Examining the Role of Physician Characteristics in Web-Based Verified Primary Care Physician Reviews: Observational Study.

BACKGROUND: Doctor review websites have become increasingly popular as a source of information for patients looking to select a primary care provider. Zocdoc is one such platform that allows patients to not only rate and review their experiences with doctors but also directly schedule appointments. This study examines how several physician characteristics including gender, age, race, languages spoken in a physician's office, education, and facial attractiveness impact the average numerical rating of primary care doctors on Zocdoc. OBJECTIVE: The aim of this study was to investigate the association between physician characteristics and patient satisfaction ratings on Zocdoc. METHODS: A data set of 1455 primary care doctor profiles across 30 cities was scraped from Zocdoc. The profiles contained information on the physician's gender, education, and languages spoken in their office. Age, facial attractiveness, and race were imputed from profile pictures using commercial facial analysis software. Each doctor profile listed an average overall satisfaction rating, bedside manner rating, and wait time rating from verified patients. Descriptive statistics, the Wilcoxon rank sum test, and multivariate logistic regression were used to analyze the data. RESULTS: The average overall rating on Zocdoc was highly positive, with older age, lower facial attractiveness, foreign degrees, allopathic degrees, and speaking more languages negatively associated with the average rating. However, the effect sizes of these factors were relatively small. For example, graduates of Latin American medical schools had a mean overall rating of 4.63 compared to a 4.77 rating for US graduates (P<.001), a difference roughly equivalent to a 2.8% decrease in appointments. On multivariate analysis, being Asian and having a doctor of osteopathic medicine degree were positively associated with higher overall ratings, while attending a South Asian medical school and speaking more European and Middle Eastern languages in the office were negatively associated with higher overall ratings. CONCLUSIONS: Overall, the findings suggest that age, facial attractiveness, education, and multilingualism do have some impact on web-based doctor reviews, but the numerical effect is small. Notably, bias may play out in many forms. For example, a physician's appearance or accent may impact a patient's trust, confidence, or satisfaction with their physician, which could in turn influence their take-up of preventative services and lead to either better or worse health outcomes. The study highlights the need for further research in how physician characteristics influence patient ratings of care.

The Role of Physician Networks and Receipt of Opioid-Related Payments.

BACKGROUND: Opioid-related promotional payments are associated with increased prescribing of the promoted drug, but little is known about whether physicians receiving payments influence peers to accept similar payments. OBJECTIVE: We examine the association of physician network-level position among peers and the acceptance of opioid-related promotional payments using national publicly available datasets from 2015. Design National cross-sectional data from the Centers for Medicare and Medicaid Services (CMS) National Downloadable File and Open Payment data. SUBJECTS: Physicians who shared Medicare patients with at least two other physicians in 2015. MAIN MEASURES: Modified Poisson's regressions are used to estimate the adjusted incidence rate ratio (aIRR) for social network position (i.e., degree, betweenness, and transitivity) and number of peers with payments as a function of individual receipt of opioid-related promotional payment and among those with payments, those who have five or more payments, and those who have $100 or more in payments. KEY RESULTS: Physicians with opioid-related payments were significantly more likely to have at least one peer with an opioid-related payment (IRR: 2.5, 95% CI: 2.3-2.8), but had fewer shared patients (i.e., top quartile compared to the first quartile for degree centrality: 0.4, 95% CI: 0.3-0.4) and belonged to less cohesive networks (i.e., top quartile compared to the first quartile for betweenness centrality: 0.9, 95% CI: 0.8-0.9). CONCLUSIONS: Our study demonstrates that physicians receiving opioid-related payments are more likely to cluster within physician networks.

The Relationship Between Peripheral Arterial Disease Severity and Socioeconomic Status.

