Exploring infectious disease spread as a function of seasonal and pandemic-induced changes in human mobility.

Introduction: Community-level changes in population mobility can dramatically change the trajectory of any directly-transmitted infectious disease, by modifying where and between whom contact occurs. This was highlighted throughout the COVID-19 pandemic, where community response and nonpharmaceutical interventions changed the trajectory of SARS-CoV-2 spread, sometimes in unpredictable ways. Population-level changes in mobility also occur seasonally and during other significant events, such as hurricanes or earthquakes. To effectively predict the spread of future emerging directly-transmitted diseases, we should better understand how the spatial spread of infectious disease changes seasonally, and when communities are actively responding to local disease outbreaks and travel restrictions. Methods: Here, we use population mobility data from Virginia spanning Aug 2019-March 2023 to simulate the spread of a hypothetical directly-transmitted disease under the population mobility patterns from various months. By comparing the spread of disease based on where the outbreak begins and the mobility patterns used, we determine the highest-risk areas and periods, and elucidate how seasonal and pandemic-era mobility patterns could change the trajectory of disease transmission. Results and discussion: Through this analysis, we determine that while urban areas were at highest risk pre-pandemic, the heterogeneous nature of community response induced by SARS-CoV-2 cases meant that when outbreaks were occurring across Virginia, rural areas became relatively higher risk. Further, the months of September and January led to counties with large student populations to become particularly at risk, as population flows in and out of these counties were greatly increased with students returning to school.

Practice Facilitation to Address Unhealthy Alcohol Use in Primary Care: A Cluster Randomized Clinical Trial.

Importance: Unhealthy alcohol use (UAU) is the fourth most preventable cause of death in the US. The US Preventive Services Task Force recommends that primary care clinicians routinely screen all adults 18 years and older for UAU; however, this preventive service is poorly implemented. Objective: To determine if practice facilitation improved delivery of the recommended care for UAU compared to usual care. Design, Setting, and Participants: This practice-level cluster randomized clinical trial was conducted across diverse and representative primary care practices throughout Virginia. A total of 76 primary care practices enrolled between October 2019 and January 2023. Intervention: Practices received immediate (intervention) or 6-month delayed (control) practice facilitation, which included tailored educational sessions, workflow management, and tools for addressing UAU. Main Outcomes and Measures: Outcomes included the increase in recommended screening for UAU, brief interventions, referral for counseling, and medication treatment. Data were collected via medical record review (structured and free text data) and transcripts of practice facilitator sessions and exits interviews. Results: Of the 76 primary care practices enrolled, 32 were randomized to intervention and 35 to control; 11 789 patients (mean [SD] age, 50.1 [16.3] years; 61.1% women) were randomly selected for analysis, with patient demographics similar to Virginia at large. From baseline to 6 months after intervention, screening with a validated instrument increased from 2.1% (95% CI, 0.5%-8.4%) to 35.5% (95% CI, 11.5%-69.9%) in the intervention group compared to 0.4% (95% CI, 0.1%-1.8%) to 1.4% (95% CI, 0.3%-5.8%) in the control group (P < .001). Brief office-based interventions for the intervention group increased from 26.2% (95% CI, 14.2%-45.8%) to 62.6% (95% CI, 43.6%-78.3%) vs 45.5% (95% CI, 28.0%-64.1%) to 55.1% (95% CI, 36.5%-72.3%) in the control group (P = .008). Identification of UAU, referral for counseling, and medication treatment had similar changes for both groups. Qualitative analyses of transcripts revealed that few clinicians understood the preventive service prior to practice facilitation, but at the end most felt much more competent and confident with screening and brief intervention for UAU. Conclusions and Relevance: This cluster randomized clinical trial demonstrated that practice facilitation can help primary care practices to better implement screening and counseling for UAU into their routine workflow. Effective primary care practice implementation interventions such as this can have a profound effect on the health of communities. Given the number of people that the participating practices care for, this intervention resulted in an additional 114 604 patients being screened annually for UAU who would not have been otherwise. Trial Registration: ClinicalTrials.gov Identifier: NCT04248023.

