Disparities in Access to Mental Health Services Among Children Diagnosed with Anxiety and Depression in the United States.

Child and adolescent mental health are major public health concerns in the US. Overall, 20% of US children have a reported mental health condition, while an estimated 40% will be diagnosed with one by age 18. Despite these concerns, little is known about factors associated with access to mental health services among children and adolescents. We analyzed data from a sample of 6655 children (aged 6 to 17 years) with either anxiety and/or depression drawn from the 2020-2021 National Survey of Children's Health (NSCH). A multivariable logistic regression model was fit to investigate predisposing, enabling, and need factors associated with caregiver's (i.e., parent or other guardian) perceived access to mental health services for their children. Approximately 50.8% of caregivers perceived obtaining mental health services for their children to be somewhat difficult, very difficult, or impossible. Children meeting criteria for having a medical home had lower odds of experiencing such difficulties (adjusted [a]OR = 0.38; 95% CI: 0.30-0.49). Further, compared to children who sometimes or never had health insurance coverage for mental or behavioral health needs, children who were always insured (aOR: 0.19; 95% CI 0.14, 0.25) and those who usually had coverage (aOR: 0.38; 95% CI 0.28, 0.51) had lower odds of experiencing perceived difficulties in obtaining care. The results indicate several enabling and need predictors of perceived access to mental health services--highlighting potential structural barriers to care access. Efforts to address access challenges should adopt a multifaceted approach and be tailored to families living in poverty, those with limited health coverage, and minoritized children with less than optimal general health.

Food security status and breast cancer screening among women in the United States: Evidence from the Health and Retirement Study and Health Care and Nutrition Study.

PURPOSE: To assess the impact of food insecurity on biennial breast cancer screenings (i.e., mammography or breast X-ray) among older women in the United States (US). METHODS: Data from the 2014 and 2016 waves of the Health and Retirement Study and the 2013 Health Care and Nutrition Study were used. The analyses were limited to a nationally representative sample of 2,861 women between 50 and 74 years of age, residing in the US. We employed a propensity score weighting method to balance observed confounders between food-secure and food-insecure women and fit a binary logistic regression to investigate population-level estimates for the association between food security and breast cancer screening. RESULTS: Food insecurity was significantly associated with failure to obtain a mammogram or breast X-ray within the past two years. Food-insecure women had 54% lower odds of reporting breast cancer screening in the past 2 years (adjusted OR = 0.46; 95% CI 0.30-0.70, p-value < 0.001) as compared to food-secure women. Additional factors associated with a higher likelihood of receiving breast cancer screenings included greater educational attainment, higher household income, regular access to health care/advice, not smoking, and not being physically disabled or experiencing depressive symptoms. CONCLUSION: Results demonstrate a socioeconomic gradient existing in regard to the utilization of regular breast cancer screenings among women. Those who tend to have lower education, lower income, and lack of reliable healthcare access are more likely to be food insecure. Thus, more likely to face the financial, logistical, or environmental barriers in obtaining screening services that accompany food insecurity.

Impact of the Affordable Care Act on participation in the Supplemental Nutrition Assistance Program among low-income older Medicare beneficiaries.

