Effective and inclusive mentorship in the field of epidemiology.

Quality mentoring improves outcomes across career stages, including a sense of belonging, persistence, and productivity. However, the status quo in mentorship culture-including in epidemiology-is an ad hoc approach. This pervasive culture adversely affects individual mentees and the entire scientific research enterprise. Public health disciplines such as epidemiology bear a distinct responsibility to foster an inclusive mentorship culture, ensuring the next generation is equipped not only with methodological expertise but also with a commitment to diversity, equity, inclusion, and the principles of public health. In this commentary, we outline the primary attributes of effective mentors, core competencies, and the evidence base underlying how mentors can improve their skills with comprehensive training. We call on mentors, as well as institutional leaders, to make personal and structural changes, such as requiring mentor training, implementing evidence-based tools (e.g., individual development plans), and regularly evaluating mentorship quality. Institutional leaders can remove barriers (e.g., costs to enroll in mentor training) and facilitate mentorship in non-monetary ways, for example, by making it a formal part of the promotion process. Mentors and leaders must champion these changes, fortifying not only individual career trajectories but also advancing scientific integrity, inclusivity, and justice within the epidemiologic community.

Medicare Part D Coverage of Anti-obesity Medications: a Call for Forward-Looking Policy Reform.

When the Medicare Part D benefit was constructed, drugs for weight loss were explicitly excluded from coverage, as the limited effectiveness and unfavorable safety profile of medications available at the time failed to justify coverage of drugs perceived to be used for cosmetic purposes. In recent years, drugs activating the glucagon-like peptide-1 receptor (GLP-1R) pathway have proved to achieve significant reductions in body weight with a favorable safety profile. The effectiveness of GLP-1R agonists in reducing weight and improving the metabolic profile warrants the reconsideration of the historical exclusion of weight loss drugs from Part D coverage. In this perspective, we outline policy options to enable Part D coverage of GLP-1R agonists. These include legislative change through the passage of the Treat and Reduce Obesity Act and evaluation of coverage policies under the waiver authority of the Center for Medicare and Medicaid Innovation.

"You Have to Rob Peter to Pay Paul So Your Kid Can Breathe": Using Qualitative Methods to Characterize Trade-Offs and Economic Impact of Asthma Care Costs.

BACKGROUND: Economic analyses often focus narrowly on individual patients' health care use, while overlooking the growing economic burden of out-of-pocket costs for health care on other family medical and household needs. OBJECTIVE: The aim of this study was to explore intrafamilial trade-offs families make when paying for asthma care. RESEARCH DESIGN: In 2018, we conducted telephone interviews with 59 commercially insured adults who had asthma and/or had a child with asthma. We analyzed data qualitatively via thematic content analysis. PARTICIPANTS: Our purposive sample included participants with high-deductible and no/low-deductible health plans. We recruited participants through a national asthma advocacy organization and a large nonprofit regional health plan. MEASURES: Our semistructured interview guide explored domains related to asthma adherence and cost burden, cost management strategies, and trade-offs. RESULTS: Participants reported that they tried to prioritize paying for asthma care, even at the expense of their family's overall financial well-being. When facing conflicting demands, participants described making trade-offs between asthma care and other health and nonmedical needs based on several criteria: (1) short-term needs versus longer term financial health; (2) needs of children over adults; (3) acuity of the condition; (4) effectiveness of treatment; and (5) availability of lower cost alternatives. CONCLUSIONS: Our findings suggest that cost-sharing for asthma care often has negative financial consequences for families that traditional, individually focused economic analyses are unlikely to capture. This work highlights the need for patient-centered research to evaluate the impact of health care costs at the family level, holistically measuring short-term and long-term family financial outcomes that extend beyond health care use alone.

Preferences and experiences of pediatricians on implementing national guidelines on universal routine screening of adolescents for major depressive disorder: A qualitative study.

