Disparities in healthcare utilization by insurance status among patients with symptomatic peripheral artery disease.

BACKGROUND: Peripheral artery disease (PAD) is a common circulatory disorder associated with increased hospitalizations and significant health care-related expenditures. Among patients with PAD, insurance status is an important determinant of health care utilization, treatment of disease, and treatment outcomes. However, little is known about PAD-costs differences across different insurance providers. In this study we examined possible disparities in length of stay and total charge of inpatient hospitalizations among patients with PAD by insurance type. METHODS: We conducted a cross-sectional analysis of length of stay and total charge by insurance provider for all hospitalizations for individuals with PAD in South Carolina (2010-2018). Cross-classified multilevel modeling was applied to account for the non-nested hierarchical structure of the data, with county and hospital included as random effects. Analyses were adjusted for patient age, race/ethnicity, county, year of admission, admission type, all-patient refined diagnostic groups, and Charlson comorbidity index. RESULTS: Among 385,018 hospitalizations for individuals with PAD in South Carolina, the median length of stay was 4 days (IQR: 5) and the median total charge of hospitalization was $43,232 (IQR: $52,405). Length of stay and total charge varied significantly by insurance provider. Medicare patients had increased length of stay (IRR = 1.08, 95 CI%: 1.07, 1.09) and higher total charges (ß: 0.012, 95% CI: 0.007, 0.178) than patients with private insurance. Medicaid patients also had increased length of stay (IRR = 1.26, 95% CI: 1.24,1.28) but had lower total charges (ß: -0.022, 95% CI: -0.003. -0.015) than patients with private insurance. CONCLUSIONS: Insurance status was associated with inpatient length of stay and total charges in patients with PAD. It is essential that Medicare and Medicaid individuals with PAD receive proper management and care of their PAD, particularly in the primary care settings, to prevent hospitalizations and reduce the excess burden on these patients.

"It's a proactive intervention instead of a reactive one": measuring facilitators and barriers regarding readiness to implement a treatment program for infants with neonatal opioid withdrawal syndrome.

BACKGROUND: Managing Abstinence in Newborns (MAiN) is an evidence-based, cost-saving approach to caring for infants at risk of developing neonatal opioid withdrawal syndrome (NOWS). MAiN provides medication management in combination with education and is being implemented in hospitals across South Carolina (SC). This expansion of MAiN throughout the state includes educational training for providers on managing NOWS symptomology and evaluation support for data collection and analysis. This evaluation assessed the readiness of hospitals to implement MAiN by identifying potential barriers and facilitators to early program adoption. METHODS: We used the Consolidated Framework for Implementation Framework (CFIR) to guide the evaluation. As part of the ongoing evaluation of MAiN implementation, brief, structured interviews were conducted with healthcare providers (n = 82) at seven hospitals between 2019 and 2022 to learn more about perceived barriers and facilitators to implementation readiness. Two coders independently reviewed all transcripts and used deductive thematic analysis to code qualitative data using Atlas.ti Web using the established CFIR codebook. RESULTS: We identified barriers and facilitators to implementing MAiN in all five CFIR domains. Providers identified MAiN as an evidence-based, patient-centered model with the flexibility to adapt to patients' complex needs. Specific champions, external support, alignment with providers' personal motivation, and an adaptable implementation climate were identified as facilitators for implementation readiness. Barriers included a lack of consistent communication among hospital providers, minimal community resources to support patients and families after discharge, and a lack of provider buy-in early in implementation. CONCLUSIONS: Key barriers and facilitators of MAiN implementation readiness were identified at seven participating hospitals throughout SC. Communication, staff and hospital culture and climate, and internal and external resource were all reported as essential to implementation. These findings could inform the MAiN program expansion in hospitals across SC.

"I Don't Want to Go to Work": A Mixed-Methods Analysis of Healthcare Worker Experiences from the Front- and Side-Lines of COVID-19.

