AHRQ's Healthcare Extension Service-State-Based Solutions to Health Care Improvement.

This Viewpoint from AHRQ describes the plan to create a national health care extension service to disseminate actionable knowledge, with a goal to reduce the gap from evidence of clinical effectiveness to clinical practice.

Heavy vs Light Smoking: Its Association with Opioid Use, Chronic Pain, and Mental Health.

INTRODUCTION: There is much concern that substance use treatment programs are rarely integrated with smoking cessation programs. Here, the first national statistics are presented on the connection between heavy vs. light smoking and the opioid epidemic. METHODS: Using the 2013-2021 Medical Expenditure Panel Survey linked to the National Health Interview Survey, N=81,400 adults-years, logit regressions estimate the impact of heavy vs. light smoking on opioid use, chronic pain, work limitations due to pain, and poor mental health. Analyses were conducted from October 2023 -May 2024. RESULTS: Only 37 percent of the population has ever smoked, but they used 69% of the nation's annual prescription opioids. Adults who smoked more than five cigarettes a day composed 12% of the population but used about the same number of opioids as the 63% of the population who never smoked. Adults who formerly smoked used 16% fewer opioids than adults who currently smoke (p<.01). The percent with chronic pain during the year varied from 12.2% for adults who never smoked to 14.2% for light smoking, to 16.5% for those smoking more than a pack a day (p<.01). Severe work limitations due to pain varied from 7.3% for adults who never smoked to 16.9% for those smoking more than a pack a day (p<.01). Adults smoking more than a pack a day were twice as likely to report fair or poor mental health compared to those who never smoked (29.2% vs. 13.6%) (p<.01). CONCLUSIONS: As nations deal with the opioid epidemic, integrating smoking cessation programs into substance abuse treatment programs appears prudent. FUNDING: AHRQ.

COVID-19 Admission Rates and Changes in Care Quality in US Hospitals.

Importance: Unprecedented increases in hospital occupancy rates during COVID-19 surges in 2020 caused concern over hospital care quality for patients without COVID-19. Objective: To examine changes in hospital nonsurgical care quality for patients without COVID-19 during periods of high and low COVID-19 admissions. Design, Setting, and Participants: This cross-sectional study used data from the 2019 and 2020 Agency for Healthcare Research and Quality's Healthcare Cost and Utilization Project State Inpatient Databases. Data were obtained for all nonfederal, acute care hospitals in 36 states with admissions in 2019 and 2020, and patients without a diagnosis of COVID-19 or pneumonia who were at risk for selected quality indicators were included. The data analysis was performed between January 1, 2023, and March 15, 2024. Exposure: Each hospital and week in 2020 was categorized based on the number of COVID-19 admissions per 100 beds: less than 1.0, 1.0 to 4.9, 5.0 to 9.9, 10.0 to 14.9, and 15.0 or greater. Main Outcomes and Measures: The main outcomes were rates of adverse outcomes for selected quality indicators, including pressure ulcers and in-hospital mortality for acute myocardial infarction, heart failure, acute stroke, gastrointestinal hemorrhage, hip fracture, and percutaneous coronary intervention. Changes in 2020 compared with 2019 were calculated for each level of the weekly COVID-19 admission rate, adjusting for case-mix and hospital-month fixed effects. Changes during weeks with high COVID-19 admissions (≥15 per 100 beds) were compared with changes during weeks with low COVID-19 admissions (<1 per 100 beds). Results: The analysis included 19 111 629 discharges (50.3% female; mean [SD] age, 63.0 [18.0] years) from 3283 hospitals in 36 states. In weeks 18 to 48 of 2020, 35 851 hospital-weeks (36.7%) had low COVID-19 admission rates, and 8094 (8.3%) had high rates. Quality indicators for patients without COVID-19 significantly worsened in 2020 during weeks with high vs low COVID-19 admissions. Pressure ulcer rates increased by 0.09 per 1000 admissions (95% CI, 0.01-0.17 per 1000 admissions; relative change, 24.3%), heart failure mortality increased by 0.40 per 100 admissions (95% CI, 0.18-0.63 per 100 admissions; relative change, 21.1%), hip fracture mortality increased by 0.40 per 100 admissions (95% CI, 0.04-0.77 per 100 admissions; relative change, 29.4%), and a weighted mean of mortality for the selected indicators increased by 0.30 per 100 admissions (95% CI, 0.14-0.45 per 100 admissions; relative change, 10.6%). Conclusions and Relevance: In this cross-sectional study, COVID-19 surges were associated with declines in hospital quality, highlighting the importance of identifying and implementing strategies to maintain care quality during periods of high hospital use.

