Structural and relational factors for successful cross-sector collaboration in home visiting: a multiple case study.

BACKGROUND: Aligning delivery and financing systems across sectors to create broader systems of care can improve the health and well-being of families experiencing adversities. We aimed to identify structural and relational factors for best practices to achieve successful cross-sector collaboration among home visiting programs in the United States. MATERIALS AND METHODS: We used a multiple case study approach to identify best practices for successful cross-sector collaboration between home visitors and other community service providers. We selected five diverse exemplary cases with cross-sector collaboration with variation in implementing agency type and geographic location. Cases were selected using a positive deviance approach based on strong coordination and integration with different community service provider types identified from previous survey data. We conducted in-depth qualitative interviews with home visiting staff, community providers, and clients with a total of 76 interviews conducted from 2021 to 2022. We wrote memos to synthesize themes within each case through data triangulation using interview data, documents, and site visit observations. We compared themes across the five cases to create a cross-case synthesis of best practices for successful cross-sector collaboration. RESULTS: Across the five cases, relational factors including leadership from all levels, champions across sectors, and shared goals between community providers were key factors for successful collaboration. Interpersonal relationships, coupled with the desire and capacity to engage, facilitated effective coordination to address families' needs. At the structural level, shared data systems, written agreements, and co-location enabled care coordination activities. Community Advisory Boards provided a venue for developing partnerships, relationship-building, resource-sharing, and increasing awareness of home visiting. CONCLUSIONS: We identified key elements of successful cross-sector collaboration across five case studies where home visitors coordinate care frequently and/or are structurally integrated with a range of providers. These learnings will inform future interventions to improve home visiting collaboration with other community providers to create a system of care to enhance family well-being.

Legislative Health Notes: Preliminary Learnings From Piloting a New Policy Analysis Tool.

CONTEXT: In 2018, the Health Impact Project (the Project) developed and tested a new health in all policies (HiAP) tool called "legislative health notes" to provide state and local legislators with peer-reviewed evidence, public health data, and local data that illustrate potential positive and negative health and equity effects of proposed bills. OBJECTIVES: The Project sought to refine the health note methodology while piloting the tool in the Colorado and Indiana General Assemblies, and with the Council of the District of Columbia, and worked with affiliates to introduce them in North Carolina, Ohio, and California. DESIGN AND PARTICIPANTS: External partners solicited feedback on health notes via semistructured interviews and surveys from legislators, legislative staff, and expert reviewers who were familiar with health notes in each of these jurisdictions. RESULTS: Respondents shared that health notes were nonpartisan, were easy for nonexperts to understand, and would be more effective if delivered earlier in the legislative process. CONCLUSION: In response to informant feedback, practitioners can explore adding high-level summaries, increasing focus on health equity implications and the potential to work with legislators during the policy formulation phase. Data from this pilot suggest that legislative health notes are a promising nonpartisan and standardized tool to better understand the health and equity implications of proposed legislation.

Coordination of family's care in an evidence-based nurse home visiting program.

Interprofessional care coordination within evidence-based prevention programs like Nurse-Family Partnership® (NFP) is necessary to meet family needs and maximize program impact. This study aimed to describe the coordination of families' care in the NFP home visiting context. We used an adapted grounded theory approach and purposively sampled seven NFP sites. We conducted telephone interviews with 95 participants: 51 NFP staff (54%), 39 healthcare providers (41%), and 5 social service providers (5%). All interviews were recorded, transcribed, validated, and analyzed in NVivo11. Many community providers in all sites described their knowledge of the characteristics of the NFP intervention, including the strength of its evidence to achieve outcomes. Care coordination was dynamic and changed over time based on client needs and staff willingness to work together. Effective care coordination in the NFP context from the provider perspective is driven by shared knowledge, integrated systems, mission alignment, and individual champions who value the program.

Impact of Recreational Cannabis Legalization on Opioid Prescribing and Opioid-Related Hospital Visits in Colorado: an Observational Study.

