US Medical-Legal Partnerships to Address Health-Harming Legal Needs: Closing the Health Injustice Gap.

The medical-legal partnership (MLP) model is emerging across the USA as a powerful tool to address the adverse social conditions underlying health injustice. MLPs embed legal experts into healthcare teams to address health-harming legal needs with civil legal remedies. We conducted a narrative review of peer-reviewed articles published between 2007 and 2022 to characterize the structure and impacts of US MLPs on patients, providers, and healthcare systems. We found that MLPs largely serve vulnerable patient populations by integrating legal experts into community-based clinical settings or children's hospitals, although patient populations and settings varied widely. In most models, healthcare providers were trained to screen patients for legal needs and refer them to legal experts. MLPs provided a wide range of services, such as assistance accessing public benefits (e.g., Social Security, Medicaid, cash assistance) and legal representation for immigration and family law matters. Patients and their families also benefited from increased knowledge about legal rights and systems. Though the evidence base remains nascent, available studies show MLPs to be associated with greater access to care, fewer hospitalizations, and improved physical and mental health outcomes. Medical and legal providers who were engaged in MLPs reported interdisciplinary learning, and healthcare systems often experienced high returns on investment through cost savings and increased Medicaid reimbursement. Many MLPs also conducted advocacy and education to effect broader policy changes related to population health and social needs. To optimize the MLP model, more rigorous research, systematic implementation practices, evaluation metrics, and sustainable funding mechanisms are recommended. Broader integration of MLPs into healthcare systems could help address root causes of health inequity among historically marginalized populations in the USA.

Screening for Financial Hardship: Comparing Patient Survey Responses Using Two Different Screening Tools.

BACKGROUND: Healthcare delivery organizations are increasingly screening patients for social risks using tools that vary in content and length. OBJECTIVES: To compare two screening tools both containing questions related to financial hardship. DESIGN: Cross-sectional survey. PARTICIPANTS: Convenience sample of adult patients (n = 471) in three primary care clinics. MAIN MEASURES: Participants randomly assigned to self-complete either: (1) a screening tool developed by the Centers for Medicare & Medicaid Services (CMS) consisting of six questions on financial hardship (housing stability, housing quality, food security, transportation security, utilities security); or (2) social and behavioral risk measures recommended by the National Academy of Medicine (NAM), including one question on financial hardship (financial strain). We compared patient acceptability of screening, positive screening rates for financial hardship, patient interest in assistance, and self-rated health. RESULTS: Ninety-one percent of eligible/interested patients completed the relevant survey questions to be included in the study (N = 471/516). Patient acceptability was high for both tools, though more participants reported screening was appropriate when answering the CMS versus NAM questions (87% vs. 79%, p = 0.02). Of respondents completing the CMS tool, 57% (132/232) reported at least one type of financial hardship; on the NAM survey, 52% (125/239) reported financial hardship (p = 0.36). Nearly twice as many respondents indicated interest in assistance related to financial hardship after completing items on the CMS tool than on the NAM question (39% vs. 21%, p < 0.01). CONCLUSIONS: Patients reported high acceptability of both social risk assessment tools. While rates of positive screens for financial hardship were similar across the two measures, more patients indicated interest in assistance after answering questions about financial hardship on the CMS tool. This might be because the screening questions on the CMS tool help patients to appreciate the types of assistance related to financial hardship that may be available after screening. Future research should assess the validity and comparative validity of individual measures and measure sets. Tool selection should be based on setting and population served, screening goals, and resources available.

Exploring Experiences of Traumatic Microaggressions Toward Surgeons and Surgical Residents.

