Advance Care Planning (ACP) in Medicare Beneficiaries with Heart Failure.

BACKGROUND: Heart failure is a leading cause of death in the USA, contributing to high expenditures near the end of life. Evidence remains lacking on whether billed advance care planning changes patterns of end-of-life healthcare utilization among patients with heart failure. Large-scale claims evaluation assessing billed advance care planning and end-of-life hospitalizations among patients with heart failure can fill evidence gaps to inform health policy and clinical practice. OBJECTIVE: Assess the association between billed advance care planning delivered and Medicare beneficiaries with heart failure upon the type and quantity of healthcare utilization in the last 30 days of life. DESIGN: This retrospective cross-sectional cohort study used Medicare fee-for-service claims from 2016 to 2020. PARTICIPANTS: A total of 48,466 deceased patients diagnosed with heart failure on Medicare. MAIN MEASURES: Billed advance care planning services between the last 12 months and last 30 days of life will serve as the exposure. The outcomes are end-of-life healthcare utilization and total expenditure in inpatient, outpatient, hospice, skilled nursing facility, and home healthcare services. KEY RESULTS: In the final cohort of 48,466 patients (median [IQR] age, 83 [76-89] years; 24,838 [51.2%] women; median [IQR] Charlson Comorbidity Index score, 4 [2-5]), 4406 patients had an advance care planning encounter. Total end-of-life expenditure among patients with billed advance care planning encounters was 19% lower (95% CI, 0.77-0.84) compared to patients without. Patients with billed advance care planning encounters had 2.65 times higher odds (95% CI, 2.47-2.83) of end-of-life outpatient utilization with a 33% higher expected total outpatient expenditure (95% CI, 1.24-1.42) compared with patients without a billed advance care planning encounter. CONCLUSIONS: Billed advance care planning delivery to individuals with heart failure occurs infrequently. Prioritizing billed advance care planning delivery to these individuals may reduce total end-of-life expenditures and end-of-life inpatient expenditures through promoting use of outpatient end-of-life services, including home healthcare and hospice.

Out-of-Network Care in Commercially Insured Pediatric Patients According to Medical Complexity.

BACKGROUND: Commercial health plans establish networks and require much higher cost sharing for out-of-network (OON) care. Yet, the adequacy of health plan networks for access to pediatric specialists, especially for children with medical complexity, is largely unknown. OBJECTIVE: To examine differences in OON care and associated cost-sharing payments for commercially insured children with different levels of medical complexity. DESIGN: Cross-sectional study using a nationwide commercial claims database. SUBJECTS: Enrollees 0-18 years old in employer-sponsored insurance plans. The Pediatric Medical Complexity Algorithm was used to classify individuals into 3 levels of medical complexity: children with no chronic disease, children with non-complex chronic diseases, and children with complex chronic diseases. MAIN OUTCOMES: OON care rates, cost-sharing payments for OON care and in-network care, OON cost sharing as a proportion of total health care spending, and OON cost sharing as a proportion of total cost sharing. RESULTS: The study sample included 6,399,006 individuals with no chronic disease, 1,674,450 with noncomplex chronic diseases, and 603,237 with complex chronic diseases. Children with noncomplex chronic diseases were more likely to encounter OON care by 6.77 percentage points with higher cost-sharing by $288 for OON care, relative to those with no chronic disease. For those with complex chronic diseases, these differences rose to 16.08 percentage points and $599, respectively. Among children who saw behavioral health providers, rates of OON care were especially high. CONCLUSIONS: Commercially insured children with medical complexity experience higher rates of OON care with higher OON cost-sharing payments compared with those with no chronic disease.

Guidelines for Artificial Intelligence in Medicine: Literature Review and Content Analysis of Frameworks.