BACKGROUND: Cannabis may be a substitute for opioids but previous studies have found conflicting results when using data from more recent years. Most studies have examined the relationship using state-level data, missing important sub-state variation in cannabis access. OBJECTIVE: To examine cannabis legalization on opioid use at the county level, using Colorado as a case study. Colorado allowed recreational cannabis stores in January 2014. Local communities could decide whether to allow dispensaries, creating variation in the level of exposure to cannabis outlets. DESIGN: Observational, quasi-experimental design exploiting county-level variation in allowance of recreational dispensaries. SUBJECTS: Colorado residents MEASURES: We use licensing information from the Colorado Department of Revenue to measure county-level exposure to cannabis outlets. We use the state's Prescription Drug Monitoring Program (2013-2018) to construct opioid-prescribing measures of number of 30-day fills and total morphine equivalents, both per county resident per quarter. We construct outcomes of opioid-related inpatient visits (2011-2018) and emergency department visits (2013-2018) with Colorado Hospital Association data. We use linear models in a differences-in-differences framework that accounts for the varying exposure to medical and recreational cannabis over time. There are 2048 county-quarter observations used in the analysis. RESULTS: We find mixed evidence of cannabis exposure on opioid-related outcomes at the county level. We find increasing exposure to recreational cannabis is associated with a statistically significant decrease in number of 30-day fills (coefficient: -117.6, p-value<0.01) and inpatient visits (coefficient: -0.8, p-value: 0.03), but not total MME nor ED visits. Counties with no medical exposure prior to recreational legalization experience greater reductions in the number of 30-day fills and MME than counties with prior medical exposure (p=0.02 for both). CONCLUSIONS: Our mixed findings suggest that further increases in cannabis beyond medical access may not always reduce opioid prescribing or opioid-related hospital visits at a population level.

Health Effects of High-Concentration Cannabis Products: Scoping Review and Evidence Map.

Background. The concentration of pharmacologically active tetrahydrocannabinol (THC) in cannabis products has been increasing over the past decade. Concerns about potential harmful health effects of using these increasingly higher-concentration products have led some states to consider regulation of cannabis product THC concentration. We conducted a scoping review of health effects of high-concentration cannabis products to inform policy on whether the THC concentrations of cannabis product should be regulated or limited. Objectives. We conducted a scoping review to (1) identify and describe human studies that explore the relationship of high-concentration cannabis products with any health outcomes in the literature and (2) create an interactive evidence map of the included studies to facilitate further analyses. Search Methods. An experienced medical information specialist designed a comprehensive search strategy of 7 electronic databases. Selection Criteria. We included human studies of any epidemiological design with no restrictions by age, sex, health status, country, or outcome measured that reported THC concentration or included a known high-concentration cannabis product. Data Collection and Analysis. We imported search results into Distiller SR, and trained coders conducted artificial intelligence‒assisted screening. We developed, piloted, and revised data abstraction forms. One person performed data abstraction, and a senior reviewer verified a subset. We provide a tabular description of study characteristics, including exposures and outcomes measured, for each included study. We interrogated the evidence map published in Tableau to answer specific questions and provide the results as text and visual displays. Main Results. We included 452 studies in the scoping review and evidence map. There was incomplete reporting of exposure characteristics including THC concentration, duration and frequency of use, and products used. The evidence map shows considerable heterogeneity among studies in exposures, outcomes, and populations studied. A limited number of reports provided data that would facilitate further quantitative synthesis of the results across studies. Conclusions. This scoping review and evidence map support strong conclusions concerning the utility of the literature for characterizing risks and benefits of the current cannabis marketplace and the research approaches followed in the studies identified. Relevance of the studies to today's products is limited. Public Health Implications. High-quality evidence to address the policy question of whether the THC concentration of cannabis products should be regulated is scarce. The publicly available interactive evidence map is a timely resource for other entities concerned with burgeoning access to high-concentration cannabis. (Am J Public Health. 2023;113(12):1332-1342. https://doi.org/10.2105/AJPH.2023.307414).

Cross-sector Collaboration Between Public Health, Healthcare and Social Services Improves Retention: Findings from a Nurse Home Visiting Program.