Effects of Cannabis Use on Sedation Requirements for Endoscopic Procedures: A Replication Study.

On July 1, 2021, cannabis became legal in Virginia for adults 21 years of age and older. Cannabis consumption may have significant implications for outcomes related to medical care, including procedural sedation. The purpose of this study was to determine whether self-reported cannabis consumption has any relationship to sedation medication requirements during endoscopic procedures. A retrospective analysis was conducted to examine two groups of surgical patients (self-reported cannabis use versus self-reported non-cannabis use) at a community hospital in the mid-Atlantic region. Results demonstrate that there were no significant differences between groups for either Time to Aldrete ≥8 (p = .486) or Time to Meet Phase II Criteria (p = .762). Equivalent recovery times for both groups may be an indicator that comparable sedation levels were maintained, despite the increased propofol requirements of the cannabis group. Open conversations to establish patient use of cannabis products prior to procedural sedation is important for determining appropriate plans of care related to risk factors and medication dosage requirements during endoscopic evaluations.

Biotic and abiotic factors affecting Atlantic ghost crab (Ocypode quadrata) spatiotemporal activity at an important shorebird nesting site in Virginia.

Atlantic ghost crabs (Ocypode quadrata) are predators of beach-nesting shorebird nests and chicks on the United States' Atlantic and Gulf coasts. Ghost crabs may also disturb birds, altering foraging, habitat use, or nest and brood attendance patterns. Shorebird conservation strategies often involve predator and disturbance management to improve reproductive success, but efforts rarely target ghost crabs. Despite the threat to shorebird reproductive success, ghost crabs are a poorly understood part of the beach ecosystem and additional knowledge about ghost crab habitat selection is needed to inform shorebird conservation. We monitored ghost crab activity, defined as burrow abundance, throughout the shorebird breeding season on Metompkin Island, Virginia, an important breeding site for piping plovers (Charadrius melodus) and American oystercatchers (Haematopus palliatus). We counted burrows at shorebird nests and random locations throughout the breeding season and investigated whether ghost crab activity was greater at nest sites relative to random locations without shorebird nests. While we observed burrows at all nest sites (n = 63 nests), we found that burrow counts were lower at piping plover nests with shell cover, relative to random locations with no shell cover. Ghost crabs may avoid piping plover nest sites due to anti-predator behaviors from incubating adults or differences in microhabitat characteristics selected by piping plovers. We also investigated the effects of habitat type, date, and air temperature on the abundance of ghost crab burrows. We found that while crab burrows were present across the barrier island landscape, there were more burrows in sandy, undisturbed habitats behind the dunes, relative to wave-disturbed beach. Additionally, ghost crab activity increased later in the shorebird breeding season. Understanding when and where ghost crabs are most likely to be active in the landscape can aid decision-making to benefit imperiled shorebird populations.

A Targeted Clinical Reasoning Remediation Program for Residents and Fellows in Need.

Background There is no standardized, widely accepted process for individualized clinical reasoning remediation. Objective We describe a novel, targeted assessment and coaching process that allows for individualized intervention for residents and fellows struggling with clinical reasoning. Methods Residents and fellows at the University of Virginia with performance concerns are referred to COACH (Committee on Achieving Competence Through Help) and assessed by a remediation expert. A subset is referred to a clinical reasoning remediation coach who performs an additional assessment and cocreates an individualized remediation plan. Following remediation, residents and fellows are reassessed by their respective programs. We report the frequency of struggle, remediation time invested, and academic outcomes. Results From 2017 to 2022, 114 residents and fellows referred to COACH met inclusion criteria, of which 38 (33%) had a deficiency in clinical reasoning. Targeted assessment revealed the following microskill deficits: hypothesis generation (16 of 38, 42%); data gathering (6 of 38, 16%); problem representation (7 of 38, 18%); hypothesis refinement (3 of 38, 8%); and management (6 of 38, 16%). Remediation required a mean of nearly 23 hours per trainee. Of the 38 trainees, 33 (87%) are in good standing at the time of writing. Conclusions Our unique program offers a feasible, targeted approach to clinical reasoning remediation based on our current understanding of the clinical reasoning process. Early hypothesis generation was the most common microskill deficit identified.

