Variation in multimorbidity by sociodemographics and social drivers of health among patients seen at community-based health centers.

Purpose: Understanding variation in multimorbidity across sociodemographics and social drivers of health is critical to reducing health inequities. Methods: From the multi-state OCHIN network of community-based health centers (CBHCs), we identified a cross-sectional cohort of adult (> 25 years old) patients who had a visit between 2019-2021. We used generalized linear models to examine the relationship between the Multimorbidity Weighted Index (MWI) and sociodemographics and social drivers of health (Area Deprivation Index [ADI] and social risks [e.g., food insecurity]). Each model included an interaction term between the primary predictor and age to examine if certain groups had a higher MWI at younger ages. Results: Among 642,730 patients, 28.2% were Hispanic/Latino, 42.8% were male, and the median age was 48. The median MWI was 2.05 (IQR: 0.34, 4.87) and was higher for adults over the age of 40 and American Indians and Alaska Natives. The regression model revealed a higher MWI at younger ages for patients living in areas of higher deprivation. Additionally, patients with social risks had a higher MWI (3.16; IQR: 1.33, 6.65) than those without (2.13; IQR: 0.34, 4.89) and the interaction between age and social risk suggested a higher MWI at younger ages. Conclusions: Greater multimorbidity at younger ages and among those with social risks and living in areas of deprivation shows possible mechanisms for the premature aging and disability often seen in community-based health centers and highlights the need for comprehensive approaches to improving the health of vulnerable populations.

Evaluating the Acceptability and Feasibility of a Sexual Health-Focused Contraceptive Decision Aid for Diverse Young Adults: User-Centered Usability Study.

BACKGROUND: Young adults with low sexual health literacy levels may find it difficult to make informed decisions about contraceptive methods. We developed and pilot-tested a web-based decision aid-Healthy Sex Choices-designed to support diverse young adults with their contraceptive decision-making. OBJECTIVE: This pilot study aimed to evaluate whether the Healthy Sex Choices decision aid is acceptable and feasible to patients and clinicians. METHODS: We used the Ottawa Decision Support Framework and the International Patient Decision Aid Standards to develop and pilot the decision tool. We first conducted a needs assessment with our advisory panel (5 clinicians and 2 patients) that informed decision aid development. All panelists participated in semistructured interviews about their experience with contraceptive counseling. Clinicians also completed a focus group session centered around the development of sex education content for the tool. Before commencing the pilot study, 5 participants from ResearchMatch (Vanderbilt University Medical Center) assessed the tool and suggested improvements. RESULTS: Participants were satisfied with the tool, rating the acceptability as "good." Interviewees revealed that the tool made contraceptive decision-making easier and would recommend the tool to a family member or friend. Participants had a nonsignificant change in knowledge scores (53% before vs 45% after; P=.99). Overall, decisional conflict scores significantly decreased (16.1 before vs 2.8 after; P<.001) with the informed subscale (patients feeling more informed) having the greatest decline (23.1 vs 4.7; mean difference 19.0, SD 27.1). Subanalyses of contraceptive knowledge and decisional conflict illustrated that participants of color had lower knowledge scores (48% vs 55%) and higher decisional conflict (20.0 vs 14.5) at baseline than their white counterparts. CONCLUSIONS: Participants found Healthy Sex Choices to be acceptable and reported reduced decisional conflict after using the tool. The development and pilot phases of this study provided a foundation for creating reproductive health decision aids that acknowledge and provide guidance for diverse patient populations.

Clinicians' Perspectives and Proposed Solutions to Improve Contraceptive Counseling in the United States: Qualitative Semistructured Interview Study With Clinicians From the Society of Family Planning.

BACKGROUND: Contraceptive care is a key element of reproductive health, yet only 12%-30% of women report being able to access and receive the information they need to make these complex, personal health care decisions. Current guidelines recommend implementing shared decision-making approaches; and tools such as patient decision aid (PtDA) applications have been proposed to improve patients' access to information, contraceptive knowledge, decisional conflict, and engagement in decision-making and contraception use. To inform the design of meaningful, effective, elegant, and feasible PtDA applications, studies are needed of all users' current experiences, needs, and barriers. While multiple studies have explored patients' experiences, needs, and barriers, little is known about clinicians' experiences, perspectives, and barriers to delivering contraceptive counseling. OBJECTIVE: This study focused on assessing clinicians' experiences, including their perspectives of patients' needs and barriers. It also explored clinicians' suggestions for improving contraceptive counseling and the feasibility of a contraceptive PtDA. METHODS: Following the decisional needs assessment approach, we conducted semistructured interviews with clinicians recruited from the Society of Family Planning. The Ottawa Decision Support Framework informed the interview guide and initial codebook, with a specific focus on decision support and decisional needs as key elements that should be assessed from the clinicians' perspective. An inductive content approach was used to analyze data and identify primary themes and suggestions for improvement. RESULTS: Fifteen clinicians (12 medical doctors and 3 nurse practitioners) participated, with an average of 19 years of experience in multiple regions of the United States. Analyses identified 3 primary barriers to the provision of quality contraceptive counseling: gaps in patients' underlying sexual health knowledge, biases that impede decision-making, and time constraints. All clinicians supported the development of contraceptive PtDAs as a feasible solution to these main barriers. Multiple suggestions for improvement were provided, including clinician- and system-level training, tools, and changes that could support successful implementation. CONCLUSIONS: Clinicians and developers interested in improving contraceptive counseling and decision-making may wish to incorporate approaches that assess and address upstream factors, such as sexual health knowledge and existing heuristics and biases. Clinical leaders and administrators may also wish to prioritize solutions that improve equity and accessibility, including PtDAs designed to provide education and support in advance of the time-constrained consultations, and strategic training opportunities that support cultural awareness and shared decision-making skills. Future studies can then explore whether well-designed, user-centered shared decision-making programs lead to successful and sustainable uptake and improve patients' reproductive health contraceptive decision-making.

