Neighborhood-level economic characteristics and depression and PTSD symptoms among Houstonians who have experienced Hurricane Harvey and COVID-19.

Little is known about how neighborhood economic characteristics relate to risk of depression and Posttraumatic Stress Disorder (PTSD) in the context of multiple disasters. We sampled 88 super neighborhoods in Houston, Texas and surveyed 872 residents who were living in Houston during Hurricane Harvey and COVID-19 and lived in the same residence since Hurricane Harvey, about their demographics and symptoms of depression and PTSD. Using data from the American Community Survey, we estimated neighborhood-level unemployment, median income, and income inequality (i.e., Gini coefficient). We investigated whether these underlying neighborhood socioeconomic factors were associated with the mental health consequences of mass traumatic events. We examined associations between neighborhood-level constructs and individual-level depression and PTSD, using multilevel linear models. Partially adjusted multilevel models showed that lower neighborhood median income was associated with higher symptom scores of PTSD, while greater neighborhood income inequality was associated with higher symptom scores of depression and PTSD. However, fully adjusted models showed that these associations are better accounted for by event-specific stressors and traumas. These findings suggest that in the context of multiple large scale traumatic events, neighborhood socioeconomic context may structure individual-level exposure to stressful and traumatic events.

I kua na'u "Let me carry out your last wishes" Clinical trial protocol to promote advance care planning among native Hawaiian populations.

Advance Care Planning (ACP) is a communication process about serious illness decision making designed to inform patients of possible medical options. Native Hawaiians consistently have low rates of ACP and low use of palliative and hospice care services. Our multidisciplinary community and research group partnered to create I kua na'u "Let Me Carry Out Your Last Wishes," an ACP intervention featuring culturally tailored videos and are now testing its efficacy. Focus groups and informant interviews were conducted with Native Hawaiian community members to ensure the curriculum honored the history, opinions, and culture of Native Hawaiians. Native Hawaiian culture has traditionally been an oral culture; the spoken word transmitted the mo'olelo, stories, traditions, histories and genealogies, which merges seamlessly with video media. The I kua na'u intervention included multiple educational sessions enhanced with videos (informational and personal). The specific aims are to compare ACP knowledge (primary outcome) and readiness for ACP engagement, ACP preferences, decisional conflict, and ACP completion rates via electronic medical record review (secondary outcomes) in 220 Native Hawaiians over age 55 in: (a) a randomized controlled trial of 110 people recruited from ambulatory clinics, and (b) a pre-post study design among 110 people living on Hawaiian Homestead communities located on lands set aside for Native Hawaiians or assisted living. Our protocol aims to evaluate the efficacy of our video-based educational intervention for Native Hawaiians to support decision making in this community and decrease disparities in serious illness care. Clinical Trial Registration Number: NCT04771208.

Effectiveness of an Enhanced Community Doula Intervention in a Safety Net Setting: A Randomized Controlled Trial.

Background: Racial inequities in maternal health outcomes, the result of systemic racism and social determinants of health, require maternity care systems to implement interventions that reduce disparities. One such approach may be support from a community doula, a health worker who provides emotional support, peer education, navigation, and advocacy for pregnant, birthing, and postpartum people who share similar racial identities, cultural backgrounds, and/or lived experiences. While community support during birth has a long tradition within communities of Black Indigenous and People of Color (BIPOC), the reframing of community doula support as a social intervention that reduces disparities in clinical outcomes is recent. Methods: We conducted a pragmatic randomized trial at an urban safety net hospital, comparing standard maternity care with standard care plus enhanced community doula support. We tested the effectiveness of a community doula program embedded in a safety net hospital in improving birth outcomes and explored the association between community doula support and health equity. Participants were nulliparous, insured by publicly funded health plans, and had lower risk pregnancies. The primary outcome was cesarean birth. Secondary outcomes included preterm birth and breastfeeding outcomes. Exploratory subgroup analysis was conducted by race-ethnicity. Results: Three hundred sixty-seven participants were included in the primary analysis. In the intent-to-treat analysis, outcomes were similar between groups. There was a trend toward increased breastfeeding initiation (p=0.08). There was a statistically nonsignificant 12% absolute reduction in cesarean birth and 11.5% increase in exclusive breastfeeding during delivery hospitalization among Black non-Hispanic participants. Discussion: While outcomes for the study sample were similar between randomization groups, health outcomes were improved for Black birthing people in cesarean and breastfeeding rates. Conclusion: This study demonstrates the need for larger studies of community doula support for Black birthing people. Clinicaltrials.gov ID: NCT02550730.

