Exploring Parental Incarceration, US Government Support Programs, and Child Health and Well-Being: A National Cross-Sectional Study.

OBJECTIVES: To describe relationships between parental incarceration and child health and flourishing-a measure of curiosity, resilience, and self-regulation-and to identify government programs that moderate this relationship. METHODS: Using the National Survey of Children's Health data from 2016 through 2019 for children 6-17 years old, we estimated associations with logistic regression between parental incarceration and overall health and flourishing, adjusting for child, caregiver, and household factors. We secondarily examined physical health (asthma, headaches), mental health (attention deficit disorder/attention deficit hyperactivity disorder, depression), developmental needs (learning disability, special educational plan use), and educational (missing ≥11 school days, repeated grade) outcomes. We performed interaction analyses to determine whether government program participation (eg, free/reduced lunch, cash assistance) moderated relationships between parental incarceration and child outcomes. RESULTS: Children with parental incarceration accounted for 9.3% of the sample (weighted n = 4 400 000). Black, American Indian/Alaska Native, and multiracial children disproportionately experienced parental incarceration. Parental incarceration was associated with worse health (aOR, 1.31; 95% CI, 1.11-1.55) and higher odds of not flourishing (aOR, 1.66; 95% CI, 1.46-1.89). Physical health, mental health, developmental issues, and educational needs were also associated with parental incarceration. Participation in free and reduced lunch moderated the relationships between parental incarceration and general health and flourishing, and cash assistance moderated the association between parental incarceration and flourishing. For each, parental incarceration had an attenuated association with health among people who participated in government programs. CONCLUSIONS: Parental incarceration is disproportionately experienced by Black and Indigenous children and associated with worse child health and well-being. Government support program participation may mitigate negative associations between parental incarceration and child outcomes.

Measuring Equity in Readmission as a Distinct Assessment of Hospital Performance.

Importance: Equity is an essential domain of health care quality. The Centers for Medicare & Medicaid Services (CMS) developed 2 Disparity Methods that together assess equity in clinical outcomes. Objectives: To define a measure of equitable readmissions; identify hospitals with equitable readmissions by insurance (dual eligible vs non-dual eligible) or patient race (Black vs White); and compare hospitals with and without equitable readmissions by hospital characteristics and performance on accountability measures (quality, cost, and value). Design, Setting, and Participants: Cross-sectional study of US hospitals eligible for the CMS Hospital-Wide Readmission measure using Medicare data from July 2018 through June 2019. Main Outcomes and Measures: We created a definition of equitable readmissions using CMS Disparity Methods, which evaluate hospitals on 2 methods: outcomes for populations at risk for disparities (across-hospital method); and disparities in care within hospitals' patient populations (within-a-single-hospital method). Exposures: Hospital patient demographics; hospital characteristics; and 3 measures of hospital performance-quality, cost, and value (quality relative to cost). Results: Of 4638 hospitals, 74% served a sufficient number of dual-eligible patients, and 42% served a sufficient number of Black patients to apply CMS Disparity Methods by insurance and race. Of eligible hospitals, 17% had equitable readmission rates by insurance and 30% by race. Hospitals with equitable readmissions by insurance or race cared for a lower percentage of Black patients (insurance, 1.9% [IQR, 0.2%-8.8%] vs 3.3% [IQR, 0.7%-10.8%], P < .01; race, 7.6% [IQR, 3.2%-16.6%] vs 9.3% [IQR, 4.0%-19.0%], P = .01), and differed from nonequitable hospitals in multiple domains (teaching status, geography, size; P < .01). In examining equity by insurance, hospitals with low costs were more likely to have equitable readmissions (odds ratio, 1.57 [95% CI, 1.38-1.77), and there was no relationship between quality and value, and equity. In examining equity by race, hospitals with high overall quality were more likely to have equitable readmissions (odds ratio, 1.14 [95% CI, 1.03-1.26]), and there was no relationship between cost and value, and equity. Conclusion and Relevance: A minority of hospitals achieved equitable readmissions. Notably, hospitals with equitable readmissions were characteristically different from those without. For example, hospitals with equitable readmissions served fewer Black patients, reinforcing the role of structural racism in hospital-level inequities. Implementation of an equitable readmission measure must consider unequal distribution of at-risk patients among hospitals.