BACKGROUND: To explore the preferences of pediatricians for key factors around the implementation of universal routine screening guidelines for major depressive disorder in adolescent patients in a primary care setting. METHOD: Semi-structured qualitative interviews were conducted with U.S. pediatricians. Participants were recruited by convenience sampling and snowball sampling. Qualitive data were summarized using thematic analysis to identify themes relevant to preferences around implementing screening strategies for adolescent patients. Recruitment ended upon reaching thematic saturation when no new themes were revealed. RESULTS: Of the 14 participants, 11 identified as female, 3 male, 10 white, and 4 Asian. Top themes among pediatrician participants were around the screening modality (14/14 participants), screening validity (14/14), time barriers (14/14), and confidentiality barriers (12/14). Less frequently mentioned themes by pediatricians were workplace coordination and logistics (7/14), alternative starting ages for screening (7/14), more frequent screenings than annual screenings (3/14), and additional clinical training regarding depression diagnosis and treatment (2/14). LIMITATIONS: Pool of interviewed participants was limited by diversity in terms of geography, race/ethnicity, or practice settings. CONCLUSIONS: To promote the uptake of universal routine screening of adolescent major depression, pediatricians expressed it was important to address key implementation factors regarding the screening modality, screening validity, time constraints, and confidential care concerns in a primary care delivery context. Findings could be used to inform the development of implementation strategies to facilitate depression screening in primary care. Future research is needed to quantitively assess decisions and tradeoffs that pediatricians make when implementing universal screening to support adolescent mental health.

Impact of the COVID-19 Pandemic on Cardiovascular Science: Anticipating Problems and Potential Solutions: A Presidential Advisory From the American Heart Association.

The coronavirus disease 2019 (COVID-19) pandemic has had worldwide repercussions for health care and research. In spring 2020, most non-COVID-19 research was halted, hindering research across the spectrum from laboratory-based experimental science to clinical research. Through the second half of 2020 and the first half of 2021, biomedical research, including cardiovascular science, only gradually restarted, with many restrictions on onsite activities, limited clinical research participation, and the challenges associated with working from home and caregiver responsibilities. Compounding these impediments, much of the global biomedical research infrastructure was redirected toward vaccine testing and deployment. This redirection of supply chains, personnel, and equipment has additionally hampered restoration of normal research activity. Transition to virtual interactions offset some of these limitations but did not adequately replace the need for scientific exchange and collaboration. Here, we outline key steps to reinvigorate biomedical research, including a call for increased support from the National Institutes of Health. We also call on academic institutions, publishers, reviewers, and supervisors to consider the impact of COVID-19 when assessing productivity, recognizing that the pandemic did not affect all equally. We identify trainees and junior investigators, especially those with caregiving roles, as most at risk of being lost from the biomedical workforce and identify steps to reduce the loss of these key investigators. Although the global pandemic highlighted the power of biomedical science to define, treat, and protect against threats to human health, significant investment in the biomedical workforce is required to maintain and promote well-being.

The clock is ticking: Parental stress around emerging adulthood for adolescents with type 1 diabetes.

PURPOSE: Our goal was to explore parental views on the challenges and stressors of transition to young adulthood for adolescents with type 1 diabetes and to describe specific strategies used to reduce parents' own stress during this time. DESIGN AND METHODS: Focus groups with 39 parents of adolescents with type 1 diabetes were conducted in the greater Seattle area. Semi-structured prompts addressed adolescents' self-care tasks, parental assistance with care, challenges and barriers with self-care tasks, and stress/pressure around self-care. Data was analyzed using qualitative methods for emerging themes. RESULTS: Parental stress was heightened when adolescents were approaching common developmental milestones such as driving, moving out, and engaging in risky behaviors that could be exacerbated by poor diabetes management. Thus, most parents reported providing assistance even late into adolescence. Parents shared strategies for guiding adolescents' transition from assisted to independent care with an emphasis on active behaviors parents could continue, thereby lowering their own stress. CONCLUSIONS: Parents of adolescents with type 1 diabetes experienced significant stress around their children's transition to independent diabetes self-care management. PRACTICE IMPLICATIONS: As part of overall preparation for transition, care providers should be encouraged to communicate with parents about these common stressors and promising avenues for nurturing a teen's independence.

Adolescent and parent perspectives on the acceptability of financial incentives to promote self-care in adolescents with type 1 diabetes.