BACKGROUND: Artificial intelligence (AI) is rapidly expanding in medicine despite a lack of consensus on its application and evaluation. OBJECTIVE: We sought to identify current frameworks guiding the application and evaluation of AI for predictive analytics in medicine and to describe the content of these frameworks. We also assessed what stages along the AI translational spectrum (ie, AI development, reporting, evaluation, implementation, and surveillance) the content of each framework has been discussed. METHODS: We performed a literature review of frameworks regarding the oversight of AI in medicine. The search included key topics such as "artificial intelligence," "machine learning," "guidance as topic," and "translational science," and spanned the time period 2014-2022. Documents were included if they provided generalizable guidance regarding the use or evaluation of AI in medicine. Included frameworks are summarized descriptively and were subjected to content analysis. A novel evaluation matrix was developed and applied to appraise the frameworks' coverage of content areas across translational stages. RESULTS: Fourteen frameworks are featured in the review, including six frameworks that provide descriptive guidance and eight that provide reporting checklists for medical applications of AI. Content analysis revealed five considerations related to the oversight of AI in medicine across frameworks: transparency, reproducibility, ethics, effectiveness, and engagement. All frameworks include discussions regarding transparency, reproducibility, ethics, and effectiveness, while only half of the frameworks discuss engagement. The evaluation matrix revealed that frameworks were most likely to report AI considerations for the translational stage of development and were least likely to report considerations for the translational stage of surveillance. CONCLUSIONS: Existing frameworks for the application and evaluation of AI in medicine notably offer less input on the role of engagement in oversight and regarding the translational stage of surveillance. Identifying and optimizing strategies for engagement are essential to ensure that AI can meaningfully benefit patients and other end users.

Racial Discrimination and Stress Across the Life Course: Associations With Prenatal Inflammation, Perceived Stress, and Depressive Symptoms.

BACKGROUND: Among Black Americans, interpersonal racial discrimination is common. Stress, including following discrimination, contributes to pregnancy complications. In this secondary analysis, we provide data on associations among discrimination, stress, and their interaction across the life course and inflammation, perceived stress, and depressive symptoms during pregnancy. METHODS: During the early third trimester, Black American women (n = 93) completed the Experiences of Discrimination Scale, the Stress and Adversity Inventory, the Perceived Stress Scale, and the Center for Epidemiological Studies Depression Inventory. Plasma interleukin-6 (IL-6), IL-8, tumor necrosis factor-α (TNF-α), and IL-ß levels were quantified. Associations were examined by linear regression, controlling for demographic, behavioral, and clinical covariates. RESULTS: Associations among racial discrimination and plasma IL-8, TNF-α, and IL-ß levels depended upon average ratings of life course stress. When stress was low, discrimination in the mid tertile was associated with the highest levels of IL-8, TNF-α, and IL-ß. Subscale analyses suggested that findings related to IL-8 were driven by chronic stress whereas findings related to TNF-α and IL-ß were driven by acute stress. When examined together, greater discrimination but not greater life course stress was associated with higher prenatal perceived stress. In subscale analyses, the association between discrimination and prenatal perceived stress depended upon average ratings of life course acute stress. When acute stress was low, discrimination in the midtertile was associated with the highest levels of prenatal perceived stress. When acute stress was high, discrimination in the high tertile was associated with the highest levels of prenatal perceived stress. There were also direct associations among greater life course chronic stress, prenatal perceived stress, and prenatal depressive symptoms. Associations were attenuated when discrimination was included as a covariate. CONCLUSIONS: The current analyses suggest that, among Black Americans, prenatal inflammation, perceived stress, and depressive symptoms may be shaped by racial discrimination and stress across the life course. In many cases, associations among discrimination and prenatal parameters depended upon how stressful exposures to life course stressors had been rated. The data suggest the potential for adaptive plasticity under some stress and highlight the deleterious nature of compounding stress.

The Firearm Suicide Crisis: Physicians Can Make a Difference.

Firearm suicide receives relatively little public attention in the United States, however, the United States is in the midst of a firearm suicide crisis. Most suicides are completed using a firearm. The age-adjusted firearm suicide rate increased 22.6% from 2005 to 2017, and globally the US firearm suicide rate is 8 times higher than the average firearm suicide rate of 22 other developed countries. The debate over how to solve the firearm suicide epidemic tends to focus on reducing the firearm supply or increasing access to behavioral health treatment. Ineffectual federal firearm control policies and inadequate behavioral health treatment access has heightened the need for primary care physicians to play a more meaningful role in firearm suicide prevention. We offer suggestions for how individual physicians and the collective medical community can take action to reduce mortality arising from firearm suicide and firearm deaths.