BACKGROUND: The Affordable Care Act (ACA) provisions, especially Medicaid expansion, are believed to have "spillover effects," such as boosting participation in the Supplemental Nutrition Assistance Program (SNAP) among eligible individuals in the United States (US). However, little empirical evidence exists about the impact of the ACA, with its focus on the dual eligible population, on SNAP participation. The current study investigates whether the ACA, under an explicit policy aim of enhancing the interface between Medicare and Medicaid, has improved participation in the SNAP among low-income older Medicare beneficiaries. METHODS: We extracted 2009 through 2018 data from the US Medical Expenditure Panel Survey (MEPS) for low-income (≤ %138 Federal Poverty Level [FPL]) older Medicare beneficiaries (n = 50,466; aged ≥ 65), and low-income (≤ %138 FPL) younger adults (aged 20 to < 65 years, n = 190,443). MEPS respondents of > %138 FPL incomes, younger Medicare and Medicaid beneficiaries, and older adults without Medicare were excluded from this study. Using a quasi-experimental comparative interrupted time-series design, we examined (1) whether ACA's support for the Medicare-Medicaid dual-eligible program, through facilitating the online Medicaid application process, was associated with an increase in SNAP uptake among low-income older Medicare beneficiaries, and (2) in the instance of an association, to assess the magnitude of SNAP uptake that can be explicitly attributed to the policy's implementation. The outcome, SNAP participation, was measured annually from 2009 through 2018. The year 2014 was set as the intervention point when the Medicare-Medicaid Coordination Office started facilitating Medicaid applications online for eligible Medicare beneficiaries. RESULTS: Overall, the change in the probability of SNAP enrollment from the pre- to post-intervention period was 17.4 percentage points higher among low-income older Medicare enrollees, compared to similarly low-income, SNAP-eligible, younger adults (ß = 0.174, P < .001). This boost in SNAP uptake was significant and more apparent among older White (ß = 0.137, P = .049), Asians (ß = 0.408, P = .047), and all non-Hispanic adults (ß = 0.030, P < .001). CONCLUSIONS: The ACA had a positive, measurable effect on SNAP participation among older Medicare beneficiaries. Policymakers should consider additional approaches that link enrollment to multiple programs to increase SNAP participation. Further, there may be a need for additional, targeted efforts to address structural barriers to uptake among African Americans and Hispanics.

Insomnia symptoms and incident heart failure: a population-based cohort study.

AIMS: Heart failure (HF) is an ongoing epidemic and a serious clinical and public health issue. Currently, little is known about prospective associations between insomnia symptoms and HF incidence. We investigated the longitudinal associations between time-varying insomnia symptoms (difficulty initiating sleep, difficulty maintaining sleep, early-morning awakening, non-restorative sleep) and incident HF. METHODS AND RESULTS: Data were obtained from the Health and Retirement Study in the US for a population-representative sample of 12,761 middle-aged and older adults (age ≥ 50 years; mean [SD] age, 66.7 [9.4] years; 57.7% females) who were free from HF at baseline in 2002. Respondents were followed for 16 years for incident HF. We employed marginal structural discrete-time survival analyses to adjust for potential time-varying biological, psycho-cognitive, and behavioral factors and to account for bias due to differential loss to follow-up. At baseline, 38.4% of the respondents reported experiencing at least one insomnia symptom. During the 16-year follow-up, 1,730 respondents developed incident HF. Respondents experiencing one (hazard ratio [HR]=1.22; 95% CI: 1.08-1.38), two (HR=1.45; 95% CI: 1.21-1.72), three (HR=1.66; 95% CI: 1.37-2.02), or four (HR=1.80; 95% CI: 1.25-2.59) insomnia symptoms had a higher hazard of incident HF than asymptomatic respondents. Respondents that had trouble initiating sleep (HR=1.17; 95%CI: 1.01-1.36), maintaining sleep (HR=1.14; 95% CI: 1.01-1.28), early-morning awakening (HR=1.20; 95% CI: 1.02-1.43), or non-restorative sleep (HR=1.25; 95% CI: 1.06-1.46) had a higher hazard of incident HF than asymptomatic respondents. CONCLUSION: Insomnia symptoms, both cumulatively and individually, are associated with incident HF. Public health awareness and screening for insomnia symptoms in at-risk populations should be encouraged to reduce HF incidence.

Access to Broadband Internet and its Utilization for Health Information Seeking and Health Communication among Informal Caregivers in the United States.

