Cancer. Suggestive signals of adaptions that could indeed be connected with differences in dietary habits of populations were only found for PLRP2 and NAT2. Contrarily, the demographic history of human populations seemed enough to explain patterns of diversity at AGXT and MTRR, once both conformed the evolutionary expectations under selective neutrality. CONCLUSIONS: Accumulated evidence indicates that CYP3A5 has been under adaptive evolution during the history of human populations. PLRP2 and NAT2 also appear to have been modelled by some selective constrains, although clear support for that did not resist to a genome wide perspective. It is still necessary to clarify which were the biological mechanisms and the environmental factors involved as well as their interactions, to understand the nature and strength of the selective pressures that contributed to shape current patterns of genetic diversity at those loci.

Evaluation of a disability-inclusive ultra-poor graduation programme in Uganda: study protocol for a cluster-randomised controlled trial with process evaluation.

BACKGROUND: There is little evidence on how to support ultra-poor people with disabilities to adopt sustainable livelihoods. The Disability-Inclusive Graduation (DIG) programme targets ultra-poor people with disabilities and/or women living in rural Uganda. The programme is an adaptation of an ultra-poor graduation model that has been shown to be effective in many contexts but not evaluated for people with disabilities. METHODS: The DIG programme works with project participants over a period of 18 months. Participants receive unconditional cash transfers for 6 months, training, access to savings-and-loans groups, and a capital asset that forms the basis of their new livelihood. The programme is also adapted to address specific barriers that people with disabilities face. Eligible households are clustered by geographical proximity in order to deliver the intervention. Eligibility is based on household screening to identify the 'ultra-poor' based on proxy means testing-both households with and without people with disabilities are included in the programme. Clusters are randomly selected prior to implementation, resulting in 96 intervention and 89 control clusters. The primary outcome of the trial is per-capita household consumption. Before the start of the intervention, a baseline household survey is conducted (November 2020) among project participants and those not offered the programme, a similar endline survey is conducted with participants with disabilities at the end of programme implementation in July 2022, and a second endline survey for all participants in October 2023. These activities are complemented by a process evaluation to understand DIG programme implementation, mechanisms, and context using complementary qualitative and quantitative methods. Ethical approval for the research has been received from Mildmay Uganda Research Ethics Committee and London School of Hygiene and Tropical Medicine. DISCUSSION: DIG is a promising intervention to evaluate for people with disabilities, adapted to be disability inclusive across programme components through extensive consultations and collaboration, and has proven efficacy at reducing poverty in other marginalised groups. However, evaluating a well-evidenced intervention among a new target group poses ethical considerations. TRIAL REGISTRATION: Registry for International Development Impact Evaluations, RIDIE-STUDY-ID-626008898983a (20/04/22). ISRCTN registry, ISRCTN78592382 . Retrospectively registered on 17/08/2023.

Improving access to family planning for women with disabilities in Kaduna city, Nigeria: study protocol for a pragmatic cluster-randomized controlled trial with integrated process evaluation.

BACKGROUND: Globally, women with disabilities are less likely to have access to family planning services compared to their peers without disabilities. However, evidence of effective interventions for promoting their sexual and reproductive health and rights remains limited, particularly in low- and middle-income settings. To help address disparities, an inclusive sexual and reproductive health project was developed to increase access to modern contraceptive methods and reduce unmet need for family planning for women of reproductive age with disabilities in Kaduna city, Nigeria. The project uses demand-side, supply-side and contextual interventions, with an adaptive management approach. This protocol presents a study to evaluate the project's impact. METHODS: A pragmatic cluster-randomized controlled trial design with surveys at baseline and endline will be used to evaluate interventions delivered for at least 1 year at health facility and community levels in comparison to 'standard' state provision of family planning services, in the context of state-wide and national broadcast media and advocacy. Randomization will be conducted based on the health facility catchment area, with 19 clusters in the intervention arm and 18 in the control arm. The primary outcome measure will be access to family planning. It was calculated that at least 950 women aged 18 to 49 years with disabilities (475 in each arm) will be recruited to detect a 50% increase in access compared to the control arm. For each woman with disabilities enrolled, a neighbouring woman without disabilities in the same cluster and age group will be recruited to assess whether the intervention has a specific effect amongst women with disabilities. The trial will be complemented by an integrated process evaluation. Ethical approval for the study has been given by the National Health Research Ethics Committee of Nigeria and London School of Hygiene & Tropical Medicine. DISCUSSION: Defining access to services is complex, as it is not a single variable that can be measured directly and need for family planning is subjectively defined. Consequently, we have conceptualized 'access to family planning' based on a composite of beliefs about using services if needed. TRIAL REGISTRATION: ISRCTN registry ISRCTN12671153. Retrospectively registered on 17/04/2023.

The Effect of COVID-19 on Dual-Eligible Beneficiaries: A Scoping Review.

OBJECTIVES: To examine the impact of COVID-19 on clinical health outcomes and health-related social needs among Medicaid-Medicare dual-eligible beneficiaries. DESIGN: Scoping review. SETTING AND PARTICIPANTS: Dual eligibles during COVID-19. METHODS: We performed a comprehensive scoping review including observational studies, clinical trials, and original empirical research studies of PubMed and CINAHL. We generated a list of terms related to programs that both serve dual eligibles and address our desired outcomes. With the assistance of a medical librarian, we identified relevant abstracts published during COVID-19 meeting our inclusion criteria. We performed full-text reviews of relevant abstracts and selected the final studies. We extracted the study population, design, and major findings, then conducted thematic analysis. RESULTS: 1100 articles were identified, with 439 deemed relevant. On full text-review, 15 articles met inclusion criteria representing more than 86 million Medicare beneficiaries. No studies were specific only to dual eligibles. Topic areas included in this review include COVID-19 case counts (2 articles), mortality (8 articles), hospitalizations (7 articles), food insecurity (1 article), self-reported mental health (1 article), and social connectedness (2 articles). Dual eligibles had disparate COVID-19-related outcomes from Medicare-only enrollees in 12 of 15 studies. Studies show higher mortality for dual eligibles overall, but this was not true for dual eligibles in nursing homes and assisted living communities. Dual eligibles were more likely to experience food insecurity. More favorably, dual eligibles reported greater social connectedness. CONCLUSIONS AND IMPLICATIONS: Dual eligibles had different outcomes from Medicare-only recipients in multiple health outcomes and health-related social needs during COVID-19, but studies are limited, particularly in terms of health-related social needs. Future work focusing on outcomes only among dual-eligible beneficiaries, integrated care programs, and fiscal alignment between Medicare and Medicaid plans may help stakeholders address health needs specific to dual eligibles.