Chi-Squared Automatic Interaction Detection Decision Tree Analysis of Social Determinants for Low Birth Weight in Virginia.

This study provides additional context to the literature regarding the social inequities that impact birth outcomes in Virginia using a decision tree analysis. Chi-squared automatic interaction detection data analysis (CHAID) was performed using data from the Virginia birth registry for the years 2015-2019. Birth weight was the outcome variable, while sociodemographic factors and maternity care deserts were the explanatory variables. The prevalence of low birth weight in Virginia was of 8.1%. The CHAID decision tree model demonstrated multilevel interaction among risk factors with three levels, with a total of 34 nodes. All the variables reached significance in the model, with race/ethnicity being the first major predictor variable, each category of race and ethnicity having different significant predictors, followed by prenatal care and maternal education in the next levels. These findings signify modifiable risk factors for low birth weight, in prioritizing efforts such as programs and policies. CHAID decision tree analysis provides an effective approach to detect target populations for further intervention as pathways derived from this decision tree shed light on the different predictors of high-risk population in each of the race/ethnicity demographic categories in Virginia.

Developing equity-aware safety performance functions for identifying hotspots of pedestrian-involved crashes.

Crashes are frequently disproportionally observed in disadvantaged areas. Despite the evident disparities in transportation safety, there has been limited exploration of quantitative approaches to incorporating equity considerations into road safety management. This study proposes a novel concept of equity-aware safety performance functions (SPFs), enabling a distinct treatment of equity-related variables such as race and income. Equity-aware SPFs introduce a fairness distance and integrate it into the log-likelihood function of the negative binomial regression as a form of partial lasso regularization. A parameter λ is used to control the importance of the regularization term. Equity-aware SPFs are developed for pedestrian-involved crashes at the census tract level in Virginia, USA, and then employed to compute the potential for safety improvement (PSI), a prevalent metric used in hotspot identification. Results show that equity-aware SPFs can diminish the effects of equity-related variables, including poverty ratio, black ratio, Asian ratio, and the ratio of households without vehicles, on the expected crash frequencies, generating higher PSIs for disadvantaged areas. Based on the results of Wilcoxon signed-rank tests, it is evident that there are significant differences in the rankings of PSIs when equity awareness is considered, especially for disadvantaged areas. This study adds to the literature a new quantitative approach to harmonize equity and effectiveness considerations, empowering more equitable decision-making in safety management, such as allocating resources for safety enhancement.

Modeling the interaction of vegetation and sea level rise on barrier island evolution.

Barrier islands provide a first line of defense against ocean flooding and storm surge. Biogeomorphic interactions are recognized as important in coastal system processes, but current barrier island models are primarily dominated by physical processes. Recent research has demonstrated different biogeomorphic states that influence response to sea level rise and other disturbance. Building on this understanding, we present a cellular model utilizing biotic and abiotic processes and their interactions for barrier island evolution. Using the literature and field derived parameters, we model barrier island evolution and compare to three decades of change for Smith Island, a Virginia Coast Reserve barrier island. We conduct simulations that show the impact of biogeomorphic states on island migration under different sea level rise scenarios. We find that migration is highest in areas with low topography and light vegetation cover (i.e. disturbance reinforcing) compared to areas with greater topographic complexity and high cover of woody vegetation i.e. disturbance resisting). This study demonstrates the importance of biogeomorphic interactions for barrier island evolution with sea level rise and will aid future predictions for these important ecosystems with climate change.

Multisystemic inflammatory disease in Pheasantshell (Unionidae, Actinonaias pectorosa) associated with Yokenella regensburgei infection at sites experiencing seasonal mass mortality events.