Advance Care Planning Among Users of a Patient Portal During the COVID-19 Pandemic: Retrospective Observational Study.

BACKGROUND: Advance care planning is the process of discussing health care treatment preferences based on patients' personal values, and it often involves the completion of advance directives. In the first months of 2020, a novel coronavirus, severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2), began circulating widely in the American state of Colorado, leading to widespread diagnosis of coronavirus disease (COVID-19), hospitalizations, and deaths. In this context, the importance of technology-based, non-face-to-face methods to conduct advance care planning via patient portals has increased. OBJECTIVE: The aim of this study was to determine the rates of use of a web-based advance care planning tool through a health system-based electronic patient portal both before and in the early months of the COVID-19 pandemic. METHODS: In 2017, we implemented web-based tools through the patient portal of UCHealth's electronic health record (EHR) for patients to learn about advance care planning and complete an electronically signed medical durable power of attorney (MDPOA) to legally appoint a medical decision maker. Patients accessing the portal can complete and submit a legally valid MDPOA, which becomes part of their medical record. We collected data on the patients' date of MDPOA completion, use of advance care planning messaging, age, sex, and geographic location during the early phase of the COVID-19 pandemic (December 29, 2019, to May 30, 2020). RESULTS: Over a 5-month period that includes the early phase of the COVID-19 pandemic in Colorado, total monthly use of the advance care planning portal tool increased from 418 users in January to 1037 users in April and then decreased slightly to 815 users in May. The number of MDPOA forms submitted per week increased 2.4-fold after the stay-at-home order was issued in Colorado on March 26, 2020 (P<.001). The mean age of the advance care planning portal users was 47.7 years (SD 16.1), and 2206/3292 (67.0%) were female. Women were more likely than men to complete an MDPOA, particularly in younger age groups (P<.001). The primary use of the advance care planning portal tools was the completion of an MDPOA (3138/3292, 95.3%), compared to sending an electronic message (148/3292, 4.5%). Over 50% of patients who completed an MDPOA did not have a prior agent in the EHR. CONCLUSIONS: Use of a web-based patient portal to complete an MDPOA increased substantially during the first months of the COVID-19 pandemic in Colorado. There was an increase in advance care planning that corresponded with state government shelter-in-place orders as well as public health reports of increased numbers of COVID-19 cases and deaths. Patient portals are an important tool for providing advance care planning resources and documenting medical decision makers during the pandemic to ensure that medical treatment aligns with patient goals and values.

Racial/Ethnic Differences in Diabetes Screening and Hyperglycemia Among US Women After Gestational Diabetes.

INTRODUCTION: Gestational diabetes mellitus (GDM) is the most common complication of pregnancy and is associated with an increased risk for type 2 diabetes. Racial/ethnic minority populations are at a higher risk than non-Hispanic white populations of developing type 2 diabetes after GDM. The aim of this study was to describe racial/ethnic differences in hyperglycemia and receipt of screening services in a nationally representative sample of women with a history of GDM. METHODS: Our sample included 765 women from the US National Health and Nutrition Examination Survey (2007-2016) with a history of GDM. We used logistic, multinomial, linear, and proportional hazards regression to evaluate racial/ethnic differences in development of diabetes after GDM, hyperglycemia (measured by HbA1c), and receipt of diabetes screening services. RESULTS: Non-Hispanic black women had 63% higher risk and Hispanic women and "other" racial/ethnic women had more than double the risk for diabetes compared with non-Hispanic white women. Among women with a GDM history who did not receive a diagnosis of diabetes by the time of the study examination, both non-Hispanic black women and Hispanic women were more likely than non-Hispanic white women to be in the prediabetes or diabetes range (measured HbA1c ≥5.7%). However, non-Hispanic black women had 2.07 (95% confidence interval, 1.29-3.81) times the odds of being screened for diabetes compared with non-Hispanic white women (P = .02). CONCLUSION: Delays in identification of hyperglycemia and diagnosis of diabetes in racial/ethnic minority women may reflect differential delivery of guideline-based care or poor follow-up of abnormal screening test results.

Validation of a Novel Electronic Health Record Patient Portal Advance Care Planning Delivery System.

