Supporting reproductive health among birthing persons with chronic conditions in the United States: A qualitative multilevel study using systems thinking to inform action.

OBJECTIVE (STUDY QUESTION): To use systems thinking with diverse system actors to (a) characterize current problems at the intersection of chronic conditions (CCs) and reproductive health (RH) care and their determinants, (b) determine necessary system actors for change, and (c) document cross-system actions that can improve identified problems in the United States. DATA SOURCES/STUDY SETTING: Data were collected from six groups of system actors via online focus groups. STUDY DESIGN: This is a qualitative multilevel study using the iceberg systems thinking framework. DATA COLLECTION/EXTRACTION METHODS: Data were collected by note-taking and recording six focus groups; analysis incorporated perspective triangulation using the systems thinking iceberg and system mapping to visualize interconnected system challenges, actors, and action ideas. PRINCIPAL FINDINGS: Participants described eight necessary system actors: health care institutions, medical leaders, medical providers, patient advocates and foundations, patients and families, payors, policy makers, and research funders. Forty pain points were identified, spread across each of the four levels of the systems thinking iceberg: undesirable outcomes (6), concerning trends (9), system structure flaws (15), and problematic mental models (10). In response to these pain points, a set of 46 action ideas was generated by participants and mapped into nine action themes: (1) adjust QI metrics, incentives, and reimbursement, (2) bolster RH medical education and training, (3) break down medical silos, (4) enrich patient education, (5) expand the health care team, (6) improve holistic health care, (7) modify research and programmatic funding to prioritize RH and CC, (8) spur innovation for patient visits, and (9) support professional champions and leaders. CONCLUSIONS: By embracing system complexity, creating visual maps, and pushing participants to identify actionable strategies for improvement, this study generates a set of specific actions that can be used to address pain points across the multiple system levels that make improving reproductive care for people with CCs so challenging.

Simulating congestion pricing policy impacts on pedestrian safety using a system dynamics approach.

Research on congestion pricing policy (CPP) impacts has generally focused on the economic and congestion-related benefits of CPPs. Few studies have examined safety effects and the interrelated factors that produce safety outcomes for vulnerable road users. We built a novel system dynamics simulation model to explore the potential mechanisms producing pedestrian injuries over time and the impacts of a CPP (and related interventions) on this trend. We found that pedestrian injury trends varied based on important decisions related to how the CPP is designed, including investments in potential safety-related supports for pedestrians. Infrastructure improvements and speed management interventions could help cities achieve both congestion-relieving goals while also improving safety. Additionally, certain CPP configurations (e.g., additional charges on for-hire vehicles) could further reduce daily vehicle trips and congestion but might lead to unintended negative safety consequences of greater pedestrian injuries. This is the first model to provide a holistic and endogenous look at how interconnected processes affecting congestion and CPP impacts also affect vulnerable road user safety. The use of system dynamics models can facilitate a holistic inspection of potential intended and unintended effects across a range of outcomes, prior to policy implementation.

Changes in cigarette smoking initiation, cessation, and relapse among U.S. adults: a comparison of two longitudinal samples.

BACKGROUND: The tobacco epidemic in the U.S. has matured in the past decade. However, due to rapidly changing social policy and commercial environments, tailored prevention and interventions are needed to support further reduction in smoking. METHODS: Using Tobacco Use Supplement to the Current Population Survey (TUS-CPS) 2002-2003 and 2010-2011 longitudinal cohorts, five smoking states are defined including daily-heavy, daily-light, non-daily, former and non-smoker. We quantified the changes between smoking states for the two longitudinal cohorts, and used a series of multivariable logistic regression models to examine the association of socio-demographic attributes and initial smoking states on smoking initiation, cessation, and relapse between waves within each cohort. RESULTS: The prevalence of adult heavy smoking decreased from 9.9% (95% CI: 9.6%, 10.2%) in 2002 to 7.1% (95% CI: 6.9%, 7.4%) in 2010. Non-daily smokers were less likely to quit in the 2010-2011 cohort than the 2002-2003 cohort (37.0% vs. 44.9%). Gender, age group, smoker type, race and marital status exhibit similar patterns in terms of their association to the odds of initiation, cessation and relapse between the two cohorts, while education groups showed some inconsistent results between the two cohorts regarding the odds of cessation. CONCLUSIONS: Transitions between smoking states are complex and increasingly unstable, requiring a holistic, population-based perspective to understand the stocks and flows that ultimately dictate the public health impact of cigarette smoking behavior. This knowledge helps to identify groups in need of increased tobacco control prevention and intervention efforts.

A non-experimental study of oral anticoagulation therapy initiation before and after national patient safety goals.

OBJECTIVES: The Joint Commission revised its National Patient Safety Goals (NPSGs) to include oral anticoagulation therapy (OAT) in 2008. We sought to examine the effect of including OAT in The Joint Commission's NPSGs on historically low rates of OAT initiation for individuals with incident atrial fibrillation (AF). SETTING: Southeastern state in the USA. PARTICIPANTS: North Carolina State Health Plan claims data from 944 500 individuals enrolled between 1 January 2006 and 31 December 2010, supplemented with data from the Area Resource File and Online Survey, Certification and Reporting data network. We evaluated OAT initiation before and after the 2008 NPSGs revisions in a retrospective cohort new user design with an AF intervention group and two control groups: a positive control-patients estimated to be at very high risk of thromboembolism (mechanical heart valve and pulmonary embolism); and a negative control-patients with very low perceived risk of thromboembolism (paroxysmal AF). We developed multivariable models using a difference-in-difference parameterisation. Effects were estimated with generalised estimating equations. PRIMARY OUTCOME MEASURE: OAT initiation, a binary outcome defined as having a prescription drug claim for warfarin within 30 days of the index claim. RESULTS: OAT initiation was low (26.8%) for eligible individuals with incident AF in 2006-2008 but increased after NPSGs implementation (31.7%, p=0.022). OAT initiation was high but decreased in the positive control group (67.5% vs 62.0%, p=0.003). Multivariate analysis resulted in a relative 11% (95% CI (4% to 18%), p<0.01) increase in OAT initiation for incident AF patients. CONCLUSIONS: We document a substantial increase in guideline concordant OAT initiation in incident AF after the establishment of NPSGs, suggesting that regulatory healthcare agency initiatives can influence clinical practice.