INTRODUCTION: Studies have suggested that experiences of gender and racial discrimination are widespread among surgeons and surgical residents. This study examines the relationship between experienced microaggressions and traumatic stress. METHODS: A one-time, deidentified survey was distributed over email to academic surgical societies. The survey consisted of 35 items including questions on prevalence of microaggressions, perceived job impacts as well as a shortened version of the Trauma Symptoms of Discrimination Scale. Chi-square tests and an independence test for trends were utilized to determine significance. RESULTS: We collected data from 130 participants with majority (81%) having experienced microaggressions in the workplace. On measures of worry (P < 0.001), avoidance (P = 0.012), anxiety (P = 0.004), and trouble relaxing (P = 0.002), racial/ethnic minority surgeons and trainees demonstrated significantly higher scores. With perceived job impacts, significant agreement was seen with occurrences of working harder to prove competence (P = 0.005), gaining patient confidence (P < 0.001), reduced career satisfaction (P = 0.011), work-related negative talk (P = 0.018), and burnout at work due to microaggressions (P = 0.019). Among participants who underwent behavioral modifications, female surgeons were more likely to change their nonverbal communication styles (P < 0.001) and spend more time with patients (P < 0.001). CONCLUSIONS: Experiences of microaggressions are associated with increased anxiety-related trauma symptoms in racial/ethnic minority surgeons and surgical trainees. Additionally, these experiences of microaggression can influence job satisfaction, burnout, career perceptions and workplace behaviors. As the field of surgery becomes more diverse, this study contributes to growing awareness of the role of implicit discrimination in the attrition and retention of racial/ethnic minority surgeons and female surgeons.

Longer-term Benefits and Risks of Sodium-Glucose Cotransporter-2 Inhibitors in Type 2 Diabetes: a Systematic Review and Meta-analysis.

BACKGROUND: Sodium-glucose cotransporter-2 inhibitors (SGLT2Is) are a recent class of medication approved for the treatment of type 2 diabetes (T2D). Previous meta-analyses have quantified the benefits and harms of SGLT2Is; however, these analyses have been limited to specific outcomes and comparisons and included trials of short duration. We comprehensively reviewed the longer-term benefits and harms of SGLT2Is compared to placebo or other anti-hyperglycemic medications. METHODS: We searched PubMed, Scopus, and clinicaltrials.gov from inception to July 2019 for randomized controlled trials of minimum 52 weeks' duration that enrolled adults with T2D, compared an SGLT2I to either placebo or other anti-hyperglycemic medications, and reported at least one outcome of interest including cardiovascular risk factors, microvascular and macrovascular complications, mortality, and adverse events. We conducted random effects meta-analyses to provide summary estimates using weighted mean differences (MD) and pooled relative risks (RR). The study was registered a priori with PROSPERO (CRD42018090506). RESULTS: Fifty articles describing 39 trials (vs. placebo, n = 28; vs. other anti-hyperglycemic medication, n = 12; vs. both, n = 1) and 112,128 patients were included in our analyses. Compared to placebo, SGLT2Is reduced cardiovascular risk factors (e.g., hemoglobin A1c, MD - 0.55%, 95% CI - 0.62, - 0.49), macrovascular outcomes (e.g., hospitalization for heart failure, RR 0.70, 95% CI 0.62, 0.78), and mortality (RR 0.87, 95% CI 0.80, 0.94). Compared to other anti-hyperglycemic medications, SGLT2Is reduced cardiovascular risk factors, but insufficient data existed for other outcomes. About a fourfold increased risk of genital yeast infections for both genders was observed for comparisons vs. placebo and other anti-hyperglycemic medications. DISCUSSION: We found that SGLT2Is led to durable reductions in cardiovascular risk factors compared to both placebo and other anti-hyperglycemic medications. Reductions in macrovascular complications and mortality were only observed in comparisons with placebo, although trials comparing SGLT2Is vs. other anti-hyperglycemic medications were not designed to assess longer-term outcomes.

The Longer-Term Benefits and Harms of Glucagon-Like Peptide-1 Receptor Agonists: a Systematic Review and Meta-Analysis.