During the COVID-19 pandemic, healthcare workers (HCW) were categorized as "essential" and "non-essential", creating a division where some were "locked-in" a system with little ability to prepare for or control the oncoming crisis. Others were "locked-out" regardless of whether their skills might be useful. The purpose of this study was to systematically gather data over the course of the COVID-19 pandemic from HCW through an interprofessional lens to examine experiences of locked-out HCW. This convergent parallel mixed-methods study captured perspectives representing nearly two dozen professions through a survey, administered via social media, and video blogs. Analysis included logistic regression models of differences in outcome measures by professional category and Rapid Identification of Themes from Audio recordings (RITA) of video blogs. We collected 1299 baseline responses from 15 April 2020 to 16 March 2021. Of those responses, 12.1% reported no signs of burnout, while 21.9% reported four or more signs. Qualitative analysis identified four themes: (1) professional identity, (2) intrinsic stressors, (3) extrinsic factors, and (4) coping strategies. There are some differences in the experiences of locked-in and locked-out HCW. This did not always lead to differing reports of moral distress and burnout, and both groups struggled to cope with the realities of the pandemic.

The association of urbanicity and travel time with lung cancer screening utilization.

BACKGROUND: To examine 1) the rate of lung cancer screening (LCS) utilization in a large healthcare system in South Carolina; 2) associations of urbanicity and travel time with LCS utilization. METHODS: LCS-eligible patients from 2019 were identified. The outcome was LCS utilization. The exposures were zip-code level urbanicity and travel time from the centroid of zip-code area to the nearest screening site (<10,10-<20, ≥20 min). Covariates included age, sex, race, marital status, insurance, body mass index, chronic obstructive pulmonary disease, Charlson Comorbidity Index (0, 1, 2, ≥3), and zip-code level median income. Chi-square tests and logistic regressions were employed. RESULTS: The analysis included 6930 patients, among whom 1432 (20.66%) received LCS. After adjusting for covariates, living in a non-metropolitan area (adjusted odds ratio: 0.32; 95% confidence interval: 0.26-0.40) and having longer travel time (0.80 [0.65-0.98] and 0.68 [0.54-0.86] for 10-<20 and ≥20 min travel time, respectively, compared to <10 min travel time) were significantly associated with lower odds of LCS utilization. CONCLUSIONS: The LCS utilization rate of a healthcare system was about 20% in 2019. Living in non-metropolitan areas or having longer travel time to LCS site were associated with lower LCS utilization.

"It Just Depends on Their Stability": A Qualitative Examination of Patient Factors Influencing Providers' Contraceptive Counseling Approaches for Persons With Substance Use Disorders.

OBJECTIVES: This qualitative study examined how patient-related factors influence providers' contraceptive counseling for persons with substance use disorders (SUDs). Specifically, we explored individual behavior and social factors that contribute to providers modifying their contraceptive counseling approaches and described how providers alter their counseling recommendations and communication strategies in the presence of such factors. METHODS: In 2019, we purposively recruited a national sample of contraceptive providers (N = 24) and conducted semistructured phone interviews to inquire about their contraceptive counseling practices for women with SUDs. Interviews were audio recorded, transcribed verbatim, and analyzed using thematic analysis with inductive codes. RESULTS: Participants included 10 medical doctors, 8 nurse practitioners, and 6 certified nurse-midwives. We found that providers modify their contraceptive counseling provision when their patients are actively using substances or have unstable living conditions, such as intimate partner violence or homelessness. With patients experiencing these instabilities, providers reported postponing contraceptive discussions until patients are stabilized in treatment, recommending long-active reversible contraceptive methods, and varying communication styles according to their own perceptions of patients' communication needs. Providers perceived that individuals in long-term recovery have increased stability and fewer barriers to contraceptive access and adherence and therefore reported increased willingness to provide greater autonomy during contraceptive decision making and shift the counseling focus to short-acting contraceptive methods. CONCLUSIONS: This study highlights that substance use and social "stability" of patients contributes to how providers approach their contraceptive counseling and make methods recommendations for their patients with SUDs. More research is needed to understand strategies that individuals with SUDs use to overcome barriers to contraceptive access and adherence in the context of active substance use and social instability.

The association between socioeconomic distress communities index and amputation among patients with peripheral artery disease.

