Twelve-month supply of short-acting contraception methods: Pharmacists' perspectives on implementation of new state law.

BACKGROUND: Oral contraceptives and other short-acting reversible contraceptive (SARC) methods such as the patch, vaginal ring, and medroxyprogesterone injections are used by approximately 30% of people using contraception. People may face barriers in obtaining a timely and adequate supply of their SARCs. It is well established that dispensing more than 1-month supply at a time is more convenient for patients, improves continuation, and decreases the risk of unintended pregnancy. Given the potential for public health impact, 20 states, including Massachusetts, have expanded access to a 12-month supply of SARCs. OBJECTIVES: The goal of this qualitative study was to explore Massachusetts pharmacists' general awareness and specific knowledge of the state's 2017 Act Advancing Contraceptive Coverage and Economic Security in Our State (ACCESS) law, explore barriers to the implementation of the law, and elicit recommendations to improve uptake of this practice. METHODS: Semistructured interviews were conducted with a purposeful sample of community pharmacists in Massachusetts between September 2020 and May 2021 using a pretested interview guide. Interviews were audio recorded and professionally transcribed. Data collection ceased when theoretical saturation was achieved. Data were analyzed using modified grounded theory, including code book development and line-by-line and axial coding. RESULTS: Sixteen pharmacists from diverse practice settings participated in the interviews. All the pharmacists (100%) reported that they had received no training on the ACCESS law, and only 1 pharmacist reported having complete knowledge of the specifics of the law. We identified key themes and subthemes related to pharmacists' concerns about implementation of the law at the system, pharmacy, and patient level, including insurance coverage, communication of new laws, stocking, supply, and misuse by patients. CONCLUSION: Addressing the need for pharmacist training and communication regarding new regulations may improve provision of an extended supply of SARC methods.

Organizational characteristics associated with high performance on quality measures in pediatric primary care: A positive deviance study.

BACKGROUND: Pediatric health care quality in the United States varies, but the reasons for variation are not fully understood. Differences in pediatric practices' organizational characteristics, such as organizational structures, strategies employed to improve quality, and other contextual factors, may contribute to the variation observed. PURPOSE: To assess the relationship between organizational characteristics and performance on clinical quality (CQ) and patient experience (PE) measures in primary care pediatric practices in Massachusetts. METHODOLOGY: A 60-item questionnaire that assessed the presence of selected organizational characteristics was sent to 172 pediatric practice managers in Massachusetts between December 2017 and February 2018. The associations between select organizational characteristics and publicly available CQ and PE scores were analyzed using analysis of variance; open-ended survey questions were analyzed using qualitative content analysis. RESULTS: Eighty-six practices (50.0%) responded; 80 (46.5%) were included in the primary analysis. Having a quality champion ( p = .03), offering co-located specialty services (e.g., behavioral health; p = .04), being a privately owned practice ( p = .04), believing that patients and families feel respected ( p = .03), and having a lower percentage of patients (10%-25%) covered by public health insurance ( p = .04) were associated with higher CQ scores. Higher PE scores were associated with private practice ownership ( p = .0006). Qualitative analysis suggested organizational culture and external factors, such as health care finance, may affect quality. CONCLUSIONS: Both modifiable organizational practices and factors external to a practice may affect quality of care. Addressing differences in practice performance may not be reducible to implementation of changes in single organizational characteristics. PRACTICE IMPLICATIONS: Pediatric practices seeking to improve quality of care may wish to adopt the strategies that were associated with higher performance on quality measures, but additional studies are needed to better understand the mechanisms behind these associations and how they relate to each other.

Spatial analysis of factors influencing choice of paediatric practice for mothers from low-income and minority populations.

AIM: Publicly reported quality data theoretically enable parents to choose higher-performing paediatric practices. However, little is known about how parents decide where to seek paediatric care. We explored the relationship between geographic factors, care quality and choice of practice to see if the decision-making process could be described in terms of a 'gravity model' of spatial data. METHODS: In the context of a randomised controlled trial, we used a geographic information system to calculate flow volume between practice locations and participants' homes, to locate subjects within a census tract, to determine distances between points and to perform exploratory mapping. Generalised linear modelling was then used to determine whether the data fit a gravity model, which is a spatial model that evaluates factors impacting travel from one set of locations to another. RESULTS: A total of 662 women and 52 paediatric practices were included in the analysis. Proximity of a practice to home was the most important factor in choosing a practice (Z = -15.01, P < 0.001). Practice size was important to a lesser extent, with larger practices more likely to be chosen (Z = 8.96, P < 0.001). A practice's performance on quality measures was associated with choice only for women who had received an intervention to increase use of quality data (Z = 2.51, P < 0.05). CONCLUSIONS: The gravity model and the concept of flow can help explain the choice of paediatric practice in a predominantly low-income, racially ethnic minority (non-White) urban population. This has important ramifications for the potential impact of publicly reported quality data.