BACKGROUND: Previous meta-analyses of the benefits and harms of glucagon-like peptide-1 receptor agonists (GLP1RAs) have been limited to specific outcomes and comparisons and often included short-term results. We aimed to estimate the longer-term effects of GLP1RAs on cardiovascular risk factors, microvascular and macrovascular complications, mortality, and adverse events in patients with type 2 diabetes, compared to placebo and other anti-hyperglycemic medications. METHODS: We searched PubMed, Scopus, and clinicaltrials.gov (inception-July 2019) for randomized controlled trials ≥ 52 weeks' duration that compared a GLP1RA to placebo or other anti-hyperglycemic medication and included at least one outcome of interest. Outcomes included cardiovascular risk factors, microvascular and macrovascular complications, all-cause mortality, and treatment-related adverse events. We performed random effects meta-analyses to give summary estimates using weighted mean differences (MD) and pooled relative risks (RR). Risk of bias was assessed using the Cochrane Collaboration risk of bias in randomized trials tool. Quality of evidence was summarized using the Grading of Recommendations, Assessment, Development, and Evaluation approach. The study was registered a priori with PROSPERO (CRD42018090506). RESULTS: Forty-five trials with a mean duration of 1.7 years comprising 71,517 patients were included. Compared to placebo, GLP1RAs reduced cardiovascular risk factors, microvascular complications (including renal events, RR 0.85, 0.80-0.90), macrovascular complications (including stroke, RR 0.86, 0.78-0.95), and mortality (RR 0.89, 0.84-0.94). Compared to other anti-hyperglycemic medications, GLP1RAs only reduced cardiovascular risk factors. Increased gastrointestinal events causing treatment discontinuation were observed in both comparisons. DISCUSSION: GLP1RAs reduced cardiovascular risk factors and increased gastrointestinal events compared to placebo and other anti-hyperglycemic medications. GLP1RAs also reduced MACE, stroke, renal events, and mortality in comparisons with placebo; however, analyses were inconclusive for comparisons with other anti-hyperglycemic medications. Given the high costs of GLP1RAs, the lack of long-term evidence comparing GLP1RAs to other anti-hyperglycemic medications has significant policy and clinical practice implications.

Building and experimenting with an agent-based model to study the population-level impact of CommunityRx, a clinic-based community resource referral intervention.

CommunityRx (CRx), an information technology intervention, provides patients with a personalized list of healthful community resources (HealtheRx). In repeated clinical studies, nearly half of those who received clinical "doses" of the HealtheRx shared their information with others ("social doses"). Clinical trial design cannot fully capture the impact of information diffusion, which can act as a force multiplier for the intervention. Furthermore, experimentation is needed to understand how intervention delivery can optimize social spread under varying circumstances. To study information diffusion from CRx under varying conditions, we built an agent-based model (ABM). This study describes the model building process and illustrates how an ABM provides insight about information diffusion through in silico experimentation. To build the ABM, we constructed a synthetic population ("agents") using publicly-available data sources. Using clinical trial data, we developed empirically-informed processes simulating agent activities, resource knowledge evolution and information sharing. Using RepastHPC and chiSIM software, we replicated the intervention in silico, simulated information diffusion processes, and generated emergent information diffusion networks. The CRx ABM was calibrated using empirical data to replicate the CRx intervention in silico. We used the ABM to quantify information spread via social versus clinical dosing then conducted information diffusion experiments, comparing the social dosing effect of the intervention when delivered by physicians, nurses or clinical clerks. The synthetic population (N = 802,191) exhibited diverse behavioral characteristics, including activity and knowledge evolution patterns. In silico delivery of the intervention was replicated with high fidelity. Large-scale information diffusion networks emerged among agents exchanging resource information. Varying the propensity for information exchange resulted in networks with different topological characteristics. Community resource information spread via social dosing was nearly 4 fold that from clinical dosing alone and did not vary by delivery mode. This study, using CRx as an example, demonstrates the process of building and experimenting with an ABM to study information diffusion from, and the population-level impact of, a clinical information-based intervention. While the focus of the CRx ABM is to recreate the CRx intervention in silico, the general process of model building, and computational experimentation presented is generalizable to other large-scale ABMs of information diffusion.

Patient Experiences with Screening and Assistance for Social Isolation in Primary Care Settings.