BACKGROUND: An understanding of acceptability among potential intervention participants is critical to the design of successful real-world financial incentive (FI) programs. The purpose of this qualitative study was to explore adolescent and parent perspectives on the acceptability of using FI to promote engagement in diabetes self-care in adolescents with type 1 diabetes (T1D). METHODS: Focus groups with 46 adolescents with T1D (12-17 years old) and 39 parents of adolescents with T1D were conducted in the Seattle metropolitan area. Semistructured questions addressed participants' current use of incentives to promote change in diabetes self-care and receptivity to a theoretical incentive program administered by a third-party. Qualitative data were analyzed and emergent themes identified. RESULTS: Three thematic categories informed participant views about the acceptability of FI programs: (a) the extent to which using FIs in the context of diabetes management fit comfortably into a family's value system, (b) the perceived effectiveness for FIs to promote improved diabetes self-care, and (c) the urgent need for improved self-care due to the threat of diabetes-related health complications. These factors together led most parents and adolescents to be open to FI program participation. CONCLUSIONS: The results from this qualitative study suggest that well-designed FI programs to support diabetes management are acceptable to families with adolescents with T1D. Additionally, the use of FIs may have the potential to support adolescents with T1D in developing strong self-care habits and ease the often-turbulent transition to independent self-care.

Ethically incentivising healthy behaviours: views of parents and adolescents with type 1 diabetes.

BACKGROUND: To assess ethical concerns associated with participation in a financial incentive (FI) programme to help adolescents with type 1 diabetes improve diabetes self-management. METHODS: Focus groups with 46 adolescents with type 1 diabetes ages 12-17 and 38 of their parents were conducted in the Seattle, Washington metropolitan area. Semistructured focus group guides addressed ethical concerns related to the use of FI to promote change in diabetes self-management. Qualitative data were analysed and emergent themes identified. RESULTS: We identified three themes related to the ethical issues adolescents and parents anticipated with FI programme participation. First, FI programmes may variably change pressure and conflict in different families in ways that are not necessarily problematic. Second, the pressure to share FIs in some families and how FI payments are structured may lead to unfairness in some cases. Third, some adolescents may be likely to fabricate information in any circumstances, not simply because of FIs, but this could compromise the integrity of FI programmes relying on measures that cannot be externally verified. CONCLUSIONS: Many adolescents with type 1 diabetes and their parents see positive potential of FIs to help adolescents improve their self-management. However, ethical concerns about unfairness, potentially harmful increases in conflict/pressure and dishonesty should be addressed in the design and evaluation of FI programmes.

The accuracy of parent-reported height and weight for 6-12 year old U.S. children.

BACKGROUND: Previous studies have examined correlations between BMI calculated using parent-reported and directly-measured child height and weight. The objective of this study was to validate correction factors for parent-reported child measurements. METHODS: Concordance between parent-reported and investigator measured child height, weight, and BMI (kg/m2) among participants in the Neighborhood Impact on Kids Study (n = 616) was examined using the Lin coefficient, where a value of ±1.0 indicates perfect concordance and a value of zero denotes non-concordance. A correction model for parent-reported height, weight, and BMI based on commonly collected demographic information was developed using 75% of the sample. This model was used to estimate corrected measures for the remaining 25% of the sample and measured concordance between correct parent-reported and investigator-measured values. Accuracy of corrected values in classifying children as overweight/obese was assessed by sensitivity and specificity. RESULTS: Concordance between parent-reported and measured height, weight and BMI was low (0.007, - 0.039, and - 0.005 respectively). Concordance in the corrected test samples improved to 0.752 for height, 0.616 for weight, and 0.227 for BMI. Sensitivity of corrected parent-reported measures for predicting overweight and obesity among children in the test sample decreased from 42.8 to 25.6% while specificity improved from 79.5 to 88.6%. CONCLUSIONS: Correction factors improved concordance for height and weight but did not improve the sensitivity of parent-reported measures for measuring child overweight and obesity. Future research should be conducted using larger and more nationally-representative samples that allow researchers to fully explore demographic variance in correction coefficients.

The Impact of an Adolescent Depressive Disorders Clinical Pathway on Healthcare Utilization.

Clinical pathways are known to improve the value of health care in medical and surgical settings but have been rarely studied in the psychiatric setting. This study examined the association between level of adherence to an adolescent depressive disorders inpatient clinical pathway and length of stay (LOS), cost, and readmissions. Patients in the high adherence category had significantly longer LOS and higher costs compared to the low adherence category. There was no difference in the odds of 30-day emergency department return visits or readmissions. Understanding which care processes within the pathway are most cost-effective for improving patient-centered outcomes requires further investigation.

The cost-effectiveness of school-based eating disorder screening.