Seminar: Scalable Preprocessing Tools for Exposomic Data Analysis.

BACKGROUND: The exposome serves as a popular framework in which to study exposures from chemical and nonchemical stressors across the life course and the differing roles that these exposures can play in human health. As a result, data relevant to the exposome have been used as a resource in the quest to untangle complicated health trajectories and help connect the dots from exposures to adverse outcome pathways. OBJECTIVES: The primary aim of this methods seminar is to clarify and review preprocessing techniques critical for accurate and effective external exposomic data analysis. Scalability is emphasized through an application of highly innovative combinatorial techniques coupled with more traditional statistical strategies. The Public Health Exposome is used as an archetypical model. The novelty and innovation of this seminar's focus stem from its methodical, comprehensive treatment of preprocessing and its demonstration of the positive effects preprocessing can have on downstream analytics. DISCUSSION: State-of-the-art technologies are described for data harmonization and to mitigate noise, which can stymie downstream interpretation, and to select key exposomic features, without which analytics may lose focus. A main task is the reduction of multicollinearity, a particularly formidable problem that frequently arises from repeated measurements of similar events taken at various times and from multiple sources. Empirical results highlight the effectiveness of a carefully planned preprocessing workflow as demonstrated in the context of more highly concentrated variable lists, improved correlational distributions, and enhanced downstream analytics for latent relationship discovery. The nascent field of exposome science can be characterized by the need to analyze and interpret a complex confluence of highly inhomogeneous spatial and temporal data, which may present formidable challenges to even the most powerful analytical tools. A systematic approach to preprocessing can therefore provide an essential first step in the application of modern computer and data science methods. https://doi.org/10.1289/EHP12901.

Big Data to Knowledge Analytics Reveals the Zika Virus Epidemic as Only One of Multiple Factors Contributing to a Year-Over-Year 28-Fold Increase in Microcephaly Incidence.

During the 2015-2016 Zika Virus (ZIKV) epidemic in Brazil, the geographical distributions of ZIKV infection and microcephaly outbreaks did not align. This raised doubts about the virus as the single cause of the microcephaly outbreak and led to research hypotheses of alternative explanatory factors, such as environmental variables and factors, agrochemical use, or immunizations. We investigated context and the intermediate and structural determinants of health inequalities, as well as social environment factors, to determine their interaction with ZIKV-positive- and ZIKV-negative-related microcephaly. The results revealed the identification of 382 associations among 382 nonredundant variables of Zika surveillance, including multiple determinants of environmental public health factors and variables obtained from 5565 municipalities in Brazil. This study compared those factors and variables directly associated with microcephaly incidence positive to ZIKV and those associated with microcephaly incidence negative to ZIKV, respectively, and mapped them in case and control subnetworks. The subnetworks of factors and variables associated with low birth weight and birthweight where birth incidence served as an additional control were also mapped. Non-significant differences in factors and variables were observed, as were weights of associations between microcephaly incidence, both positive and negative to ZIKV, which revealed diagnostic inaccuracies that translated to the underestimation of the scope of the ZIKV outbreak. A detailed analysis of the patterns of association does not support a finding that vaccinations contributed to microcephaly, but it does raise concerns about the use of agrochemicals as a potential factor in the observed neurotoxicity arising from the presence of heavy metals in the environment and microcephaly not associated with ZIKV. Summary: A comparative network inferential analysis of the patterns of variables and factors associated with Zika virus infections in Brazil during 2015-2016 coinciding with a microcephaly epidemic identified multiple contributing determinants. This study advances our understanding of the cumulative interactive effects of exposures to chemical and non-chemical stressors in the built, natural, physical, and social environments on adverse pregnancy and health outcomes in vulnerable populations.