Background: Socioeconomic factors have been shown to be associated with amputation in peripheral artery disease (PAD); however, analyses have normally focused on insurance status, race, or median income. We sought to determine whether community-level socioeconomic distress was associated with major amputation and if that association differed by race. Materials and methods: Community-level socioeconomic distress was measured using the distressed communities index (DCI). The DCI is a zip code level compositive socioeconomic score (0-100) that accounts for unemployment, education level, poverty rate, median income, business growth, and housing vacancies. A distressed community was defined as a zip code with DCI of 40 or greater. We calculated one-year risk of major amputation by DCI score for individuals with peripheral artery disease in South Carolina, 2012-2017. Treating death as competing event, we reported Fine and Gray subdistribution hazards ratios (sdHR), adjusted for patient demographic and clinical comorbidities associated with amputation. Further analyses were completed to identify potential differences in outcomes within strata of race and DCI. Results: Among 82,848 individuals with peripheral artery disease, the one-year incidence of amputation was 3.5% (95% CI: 3.3%, 3.6%) and was significantly greater in distressed communities than non-distressed communities (3.9%; 95% CI: 3.8%, 4.1% vs. 2.4%; 95% CI: 2.2%, 2.6%). After controlling for death and adjusting for covariates, we found an increased hazard of amputation among individuals in a distressed community (sdHR: 1.25; 95% CI: 1.14, 1.37), which persisted across racial strata. However, regardless of DCI score, Black individuals had the highest incidence of amputation. Conclusion: Socioeconomic status is independently predictive of limb amputation after controlling for demographic characteristics and clinical comorbidities. Race continues to be an important risk factor, with Black individuals having higher incidence of amputation, even in non-distressed communities, than White individuals had in distressed communities.

Parent/Guardian Experiences With the Healthcare System and Community Supports for Pediatric Asthma Management.

Determinants of pediatric asthma management include child, family, healthcare, and community factors. The purpose of this study is to investigate how parents/guardians are impacted by and act on these factors to aid in their child's asthma self-management. Interviews were conducted in Fall 2020 with 12 female parents/guardians of Black/African American children who participated in a community paramedic pilot study with their child in South Carolina. Children in the initial study had an asthma diagnosis of moderate persistent asthma, had Medicaid insurance, and were determined high-risk for emergency room presentation. Inductive and deductive qualitative analysis identified that child management self-efficacy and independence, parent/guardian health literacy, parent and child negative experiences related to asthma diagnosis and management, asthma management tools, and social support from multiple sources impact child self-management. Findings from this study highlight the importance of clear asthma education and management tool recommendations from healthcare and community providers, particularly for parents/guardians with low health literacy. Health literacy impacted parental responses and likely how families comprehend Medicaid and clinical asthma guidance.

Social needs screening during the COVID-19 pandemic.

BACKGROUND: Millions of Americans lost their jobs as a result of the COVID-19 pandemic, placing immeasurable stress on families and making it difficult for parents to support their children's basic needs. Research shows that screening for social determinants of health is an important part of a child's well visit, noting that awareness of these factors leads to more holistic and improved quality of care. Due to increased precautions during the COVID-19 pandemic and a significant decrease in well-child visits and in-person appointments, there was a marked decrease in the number of face-to-face opportunities for these screenings. In a time of increased need, methods such as telephone screenings represent an opportunity to assess needs and connect patients and families with helpful resources. METHODS: This study occurred in Baltimore, Maryland at the University of Maryland Pediatrics at Midtown outpatient practice (PAM). Five paediatric resident physicians and 17 medical students developed a telephone welfare screening tool and called families receiving primary care at the clinic over a 9-week period. The team documented identified needs and used a community resources database to provide resources to families over the phone. Data regarding the identified needs was collected and analysed throughout the screening process. RESULTS: Volunteers contacted 671 families using our finalized screening tool. Of those, 349 answered the telephone call (52%), and 328 (49%) agreed to participate in the screening. Results showed that families commonly identified food insecurity (20%) and symptoms of depression (18%). This was consistent across families' home locations as analysed by postal ZIP code. CONCLUSIONS: This study suggests that telephone screening is a feasible and informative method for identifying and addressing the social needs of paediatric primary care patients and their families. Furthermore, our study supports the notion that there are significant and widespread social needs resulting from the COVID-19 pandemic.

Provider Perspectives of Barriers to Contraceptive Access and Use among Women with Substance Use Disorders.