Advance care planning with patients on hemodialysis: an implementation study.

BACKGROUND: Patients with end-stage kidney disease (ESKD) on hemodialysis have limited life expectancy, yet their palliative care needs often go unmet. The aim of this study was to identify barriers and facilitators for implementation of "Shared Decision Making and Renal Supportive Care" (SDM-RSC), an intervention to improve advance care planning (ACP) for patients with ESKD on hemodialysis. METHODS: The Consolidated Framework for Implementation Research (CFIR) was the organizing framework for this study. CFIR is a theory-based implementation framework consisting of five domains (Intervention Characteristics, Inner Setting, Outer Setting, Characteristics of Individuals, and Process), each of which has associated constructs. Potential barriers and facilitators to implementation of the SDM-RSC intervention were identified through observation of study procedures, surveys of social workers nephrologists, study participants, and family members, and assessment of intervention fidelity. RESULTS: Twenty-nine nephrologists and 24 social workers, representing 18 outpatient dialysis units in Massachusetts (n = 10) and New Mexico (n = 8), were trained to conduct SDM-RSC intervention sessions. A total of 102 of 125 patient enrolled in the study received the intervention; 40 had family members present. Potential barriers and facilitators to implementation of the SDM-RSC intervention were identified in each of the five CFIR domains. Barriers included complexity of the intervention; challenges to meeting with patients on non-dialysis days; difficulties scheduling intervention sessions due to nephrologists' and social workers' caseloads; perceived need for local policy change regarding ACP; perceived need for additional ACP training for social workers and nephrologists; and lack of endorsement of the intervention by some staff members. Facilitators included: training for social workers, national dialysis chain leadership engagement and the institution of social worker/nephrologist clinic champions. CONCLUSIONS: ACP for patients on hemodialysis can have a positive impact on end-of-life outcomes for patients and their families but does not take place routinely. The barriers to effective implementation of interventions to improve ACP identified in this study might be addressed by: adapting the intervention for local contexts with input from clinicians, dialysis staff, patients and families; providing nephrologists and social workers additional training prior to delivering the intervention; and developing policy that routinizes ACP for hemodialysis patients. TRIAL REGISTRATION: Clinicaltrials.gov NCT02405312. Registered 04/01/2015.

Reporting of Patient Experience Data on Health Systems' Websites and Commercial Physician-Rating Websites: Mixed-Methods Analysis.

BACKGROUND: Some hospitals' and health systems' websites report physician-level ratings and comments drawn from the Consumer Assessment of Healthcare Providers and Systems surveys. OBJECTIVE: The aim was to examine the prevalence and content of health system websites reporting these data and compare narratives from these sites to narratives from commercial physician-rating sites. METHODS: We identified health system websites active between June 1 and 30, 2016, that posted clinician reviews. For 140 randomly selected clinicians, we extracted the number of star ratings and narrative comments. We conducted a qualitative analysis of a random sample of these physicians' narrative reviews and compared these to a random sample of reviews from commercial physician-rating websites. We described composite quantitative scores for sampled physicians and compared the frequency of themes between reviews drawn from health systems' and commercial physician-rating websites. RESULTS: We identified 42 health systems that published composite star ratings (42/42, 100%) or narratives (33/42, 79%). Most (27/42, 64%) stated that they excluded narratives deemed offensive. Of 140 clinicians, the majority had composite scores listed (star ratings: 122/140, 87.1%; narrative reviews: 114/140, 81.4%), with medians of 110 star ratings (IQR 42-175) and 25.5 (IQR 13-48) narratives. The rating median was 4.8 (IQR 4.7-4.9) out of five stars, and no clinician had a score less than 4.2. Compared to commercial physician-rating websites, we found significantly fewer negative comments on health system websites (35.5%, 76/214 vs 12.8%, 72/561, respectively; P<.001). CONCLUSIONS: The lack of variation in star ratings on health system sites may make it difficult to differentiate between clinicians. Most health systems report that they remove offensive comments, and we notably found fewer negative comments on health system websites compared to commercial physician-rating sites.

Physician-identified barriers to and facilitators of shared decision-making in the Emergency Department: an exploratory analysis.