Trends and inequities in severe maternal morbidity in Massachusetts: A closer look at the last two decades.

It is estimated that 50,000-60,000 pregnant people in the United States (US) experience severe maternal morbidity (SMM). SMM includes life-threatening conditions, such as acute myocardial infarction, acute renal failure, amniotic fluid embolism, disseminated intravascular coagulation, or sepsis. Prior research has identified both rising rates through 2014 and wide racial disparities in SMM. While reducing maternal death and SMM has been a global goal for the past several decades, limited progress has been made in the US in achieving this goal. Our objectives were to examine SMM trends from 1998-2018 to identify factors contributing to the persistent and rising rates of SMM by race/ethnicity and describe the Black non-Hispanic/White non-Hispanic rate ratio for each SMM condition. We used a population-based data system that links delivery records to their corresponding hospital discharge records to identify SMM rates (excluding transfusion) per 10, 000 deliveries and examined the trends by race/ethnicity. We then conducted stratified analyses separately for Black and White birthing people. While the rates of SMM during the same periods steadily increased for all racial/ethnic groups, Black birthing people experienced the greatest absolute increase compared to any other race/ethnic group going from 69.4 in 1998-2000 to 173.7 per 10,000 deliveries in 2016-2018. In addition, we found that Black birthing people had higher rates for every individual condition compared to White birthing people, with rate ratios ranging from a low of 1.11 for heart failure during surgery to a high of 102.4 for sickle cell anemia. Obesity was not significantly associated with SMM among Black birthing people but was associated with SMM among White birthing people [aRR 1.18 (95% CI: 1.02, 1.36)]. An unbiased understanding of how SMM has affected different race/ethnicity groups is key to improving maternal health and preventing SMM and mortality among Black birthing people. SMM needs to be addressed as both a medical and public health challenge.

Medicaid Expansion and Change in Federally Qualified Health Center Accessibility From 2008 to 2016.

BACKGROUND: The Affordable Care Act expanded health coverage for low-income residents through Medicaid expansion and increased funding for Health Center Program New Access Points from 2009 to 2015, improving federally qualified health center (FQHC) accessibility. The extent to which these provisions progressed synergistically as intended when states could opt out of Medicaid expansion is unknown. OBJECTIVE: To compare change in FQHC accessibility among census tracts in Medicaid expansion and nonexpansion states. RESEARCH DESIGN: Tract-level FQHC accessibility scores for 2008 and 2016 were estimated applying the 2-step floating catchment area method to American Community Survey and Health Resources and Services Administration data. Multivariable linear regression compared changes in FQHC accessibility between tracts in Medicaid expansion and nonexpansion states, adjusting for sociodemographic and health system factors and accounting for state-level clustering. SUBJECTS: In total, 7058 census tracts across 10 states. RESULTS: FQHC accessibility increased comparably among tracts in Medicaid expansion and nonexpansion states (coef: 0.3; 95% CI: -0.3, 0.8; P -value: 0.36). FQHC accessibility increased more in tracts with higher poverty and uninsured rates, and those with lower proportions of non-English speakers and Black or African American residents. CONCLUSION: Similar gains in FQHC accessibility across Medicaid expansion and nonexpansion states indicate improvements progressed independently from Medicaid expansion, rather than synergistically as expected. Accessibility increases appeared consistent with HRSA's goal to improve access for individuals experiencing economic barriers to health care but not for those experiencing cultural or language barriers to health care.