Associations of Unintended Pregnancy With Maternal and Infant Health Outcomes: A Systematic Review and Meta-analysis.

Importance: Unintended pregnancy is common in the US and is associated with adverse maternal and infant health outcomes; however, estimates of these associations specific to current US populations are lacking. Objective: To evaluate associations of unintended pregnancy with maternal and infant health outcomes during pregnancy and post partum with studies relevant to current clinical practice and public health in the US. Data Sources: Cochrane Central Register of Controlled Trials and Database of Systematic Reviews, PsycINFO, SocINDEX, and MEDLINE databases (January 1, 2000, to June 15, 2022) and manual review of reference lists. Study Selection: Epidemiologic studies relevant to US populations that compared key maternal and infant health outcomes for unintended vs intended pregnancies and met prespecified eligibility criteria were included after investigators' independent dual review of abstracts and full-text articles. Data Extraction and Synthesis: Investigators abstracted data from publications on study methods, participant characteristics, settings, pregnancy intention, comparators, confounders, and outcomes; data were validated by a second investigator. Risk of bias was independently dual rated by investigators using criteria developed by the US Preventive Services Task Force. Results of studies controlling for confounders were combined by using a profile likelihood random-effects model. Main Outcomes and Measures: Prenatal depression, postpartum depression, maternal experience of interpersonal violence, preterm birth, and infant low birth weight. Results: Thirty-six studies (N = 524 522 participants) were included (14 cohort studies rated good or fair quality; 22 cross-sectional studies); 12 studies used large population-based data sources. Compared with intended pregnancy, unintended pregnancy was significantly associated with higher odds of depression during pregnancy (23.3% vs 13.9%; adjusted odds ratio [aOR], 1.59 [95% CI, 1.35-1.92]; I2 = 85.0%; 15 studies [n = 41 054]) and post partum (15.7% vs 9.6%; aOR, 1.51 [95% CI, 1.40-1.70]; I2 = 7.1%; 10 studies [n = 82 673]), interpersonal violence (14.6% vs 5.5%; aOR, 2.22 [95% CI, 1.41-2.91]; I2 = 64.1%; 5 studies [n = 42 306]), preterm birth (9.4% vs 7.7%; aOR, 1.21 [95% CI, 1.12-1.31]; I2 = 1.7%; 10 studies [n = 94 351]), and infant low birth weight (7.3% vs 5.2%; aOR, 1.09 [95% CI, 1.02-1.21]; I2 = 0.0%; 8 studies [n = 87 547]). Results were similar in sensitivity analyses based on controlling for history of depression for prenatal and postpartum depression and on study design and definition of unintended pregnancy for relevant outcomes. Studies provided limited sociodemographic data and measurement of confounders and outcomes varied. Conclusions and Relevance: In this systematic review and meta-analysis of epidemiologic observational studies relevant to US populations, unintended pregnancy, compared with intended pregnancy, was significantly associated with adverse maternal and infant outcomes. Trial Registration: PROSPERO Identifier: CRD42020192981.

Effects of technology-based contraceptive decision aids: a systematic review and meta-analysis.