Informal caregivers provide unpaid care to their physically or mentally ill loved ones and play a critical role in the healthcare delivery. eHealth tools, including the broadband internet, can facilitate care processes and impact the caregiving burden through seeking health information and health communication. This study examines the predictors of access to broadband internet and the factors associated with health information seeking and health communication among informal caregivers with broadband internet. We used data from cycles 1 and 2 of the Health Information National Trends Survey (HINTS 5) and employed generalized linear regression models with the maximum likelihood estimation. Specifically, we performed a two-part model: (1) a logistic regression model of broadband internet access among all caregivers (n = 929) and (2) a logistic regression model of health information seeking and health communication among caregivers with broadband internet access (n = 404). We found that caregivers who were younger (18-34 years versus 45+ years), female (versus male), and those who were divorced/widowed/separated (versus singles) were less likely to have broadband internet access. While those who were married/living as married (versus singles), with higher incomes (≥$100,000 versus <$35,000), and those living in metropolitan areas were more likely to have broadband internet access. Among caregivers with broadband internet access, younger, female, non-Hispanic white caregivers, and those with higher levels of education and income, as well as those who cared for cancer patients, were more likely to seek health information for someone else. Additionally, caregivers aged 35-39 years and those with more education were more likely to look for health information for themselves than their counterparts. Furthermore, caregivers who were aged 40-44 years, females, divorced/widowed/separated, those with higher incomes, and those who cared for patients with Alzheimer's, confusion, and dementia were more likely to communicate electronically with a provider. The results suggest disparities in broadband internet access and indicate variations in factors associated with health information seeking and health communication. The findings underscore the need to address barriers attributed to the digital divide among informal caregiving groups.

Emergency department and inpatient utilization among U.S. older adults with multiple chronic conditions: a post-reform update.

BACKGROUND: The Affordable Care Act (ACA) was enacted to enhance access to care primarily among nonelderly and low-income populations; however, several provisions addressed key determinants of emergency department (ED) and inpatient visits among Medicare beneficiaries over age 65 years. We take stock of the overall changes in these visits among older Medicare beneficiaries, focusing on those with multiple chronic conditions (MCCs), and provide a nationally representative post-reform update. METHODS: We analyzed a sample of 32,919 older adults (65+) on Medicare from the 2006-2015 Medical Expenditure Panel Survey (MEPS). Using a survey-weighted two-part model, we examined changes in ED visits, inpatient visits, and length of stay (LOS) by MCC status, before (2006-2010), during (2011-2013), and after the ACA (2014-2015). RESULTS: Prior to the ACA, 18.1% of Medicare older adults had ≥1 ED visit, whereas 17.1% had ≥1 inpatient visits, with an average of 5.1 nights/visit. Following ACA reforms, among those with 2+ chronic conditions, the rate of ever having an ED visit increased by 4.3 percentage points [95% confidence intervals [CI]: 2.5, 6.1, p < 0.01], whereas the rate of inpatient visits decreased by 1.4 percentage points [95%CI: - 2.9, 0.2, p < 0.1], after multivariable adjustment. CONCLUSIONS: We found sizable increases in ED visits and nontrivial decreases in inpatient visits among older Medicare beneficiaries with MCCs, underscoring the continuing need for improving access to and quality of care among older adults with MCCs to decrease reliance on the ED and reduce preventable hospitalizations.

Food Insecurity and Influenza and Pneumonia Vaccines Uptake Among Community-Dwelling Older Adults in the United States.

Influenza and pneumonia vaccines can reduce morbidities and mortality associated with infectious diseases among older adults. Food security, good nutrition, and high-quality diets are critical for the wellbeing of older adults. However, little is known about the relationship between food insecurity and use of preventive health services, such as influenza and pneumonia vaccinations, among older adults. In this study, we analyzed data on 40,555 adults aged ≥ 65 years from the 2014-2018 National Health Interview Survey in the United States. Through multiple hierarchical logistic regression models, we investigated the associations between food insecurity and influenza and pneumonia vaccines uptake in this population. We found that, during 2014-2018, about 12.6 million (5.3%) adults aged ≥ 65 years lived in food-insecure households in the United States. Of those, 60.6% reported getting an influenza vaccine in the past 12 months, and 54.2% reported ever getting a pneumonia vaccine. Compared to food-secure older adults, food-insecure individuals were not significantly different in terms of influenza vaccine uptake. However, they were 25% less likely to have ever gotten a pneumonia vaccine (adjusted odds ratio = 0.75, 95% CI 0.65-0.86, P < .001). Efforts should be made to develop strategies to improve immunization rates among food-insecure older adults. Healthcare providers could routinely assess their vaccination status and screen them for food insecurity. Also, community level screening and intervention programs should target food-insecure older adults, who often face structural disadvantages. Future studies could explore and identify the underlying predictive factors contributing to low pneumonia vaccination rates among food-insecure older adults.