BACKGROUND: Although socioeconomic disparities in outcomes of peripheral artery disease (PAD) have been well studied, little is known about relationship between severity of PAD and socioeconomic status. The objective of this study was to examine this relationship. METHODS: Patients who had operations for severe PAD (rest pain or tissue loss) were identified in the National Inpatient Sample, 2005-2014. They were stratified by the median household income (MHI) quartiles of their residential ZIP codes. Other characteristics such as race/ethnicity and insurance type were extracted. Factors associated with more severe disease (tissue loss) were evaluated using multivariable regression analyses. RESULTS: There were 765,175 patients identified; 34% in the first MHI quartile and 18% in the fourth MHI quartile. Compared to patients in the first quartile, those in the fourth quartile were more likely White (69% vs. 42%, P < 0.001), more likely ≥65 years old (75% vs. 62%, P < 0.001), and were less likely to undergo amputations (25% vs. 34%, P < 0.001). After adjusting for patient characteristics, the fourth quartile was associated with more severe disease [Odds ratio: 1.19, 95% confidence interval (CI): 1.11-1.27] compared to the first quartile. CONCLUSIONS: While higher MHI was associated with higher PAD severity, patients with high MHI were less likely to undergo amputations indicating a disparity in the choice of treatment for PAD. Increased efforts are necessary to reduce socioeconomic disparities in the treatment of severe PAD.

The influence of socioeconomic status on outcomes of lower extremity arterial reconstruction.

OBJECTIVE: Although it has been shown that patient socioeconomic status (SES) is associated with the surgical treatments chosen for severe peripheral arterial disease (PAD), the association between SES and outcomes of arterial reconstruction have not been well-studied. The objective of this study was to determine if SES is associated with outcomes following lower extremity arterial reconstruction. METHODS: Patients 40 years and older who had surgical revascularization for severe lower extremity PAD were identified in the Nationwide Readmissions Database, 2010 to 2014. Measures of SES including median household income (MHI) quartiles of patients' residential ZIP codes were extracted. Factors associated with repeat revascularization, subsequent major amputations, hospital mortality, and 30-day all-cause readmission were evaluated using multivariable regression analyses. RESULTS: Of the 131,529 patients identified, the majority (61%) were male, and the average age was 69 years. On unadjusted analyses, subsequent amputations were higher among patients in the lowest MHI quartile compared with patients in the highest MHI quartile (13% vs 10%; overall P < .001). On multivariable analyses, compared with patients in the lowest quartile, those in the highest quartile had lower amputation (adjusted odds ratio [aOR], 0.70; 95% confidence interval (CI), 0.63-0.77; overall P < .001) and readmission (aOR, 0.91; 95% CI, 0.84-0.99; overall P = .028) rates. However, subsequent revascularization (aOR, 1.04; 95% CI, 0.94-1.15) and mortality (aOR, 1.01; 95% CI, 0.79-1.28) rates were not different across the groups. CONCLUSIONS: Lower SES is associated with disproportionally worse outcomes following lower extremity arterial reconstruction for severe PAD. These data suggest that improving outcomes of lower extremity arterial reconstruction may involve addressing socioeconomic disparities.

The Benefits of Crowdsourcing to Seed and Align an Algorithm in an mHealth Intervention for African American and Hispanic Adults: Survey Study.

BACKGROUND: The lack of publicly available and culturally relevant data sets on African American and bilingual/Spanish-speaking Hispanic adults' disease prevention and health promotion priorities presents a major challenge for researchers and developers who want to create and test personalized tools built on and aligned with those priorities. Personalization depends on prediction and performance data. A recommender system (RecSys) could predict the most culturally and personally relevant preventative health information and serve it to African American and Hispanic users via a novel smartphone app. However, early in a user's experience, a RecSys can face the "cold start problem" of serving untailored and irrelevant content before it learns user preferences. For underserved African American and Hispanic populations, who are consistently being served health content targeted toward the White majority, the cold start problem can become an example of algorithmic bias. To avoid this, a RecSys needs population-appropriate seed data aligned with the app's purposes. Crowdsourcing provides a means to generate population-appropriate seed data. OBJECTIVE: Our objective was to identify and test a method to address the lack of culturally specific preventative personal health data and sidestep the type of algorithmic bias inherent in a RecSys not trained in the population of focus. We did this by collecting a large amount of data quickly and at low cost from members of the population of focus, thereby generating a novel data set based on prevention-focused, population-relevant health goals. We seeded our RecSys with data collected anonymously from self-identified Hispanic and self-identified non-Hispanic African American/Black adult respondents, using Amazon Mechanical Turk (MTurk). METHODS: MTurk provided the crowdsourcing platform for a web-based survey in which respondents completed a personal profile and a health information-seeking assessment, and provided data on family health history and personal health history. Respondents then selected their top 3 health goals related to preventable health conditions, and for each goal, reviewed and rated the top 3 information returns by importance, personal utility, whether the item should be added to their personal health library, and their satisfaction with the quality of the information returned. This paper reports the article ratings because our intent was to assess the benefits of crowdsourcing to seed a RecSys. The analysis of the data from health goals will be reported in future papers. RESULTS: The MTurk crowdsourcing approach generated 985 valid responses from 485 (49%) self-identified Hispanic and 500 (51%) self-identified non-Hispanic African American adults over the course of only 64 days at a cost of US $6.74 per respondent. Respondents rated 92 unique articles to inform the RecSys. CONCLUSIONS: Researchers have options such as MTurk as a quick, low-cost means to avoid the cold start problem for algorithms and to sidestep bias and low relevance for an intended population of app users. Seeding a RecSys with responses from people like the intended users allows for the development of a digital health tool that can recommend information to users based on similar demography, health goals, and health history. This approach minimizes the potential, initial gaps in algorithm performance; allows for quicker algorithm refinement in use; and may deliver a better user experience to individuals seeking preventative health information to improve health and achieve health goals.

