Lipid Testing among Youth in Medicaid: The Role of Social Determinants of Health and Providers.

OBJECTIVE: To assess recent temporal trends in guideline-compliant pediatric lipid testing, and to examine the influence of social determinants of health (SDoH) and provider characteristics on the likelihood of testing in youth. STUDY DESIGN: In this observational, multiyear cross-sectional study, we calculated lipid testing prevalence by year among 268 627 12-year olds from 2015 through 2019 who were enrolled in Florida Medicaid and eligible for universal lipid screening during age 9 to 11, and 11 437 22-year olds (2017-2019) who were eligible for screening during age 17-21. We compared trends in testing prevalence by SDoH and health risk factors at two recommended ages and modeled the associations between patient characteristics and provider type on lipid testing using generalized estimating equations. RESULTS: Testing among 12-year olds remained low between 2015 through 2019 with the highest prevalence in 2015 (8.0%) and lowest in 2017 (6.7%). Screening compliance among 22-year olds was highest in 2017 (21.1%) and fell to 17.8% in 2019. Hispanics and non-Hispanic Blacks in both age groups had about 2%-3% lower testing prevalence than non-Hispanic Whites. Testing in 12-year olds was 12.3% vs 7.7% with and without obesity, and 14.4% vs 7.6% with and without antipsychotic use. Participants who saw providers who were more likely to prescribe lipid testing were more likely to receive testing (OR = 2.3, 95% CI 2.0-2.8, P < .001). CONCLUSIONS: Although lipid testing prevalence was greatest among high-risk children, overall prevalence of lipid testing in youth remains very low. Provider specialty and choices by individual providers play important roles in improving guideline-compliant pediatric lipid testing.

COVID-19 impacts and inequities among underserved communities with diabetes.

Background: People with diabetes have higher COVID-19 morbidity and mortality. These risks are amplified for underserved communities including racial/ethnic minorities and people with lower socioeconomic status. However, limited research has examined COVID-19 outcomes specifically affecting underserved communities with diabetes. Methods: From November 2021 to July 2022, adults with insulin-requiring diabetes at federally qualified health centers in Florida and California (n = 450) completed surveys examining COVID-19 outcomes and demographics. Surveys assessed COVID-19 severity, vaccination uptake, mask-wearing habits, income changes, and healthcare access changes. Surveys also included the full Coronavirus Anxiety Scale (CAS-19). Descriptive statistics were computed for all outcomes. Between-group comparisons for state and race/ethnicity were evaluated via Chi-Squared, Fisher's Exact, Cochran-Mantel-Haenszel, One-Way ANOVA, and t-tests. Logistic regression determined factors associated with COVID-19 vaccination uptake. Data were self-reported and analyzed cross-sectionally. Results: Overall, 29.7 % reported contracting COVID-19; of those, 45.3 % sought care or were hospitalized. Most (81.3 %) received ≥ 1 vaccine. Hispanics had the highest vaccination rate (91.1 %); Non-Hispanic Blacks (NHBs) had the lowest (73.9 %; p =.0281). Hispanics had 4.63x greater vaccination odds than Non-Hispanic Whites ([NHWs]; 95 % CI = [1.81, 11.89]). NHWs least often wore masks (18.8 %; p <.001). Participants reported pandemic-related healthcare changes (62 %) and higher costs of diabetes medications (41 %). Income loss was more frequent in Florida (76 %; p <.001). NHBs most frequently reported "severe" income loss (26.4 %; p =.0124). Loss of health insurance was more common among NHBs (13.3 %; p =.0416) and in Florida (9.7 %; p =.039). COVID-19 anxiety was highest among NHBs and Hispanics (IQR = [0.0, 3.0]; p =.0232) and in Florida (IQR = [0.0, 2.0]; p =.0435). Conclusions: Underserved communities with diabetes had high COVID-19 vaccine uptake but experienced significant COVID-19-related physical, psychosocial, and financial impacts. NHBs and those in Florida had worse outcomes than other racial/ethnic groups and those in California. Further research, interventions, and policy changes are needed to promote health equity for this population.