Self-Check-In Kiosks Utilization and Their Association With Wait Times in Emergency Departments in the United States.

BACKGROUND: Delayed care in emergency departments (EDs) is a serious problem in the United States. Patient wait time is considered a critical measure of delayed care in EDs. Several strategies have been employed by EDs to reduce wait time, including implementation of self-check-in kiosks. However, the effect of kiosks on wait time in EDs is understudied. OBJECTIVES: To assess the association between patient wait time and utilization of self-check-in kiosks in EDs. To investigate a series of other patient-, ED-, and hospital-level predictors of wait time in EDs. METHODS: Using data from the 2015 and 2016 National Hospital Ambulatory Medical Care Survey, we analyzed 40,528 ED visits by constructing a multivariable linear regression model of the log-transformed wait time data as an outcome, then computing percent changes in wait times. RESULTS: During the study period, about 9% of EDs in the United States implemented kiosks. In our linear regression model, the wait time in EDs with kiosk self-check-in services was 56.8% shorter (95% confidence interval ̶ 130% to ̶ 6.4%, p < 0.05) compared with EDs without kiosk services. In addition to kiosks, patients' day of visit, arrival time, triage assessment, arrival by ambulance, chronic medical conditions, ED boarding, hospitals' full-capacity protocol, and hospitals' location were significant predictors of wait time. CONCLUSIONS: Self-check-in kiosks are associated with shorter ED wait time in the United States. However, prolonged ED wait time continues to be a system-wide problem, and warrants multilayered interventions to address this challenge for those who are in acute need of immediate care.

Access to Personal Health Records and Screening for Breast and Cervical Cancer Among Women with a Family History of Cancer.

It is essential for at-risk women to be screened for breast and cervical cancer in a timely manner. Despite a growing interest in the role of health information technology including personal health records (PHRs) to improve quality and outcomes in health care, less is known about the effectiveness of PHRs to promote breast and cervical cancer screening among women with a family history of cancer (FHC). We examined the association between access to PHRs and the use of a recommended mammography and a Pap smear testing among women with a FHC using data from the 2015 Health Information National Trends Survey (HINTS 4-cycle 4) and the 2016 Area Health Resource Files. The study sample was comprised of 1250 women aged 20-75 years with a FHC, a subsample of 3677 survey respondents. Of the 1250 women, 64.96% received a mammogram, and 75.44% underwent a Pap testing. Among women with a FHC, there was a significant and positive association between access to PHRs and the receipt of a mammogram (adjusted odds ratio (aOR) 4.20; 95% CI, 2.23-7.94; p < .001) and a Pap testing (aOR 3.13; 95% CI, 1.56-6.28; p < .01). Our findings suggest that at-risk women can benefit from greater access to PHRs. Policymakers should consider incentivizing providers and healthcare organizations who provide access to PHRs to their patients as well as developing programs that can help improve access to PHRs among at-risk women.

Mobile Health Application and e-Health Literacy: Opportunities and Concerns for Cancer Patients and Caregivers.

Health literacy is critical for cancer patients as they must understand complex procedures or treatment options. Caregivers' health literacy also plays a crucial role in caring for cancer patients. Low health literacy is associated with low adherence to medications, poor health status, and increased health care costs. There is a growing interest in the use of mobile health applications (apps) to improve health literacy. Mobile health apps can empower underserved cancer patients and their caregivers by providing features or functionalities to enhance interactive patient-provider communication and to understand medical information more readily. Despite the potentiality of improving health literacy through mobile health apps, there exist several related concerns: no equal access to mobile technology, no familiarity or knowledge of using mobile health apps, and privacy and security concerns. These elements should be taken into account for health policy making and mobile apps design and development. Importantly, mobile apps should be developed with the goal of achieving a high range of user access by considering all health literacy level and various cultural and linguistic needs.

Predictors of U.S. Adults' Opinion Toward an R-Rating Policy for Movies With Cigarette Smoking.