Using community-engaged methods to develop a study protocol for a cost analysis of a multi-site patient navigation intervention for breast cancer care.

BACKGROUND: Patient navigation is an evidence-based intervention for reducing delays in oncology care among underserved populations. In order to address the financial sustainability of this intervention, information is needed on the cost of implementing patient navigation in diverse healthcare settings. Because patient navigation programs and care settings are highly variable, this paucity of cost data creates difficulties in identifying best practices and decisions about the feasibility of implementing navigation programs within a health care system. One barrier to collecting these cost data is the lack of assessment tools available to support patient navigation programs. These tools must be relevant to the wide variety of navigation activities that exist in health care settings, and be flexible enough to collect cost data important to stakeholders in fee-for-service and value-based care environments. METHODS AND RESULTS: We present a novel approach and methods for assessing the cost of a patient navigation program implemented across six hospital systems to enhance timely entry and uptake of breast cancer care and treatment. These methods and tools were developed in partnership with breast oncology patient navigators and supervisors using principles of stakeholder engagement, with the goal of increasing usability and feasibility in the field. CONCLUSIONS: This methodology can be used to strengthen cost analysis and assessment tools for other navigation programs for improving care and treatment for patients with chronic conditions. TRIAL REGISTRATION: NCT03514433.

Calculating power for the Finkelstein and Schoenfeld test statistic for a composite endpoint with two components.

The Finkelstein and Schoenfeld (FS) test is a popular generalized pairwise comparison approach to analyze prioritized composite endpoints (eg, components are assessed in order of clinical importance). Power and sample size estimation for the FS test, however, are generally done via simulation studies. This simulation approach can be extremely computationally burdensome, compounded by increasing number of composite endpoints and with increasing sample size. Here we propose an analytical solution to calculate power and sample size for commonly encountered two-component hierarchical composite endpoints. The power formulas are derived assuming underlying distributions in each of the component outcomes on the population level, which provide a computationally efficient and practical alternative to the standard simulation approach. Monte Carlo simulation results demonstrate that performance of the proposed power formulas are consistent with that of the simulation approach, and have generally desirable objective properties including robustness to mis-specified distributional assumptions. We demonstrate the application of the proposed formulas by calculating power and sample size for the Transthyretin Amyloidosis Cardiomyopathy Clinical Trial.

Utility of a virtual counselor (VICKY) to collect family health histories among vulnerable patient populations: A randomized controlled trial.

OBJECTIVES: This study is a randomized controlled trial comparing the efficacy of a virtual counselor (VICKY) to the My Family Health Portrait (MFHP) tool for collecting family health history (FHx). METHODS: A total of 279 participants were recruited from a large safety-net hospital and block randomized by health literacy to use one of the digital FHx tools, followed by a genetic counselor interview. A final sample of 273 participants were included for analyses of primary study aims pertaining to tool concordance, which assessed agreement between tool and genetic counselor. RESULTS: Tool completion differed significantly between tools (VICKY = 97%, MFHP = 51%; p < .0001). Concordance between tool and genetic counselor was significantly greater for participants randomized to VICKY compared to MFHP for ascertaining first- and second-degree relatives (ps<.0001), and most health conditions examined. There was significant interaction by health literacy, with greater differences in concordance observed between tools among those with limited literacy. CONCLUSIONS: A virtual counselor overcomes many of the literacy-related barriers to using traditional digital tools and highlights an approach that may be important to consider when collecting health histories from vulnerable populations. PRACTICE IMPLICATIONS: The usability of digital health history tools will have important implications for the quality of the data collected and its downstream clinical utility.

Phone-based monitoring to evaluate health policy and program implementation in Kenya.