BACKGROUND: Advance care planning allows patients to articulate their future care preferences should they no longer be able to make decisions on their own. Early advance care planning in outpatient settings provides benefits such as less aggressive care and fewer hospitalizations, yet it is underutilized due to barriers such as provider time constraints and communication complexity. Novel methods, such as patient portals, provide a unique opportunity to conduct advance care planning previsit planning for outpatient care. This follow-up to our pilot study aimed to conduct pragmatic testing of a novel electronic health record-tethered framework and its effects on advance care planning delivery in a real-world primary care setting. OBJECTIVE: Our intervention tested a previsit advance care planning workflow centered around a framework sent via secure electronic health record-linked patient portal in a real-world clinical setting. The primary objective of this study was to determine its impact on frequency and quality of advance care planning documentation. METHODS: We conducted a pragmatic trial including 2 sister clinical sites, one site implementing the intervention and the other continuing standard care. A total of 419 patients aged between 50 and 93 years with active portal accounts received intervention (n=200) or standard care (n=219). Chart review analyzed the presence of advance care planning and its quality and was graded with previously established scoring criteria based on advance care planning best practice guidelines from multiple nations. RESULTS: A total of 19.5% (39/200) of patients who received previsit planning responded to the framework. We found that the intervention site had statistically significant improvement in new advance care planning documentation rates (P<.01) and quality (P<.01) among all eligible patients. Advance care planning documentation rates increased by 105% (19/39 to 39/39) and quality improved among all patients who engaged in the previsit planning framework (n=39). Among eligible patients aged between 50 and 60 years at the intervention site, advance care planning documentation rates increased by 37% (27/96 to 37/96). Advance care planning documentation rates increased 34% among high users (27/67 to 36/67). CONCLUSIONS: Advance care planning previsit planning using a secure electronic health record-supported patient portal framework yielded improvement in the presence of advance care planning documentation, with highest improvement in active patient portal users and patients aged between 50 and 60 years. Targeted previsit patient portal advance care planning delivery in these populations can potentially improve the quality of care in these populations.

Supplemental Nutrition Assistance Program and Adherence to Antihypertensive Medications.

Importance: Nonadherence to antihypertensive medications is associated with uncontrolled blood pressure, higher mortality rates, and increased health care costs, and food insecurity is one of the modifiable medication nonadherence risk factors. The Supplemental Nutrition Assistance Program (SNAP), a social intervention program for addressing food insecurity, may help improve adherence to antihypertensive medications. Objective: To evaluate whether receipt of SNAP benefits can modify the consequences of food insecurity on nonadherence to antihypertensive medications. Design, Setting, and Participants: A retrospective cohort study design was used to assemble a cohort of antihypertensive medication users from the linked Medical Expenditure Panel Survey (MEPS)-National Health Interview Survey (NHIS) dataset for 2016 to 2017. The MEPS is a national longitudinal survey on verified self-reported prescribed medication use and health care access measures, and the NHIS is an annual cross-sectional survey of US households that collects comprehensive health information, health behavior, and sociodemographic data, including receipt of SNAP benefits. Receipt of SNAP benefits in the past 12 months and food insecurity status in the past 30 days were assessed through standard questionnaires during the study period. Data analysis was performed from March to December 2021. Exposure: Status of SNAP benefit receipt. Main Outcomes and Measures: The main outcome, nonadherence to antihypertensive medication refill adherence (MRA), was defined using the MEPS data as the total days' supply divided by 365 days for each antihypertensive medication class. Patients were considered nonadherent if their overall MRA was less than 80%. Food insecurity status in the 30 days prior to the survey was modeled as the effect modifier. Inverse probability of treatment (IPT) weighting was used to control for measured confounding effects of baseline covariates. A probit model was used, weighted by the product of the computed IPT weights and MEPS weights, to estimate the population average treatment effects (PATEs) of SNAP benefit receipt on nonadherence. A stratified analysis approach was used to assess for potential effect modification by food insecurity status. Results: This analysis involved 6692 antihypertensive medication users, of whom 1203 (12.8%) reported receiving SNAP benefits and 1338 (14.8%) were considered as food insecure. The mean (SD) age was 63.0 (13.3) years; 3632 (51.3%) of the participants were women and 3060 (45.7%) were men. Although SNAP was not associated with nonadherence to antihypertensive medications in the overall population, it was associated with a 13.6-percentage point reduction in nonadherence (PATE, -13.6 [95% CI, -25.0 to -2.3]) among the food-insecure subgroup but not among their food-secure counterparts. Conclusions and Relevance: This analysis of a national observational dataset suggests that patients with hypertension who receive SNAP benefits may be less likely to become nonadherent to antihypertensive medication, especially if they are experiencing food insecurity. Further examination of the role of SNAP as a potential intervention for preventing nonadherence to antihypertensive medications through prospectively designed interventional studies or natural experiment study designs is needed.