Recently, multiple health organizations and advocacy groups have pushed for giving an R-rating for movies depicting tobacco imagery. This study examined several predictors of U.S. adults' opinion toward an R-rating policy for movies depicting cigarette smoking. We used data from the Health Information National Trends Survey (2020 cycle), for a nationally representative sample of 3,865 US adults (aged ≥ 18). The outcome variable was opinion toward an R-rating policy (support, neutral, and oppose) for movies depicting cigarette smoking. A weighted adjusted multinomial logistic regression analysis with comparisons of support versus oppose, support versus neutral, and neutral versus oppose was performed. About 48.2% of respondents were supportive of, 31.1% were neutral toward, and 20.7% were opposed to an R-rating policy. Adults aged 50 to 64 years (adjusted odds ratio [aOR] = 2.28, p = .008) and ≥65 years (aOR = 4.54, p <.001) (vs. 18-34 years) were more likely to support the R-rating policy than oppose it. Non-Hispanic Black respondents (vs. non-Hispanic Whites) were 1.74 times more likely to support than oppose the policy (aOR = 1.74, p = .04), whereas adults with a household annual income of US$75,000 or more (vs. <$20,000) and those with moderate (vs. liberal) political viewpoints were more likely to be neutral than oppose the policy. Former and current e-cigarette users (vs. never users) were less likely to support than oppose the policy. Tailored messaging addressing the rationale behind R-rating policy should be directed towards communities based on age, race/ethnicity, household income, e-cigarette usage, and political ideologies.

mHealth Apps Use and Their Associations With Healthcare Decision-Making and Health Communication Among Informal Caregivers: Evidence From the National Cancer Institute's Health Information National Trends Survey.

PURPOSE: The current study investigates associations between mHealth apps and healthcare decision-making and health communication among informal caregivers in the US. DESIGN: Cross-sectional study employing secondary data. SETTING: The Health Information National Trends Survey (HINTS5, Cycles 2 through 4, 2018 - 2020). SAMPLE: Self-identified informal caregivers (n = 1386; had mHealth apps = 61.3%, female = 63.2%, some college or more in education = 80.3%) who reported owning at least a smartphone or a tablet computer (i.e., ownership of a "smart device"). MEASURES: Sociodemographic characteristics, reports of having mHealth apps, smart device utilization in healthcare decision-making and health communication. ANALYSIS: Accounting for the complex design features of the HINTS data, we constructed multiple hierarchical logistic regressions to compute adjusted odds ratios (aOR) and their 95% confidence intervals (CI). RESULTS: Compared to caregivers without mHealth apps, those with the apps had higher odds of utilizing their smart devices to make a health-related decision, such as how to treat a disease or a medical condition (aOR = 1.65; 95% CI: 1.13-2.39, P < .01), or engage in health-related discussions with a healthcare provider (aOR = 2.36; 95% CI: 1.54-3.61, P < .001). CONCLUSION: Having mHealth apps was associated with a higher likelihood of using smart devices in healthcare decision-making and health communication by informal caregivers. Empowering caregivers to make informed health-related decisions and communicate effectively with healthcare providers are both crucial to health promotion and well-being. Future studies should investigate facilitators as well as barriers to using mHealth apps and smart devices in health-promoting strategies involving informal caregivers.

Impact of Residential Segregation on Healthcare Utilization and Perceived Quality of Care Among Informal Caregivers in the United States.

This study aimed to investigate the impact of racial residential segregation on healthcare utilization and perceived quality of care among informal caregivers in the US. It further assessed potential variations in the estimated impact across caregivers' race and socioeconomic status. We used data from the Health Information National Trends Survey Data Linkage Project (fielded in 2020) for a sample of 583 self-identified informal caregivers in the US. Fitting a series of regression models with the maximum likelihood estimation, we computed the beta coefficients (ß) of interest and their associated Wald 95% confidence limits (CI). Caregivers who resided in areas with higher segregation, compared to those living in lower segregated areas, were less likely to visit a healthcare professional [ß = - 2.08; Wald 95%CI - 2.093, - 2.067] (moderate); [ß = - 2.53; Wald 95%CI - 2.549, - 2.523] (high)]. Further, caregivers residing in moderate [ß = - 0.766; Wald 95%CI - 0.770, - 0.761] and high [ß = - 0.936; Wald 95%CI - 0.941, - 0.932] segregation regions were less likely to perceive a better quality of care compared to those located in low segregation areas. Moreover, as segregation level increased, Black caregivers were less likely to see a health professional, less frequently used healthcare services, and had poorer perceived healthcare quality when compared to Whites. Our findings indicate that higher residential segregation is associated with lower healthcare utilization, such as visiting a healthcare professional, and poorer perceived healthcare quality among informal caregivers. Given the essential role of informal caregivers in the current healthcare system, it is vital to investigate and address challenges associated with access to and quality of essential healthcare services to improve caregivers' health and well-being, specifically for caregivers of minority backgrounds.