Monitoring and evaluating policies and programs in low- and middle-income countries are often difficult because of the lack of routine data. High mobile phone ownership in these countries presents an opportunity for efficient data collection through telephone interviews. This study examined the feasibility of collecting data on medicines through telephone interviews in Kenya. Data on the availability and prices of medicines at 137 health facilities and 639 patients were collected in September 2016 via in-person interviews. Between December 2016 and December 2017, monthly telephone interviews were conducted with health facilities and patients. An unannounced in-person interview was conducted with respondents to validate the telephone interview within 24 h. A bottom-up itemization costing approach was used to estimate the costs of telephone and in-person data collection. In-depth interviews were conducted with data collectors and respondents to explore their perceptions on both modes of data collection. The level of agreement between data on medicines availability collected through phone and in-person interviews was strong at the health facility level [kappa = 0.90; confidence interval (CI) 0.88-0.92] and moderate at the household level (kappa = 0.50, CI 0.39-0.60). Price data from telephone and in-person interviews showed strong intra-class correlation at health facilities [intra-class correlation coefficient (ICC) = 0.96] and moderate intra-class correlation at households (ICC = 0.47). The cost per phone interview at health facilities and households were $19.73 and $16.86, respectively, compared to $186.20 for a baseline in-person interview. Participants considered telephone interviews to be more convenient. In countries with high cell phone penetration, telephone data collection should be considered in monitoring and evaluating public health programs especially at health facilities. Additional strategies may be needed to optimize this mode of data collection at the household level. Variations in cell phone ownership, telecommunication network and data collection costs across different settings may limit the generalizability of the findings from this study.

Frailty and Function in Heart Failure: Predictors of 30-Day Hospital Readmission?

BACKGROUND AND PURPOSE: Although there have been decreases noted in 30-day readmission rates for persons with heart failure since enactment of the Hospital Readmissions Reduction Program, costs related to heart failure readmissions remain high. Consequently, there is a need to better identify persons with heart failure who are at risk for 30-day hospital readmission. Therefore, this study aimed to compare the ability of measures of function and frailty to predict 30-day hospital readmissions for adults 65 years and older with heart failure. METHODS: Secondary data analysis using the 2011 National Health and Aging Trends Study analysis merged with Medicare claims data. Logistic regression modeling was used to compare the ability of function (Short Physical Performance Battery) and frailty (Fried's Physical Frailty Phenotype) to predict 30-day readmission. Receiver operating characteristic curves were constructed to examine the ability of function and frailty to identify those who were readmitted. RESULTS AND DISCUSSION: Frailty and function demonstrated comparable ability to predict 30-day readmissions (R2 = 0.087 and R2 = 0.087, respectively). Neither measure identified persons at risk for readmission (AUCSPPB = 0.608; AUCPFP = 0.587). CONCLUSIONS: Functional assessment demonstrated comparable ability to predict 30-day readmissions in persons with heart failure compared with frailty. However, neither measure was able to identify persons at high risk for readmission. Although frailty status is emphasized in research for older adults with heart failure, functional status is an important patient-level factor associated with readmission.

Improving the health of young African American women in the preconception period using health information technology: a randomised controlled trial.

BACKGROUND: Preconception care focuses on improving women's health before pregnancy as a means to improve their health and future pregnancy outcomes. How to effectively deliver such care is unknown. The aim of this research was to assess the impact of an embodied conversational agent system on preconception risks among African American and Black women. METHODS: We did an open-label, randomised controlled trial of women aged 18-34 years, self-identified as African American or Black, or both, and not pregnant, recruited from 35 states in the USA. Sealed allocation envelopes (in permuted blocks of six and eight, prepared using a random number generator) were opened after enrolment. Intervention participants received an online conversational agent called Gabby that assessed 102 preconception risks and delivered 12 months of tailored dialogue using synthesised speech, non-verbal behaviour, visual aids, and health behaviour change techniques such as motivational interviewing. The control group received a letter listing their preconception risks and encouraging them to talk with a clinician. The primary outcome was the proportion of identified risks at the action or maintenance stage of change at months 6 and 12. The study is registered with ClinicalTrials.gov, NCT01827215. FINDINGS: From March 11, 2014, through July 8, 2018, 528 women recruited from 35 states and 242 cities across the USA received the Gabby intervention (n=262) or were assigned to the control group (n=266). Participants identified a mean of 21 preconception risks per woman (SD 9·9). In the intention-to-treat analysis, at 6 months, intervention women reported reaching the action or maintenance stage of change for 50·0% (SD 28·9) of those preconception risks identified compared with 42·7% (28·3) in the control group (incidence rate ratio 1·16, 95% CI 1·07-1·26; p=0·0004). This result persisted at 12 months. INTERPRETATION: The Gabby system has the potential to improve women's preconception health. Further research is needed to determine if improving preconception risks impacts outcomes such as preterm delivery. FUNDING: National Institute for Minority Health and Health Disparities.

