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Objectives: This study aimed to develop and validate an algorithm for the identification of opioid use disorder (OUD) in pregnant patients using electronic medical record (EMR) data. Materials and Methods: A cohort of pregnant patients from a single institution was used to develop and validate the algorithm. Five algorithm components were used, and chart reviews were conducted to confirm OUD diagnoses based on established criteria. Positive predictive values (PPV) of each of the algorithm's components were assessed. Results: Of the 334 charts identified by the algorithm, 256 true cases were confirmed. The overall PPV of the algorithm was 76.6%, with 100% accuracy for outpatient medication lists, and high PPVs ranging from 81.3% to 93.4% across other algorithm components. Discussion and Conclusion: The study highlights the significance of a multifaceted approach in identifying OUD among pregnant patients, aiming to improve patient care and target interventions for patients at risk.
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Algoritmos , Registros Eletrônicos de Saúde , Transtornos Relacionados ao Uso de Opioides , Complicações na Gravidez , Humanos , Feminino , Gravidez , Transtornos Relacionados ao Uso de Opioides/epidemiologia , Complicações na Gravidez/epidemiologia , AdultoRESUMO
BACKGROUND: Opioid use disorder (OUD) significantly impacts individual and public health and exacerbated further by concurrent infectious diseases. A syndemic approach is needed to address the intertwined OUD, HIV, and HCV epidemics, including the expanded use of medications for opioid use disorder (MOUD). METHODS: To identify MOUD scale-up opportunities, we conducted a retrospective cohort study, representing commercially insured persons, and created the OUD care continuum, including HIV and HCV influences in adults (18-64 years) newly diagnosed with OUD in 2019 using Merative MarketSan data. RESULTS: Among 124,467,633 individuals, the prevalence of OUD was 0.4 % (95 % CI: 0.36 %-0.46 %; N = 497,871), with 327,277 (65.7 %, 95 % CI: 65.60 %-65.87 %) newly diagnosed in 2019. Among these newly diagnosed individuals (54 % men, mean age 44±0.01), 53,568 (27.0 %, 95 % CI: 26.4 %-27.5 %) were prescribed MOUD, with retention rates at 1, 3, and 6 months being 89.0 % (95 % CI: 88.2 %-89.8 %), 66.0 % (95 % CI: 64.8 %-67.2 %), and 50.3 % (95 % CI: 48.3 %-51.6 %), respectively. Buprenorphine was the most prescribed MOUD (79.6 %, 95 % CI: 78.6 %-80.7 %), followed by XR-NTX (14.9 %, 95 % CI:14.0 %-15.8 %) and methadone (5.5 %, 95 % CI: 4.9 %-6.1 %). Six-month retention was highest for methadone (73.4 %, 95 % CI: 73.0 %-73.8 %), however, followed by buprenorphine (55.7 %, 95 % CI: 55.3 %-57.1 %) and substantially lower for XR-NTX (12.6 %, 95 % CI: 10.6 %-14.6 %). Screening for HIV and HCV was low among OUD enrollees (11.1 %, 14.4 %), slightly higher for MOUD initiators (18.0 %, 21.6 %). Being prescribed MOUD was correlated with HCV infection (AOR: 2.54; 95 % CI: 2.41-2.68), HCV/HIV coinfection (AOR: 1.89; 95 % CI: 1.41-2.53), and hospitalization for OUD-related services (AOR: 1.14; 95 % CI: 1.11-1.17), yet hospitalization for OUD-related services was positively correlated with XR-NTX (AOR: 2.72; 95 % CI: 2.56-2.85) prescription and negatively with methadone (AOR: 0.19; 95 % CI: 0.16-0.23) prescription. Having HIV was negatively correlated with being prescribed methadone (AOR: 0.33; 95 % CI: 0.13-0.86). CONCLUSIONS: Substantial gaps in the OUD cascade persist, underscoring better implementation opportunities for MOUD prescription in hospital-based settings and expanding access to methadone beyond highly regulated sites given its low coverage yet high treatment retention.