The Tennessee Heart Health Network effectiveness study: A stepped wedge cluster randomized controlled trial to assess the effectiveness of statewide quality improvement cooperative participation on cardiovascular outcomes.

BACKGROUND: Cardiovascular disease (CVD) is the primary cause of premature morbidity and mortality in the United States and Tennessee ranks among the highest in CVD events. While patient-centered outcomes research (PCOR) evidence-based approaches that reach beyond the traditional doctor-patient visit hold promise to improve CVD care and prevent serious complications, most primary care providers lack time, knowledge, and infrastructure to implement these proven approaches. Statewide primary care quality improvement (QI) collaboratives hold potential to help address primary care needs, however, little is known regarding their effectiveness in improving uptake of PCOR evidence-based population health approaches and improving CVD outcomes. This study describes the design and implementation of a stepped-wedge cluster randomized controlled trial to assess the effectiveness of participation in a statewide quality improvement cooperative (The Tennessee Heart Health Network [TN-HHN]) on cardiovascular outcomes. METHODS/DESIGN: The TN-HHN Effectiveness Study randomized 77 practices to 4 waves (i.e., clusters), with each wave beginning three months after the start of the prior wave and lasting for 18 months. All practice clusters received one of three Network interventions, and outcomes are measured for each three months both in the control phase and the intervention phase. Primary outcomes include Center for Medicare and Medicaid Services measures for aspirin use, blood pressure control, cholesterol control, and smoking cessation (ABCS). CONCLUSIONS: This trial, upon its conclusion, will allow us to assess the effect of participation in a statewide quality improvement cooperative on cardiovascular outcomes as well as key contributors to successful practice transformation.

Driving under the influence of substances and motor vehicle fatalities among older adults in the United States.

OBJECTIVE: This study examines contribution of substance use (including alcohol, cannabinoids, stimulants, narcotics, depressants, and hallucinogens) on the probability of drivers being at-fault for a crash on U.S. public roads, with specific emphasis on older adult drivers. METHODS: Data from the National Highway Traffic Safety Administration's Fatality Analysis Reporting System (FARS) for the years 2010-2018 were employed for 87,060 drivers (43,530 two-vehicle crash pairs) involved in two moving vehicle crashes. The quasi-induced exposure (QIE) method was used to compute the relative crash involvement ratios (CIRs) for each relevant substance and illicit drug. Mixed-effect generalized linear regression models were fit to examine the effect of substance use on the probability of a driver being at-fault for a crash. RESULTS: There were 75.51% males and 73.88% Non-Hispanic Whites in our sample. The CIR for those aged 70-79 years was 1.17, and more than double (2.56) for the ≥80 years old drivers, while being relatively low among drivers of ages 20 to 69. Substance use, in general, disproportionately increased the probability of being at-fault during a crash, regardless of driver's age. Though older drivers are less likely than other age groups to report substance use, presence of substances among older drivers increased the probability of their being at-fault two to four times during a crash across almost all substances. The regression models, after adjusting for driver's sex, road grade, weather, light conditions, distraction, and speeding at time of crash, revealed that older drug-impaired drivers were twice as likely to be at fault in a fatal crash (aOR = 1.947; 95% CI = 1.821, 2.082; <0.0001) compared to their middle-aged counterparts. Similarly, most substance use categories were responsible for the probabilities of higher CIRs among the drivers. CONCLUSION: These findings necessitate continued efforts to bring awareness to the deadly consequences of "drugged driving," especially among older adult drivers.

Methamphetamine-Induced Wakefulness and Sleep Management: A Qualitative Analysis of Online Narratives.