Assessing Concordance Across Nonprofit Hospitals' Public Reporting on Housing as a Community Health Need in the Era of the Affordable Care Act.

Although the Affordable Care Act requires nonprofit hospital organizations to report how they identify and invest in community health needs, the utility of mandated reporting documents for tracking investments in the social determinants of health has been questioned. Using public reporting documents and focusing on housing as a social determinant of health, we describe how nonprofit hospital organizations in 5 communities with the highest rates of homelessness document needs and investments related to housing on their Community Health Needs Assessments, Implementation Strategies, and Schedule H (990H) tax forms. Of 47 organizations, 55% identified housing as a health need, 36% described housing-related implementation strategies, and 26% reported relevant 990H spending. Overall concordance among identified needs, strategies, and spending was low, with only 15% of organizations addressing housing across all 3 documents. Regulatory reform could help promote accountability and transparency in organizations' efforts to address housing and other health-related social needs.

US Postgraduate Trainee Racial, Ethnic, and Gender Representation and Faculty Compensation By Specialty.

This study compares postgraduate trainee racial, ethnic, and gender representation and faculty compensation for 21 clinical specialties using 2015-2022 data.

Why Are There So Few Women Medical School Deans? Debunking the Myth That Shorter Tenures Drive Disparities.

PURPOSE: Gender disparities among the senior echelons of academic medicine are striking and persistent. The role of medical school dean has been particularly immune to gender diversity, and limited prior research identified women's shorter decanal tenures as a potential driver. The authors assessed gender differences in tenure length of deanships in the current era to elucidate this finding. METHOD: From October 2020 to June 2021, the authors collected information about medical school deanships that were held from January 1, 2006, to June 30, 2020. All schools were members of the Association of American Medical Colleges (AAMC). The authors collected data from online public records and augmented their findings via direct outreach to medical schools. They used time-to-event analyses before and after adjustment for interim vs permanent status of the initial appointment, school ownership (public/private), and school size to assess for gender differences in length of deanship tenure during the study period. The unit of analysis was deanships, and the primary outcome was length of deanships measured in years. RESULTS: Authors included data on 528 deanships. Women held 91 (17%) of these terms. Men held the majority of permanent deanships (n = 352 [85%]). A greater percentage of the deanships held by women were interim only (n = 27 [30%]) compared with men (n = 85 [20%]). In unadjusted and adjusted analyses, there were no significant gender differences in length of deanship tenures. CONCLUSIONS: Analysis of appointments of AAMC-member medical school deans from 2006 to 2020 revealed that women have remained in their deanships as long as their male counterparts. The myth about women deans' shorter longevity should no longer be promulgated. Academic medicine should consider novel solutions to addressing women's persistent underrepresentation in the dean role, including employing the gender proportionality principle used in the business and legal communities.

Neighborhood Incarceration Rates and Adverse Birth Outcomes in New York City, 2010-2014.

