Disparities in pre-health advising across California's public universities.

BACKGROUND: The Supreme Court's decision in Students for Fair Admissions, Inc., v. Harvard College is likely to result in the matriculation of fewer students from historically excluded racial/ethnic groups at more selective colleges and universities and matriculation of more students at less selective colleges and universities. Because of this, it is important to understand how resources for pre-health advising, a modifiable factor that can help increase the diversity of the health workforce, vary across institutions with differing levels of selectivity. Colleges are known to vary in resources, structure, and investment in pre-health advising but data are lacking and there is no estimate of any pre-health advising resource gap. PURPOSE: To quantify availability of advising resources and identify perceived challenges in pre-health advising in California's highly diverse public and select private undergraduate institutions. METHODS: Structured 60-minute Zoom interviews from June 2022 -October 2022 at 18/23 CSU (California State Universities), 9/9 University of California (UC) institutions and 6 select private institutions with varying levels of selectivity. Two investigators independently analyzed interviews using a Grounded Theory Approach. The full study team reviewed transcripts and themes. KEY RESULTS: Pre-health advisor capacity varied greatly across the three types of institutions. CSU: mean = 1 FTE advisor: 24,620 graduates (range: 1: 1,059-1: 150,520); UC mean = 1 FTE advisor: 4,526 graduates (range: 1: 1,912-1: 10,920); private institutions mean = 1 FTE advisor:1,794 graduates (range: 1: 722-1: 5,300). Participants reported common challenges: advising capacity, lack of advisor training, advisor turnover, and student difficulties in accessing clinical opportunities and required coursework. CSU and UC participants noted that these had greatest impact for first generation and racially/ethnically underrepresented students for whom lack of informal professional networks, lack of other mentors, and financial responsibilities complicate college navigation and professional school application. CONCLUSIONS: Students at CSU campuses had 5 times less access to pre-health advising per graduate than UC students, and 13 times less than students at private institutions. Much greater investment is needed in California's public institutions, particularly CSUs, to increase equity in access to advising for pre-health professional students. Research should examine pre-health advising resource capacity in other states, especially those that are now facing race-neutral admissions policies at undergraduate institutions and health professions schools.

Policy Considerations for Routine Screening for Adverse Childhood Events (ACEs).

In October of 2021, California enacted SB 428, the ACEs Equity Act, which mandates commercial insurance coverage of adverse childhood experiences (ACEs) screening in addition to ACEs screening already covered for the state's Medicaid enrollees. California is the first state to expand ACEs screening coverage, but it is possible other states may follow similar paths given the increasing interest in policy action to address ACEs. Increase in stress and trauma among Americans and evidence of the disproportionate impact ACEs have on historically marginalized and disadvantaged communities has increased the urgency with which policy makers, clinicians and researchers have sought to address ACEs and encourage trauma-informed care delivery to better meet the needs of patients. Family practice and other primary care providers are at the core of prevention and are arguably the largest group of stakeholders at the forefront of movements toward increasing ACEs screenings. However, debate persists among policy makers, clinicians, and researchers on whether the ACEs screening approach improves outcomes and avoids harms. In this health policy article, we describe key issues under debate with regards to ACEs screening and estimate potential change in screening utilization and expenditures due to the new ACEs legislation in California. The lessons being learned in California are applicable to other states and the US as a whole.

Scope-of-Practice for Nurse Practitioners and Adherence to Medications for Chronic Illness in Primary Care.

BACKGROUND: Nonadherence to medications is costly and improving adherence is difficult, requiring multifactorial solutions, including policy solutions. OBJECTIVE: The purpose of this study is to evaluate the effect of one policy strategy on medication adherence. Specifically, we examine the effect on adherence of expanding scope-of-practice regulations for nurse practitioners (NPs) to practice and prescribe without physician supervision. DESIGN: We conducted three difference-in-difference multivariable analyses of commercial insurance claims. PARTICIPANTS: Patients who filled at least two prescriptions in one of three chronic therapeutic medications: anti-diabetics (n = 514,255), renin angiotensin system antagonists (RASA) (n = 1,679,957), and anti-lipidemics (n = 1,613,692). MAIN MEASURES: Medication adherence was measured as the proportion of days covered (PDC). We used one continuous (PDC 0-1) and one binary outcome (PDC of > .8), the latter indicating good adherence. KEY RESULTS: Patients taking anti-diabetic medications had a 1.9 percentage point higher medication adherence rate (p < 0.05) and a 2.7 percentage point higher probability of good adherence (p < 0.001) in states that expanded NP scope-of-practice. Medication adherence for patients taking RASA was higher by 2.3 percentage points (p < 0.001) and 3.4 percentage points (p < 0.01) for both measures, respectively. Patients taking anti-lipidemics saw a smaller, but statistically insignificant, improvement in adherence. CONCLUSIONS: Results indicate that scope-of-practice regulations that allow NPs to practice and prescribe without physician oversight are associated with improved medication adherence. We postulate that the mechanism for this effect is increased access to health care services, which in turn increases access to prescriptions. Our results suggest that policies allowing NPs to maximally use their skills can be beneficial to patients.

Language-Concordant Primary Care Physicians for a Diverse Population: The View from California.