Tools for tomorrow: a scoping review of patient-facing tools for advance care planning.

Advance care planning (ACP) supports individuals in aligning their medical care with personal values and preferences in the face of serious illness. The variety of ACP tools available reflects diverse strategies intended to facilitate these critical conversations, yet evaluations of their effectiveness often show mixed results. Following the Arskey and O'Malley framework, this scoping review aims to synthesize the range of ACP tools targeted at patients and families, highlighting their characteristics and delivery methods to better understand their impact and development over time. Studies included focused on patient-facing ACP tools across all settings and mediums. Exclusions were applied to studies solely targeting healthcare providers or those only aiming at completion of advance directives without broader ACP discussions. Searches were conducted across PubMed, Embase, CINAHL, The Cochrane Library, and Web of Science. Data were extracted using a predesigned spreadsheet, capturing study population, setting, intervention modality, and intervention theme. Tools were categorized by delivery method and further analyzed through a year-wise distribution to track trends and developments. We identified 99 unique patient-facing tools, with those focusing on counseling (31) and video technologies (21) being the most prevalent while others incorporated online platforms, print materials, games, or some combination of different delivery methods. Over half the tools were designed for specific patient groups, especially for various diseases and racial or ethnic communities. Recent years showed a surge in tool variety and innovation, including integrated patient portals and psychological techniques. The review demonstrates a broad array of innovative ACP tools that facilitate personalized and effective ACP. Our findings contribute to an enhanced understanding of their utilization and potential impacts, offering valuable insights for future tool development and policy making in ACP.

Scanning the landscape of tools to assist patients with advance care planning This review investigates the variety of tools, programs, and interventions designed to help patients plan their healthcare in advance, a process known as advance care planning (ACP). ACP is crucial because it ensures individuals receive medical care aligned with their wishes, especially during serious illness or near the end of life. Our study gathered information from various sources, focusing on tools aimed directly at patients and their families. We found 99 unique tools that assist in ACP, including individual counseling sessions, video-based tools, and digital platforms. Some tools are designed specifically for certain patient groups, such as those with particular diseases or belonging to diverse racial and ethnic communities. Our review highlights the recent surge in the variety and innovation of these tools, such as integrated patient portals and methods incorporating psychological techniques, suggesting a growing effort to make ACP more accessible and tailored to individual needs. However, despite this variety, more research is needed to understand how these tools impact healthcare outcomes and how they can be effectively implemented in different care settings. Our findings aim to guide future development of ACP tools, improve their integration into healthcare practices, and ensure they meet the diverse needs of patients and families.

Preventive service utilization among adults with cystic fibrosis covered by private insurance is comparable to the general population.

BACKGROUND: As the life expectancy of the cystic fibrosis (CF) population is lengthening with modulator therapies, diligent age-appropriate screening and preventive care are increasingly vital for long-term health and wellbeing. METHODS: We performed a retrospective analysis comparing rates of receiving age- and sex-appropriate preventive services by commercially insured adult people with CF (PwCF) and adults without CF from the general population (GP) via the Truven Health MarketScan database (2012-2018). RESULTS: We captured 25,369 adults with CF and 488,534 adults from the GP in the United States. Comparing these groups, we found that 43% versus 39% received an annual preventive visit, 28% versus 28% were screened for chlamydia, 38% versus 37% received pap smears every 3 years (21-29-year-old females), 33% versus 31% received pap smears every 5 years (30-64-year-old females), 55% versus 44% received mammograms, 23% versus 21% received colonoscopies, and 21% versus 20% received dyslipidemia screening (all screening rates expressed per 100 person-years). In age-stratified analysis, 18-27-year-old PwCF had a lower rate of annual preventive visits compared to adults in the same age group of the GP (27% versus 42%). CONCLUSIONS: We discovered a comparable-to-superior rate of preventive service utilization in adults with CF relative to the GP, except in young adulthood from 18-27 years. Our findings establish the importance of meeting the primary care needs of adults with CF and call for development of strategies to improve preventive service delivery to young adults.