Importance: The US has high rates of adverse birth outcomes, with substantial racial disparities augmented by stress and neighborhood disadvantage. Black people are more likely to live in neighborhoods with high rates of incarceration, which is a source of both stress and neighborhood disadvantage and, thus, may contribute to adverse birth outcomes. Objective: To determine whether neighborhoods with high incarceration rates also have higher rates of adverse birth outcomes compared with neighborhoods with lower rates. Design, Setting, and Participants: This cross-sectional study used publicly available data from the New York City Department of Health (2010-2014). Censored Poisson regression, with the US Census tract as the unit of analysis, was used to examine the association of neighborhood incarceration rate and birth outcomes. Multivariable models included percentage of births aggregated to the Census tract by maternal factors (age, parity, singleton vs multiple birth, insurance, and race) and neighborhood factors (poverty, education, and violent crime). Analyses were performed between May 2021 and October 2022. Exposure: Neighborhood incarceration rate, categorized into quintiles. Main Outcomes and Measures: The primary outcome was the incidence rate ratio (IRR) of preterm birth and low birth weight. Secondary outcomes were IRRs of very preterm birth, extremely preterm birth, and very low birth weight. Hypotheses were formulated before data collection. Results: Among 2061 Census tracts with 562 339 births, incarceration rates varied from 0 to 4545 people incarcerated per 100 000, and high-incarceration neighborhoods had more residents of Black race (54.00% vs 1.90%), living in poverty (32.30% vs 10.00%), and without a general educational development equivalent (28.00% vs 12.00%) compared with low-incarceration neighborhoods. In fully adjusted models, high-incarceration neighborhoods had a 13% higher IRR of preterm birth (IRR, 1.13; 95% CI, 1.08-1.18), 45% higher IRR of very preterm birth (IRR, 1.45; 95% CI, 1.24-1.71), 125% higher IRR of extremely preterm birth (IRR, 2.25; 95% CI, 1.59-3.18), 10% higher IRR of low birth weight (IRR, 1.10; 95% CI, 1.05-1.16), and 52% higher IRR of very low birth weight compared with low-incarceration neighborhoods (IRR, 1.52; 95% CI, 1.28-1.81). Conclusions and Relevance: Neighborhood incarceration rate was positively associated with adverse birth outcomes, particularly those associated with infant mortality. Black people were significantly more likely to live in high-incarceration neighborhoods, suggesting that mass incarceration may contribute to racial disparities in birth outcomes.

Differences In Debt Among Postgraduate Medical Residents By Self-Designated Race And Ethnicity, 2014-19.

The US physician workforce does not reflect the racial and ethnic makeup of the country's population, despite efforts to promote diversity. Becoming a physician requires significant time and financial investment, and populations that are underrepresented in medicine have also been excluded from building wealth. Understanding the differential burden of debt by race and ethnicity may inform strategies to improve workforce diversity. We used 2014-19 data on postgraduate resident trainees from the Association of American Medical Colleges to examine the association between race and ethnicity and debt independent of other demographics and residency characteristics. Black trainees were significantly more likely to have every type of debt than the overall sample and all other racial and ethnic groups (96 percent of Black trainees had any debt versus 83 percent overall; 60 percent had premedical education loans versus 35 percent overall, and 50 percent had consumer debt versus 25 percent overall). American Indian/Alaska Native, Hispanic, and Native Hawaiian/Pacific Islander trainees were more likely to have debt compared with White and Asian trainees. Overall, debt prevalence decreased over time and varied by specialty; however, for Black trainees, debt decreased minimally over time and was stable across specialties. Scholarships, debt relief, and financial guidance should be explored to improve diversity and inclusion in medicine across specialties.

Association of Receipt of Paycheck Protection Program Loans With Staffing Patterns Among US Nursing Homes.