OBJECTIVES: Shared decision-making (SDM) is receiving increasing attention in emergency medicine because of its potential to increase patient engagement and decrease unnecessary healthcare utilisation. This study sought to explore physician-identified barriers to and facilitators of SDM in the ED. METHODS: We conducted semistructured interviews with practising emergency physicians (EP) with the aim of understanding when and why EPs engage in SDM, and when and why they feel unable to engage in SDM. Interviews were transcribed verbatim and a three-member team coded all transcripts in an iterative fashion using a directed approach to qualitative content analysis. We identified emergent themes, and organised themes based on an integrative theoretical model that combined the theory of planned behaviour and social cognitive theory. RESULTS: Fifteen EPs practising in the New England region of the USA were interviewed. Physicians described the following barriers: time constraints, clinical uncertainty, fear of a bad outcome, certain patient characteristics, lack of follow-up and other emotional and logistical stressors. They noted that risk stratification methods, the perception that SDM decreased liability and their own improving clinical skills facilitated their use of SDM. They also noted that the culture of the institution could play a role in discouraging or promoting SDM, and that patients could encourage SDM by specifically asking about alternatives. CONCLUSIONS: EPs face many barriers to using SDM. Some, such as lack of follow-up, are unique to the ED; others, such as the challenges of communicating uncertainty, may affect other providers. Many of the barriers to SDM are amenable to intervention, but may be of variable importance in different EDs. Further research should attempt to identify which barriers are most prevalent and most amenable to intervention, as well as capitalise on the facilitators noted.

Improving Rates of Outpatient Influenza Vaccination Through EHR Portal Messages and Interactive Automated Calls: A Randomized Controlled Trial.

BACKGROUND: Patient reminders for influenza vaccination, delivered via electronic health record (EHR) patient portal messages and interactive voice response (IVR) calls, offer an innovative approach to improving patient care. OBJECTIVE: To test the effectiveness of portal and IVR outreach in improving rates of influenza vaccination. DESIGN: Randomized controlled trial of EHR portal messages and IVR calls promoting influenza vaccination. PARTICIPANTS: Adults with no documented influenza vaccination 2 months after the start of influenza season (2014-2015). INTERVENTION: Using a factorial design, we assigned 20,000 patients who were active portal users to one of four study arms: (a) receipt of a portal message promoting influenza vaccines, (b) receipt of IVR call with similar content, (c) both a and b, or (d) neither (usual care). We randomized 10,000 non-portal users to receipt of IVR call or usual care. In all intervention arms, information on pneumococcal vaccination was included if the targeted patient was overdue for pneumococcal vaccine. MAIN MEASURES: EHR-documented influenza vaccination during the 2014-2015 influenza season, measured April 2015. KEY RESULTS: Among portal users, 14.0% (702) of those receiving both portal messages and calls, 13.4% (669) of message recipients, 12.8% (642) of call recipients, and 11.6% (582) of those with usual care received vaccines. On multivariable analysis of portal users, those receiving portal messages alone (OR 1.20, 95% CI 1.06-1.35) or IVR calls alone (OR 1.15 95% CI 1.02-1.30) were more likely than usual care recipients to be vaccinated. Those receiving both messages and calls were also more likely than the usual care group to be vaccinated (ad hoc analysis, using a Bonferroni correction: OR 1.29, 97.5% CI 1.13, 1.48). Among non-portal users, 8.5% of call recipients and 8.6% of usual care recipients received influenza vaccines (p = NS). Pneumococcal vaccination rates showed no significant improvement. CONCLUSIONS: Our outreach achieved a small but significant improvement in influenza vaccination rates. Registration: ClinicalTrials.gov Identifier NCT02266277 ( https://clinicaltrials.gov/ct2/show/NCT02266277 ).

Internal Medicine Hospitalists' Perceived Barriers and Recommendations for Optimizing Secondary Prevention of Osteoporotic Hip Fractures.

OBJECTIVES: Osteoporosis is a major public health concern affecting an estimated 10 million people in the United States. To the best of our knowledge, no qualitative study has explored barriers perceived by medicine hospitalists to secondary prevention of osteoporotic hip fractures. We aimed to describe these perceived barriers and recommendations regarding how to optimize secondary prevention of osteoporotic hip fracture. METHODS: In-depth, semistructured interviews were performed with 15 internal medicine hospitalists in a tertiary-care referral medical center. The interviews were analyzed with directed content analysis. RESULTS: Internal medicine hospitalists consider secondary osteoporotic hip fracture prevention as the responsibility of outpatient physicians. Identified barriers were stratified based on themes including physicians' perception, patients' characteristics, risks and benefits of osteoporosis treatment, healthcare delivery system, and patient care transition from the inpatient to the outpatient setting. Some of the recommendations include building an integrated system that involves a multidisciplinary team such as the fracture liaison service, initiating a change to the hospital policy to facilitate inpatient care and management of osteoporosis, and creating a smooth patient care transition to the outpatient setting. CONCLUSIONS: Our study highlighted how internal medicine hospitalists perceive their role in the secondary prevention of osteoporotic hip fractures and what they perceive as barriers to initiating preventive measures in the hospital. Inconsistency in patient care transition and the fragmented nature of the existing healthcare system were identified as major barriers. A fracture liaison service could remove some of these barriers.