The study aimed to examine the association between cross-sector collaboration in Nurse-Family Partnership (NFP), a model home visiting program, and participant retention. We used the 2018 NFP Collaboration Survey that measured agency-level collaboration, operationalized as relational coordination and structural integration, among nine community provider types (including obstetrics care, substance use treatment, child welfare). This dataset was linked to 2014-2018 NFP program implementation data (n = 36,900). We used random-intercept models with nurse-level random effects to examine the associations between provider-specific collaborations and participant retention adjusting for client, nurse, and agency characteristics. The adjusted models suggest that stronger relational coordination between nurses and substance use treatment providers (OR:1.177, 95% CI: 1.09-1.26) and greater structural integration with child welfare (OR: 1.062, CI: 1.04-1.09) were positively associated with participant retention at birth. Stronger structural integration between other home visiting programs and supplemental nutrition for women, infants, and children was negatively associated with participant retention at birth (OR: 0.985, CI: 0.97-0.99). Structural integration with child welfare remained significantly associated with participant retention at 12-month postpartum (OR: 1.032, CI: 1.01-1.05). In terms of client-level characteristics, clients who were unmarried, African-American, or visited by nurses who ceased NFP employment prior to their infant's birth were more likely to drop out of the NFP program. Older clients and high school graduates were more likely to remain in NFP. Visits by a nurse with a master's degree, agency rurality, and healthcare systems that implement the program were associated with participant retention. Cross-sector collaboration in a home visiting setting that bridges healthcare and addresses social determinants of health has potential to improve participant retention. This study sets the groundwork for future research to explore the implications of collaborative activities between preventive services and community providers.

Cannabis legalization and cannabis-involved pregnancy hospitalizations in Colorado.

The primary objective of this study was to evaluate the association between presence of recreational cannabis dispensaries and prevalence of cannabis-involved pregnancy hospitalizations in Colorado. This was a retrospective cohort study of pregnancy-related hospitalizations co-coded with cannabis diagnosis codes in the Colorado Hospital Association from January 1, 2011, through December 31, 2018 (recreational cannabis began January 1, 2014). Our primary outcome was cannabis-involved pregnancy hospitalizations per 10 k live births per county. The primary exposure measure was county variation in the number of recreational dispensaries. We controlled for counties' baseline exposure to medical cannabis dispensaries and used Poisson regression to evaluate the association between exposure to recreational cannabis and hospitalizations. During the study period, cannabis-involved pregnancy hospitalizations increased from 429 to 1210. Mean hospitalizations per county (1.7 to 4.7) and per 10 k live births (13.2 to 55.7) increased. Overall, increasing recreational dispensaries were associated with increases in hospitalizations (1.02, CI: 1.00,1.04). When comparing counties with different densities of baseline medical cannabis market, low and high exposure counties had fewer hospitalizations than those counties with no exposure (low: IRR 0.97, CI: 0.96-0.99; high: 0.98, CI: 0.96-0.99). In Colorado, there was more than a two-fold increase in cannabis-involved pregnancy hospitalizations between 2011 and 2018. Counties with no baseline exposure to medical cannabis had a greater increase than other counties, suggesting the recreational market may influence cannabis use among pregnant individuals.

Comparison of hospital claims and poison center data to evaluate health impact of opioids, cannabis and synthetic cannabinoids.

INTRODUCTION: Over the past 10 years, opioids and cannabis have garnered significant attention due to misuse and legalization trends. Different datasets and surveillance mechanisms can lead to different conclusions the due to a variety of factors. The primary objective of this study was to compare and describe trends of opioid, cannabis, and synthetic cannabinoid-related healthcare encounters and poison center (PC) cases in Colorado, a state that has legalized cannabis. METHODS: This was a retrospective study comparing hospital claims data (Colorado Hospital Association (CHA)) and poison center cases to describe opioid, cannabis and synthetic cannabinoid-related healthcare encounters and exposures in Colorado from 2013 to 2017 using related genetic codes and International Statistical Classification of Disease codes. RESULTS: Both datasets observed increases in cannabis related encounters and exposures after recreational cannabis legalization in 2014. CHA reported an increase for cannabis-related ER visits from 14,109 in 2013 to 18,118 in 2017 while PC noted a 74.4% increase in cannabis-related cases (125 to 218). CHA inpatient visits associated with cannabis also increased (8311 in 2013 to 14,659 in 2017). On the other hand, Opioid-related exposures to the PC fell (1092 in 2013 to 971 in 2017) while both Opioid-related ER visits (8580 in 2013 to 12,928 in 2017) and inpatient visits in CHA increased (9084 in 2013 to 13,205). CONCLUSIONS: This study demonstrates the differences in surveillance methodology for concurrent drug abuse epidemics using hospital claims and PC data. Both systems provide incomplete reports, but in combination can provide a more complete picture.

A Qualitative Study of Mothers' Perspectives on Enrolling and Engaging in an Evidence-Based Nurse Home Visiting Program.