Improving Adult Vaccination Status in the United States.

Adult immunization practices leave much to be desired. Misinformation has increased mistrust. As a result, Latino and African American populations have low rates of annual flu vaccinations and, during the COVID-19 pandemic, lag behind for COVID-19 vaccination. Historically, healthcare staff have failed to adhere to adult immunization guidelines contributing to patient infections. Healthcare staff, both clinical and non-clinical, must lead by example by making "prevention primary". Most adults may not realize they need immunizations. We recommend the following steps to increase immunization uptake: Make adult immunization a standard of patient care as we do for children. Assess immunization status at every clinical opportunity. Strongly recommend vaccinations needed. Administer needed vaccinations, multiple if warranted. Document vaccines received by your patient. Participate in your state's immunization registry and work with community organizations that can help make adult immunization the norm.

Workplace stress and discrimination effects on the physical and depressive symptoms of underrepresented minority faculty.

Evidence-based research and interventions to address systemic institutional racism have never been more urgent. Yet, underrepresented minority (URM) professionals in research institutions who primarily produce that evidence have remained abysmally low for decades. This unique study of URM university professors assesses factors-vocational strain, role overload, discrimination, coping strategies-that contribute to health and well-being, research productivity, and ultimately their retention in high impact research positions. We administered a web-based survey assessing demographics, workplace stressors, perceived discrimination, life events, coping strategies, and physical and depressive symptoms. Study participants include 404 faculty of whom 254 are African Americans, 99 are Mexican Americans, and 51 are Puerto Ricans. Hierarchical regression analyses were employed to assess the associations between workplace stress, coping strategies, and symptoms. Results show that perceived discrimination, vocational strain, role overload, and life events directly affected physical symptoms, with self-care (p < 0.001) moderating these effects. Vocational strain and life events had direct effects on depressive symptoms with self-care (p < 0.05) and social support (p < 0.001) moderating these effects. Findings inform health care providers and university leaders about work stress and health conditions that may explain early morbidity and premature departures of URM faculty, and proffer institutional interventions to retain these faculty.

Structural and Social Determinants of Health Factors Associated with County-Level Variation in Non-Adherence to Antihypertensive Medication Treatment.

BACKGROUND: Non-adherence to antihypertensive medication treatment (AHM) is a complex health behavior with determinants that extend beyond the individual patient. The structural and social determinants of health (SDH) that predispose populations to ill health and unhealthy behaviors could be potential barriers to long-term adherence to AHM. However, the role of SDH in AHM non-adherence has been understudied. Therefore, we aimed to define and identify the SDH factors associated with non-adherence to AHM and to quantify the variation in county-level non-adherence to AHM explained by these factors. METHODS: Two cross-sectional datasets, the Centers for Disease Control and Prevention (CDC) Atlas of Heart Disease and Stroke (2014-2016 cycle) and the 2016 County Health Rankings (CHR), were linked to create an analytic dataset. Contextual SDH variables were extracted from the CDC-CHR linked dataset. County-level prevalence of AHM non-adherence, based on Medicare fee-for-service beneficiaries' claims data, was extracted from the CDC Atlas dataset. The CDC measured AHM non-adherence as the proportion of days covered (PDC) with AHM during a 365 day period for Medicare Part D beneficiaries and aggregated these measures at the county level. We applied confirmatory factor analysis (CFA) to identify the constructs of social determinants of AHM non-adherence. AHM non-adherence variation and its social determinants were measured with structural equation models. RESULTS: Among 3000 counties in the U.S., the weighted mean prevalence of AHM non-adherence (PDC < 80%) in 2015 was 25.0%, with a standard deviation (SD) of 18.8%. AHM non-adherence was directly associated with poverty/food insecurity (ß = 0.31, P-value < 0.001) and weak social supports (ß = 0.27, P-value < 0.001), but inversely with healthy built environment (ß = -0.10, P-value = 0.02). These three constructs explained one-third (R2 = 30.0%) of the variation in county-level AHM non-adherence. CONCLUSION: AHM non-adherence varies by geographical location, one-third of which is explained by contextual SDH factors including poverty/food insecurity, weak social supports and healthy built environments.