While much attention has been given to methamphetamine's wake-promoting properties and the concept of using methamphetamine to increase energy, little is known about the ways people who use methamphetamine manage their use to pursue their functional goals or the challenges they encounter doing so. This qualitative study explores the experiences of people who used methamphetamine to manage wakefulness and reduce sleep as a means to achieve functional goals. We conducted a grounded theory analysis of 202 anonymous letters submitted to an online forum. Five themes emerged from this process: (1) Using methamphetamine to extend wakefulness and reduce the need for sleep; (2) Losing control over wakefulness and the need for sleep; (3) Managing wakefulness and the need for sleep while on methamphetamine; (4) Getting caught in a cycle of wakefulness and sleep; and (5) Sleep disruptions even after ceasing methamphetamine use. Participants believed methamphetamine was critical to meeting their functional goals, and they went to great lengths to try to manage the substance's ill effects. Thus, clients in treatment for methamphetamine use disorder may benefit from interventions addressing their underlying motivations and perceived associations between methamphetamine and meeting functional goals.

Wearable Activity Tracker Use and Physical Activity Among Informal Caregivers in the United States: Quantitative Study.

BACKGROUND: With an increase in aging population and chronic medical conditions in the United States, the role of informal caregivers has become paramount as they engage in the care of their loved ones. Mounting evidence suggests that such responsibilities place substantial burden on informal caregivers and can negatively impact their health. New wearable health and activity trackers (wearables) are increasingly being used to facilitate and monitor healthy behaviors and to improve health outcomes. Although prior studies have examined the efficacy of wearables in improving health and well-being in the general population, little is known about their benefits among informal caregivers. OBJECTIVE: This study aimed to examine the association between use of wearables and levels of physical activity (PA) among informal caregivers in the United States. METHODS: We used data from the National Cancer Institute's Health Information National Trends Survey 5 (cycle 3, 2019 and cycle 4, 2020) for a nationally representative sample of 1273 community-dwelling informal caregivers-aged ≥18 years, 60% (757/1273) female, 75.7% (990/1273) had some college or more in education, and 67.3% (885/1273) had ≥1 chronic medical condition-in the United States. Using jackknife replicate weights, a multivariable logistic regression was fit to assess an independent association between the use of wearables and a binary outcome: meeting or not meeting the current World Health Organization's recommendation of PA for adults (≥150 minutes of at least moderate-intensity PA per week). RESULTS: More than one-third (466/1273, 37.8%) of the informal caregivers met the recommendations for adult PA. However, those who reported using wearables (390/1273, 31.7%) had slightly higher odds of meeting PA recommendations (adjusted odds ratios 1.1, 95% CI 1.04-1.77; P=.04) compared with those who did not use wearables. CONCLUSIONS: The results demonstrated a positive association between the use of wearables and levels of PA among informal caregivers in the United States. Therefore, efforts to incorporate wearable technology into the development of health-promoting programs or interventions for informal caregivers could potentially improve their health and well-being. However, any such effort should address the disparities in access to innovative digital technologies, including wearables, to promote health equity. Future longitudinal studies are required to further support the current findings of this study.

Longitudinal associations between time-varying insomnia symptoms and all-cause health care services utilization among middle-aged and older adults in the United States.