Development and evaluation of a clinical guideline for a paediatric telemedicine service in a low-resource setting.

OBJECTIVE: To develop and evaluate a guideline for a paediatric telemedicine and medication delivery service (TMDS). METHODS: A clinical guideline for paediatric telemedicine was derived from the World Health (WHO) Organization Integrated Management of Childhood Illness (IMCI) Handbook. The guideline was deployed at a TMDS in Haiti and evaluated through a prospective cohort study; children ≤10 years were enrolled. For non-severe cases, paired virtual and in-person examinations were conducted at the call centre and household; severe cases were referred to the hospital. The performance of virtual examination components were evaluated by comparison with the paired in-person examination findings (reference). RESULTS: A total of 391 cases were enrolled. Among the 320 cases with paired examinations, no general WHO danger signs were identified during in-person examinations; 5 cases (2%) required hospital referral due to problem-specific danger signs or other reasons for escalation. Cohen's kappa for the virtual designation of mild cases was 0.78 (95% CI: 0.69 to 0.87). The sensitivity and specificity of a virtually reported fever were 91% (95% CI: 87% to 96%) and 69% (95% CI: 62% to 76%), respectively; the sensitivity and specificity of virtually reported 'fast breathing' were 47% (95% CI: 21% to 72%) and 89% (95% CI: 85% to 94%), respectively. Kappa for 'no' and 'some' dehydration indicated moderate congruence between virtual and in-person examinations (0.69; 95% CI: 0.41 to 0.98). At 10 days, 273 (95%) of the 287 cases reached by phone were better/recovered. CONCLUSION: Critical components of the virtual examination (triage, danger signs and dehydration assessment) performed well despite varied performance among the problem-specific components. The study and associated resources represents formative steps towards an evidence-based paediatric telemedicine guideline built on WHO clinical principles. In-person examinations for select cases were important to address limitations with virtual examinations and identify cases for escalation. TRIAL REGISTRATION NUMBER: NCT03943654.

Variation by race/ethnicity in the utilization and weight loss following metabolic bariatric surgery.

BACKGROUND: Understanding the disparities in utilization and weight loss outcomes of metabolic and bariatric surgery (MBS) by demographics will inform strategies targeting potential treatment gaps and enhance overall clinical obesity treatment. OBJECTIVE: To identify factors associated with utilization and longitudinal weight loss after MBS. SETTING: OneFlorida Clinical Research Consortium Database. METHODS: We performed a retrospective study using data from the OneFlorida Clinical Research Consortium between 2012 and 2018. We used logistic regression with intersectional effects to identify factors associated with utilization of MBS. Mixed-effect models were used to estimate longitudinal percentage total weight loss among those who underwent MBS with up to 18 months of follow-up. RESULTS: Among 429,821 patients eligible for MBS, 8290 (1.9%) underwent MBS between 2012 and 2018. Intersectional analysis revealed that non-Hispanic Black patients experienced an inferior utilization of MBS compared with non-Hispanic White and Hispanic counterparts, defined by the interaction between race/ethnicity and demographic factors, including male sex, older age, and insurance coverage. In the longitudinal weight loss assessment, 4016 patients (48.3% Roux-en-Y gastric bypass, 51.7% sleeve gastrectomy) were included. We found that non-Hispanic Black patients experienced significantly less weight loss than non-Hispanic White and Hispanic counterparts. Other factors associated with less weight loss over time included undergoing sleeve gastectomy, male sex, lower preoperative body mass index, and having type 2 diabetes at the time of surgery. CONCLUSIONS: Our findings will help to design new strategies focusing on the intersection of race/ethnicity and sociodemographic factors to improve access and effectiveness of MBS.

The Promising Success of Project Extension for Community Healthcare Outcomes (ECHO) Diabetes: Case Series.

