Prevalence of 12 Common Health Conditions in Sexual and Gender Minority Participants in the All of Us Research Program.

Importance: Limited data describe the health status of sexual or gender minority (SGM) people due to inaccurate and inconsistent ascertainment of gender identity, sex assigned at birth, and sexual orientation. Objective: To evaluate whether the prevalence of 12 health conditions is higher among SGM adults in the All of Us Research Program data compared with cisgender heterosexual (non-SGM) people. Design, Setting, and Participants: This cross-sectional study used data from a multidisciplinary research consortium, the All of Us Research Program, that links participant-reported survey information to electronic health records (EHR) and physical measurements. In total, 372 082 US adults recruited and enrolled at an All of Us health care provider organization or by directly visiting the enrollment website from May 31, 2017, to January 1, 2022, and were assessed for study eligibility. Exposures: Self-identified gender identity and sexual orientation group. Main Outcomes and Measures: Twelve health conditions were evaluated: 11 using EHR data and 1, body mass index (BMI; calculated as weight in kilograms divided by height in meters squared), using participants' physical measurements. Logistic regression (adjusting for age, income, and employment, enrollment year, and US Census division) was used to obtain adjusted odds ratios (AORs) for the associations between each SGM group and health condition compared with a non-SGM reference group. Results: The analytic sample included 346 868 participants (median [IQR] age, 55 [39-68] years; 30 763 [8.9%] self-identified as SGM). Among participants with available BMI (80.2%) and EHR data (69.4%), SGM groups had higher odds of anxiety, depression, HIV diagnosis, and tobacco use disorder but lower odds of cardiovascular disease, kidney disease, diabetes, and hypertension. Estimated associations for asthma (AOR, 0.39 [95% CI, 0.24-0.63] for gender diverse people assigned male at birth; AOR, 0.51 [95% CI, 0.38-0.69] for transgender women), a BMI of 25 or higher (AOR, 1.65 [95% CI, 1.38-1.96] for transgender men), cancer (AOR, 1.15 [95% CI, 1.07-1.23] for cisgender sexual minority men; AOR, 0.88 [95% CI, 0.81-0.95] for cisgender sexual minority women), and substance use disorder (AOR, 0.35 [95% CI, 0.24-0.52] for gender diverse people assigned female at birth; AOR, 0.65 [95% CI, 0.49-0.87] for transgender men) varied substantially across SGM groups compared with non-SGM groups. Conclusions and Relevance: In this cross-sectional analysis of data from the All of Us Research Program, SGM participants experienced health inequities that varied by group and condition. The All of Us Research Program can be a valuable resource for conducting health research focused on SGM people.

Assessing the impact of multicomponent interventions on colorectal cancer screening through simulation: What would it take to reach national screening targets in North Carolina?

Healthy People 2020 and the National Colorectal Cancer Roundtable established colorectal cancer (CRC) screening targets of 70.5% and 80%, respectively. While evidence-based interventions (EBIs) have increased CRC screening, the ability to achieve these targets at the population level remains uncertain. We simulated the impact of multicomponent interventions in North Carolina over 5 years to assess the potential for meeting national screening targets. Each intervention scenario is described as a core EBI with additional components indicated by the "+" symbol: patient navigation for screening colonoscopy (PN-for-Col+), mailed fecal immunochemical testing (MailedFIT+), MailedFIT+ targeted to Medicaid enrollees (MailedFIT + forMd), and provider assessment and feedback (PAF+). Each intervention was simulated with and without Medicaid expansion and at different levels of exposure (i.e., reach) for targeted populations. Outcomes included the percent up-to-date overall and by sociodemographic subgroups and number of CRC cases and deaths averted. Each multicomponent intervention was associated with increased CRC screening and averted both CRC cases and deaths; three had the potential to reach screening targets. PN-for-Col + achieved the 70.5% target with 97% reach after 1 year, and the 80% target with 78% reach after 5 years. MailedFIT+ achieved the 70.5% target with 74% reach after 1 year and 5 years. In the Medicaid population, assuming Medicaid expansion, MailedFIT + forMd reached the 70.5% target after 5 years with 97% reach. This study clarifies the potential for states to reach national CRC screening targets using multicomponent EBIs, but decision-makers also should consider tradeoffs in cost, reach, and ability to reduce disparities when selecting interventions.

Estimating the impact of insurance expansion on colorectal cancer and related costs in North Carolina: A population-level simulation analysis.

Although screening is effective in reducing incidence, mortality, and costs of treating colorectal cancer (CRC), it remains underutilized, in part due to limited insurance access. We used microsimulation to estimate the health and financial effects of insurance expansion and reduction scenarios in North Carolina (NC). We simulated the full lifetime of a simulated population of 3,298,265 residents age-eligible for CRC screening (ages 50-75) during a 5-year period starting January 1, 2018, including polyp incidence and progression and CRC screening, diagnosis, treatment, and mortality. Insurance scenarios included: status quo, which in NC includes access to the Health Insurance Exchange (HIE) under the Affordable Care Act (ACA); no ACA; NC Medicaid expansion, and Medicare-for-all. The insurance expansion scenarios would increase percent up-to-date with screening by 0.3 and 7.1 percentage points for Medicaid expansion and Medicare-for-all, respectively, while insurance reduction would reduce percent up-to-date by 1.1 percentage points, compared to the status quo (51.7% up-to-date), at the end of the 5-year period. Throughout these individuals' lifetimes, this change in CRC screening/testing results in an estimated 498 CRC cases averted with Medicaid expansion and 6031 averted with Medicare-for-all, and an additional 1782 cases if health insurance gains associated with ACA are lost. Estimated cost savings - balancing increased CRC screening/testing costs against decreased cancer treatment costs - are approximately $30 M and $970 M for Medicaid expansion and Medicare-for-all scenarios, respectively, compared to status quo. Insurance expansion is likely to improve CRC screening both overall and in underserved populations while saving money, with the largest savings realized by Medicare.