Prevention programs like Nurse-Family Partnership® (NFP) must enroll and retain clients of the intended population to maximize program impact. NFP is an evidence-based nurse home visitation program shown in randomized trials to improve maternal and child health and life course outcomes for first-time parents experiencing economic adversity, particularly for mothers with limited psychological resources. The purpose of this study was to understand enrollment and engagement experiences of mothers with previous live births referred to NFP in a formative study of the program for this population, but did not enroll or dropped out before program graduation. We used a grounded theory approach and purposively selected three NFP sites with variation in enrollment rates. We conducted telephone interviews with 23 mothers who were either referred to NFP and declined enrollment or former clients who dropped out before graduation. All interviews were conducted in English, recorded, transcribed, and validated. We developed an iterative codebook with multiple coders to analyze our data in NVivo11 and wrote thematic memos to synthesize data across study sites. Mothers described experiencing overlapping risk factors including physical and behavioral health conditions, child welfare involvement, and housing insecurity. Mothers from all sites discussed how they were referred to the NFP program, their experience of the enrollment process, reasons for enrolling or not enrolling, and reasons for dropping out after initial enrollment. Key themes that influenced mothers' decision-making were: perceptions of program value, not needing the program, their living situation or being too busy as a deterrence, and past experiences including a distrust of health care. Reasons for attrition were related to no longer needing the service, being assigned a new nurse, being too tired postpartum, and moving out of the service area. One way to support home visiting nurses in family enrollment and engagement is to build their professional capacity to implement trauma-informed strategies given mothers' life experiences.

National survey of nurse home visitor collaboration with health care and social services.

OBJECTIVE: To assess the degree to which nurses in a national public health home visiting program collaborate with interprofessional providers to serve families experiencing adversity. DESIGN: A descriptive, cross-sectional survey measured collaborative practices between nurse home visitors, health care, and social service providers. A census of 263 nursing supervisors completed a web-based survey. MEASUREMENTS: The survey included the validated 7-item Relational Coordination Scale, adapted items from the Interagency Collaboration Activities Scale on shared resources, and items related to collaboration attitudes and beliefs. Data were analyzed with descriptive statistics. RESULTS: Relational coordination scores, which are relative measures, ranged from 1 to 5; highest with supplemental nutrition for Women, Infants & Children (M = 3.77) and early intervention (M = 3.44); and lowest with housing (M = 2.55). The greatest sharing of resources was with supplemental nutrition (sum = 12.95) and mental health providers (sum = 11.81), and least with housing (sum = 7.26); with a range of 1-30 where higher scores indicated greater resource-sharing. CONCLUSION: Home visiting nurses collaborate with interprofessional providers with variation in the degree of collaboration between agencies and by provider type within an agency. Collaboration was a function of two interrelated domains: interpersonal relationships supported by organizational and contextual factors at the systems-level.

Kids, Cops, and Community: A Qualitative Assessment of Police, Youth, and Parent Perceptions of Each Other.

CONTEXT: Police and communities alike have experienced many traumatic incidents over the last 4 years, prompting police departments across the country to rethink their approach to community programs. PROGRAM: Aurora's Gang Reduction Impact Program (A-GRIP) launched "Kids, Cops, and Community" (KC&C) in Aurora, Colorado, as a community-based quality improvement project designed to improve community relations by better understanding Aurora police and community members' perceptions of each other and current A-GRIP and Aurora for Youth programs by assessing police, youth, and parents' perceptions of each other. IMPLEMENTATION: After a review of current scientific literature on police-community relations, a KC&C advisory group oversaw the creation of key informant interview and focus group guides. A-GRIP recruited participants for 37 interviews (20 police, 8 youth, and 9 parents) and 3 youth focus groups. The community advisory group assisted in the development of salient themes and practical recommendations. The final report outlined 5 major themes (pros/cons of types of police interactions, respectful communication, false uniqueness effect, parenting and police as parents, and youth-police programming awareness) and 2 specific recommendations (sustain/increase opportunities for police-youth interactions and increase community awareness of youth programming). EVALUATION: A-GRIP members had a rich discussion of the implications of these findings in which there was broad support for identifying a strategy to use these results to improve police-community relations. The coalition was challenged by identifying clear next steps because of turnover in administration and coalition leadership, but they have made progress in increasing information and resource sharing. DISCUSSION: This project provides the first model we are aware of that incorporates a systematic assessment of police, youth, and parent perspectives from the same community. Other communities may find value in adapting the KC&C process to identify promising approaches and refine programming elements of police-community engagement activities.