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The global mpox epidemic in 2022 was likely caused by transmission of mpox virus (MPXV) through sexual contact networks, with New York City (NYC) experiencing the first and largest outbreak in the United States. By performing a phylogeographic and epidemiological analysis of MPXV, we identify at least 200 introductions of MPXV into NYC and 84 leading to onward transmission. Through a comparative analysis with human immunodeficiency virus (HIV) in NYC, we find that both MPXV and HIV genomic cluster sizes are best fit by scale-free distributions and that people in MPXV clusters are more likely to have previously received an HIV diagnosis (odds ratio=1.58; p=0.012) and be a member of a recently growing HIV transmission cluster, indicating overlapping sexual contact networks. We then model the transmission of MPXV through sexual contact networks and show that highly connected individuals would be disproportionately infected at the start of an epidemic, thereby likely resulting in the exhaustion of the most densely connected parts of the sexual network. This dynamic explains the rapid expansion and decline of the NYC outbreak, as well as the estimated cumulative incidence of less than 2% within high-risk populations. By synthesizing the genomic epidemiology of MPXV and HIV with epidemic modeling, we demonstrate that MPXV transmission dynamics can be understood by general principles of sexually transmitted pathogens.
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A woman in her 40s who vaped reported rapid onset of shortness of breath and cough. Pulmonary function testing showed severe obstruction and no substantial response to an inhaled bronchodilator, and chest computed tomography revealed extensive air trapping. A lung cryobiopsy was done after a comprehensive and unrevealing evaluation, which showed characteristics of airway inflammation and prominent bronchial-associated lymphoid tissue. With this knowledge and her vaping history, we diagnosed vaping-associated constrictive bronchiolitis. This phenomenon has not been well described. Clinicians should know to consider vaping when a patient with a vaping history presents with severe airway obstruction.
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Belief in health misinformation can affect individual health decisions and actions. Repeated exposure to the same misinformation strengthens its impact, yet little is known about how commonly repeated exposure occurs. To estimate the prevalence, we tracked exposure to 5 inaccurate COVID-19 claims every week for up to 23 consecutive weeks in a racially diverse panel of adults (n = 213). Repeated exposure was common: across the 5 claims, 10%-43% of respondents reported hearing the misinformation in ≥ 3 different weeks. Frontline workers were more likely than other community members to experience repeated exposure, with adjusted incidence rate ratios (IRRs) ranging from 1.8 to 4.9 across the 4 items. Repeated exposure was most common among older adults. Adjusted IRR for those ages ≥ 50 versus 18-29 years ranged from 1.8 to 2.5 per misinformation claim. Public health planning efforts to counter health misinformation should anticipate multiple exposures to the same false claim, especially in certain subgroups.