Freshwater mussels are integral components of riverine ecosystems, influencing water quality, nutrient cycling, and habitat characteristics. Enigmatic freshwater mussel declines, often characterized by sudden mass mortality events, pose significant challenges to conservation efforts. The Clinch River, a freshwater biodiversity hotspot in Virginia and Tennessee, USA, has experienced several enigmatic mass mortality events since 2016. Studies have reported bacteria associated with moribund Pheasantshell (Actinonaias pectorosa) during mortality events in the Clinch River, specifically Yokenella regensburgei. Despite reports of bacterial infection, little is known about their role as pathogens. Through a multiyear case-control study, combining in-situ experiments, field surveys, histology, bacterial isolation, and high-throughput sequencing, we assessed the role of bacteria in Pheasantshell (Actinonais pectorosa) mortality at three sites in the Clinch River. Between May 2021 and December 2023, we collected 21 wild moribund free-living A. pectorosa and 68 hatchery-reared A. pectorosa maintained in silos at the same sites and investigated differences in pathology and microbiologye between groups. No silo mussels presented clinical signs of disease, or gross or microscopic lesions associated with pathological conditions leading to mortality. Our findings reveal a significant association between Yokenella regensburgei and severe multisystemic and multifocal infiltrative hemocytosis with necrosis, consistent with sepsis. Lesions associated with yokenellosis were of sufficient severity and physiological significance to explain mortality in infected hosts. Although our study does not explain the cause of these infections, it confirms that mussels at our study sites are ultimately dying with an infectious disease and that Y. regensburgei can be pathogenic in free-living mussels. Our results underscore the importance of considering bacterial diseases in wild mussel populations and emphasize the need for further research to elucidate the epidemiology and pathogenicity of Y. regensburgei. Overall, our study highlights the importance of integrated approaches combining pathology, microbiology, and epidemiology in freshwater mussel conservation efforts.

Movement patterns of foraging common terns (Sterna hirundo) breeding in an urban environment in coastal Virginia.

Nesting colonial seabirds are prime examples of central-place foragers, animals that must return to a central location (e.g., a breeding colony) after each bout of foraging. They must balance the costs and benefits of foraging with the need to return to their colonies frequently to form pair bonds during courtship, incubate, provision mates and offspring, and protect and rear young. For some populations, the loss and degradation of suitable breeding habitat due to human activities have necessitated the construction of new breeding sites and/or the restoration of previously occupied sites. South Island, which is part of the Hampton Roads Bridge-Tunnel (HRBT) complex in the Commonwealth of Virginia, U.S.A., is a human-created island that supported Virginia's largest mixed species seabird colony until 2020, when the expansion of the HRBT began and when all nesting seabirds were permanently excluded from the site. We studied the movement patterns of foraging common terns (Sterna hirundo) to determine how travel to and around foraging sites related to their colony location and to inform the siting and construction of a new breeding island. We tracked 18 individual common terns from 07 June to 29 June 2018, and we used a hidden Markov model to assign behavioral states and investigate common tern movements around the HRBT. Common terns spent more than half their time in the colony (58%), followed by time devoted to foraging (22%), and the remainder of their time was spent on outbound (15%) and inbound (5%) transit. Terns traveled as far as 98km from the colony, but on average foraged relatively close to South Island (13.6 ± 0.3km, mean ± 1 SD). Individuals tended to forage in the same locations, but there was variation among individuals. Flying to foraging sites uses energy during the already energetically costly breeding season, thus managers should prioritize placing a new colony site in a location that minimizes the distance traveled to the foraging locations frequented by the South Island birds while accounting for other life-history characteristics. These findings could help in the design and construction of new breeding sites or the restoration of current sites for other, related species, particularly for which these data do not exist.

Uranium Mine Proposed Experimental Design for Natural Background Gross Gamma Exposure Rates, Post Remediation Final Status Survey Sampling Density, and Radiological Water Quality Modeling for a Worst-case Catastrophic Failure, Coles Hill, Virginia.