Estimated Travel Time and Spatial Access to Abortion Facilities in the US Before and After the Dobbs v Jackson Women's Health Decision.

Importance: Abortion facility closures resulted in a substantial decrease in access to abortion care in the US. Objectives: To investigate the changes in travel time to the nearest abortion facility after the Dobbs v Jackson Women's Health Organization (referred to hereafter as Dobbs) US Supreme Court decision. Design, Setting, and Participants: Repeated cross-sectional spatial analysis of travel time from each census tract in the contiguous US (n = 82 993) to the nearest abortion facility (n = 1134) listed in the Advancing New Standards in Reproductive Health database. Census tract boundaries and demographics were defined by the 2020 American Community Survey. The spatial analysis compared access during the pre-Dobbs period (January-December 2021) with the post-Dobbs period (September 2022) for the estimated 63 718 431 females aged 15 to 44 years (reproductive age for this analysis) in the US (excluding Alaska and Hawaii). Exposures: The Dobbs ruling and subsequent state laws restricting abortion procedures. The pre-Dobbs period measured abortion access to all facilities providing abortions in 2021. Post-Dobbs abortion access was measured by simulating the closure of all facilities in the 15 states with existing total or 6-week abortion bans in effect as of September 30, 2022. Main Outcomes and Measures: Median and mean changes in surface travel time (eg, car, public transportation) to an abortion facility in the post-Dobbs period compared with the pre-Dobbs period and the total percentage of females of reproductive age living more than 60 minutes from abortion facilities during the pre- and post-Dobbs periods. Results: Of 1134 abortion facilities in the US (at least 1 in every state; 8 in Alaska and Hawaii excluded), 749 were considered active during the pre-Dobbs period and 671 were considered active during a simulated post-Dobbs period. Median (IQR) and mean (SD) travel times to pre-Dobbs abortion facilities were estimated to be 10.9 (4.3-32.4) and 27.8 (42.0) minutes. Travel time to abortion facilities in the post-Dobbs period significantly increased (paired sample t test P <.001) to an estimated median (IQR) of 17.0 (4.9-124.5) minutes and a mean (SD) of and 100.4 (161.5) minutes. In the post-Dobbs period, an estimated 33.3% (sensitivity interval, 32.3%-34.8%) of females of reproductive age lived in a census tract more than 60 minutes from an abortion facility compared with 14.6.% (sensitivity interval, 13.0%-16.9%) of females of reproductive age in the pre-Dobbs period. Conclusions and Relevance: In this repeated cross-sectional spatial analysis, estimated travel time to abortion facilities in the US was significantly greater in the post-Dobbs period after accounting for the closure of abortion facilities in states with total or 6-week abortion bans compared with the pre-Dobbs period, during which all facilities providing abortions in 2021 were considered active.

The effect of income and insurance on the likelihood of major leg amputation.