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COVID-19 , Comunicação , SARS-CoV-2 , Humanos , COVID-19/epidemiologia , Feminino , Masculino , Adulto , Pessoa de Meia-Idade , Prevalência , Estudos Longitudinais , Adolescente , Idoso , Inquéritos e QuestionáriosRESUMO
Introduction: Globally, overdose deaths increased near the beginning of the COVID-19 pandemic, which created availability and access barriers to addiction and social services. Especially in times of a crisis like a pandemic, local exposures, service availability and access, and system responses have major influence on people who use drugs. For policy makers to be effective, an understanding at the local level is needed. Methods: This retrospective epidemiologic study from 2019 through 2021 compares immediate and 20-months changes in overdose deaths from the pandemic start to 16 months before its arrival in Pinellas County, FL We examine toxicologic death records of 1,701 overdoses to identify relations with interdiction, and service delivery. Results: There was an immediate 49% increase (95% CI 23-82%, p < 0.0001) in overdose deaths in the first month following the first COVID deaths. Immediate increases were found for deaths involving alcohol (171%), heroin (108%), fentanyl (78%), amphetamines (55%), and cocaine (45%). Overdose deaths remained 27% higher (CI 4-55%, p = 0.015) than before the pandemic through 2021.Abrupt service reductions occurred when the pandemic began: in-clinic methadone treatment dropped by two-thirds, counseling by 38%, opioid seizures by 29%, and drug arrests by 56%. Emergency transport for overdose and naloxone distributions increased at the pandemic onset (12%, 93%, respectively) and remained higher through 2021 (15%, 377%,). Regression results indicate that lower drug seizures predicted higher overdoses, and increased 911 transports predicted higher overdoses. The proportion of excess overdose deaths to excess non-COVID deaths after the pandemic relative to the year before was 0.28 in Pinellas County, larger than 75% of other US counties. Conclusions: Service and interdiction interruptions likely contributed to overdose death increases during the pandemic. Relaxing restrictions on medical treatment for opioid addiction and public health interventions could have immediate and long-lasting effects when a major disruption, such as a pandemic, occurs. County level data dashboards comprised of overdose toxicology, and interdiction and service data, can help explain changes in overdose deaths. As a next step in predicting which policies and practices will best reduce local overdoses, we propose using simulation modeling with agent-based models to examine complex interacting systems.
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COVID-19 , Overdose de Drogas , Humanos , COVID-19/mortalidade , COVID-19/epidemiologia , Overdose de Drogas/mortalidade , Overdose de Drogas/epidemiologia , Estudos Retrospectivos , Adulto , Masculino , Florida/epidemiologia , Feminino , Pessoa de Meia-Idade , Pandemias , SARS-CoV-2RESUMO
Introduction: Clinician implicit racial bias (IB) may lead to lower quality care and adverse health outcomes for Black patients. Educational efforts to train clinicians to mitigate IB vary widely and have insufficient evidence of impact. We developed and pilot-tested an evidence-based clinician IB curriculum, "REACHing Equity." Methods: To assess acceptability and feasibility, we conducted an uncontrolled one-arm pilot trial with post-intervention assessments. REACHing Equity is designed for clinicians to: (1) acquire knowledge about IB and its impact on healthcare, (2) increase awareness of one's own capacity for IB, and (3) develop skills to mitigate IB in the clinical encounter. We delivered REACHing Equity virtually in three facilitated, interactive sessions over 7-9 weeks. Participants were health care providers who completed baseline and end-of-study evaluation surveys. Results: Of approximately 1,592 clinicians invited, 37 participated, of whom 29 self-identified as women and 24 as non-Hispanic White. Attendance averaged 90% per session; 78% attended all 3 sessions. Response rate for evaluation surveys was 67%. Most respondents agreed or strongly agreed that the curriculum objectives were met, and that REACHing Equity equipped them to mitigate the impact of implicit bias in clinical care. Participants consistently reported higher self-efficacy for mitigating IB after compared to before completing the curriculum. Conclusions: Despite apparent barriers to clinician participation, we demonstrated feasibility and acceptability of the REACHing Equity intervention. Further research is needed to develop objective measures of uptake and clinician skill, test the impact of REACHing Equity on clinically relevant outcomes, and refine the curriculum for uptake and dissemination.ClinicalTrials.gov ID: NCT03415308.
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Pulse oximeters measure peripheral arterial oxygen saturation (SpO2) noninvasively, while the gold standard (SaO2) involves arterial blood gas measurement. There are known racial and ethnic disparities in their performance. BOLD is a dataset that aims to underscore the importance of addressing biases in pulse oximetry accuracy, which disproportionately affect darker-skinned patients. The dataset was created by harmonizing three Electronic Health Record databases (MIMIC-III, MIMIC-IV, eICU-CRD) comprising Intensive Care Unit stays of US patients. Paired SpO2 and SaO2 measurements were time-aligned and combined with various other sociodemographic and parameters to provide a detailed representation of each patient. BOLD includes 49,099 paired measurements, within a 5-minute window and with oxygen saturation levels between 70-100%. Minority racial and ethnic groups account for ~25% of the data - a proportion seldom achieved in previous studies. The codebase is publicly available. Given the prevalent use of pulse oximeters in the hospital and at home, we hope that BOLD will be leveraged to develop debiasing algorithms that can result in more equitable healthcare solutions.