Gun retailers as storage partners for suicide prevention: what barriers need to be overcome?

INTRODUCTION: Safe storage of guns outside the household while someone is at risk for suicide is important for suicide prevention. Some gun retailers offer temporary firearm storage as a community resource. Others may be willing if perceived barriers can be addressed. METHODS: We invited all gun retailers in eight Mountain West states to respond to a questionnaire about the barriers they perceive in offering temporary, voluntary gun storage for community members. RESULTS: Ninety-five retailers responded (25% response rate). Fifty-eight percent believed federal laws make it harder to store guns and 25% perceived state laws to be obstacles. Over 60% cited legal liability in storing and returning guns as barriers. Other important barriers included cost, space and logistical issues of drop off and pick up. CONCLUSIONS: Strategies to reduce legal and other barriers will need to be addressed to better engage gun retailers as a community resource for safe gun storage.

State Laws and Nonprofit Hospital Community Benefit Spending.

OBJECTIVE: To determine the association of state laws on nonprofit hospital community benefit spending. DESIGN: We used multivariate models to estimate the association between different types of state-level community benefit laws and nonprofit hospital community benefit spending from tax filings. SETTING: All 50 US states. PARTICIPANTS: A total of 2421 nonprofit short-term acute care hospital organizations that filled an internal revenue service Form 990 and Schedule H for calendar during years 2009-2015. RESULTS: Between 2009 and 2015, short-term acute care hospitals spent an average of $46 billion per year in total, or $20 million per hospital on community benefit activities. Exposure to a state-level community benefit law of any type was associated with an $8.42 (95% confidence interval: 1.20-15.64) per $1000 of total operating expense greater community benefit spending. Spending amounts and patterns varied on the basis of the type of community benefit law and hospital urbanicity. CONCLUSIONS: State laws are associated with nonprofit hospital community benefit spending. Policy makers can use community benefit laws to increase nonprofit hospital engagement with public health.

Counseling Suicidal Patients About Access to Lethal Means: Attitudes of Emergency Nurse Leaders.

INTRODUCTION: For ED patients at risk of suicide, counseling to reduce access to lethal means (including firearms) is recommended yet not routine. To enhance practice uptake, we sought to examine the attitudes and beliefs of emergency nurse leaders concerning the acceptability and effectiveness of lethal-means counseling. METHODS: We invited a nurse leader (ED nurse manager or Chief Nursing Officer [CNO]) at each hospital-based emergency department in the 8-state Mountain West region of the United States to complete a closed-ended telephone survey. Questions assessed current practices and leaders' views on suicide prevention and lethal-means counseling. Reponses were weighted to all eligible hospitals to adjust for nonresponse. RESULTS: From 363 eligible hospitals, 190 emergency nurse leaders responded (overall response rate: 52%). Emergency nurse leaders thought providers at their emergency departments did an excellent job of safety counseling (74%) for suicidal patients. Most respondents believed that talking about firearms with suicidal patients is acceptable to patients (77%), supported by hospital administration (64%), effective in preventing suicide (69%), and something that providers should do (91%). However, the majority also had doubts about whether suicide is preventable (60%). DISCUSSION: Despite expressing high levels of support for the acceptability and effectiveness of lethal-means counseling, high proportions of emergency nurse leaders expressed skepticism regarding the preventability of suicide, a finding consistent with previous work. Our results support the need to address and modify misperceptions about prevention of suicide in any efforts for widespread implementation and dissemination of lethal-means counseling.

Law Enforcement and Gun Retailers as Partners for Safely Storing Guns to Prevent Suicide: A Study in 8 Mountain West States.

OBJECTIVES: To examine the extent to which law enforcement agencies (LEAs) and gun retailers are willing to offer voluntary, temporary storage as a part of an overall suicide prevention effort. METHODS: We invited all LEAs and gun retailers in 8 US states to respond to questionnaires asking about their willingness to offer temporary gun storage and their recommendations to gun owners about safe storage. RESULTS: We collected data in 2016 from 448 LEAs and 95 retailers (response rates of 53% and 25%, respectively). Three quarters of LEAs (74.8%; 95% confidence interval [CI] = 72.1, 77.5) indicated they already provided temporary storage compared with 47.6% (95% CI = 39.2, 56.0) of retailers. LEAs were most willing to provide storage when a gun owner was concerned about the mental health of a family member. Retailers were more receptive than were LEAs to providing storage when visitors were coming or for people wanting storage while traveling. Both groups recommended locking devices within the home, but LEAs were slightly more favorable to storing guns away from the home. CONCLUSIONS: Law enforcement agencies and gun retailers are important resources for families concerned about suicide.