BACKGROUND: Social isolation is a known predictor of mortality that disproportionately affects vulnerable populations in the USA. Although experts began to recognize it as a public health crisis prior to 2020, the novel coronavirus pandemic has accelerated recognition of social isolation as a serious threat to health and well-being. OBJECTIVE: Examine patient experiences with screening and assistance for social isolation in primary care settings, and whether patient experiences with these activities are associated with the severity of reported social isolation. DESIGN: Cross-sectional survey conducted in 2018. PARTICIPANTS: Adults (N = 251) were recruited from 3 primary care clinics in Boston, Chicago, and San Francisco. MAIN MEASURES: A modified version of the Berkman-Syme Social Network Index (SNI), endorsed by the National Academies of Sciences, Engineering, and Medicine; items to assess for prior experiences with screening and assistance for social isolation. KEY RESULTS: In the sample population, 12.4% reported the highest levels of social isolation (SNI = 0/1), compared to 36.7%, 34.7%, and 16.3% (SNI = 2-4, respectively). Most patients had not been asked about social isolation in a healthcare setting (87.3%), despite reporting no discomfort with social isolation screening (93.9%). Neither discomfort with nor participation in prior screening for social isolation was associated with social isolation levels. Desire for assistance with social isolation (3.2%) was associated with a higher level of social isolation (AOR = 6.0, 95% CI, 1.3-28.8), as well as poor or fair health status (AOR = 9.1; 95% CI, 1.3-64.1). CONCLUSIONS: In this study, few patients reported being screened previously for social isolation in a primary care setting, despite low levels of discomfort with screening. Providers should consider broadening social isolation screening and referral practices in healthcare settings, especially among sicker and more isolated patients who express higher levels of interest in assistance with social isolation.

Neighborhood Disadvantage and Hospital Quality Ratings in the Medicare Hospital Compare Program.

BACKGROUND: The Centers for Medicare and Medicaid Services provide nationwide hospital ratings that may influence reimbursement. These ratings do not account for the social risk of communities and may inadvertently penalize hospitals that service disadvantaged neighborhoods. OBJECTIVE: This study examines the relationship between neighborhood social risk factors (SRFs) and hospital ratings in Medicare's Hospital Compare Program. RESEARCH DESIGN: 2017 Medicare Hospital Compare ratings were linked with block group data from the 2015 American Community Survey to assess hospital ratings as a function of neighborhood SRFs. SUBJECTS: A total of 3608 Medicare-certified hospitals in 50 US states. MEASURES: Hospital summary scores and 7 quality group scores (100 percentile scale), including effectiveness of care, efficiency of care, hospital readmission, mortality, patient experience, safety of care, and timeliness of care. RESULTS: Lower hospital summary scores were associated with caring for neighborhoods with higher social risk, including a reduction in hospital score for every 10% of residents who reported dual-eligibility for Medicare/Medicaid [-3.3%; 95% confidence interval (CI), -4.7 to -2.0], no high-school diploma (-0.8%; 95% CI, -1.5 to -0.1), unemployment (-1.2%; 95% CI, -1.9 to -0.4), black race (-1.2%; 95% CI, -1.7 to -0.8), and high travel times to work (-2.5%; 95% CI, -3.3 to -1.6). Associations between neighborhood SRFs and hospital ratings were largest in the timeliness of care, patient experience, and hospital readmission groups; and smallest in the safety, efficiency, and effectiveness of care groups. CONCLUSIONS: Hospitals serving communities with higher social risk may have lower ratings because of neighborhood factors. Failing to account for neighborhood social risk in hospital rating systems may reinforce hidden disincentives to care for medically underserved areas in the United States.

Impact of a Low-Intensity Resource Referral Intervention on Patients' Knowledge, Beliefs, and Use of Community Resources: Results from the CommunityRx Trial.