Pediatric Nirmatrelvir/Ritonavir Prescribing Patterns During the COVID-19 Pandemic.

OBJECTIVES: This study seeks to identify demographic and clinical factors prompting clinician prescribing of nirmatrelvir/ritonavir to pediatric patients for management of coronavirus disease 2019 (COVID-19) infection. METHODS: Patients aged 12 to 17 years with a COVID-19 infection and nirmatrelvir/ritonavir prescription during an outpatient clinical encounter within a PEDSnet-affiliated institution between January 2022 and August 2023 were identified using electronic health record data. A multivariate logistic regression analysis was used to estimate odds of nirmatrelvir/ritonavir prescription after adjusting for various factors. RESULTS: A total of 20 959 patients aged 12 to 17 years were diagnosed with a COVID-19 infection on the basis of an electronic health record-documented positive polymerase chain reaction or antigen test or diagnosis during an outpatient clinical visit. Of these patients, 408 received a nirmatrelvir/ritonavir prescription within 5 days of diagnosis. Higher odds of nirmatrelvir/ritonavir treatment were associated with having chronic or complex chronic disease (chronic: odds ratio [OR] 2.50 [95% confidence interval (CI) 1.83-3.38]; complex chronic: OR 2.21 [95% CI 1.58-3.08]). Among patients with chronic disease, each additional body system conferred 1.18 times higher odds of treatment (95% CI 1.10-1.26). Compared with non-Hispanic white patients, Hispanic patients (OR 0.61 [95% CI 0.44-0.83]) had lower odds of treatment. CONCLUSIONS: Children with chronic conditions are more likely than those without to receive nirmatrelvir/ritonavir prescriptions. However, nirmatrelvir/ritonavir prescribing to children with chronic conditions remains infrequent. Pediatric data concerning nirmatrelvir/ritonavir safety and effectiveness in preventing severe disease and hospitalization are critical optimizing clinical decision-making and use among children.

Hospice Transitions From the Perspective of the Caregiver: A Qualitative Study and Development of a Preliminary Hospice Transition Checklist.

Background: Relative to curative and traditional care delivery, hospice care has been associated with superior end of life (EOL) outcomes for both patient and caregiver. Still, comprehensive orientation and caregiver preparation for the transition to hospice is variable and often inadequate. From the perspective of the caregiver, it is unclear what information would better prepare them to support the transition of their loved one to hospice. Objectives: Our two sequential objectives were: 1) Explore caregivers' experiences and perceptions on the transition of their loved one to hospice; and 2) Develop a preliminary checklist of considerations for a successful transition. Design: We conducted semi-structured interviews and used a descriptive inductive/deductive thematic analysis to identify themes. Subjects: 19 adult caregivers of patients across the United States who had enrolled in hospice and died in the year prior (January - December 2019). Measurements: An interview guide was iteratively developed based on prior literature and expanded through collaborative coding and group discussion. Results: Four key themes for inclusion in our framework emerged: hospice intake, preparedness, burden of care and hospice resources. Conclusions: Focusing on elements of our preliminary checklist, such as educating families on goals of hospice or offering opportunities for respite care, into the orientation procedures may be opportunities to improve satisfaction with the transition and the entirety of the hospice experience. Future directions include testing the effectiveness of the checklist and adapting for expanded poputlations.

Patterns of Postpartum Primary Care Follow-up and Diabetes-Related Care After Diagnosis of Gestational Diabetes.