BACKGROUND: In the United States, there are over 37 million people with diabetes but only 8000 endocrinologists. Therefore, many people with diabetes receive care exclusively from primary care providers (PCPs). To democratize knowledge regarding insulin-requiring diabetes through tele-education, Stanford University and the University of Florida developed Project Extension for Community Healthcare Outcomes (ECHO) Diabetes. OBJECTIVE: ECHO Diabetes uses a Hub and Spoke model connecting specialists (the "Hub") with PCPs (the "Spokes"). One-hour, weekly sessions include Hub diabetes didactic presentations and Spoke deidentified case presentations. Lessons learned during these sessions target provider knowledge and confidence surrounding diabetes management and patient care. METHODS: Spokes were asked to provide short descriptions of people with diabetes whose diabetes management improved directly or indirectly from their providers' participation or their involvement with a Diabetes Support Coach (DSC). We provide a case series to describe individuals and outcomes. Because this study was not a randomized controlled trial and was a prospective observation of patients with the intervention delivered to providers, the trial is not registered in a public trials registry. RESULTS: A case series of 11 people with diabetes was compiled from 10 PCPs and 1 DSC from California and Florida between 2021 and 2022. The principal impact of ECHO Diabetes is the education amplified from PCPs and DSCs to people with diabetes. In all cases, people with diabetes reported increased engagement and improved diabetes management. Several cases reflected increased access to diabetes technology, improvement in glycemic outcomes, and positive trends in mental health measures. CONCLUSIONS: This case series elucidates the potential value of the ECHO Diabetes program to people with diabetes who receive their diabetes care from PCPs. Those matched with a DSC saw clinically significant improvements in hemoglobin A1c and mental health outcomes.

Recruiting historically under-represented individuals into Project ECHO Diabetes: using barrier analysis to understand disparities in clinical research in the USA.

OBJECTIVES: Individuals under-recruited in diabetes research studies include those not seen at endocrinology centres and those from rural, low socioeconomic and/or under-represented racial/ethnic groups. The purpose of this descriptive analysis is to detail recruitment and retention efforts of Project ECHO Diabetes clinical sites affiliated with Stanford University and University of Florida. DESIGN: Prospective collection of participant engagement and qualitative analysis of barriers and facilitators of research engagement within Project ECHO Diabetes, a virtual tele-education programme for healthcare providers in the management of individuals with insulin-requiring diabetes. SETTING: Data were collected at the patient level, provider level and clinic level between 1 May 2021 and 31 July 2022. PARTICIPANTS: Participants and study personnel were recruited from 33 Project ECHO Diabetes sites in California and Florida. OUTCOMES: We report study completion rates for participants recruited into 33 Project ECHO Diabetes sites. Using barrier analysis, a methodology designed for the real-time assessment of interventions and system processes to identify barriers and facilitators, study personnel identified significant barriers to recruitment and retention and mapped them to actionable solutions. RESULTS: In total, 872 participants (California n=495, Florida n=377) were recruited with differing recruitment rates by site (California=52.7%, Florida=21.5%). Barrier analysis identified lack of trust, unreliable contact information, communication issues and institutional review board (IRB) requirements as key recruitment barriers. Culturally congruent staff, community health centre (CHC) support, adequate funding and consent process flexibility were solutions to address recruitment challenges. Barriers to retention were inconsistent postal access, haemoglobin A1c kit collection challenges, COVID-19 pandemic and broadband/connectivity issues. Additional funding supporting research staff and analogue communication methods were identified as solutions address barriers to retention. CONCLUSIONS: Funded partnerships with CHCs, trusted by their local communities, were key in our recruitment and retention strategies. IRB consent process flexibility reduced barriers to recruitment. Recruiting historically under-represented populations is feasible with funding aimed to address structural barriers to research participation.

A randomized controlled clinical trial to improve health outcomes in youth with type 1 diabetes: Study design and baseline characteristics.