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Gasometria , Oximetria , Humanos , Saturação de Oxigênio , Unidades de Terapia Intensiva , Etnicidade , Oxigênio/sangueRESUMO
BACKGROUND: Access to breast screening mammogram services decreased during the COVID-19 pandemic. Our objectives were to estimate: 1) the COVID-19 affected period, 2) the proportion of pandemic-associated missed or delayed screening encounters, and 3) pandemic-associated patient attrition in screening encounters overall and by sociodemographic subgroup. METHODS: We included screening mammogram encounter EPIC data from 1-1-2019 to 12-31-2022 for females ≥40 years old. We used Bayesian State Space models to describe weekly screening mammogram counts, modeling an interruption that phased in and out between 3-1-2020 and 9-1-2020. We used the posterior predictive distribution to model differences between a predicted, uninterrupted process and the observed screening mammogram counts. We estimated associations between race/ethnicity and age group and return screening mammogram encounters during the pandemic among those with 2019 encounters using logistic regression. RESULTS: Our analysis modeling weekly screening mammogram counts included 231,385 encounters (n = 127,621 women). Model-estimated screening mammograms dropped by >98% between 03-15-2020 and 05-24-2020 followed by a return to pre-pandemic levels or higher with similar results by race/ethnicity and age group. Among 79,257 women, non-Hispanic (NH) Asians, NH Blacks, and Hispanics had significantly (p < .05) lower odds of screening encounter returns during 2020-2022 vs. NH Whites with odds ratios (ORs) from 0.70 to 0.91. Among 79,983 women, those 60-69 had significantly higher odds of any return screening encounter during 2020-2022 (OR = 1.28), while those ≥80 and 40-49 had significantly lower odds (ORs 0.77, 0.45) than those 50-59 years old. A sensitivity analysis suggested a possible pre-existing pattern. CONCLUSIONS: These data suggest a short-term pandemic effect on screening mammograms of ~2 months with no evidence of disparities. However, we observed racial/ethnic disparities in screening mammogram returns during the pandemic that may be at least partially pre-existing. These results may inform future pandemic planning and continued efforts to eliminate mammogram screening disparities.
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Neoplasias da Mama , COVID-19 , Detecção Precoce de Câncer , Mamografia , Humanos , COVID-19/epidemiologia , Feminino , Pessoa de Meia-Idade , Neoplasias da Mama/diagnóstico , Neoplasias da Mama/epidemiologia , Neoplasias da Mama/diagnóstico por imagem , Mamografia/estatística & dados numéricos , Detecção Precoce de Câncer/estatística & dados numéricos , Idoso , Adulto , Centros Médicos Acadêmicos , Meio-Oeste dos Estados Unidos/epidemiologia , Pandemias , SARS-CoV-2 , Teorema de Bayes , Programas de Rastreamento/estatística & dados numéricosRESUMO
PURPOSE: Standard tools for public health decision making such as data dashboards, trial repositories, and intervention briefs may be necessary but insufficient for guiding community leaders in optimizing local public health strategy. Predictive modeling decision support tools may be the missing link that allows community level decision makers to confidently direct funding and other resources to interventions and implementation strategies that will improve upon the status quo. METHODS: We describe a community-based model-driven decision support (MDDS) approach that requires community engagement, local data, and predictive modeling tools (agent-based modeling in our case studies) to improve decision-making on implementing strategies to address complex public health problems such as overdose deaths. We refer to our approach as a meta-implementation strategy as it provides guidance to a community on what intervention combinations and their required implementation strategies are needed to achieve desired outcomes. We use standard implementation measures including the Stages of Implementation Completion to assess adoption of this meta-implementation approach. RESULTS: Using two case studies, we illustrate how MDDS can be used to support decision making related to HIV prevention and reductions in overdose deaths at the city and county level. Even when community acceptance seems high, data acquisition and diffuse responsibility for implementing specific strategies recommended by modeling are barriers to adoption. CONCLUSIONS: MDDS has the capacity to improve community decision makers use of scientific knowledge by providing projections of the impact of intervention strategies under various scenarios. Further research is necessary to assess its effectiveness and the best strategies to implement it.