OBJECTIVES: Previous studies conducted from the patient perspective indicate that women with substance use disorders (SUDs) experience extensive barriers to contraceptive access and use (CAU), but there is limited research investigating this topic from the provider perspective. We explored provider perspectives on the barriers to CAU for women with SUDs. As a secondary objective, we highlighted provider contraceptive counseling strategies to address patient CAU barriers. METHODS: We conducted 24 qualitative interviews with a purposeful sample of women's health providers, including medical doctors, nurse practitioners, and certified nurse-midwives. We used thematic analysis to code the interviews with inductive codes and organized findings according to levels of influence within the Dahlgren and Whitehead rainbow model, a socioecological model of health. RESULTS: Provider-reported barriers to CAU were identified at four levels of socioecological influence and included reproductive misconceptions; active substance use; trauma, interpersonal violence, and reproductive coercion; limited social support; lack of housing, employment, health insurance, and transportation; stigma; discrimination; and punitive prenatal substance use policies and child welfare reporting requirements. Strategies for addressing CAU barriers mainly focused on patient-centered communication, including open information exchange, shared decision-making, and relationship building. However, providers described disproportionately highlighting the benefits of long-acting reversible contraception (LARC) and directing conversations toward LARC when they perceived that such methods would help patients to overcome adherence and other challenges related to active substance use or logistical barriers. Notably, there was no mention of CAU facilitators during the interviews. CONCLUSIONS: Providers perceived that women with SUDs experience a range of CAU barriers, which they addressed within the clinical setting through use of both patient-centered communication and highlighting the benefits of LARC when they perceived that such methods would help clients to overcome barriers. Improving CAU for women with SUDs will require multidisciplinary, multipronged strategies that prioritize reproductive autonomy and are implemented across clinical, community, and policy settings.

Racial Disparity and Social Determinants in Receiving Timely Surgery Among Stage I-IIIA Non-small Cell Lung Cancer Patients in a U.S. Southern State.

Delayed surgery is associated with worse lung cancer outcomes. Social determinants can influence health disparities. This study aimed to examine the potential racial disparity and the effects from social determinants on receipt of timely surgery among lung cancer patients in Louisiana, a southern state in the U.S. White and black stage I-IIIA non-small cell lung cancer patients diagnosed in Louisiana between 2004 and 2016, receiving surgical lobectomy or a more extensive surgery, were selected. Diagnosis-to-surgery interval >6 weeks were considered as delayed surgery. Social determinants included marital status, insurance, census tract level poverty, and census tract level urbanicity. Multivariable logistic regression and generalized multiple mediation analysis were conducted. A total of 3,616 white (78.9%) and black (21.1%) patients were identified. The median time interval from diagnosis to surgery was 27 days in whites and 42 days in blacks (P < 0.0001). About 28.7% of white and 48.4% of black patients received delayed surgery (P < 0.0001). Black patients had almost two-fold odds of receiving delayed surgery than white patients (adjusted odds ratio: 1.91; 95% confidence interval: 1.59-2.30). Social determinants explained about 26% of the racial disparity in receiving delayed surgery. Having social support, private insurance, and living in census tracts with lower poverty level were associated with improved access to timely surgery. The census tract level poverty level a stronger effect on delayed surgery in black patients than in white patients. Tailored interventions to improve the timely treatment in NSCLC patients, especially black patients, are needed in the future.

Contraceptive initiation after delivery among women with and without opioid use disorders: A retrospective cohort study in a statewide Medicaid population, 2005-2016.

BACKGROUND: This study examined contraceptive initiation patterns in the 12 months following childbirth among women with opioid use disorder (OUD), women with non-opioid substance use disorders (SUDs), and women without SUDs. METHODS: We conducted a retrospective cohort study using claims data from South Carolina Medicaid-enrolled women aged 15-44 who had singleton live birth between January 2005 and December 2016. Study outcomes were initiation of most or moderately effective (MME) contraceptive methods. Using multivariable and propensity score-weighted logistic regression, we analyzed the relationship between OUD and contraceptive initiation within 12 months after delivery. RESULTS: We identified 71,283 live birth deliveries during the study period. In multivariable analysis, women with non-opioid SUDs and women without SUDs compared to women with OUD were more likely to initiate a MME method vs a least effective method or no method by 3 months (non-opioid SUDs: odds ratio [OR] = 1.32, 95 % confidence interval [CI] = 1.14-1.52; no SUDs: OR = 1.55, 95 % CI = 1.36-1.77) and 12 months (non-opioid SUD: OR = 1.23, 95 % CI = 1.06-1.42; no SUD: OR = 1.46, 95 % CI = 1.27-1.66) after delivery. With regards to the timing of initiation, women with non-opioid SUDs and women without SUDs were more likely than women with OUD to initiate a MME method vs a least effective method or no method after the immediate postpartum period through 3 months following delivery (non-opioid SUDs: OR = 1.41, 95 % CI = 1.18-1.68; no SUDs: OR = 1.87, 95 % CI = 1.59-2.21). We detected the similar patterns in analyses that used propensity score weighting. CONCLUSION: OUD was associated with decreased likelihood of initiating a MME contraceptive method within 12 months after delivery.