Federal actions to incentivise state adoption of 0.08†g/dL blood alcohol concentration laws.

OBJECTIVE: To model rates of 0.08 g/dL blood alcohol concentration (BAC) per se law implementation among the states associated with (1) a federal incentive grant programme and (2) a threat from the federal government to withhold highway transportation funds. METHODS: An observational study of state-level 0.08 g/dL BAC per se law enactment among all 50 US states from 1982 to 2006 using a parametric survival analysis to assess the time-dependent risk of policy enactment. RESULTS: The federal government's threat to withhold transportation funds was associated with a 10.30 times greater hazard (HR: 10.30, 95% CI 3.88 to 27.36) of states adopting a 0.08 g/dL BAC law compared with periods of time when this threat was not in place. The incentive grant programme created by the federal government was associated with a non-significant 17% decrease in the hazard of states adopting a 0.08 g/dL BAC law (HR: 0.83, 95% CI 0.35 to 2.0). CONCLUSION: In the case of 0.08 g/dL BAC per se laws, the federal government's threat to withhold transportation funds was effective at accelerating policy adoption.

Knowledge, Attitudes, and Risk for Sudden Unexpected Infant Death in Children of Adolescent Mothers: A Qualitative Study.

OBJECTIVE: To investigate practices, knowledge, attitudes, and beliefs regarding infant sleep among adolescent mothers, a demographic at high risk for sudden unexpected infant death, and to identify novel public health interventions targeting the particular reasons of this population. STUDY DESIGN: Seven targeted focus groups including 43 adolescent mothers were conducted at high school daycare centers throughout Colorado. Focus groups were recorded, transcribed, validated, and then analyzed in NVivo 10. Validation included coding consistency statistics and expert review. RESULTS: Most mothers knew many of the American Academy of Pediatrics recommendations for infant sleep. However, almost all teens reported bedsharing regularly and used loose blankets or soft bedding despite being informed of risks. Reasons for nonadherence to recommendations included beliefs that babies are safest and sleep more/better in bed with them, that bedsharing is a bonding opportunity, and that bedsharing is easier than using a separate sleep space. The most common justifications for blankets were infant comfort and concern that babies were cold. Participants' decision making was often influenced by their own mothers, with whom they often resided. Participants felt that their instincts trumped professional advice, even when in direct contradiction to safe sleep recommendations. CONCLUSIONS: Among focus group participants, adherence with safe sleep practices was poor despite awareness of the American Academy of Pediatrics recommendations. Many mothers expressed beliefs and instincts that infants were safe in various unsafe sleep environments. Future study should investigate the efficacy of alternative educational strategies, including education of grandmothers, who have significant influence over adolescent mothers.

Political factors affecting the enactment of state-level clean indoor air laws.

OBJECTIVES: We examined the effects of key political institutional factors on the advancement of state-level clean indoor air laws. METHODS: We performed an observational study of state-level clean indoor air law enactment among all 50 US states from 1993 to 2010 by using extended Cox hazard models to assess risk of enacting a relevant law. RESULTS: During the 18-year period from 1993 to 2010, 28 states passed a law covering workplaces, 33 states passed a law covering restaurants, 29 states passed a law covering bars, and 16 states passed a law covering gaming facilities. States with term limits had a 2.15 times greater hazard (95% confidence interval [CI] = 1.27, 3.65; P = .005) of enacting clean indoor air laws. The presence of state-level preemption of local clean indoor air laws was associated with a 3.26 times greater hazard (95% CI = 1.11, 9.53; P = .031) of state-level policy enactment. In the presence of preemption, increased legislative professionalism was strongly associated (hazard ratio = 3.28; 95% CI = 1.10, 9.75; P = .033) with clean indoor air law enactment. CONCLUSIONS: Political institutional factors do influence state-level clean indoor air law enactment and may be relevant to other public health policy areas.