Most adolescents with T1D do not meet glycemic recommendations or consistently perform the required self-management behaviors to prevent acute- and long-term deleterious health outcomes. In addition, most youth with T1D do not have access to behavioral health services to address T1D management barriers. Thus, delivering behavioral interventions during routine medical appointments may hold promise for improving T1D outcomes in adolescents. The overall objective of this study was to examine the effect of behavioral interventions, either a Personalized T1D Self-Management Behaviors Feedback Report or Problem-Solving Skills, delivered by a T1D behavioral health provider and a T1D medical provider during a joint, fully integrated appointment to improve health outcomes in youth with T1D. This paper describes the study rationale, design, and baseline characteristics for the 109 adolescent-caregiver dyads who participated. Primary and secondary outcomes include hemoglobin A1c (A1C), T1D self-management behaviors, and biological indicators of complications.

Improving Racial and Ethnic Equity in Clinical Trials Enrolling Pregnant and Lactating Individuals.

Racial and ethnic marginalized populations have historically been poorly represented, underrecruited, and underprioritized across clinical trials enrolling pregnant and lactating individuals. The objectives of this review are to describe the current state of racial and ethnic representation in clinical trials enrolling pregnant and lactating individuals and to propose evidence-based tangible solutions to achieving equity in these clinical trials. Despite efforts from federal and local organizations, only marginal progress has been made toward achieving equity in clinical research. This continued limited inclusion and transparency in pregnancy trials exacerbates health disparities, limits the generalizability of research findings, and may heighten the maternal child health crisis in the United States. Racial and ethnic underrepresented communities are willing to participate in research; however, they face unique barriers to access and participation. Multifaceted approaches are required to facilitate the participation of marginalized individuals in clinical trials including partnering with the local community to understand their priorities, needs, and assets; establishing accessible recruitment strategies; creating flexible protocols; supporting participants for their time; and increasing culturally congruent and/or culturally sensitive research staff. This article also highlights exemplars in pregnancy research.

Acceptability of an mHealth App for Monitoring Perinatal and Postpartum Mental Health: Qualitative Study With Women and Providers.

BACKGROUND: Up to 15% of pregnant and postpartum women commonly experience undiagnosed and untreated mental health conditions, such as depression and anxiety, which may result in serious health complications. Mobile health (mHealth) apps related to mental health have been previously used for early diagnosis and intervention but not among pregnant and postpartum women. OBJECTIVE: This study aims to assess the acceptability of using mHealth to monitor and assess perinatal and postpartum depression and anxiety. METHODS: Focus group discussions with pregnant and postpartum women (n=20) and individual interviews with health care providers (n=8) were conducted to inform the acceptability of mHealth and determine its utility for assessing perinatal and postpartum mood symptoms. Participants were recruited via purposive sampling from obstetric clinics and the surrounding community. A semistructured interview guide was developed by an epidemiologist with qualitative research training in consultation with an obstetrician. The first author conducted all focus group discussions and provider interviews either in person or via Zoom (Zoom Video Communications, Inc) depending on the COVID-19 protocol that was in place during the study period. All interviews were audio recorded with consent; transcribed; and uploaded for coding to ATLAS.ti 8 (ATLAS.ti Scientific Software Development Gmb H), a qualitative data analysis and retrieval software. Data were analyzed using the deductive content analysis method using a set of a priori codes developed based on the interview guide. Methodological rigor and quality were ensured by adopting a systematic approach during the implementation, data collection, data analysis, and reporting of the data. RESULTS: Almost all women and providers had downloaded and used at least 1 health app. The respondents suggested offering short questions in layperson language that could be understood by women of all educational levels and offering no more than 2 to 3 assessments per day at preferred timings decided by the women themselves. They also suggested that the women themselves receive the alerts first, with other options being family members, spouses, or friends if the women themselves did not respond within 24 to 72 hours. Customization and snooze features were strongly endorsed by women and providers to improve acceptability and utility. Women mentioned competing demands on their time during the postpartum period, fatigue, privacy, and the security of mental health data as concerns. Health care professionals highlighted the long-term sustainability of app-based mood assessment and monitoring as an important challenge. CONCLUSIONS: The findings from this study show that mHealth would be acceptable to pregnant and postpartum women for monitoring mood symptoms. This could inform the development of clinically meaningful and inexpensive tools for facilitating the continuous monitoring of, the early diagnosis of, and an early intervention for mood disorders in this vulnerable population.