ABSTRACT: Completely randomized experimental design statistical modeling techniques were employed to analyze exposure rate measurements for evaluating hypothetical natural background post uranium mill operations at Coles Hill, Virginia uranium milling processes. The proposed Coles Hill Uranium Mine is situated upstream of the Banister River. This River is nearly homogenous throughout the reach length used in analysis and feeds into the mouth of Kerr Reservoir, Lake Gaston, which serves as the main drinking water source for cities in the Hampton Roads area including Norfolk, Virginia Beach, and Chesapeake. A critical scan value (=DCGLscan) was developed to flag anomalies of surface contamination during simulated post remediation final status surveys. The natural background was critical for meeting the Multi-Agency Radiation Survey and Site Investigation Manual guidance for post remediation final status surveys. The overarching null hypothesis suggested that the selected mean natural background is equal to the survey unit's mean natural background. Using SAS Procedures Shapiro-Wilk Test, ANOVA, and CR, it was decided the exposure rate data was normal, had no extreme outliers, and no collinearity between the number of samples (=treatment) and the areas (=block). Using the q-hyper (hypergeometric) distribution, the soil sampling density was decided for a final status survey unit. The most likely worst-case catastrophic failure analysis, 500-year event, such as the1969 Hurricane Camille of 69 centimeters of rain in Nelson County, Virginia was included in the model. The model showed impact was minimal at most to the Banister River's drinking water and likely less than the Virginia's Drinking Water Standards for gross alpha, 226Ra and 228Ra, and total uranium.

Improved Patient Engagement and Cost Savings Through a Novel Medication Review Process.

Pharmacist-led interventions are pivotal in identifying and resolving potential adverse drug events (pADEs) while enhancing blood pressure control and medication adherence through educational and counseling interventions. This practice brief outlines the outcomes of the Blue Bag Initiative (BBI), which enhanced pharmacist-led comprehensive medication reviews (CMRs) across community pharmacies in Virginia under Center for Disease Control Cooperative Agreement NU58DP006535. BBI yielded a rate of 131.6 pADEs identified per 100 participants and demonstrated cost savings of 1 to 3 million dollars for the health care system. This report underscores the significance of a standardized, pharmacist-led CMR as integral to interdisciplinary team-based care models within physician practices, facilitating medication therapy management implementation. Enhanced CMR can improve cardiovascular health outcomes while reducing health care expenditures by augmenting patient engagement and medication adherence. This study thus highlights the efficacy and potential of pharmacist-led interventions in increasing access to and optimizing patient care.

Bodies and Bites: a medical school program that teaches anatomy, physiology, and nutrition to elementary school kids.

Undergraduate medical students who participate in community outreach programs gain a multitude of benefits that impact not only their professional development but also the well-being of the communities they serve. At the Virginia Tech Carilion School of Medicine (VTCSOM), students have the opportunity to volunteer in the "Bodies and Bites" program at the West End Center for Youth, an after-school educational center that serves K-12 children in Roanoke, Virginia. The purpose of Bodies and Bites is to teach elementary school children in 2nd to 5th grade how their bodies work and how to keep them healthy through good nutrition and exercise. All sessions are led by VTCSOM medical students and graduate students from our partnering academic institution, the Fralin Biomedical Research Institute (FBRI). Each week, the children and Health Professions students explore a different topic related to human anatomy and physiology using anatomical models, small group discussions, and hands-on activities. At the end of each session, the participants create a healthy snack related to the day's topic. The overall goal of the present study was to assess the perception of the Bodies and Bites program from the view of our student volunteers, and the 4th and 5th graders who attend the West End Center. Now in its 6th year, Bodies and Bites continues to be popular as a voluntary program among our Health Professions students, and is well received by the West End Center and the elementary school children they serve. Our students and community mutually benefit from this program, with the former having an opportunity to briefly disengage from the rigors of their studies while gaining valuable skills in science communication and inspiring children to pursue fields in Science, Technology, Engineering, Math, and Medicine (STEMM), and the latter having fun while learning about their bodies and discovering ways to improve their health.