OBJECTIVE: This study aimed to conduct a systematic review and meta-analysis of the effects of technology-based decision aids on contraceptive use, continuation, and patient-reported and decision-making outcomes. DATA SOURCES: A systematic search was conducted in OVID MEDLINE, Cochrane Database of Systematic Reviews, CENTRAL, CINAHL, Embase, PsycINFO, and SocINDEX databases from January 2005 to April 2022. Eligible references from a concurrent systematic review evaluating contraceptive care were also included for review. STUDY ELIGIBILITY CRITERIA: Studies were included if a contraceptive decision aid was technology-based (ie, mobile/tablet application, web, or computer-based) and assessed contraceptive use and/or continuation or patient-reported outcomes (knowledge, self-efficacy, feasibility/acceptability/usability, decisional conflict). The protocol was registered under the International Prospective Register of Systematic Reviews (CRD42021240755). METHODS: Three reviewers independently performed data abstraction and quality appraisal. Dichotomous outcomes (use and continuation) were evaluated with an odds ratio, whereas continuous outcomes (knowledge and self-efficacy) were evaluated with the mean difference. Subgroup analyses were performed for the mode of delivery (mobile and tablet applications vs web and computer-based) and follow-up time (immediate vs >1 month). RESULTS: This review included 18 studies evaluating 21 decision aids. Overall, there were higher odds of contraceptive use and/or continuation among decision aid users compared with controls (odds ratio, 1.27; 95% confidence interval, [1.05-1.55]). Use of computer and web-based decision aids was associated with higher odds of contraceptive use and/or continuation (odds ratio, 1.36; 95% confidence interval, [1.08-1.72]) than mobile and tablet decision aids (odds ratio, 1.27; 95% confidence interval, [0.83-1.94]). Decision aid users also had statistically significant higher self-efficacy scores (mean difference, 0.09; 95% confidence interval, [0.05-0.13]), and knowledge scores (mean difference, 0.04; 95% confidence interval, [0.01-0.07]), with immediate measurement of knowledge having higher retention than measurement after 1 month. Other outcomes were evaluated descriptively (eg, feasibility, applicability, decisional conflict) but had little evidence to support a definite conclusion. Overall, the review provided moderate-level evidence for contraceptive use and continuation, knowledge, and self-efficacy. CONCLUSION: The use of technology-based contraceptive decision aids to support contraceptive decision-making has positive effects on contraceptive use and continuation, knowledge, and self-efficacy. There was insufficient evidence to support a conclusion about effects on other decision-making outcomes.

Effectiveness and Harms of Contraceptive Counseling and Provision Interventions for Women : A Systematic Review and Meta-analysis.

BACKGROUND: The effectiveness and harms of contraceptive counseling and provision interventions are unclear. PURPOSE: To evaluate evidence of the effectiveness of contraceptive counseling and provision interventions for women to increase use of contraceptives and reduce unintended pregnancy, as well as evidence of their potential harms. DATA SOURCES: English-language searches of Cochrane Central Register of Controlled Trials, Cochrane Database of Systematic Reviews, PsycINFO, SocINDEX, and MEDLINE (1 January 2000 to 3 February 2022) and reference lists of key studies and systematic reviews. STUDY SELECTION: Randomized controlled trials of interventions providing enhanced contraceptive counseling, contraceptives, or both versus usual care or an active control. DATA EXTRACTION: Dual extraction and quality assessment of studies; results combined using a profile likelihood random-effects model. DATA SYNTHESIS: A total of 38 trials (43 articles [25 472 participants]) met inclusion criteria. Contraceptive use was higher with various counseling interventions (risk ratio [RR], 1.39 [95% CI, 1.16 to 1.72]; I 2 = 85.3%; 10 trials), provision of emergency contraception in advance of use (RR, 2.12 [CI, 1.79 to 2.36]; I 2 = 0.0%; 8 trials), and counseling or provision postpartum (RR, 1.15 [CI, 1.01 to 1.52]; I 2 = 6.6%; 5 trials) or at the time of abortion (RR, 1.19 [CI, 1.09 to 1.32]; I 2 = 0.0%; 5 trials) than with usual care or active controls in multiple clinical settings. Pregnancy rates were generally lower with interventions, although most trials were underpowered and did not distinguish pregnancy intention. Interventions did not increase risk for sexually transmitted infections (STIs) (RR, 1.05 [CI, 0.87 to 1.25]; I 2 = 0.0%; 5 trials) or reduce condom use (RR, 1.03 [CI, 0.94 to 1.13]; I 2 = 0.0%; 6 trials). LIMITATION: Interventions varied; few trials were adequately designed to determine unintended pregnancy outcomes. CONCLUSION: Contraceptive counseling and provision interventions that provide services beyond usual care increase contraceptive use without increasing STIs or reducing condom use. Contraceptive care in clinical practice could be improved by implementing enhanced contraceptive counseling, provision, and follow-up; providing emergency contraception in advance; and delivering contraceptive services immediately postpartum or at the time of abortion. PRIMARY FUNDING SOURCE: Resources Legacy Fund. (PROSPERO: CRD42020192981).

An Analysis of Two Sources of Cardiology Patient Data to Measure Medication Agreement.

Errors and incompleteness in electronic health record (EHR) medication lists can result in medical errors. To reduce errors in these medication lists, clinicians use patient self-reported data to reconcile EHR data. We assessed the agreement between patient self-reported medications and medications recorded in the EHR for six medication classes related to cardiovascular care and used logistic regression models to determine which patient-related factors were associated with the disagreement between these two information sources. From our 297 patients, we found self-reported medications had an overall above-average agreement with the EHR (? = .727). We observed the highest agreement level for statins (? = .831) and the lowest for other antihypertensives (? = .465). Agreement was less likely for Hispanic and male patients. We also performed an in-depth error analysis of different types of disagreement beyond medication names, which revealed that the most frequent type of disagreement was mismatched dosages.