Home Visitation Program Staff Attitudes and Intentions Towards Using Digital Technology to Educate Families About Preventing Early Childhood Obesity: A Qualitative Study.

INTRODUCTION: Home visitation programs that reach families of young children offer a unique opportunity for large-scale early childhood obesity prevention efforts. The objective of this qualitative research was to determine stakeholder attitudes, subjective norms, perceived ease of use and usefulness, behavioral control, and behavioral intentions towards utilizing technology in a home visitation program targeting early childhood obesity prevention. METHODS: Staff from the Florida Maternal, Infant, and Early Childhood Home Visiting Program (n = 27) were interviewed individually by a trained research assistant using a semi-structured script based on constructs from the Technology Acceptance Model and Theory of Planned Behavior. Demographic and technology use information were collected. Interviews were recorded and transcribed verbatim, with data extracted and coded by two trained researchers using a theoretical thematic analysis approach. RESULTS: Most of the home visiting staff (78%) were white and non-Hispanic and employed for an average of 5 years with the program. Most staff (85%) indicated they were currently using videoconferencing for home visits. Themes and subthemes emerged, including positive attitudes towards technology as a flexible and time-efficient program alternative for childhood obesity prevention with recommendations to keep content short, at a low literacy level, and available in more than one language for ease of use. Participants recommended developing training tutorials to improve program implementation. Internet access and potential social disconnect were cited as concerns for using technology. DISCUSSION: Overall, home visitation staff had positive attitudes and intentions for using technology in home visiting programs with families for early childhood obesity prevention.

Is Kawasaki Disease Caused by a Respiratory Virus?

BACKGROUND: Kawasaki disease is characterized by high fever, rash, cervical lymphadenopathy, conjunctival injection, oral mucous membrane changes and swelling of the extremities followed by skin sloughing. Despite >50 years of study, no bacterial, viral or other infectious agent has been consistently associated with the illness. The lockdown and social distancing for COVID-19 in March 2020 led to a marked decrease in respiratory virus circulation. This provided an "experiment of nature" to determine whether Kawasaki disease would decline in parallel. METHODS: Discharge ICD-10 diagnosis codes were obtained from the Vizient Clinical Data Base for Kawasaki disease and respiratory viruses, and analyzed for the age group < 5 years. Weekly respiratory virus positivity data were also obtained from BioFire Diagnostics. RESULTS: Common enveloped respiratory viruses declined precipitously from April 2020 through March 2021 to levels at or below historical seasonal minimum levels. Kawasaki Disease declined about 40% compared with 2018-2019, which is distinctly different from the pattern seen for the enveloped respiratory viruses. Strong seasonality was seen for Kawasaki disease as far back as 2010, and correlated most closely with respiratory syncytial virus, human metapneumovirus and less so with influenza virus suggesting there is a baseline level of Kawasaki disease activity that is heightened during yearly respiratory virus activity but that remains at a certain level even in the near total absence of respiratory viruses. CONCLUSIONS: The striking decrease in enveloped respiratory viruses after lockdown and social distancing was not paralleled by a comparable decrease in Kawasaki disease incidence, suggesting a different epidemiology.

Multicentric validation of a prognostic tool for predicting brain death following out-of-hospital cardiac arrest in children.