BACKGROUND: Connecting patients to community-based resources is now a cornerstone of modern healthcare that supports self-management of health. The mechanisms that link resource information to behavior change, however, remain poorly understood. OBJECTIVE: To evaluate the impact of CommunityRx, an automated, low-intensity resource referral intervention, on patients' knowledge, beliefs, and use of community resources. DESIGN: Real-world controlled clinical trial at an urban academic medical center in 2015-2016; participants were assigned by alternating week to receive the CommunityRx intervention or usual care. Surveys were administered at baseline, 1 week, 1 month, and 3 months. PARTICIPANTS: Publicly insured adults, ages 45-74 years. INTERVENTION: CommunityRx generated an automated, personalized list of resources, known as HealtheRx, near each participant's home using condition-specific, evidence-based algorithms. Algorithms used patient demographic and health characteristics documented in the electronic health record to identify relevant resources from a comprehensive, regularly updated database of health-related resources in the study area. MAIN MEASURES: Using intent-to-treat analysis, we examined the impact of HealtheRx referrals on (1) knowledge of the most commonly referred resource types, including healthy eating classes, individual counseling, mortgage assistance, smoking cessation, stress management, and weight loss classes or groups, and (2) beliefs about having resources in the community to manage health. KEY RESULTS: In a real-world controlled trial of 374 adults, intervention recipients improved knowledge (AOR = 2.15; 95% CI, 1.29-3.58) and beliefs (AOR = 1.68; 95% CI, 1.07-2.64) about common resources in the community to manage health, specifically gaining knowledge about smoking cessation (AOR = 2.76; 95% CI, 1.07-7.12) and weight loss resources (AOR = 2.26; 95% CI 1.05-4.84). Positive changes in both knowledge and beliefs about community resources were associated with higher resource use (P = 0.02). CONCLUSIONS: In a middle-age and older population with high morbidity, a low-intensity health IT intervention to deliver resource referrals promoted behavior change by increasing knowledge and positive beliefs about community resources for self-management of health. NIH TRIAL REGISTRY: NCT02435511.

CommunityRx: A Real-World Controlled Clinical Trial of a Scalable, Low-Intensity Community Resource Referral Intervention.

OBJECTIVES: To test the effect of CommunityRx, a scalable, low-intensity intervention that matches patients to community resources, on mental health-related quality of life (HRQOL) (primary outcome), physical HRQOL, and confidence in finding resources. METHODS: A real-world trial assigned publicly insured residents of Chicago, Illinois, aged 45 to 74 years to an intervention (n = 209) or control (n = 202) group by alternating calendar week, December 2015 to August 2016. Intervention group participants received usual care and an electronic medical record-generated, personalized list of community resources. Surveys (baseline, 1-week, 1- and 3-months) measured HRQOL and confidence in finding community resources to manage health. RESULTS: At 3 months, there was no difference between groups in mental (-1.03; 95% confidence interval [CI] = -3.02, 0.96) or physical HRQOL (0.59; 95% CI = -0.98, 2.16). Confidence in finding resources was higher in the intervention group (odds ratio = 2.08; 95% CI = 1.18, 3.63); the effect increased at each successive time point. Among intervention group participants, 65% recalled receiving the intervention; 48% shared community resource information with others. CONCLUSIONS: CommunityRx did not increase HRQOL, but its positive effect on confidence in finding resources for self-care suggests that this low-intensity intervention may have a role in population health promotion. TRIAL REGISTRATION: ClinicalTrials.gov Identifier: NCT02435511.

Experiences of Community Violence Among Adults with Chronic Conditions: Qualitative Findings from Chicago.

BACKGROUND: Community violence is an important social determinant of health in many high-poverty, urban communities. OBJECTIVE: The purpose of this study was to explore and characterize self-described experiences of community violence among adults with chronic health conditions. DESIGN: Qualitative study design was implemented in 2017 using in-depth, semi-structured focus groups and interviews; data were collected from two clinical sites located in geographic epicenters of high violent crime in Chicago. PARTICIPANTS: Adult patients, ages 35 years and older, who had at least one chronic condition. APPROACH: Data were analyzed using grounded theory and the constant comparison method. KEY RESULTS: The overall sample (N = 51) was predominantly female (67%) and black non-Hispanic (75%); a large proportion had hypertension (65%), arthritis (55%), obesity (53%), and/or diabetes (45%). The majority reported that a close friend or family member was seriously injured or killed due to community violence (71%); a similar proportion had never discussed their experiences of community violence with a healthcare provider (73%). Several major themes emerged: (1) perceived risk of being targeted, (2) chronic stress and worry, (3) hypervigilance, (4) social breakdown, (5) chronic isolation, (6) constrained choice (loss of freedom), (7) limited access to material resources, and (8) inadequate healthcare responses. CONCLUSIONS: Patients often struggled to balance the challenges imposed by community violence with the demands of living with and managing their chronic conditions. Emergent themes may inform practical targets for addressing community violence as a social determinant of health in vulnerable populations.