Availability and prices of medicines for non-communicable diseases at health facilities and retail drug outlets in Kenya: a cross-sectional survey in eight counties.

OBJECTIVES: The objective of this study was to determine the availability and prices of medicines for non-communicable diseases (NCDs) in health facilities and private for-profit drug outlets in Kenya. DESIGN: Cross-sectional study. METHODS: All public and non-profit health facilities in eight counties (Embu, Kakamega, Kwale, Makueni, Narok, Nyeri, Samburu and West Pokot) that purchased medicines from the Mission for Essential Drugs and Supplies, a major wholesaler, were surveyed in September 2016. For each health facility, one nearby private for-profit drug outlet was also surveyed. Data on availability and price were analysed for 24 NCD and 8 acute medicine formulations. Availability was analysed separately for medicines in the national Essential Medicines List (EML) and those in the Standard Treatment Guidelines (STGs). Median price ratios were estimated using the International Medical Products Price Guide as a reference. RESULTS: 59 public and 78 non-profit facilities and 135 drug outlets were surveyed. Availability of NCD medicines was highest in private for-profit drug outlets (61.7% and 29.3% for medicines on the EML and STGs, respectively). Availability of STG medicines increased with increasing level of care of facilities: 16.1% at dispensaries to 31.7% at secondary referral facilities. The mean proportion of availability for NCD medicines listed in the STGs (0.25) was significantly lower than for acute medicines (0.61), p<0.0001. The proportion of public facilities giving medicines for free (0.47) was significantly higher than the proportion of private non-profit facilities giving medicines for free (0.09) (p<0.0001). The mean price ratio of NCD medicines was significantly higher than for acute medicines in non-profit facilities (4.1 vs 2.0, respectively; p=0.0076), and in private for-profit drug outlets (3.5 vs 1.7; p=0.0013). CONCLUSION: Patients with NCDs in Kenya appear to have limited access to medicines. Increasing access should be a focus of efforts to achieve universal health coverage.

Translating research into practice: Protocol for a community-engaged, stepped wedge randomized trial to reduce disparities in breast cancer treatment through a regional patient navigation collaborative.

BACKGROUND: Racial and socioeconomic disparities in breast cancer mortality persist. In Boston, MA, Black, Non-Hispanic women and Medicaid-insured individuals are 2-3 times more likely to have delays in treatment compared to White or privately insured women. While evidence-based care coordination strategies for reducing delays exist, they are not systematically implemented across healthcare settings. METHODS: Translating Research Into Practice (TRIP) utilizes community engaged research methods to address breast cancer care delivery disparities. Four Massachusetts Clinical and Translational Science Institute (CTSI) hubs collaborated with the Boston Breast Cancer Equity Coalition (The Coalition) to implement an evidence-based care coordination intervention for Boston residents at risk for delays in breast cancer care. The Coalition used a community-driven process to define the problem of care delivery disparities, identify the target population, and develop a rigorous pragmatic approach. We chose a cluster-randomized, stepped-wedge hybrid type I effectiveness-implementation study design. The intervention implements three evidence-based strategies: patient navigation services, a shared patient registry for use across academic medical centers, and a web-based social determinants of health platform to identify and address barriers to care. Primary clinical outcomes include time to first treatment and receipt of guideline-concordant treatment, which are captured through electronic health records abstraction. We will use mixed methods to collect the secondary implementation outcomes of acceptability, adoption/penetration, fidelity, sustainability and cost. CONCLUSION: TRIP utilizes an innovative community-driven research strategy, focused on interdisciplinary collaborations, to design and implement a translational science study that aims to more efficiently integrate proven health services interventions into clinical practice.