AIM: Out-of-hospital cardiac arrest (OHCA) in pediatric patients is associated with high rates of mortality and neurologic injury, with no definitive evidence-based method to predict outcomes available. A prognostic scoring tool for adults, The Brain Death After Cardiac Arrest (BDCA) score, was recently developed and validated. We aimed to validate this score in pediatric patients. METHODS: Retrospective cohort study of pediatric patients admitted to 5 PICUs after OHCA between 2011 and 2021. We extracted BDCA score elements for those who survived at least 24 hours but died as a result of their OHCA. We assessed score discrimination for the definitive outcome of brain death. Subgroup analysis was performed for infants < 12mo versus children ≥ 12mo, those who likely had brain death but had withdrawal of life sustaining therapy (WLST) prior to declaration, and by etiology and duration of arrest. RESULTS: 389 subjects were identified across 5 institutions, with 282 meeting inclusion criteria. 169 (59.9%) were formally declared brain dead; 58 (20.6%) had findings consistent with brain death but had withdrawal of life sustaining therapies prior to completion of formal declaration. Area under the receiver operating characteristic curve for the age ≥ 12mo cohort was 0.82 [95% CI 0.75, 0.90], which mirrored the adult subject AUCs of 0.82 [0.77, 0.86] and 0.81 [0.76, 0.86] in the development and validation cohorts. Scores demonstrated worse discrimination in the infant cohort (AUC = 0.61). CONCLUSIONS: The BDCA score shows promise in children ≥ 12mo following OHCA and may be considered in conjunction with existing multimodal prognostication approaches.

Mixed methods evaluation of vaping and tobacco product use prevention interventions among youth in the Florida 4-H program.

INTRODUCTION: Novel prevention programs are developed to address the increase in e-cigarette use (vaping) among children. However, it remains paramount to test their feasibility in rural settings. This pilot study implemented and evaluated the feasibility and outcomes of two innovative programs, CATCH My Breath and smokeSCREEN, among youth in rural settings in Florida. METHODS: We conducted four focus groups with youth aged 11-17 recruited from 4-H rural clubs in Florida. In a subsequent randomized trial, we recruited 82 youth participants and assigned them to one of three arms: CATCH My Breath, smokeSCREEN, or control. CATCH My Breath and smokeSCREEN participants attended online group intervention sessions while the control group received educational material. Pre- and post-surveys were administered to all participants to assess knowledge, susceptibility, perceived positive outcomes and risk perceptions related to tobacco and e-cigarette use. Other feasibility parameters were also assessed. RESULTS: Focus group discussions provided insights about feasibility and informed the implementation of both interventions in terms of delivery format, scheduling of sessions and incentives. After the intervention, CATCH My Breath participants significantly improved their general tobacco-related knowledge (post-pre = 16.21-12.92 = 3.3, p <.01) and risk perceptions towards other flavored tobacco products (post-pre = 19.29-17.71 = 1.6, p <.05). smokeSCREEN participants significantly improved their general tobacco knowledge (post-pre = 18.77-13.77 = 5.0, p <.01), knowledge about e-cigarettes (post-pre = 9.08-6.31 = 2.8, p <.01) and risk perception towards e-cigarettes (post-pre = 24.69-21.92 = 2.8, p <.05). CONCLUSIONS: This study demonstrated feasibility of delivering the interventions via participant engagement, participants' willingness to be randomized, assessment of outcome measures, and exploration of different recruitment methods. Despite the potential positive influence of CATCH My Breath and smokeSCREEN on youth participants, further evaluation with larger samples is needed.

Project ECHO Diabetes Cost Modeling to Support the Replication and Expansion of Tele-mentoring Programs in Non-research Settings.