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Técnicas de Apoio para a Decisão , Humanos , Overdose de Drogas/prevenção & controle , Overdose de Drogas/mortalidade , Saúde Pública , Tomada de Decisões , Participação da ComunidadeRESUMO
BACKGROUND: Seriously ill patients rely on spiritual and existential beliefs to support coping and approach crucial treatment and healthcare decisions. Yet, we lack gold standard, validated approaches to gathering information on those spiritual beliefs. Therefore, we developed I-SPIRIT, a spiritual needs and beliefs inventory for those with serious illness (IIR-10-050). METHODS: In prior work to develop measure content, we interviewed a total of 74 participants: 20 patients (veterans with Stage IV cancer, CHF, COPD, ESRD), 19 caregivers, 14 chaplains, 10 social workers, 12 nurses, and 5 physicians. Using directed content analyses, we identified over 50 attributes of spiritual experience comprising five domains: overall importance of spirituality; affiliations and practices; impact on decisions; spiritual needs; and spiritual resources. We then translated these attributes into individual items with Likert response scales. In the quantitative validation of I-SPIRIT, we administered the instrument and a battery of comparison measures to 249 seriously ill veterans. The comparison measures captured general spiritual well-being, religious coping, and emotional functioning. Convergent and discriminant validity was examined with the FACIT-sp (faith, meaning, and purpose), BMMRS (religious/spirituality), POMS and PHQ-8 (emotional function), and FACT-G (quality of life). We administered the I-SPIRIT a week later, for test-retest reliability. RESULTS: Psychometric analyses yielded a final I-SPIRIT Tool including 30 items. Results demonstrated reliability and validity and yielded a tool with three main components: Spiritual Beliefs (seven items); Spiritual Needs (nine items); and Spiritual Resources (14 items). The Spiritual Beliefs items include key practices and affiliations, and impact of beliefs on healthcare. Higher levels of Spiritual Needs were associated with higher anxiety and depression. CONCLUSION: The I-Spirit measures relevance of spirituality, spiritual needs and spiritual resources and demonstrates validity, reliability, and acceptability for patients with serious illness.
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Adaptação Psicológica , Espiritualidade , Humanos , Masculino , Feminino , Idoso , Reprodutibilidade dos Testes , Pessoa de Meia-Idade , Psicometria , Inquéritos e Questionários , Estado Terminal/psicologia , Adulto , Veteranos/psicologiaRESUMO
Medication errors are a major patient safety issue and account for 1-2 million hospitalizations and between 100,000 and 200,000 deaths annually. Approximately 41 % of all medication errors are due to improper dose calculations. Studies have shown mean scores on the medication dosage calculation test for nursing students range from 35 to 71 %. Despite new technology created to aid in dosage calculations, the issue is still prevalent among nurses. It is critical that the elements contributing to the nurses' ability to complete dosage calculations be determined so that calculation curriculum in nursing schools can be updated to better prepare students for practice. An integrative review was completed using the databases of PubMed, CINAHL, and Embase to answer the research question: What contributors impact nurses' and nursing students' ability to complete dosage calculations? Four articles met the specified inclusion criteria and were used for this review. The three most common contributing themes among the review sample included mathematical medication calculation ability, medication calculation frequencies, and dosage calculation education. Results from this review can inform the issue of dosage calculations and highlight the need for further research regarding the medication administration competencies taught in undergraduate nursing studies.