Proyecto Mamá: a lifestyle intervention in overweight and obese Hispanic women: a randomised controlled trial--study protocol.

BACKGROUND: The proportion of women entering pregnancy overweight or obese has been rising and, in turn, is associated with adverse maternal and fetal outcomes. Gestational weight gain (GWG) exceeding Institute of Medicine (IOM) guidelines further increases health risks and has been independently associated with postpartum weight retention. Hispanic women are disproportionately affected by overweight and obesity, but have had limited access to interventions that promote healthy lifestyles due to cultural, socioeconomic, and language barriers. Therefore, the overall goal of this randomized controlled trial is to test the efficacy of a culturally and linguistically modified, individually-tailored lifestyle intervention to reduce excess GWG, increase postpartum weight loss, and improve maternal metabolic status among overweight/obese Hispanic women. METHODS/DESIGN: Overweight/obese Hispanic women are recruited in early pregnancy and randomly assigned to a Lifestyle Intervention (n = 150) or a Comparison Health and Wellness (control) intervention (n = 150). Multimodal contacts (i.e., in-person, telephone counseling, and mailed print-based materials) are used to deliver the intervention from early pregnancy (12 weeks gestation) to 6 months postpartum, with follow-up to 1 year postpartum. Targets of the intervention are to achieve IOM Guidelines for GWG and postpartum weight loss; American Congress of Obstetrician and Gynecologist guidelines for physical activity; and American Diabetes Association guidelines for diet. The intervention draws from Social Cognitive Theory and the Transtheoretical Model and includes strategies to address the specific social, cultural, and economic challenges faced by low-income Hispanic women. Assessments are conducted at baseline (~10 weeks gestation), mid pregnancy (24-28 weeks gestation), late pregnancy (32-34 weeks gestation) and postpartum at 6-weeks, 6-months, and 12-months by bicultural and bilingual personnel blinded to the intervention arm. Efficacy is assessed via GWG, postpartum weight loss, and biomarkers of glycemic control, insulin resistance, and cardiovascular disease risk factors. Changes in physical activity and diet are measured via 7-day accelerometer data and 24-h dietary recalls at each assessment time period. DISCUSSION: Hispanic women are the fastest growing minority group in the U.S. and are disproportionately affected by overweight and obesity. This randomised trial uses a high-reach, low-cost strategy that can readily be translated into clinical practice in underserved and minority populations. TRIAL REGISTRATION: NCT01868230 May 29, 2013.

A qualitative analysis of hospital leaders' opinions about publicly reported measures of health care quality.

BACKGROUND: Hospital leaders play an important role in the success of quality improvement (QI) initiatives, yet little is known about how leaders engaged in QI currently view quality performance measures. In a follow-up to a quantitative study conducted in 2012, a study employing qualitative content analysis was conducted to (1) describe leaders' opinions about the quality measures reported on the Centers for Medicare & Medicaid Services (CMS) Hospital Compare website, (2) to generate hypotheses about barriers/facilitators to improving hospitals' performance, and (3) to elicit recommendations about how to improve publicly reported quality measures. METHODS: The opinions of leaders from a stratified sample of 630 hospitals across the United States regarding quality measures were assessed with an open-ended prompt that was part of a 21-item questionnaire about quality measures publicly reported by CMS. Their responses were qualitatively analyzed in an iterative process, resulting in the identification of the presence and frequency of major themes and subthemes. RESULTS: Participants from 131 (21%) of the 630 hospitals surveyed replied to the open-ended prompt; 15% were from hospitals with higher-than-average performance scores, and 52% were from hospitals with lower-than-average scores. Major themes included (1) concerns regarding quality measurement (measure validity, importance, and fairness) and/or public reporting; 76%); (2) positive views of quality measurement (stimulate improvement, focus efforts; 13%); and (3) recommendations for improving quality measurement. CONCLUSIONS: Among hospital leaders responding to an open-ended survey prompt, some supported the concept of measuring quality, but the majority criticized the validity and utility of current quality measures. Although quality measures are frequently being reevaluated and new measures developed, the ability of such measures to stimulate improvement may be limited without greater buy-in from hospital leaders.