INTRODUCTION: Project ECHO Diabetes is a tele-education learning model for primary care providers (PCPs) seeking to improve care for patients with diabetes from marginalized communities. Project ECHO Diabetes utilized expert "hub" teams comprising endocrinologists, dieticians, nurses, psychologists, and social workers and "spokes" consisting of PCPs and their patients with diabetes. This Project ECHO Diabetes model provided diabetes support coaches to provide additional support to patients. We sought to estimate the costs of operating a Project ECHO Diabetes hub, inclusive of diabetes support coach costs. METHODS: Data from Project ECHO Diabetes from June 2021 to June 2022 and wages from national databases were used to estimate hub and diabetes support coach costs to operate a 6-month, 24-session Project ECHO Diabetes program at hubs (University of Florida and Stanford University) and spokes (PCP clinic sites in Florida and California). RESULTS: Hub costs for delivering a 6-month Project ECHO Diabetes program to five spoke clinics were $96,873. Personnel costs were the principal driver. Mean cost was $19,673 per spoke clinic and $11.37 per spoke clinic patient. Diabetes support coach costs were estimated per spoke clinic and considered scalable in that they would increase proportionately with the number of spoke clinics in a Project ECHO Diabetes cohort. Mean diabetes support coach costs were $6,506 per spoke clinic and $3.72 per patient. Total program costs per hub were $129,404. Mean cost per clinic was $25,881. Mean cost per patient was $15.03. CONCLUSION: Herein, we document real-world costs to operate a Project ECHO Diabetes hub and diabetes support coaches. Future analysis of Project ECHO Diabetes will include estimates of spoke participation costs and changes in health care costs and savings. As state agencies, insurers, and philanthropies consider the replication of Project ECHO Diabetes, this analysis provides important initial information regarding primary operating costs.

An external exposome-wide association study of opioid use disorder diagnosed during pregnancy in Florida.

The prevalence of opioid use disorder (OUD) during pregnancy has quadrupled in recent years and widely varies geographically in the US. However, few studies have examined which environmental factors are associated with OUD during pregnancy. We conducted an external exposome-wide association study (ExWAS) to investigate the associations between external environmental factors and OUD diagnosed during pregnancy. Data were obtained from a unique, statewide database in Florida comprising linked individual-level birth and electronic health records. A total of 255,228 pregnancies with conception dates between 2012 and 2016 were included. We examined 82 exposome measures characterizing seven aspects of the built and social environment and spatiotemporally linked them to each individual record. A two-phase procedure was utilized for the external ExWAS. In Phase 1, we randomly divided the data into a discovery set (50 %) and a replication set (50 %). Associations between exposome measures (normalized and standardized) and OUD initially diagnosed during pregnancy were examined using logistic regression. A total of 15 variables were significant in both the discovery and replication sets. In Phase 2, multivariable logistic regression was used to fit all variables selected from Phase 1. Measures of walkability (the national walkability index, OR: 1.23, 95 % CI: 1.17, 1.29), vacant land (the percent vacant land for 36 months or longer, OR: 1.06, 95 % CI: 1.00, 1.12) and food access (the percentage of low food access population that are seniors at 1/2 mile, OR: 1.47, 95 % CI: 1.38, 1.57) were each associated with diagnosis of OUD during pregnancy. This is the first external ExWAS of OUD during pregnancy, and the results suggest that low food access, high walkability, and high vacant land in under-resourced neighborhoods are associated with diagnosis of OUD during pregnancy. These findings could help develop complementary tools for universal screening for substance use and provide direction for future studies.

Initial Antihypertensive Regimens in Newly Treated Patients: Real World Evidence From the OneFlorida+ Clinical Research Network.

Background Knowledge of real-world antihypertensive use is limited to prevalent hypertension, limiting our understanding of how treatment evolves and its contribution to persistently poor blood pressure control. We sought to characterize antihypertensive initiation among new users. Methods and Results Using Medicaid and Medicare data from the OneFlorida+ Clinical Research Consortium, we identified new users of ≥1 first-line antihypertensives (angiotensin-converting enzyme inhibitor, calcium channel blocker, angiotensin receptor blocker, thiazide diuretic, or ß-blocker) between 2013 and 2021 among adults with diagnosed hypertension, and no antihypertensive fill during the prior 12 months. We evaluated initial antihypertensive regimens by class and drug overall and across study years and examined variation in antihypertensive initiation across demographics (sex, race, and ethnicity) and comorbidity (chronic kidney disease, diabetes, and atherosclerotic cardiovascular disease). We identified 143 054 patients initiating 188 995 antihypertensives (75% monotherapy; 25% combination therapy), with mean age 59 years and 57% of whom were women. The most commonly initiated antihypertensive class overall was angiotensin-converting enzyme inhibitors (39%) followed by ß-blockers (31%), calcium channel blockers (24%), thiazides (19%), and angiotensin receptor blockers (11%). With the exception of ß-blockers, a single drug accounted for ≥75% of use of each class. ß-blocker use decreased (35%-26%), and calcium channel blocker use increased (24%-28%) over the study period, while initiation of most other classes remained relatively stable. We also observed significant differences in antihypertensive selection across demographic and comorbidity strata. Conclusions These findings indicate that substantial variation exists in initial antihypertensive prescribing, and there remain significant gaps between current guideline recommendations and real-world implementation in early hypertension care.