OBJECTIVE: To examine longitudinal associations between time-varying insomnia symptoms (difficulty initiating sleep, difficulty maintaining sleep, early-morning awakenings, and nonrestorative sleep) and all-cause health care services utilization (HSU), including overnight hospital stays, nursing home stays, and home health care services among middle-aged and older adults. DATA SOURCES: The Health and Retirement Study (HRS), a nationwide, population-representative survey of primarily middle-aged and older adults in the United States. STUDY DESIGN: This study is an analysis of prospective data from the HRS for a cohort of 13,168 adults (aged ≥50 years; females = 57.7%). Study participants were followed for 16 years. This study focuses on the associations between time-varying insomnia symptoms, both cumulatively and independently, and repeated HSUs. A marginal structural modeling approach was used to capture time-varying biological, psycho-cognitive, and behavioral health factors, and to adjust for selection bias such as differential loss to follow-up. Generalized estimating equations were employed to compute average marginal effects and their 95% confidence intervals. DATA COLLECTION/EXTRACTION METHODS: We extracted longitudinal data from 2002 through 2018 waves of the HRS. PRINCIPAL FINDINGS: Experiencing higher numbers of insomnia symptoms on a cumulative scale was associated with higher probabilities of HSU. For instance, the likelihood of overnight hospital stays for individuals reporting one symptom increased from 4.7 percentage points on average (95% CI: 3.7-5.6, p < 0.001), to 13.9 percentage points (95% CI: 10.3-17.5, p < 0.001) for those reporting four symptoms, relative to individuals experiencing no insomnia symptoms. Further, experiencing each of difficulty initiating and maintaining sleep, and nonrestorative sleep, as standalone symptoms, was associated with a higher likelihood of HSU when compared to those not experiencing the symptoms. CONCLUSIONS: The results demonstrate the potential consequences and adverse impacts of insomnia symptoms on HSU among middle-aged and older adults. Future investigations should focus on the underlying causes and health systems pathways linking insomnia symptoms to HSU.

Longitudinal associations between insomnia symptoms and all-cause mortality among middle-aged and older adults: a population-based cohort study.

To date, there is no scientific consensus on whether insomnia symptoms increase mortality risk. We investigated longitudinal associations between time-varying insomnia symptoms (difficulty initiating sleep, difficulty maintaining sleep, early-morning awakening, and nonrestorative sleep) and all-cause mortality among middle-aged and older adults during 14 years of follow-up. Data were obtained from 2004 through 2018 survey waves of the Health and Retirement Study in the United States for a population-representative sample of 15 511 respondents who were ≥50 years old in 2004. Respondents were interviewed biennially and followed through the end of the 2018 survey wave for the outcome. Marginal structural discrete-time survival analyses were employed to account for time-varying confounding and selection bias. Of the 15 511 cohort respondents (mean [±SD] age at baseline, 63.7 [±10.2] years; 56.0% females), 5878 (31.9%) died during follow-up. At baseline (2004), 41.6% reported experiencing at least one insomnia symptom. Respondents who experienced one (HR = 1.11; 95% CI: 1.03-1.20), two (HR = 1.12; 95% CI: 1.01-1.23), three (HR = 1.15; 95% CI: 1.05-1.27), or four (HR = 1.32; 95% CI: 1.12-1.56) insomnia symptoms had on average a higher hazard of all-cause mortality, compared to those who were symptom-free. For each insomnia symptom, respondents who experienced difficulty initiating sleep (HR = 1.12; 95% CI: 1.02-1.22), early-morning awakening (HR = 1.09; 95% CI: 1.01-1.18), and nonrestorative sleep (HR = 1.17; 95% CI: 1.09-1.26), had a higher hazard of all-cause mortality compared to those not experiencing the symptom. The findings demonstrate significant associations between insomnia symptoms and all-cause mortality, both on a cumulative scale and independently, except for difficulty maintaining sleep. Further research should investigate the underlying mechanisms linking insomnia symptoms and mortality.

Hospital value-based payment programs and disparity in the United States: A review of current evidence and future perspectives.

Beginning in the early 2010s, an array of Value-Based Purchasing (VBP) programs has been developed in the United States (U.S.) to contain costs and improve health care quality. Despite documented successes in these efforts in some instances, there have been growing concerns about the programs' unintended consequences for health care disparities due to their built-in biases against health care organizations that serve a disproportionate share of disadvantaged patient populations. We explore the effects of three Medicare hospital VBP programs on health and health care disparities in the U.S. by reviewing their designs, implementation history, and evidence on health care disparities. The available empirical evidence thus far suggests varied impacts of hospital VBP programs on health care disparities. Most of the reviewed studies in this paper demonstrate that hospital VBP programs have the tendency to exacerbate health care disparities, while a few others found evidence of little or no worsening impacts on disparities. We discuss several policy options and recommendations which include various reform approaches and specific programs ranging from those addressing upstream structural barriers to health care access, to health care delivery strategies that target service utilization and health outcomes of vulnerable populations under the VBP programs. Future studies are needed to produce more explicit, conclusive, and consistent evidence on the impacts of hospital VBP programs on disparities.