Using Health Information Technology to Engage African American Women on Nutrition and Supplement Use During the Preconception Period.

Importance: Healthy nutrition and appropriate supplementation during preconception have important implications for the health of the mother and newborn. The best way to deliver preconception care to address health risks related to nutrition is unknown. Methods: We conducted a secondary analysis of data from a randomized controlled trial designed to study the impact of conversational agent technology in 13 domains of preconception care among 528 non-pregnant African American and Black women. This analysis is restricted to those 480 women who reported at least one of the ten risks related to nutrition and dietary supplement use. Interventions: An online conversational agent, called "Gabby", assesses health risks and delivers 12 months of tailored dialogue for over 100 preconception health risks, including ten nutrition and supplement risks, using behavioral change techniques like shared decision making and motivational interviewing. The control group received a letter listing their preconception risks and encouraging them to talk to a health care provider. Results: After 6 months, women using Gabby (a) reported progressing forward on the stage of change scale for, on average, 52.9% (SD, 35.1%) of nutrition and supplement risks compared to 42.9% (SD, 35.4) in the control group (IRR 1.22, 95% CI 1.03-1.45, P = 0.019); and (b) reported achieving the action and maintenance stage of change for, on average, 52.8% (SD 37.1) of the nutrition and supplement risks compared to 42.8% (SD, 37.9) in the control group (IRR 1.26, 96% CI 1.08-1.48, P = 0.004). For subjects beginning the study at the contemplation stage of change, intervention subjects reported progressing forward on the stage of change scale for 75.0% (SD, 36.3%) of their health risks compared to 52.1% (SD, 47.1%) in the control group (P = 0.006). Conclusion: The scalability of Gabby has the potential to improve women's nutritional health as an adjunct to clinical care or at the population health level. Further studies are needed to determine if improving nutrition and supplement risks can impact clinical outcomes including optimization of weight. Clinical Trial Registration: ClinicalTrials.gov, identifier NCT01827215.

A novel confidence interval for a single proportion in the presence of clustered binary outcome data.

Estimating the precision of a single proportion via a 100(1-α)% confidence interval in the presence of clustered data is an important statistical problem. It is necessary to account for possible over-dispersion, for instance, in animal-based teratology studies with within-litter correlation, epidemiological studies that involve clustered sampling, and clinical trial designs with multiple measurements per subject. Several asymptotic confidence interval methods have been developed, which have been found to have inadequate coverage of the true proportion for small-to-moderate sample sizes. In addition, many of the best-performing of these intervals have not been directly compared with regard to the operational characteristics of coverage probability and empirical length. This study uses Monte Carlo simulations to calculate coverage probabilities and empirical lengths of five existing confidence intervals for clustered data across various true correlations, true probabilities of interest, and sample sizes. In addition, we introduce a new score-based confidence interval method, which we find to have better coverage than existing intervals for small sample sizes under a wide range of scenarios.

Unrestricted Direct Access to Physical Therapist Services Is Associated With Lower Health Care Utilization and Costs in Patients With New-Onset Low Back Pain.