Geographic Disparities in Readmissions for Peripheral Artery Disease in South Carolina.

Readmissions constitute a major health care burden among peripheral artery disease (PAD) patients. This study aimed to 1) estimate the zip code tabulation area (ZCTA)-level prevalence of readmission among PAD patients and characterize the effect of covariates on readmissions; and (2) identify hotspots of PAD based on estimated prevalence of readmission. Thirty-day readmissions among PAD patients were identified from the South Carolina Revenue and Fiscal Affairs Office All Payers Database (2010-2018). Bayesian spatial hierarchical modeling was conducted to identify areas of high risk, while controlling for confounders. We mapped the estimated readmission rates and identified hotspots using local Getis Ord (G*) statistics. Of the 232,731 individuals admitted to a hospital or outpatient surgery facility with PAD diagnosis, 30,366 (13.1%) experienced an unplanned readmission to a hospital within 30 days. Fitted readmission rates ranged from 35.3 per 1000 patients to 370.7 per 1000 patients and the risk of having a readmission was significantly associated with the percentage of patients who are 65 and older (0.992, 95%CI: 0.985-0.999), have Medicare insurance (1.013, 1.005-1.020), and have hypertension (1.014, 1.005-1.023). Geographic analysis found significant variation in readmission rates across the state and identified priority areas for targeted interventions to reduce readmissions.

Third trimester maternal vitamin D and early childhood socioemotional development.

BACKGROUND: Whether maternal vitamin D affects offspring socioemotional development in early childhood has been underexplored. OBJECTIVES: This study examined associations between maternal vitamin D during in the 3rd trimester and offspring socioemotional development between 30 and 59 months. METHODS: Data from 87 maternal-offspring pairs enrolled in the National Children's Study were used. Total plasma maternal vitamin D (25-hydroxyergocalciferol + 25-hydroxycholecalciferol) was measured between 28 and 35 gestational weeks and categorised as quartiles (Q). Multivariable regression models, adjusting for maternal race/ethnicity, education, and prepregnancy body mass index (BMI [kg/m2 ]), were used to estimate the association between vitamin D and offspring scores on the Brief Infant-Toddler Social and Emotional Assessment (BITSEA). RESULTS: The mean (standard deviation) vitamin D concentration was 86.5 (27.8) nmol/L. The median (range) BITSEA problem score was 6.0 (0.0-30.0), and competence score was 19.0 (7.0-22.0). Maternal vitamin D was inversely related to offspring problem scores. Compared to offspring of women with 25(OH)D in Q1, offspring problem scores were -4.80 (95% confidence interval [CI] -8.29, -1.33) units lower for Q2 vs Q1, -5.64 (95% CI -9.60, -1.68) units lower for Q3 vs Q1, and -4.70 (95% CI -8.59, -0.82) units lower for Q4 vs Q1. Vitamin D was not associated with offspring competence score. CONCLUSIONS: Higher maternal vitamin D was associated with lower offspring behaviour problems and not associated with socioemotional competence. These data indicate the association of maternal vitamin D and offspring development may be dependent on the specific developmental component being investigated.

"It's a very nuanced discussion with every woman": Health care providers' communication practices during contraceptive counseling for patients with substance use disorders.

OBJECTIVE: To explore health care providers' communication practices during contraceptive counseling for women with substance use disorders (SUDs). STUDY DESIGN: In 2019, we conducted semi-structured phone interviews with a purposive sample of medical doctors and advanced practice nurses (n = 24). A two-member team analyzed these interviews for themes using deductive and inductive techniques and ATLAS.ti to manage the data. RESULTS: Providers discussed that developing strong interpersonal relationships and trust is critically important to provide effective contraceptive counseling to women with SUDs. Providers reported exchanging information with patients by asking open-ended questions, tailoring discussions to patients' responses, and being direct but not judgmental. To facilitate contraceptive decision-making, providers described eliciting patients' preferences for contraceptive methods while simultaneously using their own clinical judgment and professional experience to identify which methods would be most effective and appropriate for their patients. Most often these were long-acting reversible contraceptive methods, and providers emphasized the benefits of these methods for women with SUDs. CONCLUSION: Providers used a variety of communication strategies, some of which were grounded in the principles of patient-centered care and others that were directive, to discuss contraception with women with SUDs. IMPLICATIONS: Because of past and ongoing stigma and discrimination by health care professionals and the general public, women with SUDs may be distrustful of contraceptive providers. Patient-centered contraceptive counseling may be an effective approach to increase trust and improve relationships and communication between women with SUDs and their providers. Additional research with women with SUDs is needed to understand women's experiences with and preferences for patient-provider communication during contraceptive counseling.