New report of Haemaphysalis longicornis (Ixodida: Ixodidae) in Mecklenburg County, Virginia from field collections.

Haemaphysalis longicornis (Neumann) was first established in New Jersey and has rapidly spread across most of the eastern United States. This tick has the potential to infest a wide variety of hosts and can reproduce quickly via parthenogenesis, presenting a new threat to animal health. Here we report the first record of a single H. longicornis tick in Mecklenburg County, Virginia, from incidental field collections of ticks. In addition to H. longicornis, we collected 787 Amblyomma americanum, 25 Dermacentor variabilis, 6 Ixodes affinis, 1 Haemaphysalis leporispalustris, and 1 Amblyomma maculatum using standard dragging and flagging techniques. The expansion of H. longicornis will have economic consequences for livestock producers in south-central Virginia, who must now manage this species. Enhanced surveillance is needed to fully understand its growing geographic distribution in the United States and the subsequent consequences of its spread.

Widespread exposure to SARS-CoV-2 in wildlife communities.

Pervasive SARS-CoV-2 infections in humans have led to multiple transmission events to animals. While SARS-CoV-2 has a potential broad wildlife host range, most documented infections have been in captive animals and a single wildlife species, the white-tailed deer. The full extent of SARS-CoV-2 exposure among wildlife communities and the factors that influence wildlife transmission risk remain unknown. We sampled 23 species of wildlife for SARS-CoV-2 and examined the effects of urbanization and human use on seropositivity. Here, we document positive detections of SARS-CoV-2 RNA in six species, including the deer mouse, Virginia opossum, raccoon, groundhog, Eastern cottontail, and Eastern red bat between May 2022-September 2023 across Virginia and Washington, D.C., USA. In addition, we found that sites with high human activity had three times higher seroprevalence than low human-use areas. We obtained SARS-CoV-2 genomic sequences from nine individuals of six species which were assigned to seven Pango lineages of the Omicron variant. The close match to variants circulating in humans at the time suggests at least seven recent human-to-animal transmission events. Our data support that exposure to SARS-CoV-2 has been widespread in wildlife communities and suggests that areas with high human activity may serve as points of contact for cross-species transmission.

Association between summertime emergency department visits and maximum daily heat index in rural and non-rural areas of Virginia (2015-2022).

There is growing evidence that high ambient temperatures are associated with a range of adverse health outcomes. Further evidence suggests differences in rural versus non-rural populations' vulnerability to heat-related adverse health outcomes. The current project aims to 1) refine estimated associations between maximum daily heat index (HI) and emergency department (ED) visits in regions of Virginia, and 2) compare associations between maximum daily HI and ED visits in rural versus non-rural areas of Virginia and within those areas, for persons 65 years of age and older versus those younger than 65 years. Our study utilized 16,873,213 healthcare visits from Virginia facilities reporting to the Virginia Department of Health syndromic surveillance system between May and September 2015-2022. Federal Office of Rural Health Policy defined rural areas were assigned to patient home ZIP code. The estimated daily maximum HI at which ED visits begin to rise varies between 25 °C and 33 °C across climate zones and regions of Virginia. Across all regions, estimated ED visits attributable to days with maximum HI above 25.7 °C were higher in rural areas (3.7%, 95% CI: 3.5%, 3.9%) versus in non-rural areas (3.1%, 95% CIs: 3.0%, 3.2%). Patients aged 0-64 years had a higher estimated heat attributable fraction of ED visits (4.2%, 95% CI: 4.0%, 4.3%) than patients 65 years and older (3.1%, 95% CI: 2.9%, 3.4%). Rural patients older than 65 have a higher estimated fraction of heat attributable ED visits (2.7%, 95% CI: 2.2%, 3.1%) compared to non-rural patients 65 years and older (1.5%, 95% CI: 1.3%, 1.8%). State-level syndromic surveillance data can be used to optimize heat warning messaging based on expected changes in healthcare visits given a set of meteorological variables, and can be further refined based on climate, rurality and age.