Importance: Staffing shortages in nursing homes (NHs) threaten the quality of resident care, and the COVID-19 pandemic magnified critical staffing shortages within NHs. During the pandemic, the US Congress enacted the Paycheck Protection Program (PPP), a forgivable loan program that required eligible recipients to appropriate 60% to 75% of the loan toward staffing to qualify for loan forgiveness. Objective: To evaluate characteristics of PPP loan recipient NHs vs nonloan recipient NHs and whether there were changes in staffing hours at NHs that received a loan compared with those that did not. Design, Setting, and Participants: This economic evaluation used national data on US nursing homes that were aggregated from the Small Business Administration, Nursing Home Compare, LTCFocus, the Centers for Medicare & Medicaid Services Payroll Based Journal, the Minimum Data Set, the Area Deprivation Index, the Healthcare Cost Report Information System, and the US Department of Agriculture Rural-Urban Continuum Codes from January 1 to December 23, 2020. Exposure: Paycheck Protection Program loan receipt status. Main Outcome and Measures: Staffing variables included registered nurse, licensed practical nurse (LPN), and certified nursing assistant (CNA) total hours per week. Staffing hours were examined on a weekly basis before and after loan receipt during the study period. An event-study approach was used to estimate the staffing total weekly hours at NHs that received PPP loans compared with NHs that did not receive a PPP loan. Results: Among 6008 US NHs, 1807 (30.1%) received a PPP loan and 4201 (69.9%) did not. The median loan amount was $664 349 (IQR, $407 000-$1 058 300). Loan recipients were less likely to be part of a chain (733 [40.6%] vs 2592 [61.7%]) and more likely to be for profit (1342 [74.3%] vs 2877 [68.5%]), be located in nonurban settings (159 [8.8%] vs 183 [4.4%]), have a greater proportion of Medicaid-funded residents (mean [SD], 60.92% [21.58%] vs 56.78% [25.57%]), and have lower staffing quality ratings (mean [SD], 2.88 [1.20] vs 3.03 [1.22]) and overall quality star ratings (mean [SD], 3.08 [1.44] vs 3.22 [1.44]) (P < .001 for all). Twelve weeks after PPP loan receipt, NHs that received a PPP loan experienced a mean difference of 26.19 more CNA hours per week (95% CI, 14.50-37.87 hours per week) and a mean difference of 6.67 more LPN hours per week (95% CI, 1.21-12.12 hours per week) compared with nursing homes that did not receive a PPP loan. No associations were found between PPP loan receipt and weekly RN staffing hours (12 weeks: mean difference, 1.99 hours per week; 95% CI, -2.38 to 6.36 hours per week). Conclusions and Relevance: In this economic evaluation, a forgivable loan program that required funding to be appropriated toward staffing was associated with a significant increase in CNA and LPN staffing hours among NH PPP loan recipients. Because the PPP loans are temporary, federal and state entities may need to institute sufficient and sustainable support to mitigate NH staffing shortages.

"We know what's going on in our community": A qualitative analysis identifying community assets that deter gun violence.

Communities of color are disproportionately impacted by gun violence. Unlocking potential community-led solutions could be the key to quelling the gun violence epidemic and its impact on these communities. In this qualitative study, we explored community perspectives on local assets that may prevent and mitigate gun violence. We conducted semi-structured, in-depth interviews (n = 45) among individuals not directly involved in gun violence (i.e., shooting victim or perpetrator) despite having a high probability of being involved in gun violence in New Haven, CT. Participants were asked to describe social structures that may deter local gun violence. Here, we report emergent themes to preventing gun violence across multiple levels, including role models (interpersonal), social cohesion and home ownership (neighborhood), and community-based organizations (organizational). Our findings suggest that investments in stable housing, efforts to build social cohesion, access to community-based mental health services, and youth activities are needed to curb the drivers of community gun violence.

Access to High-Volume Hospitals for High-Risk Cancer Surgery for Racial and Ethnic Minoritized Groups.

High-volume hospitals have been associated with better outcomes for high-risk cancer surgeries, although concerns exist concerning inequitable access to these high-volume hospitals. We assessed tendencies in access to high-volume hospitals for 4 (lung, pancreatic, rectal, esophageal) high-risk cancer surgeries for Black and Hispanic patients in the National Cancer Database. Hospitals were classified as high volume according to Leapfrog Group volume thresholds. Odds of accessing high-volume hospitals increased over time for Black and Hispanic patients for 3 surgeries, but Black patients had lower probabilities of undergoing a pancreatectomy, proctectomy, or esophagectomy at high-volume hospitals than non-Black patients (eg, 2016 pancreatectomy rate: 49.0% [95% confidence interval (CI) = 45.4% to 52.5%] vs 62.3% [95% CI = 61.1% to 63.5%]). Although for Hispanics the gap narrowed for lung resection and pancreatectomy, these populations continued to have lower probabilities of accessing high-volume hospitals than non-Hispanic patients (eg, 2016 pancreatectomy: 48.8% [95% CI = 44.1% to 53.5%] vs 61.6% [95% CI = 60.5% to 62.8%]). Despite increased access to high-volume hospitals for high-risk cancer surgeries, ongoing efforts to improve equity in access are needed.