OBJECTIVES: We aimed to assess the value of school-based eating disorder (ED) screening for a hypothetical cohort of US public school students. METHODS: We used a decision-analytic microsimulation model to model the effectiveness (life-years with ED and quality-adjusted life-years [QALYs]), total direct costs, and cost-effectiveness (cost per QALY gained) of screening relative to current practice. RESULTS: The screening strategy cost $2260 (95% confidence interval [CI] = $1892, $2668) per student and resulted in a per capita gain of 0.25 fewer life-years with ED (95% CI = 0.21, 0.30) and 0.04 QALYs (95% CI = 0.03, 0.05) relative to current practice. The base case cost-effectiveness of the intervention was $9041 per life-year with ED avoided (95% CI = $6617, $12,344) and $56,500 per QALY gained (95% CI = $38,805, $71,250). CONCLUSIONS: At willingness-to-pay thresholds of $50,000 and $100,000 per QALY gained, school-based ED screening is 41% and 100% likely to be cost-effective, respectively. The cost-effectiveness of ED screening is comparable to many other accepted pediatric health interventions, including hypertension screening.

The cost of a primary care-based childhood obesity prevention intervention.

BACKGROUND: United States pediatric guidelines recommend that childhood obesity counseling be conducted in the primary care setting. Primary care-based interventions can be effective in improving health behaviors, but also costly. The purpose of this study was to evaluate the cost of a primary care-based obesity prevention intervention targeting children between the ages of two and six years who are at elevated risk for obesity, measured against usual care. METHODS: High Five for Kids was a cluster-randomized controlled clinical trial that aimed to modify children's nutrition and TV viewing habits through a motivational interviewing intervention. We assessed visit-related costs from a societal perspective, including provider-incurred direct medical costs, provider-incurred equipment costs, parent time costs and parent out-of-pocket costs, in 2011 dollars for the intervention (n = 253) and usual care (n =192) groups. We conducted a net cost analysis using both societal and health plan costing perspectives and conducted one-way sensitivity and uncertainty analyses on results. RESULTS: The total costs for the intervention group and usual care groups in the first year of the intervention were $65,643 (95% CI [$64,522, $66,842]) and $12,192 (95% CI [$11,393, $13,174]). The mean costs for the intervention and usual care groups were $259 (95% CI [$255, $264]) and $63 (95% CI [$59, $69]) per child, respectively, for a incremental difference of $196 (95% CI [$191, $202]) per child. Children in the intervention group attended a mean of 2.4 of a possible 4 in-person visits and received 0.45 of a possible 2 counseling phone calls. Provider-incurred costs were the primary driver of cost estimates in sensitivity analyses. CONCLUSIONS: High Five for Kids was a resource-intensive intervention. Further studies are needed to assess the cost-effectiveness of the intervention relative to other pediatric obesity interventions.

Meeting the Needs of Patient Preferences in Imaging.

Healthcare continues to transition toward a patient-centered paradigm, where patients are active in medical decisions. Fully embracing this new paradigm means updating how clinical guidelines are formulated, accounting for patient preferences for medical care. Recently, several societies have incorporated patient preference evidence in their updated clinical practice guidelines, and patients in their expert panels. To fully transition to a patient-centered-paradigm, imaging organizations should rethink the formulation of clinical guidelines, accounting for patient preference evidence.

#SharingHEOR: Developing Modern Media for Communication and Dissemination of Health Economics and Outcomes Research.

Questions regarding the effectiveness and safety of health interventions and allocation of health care resources are frequently discussed in mainstream and social media. Additionally, government and foundation funders are increasingly mandating that results be disseminated to the lay public and patients may benefit from being able to digest scientific research regarding their health conditions. Therefore, it is important to widely disseminate and clearly communication health economics and outcomes research (HEOR) findings to a range of interested parties. Digital media features such as graphical or visual abstracts, infographics and videos are informative and add value to research articles by improving reader engagement with articles, potentially increasing their impact, and allowing results to be more widely disseminated. However, use of novel digital media for research dissemination has been relatively limited to date. In this article, we discuss the rationale for developing novel media to communicate and disseminate research findings and offer practical advice for doing so. We conclude by outlining a future agenda for research regarding HEOR communication and dissemination.

Estimating Transition Probabilities for Modeling Major Depression in Adolescents by Sex and Race or Ethnicity Combinations in the USA.