Shared decision-making in end-stage renal disease: a protocol for a multi-center study of a communication intervention to improve end-of-life care for dialysis patients.

BACKGROUND: End-stage renal disease carries a prognosis similar to cancer yet only 20 % of end-stage renal disease patients are referred to hospice. Furthermore, conversations between dialysis team members and patients about end-of-life planning are uncommon. Lack of provider training about how to communicate prognostic data may contribute to the limited number of end-of-life care discussions that take place with this chronically ill population. In this study, we will test the Shared Decision-Making Renal Supportive Care communication intervention to systematically elicit patient and caretaker preferences for end-of-life care so that care concordant with patients' goals can be provided. METHODS/DESIGN: This multi-center study will deploy an intervention to improve end-of-life communication for hemodialysis patients who are at high risk of death in the ensuing six months. The intervention will be carried out as a prospective cohort with a retrospective cohort serving as the comparison group. Patients will be recruited from 16 dialysis units associated with two large academic centers in Springfield, Massachusetts and Albuquerque, New Mexico. Critical input from patient advisory boards, a stakeholder panel, and initial qualitative analysis of patient and caretaker experiences with advance care planning have informed the communication intervention. Rigorous communication training for hemodialysis social workers and providers will ensure that standardized study procedures are performed at each dialysis unit. Nephrologists and social workers will communicate prognosis and provide advance care planning in face-to-face encounters with patients and families using a social work-centered algorithm. Study outcomes including frequency and timing of hospice referrals, patient and caretaker satisfaction, quality of end-of-life discussions, and quality of death will be assessed over an 18 month period. DISCUSSION: The Shared Decision-Making Renal Supportive Care Communication intervention intends to improve discussions about prognosis and end-of-life care with end-stage renal disease patients. We anticipate that the intervention will help guide hemodialysis staff and providers to effectively participate in advance care planning for patients and caretakers to establish preferences and goals at the end of life. TRIAL REGISTRATION: NCT02405312.

Handoff quality for obstetrical inpatients varies depending on time of day and provider type.

OBJECTIVE: To determine whether obstetric handoff quality differs morning versus evening, weekend versus weekday, or based on provider type. STUDY DESIGN: Using the American College of Obstetricians and Gynecologists (ACOG) handoff guidelines, we developed an observational tool to assess whether handoffs included its 8 recommended elements. We observed handoffs between attending obstetricians, Obstetrics and Gynecology residents, labor and delivery nurses, and certified nurse midwives. Observation times included a balance of morning, evening, weekdays, and weekends. Participants were blinded to the study objectives. We defined high-quality handoffs as those that included 7 of the 8 recommended ACOG elements. RESULTS: A total of 425 inpatient handoffs were observed: 233 (55%) were morning handoffs and 189 (45%) were evening; 251 (59%) were on weekdays and 171 (41%) on weekends. Of the handoffs observed, 201 (48%) were presented by residents, 139 (33%) by nurses, 56 (13%) by attending obstetricians, and 26 (6%) by midwives. Only 169 (40%) of all handoffs met criteria for high quality. A greater percentage of all morning handoffs met criteria as compared to evening handoffs (45% vs. 34%, p < 0.05). There was no significant difference between the overall percentage of weekday and weekend handoffs meeting criteria (39% vs. 42%, p = 0.48). Residents had a higher percentage of high-quality handoffs as compared to nurses (55% vs. 32%, p < 0.001). CONCLUSION: Based on criteria developed for this study, handoff quality may vary based on time of day and provider type. These findings present an opportunity to further assess reasons for variation and propose changes to standardize and improve the handoff process.

Readiness to Implement a Doula-Hospital Partnership Program.

OBJECTIVE: To assess obstetric clinicians' and leaders' baseline knowledge, attitudes, and experience with doulas and their readiness to implement a novel doula-hospital partnership program. DESIGN: Survey of obstetric clinicians and leaders before implementation of the doula program. SETTING/LOCAL PROBLEM: Academic medical center in Western Massachusetts that was preparing to pilot a doula-hospital partnership program with Black doulas for Black women to address racial disparities in maternal morbidity and mortality. PARTICIPANTS: Obstetric clinicians and leaders (N = 48). INTERVENTION/MEASUREMENTS: We used established questions from the Organizational Readiness for Implementing Change (ORIC) scale and original questions to assess participants' knowledge, attitudes, and experiences with doulas and their readiness to implement the planned doula program. We distributed the questionnaire to 103 potential respondents. We conducted descriptive and bivariate analyses and analyzed open-ended responses using content analysis. RESULTS: Forty-eight participants responded to the survey. Of those who provided intrapartum care (n = 45), all were familiar with doula roles. Respondents who reported having experience working with a doula, 47.3% (n = 18/38) had at least one prior negative experience with a doula and 76.3% (n = 29/38) reported positive experiences with doulas. However, there was a mean score of 12.62 on the attitude toward doulas (scale range: 3-15). The mean score on the ORIC change commitment subscale was 20.65 (range: 15-25) and on the ORIC change efficacy subscale, mean score was 29.31 (range: 19-35). Results did not differ by participants characteristics. CONCLUSION: Our findings suggested strong support for and readiness to implement the doula-hospital partnership program.