Phylogeography and paleoclimatic range dynamics explain variable outcomes to contact across a species' range.

Replicability of divergence after contact is a poorly characterized process, particularly in the contexts of phylogeography and postglacial range dynamics within species. Using contact zones located at the leading-, mid- and rear-edges of a species' range, we examined variation in outcomes to contact between divergent lineages of Campanula americana. We investigated whether contact zones vary in quantity and directionality of gene flow, how phylogeographic structure differs between contact zones, and how historic range dynamics may affect outcomes to contact. We found that all contact zones formed at similar times via primary contact yet detected significant admixture in only the rear-edge (RE) contact zone. In the northern leading-edge contact zone and the mid-range Virginia contact zone, gene flow was minimal and asymmetric. In the southern RE contact zone, gene flow was strong and symmetric. Asymmetric admixture in the leading-edge and Virginia contact zones matches the directionality of a known cosmopolitan cytonuclear incompatibility between lineages of C. americana. Our results emphasize the dependence of speciation processes on phylogeographic structure, evolutionary history and range dynamics.

Beneficiary Experience of Care by Level of Integration in Dual Eligible Special Needs Plans.

Importance: Dual Eligible Special Needs Plans (D-SNPs) are private managed care plans designed to promote Medicare and Medicaid integration for full-benefit, dually eligible beneficiaries. Currently, the highest level of D-SNP integration occurs in plans with exclusively aligned enrollment (EAE). Objective: To compare patient experience of care, out-of-pocket spending, and satisfaction among dually enrolled Medicaid beneficiaries in D-SNPs with EAE, those in D-SNPs without EAE, and those with traditional Medicare. Design, Setting, and Participants: This cross-sectional study included respondents to a mail survey fielded to a stratified random sample of full-benefit, community-dwelling, dual-eligible Medicaid beneficiaries who qualified for receipt of home and community-based services in the Virginia Medicaid Commonwealth Coordinated Care Plus program between March and October 2022. Exposure: Enrollment in a D-SNP with EAE or a D-SNP without EAE vs traditional Medicare. Main Outcomes and Measures: The main outcomes were self-reported measures of access and delays in receiving plan approvals, out-of-pocket spending, and satisfaction with health plans' customer service and choice of primary care and specialist physicians. Results: Of 7200 surveys sent, 2226 were completed (response rate, 30.9%). The analytic sample consisted of 1913 Medicaid beneficiaries with nonmissing data on covariates (mean [SD] age, 70.8 [15.6] years; 1367 [71.5%] female). Of these, 583 (30.5%) were enrolled in D-SNPs with EAE, 757 (39.6%) in D-SNPs without EAE, and 573 (30.0%) in traditional Medicare. Compared with respondents enrolled in D-SNPs without EAE, those in D-SNPs with the highest level of integration (EAE) were 6.77 percentage points (95% CI, 8.81-12.66 percentage points) more likely to report being treated with courtesy and respect and 5.83 percentage points (95% CI, 0.21-11.46 percentage points) more likely to know who to call when they had a health problem. No statistically significant differences were found between members in either type of D-SNP and between those in D-SNPs and traditional Medicare in terms of their difficulty accessing care, delays in care, and satisfaction with care coordination and physician choice. Conclusions and Relevance: This cross-sectional study found some benefits of integrating administrative processes under Medicare and Medicaid but suggests that care coordination and access improvements under full integration require additional time and/or efforts to achieve.

Self-Reported Religiosity and Spirituality of Registered Nurses in Virginia.

ABSTRACT: The professional nurse cares for an increasingly diverse population, varying in ethnicity, culture, and faith beliefs that influence health and wellness. The moral obligation of the nurse to provide individualized, holistic care of clients includes spiritual care. Supported by the Agape Model of Nursing, nurses should understand their personal religiosity and its impact on the care they provide. The purpose of this study was to better understand the self-reported religiosity and spirituality of registered nurses licensed to practice in the Commonwealth of Virginia.