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Bacharelado em Enfermagem , Educação em Enfermagem , Estudantes de Enfermagem , Humanos , Bacharelado em Enfermagem/métodos , Cálculos da Dosagem de Medicamento , Competência ClínicaRESUMO
OBJECTIVE: Many have found racial differences in clinician-patient communication using validated codebooks that represent effective communication. No codebooks used for examining racial differences, however, have included patient input. In this paper, we describe creating codebook with Black patient advocates to determine if we could reliably code discriminatory/valuing communication and assess racial differences in these behaviors. METHODS: We created a codebook for discriminatory/valuing communication behaviors with the input of Black patient advocates. We used the codebook to analyze data from 101 audio recorded encounters between White cardiologists and Black and White patients. We examined the differences in the prevalence of behaviors in cardiology encounters. RESULTS: In comparison to White patients, cardiologists made fewer tailoring statements to their Black patients (68% vs. 49%, p = 0.07). Coders found 4 instances of stereotyping behaviors and only Black patients (p = 0.12). We found no significant associations between any of the other outcomes and patient race. Black patients had a lower incidence of tailoring statements (p = 0.13), lower incidence of interrupting statements (p = 0.16), and higher rushed global score (p = 0.14). CONCLUSION AND PRACTICE IMPLICATIONS: We found that coders can reliably identify discriminatory/valuing behaviors in cardiology encounters. Future work should apply these codes to other datasets to assess their validity and generalizability.
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Cardiologia , Comunicação , Relações Médico-Paciente , Discriminação Social , Humanos , Negro ou Afro-Americano , BrancosRESUMO
INTRODUCTION: Among patients with cancer in the United States, Medicaid insurance is associated with worse outcomes than private insurance and with similar outcomes as being uninsured. However, prior studies have not addressed the impact of individual-level socioeconomic status, which determines Medicaid eligibility, on the associations of Medicaid status and cancer outcomes. Our objective was to determine whether differences in cancer outcomes by insurance status persist after accounting for individual-level income. METHODS: The Surveillance, Epidemiology, and End Results (SEER) database was queried for 18-64 year-old individuals with cancer from 2014-2016. Individual-level income was imputed using a model trained on Behavioral Risk Factors Surveillance Survey participants including covariates also present in SEER. The association of 1-year overall survival and insurance status was estimated with and without adjustment for estimated individual-level income and other covariates. RESULTS: A total of 416,784 cases in SEER were analyzed. The 1-yr OS for patients with private insurance, Medicaid insurance, and no insurance was 88.7%, 76.1%, and 73.7%, respectively. After adjusting for all covariates except individual-level income, 1-year OS differences were worse with Medicaid (-6.0%, 95% CI = -6.3 to -5.6) and no insurance (-6.7%, 95% CI = -7.3 to -6.0) versus private insurance. After also adjusting for estimated individual-level income, the survival difference for Medicaid patients was similar to privately insured (-0.4%, 95% CI = -1.9 to 1.1) and better than uninsured individuals (2.1%, 95% CI = 0.7 to 3.4). CONCLUSIONS: Income, rather than Medicaid status, may drive poor cancer outcomes in the low-income and Medicaid-insured population. Medicaid insurance coverage may improve cancer outcomes for low-income individuals.