BACKGROUND: Although it has been suggested that individuals of low socioeconomic status and those with Medicaid or no insurance may be more likely to have their peripheral artery disease treated by leg amputation rather than by limb-saving revascularization, it is not clear if this disparity occurs consistently on a national basis, and if it does so in a linear fashion, such that poorer individuals are at progressively greater risk for amputation. OBJECTIVE: We undertook this study to determine if lower median household income and Medicaid/no insurance status are associated with a higher risk for amputation, and if this occurs in a progressively linear fashion. METHODS: The National (Nationwide) Inpatient Sample Database was queried to identify patients who were admitted with a diagnosis of critical limb ischemia from 2005 to 2014 and underwent either a major amputation or a revascularization procedure during that admission. Patients were stratified according to their insurance status and their median household income into four income quartiles. Multivariate logistic regression was performed to determine the effect of income and insurance status on the odds of undergoing amputation vs leg revascularization. RESULTS: Across the different insurance types, there was a significant decrease in the odds ratios for amputation as one progressed from one MHI quartile to a higher one: namely, Medicare (2.23, 1.87, 1.65, and 1.42 for the first, second, third, and fourth MHI quartiles); Medicaid (2.50, 2.28, 2.04, and 1.80 for the first, second, third, and fourth MHI quartiles); private insurance (1.52, 1.21, 1.16, and 1.00 for the first, second, third, and fourth MHI quartiles), and uninsured (1.91, 1.64, 1.10, and 1.22, for the first, second, third, and fourth MHI quartiles). CONCLUSIONS: Lower MHI, Medicaid insurance, and uninsured status are associated with a greater likelihood of amputation and a lower likelihood of undergoing limb-saving revascularization. These disparities are exacerbated in stepwise fashion, such that lower income quartiles are at progressively greater risk for amputation.

Preventability of Early Versus Late Hospital Readmissions in a National Cohort of General Medicine Patients.

Background: Many experts believe that hospitals with more frequent readmissions provide lower-quality care, but little is known about how the preventability of readmissions might change over the postdischarge time frame. Objective: To determine whether readmissions within 7 days of discharge differ from those between 8 and 30 days after discharge with respect to preventability. Design: Prospective cohort study. Setting: 10 academic medical centers in the United States. Patients: 822 adults readmitted to a general medicine service. Measurements: For each readmission, 2 site-specific physician adjudicators used a structured survey instrument to determine whether it was preventable and measured other characteristics. Results: Overall, 36.2% of early readmissions versus 23.0% of late readmissions were preventable (median risk difference, 13.0 percentage points [interquartile range, 5.5 to 26.4 percentage points]). Hospitals were identified as better locations for preventing early readmissions (47.2% vs. 25.5%; median risk difference, 22.8 percentage points [interquartile range, 17.9 to 31.8 percentage points]), whereas outpatient clinics (15.2% vs. 6.6%; median risk difference, 10.0 percentage points [interquartile range, 4.6 to 12.2 percentage points]) and home (19.4% vs. 14.0%; median risk difference, 5.6 percentage points [interquartile range, -6.1 to 17.1 percentage points]) were better for preventing late readmissions. Limitation: Physician adjudicators were not blinded to readmission timing, community hospitals were not included in the study, and readmissions to nonstudy hospitals were not included in the results. Conclusion: Early readmissions were more likely to be preventable and amenable to hospital-based interventions. Late readmissions were less likely to be preventable and were more amenable to ambulatory and home-based interventions. Primary Funding Source: Association of American Medical Colleges.

Travel Time and Costs for Abortion for Military Service Members After the Dobbs Decision.

This study quantifies the change in travel times for military service personnel to abortion facilities following the US Supreme Court Dobbs decision and estimates the cost of an abortion-related travel reimbursement policy.

Partisan divide and Racial/Ethnic disparities in COVID-19 vaccine hesitancy among Parents/Guardians and vaccine uptake among children in the U.S.

OBJECTIVES: We undertook an observational study to assess the impact of state-level partisanship and parents'/guardians' race/ethnicity on their degree of COVID-19 vaccine hesitancy. MATERIAL AND METHODS: We observed a pooled cross-section of 59,280 U.S. adults residing with children in the same household between June 29 and November 14, 2022. Using household-weighted logistic regression models, we evaluated the association between partisanship, race/ethnicity, and vaccine hesitancy, while controlling for other social determinants of COVID-19 vaccine hesitancy. RESULTS AND CONCLUSIONS: We found that children were less likely to receive a COVID-19 vaccine if they resided in Republican as compared to Democratic states, with the difference in probability greatest among those households where parents/guardians identified as White. We also found that children were less likely to receive a COVID-19 vaccine if their parents/guardians identified as White as compared to any other race/ethnicity, with the differences in probability greatest among households in Republican states.