Changes in cross-sector collaboration between nurse home visitors and community providers in the United States: A panel survey analysis.

OBJECTIVE: Assess changes in cross-sector collaboration between Nurse-Family Partnership (NFP) nurse home visitors and community providers in the United States. DATA SOURCES AND STUDY SETTING: We collected primary data via internet-based surveys of all NFP nursing supervisors in the United States in 2018, 2020, and 2021. STUDY DESIGN: We conducted a panel survey to measure changes in cross-sector collaboration between NFP nurses and 10 provider types in healthcare and social services. We assessed relational coordination using the validated seven item Relational Coordination Scale and structural integration using four items adapted from the Interagency Collaboration Activities Scale. Responses over time were compared using one-way analysis of variances (ANOVAs) and pairwise t-tests. We used the Kruskal-Wallis rank test to assess differences in collaboration by implementing agency type. DATA COLLECTION: All nursing supervisors from NFP implementing agencies in the United States were eligible for the study. Survey implementation was conducted using Qualtrics and administered to all eligible participants (N = 370 [2018], 383 [2020], 414 [2021]). Email reminders were sent every 7-10 days, followed by a final telephone outreach. PRINCIPAL FINDINGS: The response rate was 71% in 2018, 83% in 2020, and 74% in 2021. Relational coordination scores were calculated as a mean of the seven items and ranged from 1 to 5 (not at all to completely); integration scores were calculated as a sum of the four items and ranged from 4 to 20, where higher scores indicated greater sharing of resources. Coordination with women's care increased from 2018 to 2020 (M = 3.39 vs. 3.57; p < 0.01); while coordination (M = 3.23 vs. 3.01; p < 0.05) and integration (M = 6.50 vs. 5.28 vs. 5.43; p < 0.01) with parenting programs decreased. CONCLUSIONS: Changes to cross-sector collaboration varied by provider type, likely due to the delivery of NFP and other services via telehealth during the COVID-19 pandemic. There is an opportunity to improve cross-sector collaboration in home visiting to better address family needs.

US Hospital Service Availability and New 340B Program Participation.

Importance: The US 340B Drug Pricing Program enables eligible hospitals to receive substantial discounts on outpatient drugs to improve hospitals' financial sustainability and maintain access to care for patients who have low income and/or are uninsured. However, it is unclear whether hospitals use program savings to subsidize access as intended. Objective: To evaluate whether the 340B program is associated with improvements in access to hospital-based services and to test whether the association varies by hospital ownership. Design, Setting, and Participants: Difference-in-differences and cohort analysis from 2010 to 2019. Never and newly participating 340B general, acute, nonfederal hospitals in the US using data from the American Hospital Association's Annual Survey of Hospitals merged with hospital and market characteristics. Data were analyzed from January 1, 2023, to January 31, 2024. Exposures: New enrollment in 340B between 2012 and 2018. Main Outcomes and Measures: Total number of unprofitable service lines, ie, substance use, psychiatric (inpatient and outpatient), burn clinic, and obstetrics services; and profitable services, ie, cardiac surgery and orthopedic, oncologic, neurologic, and neonatal intensive services. Results: The study sample comprised a total of 2152 hospitals, 1074 newly participating and 1078 not participating in the 340B program. Participating hospitals were more likely than nonparticipating hospitals to be critical access and teaching hospitals, have higher Medicaid shares, and be located in rural areas and in Medicaid expansion states. At public hospitals, participation in the 340B program was associated with a significant increase in total unprofitable services (0.21; 95% CI, 0.04 to 0.38; P = .02) and marginal increases in substance use (5.4 percentage points [pp]; 95% CI, -0.8 pp to 11.6 pp; P = .09) and inpatient psychiatric (6.5 pp; 95% CI, -0.7 pp to 13.7 pp; P = .09) services. Among nonprofit hospitals, there was no significant association between 340B and service offerings (profitable and unprofitable) except for an increase in oncologic services (2.5 pp; 95% CI, 0.0 pp to 5.0 pp; P = .05). Conclusions and Relevance: The finding of the cohort study indicate that participation in the 340B program was associated with an increase in unprofitable services among newly participating public hospitals. Nonprofit hospitals were largely unaffected. These findings suggest that public hospitals responded to 340B savings by improving patient access, whereas nonprofits did not. This heterogeneous response should be considered when evaluating the eligibility criteria for the 340B program and how it affects social welfare.