Baby-Friendly Hospital Initiative Is Associated with Lower Rates of Neonatal Hyperbilirubinemia.

Background: The Baby-Friendly Hospital Initiative (BFHI) advances practices that support exclusive breastfeeding. BFHI practices are associated with increased breastfeeding rates, however, other patient outcomes are not well described. This study examined the association of BFHI practices with hyperbilirubinemia and phototherapy between groups of newborns born before and after BFHI implementation at an urban, tertiary academic medical center in South Carolina. Materials and Methods: We conducted a retrospective study of healthy, term newborns born between July and September 2011 (n = 956), before BFHI implementation, and newborns born during the same period in 2013 (n = 1,131) after BFHI implementation. Primary outcomes were neonatal hyperbilirubinemia, phototherapy treatment, and hospital readmissions for hyperbilirubinemia within 30 days of discharge. We compared rates of outcomes between the study groups using unadjusted and adjusted odds ratios (OR). Results: Among newborns born before versus after BFHI implementation, 20.3% versus 6.98% were diagnosed with hyperbilirubinemia (p < 0.001), 5.75% versus 1.95% received phototherapy (p < 0.001), and 0.31% versus 0.35% were readmitted to the hospital for hyperbilirubinemia within 30 days (p = 0.88). In adjusted analyses, newborns born after BFHI implementation were significantly less likely to develop neonatal hyperbilirubinemia (OR 0.28 [95% confidence intervals; CI 0.20-0.37]) and receive phototherapy treatment (OR 0.27 [95% CI 0.15-0.49]) than newborns born before BFHI implementation. Conclusions: Implementation of BFHI practices is associated with significant decreases in neonatal hyperbilirubinemia and phototherapy without affecting readmission rates. Exclusive breastfeeding has traditionally been considered a risk factor for the development of neonatal jaundice. This study demonstrates that BFHI practices may mitigate that risk.

Factors associated with longer endocrine therapy use by South Carolina Medicaid-insured breast cancer survivors.

PURPOSE: The objective of this study is to determine demographic, clinical, and pharmaceutical factors that are associated with longer endocrine therapy usage duration. METHODS: South Carolina Central Cancer Registry incidence data linked with South Carolina Medicaid prescription claims and administrative data were used. The study included a sample (N = 1399) of female South Carolina Medicaid recipients with hormone receptor-positive breast cancer diagnosed between 2000 and 2012 who filled at least one ET prescription. A series of multiple regression models were built to explore the association of demographic, clinical, and pharmaceutical factors with the endocrine therapy usage duration. RESULTS: Multiple linear regression analysis showed that none of the demographic or clinical factors tested were significantly associated with the endocrine therapy usage duration. However, the type of endocrine therapy taken as well as receipt of the prescriptions that could have been used to alleviate side-effects (adrenals, nonsteroidal anti-inflammatory agents, anti-inflammatory agents, and vitamins) were significantly associated. CONCLUSION: Our study highlights the potential value of concurrent prescriptions for improving the endocrine therapy usage duration, with an optimal intervention point before 14 months post ET initiation. This work informs further research needed to test pharmacologic interventions that may significantly increase the endocrine therapy duration as well as other nonpharmacologic strategies for side-effect management.

Endocrine therapy use in the twenty-first century: usage rates and temporal trends illustrate opportunities for improvement for South Carolina Medicaid women.