Racial and Ethnic Disparities in Diabetes Screening Between Asian Americans and Other Adults: BRFSS 2012-2014.

BACKGROUND: Although Asian Americans are at high risk for type 2 diabetes, it is not known whether they are appropriately screened for this disease. OBJECTIVE: To assess racial and ethnic disparities in diabetes screening between Asian Americans and other adults. DESIGN: Analysis of pooled cross-sectional data from 45 U.S. states and territories using the 2012-2014 Behavioral Risk Factor Surveillance System. We calculated the weighted proportions of adults in each racial and ethnic group who received recommended diabetes screening. To assess for racial and ethnic disparities, we used multivariable logistic regression to model receipt of recommended diabetes screening as a function of race and ethnicity, adjusting for demographics, healthcare access, survey year, and state. PARTICIPANTS: A total of 526,000 adults who were eligible to receive diabetes screening according to American Diabetes Association guidelines from 2012 to 2014 (age ≥ 45 years or age < 45 years with a body mass index [BMI] ≥ 25 kg/m2). MAIN MEASURES: Self-reported receipt of diabetes screening (defined as a test for high blood sugar or diabetes within the past 3 years) and self-reported race/ethnicity (non-Hispanic white, non-Hispanic Asian, non-Hispanic Pacific Islander, non-Hispanic American Indian or Alaskan Native, non-Hispanic black, Hispanic or Latino, and non-Hispanic multiracial or other). KEY RESULTS: Asian Americans were the least likely racial and ethnic group to receive recommended diabetes screening. Overall, Asian Americans had 34% lower adjusted odds of receiving recommended diabetes screening compared to non-Hispanic whites (95 % CI: 0.60, 0.73). In subgroup analyses by age and weight status, disparities were widest among obese Asian Americans ≥ 45 years (AOR = 0.56; 95 % CI: 0.39, 0.81). Disparities persisted among Asian Americans who completed other types of preventive cancer screening. CONCLUSIONS: Despite their high risk of diabetes, Asian Americans were the least likely racial and ethnic group to receive recommended diabetes screening.

Spatial Context and Health Inequity: Reconfiguring Race, Place, and Poverty.

Intimate connections among race, place, and poverty are increasingly featured in the health disparities literature. However, few models exist that can guide our understanding of these interconnections. We build on the Chicago School of Sociology's contributions in urban research and one of its contemporary elaborations, often described as the "neighborhood effects approach," to propose a three-axis model of health inequity. This model, in alignment with Chicago School theory, postulates a dynamic and adaptive relationship between spatial context and health inequity. Compositional axes of race and poverty form the foundation of the model. These compositional axes then intersect with a third axis of place to compose the built and social environment planes. We develop this model to provide conceptual guidance for clinical, policy, and public health researchers who aim to examine how these three features, taken together, have important implications for urban health.

Social Disorder in Adults with Type 2 Diabetes: Building on Race, Place, and Poverty.

The recent resurgence of social and civic disquiet in the USA has contributed to increasing recognition that social conditions are meaningfully connected to disease and death. As a "lifestyle disease," control of diabetes requires modifications to daily activities, including healthy dietary practices, regular physical activity, and adherence to treatment regimens. One's ability to develop the healthy practices necessary to prevent or control type 2 diabetes may be influenced by a context of social disorder, the disruptive social and economic conditions that influence daily activity and, consequently, health status. In this paper, we report on our narrative review of the literature that explores the associations between social disorder and diabetes-related health outcomes within vulnerable communities. We also propose a multilevel ecosocial model for conceptualizing social disorder, specifically focusing on its role in racial disparities and its pathways to mediating diabetes outcomes.

Linking community resources in diabetes care: a role for technology?