Health Insurance Type and Outpatient Specialist Care Among Children With Asthma.

Importance: Although children with asthma are often successfully treated by primary care clinicians, outpatient specialist care is recommended for those with poorly controlled disease. Little is known about differences in specialist use for asthma among children with Medicaid vs private insurance. Objective: To examine differences among children with asthma regarding receipt of asthma specialist care by insurance type. Design, Setting, and Participants: In this cross-sectional study using data from the Massachusetts All Payer Claims Database (APCD) between 2014 to 2020, children with asthma were identified and differences in receipt of outpatient specialist care by whether their insurance was public (Medicaid and the Children's Health Insurance Program) or private were examined. Eligible participants included children with asthma in 2015 to 2020 aged 2 to 17 years. Data analysis was conducted from January 2023 to April 2024. Exposure: Medicaid vs private insurance. Main Outcomes and Measures: The primary outcome was receipt of specialist care (any outpatient visit with a pulmonology, allergy and immunology, or otolaryngology physician). Multivariable logistic regression models estimated differences in receipt of specialist care by insurance type accounting for child and area characteristics including demographics, health status, persistent asthma, calendar year, and zip code characteristics. Additional analyses examined if the associations of specialist care with insurance type varied by asthma persistence and severity, and whether associations varied over time. Results: Among 198 101 unique children, there were 432 455 child-year observations (186 296 female [43.1%] and 246 159 male [56.9%]; 211 269 aged 5 to 11 years [48.9%]; 82 108 [19.0%] with persistent asthma) including 286 408 (66.2%) that were Medicaid insured and 146 047 (33.8%) that were privately insured. Although persistent asthma was more common among child-year observations with Medicaid vs private insurance (57 381 [20.0%] vs 24 727 [16.9%]), children with Medicaid were less likely to receive specialist care. Overall, 64 239 child-year observations (14.9%) received specialist care, with substantially lower rates for children with Medicaid vs private insurance (34 093 child-year observations [11.9%] vs 30 146 child-year observations [20.6%]). Regression-based estimates confirmed these disparities; children with Medicaid had 55% lower odds of receiving specialist care (adjusted odds ratio, 0.45; 95% CI, 0.43 to 0.47) and a regression-adjusted 9.7 percentage point (95% CI, -10.4 percentage points to -9.1 percentage points) lower rate of receipt of specialist care. Compared with children with private insurance, there was an additional 3.2 percentage point (95% CI, 2.0 percentage points to 4.4 percentage points) deficit for children with Medicaid with persistent asthma. Conclusions and Relevance: In this cross-sectional study, children with Medicaid were less likely to receive specialist care, with the largest gaps among those with persistent asthma. These findings suggest that closing this care gap may be one approach to addressing ongoing disparities in asthma outcomes.

Differences in Health Care Utilization for Asthma by Children with Medicaid versus Private Insurance.

Asthma is the most common chronic disease in children, disproportionately affects families with lower incomes, and is a leading reason for acute care visits and hospitalizations. This retrospective cohort study used the Massachusetts All Payer Claims Database (2014-2018) to examine differences in acute care utilization and quality of care for asthma between Medicaid- and privately insured children in Massachusetts. Outcomes included acute care use (emergency department [ED] or hospitalization), ED visits with asthma, routine asthma visits, and filled prescriptions for asthma medications. Multivariable logistic regression was used to account for differences in demographics, ZIP codes, health status, and asthma severity. Overall, 10.0% of Medicaid-insured children and 5.6% of privately insured were classified as having asthma. Among 317,596 child-year observations for children with asthma, 64.4% were insured by Medicaid. Medicaid-insured children had higher rates of any acute care use (50.4% vs. 30.0%) and ED visits with an asthma diagnosis (27.2% vs. 13.3%) compared to privately insured children. Only 65.4% of Medicaid enrollees had at least one routine asthma visit compared to 74.3% of privately insured children. Most children received at least one asthma medication (88.6% Medicaid vs. 83.3% privately insured), but a higher percentage of Medicaid-insured children received at least one rescue medication (84.0% vs. 73.7%), and a lower percentage of Medicaid-insured (46.1% vs. 49.2%) received a controller medication. These results suggest that opportunities for improvement in childhood asthma persist, particularly for children insured by Medicaid.