OBJECTIVE: About one-fifth of US adolescents experienced major depressive symptoms, but few studies have examined longitudinal trends of adolescents developing depression or recovering by demographic factors. We estimated new transition probability inputs, and then used them in a simulation model to project the epidemiologic burden and trajectory of depression of diverse adolescents by sex and race or ethnicity combinations. METHODS: Transition probabilities were first derived using parametric survival analysis of data from the National Longitudinal Study of Adolescent to Adult Health and then calibrated to cross-sectional data from the National Survey on Drug Use and Health. We developed a cohort state-transition model to simulate age-specific depression outcomes of US adolescents. A hypothetical adolescent cohort was modeled from 12-22 years with annual transitions. Model outcomes included proportions of youth experiencing depression, recovery, or depression-free cases and were reported for a US adolescent population by sex, race or ethnicity, and sex and race or ethnicity combinations. RESULTS: At 22 years of age, approximately 16% of adolescents had depression, 12% were in recovery, and 72% had never developed depression. Depression prevalence peaked around 16-17 years-old. Adolescents of multiracial or other race or ethnicity, White, American Indian or Alaska Native, and Hispanic, Latino, or Spanish descent were more likely to experience depression than other racial or ethnic groups. Depression trajectories generated by the model matched well with historical observational studies by sex and race or ethnicity, except for individuals from American Indian or Alaska Native and multiracial or other race or ethnicity backgrounds. CONCLUSIONS: This study validated new transition probabilities for future use in decision models evaluating adolescent depression policies or interventions. Different sets of transition parameters by demographic factors (sex and race or ethnicity combinations) were generated to support future health equity research, including distributional cost-effectiveness analysis. Further data disaggregated with respect to race, ethnicity, religion, income, geography, gender identity, sexual orientation, and disability would be helpful to project accurate estimates for historically minoritized communities.

Use of Financial Incentives to Promote Adolescent Type 1 Diabetes Self-management: A Pilot Randomized Controlled Trial.

OBJECTIVE: To evaluate whether financial incentives lead to improvement in self-management behaviors and glycemia in adolescents with type 1 diabetes (T1D). RESEARCH DESIGN AND METHODS: Adolescents (12- to 18-year-olds) with T1D selected incentivized self-management behavior and clinical outcome goals in a three-treatment (gain frame, loss frame, no incentives) crossover randomized controlled trial. Participants could earn up to $180 in each 12-week incentive treatment arm. RESULTS: Compared with a mean 41% behavioral goal attainment within the nonfinancial incentives arm, mean behavioral goal attainment under gain and loss frames was 50% (P < 0.01) and 45% (P < 0.01), respectively. Mean time in range (TIR) in gain frame and loss frame arms was higher 43% (P < 0.01) and 42% (P < 0.01), respectively, compared with when not receiving financial incentives (38%). There was no difference in A1C among the three arms. CONCLUSIONS: Financial incentives can improve diabetes self-management behaviors and TIR in adolescents with T1D in the short-term.

Adolescent-Preferred financial incentives to promote type 1 diabetes Self-Care: A discrete choice experiment.

AIMS: This study aimed to quantify preferences for the characteristics of a financial incentives program that would motivate adolescent engagement in type 1 diabetes (T1D) self-care. METHOD: We performed a discrete choice experiment with 12-18 year-olds with T1D from two pediatric hospital endocrinology clinics (n = 317). We identified key attributes of incentives: (1) monthly value of the reward, (2) payment structure, and (3) difficulty of incentivized behaviors. In twelve choice questions, adolescents chose the incentive option from a pair of profiles that was more likely to motivate them to increase adherence to recommended self-care. Options presented were tailored to adolescents' T1D technology use and perceived difficulty of completing each behavior. We analyzed data using a conditional logit model. RESULTS: The value of the reward accounted for 60.8% of preferences. Adolescents were willing to accept lower value rewards when incentive payments used positive vs. negative reinforcement (-$10.88 (95% CI: -$12.60, -9.24)) and preferred higher incentives for performing hard vs. easier behaviors (+$14.92 (95% CI: +$12.66, +$17.28)). CONCLUSIONS: Stated preferences can inform intervention design. Future research will evaluate the external validity of the discrete choice experiment-informed intervention design by assessing adolescent health and behavioral outcomes in a randomized controlled trial.