PURPOSE: This study examines endocrine therapy (ET) non-initiation, non-adherence, and duration by age, race, temporal trend for South Carolina Medicaid-enrolled women diagnosed with estrogen receptor-positive breast cancer between 2000 and 2014 (N = 3830). METHODS: Age, race, relative risk, and median duration of ET use were compared. Temporal trends in ET non-initiation, non-adherence, and duration were observed using linear and logistic regression models, controlling for age and race. RESULTS: Fifty-three percent of women in the sample did not initiate ET, with highest non-initiation rates among African Americans and survivors under age 50. Of those who did initiate ET, 42% were non-adherent with a median ET usage duration of 37 months. Twenty-one percent of initiators continued taking ET for 5 years or more. There was no change in the odds of ET non-initiation from 2000 to 2004 (OR 1.02, p = 0.67). The odds of ET non-initiation decreased from 2005 to 2009 (OR 0.81, p < 0.001) but then increased from 2010 to 2014 (OR 1.08, p = 0.002). There was no change in the odds of ET non-adherence from 2000 to 2006 (OR 1.02, p = 0.53), but from 2007 to 2012, the odds of ET non-adherence decreased each year (OR 0.93, p = 0.02). The average ET usage duration was increasing from 2000 to 2006 (ß = 2.74, p < 0.001) but decreasing from 2006 to 2012 (ß = - 1.46, p < 0.001). CONCLUSIONS: This study provides a realistic picture of the challenges associated with ET usage among South Carolina Medicaid breast cancer patients. It particularly highlights small improvements over time in ET usage rates, indicating more opportunities for improvement in ET initiation, adherence, and duration among younger women of lower socio-economic status.

Early Treatment Innovation for Opioid-Dependent Newborns: A Retrospective Comparison of Outcomes, Utilization, Quality, and Safety, 2006-2014.

BACKGROUND: Few coordinated treatment programs address the needs of infants and families struggling with the effects of substance use. In 2003 a large Southeastern regional hospital launched the Managing Abstinence in Newborns (MAiN) program, providing multidisciplinary, coordinated, community-based care for neonatal abstinence syndrome (NAS). A hypothesis-generating study was conducted to compare the outcomes of MAiN infants to comparable NAS infants receiving traditional care from 2006 through 2014 in South Carolina. METHODS: De-identified sociodemographic and clinical data on MAiN infants, as well as NAS infants not treated with MAiN, were obtained from South Carolina statewide databases. Study measures included medical and safety outcomes, health services utilization, child protective services involvement, emergency services utilization, and inpatient readmissions. RESULTS: Some 110 infants were identified who received the MAiN intervention and 356 NAS infants, also in South Carolina, who were potentially MAiN eligible. Overall, there were no significant differences in the two groups regarding medical or safety outcomes or child protective services involvement. Traditional care NAS infants were more likely to be treated in a higher-level nursery (68.8% vs. 0%). MAiN infants had $8,204 less per birth in median charges (p <0.001) than the traditional care NAS infants. MAiN infants also had a lower percentage of ED visits (p = 0.01) assessed as possibly or likely NAS related compared to traditional care NAS infants. CONCLUSION: This study demonstrates the potential value of implementing the MAiN model in eligible NAS infants. With no difference in medical and safety outcomes and a significant reduction in charges, the MAiN model can be considered safe and cost-effective.

Behavioral Economics: A New Lens for Understanding Genomic Decision Making.

PURPOSE: This article seeks to take the next step in examining the insights that nurses and other healthcare providers can derive from applying behavioral economic concepts to support genomic decision making. As genomic science continues to permeate clinical practice, nurses must continue to adapt practice to meet new challenges. Decisions associated with genomics are often not simple and dichotomous in nature. They can be complex and challenging for all involved. DESIGN: This article offers an introduction to behavioral economics as a possible tool to help support patients', families', and caregivers' decision making related to genomics. METHODS: Using current writings from nursing, ethics, behavioral economic, and other healthcare scholars, we review key concepts of behavioral economics and discuss their relevance to supporting genomic decision making. FINDINGS: Behavioral economic concepts-particularly relativity, deliberation, and choice architecture-are specifically examined as new ways to view the complexities of genomic decision making. Each concept is explored through patient decision making and clinical practice examples. This article also discusses next steps and practice implications for further development of the behavioral economic lens in nursing. CONCLUSIONS: Behavioral economics provides valuable insight into the unique nature of genetic decision-making practices. CLINICAL RELEVANCE: Nurses are often a source of information and support for patients during clinical decision making. This article seeks to offer behavioral economic concepts as a framework for understanding and examining the unique nature of genomic decision making. As genetic and genomic testing become more common in practice, it will continue to grow in importance for nurses to be able to support the autonomous decision making of patients, their families, and caregivers.