Patterns of obstetric infection rates in a large sample of US hospitals.

OBJECTIVE: Maternal infection is a common complication of childbirth, yet little is known about the extent to which infection rates vary among hospitals. We estimated hospital-level risk-adjusted maternal infection rates (RAIR) in a large sample of US hospitals and explored associations between RAIR and select hospital features. STUDY DESIGN: This retrospective cohort study included hospitals in the Perspective database with >100 deliveries over 2 years. Using a composite measure of infection, we estimated and compared RAIR across hospitals using hierarchical generalized linear models. We then estimated the amount of variation in RAIR attributable to hospital features. RESULTS: Of the 1,001,189 deliveries at 355 hospitals, 4.1% were complicated by infection. Patients aged 15-19 years were 50% more likely to experience infection than those aged 25-29 years. Rupture of membranes >24 hours (odds ratio [OR], 3.0; 95% confidence interval [CI], 3.24-3.5), unengaged fetal head (OR, 3.11; 95% CI, 2.97-3.27), and blood loss anemia (OR, 2.42; 95% CI, 2.34-2.49) had the highest OR among comorbidities commonly found in patients with infection. RAIR ranged from 1.0-14.4% (median, 4.0%; interquartile range, 2.8-5.7%). Hospital features such as geographic region, teaching status, urban setting, and higher number of obstetric beds were associated with higher infection rates, accounting for 14.8% of the variation observed. CONCLUSION: Obstetric RAIR vary among hospitals, suggesting an opportunity to improve obstetric quality of care. Hospital features such as region, number of obstetric beds, and teaching status account for only a small portion of the observed variation in infection rates.

A mixed-methods analysis of patient reviews of hospital care in England: implications for public reporting of health care quality data in the United States.

BACKGROUND: In the United States patients have limited opportunities to read and write narrative reviews about hospitals. In contrast, the National Health Service (NHS) in England encourages patients to provide feedback to hospitals on their quality-reporting website, NHS Choices. The scope and content of the narrative feedback was studied. METHODS: All NHS hospitals with more than 10 reviews posted on NHS Choices were included in a cross-sectional mixed-methods (qualitative and quantitative) analysis of patients' reviews of 20 randomly selected hospitals. RESULTS: The final sample consisted of 264 hospitals and 2,640 patient responses to structured questions. All 200 reviews from the 20 hospitals randomly selected were subjected to further quantitative and qualitative analysis. Comments about clinicians and staff were common (179 [90%]) and overwhelmingly positive, with 149 (83%) favorable to workers. In 124 (62%) of the 200 reviews, patients commented on technical aspects of hospital care, including quality of care, injuries, errors, and incorrect medical record or discharge documentation. Perceived medical errors were described in 51 (26%) hospital reviews. Comments about the hospital facility appeared in half (52%) of reviews, describing hospital cleanliness, food, parking, and amenities. Hospitals replied to 56% of the patient reviews. DISCUSSION: NHS Choices represents the first government-run initiative that enables any patient to provide narrative feedback about hospital care. Reviews appear to have similar domains to those covered in existing satisfaction surveys but also include detailed feedback that would be unlikely to be revealed by such surveys. Online narrative reviews can therefore provide useful and complementary information to consumers (patients) and hospitals, particularly when combined with systematically collected patient experience data.

A qualitative study of clinicians' perspectives on a law that allows for a 12-month supply of short-acting contraceptives in Massachusetts: Barriers and facilitators to implementation.