Loneliness, sadness, and feelings of social disconnection in older adults during the COVID-19 pandemic.

BACKGROUND: Public health measures to control the COVID-19 pandemic have led to feelings of loneliness among older adults, which, prior to COVID, has been associated with subsequent morbidity and mortality. We sought to identify differences in feelings of loneliness, sadness, and social disconnection early in the pandemic across racial groups, and possible mitigating factors. METHODS: We performed a cross-sectional analysis using the weighted nationally-representative Medicare Current Beneficiaries Survey COVID-19 supplement, collected summer 2020. We included all Medicare beneficiaries aged 65 years and older who did not respond by proxy. We examined changes in loneliness, sadness, or feelings of social disconnection. Multivariable logistic regression models accounted for sociodemographic variables, access to primary care and the internet, and history of depression or dementia. RESULTS: Among 8125 beneficiaries, representative of 43.7 million Medicare beneficiaries, 22.6% reported loneliness or sadness, and 37.1% feeling socially disconnected. In fully-adjusted models, Hispanic/Latinx beneficiaries were most likely to report loneliness or sadness (OR = 1.3, CI: 1.02-1.65; p = 0.02) and Black beneficiaries were least likely to report feeling socially disconnected (OR = 0.55; CI: 0.42-0.73; p < 0.001). Internet access was associated with increased odds of both (OR = 1.29, 95 CI: 1.07-1.56; p = 0.009; and OR = 1.42, 95 CI: 1.24-1.63; p < 0.001, respectively). Access to primary care was associated with lower odds of both (OR = 0.77, 95 CI: 0.61-0.96; p = 0.02; and OR = 0.72, 95 CI: 0.61-0.87; p < 0.001). CONCLUSIONS: Loneliness, sadness, and feelings of social disconnection were common among older Medicare beneficiaries early in the COVID-19 pandemic. Differences by race/ethnicity may be driven by different living structures and social networks, and warrant further study. Policy makers and clinicians should consider facilitating connection by phone or in person, as internet access did not diminish feelings of loneliness, particularly for those living alone. Access to primary care, and tools for clinicians to address loneliness should be prioritized.

Effectiveness of training primary care internal medicine residents in etonogestrel implants and impact on their future practice: A cross-sectional study.

OBJECTIVE: To evaluate the impact of an etonogestrel implant training program within a primary care Internal Medicine residency training program. STUDY DESIGN: We surveyed graduates of our primary care Internal Medicine residency program in the Bronx, New York who performed implant procedures though the first 32 months after implementation of a monthly faculty-supervised resident implant clinic. We assessed the number of implants placed and removed per graduate, and surveyed graduates' satisfaction with the implant training program, perceived competence with implant procedures, and intent and ability to perform implant procedures and barriers to performing implant procedures postgraduation. RESULTS: Between July 2017 and February 2020, 14 residents placed a total of 34 devices and removed four. All 14 program graduates completed the survey in August 2020. All but one respondent felt this training was valuable and 11 felt competent placing implants without supervision. Although 10 planned to provide implants following graduation, none have been able to, largely because of credentialing and clinic-practice level barriers. CONCLUSIONS: The primary care Internal Medicine program graduates we surveyed (n = 14) valued our etonogestrel implant training program and perceived competence, particularly with implant placement. However, even those who intended to provide etonogestrel implants postgraduation were unable to do so. IMPLICATIONS: Internal Medicine residents trained to place and remove etonogestrel implants are most comfortable with implant placement. However, these physicians may face barriers related to credentialing and ambulatory practice scope when attempting to provide this care in clinical practice.

Association of census tract-level incarceration rate and life expectancy in New York State.