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Neoplasias , Adulto , Humanos , Estados Unidos/epidemiologia , Adolescente , Adulto Jovem , Pessoa de Meia-Idade , Sistema de Vigilância de Fator de Risco Comportamental , Programa de SEER , Neoplasias/epidemiologia , Medicaid , Cobertura do Seguro , Seguro SaúdeRESUMO
Importance: Shared decision-making is the preferred method for evaluating complex tradeoffs in the care of patients with critical illness. However, it remains unknown whether critical care clinicians engage diverse patients and caregivers equitably in shared decision-making. Objective: To compare critical care clinicians' approaches to shared decision-making in recorded conversations with Black and White caregivers of patients with critical illness. Design, Setting, and Participants: This thematic analysis consisted of unstructured clinician-caregiver meetings audio-recorded during a randomized clinical trial of a decision aid about prolonged mechanical ventilation at 13 intensive care units in the US. Participants in meetings included critical care clinicians and Black or White caregivers of patients who underwent mechanical ventilation. The codebook included components of shared decision-making and known mechanisms of racial disparities in clinical communication. Analysts were blinded to caregiver race during coding. Patterns within and across racial groups were evaluated to identify themes. Data analysis was conducted between August 2021 and April 2023. Main Outcomes and Measures: The main outcomes were themes describing clinician behaviors varying by self-reported race of the caregivers. Results: The overall sample comprised 20 Black and 19 White caregivers for a total of 39 audio-recorded meetings with clinicians. The duration of meetings was similar for both Black and White caregivers (mean [SD], 23.9 [13.7] minutes vs 22.1 [11.2] minutes, respectively). Both Black and White caregivers were generally middle-aged (mean [SD] age, 47.6 [9.9] years vs 51.9 [8.8] years, respectively), female (15 [75.0%] vs 14 [73.7%], respectively), and possessed a high level of self-assessed health literacy, which was scored from 3 to 15 with lower scores indicating increasing health literacy (mean [SD], 5.8 [2.3] vs 5.3 [2.0], respectively). Clinicians conducting meetings with Black and White caregivers were generally young (mean [SD] age, 38.8 [6.6] years vs 37.9 [8.2] years, respectively), male (13 [72.2%] vs 12 [70.6%], respectively), and White (14 [77.8%] vs 17 [100%], respectively). Four variations in clinicians' shared decision-making behaviors by caregiver race were identified: (1) providing limited emotional support for Black caregivers, (2) failing to acknowledge trust and gratitude expressed by Black caregivers, (3) sharing limited medical information with Black caregivers, and (4) challenging Black caregivers' preferences for restorative care. These themes encompass both relational and informational aspects of shared decision-making. Conclusions and Relevance: The results of this thematic analysis showed that critical care clinicians missed opportunities to acknowledge emotions and value the knowledge of Black caregivers compared with White caregivers. These findings may inform future clinician-level interventions aimed at promoting equitable shared decision-making.
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Estado Terminal , Tomada de Decisões , Pessoa de Meia-Idade , Humanos , Masculino , Feminino , Adulto , Estado Terminal/terapia , Fatores Raciais , Tomada de Decisão Compartilhada , EmoçõesRESUMO
BACKGROUND: Medicaid-associated disparities in childhood and adolescent (pediatric) cancer diagnosis stage and survival have been reported. However, a key limitation of prior studies is the assessment of health insurance at a single time point. To evaluate Medicaid-associated disparities more robustly, we used Surveillance, Epidemiology, and End Results (SEER)-Medicaid linked data to examine diagnosis stage and survival disparities in those (i) Medicaid-enrolled and (ii) with discontinuous and continuous Medicaid enrollment. METHODS: SEER-Medicaid linked data from 2006 to 2013 were obtained on cases diagnosed from 0 to 19 years. Medicaid enrollment was classified as enrolled versus not enrolled, with further classifications as continuous when enrolled 6 months before through 6 months after diagnosis, and discontinuous when not enrolled continuously for this period. We used multinomial logistic and Cox proportional hazards regression models to determine associations between enrollment measures, diagnosis stage, and cancer death adjusted for covariates. RESULTS: Among 21,502 cases, a higher odds of distant stage diagnoses were observed in association with Medicaid enrollment (odds ratio [OR] = 1.56, 95% confidence interval [CI]: 1.48-1.65), with the highest odds for discontinuous enrollment (OR = 2.0, 95% CI: 1.86-2.15). Among 30,654 cases, any Medicaid enrollment, continuous enrollment, and discontinuous enrollment were associated with 1.68 (95% CI: 1.35-2.10), 1.66 (95% CI: 1.35-2.05), and 1.89 (95% CI: 1.54-2.33) times higher hazards of cancer death versus no enrollment, respectively. CONCLUSIONS: Medicaid enrollment, particularly discontinuous enrollment, is associated with a higher distant stage diagnosis odds and risk of death. This study supports the critical need for consistent health insurance coverage in children and adolescents.