Designing and implementing effective lifestyle modification strategies remains one of the great challenges in diabetes care. Historically, programs have focused on individual behavior change with little or no attempt to integrate change within the broader social framework or community context. However, these contextual factors have been shown to be associated with poor diabetes outcomes, particularly in low-income minority populations. Recent evidence suggests that one way to address these disparities is to match patient needs to existing community resources. Not only does this position patients to more quickly adapt behavior in a practical way, but this also refers patients back to their local communities where a support mechanism is in place to sustain healthy behavior. Technology offers a new and promising platform for connecting patients to meaningful resources (also referred to as "assets"). This paper summarizes several noteworthy innovations that use technology as a practical bridge between healthcare and community-based resources that promote diabetes self-care.

Primary Care Patients' Perspectives on Health Care Screening for Firearms in a Diverse, Urban Area: A Qualitative Study.

Importance: Firearm violence is increasingly recognized as a public health issue, but whether physicians should intervene remains politically contested. Objective: To explore self-described patient perspectives about the appropriateness and acceptability of health care screening for firearms. Design, Setting, and Participants: This qualitative study recruited 50 adult patients from a primary care clinic in Chicago, Illinois, from June 7, 2019, to January 11, 2021, to participate in 1 of 12 one-time qualitative focus groups. Focus group discussions were facilitated using an in-depth, semistructured guide, transcribed verbatim from audio recordings, and analyzed for major themes using a pragmatic approach to basic thematic analysis, which is commonly used in implementation science, between December 12, 2019, and November 29, 2022. Main Outcomes and Measures: Patient perspectives of health care screening for firearms were evaluated to examine complexities of a practice change goal. Results: Participants were a median age of 60.0 (IQR, 50.5-66.5) years and predominantly female (37 [74%]; male, 11 [22%]; nonbinary, 1 [2%]; transgender, 1 [2%]) and non-Hispanic Black (42 [84%]; non-Hispanic Asian or Pacific Islander, 2 [4%]; non-Hispanic White, 5 [10%]). Two-thirds (32 [64%]) of participants thought that health care screening for firearms was at least sometimes appropriate, recognizing clear benefits, for instance, among patients at risk for suicide. However, few (2 [4%]) had ever discussed firearms with a physician or other health care professional. Even among those who recognized benefits, several barriers to acceptability were described, especially related to bias, stigma, and increased risk for criminal legal involvement. Other major themes included insufficient time to address firearms during health care visits and doubts about a clinician's ability to intervene. Facilitators to acceptability included screening strategies that were patient centered, sensitive to racial bias, clinically efficient, and accompanied by tangible resources. Conclusions and Relevance: Incorporating these findings and emergent themes into clinical practice may guide efforts to make firearm screening more acceptable for patients from historically marginalized communities.

Impact of 2009 American Recovery and Reinvestment Act (ARRA) health center investments on disadvantaged neighborhoods after recession.

BACKGROUND: Federally qualified health centers (FQHCs) are integral to the U.S. healthcare safety net and uniquely situated in disadvantaged neighborhoods. The 2009 American Recovery and Reinvestment Act (ARRA) invested $2 billion in FQHC stimulus during the Great Recession; but it remains unknown whether this investment was associated with extended benefits for disadvantaged neighborhoods. METHODS: We used a propensity-score matched longitudinal design (2008-2012) to examine whether the 2009 ARRA FQHC investment was associated with local jobs and establishments recovery in FQHC neighborhoods. Job change data were obtained from the Longitudinal Employer-Household Dynamics (LEHD) survey and calculated as an annual rate per 1,000 population. Establishment change data were obtained from the National Neighborhood Data Archive (NaNDA) and calculated as an annual rate per 10,000 population. Establishment data included 4 establishment types: healthcare services, eating/drinking places, retail establishments, and grocery stores. Fixed effects were used to compare annual rates of jobs and establishments recovery between ARRA-funded FQHC census tracts and a matched control group. RESULTS: Of 50,381 tracts, 2,223 contained ≥ 1 FQHC that received ARRA funding. A higher proportion of FQHC tracts had an extreme poverty designation (11.6% vs. 5.4%), high unemployment rate (45.4% vs. 30.3%), and > 50% minority racial/ethnic composition (48.1% vs. 36.3%). On average, jobs grew at an annual rate of 3.84 jobs per 1,000 population (95% CI: 3.62,4.06). In propensity-score weighted models, jobs in ARRA-funded tracts grew at a higher annual rate of 4.34 per 1,000 (95% CI: 2.56,6.12) relative to those with similar social vulnerability. We observed persistent decline in non-healthcare establishments (-1.35 per 10,000; 95% CI: -1.68,-1.02); but did not observe decline in healthcare establishments. CONCLUSIONS: Direct funding to HCs may be an effective strategy to support healthcare establishments and some jobs recovery in disadvantaged neighborhoods during recession, reinforcing the important multidimensional roles HCs play in these communities. However, HCs may benefit from additional investments that target upstream determinants of health to mitigate uneven recovery and neighborhood decline.