BACKGROUND: Jail incarceration rates are positively associated with mortality at the county level. However, incarceration rates vary within counties, limiting the generalisability of this finding to neighbourhoods, where incarceration may have the greatest effects. METHODS: We performed a cross-sectional analysis of census tract-level state imprisonment rates in New York State (2010) and life expectancy data from the US Small-area Life Expectancy Estimates Project (2010-2015). We modelled fixed-effects for counties and controlled for tract-level poverty, racial makeup, education, and population density from the American Community Survey (2010-2014), and violent crime data from the New York City Police Department (2010). We also examined interactions between incarceration rate and poverty, racial makeup, and population density on life expectancy. RESULTS: Life expectancy at the highest quintile of incarceration was 5.5 years lower than in the lowest quintile, and over 2 years lower in a fully-adjusted model. Census tract-level poverty and racial makeup both moderated the association between incarceration and life expectancy. CONCLUSION: Census tract-level incarceration is associated with lower life expectancy. Decarceration, including alternatives to incarceration, and release of those currently incarcerated, may help to improve life expectancy at the neighbourhood level.

Correlating students' educational background, study habits, and resource usage with learning success in medical histology.

Histology is a traditional core basic science component of most medical and dental education programs and presents a didactic challenge for many students. Identifying students that are likely to struggle with histology would allow for early intervention to support and encourage their learning success. To identify student characteristics that are associated with learning success in histology, three first-year medical school classes at the University of Michigan (>440 students) were surveyed about their educational background, attitudes toward learning histology, and their use of histology learning strategies and resources. These characteristics were linked with the students' quiz and examination results in histology. Students who reported previous experience in histology or pathology and hold science or biomedical science college degrees usually did well in histology. Learning success in histology was also positively associated with students' perception that histology is important for their professional career. Other positive indicators were in-person participation in teacher-guided learning experiences, specifically lecture and laboratory sessions. In contrast, students who relied on watching histology lectures by video rather than going to lectures in-person performed significantly worse. These characteristics and learning strategies of students who did well in this very visual and challenging study subject should be of help for identifying and advising students early, who might be at risk of failing a histology course or component.

Association of fibrillin-3 and transcription factor-7-like 2 gene variants with metabolic phenotypes in PCOS.

Polycystic ovary syndrome (PCOS) is a complex genetic disease characterized by heritable reproductive and metabolic abnormalities. Genetic variants associated with the reproductive phenotype have been mapped to the fibrillin-3 (FBN3) gene and to a novel transcription factor-7-like 2 (TCF7L2) locus (rs11196236 G). The association of these genetic variants with metabolic phenotypes was investigated in 31 PCOS and 18 control women of European ancestry. The insulinogenic index during an oral glucose tolerance test (ΔI30/ΔG30) and insulin secretion rates at the maximal dose during a graded-glucose infusion (ISRmax) were used as indexes of insulin secretion. Endogenous glucose production (EGP) and insulin sensitivity (M/I) were determined during a euglycemic clamp. The disposition index (DI) was calculated using M/I and ΔI30/ΔG30 or ISRmax. Compared with noncarriers (n = 10) and control (n = 10), M/I was decreased (P = 1.1 × 10(-5)) in heterozygous and homozygous PCOS carriers (n = 14) of rs11196236 G and this variant predicted M/I (partial r(2) = 0.34, P = 0.005) in a regression analysis. Postabsorptive EGP tended to be higher (P = 0.040) in heterozygous and homozygous PCOS carriers of the FBN3-associated allele (n = 12), allele 8 of D19S884 (FBN3(+)), compared to PCOS noncarriers (n = 19). PCOS carriers of the rs12255372 T (TCF7L2 Caucasian type 2 diabetes mellitus (T2D) locus) had no significant associated metabolic phenotypes. We conclude that rs11196236 G TCF7L2 variant is associated with peripheral insulin resistance in PCOS but this effect is not seen in control women. The FBN3 risk allele may be associated with changes in basal glucose homeostasis in PCOS. These findings require replication in additional PCOS cohorts.