Slaveholder ancestry and current net worth of members of the United States Congress.

BACKGROUND: Whether and how much past slavery affects contemporary social and economic conditions in the United States is an area of active debate. Newly available data on which members of the United States Congress are descendants of slaveholders provides an opportunity to examine this topic. This study sought to determine the relationship between slaveholder ancestry and net worth among members of Congress. METHODS: Total assets and liabilities were collected from financial declarations of all members of Congress as of April 15, 2021. Net worth was estimated as the difference between total assets and liabilities. Information on slaveholder ancestry was obtained from a Reuters investigative series based on an extensive review of historical documents and verification by board-certified genealogists. Quantile regression was used to determine the association between net worth and slaveholder ancestry after adjustment for demographic factors. RESULTS: The median net worth of the 535 members of Congress was $1.28 million (interquartile range $0.11-5.87 million). On univariate analysis, net worth was associated with increased age, White race, increased education, and number of individuals enslaved by ancestors. On multivariate analysis, net worth was independently associated with age, White race, and number enslaved. Legislators whose ancestors enslaved 16 or more individuals had a $3.93 million (95% confidence interval 2.39-5.46) higher net worth compared to legislators whose ancestors were not slave owners after adjustment for age, sex, race, ethnicity, and education. CONCLUSIONS: Past slaveholding practices are independently associated with current wealth among members of Congress. Because members of Congress are a highly selected group, further work is needed to understand how slaveholder ancestry affects current wealth in the general population to inform efforts to reduce social and economic disparities.

Adherence to non-pharmaceutical interventions following COVID-19 vaccination: a federated cohort study.

In pandemic mitigation, strategies such as social distancing and mask-wearing are vital to prevent disease resurgence. Yet, monitoring adherence is challenging, as individuals might be reluctant to share behavioral data with public health authorities. To address this challenge and demonstrate a framework for conducting observational research with sensitive data in a privacy-conscious manner, we employ a privacy-centric epidemiological study design: the federated cohort. This approach leverages recent computational advances to allow for distributed participants to contribute to a prospective, observational research study while maintaining full control of their data. We apply this strategy here to explore pandemic intervention adherence patterns. Participants (n = 3808) were enrolled in our federated cohort via the "Google Health Studies" mobile application. Participants completed weekly surveys and contributed empirically measured mobility data from their Android devices between November 2020 to August 2021. Using federated analytics, differential privacy, and secure aggregation, we analyzed data in five 6-week periods, encompassing the pre- and post-vaccination phases. Our results showed that participants largely utilized non-pharmaceutical intervention strategies until they were fully vaccinated against COVID-19, except for individuals without plans to become vaccinated. Furthermore, this project offers a blueprint for conducting a federated cohort study and engaging in privacy-preserving research during a public health emergency.

Characterizing industry payments to US teaching hospitals and affiliated physicians: a cross-sectional analysis of the Open Payments datasets from 2016 to 2022.

Industry payments to US teaching hospitals are common; however, little is known about whether these financial relationships influence affiliated physicians to engage in similar financial relationships with industry. Using national hospital, physician, and industry payment data we investigated trends in industry payments made to US teaching hospitals and affiliated physicians to characterize the magnitude and nature of payments. In addition, we assessed if physicians may be influenced to accept higher value industry payments depending on the value of promotional payments accepted by the teaching hospital they affiliate with. We found that physicians with a US teaching hospital affiliation are associated with accepting higher value industry payments as the total value of industry payments of the teaching hospital increases. Our findings varied by specialty, with surgeons accepting the highest value payments. These results highlight the need for greater public disclosure and awareness of payments to better manage and mitigate industry-biased clinical decision making.

Parental compliance and reasons for COVID-19 Vaccination among American children.