BACKGROUND: Low back pain (LBP) is one of the most prevalent conditions for which patients seek physical therapy in the United States. The American Physical Therapy Association categorizes direct access to physical therapist services into 3 levels: limited, provisional, and unrestricted. OBJECTIVE: The objective of this study was to evaluate the association of level of access to physical therapist services with LBP-related health care utilization and costs. DESIGN: This was a retrospective cohort study of patients with new-onset LBP between 2008 and 2013; data were from OptumLabs Data Warehouse. METHODS: We identified 59,670 individuals who were 18 years old or older, who had new-onset LBP, and who had commercial or Medicare Advantage insurance through a private health plan. We examined 2 samples. The first was health care utilization among individuals who saw a physical therapist first in states with either unrestricted access or provisional access. The second was LBP-related costs among individuals who saw either a physical therapist or a primary care physician first. RESULTS: Individuals who saw a physical therapist first in states with provisional access had significantly higher measures of health care utilization within 30 days, including plain imaging and frequency of physician visits, than individuals who saw a physical therapist first in states with unrestricted access. Compared with individuals who saw a primary care physician first, pooled across provisional-access and unrestricted-access states, those who saw a physical therapist first in provisional-access states had 25% higher relative costs at 30 days and 32% higher relative costs at 90 days, whereas those who saw a physical therapist first in unrestricted-access states had 13% lower costs at 30 days and 32% lower costs at 90 days. LIMITATIONS: This was a claims-based study with limited information on patient characteristics, including severity and duration of pain. CONCLUSIONS: Short-term LBP-related health care utilization and costs were lower for individuals in unrestricted-access states than in provisional-access states.

Designing and Evaluating a Digital Family Health History Tool for Spanish Speakers.

Digital family health history tools have been developed but few have been tested with non-English speakers and evaluated for acceptability and usability. This study describes the cultural and linguistic adaptation and evaluation of a family health history tool (VICKY: VIrtual Counselor for Knowing Your Family History) for Spanish speakers. In-depth interviews were conducted with 56 Spanish-speaking participants; a subset of 30 also participated in a qualitative component to evaluate the acceptability and usability of Spanish VICKY. Overall, agreement in family history assessment was moderate between VICKY and a genetic counselor (weighted kappa range: 0.4695 for stroke-0.6615 for heart disease), although this varied across disease subtypes. Participants felt comfortable using VICKY and noted that VICKY was very likeable and possessed human-like characteristics. They reported that VICKY was very easy to navigate, felt that the instructions were very clear, and thought that the time it took to use the tool was just right. Spanish VICKY may be useful as a tool to collect family health history and was viewed as acceptable and usable. The study results shed light on some cultural differences that may influence interactions with family history tools and inform future research aimed at designing and testing culturally and linguistically diverse digital systems.

Observational retrospective study of the association of initial healthcare provider for new-onset low back pain with early and long-term opioid use.

OBJECTIVE: This study examined the association of initial provider treatment with early and long-term opioid use in a national sample of patients with new-onset low back pain (LBP). DESIGN: A retrospective cohort study of patients with new-onset LBP from 2008 to 2013. SETTING: The study evaluated outpatient and inpatient claims from patient visits, pharmacy claims and inpatient and outpatient procedures with initial providers seen for new-onset LBP. PARTICIPANTS: 216 504 individuals aged 18 years or older across the USA who were diagnosed with new-onset LBP and were opioid-naïve were included. Participants had commercial or Medicare Advantage insurance. EXPOSURES: The primary independent variable is type of initial healthcare provider including physicians and conservative therapists (physical therapists, chiropractors, acupuncturists). MAIN OUTCOME MEASURES: Short-term opioid use (within 30 days of the index visit) following new LBP visit and long-term opioid use (starting within 60 days of the index date and either 120 or more days' supply of opioids over 12 months, or 90 days or more supply of opioids and 10 or more opioid prescriptions over 12 months). RESULTS: Short-term use of opioids was 22%. Patients who received initial treatment from chiropractors or physical therapists had decreased odds of short-term and long-term opioid use compared with those who received initial treatment from primary care physicians (PCPs) (adjusted OR (AOR) (95% CI) 0.10 (0.09 to 0.10) and 0.15 (0.13 to 0.17), respectively). Compared with PCP visits, initial chiropractic and physical therapy also were associated with decreased odds of long-term opioid use in a propensity score matched sample (AOR (95% CI) 0.21 (0.16 to 0.27) and 0.29 (0.12 to 0.69), respectively). CONCLUSIONS: Initial visits to chiropractors or physical therapists is associated with substantially decreased early and long-term use of opioids. Incentivising use of conservative therapists may be a strategy to reduce risks of early and long-term opioid use.