Importance: Gestational diabetes (GD) affects up to 10% of pregnancies and increases lifetime risk of type 2 diabetes 10-fold; postpartum diabetes evaluation and primary care follow-up are critical in preventing and detecting type 2 diabetes. Despite clinical guidelines recommending universal follow-up, little remains known about how often individuals with GD access primary care and type 2 diabetes screening. Objective: To describe patterns of primary care follow-up and diabetes-related care among individuals with and without GD in the first year post partum. Design, Setting, and Participants: This cohort study used a private insurance claims database to compare follow-up in the first year post partum between individuals with GD, type 2 diabetes, and no diabetes diagnosis. Participants included postpartum individuals aged 15 to 51 years who delivered between 2015 and 2018 and had continuous enrollment from 180 days before to 366 days after the delivery date. Data were analyzed September through October 2021 and reanalyzed November 2022. Main Outcomes and Measures: Primary care follow-up visits and diabetes-related care (blood glucose testing and diabetes-associated visit diagnoses) were determined by evaluation and management, Current Procedural Terminology, and International Classification of Diseases, Ninth Revision and International Statistical Classification of Diseases and Related Health Problems, Tenth Revision codes, respectively. Results: A total of 280 131 individuals were identified between 2015 and 2018 (mean age: 31 years; 95% CI, 27-34 years); 12 242 (4.4%) had preexisting type 2 diabetes and 18 432 (6.6%) had GD. A total of 50.9% (95% CI, 49.9%-52.0%) of individuals with GD had primary care follow-up, compared with 67.2% (95% CI, 66.2%-68.2%) of individuals with preexisting type 2 diabetes. A total of 36.2% (95% CI, 35.1%-37.4%) of individuals with GD had diabetes-related care compared with 56.9% (95% CI, 55.7%-58.0%) of individuals with preexisting diabetes. Only 36.0% (95% CI, 34.4%-37.6%) of individuals with GD connected with primary care received clinical guideline concordant care with blood glucose testing 12 weeks post partum. Conclusions and Relevance: In this cohort study of postpartum individuals, individuals with GD had lower rates of primary care and diabetes-related care compared with those with preexisting type 2 diabetes, and only 36% of those with GD received guideline-recommended blood glucose testing in the first 12 weeks post partum. This illustrates a missed opportunity for early intervention in diabetes surveillance and prevention and demonstrates the need to develop a multidisciplinary approach for postpartum follow-up.

A Portfolio Coach-Informed Professional Development Framework.

INTRODUCTION: A majority of US medical schools have incorporated faculty coach-supported educational portfolios into the curriculum. Existing research describes coach professional development, competencies, and program perceptions. However, limited research exists on how programs address coach professional development needs. Our sequential objectives were to (1) explore faculty coach professional development experiences within medical student coaching programs and (2) develop a preliminary framework for medical faculty coach professional development. METHODS: Faculty portfolio coaches who completed 4 years of a longitudinal coaching program were recruited to complete a semi-structured exit interview. Interviews were transcribed using detailed transcription. Two analysts inductively generated a codebook of parent and child codes to identify themes. They compared themes to the professional development model proposed by O'Sullivan and Irby. RESULTS: Of the 25 eligible coaches, 15 completed the interview. Our team organized themes into two broad domains paralleling the established model: program-specific professional development and career-relevant professional development. Four program-specific professional development themes emerged: doing; modeling; relating; and hosting. Three career-relevant professional development themes emerged: advancement; meaning; and understanding. We then applied themes within each domain to propose strategies to optimize coach professional development and develop a framework modeled after O'Sullivan and Irby. DISCUSSION: To our knowledge, we propose the first portfolio coach-informed framework for professional development. Our work builds on established standards, expert opinion, and research responsible for portfolio coach professional development and competencies. Allied health institutions with portfolio coaching programs can apply the framework for professional development innovation.

Psychological Distress in Young Adults with Acute Myeloid Leukemia Undergoing Induction Chemotherapy.

Young adults (YAs), aged 18-39 years, with acute myeloid leukemia (AML) navigate life disruptions amid an unpredictable illness trajectory. We conducted a secondary analysis of patient-reported outcomes for hospitalized YAs with high-risk AML receiving intensive chemotherapy, collected during a multisite randomized clinical trial. Of the 160 patients, 14 (8.8%) were YAs. At week 2 of hospitalization, YAs demonstrated significant worse quality of life (ß = -18.27; p = 0.036), higher anxiety (ß = 2.72; p = 0.048), and higher post-traumatic stress disorder (PTSD; ß = 10.34; p = 0.007) compared with older adults. Our analysis demonstrated a longitudinal presence of anxiety and PTSD, suggesting persistent unmet psychological needs for YAs with AML.