A review of instruments assessing public health preparedness.

OBJECTIVES: The purpose of this study was to review instruments that assess the level of preparedness of state and local public health departments to respond to health threats such as bioterrorism. METHODS: The authors examined 27 published population-based instruments for planning or evaluating preparedness that were mostly unavailable in the peer-reviewed literature. Using the Essential Public Health Services framework, the instruments were evaluated for (1) clarity of measurement parameters, (2) balance between structural and process measures, (3) evidence of effectiveness, and (4) specification of an accountable entity. RESULTS: There was a great deal of overlap but little consistency in what constitutes "preparedness" or how it should be measured. Most instruments relied excessively on subjective or structural measures, lacked scientific evidence for measures assessed, and failed to clearly define what entity was accountable for accomplishing the task or function. CONCLUSION: Strategies for improvement include measure standardization, better interagency communication, and investment in public health practice research to develop the underlying evidence base required for developing quality measures and assessments.

Tough times, tough choices: the impact of the rising medical costs on the U.S. Latino electorate's health care-seeking behaviors.

Utilizing a survey of Latino registered voters conducted in Spring 2009, we focus our attention on the impact of the rapidly rising costs of health care on the health-seeking behavior of Latino registered voters, and the impact of high medical costs on their economic status. We find that a third of Latinos used up all or most of their savings and a quarter of Latinos skipped a recommended test or treatment due to high medical costs, rates that are particularly high given that our sample is of Latino registered voters. Furthermore having health insurance is not statistically related to preventing economic hardship due to medical costs for Latinos. Our results suggest that the expansion of insurance coverage alone will not insulate the Latino community from being faced with economic difficulties unless the reform policy directly addresses individual costs of care.

Explaining public support (or lack thereof) for extending health coverage to undocumented immigrants.

While the recent passage of health care reform is estimated to provide millions of currently uninsured Americans with access to health coverage, undocumented immigrants are excluded from federal mandates. Since federal reform excludes undocumented immigrants, state governments will largely decide the fate of this vulnerable population. This article investigates public support for including undocumented immigrants in state health care reform efforts in New Mexico. Understanding the public's perception of extending health coverage to this population is important because public opinion influences health policy formation at the state and federal levels. Our results suggest that there is little support for including undocumented immigrants (or recent migrants from other parts of the United States) in state health care reform, particularly when compared with other segments of the New Mexican population, such as the homeless or unemployed. Our discussion highlights the economic and public health consequences of excluding undocumented immigrants from coverage options.

The health of Latino children: urgent priorities, unanswered questions, and a research agenda.

Latinos recently became the largest racial/ethnic minority group of US children. The Latino Consortium of the American Academy of Pediatrics Center for Child Health Research, consisting of 13 expert panelists, identified the most important urgent priorities and unanswered questions in Latino child health. Conclusions were drawn when consensus was reached among members, with refinement through multiple iterations. A consensus statement with supporting references was drafted and revised. This article summarizes the key issues, including lack of validated research instruments, frequent unjustified exclusion from studies, and failure to analyze data by pertinent subgroups. Latino children are at high risk for behavioral and developmental disorders, and there are many unanswered questions about their mental health needs and use of services. The prevalence of dental caries is disproportionately higher for Latino children, but the reasons for this disparity are unclear. Culture and language can profoundly affect Latino children's health, but not enough cultural competency training of health care professionals and provision of linguistically appropriate care occur. Latinos are underrepresented at every level of the health care professions. Latino children are at high risk for school dropout, environmental hazards, obesity, diabetes mellitus, asthma, lack of health insurance, nonfinancial barriers to health care access, and impaired quality of care, but many key questions in these areas remain unanswered. This article suggests areas in which more research is needed and ways to improve research and care of Latino children.