OBJECTIVE: To explore clinicians' perspectives regarding the Massachusetts 2017 law, 'An Act Relative to Advancing Contraceptive Coverage and Economic Security in Our State' (ACCESS), including awareness of the law, perceived barriers and facilitators to successful implementation, and recommendations to improve uptake. ACCESS requires all insurers, except self-insured businesses, to cover short-acting reversible contraceptives (SARCs) at no cost to patients and for a 12-month supply to be prescribed/dispensed if desired after the completion of a three-month trial. DATA SOURCES AND STUDY SETTING: We collected primary data from clinicians in Massachusetts from February 1 to July 31, 2021. STUDY DESIGN: Semi-structured interviews of a purposeful sample of Massachusetts clinicians who provide primary and/or women's health care were conducted via Zoom. DATA COLLECTION/EXTRACTION METHODS: Interview guide and codebook were created using the Theoretical Domains Framework. Interviews were analyzed using framework analysis, including deductive and inductive approaches. Major themes and subthemes were organized by a four-level model of the health care system: patient, care team (clinician), organization, and environment. PRINCIPAL FINDINGS: Most (58.1%) of the 31 participants were not aware of the law. Perceived advantages of this law included decreasing burden on patients, unnecessary clinical visits, and administrative burden on staff for refill requests. Perceived disadvantages focused on concerns that patients would lose their medications or devices (patient-level) and decreased clinician contact with patients (provider-level). Perceived organization- and environmental-level barriers to implementation included lack of electronic medical record (EMR) prescription defaults and insurance coverage issues. Many felt EMR modifications and more training for clinicians and pharmacists could lead to a change in practice. CONCLUSION: Our study identifies potentially modifiable barriers to the implementation of the ACCESS law. Massachusetts clinicians' lack of awareness of the law demonstrates the need for statewide education, which may allow more eligible patients to obtain a 12-month SARC supply.

Knowledge, attitudes, and practices regarding COVID-19 among university students and employees in Massachusetts, USA: A qualitative study.

OBJECTIVE: To explore the knowledge, attitudes, and practices regarding COVID-19 in university affiliates to inform future COVID-19 policies and practices. PARTICIPANTS: Undergraduate students, graduate students and university employees at a large public university. METHODS: Semi-structured focus groups and interviews were conducted between December 2020 and January 2021. Data were analyzed via inductive thematic analysis. RESULTS: Analysis of data from the 36 participants generated five themes: COVID-19 knowledge, stress and coping, trust, decision-making, and institutional feedback. Misunderstanding of COVID-19 preventive behaviors was common, which appeared to compound high levels of stress and presented an educational opportunity. University investment in an asymptomatic testing program was reported to increase perceived safety. CONCLUSIONS: Participants' experiences with a large university's COVID-19 response suggest a desire for consistent and transparent communication and an opportunity for institutions to examine the effectiveness of their communication strategies, public health protocols, and mechanisms for assessing and mitigating stress.

Communication of COVID-19 Misinformation on Social Media by Physicians in the US.

Importance: Approximately one-third of the more than 1 100 000 confirmed COVID-19-related deaths as of January 18, 2023, were considered preventable if public health recommendations had been followed. Physicians' propagation of misinformation about COVID-19 on social media and other internet-based platforms has raised professional, public health, and ethical concerns. Objective: To characterize (1) the types of COVID-19 misinformation propagated by US physicians after vaccines became available, (2) the online platforms used, and (3) the characteristics of the physicians spreading misinformation. Design, Setting, and Participants: Using US Centers for Disease Control and Prevention guidelines for the prevention and treatment of COVID-19 infection during the study window to define misinformation, structured searches of high-use social media platforms (Twitter, Facebook, Instagram, Parler, and YouTube) and news sources (The New York Times, National Public Radio) were conducted to identify COVID-19 misinformation communicated by US-based physicians between January 2021 and December 2022. Physicians' state of licensure and medical specialty were identified. The number of followers for each physician on 4 major platforms was extracted to estimate reach and qualitative content analysis of the messages was performed. Main Outcomes and Measures: Outcome measures included categories of COVID-19 misinformation propagated, the number and traits of physicians engaged in misinformation propagation, and the type of online media channels used to propagate misinformation and potential reach. Results: The propagation of COVID-19 misinformation was attributed to 52 physicians in 28 different specialties across all regions of the country. General misinformation categories included vaccines, medication, masks, and other (ie, conspiracy theories). Forty-two physicians (80.8%) posted vaccine misinformation, 40 (76.9%) propagated information in more than 1 category, and 20 (38.5%) posted misinformation on 5 or more platforms. Major themes identified included (1) disputing vaccine safety and effectiveness, (2) promoting medical treatments lacking scientific evidence and/or US Food and Drug Administration approval, (3) disputing mask-wearing effectiveness, and (4) other (unsubstantiated claims, eg, virus origin, government lies, and other conspiracy theories). Conclusions and Relevance: In this mixed-methods study of US physician propagation of COVID-19 misinformation on social media, results suggest widespread, inaccurate, and potentially harmful assertions made by physicians across the country who represented a range of subspecialties. Further research is needed to assess the extent of the potential harms associated with physician propagation of misinformation, the motivations for these behaviors, and potential legal and professional recourse to improve accountability for misinformation propagation.