Establishing a clinical informatics umbilical cord: lessons learned in launching infrastructure to support dyadic mother/infant primary care.

The Multimodal Maternal Infant Perinatal Outpatient Delivery System (MOMI PODS) was developed to facilitate the pregnancy to postpartum primary care transition, particularly for individuals at risk for severe maternal morbidity, via a unique multidisciplinary model of mother/infant dyadic primary care. Specialized clinical informatics platforms are critical to ensuring the feasibility and scalability of MOMI PODS and a smooth perinatal transition into longitudinal postpartum primary care. In this manuscript, we describe the MOMI PODS transition and management clinical informatics platforms developed to facilitate MOMI PODS referrals, scheduling, evidence-based multidisciplinary care, and program evaluation. We discuss opportunities and lessons learned associated with our applied methods, as advances in clinical informatics have considerable potential to enhance the quality and evaluation of innovative maternal health programs like MOMI PODS.

Understanding pediatric long COVID using a tree-based scan statistic approach: an EHR-based cohort study from the RECOVER Program.

Objectives: Post-acute sequalae of SARS-CoV-2 infection (PASC) is not well defined in pediatrics given its heterogeneity of presentation and severity in this population. The aim of this study is to use novel methods that rely on data mining approaches rather than clinical experience to detect conditions and symptoms associated with pediatric PASC. Materials and Methods: We used a propensity-matched cohort design comparing children identified using the new PASC ICD10CM diagnosis code (U09.9) (N = 1309) to children with (N = 6545) and without (N = 6545) SARS-CoV-2 infection. We used a tree-based scan statistic to identify potential condition clusters co-occurring more frequently in cases than controls. Results: We found significant enrichment among children with PASC in cardiac, respiratory, neurologic, psychological, endocrine, gastrointestinal, and musculoskeletal systems, the most significant related to circulatory and respiratory such as dyspnea, difficulty breathing, and fatigue and malaise. Discussion: Our study addresses methodological limitations of prior studies that rely on prespecified clusters of potential PASC-associated diagnoses driven by clinician experience. Future studies are needed to identify patterns of diagnoses and their associations to derive clinical phenotypes. Conclusion: We identified multiple conditions and body systems associated with pediatric PASC. Because we rely on a data-driven approach, several new or under-reported conditions and symptoms were detected that warrant further investigation.

Rationale and design of the linking education, produce provision, and community referrals to improve diabetes care (LINK) study.

BACKGROUND: Individuals with type 2 diabetes (T2D) experiencing food insecurity may have other non-medical, health-related social needs (e.g., transportation, housing instability) that decrease their ability to attain T2D control and impact other health outcomes. METHODS: A pragmatic randomized controlled trial (pRCT) to test the effect of produce provision, diabetes and culinary skills training and education, and social needs screening, navigation, and resolution, on hemoglobin A1c (A1c) levels in individuals with T2D (A1c ≥7.5%) experiencing food insecurity; a cost-effectiveness evaluation of the interventions that comprise the pRCT; and a process evaluation to understand the contextual factors that impact the uptake, effectiveness, and sustainability of the interventions. SETTING: Ambulatory care clinics (e.g., family medicine, general internal medicine, endocrinology) affiliated with an academic medical center in an urban environment in the Midwest. DESIGN: 2 × 2 factorial design. INTERVENTIONS: Cooking Matters for Diabetes is a 6-week diabetes and culinary education intervention. The Health Impact Ohio Central Ohio Pathways Hub intervention is a community health worker model designed to evaluate and address participants' social needs. All participants will receive referral to the Mid-Ohio Farmacy to provide weekly access to fresh produce. OUTCOMES: Primary outcome of the pRCT is change in A1c at 3 months; secondary outcomes include A1c at 6 months, and diabetes self-efficacy, food insecurity, and diet quality at 3 and 6 months. DISCUSSION: Food insecurity, unmet social needs, diabetes education and self-efficacy are critical issues that must be addressed to improve T2D treatment, care, and health equity. CLINICALTRIALS: gov: NCT05472441.