Mailed FIT (fecal immunochemical test), navigation or patient reminders? Using microsimulation to inform selection of interventions to increase colorectal cancer screening in Medicaid enrollees.

Colorectal cancer (CRC) can be effectively prevented or detected with guideline concordant screening, yet Medicaid enrollees experience disparities. We used microsimulation to project CRC screening patterns, CRC cases averted, and life-years gained in the population of 68,077 Oregon Medicaid enrollees 50-64 over a five year period starting in January 2019. The simulation estimated the cost-effectiveness of five intervention scenarios - academic detailing plus provider audit and feedback (Detailing+), patient reminders (Reminders), mailing a Fecal Immunochemical Test (FIT) directly to the patient's home (Mailed FIT), patient navigation (Navigation), and mailed FIT with Navigation (Mailed FIT + Navigation) - compared to usual care. Each intervention scenario raised CRC screening rates compared to usual care, with improvements as high as 11.6 percentage points (Mailed FIT + Navigation) and as low as 2.5 percentage points (Reminders) after one year. Compared to usual care, Mailed FIT + Navigation would raise CRC screening rates 20.2 percentage points after five years - averting nearly 77 cancer cases (a reduction of 113 per 100,000) and exceeding national screening targets. Over a five year period, Reminders, Mailed FIT and Mailed FIT + Navigation were expected to be cost effective if stakeholders were willing to pay $230 or less per additional year up-to-date (at a cost of $22, $59, and $227 respectively), whereas Detailing+ and Navigation were more costly for the same benefits. To approach national CRC screening targets, health system stakeholders are encouraged to implement Mailed FIT with or without Navigation and Reminders.

Objective measures of workload in healthcare: a narrative review.

PURPOSE: Workload is a critical concept in the evaluation of performance and quality in healthcare systems, but its definition relies on the perspective (e.g. individual clinician-level vs unit-level workload) and type of available metrics (e.g. objective vs subjective measures). The purpose of this paper is to provide an overview of objective measures of workload associated with direct care delivery in tertiary healthcare settings, with a focus on measures that can be obtained from electronic records to inform operationalization of workload measurement. DESIGN/METHODOLOGY/APPROACH: Relevant papers published between January 2008 and July 2018 were identified through a search in Pubmed and Compendex databases using the Sample, Phenomenon of Interest, Design, Evaluation, Research Type framework. Identified measures were classified into four levels of workload: task, patient, clinician and unit. FINDINGS: Of 30 papers reviewed, 9 used task-level metrics, 14 used patient-level metrics, 7 used clinician-level metrics and 20 used unit-level metrics. Key objective measures of workload include: patient turnover (n=9), volume of patients (n=6), acuity (n=6), nurse-to-patient ratios (n=5) and direct care time (n=5). Several methods for operationalization of these metrics into measurement tools were identified. ORIGINALITY/VALUE: This review highlights the key objective workload measures available in electronic records that can be utilized to develop an operational approach for quantifying workload. Insights gained from this review can inform the design of processes to track workload and mitigate the effects of increased workload on patient outcomes and clinician performance.

Low-Cost Sensor System Design for In-Home Physical Activity Tracking.

An aging and more sedentary population requires interventions aimed at monitoring physical activity, particularly within the home. This research uses simulation, optimization, and regression analyses to assess the feasibility of using a small number of sensors to track movement and infer physical activity levels of older adults. Based on activity data from the American Time Use Survey and assisted living apartment layouts, we determined that using three to four doorway sensors can be used to effectively capture a sufficient amount of movements in order to estimate activity. The research also identified preferred approaches for assigning sensor locations, evaluated the error magnitude inherent in the approach, and developed a methodology to identify which apartment layouts would be best suited for these technologies.

Towards Evaluating and Enhancing the Reach of Online Health Forums for Smoking Cessation.

Online pro-health social networks facilitating smoking cessation through web-assisted interventions have flourished in the past decade. In order to properly evaluate and increase the impact of this form of treatment on society, one needs to understand and be able to quantify its reach, as defined within the widely-adopted RE-AIM framework. In the online communication context, user engagement is an integral component of reach. This paper quantitatively studies the effect of engagement on the users of the Alt.Support.Stop-Smoking forum that served the needs of an online smoking cessation community for more than ten years. The paper then demonstrates how online service evaluation and planning by social network analysts can be applied towards strategic interventions targeting increased user engagement in online health forums. To this end, the challenges and opportunities are identified in the development of thread recommendation systems using core-users as a strategic resource for effective and efficient spread of healthy behaviors, in particular smoking cessation.