Health Literacy and Income Mediate Racial/Ethnic Asthma Disparities.

BACKGROUND: Health literacy and socioeconomic status (SES) are associated with both race/ethnicity and asthma outcomes. The extent to which health literacy and SES mediate racial/ethnic asthma disparities is less clear. OBJECTIVE: To determine if health literacy and SES mediate racial/ethnic asthma disparities using advanced mediation analyses. METHODS: A secondary analysis was performed using a Chicago-based longitudinal cohort study conducted from 2004 to 2007 involving 342 adults age 18 to 41 years with persistent asthma. Phone interviews were conducted every 3 months assessing asthma quality of life (AQOL; scored 1-7, with 7 being the highest) and asthma-related health care use measures. Structural equation models assessed mediation of race/ethnicity effects on AQOL and health care use through health literacy and SES. Covariates in the best-fit model included sex, year and season of interview, and cigarette smoking. KEY RESULTS: The study sample was 77.8% female, 57.3% African American/non-Hispanic, and 28.7% Hispanic. Race/ethnicity was significantly associated with AQOL and asthma-related emergency department (ED) visits, but only indirectly, through the effects of health literacy and income. Compared with White/non-Hispanics, African American/non-Hispanics and Hispanics had significantly higher odds of low health literacy and lower income. Low health literacy was associated with significantly lower AQOL scores (ß = -0.24, 95% confidence interval (CI) [-0.38, -0.10]) and higher odds of an ED visit (adjusted odds ratio = 1.24, 95% CI [1.07, 1.43]). Increasing income was associated with significantly higher AQOL scores (ß = 0.18, 95% CI [0.08, 0.28]) and lower odds of an ED visit (adjusted odds ratio = 0.88, 95% CI [0.80, 0.97]). CONCLUSIONS: The relationships between race/ethnicity and several asthma outcomes were mediated by health literacy and income. Interventions to improve racial/ethnic asthma disparities should target health literacy and income barriers. [HLRP: Health Literacy Research and Practice. 2019;3(1):e9-e18.]. PLAIN LANGUAGE SUMMARY: Using advanced statistical methods, this study suggests racial/ethnic differences in several asthma outcomes are largely due to effects of health literacy and income. Interventions to improve racial/ethnic asthma disparities should target health literacy and income barriers.

Health insurance design and conservative therapy for low back pain.

OBJECTIVES: To determine the association of health insurance benefit design features with choice of early conservative therapy for patients with new-onset low back pain (LBP). STUDY DESIGN: Observational study of 117,448 commercially insured adults 18 years or older presenting with an outpatient diagnosis of new-onset LBP between 2008 and 2013 as recorded in the OptumLabs Data Warehouse. METHODS: We identified patients who chose a primary care physician (PCP), physical therapist, or chiropractor as their entry-point provider. The main analyses were logistic regression models that estimated the likelihood of choosing a physical therapist versus a PCP and choosing a chiropractor versus a PCP. Key independent variables were health plan type, co-payment, deductible, and participation in a health reimbursement account (HRA) or health savings account (HSA). Models controlled for patient demographic and clinical characteristics. RESULTS: Selection of entry-point provider was moderately responsive to the incentives that patients faced. Those covered under plan types with greater restrictions on provider choice were less likely to choose conservative therapy compared with those covered under the least restrictive plan type. Results also indicated a general pattern of higher likelihood of treatment with physical therapy at lower levels of patient cost sharing. We did not observe consistent associations between participation in HRAs or HSAs and choice of conservative therapy. CONCLUSIONS: Modification of health insurance benefit designs offers an opportunity for creating greater value in treatment of new-onset LBP by encouraging patients to choose noninvasive conservative management that will result in long-term economic and social benefits.