Implementation of a Pediatric Telemedicine and Medication Delivery Service in a Resource-limited Setting: A Pilot Study for Clinical Safety and Feasibility.

OBJECTIVE: Determine the clinical safety and feasibility of implementing a telemedicine and medication delivery service (TMDS) to address gaps in nighttime access to health care for children in low-resource settings. STUDY DESIGN: We implemented a TMDS called 'MotoMeds' in Haiti as a prospective cohort study. A parent/guardian of a sick child ≤ 10 years contacted the call center (6 PM-5 AM). A nurse provider used decision support tools to triage cases (mild, moderate, or severe). Severe cases were referred to emergency care. For nonsevere cases, providers gathered clinical findings to generate an assessment and plan. For cases within the delivery zone, a provider and driver were dispatched and the provider performed a paired in-person exam as a reference standard for the virtual call center exam. Families received a follow-up call at 10 days. Data were analyzed for clinical safety and feasibility. RESULTS: A total of 391 cases were enrolled from September 9, 2019, to January 19, 2021. Most cases were nonsevere (92%; 361); household visits were completed for 89% (347) of these cases. Among the 30 severe cases, 67% (20) sought referred care. Among all cases, respiratory problems were the most common complaint (63%; 246). At 10 days, 95% (329) of parents reported their child had "improved" or "recovered". Overall, 99% (344) rated the TMDS as "good" or "great". The median phone consultation time was 20 minutes, time to household arrival was 73 minutes, and total case time was 114 minutes. CONCLUSION: The TMDS was a feasible health care delivery model. Although many cases were likely self-limiting, the TMDS was associated with high rates of reported improvement in clinical status at 10 days. TRIAL REGISTRATION: clinicaltrials.gov: NCT03943654.

Implementation of a pediatric asthma management program in rural primary care clinics.

OBJECTIVE: Rural communities experience a significant asthma burden. We pilot tested the implementation of Easy Breathing, a decision support program for improving primary care provider adherence to asthma guidelines in a rural community, and characterized asthma risk factors for enrollees. METHODS: We implemented Easy Breathing in two rural primary care practices for two years. Patient demographics, exposure histories, asthma severity, asthma medications, and treatment plans were collected. Providers' adherence to guidelines included the frequency of children with persistent asthma who were prescribed guidelines-based therapy and the frequency of children with a written asthma treatment plan on file. Clinicians provided feedback on the feasibility and acceptability of Easy Breathing using a validated survey tool and through semi-structured interviews. RESULTS: Two providers implemented the program. Enrollment included 518 children, of whom 135 (26%) had physician-confirmed asthma. After enrollment into Easy Breathing, 75% of children with asthma received a written asthma treatment plan All children with persistent asthma were prescribed an anti-inflammatory drug as part of their treatment plan. Providers (n = 2) rated Easy breathing as highly acceptable (M = 4.5), feasible (M = 4.5), and appropriate (M = 4.5). Qualitative feedback was positive, with suggestions to integrate the paper-based program into the electronic health record system for broader uptake. Enrollees with asthma were more likely to have a family history of asthma and endorse exposure to tobacco smoke and cockroaches. CONCLUSIONS: Easy Breathing shows promise as a decision support system that can be implemented in rural, medically underserved communities via primary care.