COVID-19 vaccination rates among children have stalled, while new coronavirus strains continue to emerge. To improve child vaccination rates, policymakers must better understand parental preferences and reasons for COVID-19 vaccination among their children. Cross-sectional surveys were administered online to 30,174 US parents with at least one child of COVID-19 vaccine eligible age (5-17 years) between January 1 and May 9, 2022. Participants self-reported willingness to vaccinate their child and reasons for refusal, and answered additional questions about demographics, pandemic related behavior, and vaccination status. Willingness to vaccinate a child for COVID-19 was strongly associated with parental vaccination status (multivariate odds ratio 97.9, 95% confidence interval 86.9-111.0). The majority of fully vaccinated (86%) and unvaccinated (84%) parents reported concordant vaccination preferences for their eligible child. Age and education had differing relationships by vaccination status, with higher age and education positively associated with willingness among vaccinated parents. Among all parents unwilling to vaccinate their children, the two most frequently reported reasons were possible side effects (47%) and that vaccines are too new (44%). Unvaccinated parents were much more likely to list a lack of trust in government (41% to 21%, p < .001) and a lack of trust in scientists (34% to 19%, p < .001) as reasons for refusal. Cluster analysis identified three groups of unwilling parents based on their reasons for refusal to vaccinate, with distinct concerns that may be obscured when analyzed in aggregate. Factors associated with willingness to vaccinate children and reasons for refusal may inform targeted approaches to increase vaccination.

The online language of work-personal conflict.

With the blurring of boundaries in this digital age, there is increasing concern around work-personal conflict. Assessing and tracking work-personal conflict is critical as it not only affects individual workers but is also a vital measure among broader well-being and economic indices. This inductive study examines the extent to which work-personal conflict corresponds to individuals' language use on social media. We apply an open-vocabulary analysis to the posts of 2810 Facebook users who also completed a survey for an established work-personal conflict scale. It was found that the language-based model can predict personal-to-work conflict (r = 0.23) and work-to-personal conflict (r = 0.15) and provide important insights into such conflicts. Specifically, we found that high personal-to-work conflict was associated with netspeak and swearing, while low personal-to-work conflict was associated with language about work and positivity. We found that high work-to-personal conflict was associated with negative emotion and negative tone, while low work-to-personal conflict was associated with positive emotion and language about birthdays.

Metrics for Phased Prevention of Coronavirus Disease 2019 Transmission for Institutions of Higher Education: 2022 and Beyond.

In the nearly 2 years since suspending in-person activities, many institutions of higher education (IHEs) have struggled with returning students, staff, and faculty to campus safely and developed robust mitigation plans, continuing or instituting surveillance testing, and codifying stringent coronavirus disease 2019 codes of conduct. Essential to return-to-campus planning is a strategy for when and how to reduce activities to slow transmission through phased prevention-a strategy for reintroducing nonpharmaceutical interventions and "metering" activities at IHEs based on the levels of community severe acute respiratory syndrome coronavirus 2 transmission and testing. In this regard, I propose a series of mitigation measures and the metrics for their implementation, color coded and categorized in phases similar to those recommended by the federal and numerous state governments to open nonessential businesses and resume in-person services, and specific where applicable to IHEs that require vaccination and those at which vaccination is optional.

Association of historic redlining and present-day health in Baltimore.

BACKGROUND: In the 1930s, the Home Owners' Loan Corporation categorized neighborhoods by investment grade along racially discriminatory lines, a process known as redlining. Although other authors have found associations between Home Owners' Loan Corporation categories and current impacts on racial segregation, analysis of current health impacts rarely use these maps. OBJECTIVE: To study whether historical redlining in Baltimore is associated with health impacts today. APPROACH: Fifty-four present-day planning board-defined community statistical areas are assigned historical Home Owners' Loan Corporation categories by area predominance. Categories are red ("hazardous"), yellow ("definitely declining") with blue/green ("still desirable"/"best") as the reference category. Community statistical area life expectancy is regressed against Home Owners' Loan Corporation category, controlling for median household income and proportion of African American residents. CONCLUSION: Red categorization is associated with 4.01 year reduction (95% CI: 1.47, 6.55) and yellow categorization is associated with 5.36 year reduction (95% CI: 3.02, 7.69) in community statistical area life expectancy at baseline. When controlling for median household income and proportion of African American residents, red is associated with 5.23 year reduction (95% CI: 3.49, 6.98) and yellow with 4.93 year reduction (95% CI: 3.22, 6.23). Results add support that historical redlining is associated with health today.