Associations of Adolescent School Social Networks, Gender Norms, and Adolescent-to-Young Adult Changes in Male Gender Expression With Young Adult Substance Use.

PURPOSE: Male gender expression (MGE), which is shaped by sociocultural pressures around masculinity, has been previously associated with health. This study examines associations of adolescent social network variables and school gender norms with MGE changes from adolescence to young adulthood, and associations of these changes with young adult substance use. METHODS: Analyzing data from Waves I (1994-95, adolescents, aged 12-18) and IV (2008-09, young adults, 24-32) of a nationally representative longitudinal cohort study, male participants' MGE was assessed in each wave using a validated, empirically derived measure. Linear regression was used to evaluate associations of adolescent-to-young adult MGE changes between waves with adolescent social network characteristics and school gender norms. Logistic regression was used to examine associations between adolescent-to-young adult MGE changes and young adult substance uses (cigarette, marijuana, heavy alcohol, and recreational drug use, and prescription drug misuse). RESULTS: Among 4,776 male participants, adolescent-to-young adult MGE changes were significantly associated with school gender norms such that adolescents whose MGE markedly departed from their schools' average exhibited greater MGE changes in the direction of their schools' average (ß = -0.83, p < .01) relative to those who were more similar to school means. Adolescent-to-young adult increases in MGE were significantly associated with greater odds of all young adult substance use behaviors except prescription drug misuse. DISCUSSION: Adolescents' MGE relative to other males at their school was associated with MGE changes toward school norms, with implications for young adult substance use. Adolescent gender norms may be an underexplored strategy for interventions to reduce substance misuse.

Associations of U.S. hospital closure (2007-2018) with area socioeconomic disadvantage and racial/ethnic composition.

PURPOSE: To examine whether hospital closure is associated with high levels of area socioeconomic disadvantage and racial/ethnic minority composition. METHODS: Pooled cross-sectional analysis (2007-2018) of 6467 U.S. hospitals from the American Hospital Association's Annual Survey, comparing hospital population characteristics of closed hospitals to all remaining open hospitals. We used multilevel mixed-effects logistic regression models to assess closure as a function of population characteristics, including area deprivation index ([ADI], a composite measure of socioeconomic disadvantage), racial/ethnic composition, and rural classification, nesting hospitals within hospital service areas (HSAs) and hospital referral regions. Secondary analyses examined public or private hospital type. RESULTS: Overall, 326 (5.0%) of 6467 U.S. hospitals closed during the study period. In multivariable models, hospitals in HSAs with a higher burden of socioeconomic disadvantage (per 10% above median ADI ZIP codes, AOR 1.05; 95% CI, 1.01-1.09) and Black Non-Hispanic composition (highest quartile, AOR 4.03; 95% CI, 2.62-6.21) had higher odds of closure. We did not observe disparities in closure by Hispanic/Latino composition or rurality. Disparities persisted for Black Non-Hispanic communities, even among HSAs with the lowest burden of disadvantage. CONCLUSIONS: Disproportionate hospital closure in communities with higher socioeconomic disadvantage and Black racial composition raises concerns about unequal loss of healthcare resources in the U.S.