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Medicaid , Neoplasias , Adolescente , Estados Unidos/epidemiologia , Humanos , Criança , Neoplasias/diagnóstico , Neoplasias/terapia , Seguro Saúde , Estadiamento de Neoplasias , Modelos de Riscos Proporcionais , Cobertura do SeguroRESUMO
Importance: Unmet and racially disparate palliative care needs are common in intensive care unit (ICU) settings. Objective: To test the effect of a primary palliative care intervention vs usual care control both overall and by family member race. Design, Setting, and Participants: This cluster randomized clinical trial was conducted at 6 adult medical and surgical ICUs in 2 academic and community hospitals in North Carolina between April 2019 and May 2022 with physician-level randomization and sequential clusters of 2 Black patient-family member dyads and 2 White patient-family member dyads enrolled under each physician. Eligible participants included consecutive patients receiving mechanical ventilation, their family members, and their attending ICU physicians. Data analysis was conducted from June 2022 to May 2023. Intervention: A mobile application (ICUconnect) that displayed family-reported needs over time and provided ICU attending physicians with automated timeline-driven communication advice on how to address individual needs. Main Outcomes and Measures: The primary outcome was change in the family-reported Needs at the End-of-Life Screening Tool (NEST; range 0-130, with higher scores reflecting greater need) score between study days 1 and 3. Secondary outcomes included family-reported quality of communication and symptoms of depression, anxiety, and posttraumatic stress disorder at 3 months. Results: A total of 111 (51% of those approached) family members (mean [SD] age, 51 [15] years; 96 women [86%]; 15 men [14%]; 47 Black family members [42%]; 64 White family members [58%]) and 111 patients (mean [SD] age, 55 [16] years; 66 male patients [59%]; 45 Black patients [41%]; 65 White patients [59%]; 1 American Indian or Alaska Native patient [1%]) were enrolled under 37 physicians randomized to intervention (19 physicians and 55 patient-family member dyads) or control (18 physicians and 56 patient-family member dyads). Compared with control, there was greater improvement in NEST scores among intervention recipients between baseline and both day 3 (estimated mean difference, -6.6 points; 95% CI, -11.9 to -1.3 points; P = .01) and day 7 (estimated mean difference, -5.4 points; 95% CI, -10.7 to 0.0 points; P = .05). There were no treatment group differences at 3 months in psychological distress symptoms. White family members experienced a greater reduction in NEST scores compared with Black family members at day 3 (estimated mean difference, -12.5 points; 95% CI, -18.9 to -6.1 points; P < .001 vs estimated mean difference, -0.3 points; 95% CI, -9.3 to 8.8 points; P = .96) and day 7 (estimated mean difference, -9.5 points; 95% CI, -16.1 to -3.0 points; P = .005 vs estimated mean difference, -1.4 points; 95% CI, -10.7 to 7.8; P = .76). Conclusions and Relevance: In this study of ICU patients and family members, a primary palliative care intervention using a mobile application reduced unmet palliative care needs compared with usual care without an effect on psychological distress symptoms at 3 months; there was a greater intervention effect among White family members compared with Black family members. These findings suggest that a mobile application-based intervention is a promising primary palliative care intervention for ICU clinicians that directly addresses the limited supply of palliative care specialists. Trial Registration: ClinicalTrials.gov Identifier: NCT03506438.