Purpose: The population with limited English proficiency (LEP) in California is growing. We sought to determine whether enough primary care physicians (PCPs) have the language skills to meet patient needs. Methods: The authors determined the number of PCPs who self-report proficiency in the five most common non-English languages spoken in California (Spanish, Cantonese, Mandarin, Tagalog, and Vietnamese) using Medical Board of California data from 2013 to 2015. The authors estimated LEP populations during 2011-2015 using Census data. They calculated PCP supply (the ratio of PCPs/100,000 LEP individuals) compared to a federal standard to judge adequacy. They performed a sensitivity analysis adjusting the percentage of LEP patients in a bilingual physicians' practice from 100% to the percentage of LEP individuals in California who spoke that language. Results: Of 19,310 PCPs in California, 15,933 (83%) provided information about languages they speak. There were 5,203 (33%) Spanish-, 486 (3%) Cantonese-, 986 (6%) Mandarin-, 956 (6%) Tagalog-, and 671 (4%) Vietnamese-speaking PCPs. PCP supply, compared to a federal standard, was adequate if we assumed that bilingual PCPs only care for LEP patients. However, if one assumes the number of LEP patients in a PCP's practice reflects the percentage in the general population, there is a large PCP undersupply for all languages. Conclusion: Estimates of access to language-concordant PCPs for LEP individuals are sensitive to assumptions about the percentage of LEP patients in a PCP's panel. Ensuring language-concordant access will require deliberate effort to match LEP patients with bilingual PCPs.

The effect of early child care attendance on childhood asthma and wheezing: A meta-analysis.

OBJECTIVE: Research evidence offers mixed results regarding the relationship between early child care attendance and childhood asthma and wheezing. A meta-analysis was conducted to synthesize the current research evidence of the association between early child care attendance and the risk of childhood asthma and wheezing. METHOD: Peer reviewed studies published from 1964-January 2017 were identified in MEDLINE, CINAL, and EMBASE using MeSH headings relevant to child care and asthma. Two investigators independently reviewed the selected articles from this search. All relevant articles that met our inclusion criteria were selected for further analysis. Data were extracted from studies that had sufficient data to analyze the odds of asthma or wheezing among children who attended child care. RESULTS: The meta-analysis of 32 studies found that (1) early child care attendance is protective against asthma in children 3-5 years of age but not for children with asthma 6 years of age or older. (2) Early child care attendance increases the risk of wheezing among children 2 years of age or younger, but not the risk of wheezing for children over 2 years of age. CONCLUSIONS: This meta-analysis shows that early child care attendance is not significantly associated with the risk of asthma or wheeze in children 6 years of age or older.

The Current State Of Telehealth Evidence: A Rapid Review.

Policy makers and practitioners show a continued interest in telehealth's potential to increase efficiency and reach patients facing access barriers. However, telehealth encompasses many applications for varied conditions and populations. It is therefore difficult to draw broad conclusions about telehealth's efficacy. This rapid review examines recent evidence both about telehealth's efficacy by clinical area and about telehealth's impact on utilization. We searched for systematic reviews and meta-analyses of the use of telehealth services by patients of any age for any condition published in English in the period January 2004-May 2018. Twenty systematic reviews and associated meta-analyses are included in this review, covering clinical areas such as mental health and rehabilitation. Broadly, telehealth interventions appear generally equivalent to in-person care. However, telehealth's impact on the use of other services is unclear. Many factors should be carefully considered when weighing the evidence of telehealth's efficacy, including modality, evidence quality, population demographics, and point-in-time measurement of outcomes.

Testing the Validity of Primary Care Physicians' Self-Reported Acceptance of New Patients by Insurance Status.

OBJECTIVE: To compare physicians' self-reported willingness to provide new patient appointments with the experience of research assistants posing as either a Medicaid beneficiary or privately insured person seeking a new patient appointment. DATA SOURCES/STUDY SETTING: Survey administered to California physicians and telephone calls placed to a subsample of respondents. STUDY DESIGN: Cross-sectional comparison. DATA COLLECTION/EXTRACTION METHODS: All physicians whose California licenses were due for renewal in June or July 2013 were mailed a survey, which included questions about acceptance of new Medicaid and new privately insured patients. Subsequently, research assistants using a script called the practices of a stratified random sample of 209 primary care physician respondents in an attempt to obtain a new patient appointment. By design, half of the physicians selected for the telephone validation reported on the survey that they accepted new Medicaid patients and half indicated that they did not. PRINCIPAL FINDINGS: The percentage of callers posing as Medicaid patients who could schedule new patient appointments was 18 percentage points lower than the percentage of physicians who self-reported on the survey that they accept new Medicaid patients. Callers were also less likely to obtain appointments when they posed as patients with private insurance. CONCLUSIONS: Physicians overestimate the extent to which their practices are accepting new patients, regardless of insurance status.

Future Demand For Long-Term Care Workers Will Be Influenced By Demographic And Utilization Changes.

A looming question for policy makers is how growing diversity of the US elderly population and greater use of home and community-based services will affect demand for long-term care workers. We used national surveys to analyze current use and staffing of long-term care, project demand for long-term care services and workers through 2030, and assess how projections varied if we changed assumptions about utilization patterns. If current trends continue, the occupations anticipated to grow the most over the period are counselors and social workers (94 percent), community and social services workers (93 percent), and home health and personal care aides (88 percent). Alternative projections were computed for scenarios that assumed changing racial and ethnic patterns of long-term care use or shifts toward noninstitutional care. For instance, if Hispanics used services at the same rate as non-Hispanic blacks, the projected demand for long-term care workers would be 5 percent higher than if current trends continued. If 20 percent of nursing home care were shifted to home health services, total employment growth would be about 12 percent lower. Demographic and utilization changes would have little effect on projections of robust long-term care employment growth between now and 2030. Policy makers and educators should redouble efforts to create and sustainably fund programs to recruit, train, and retain long-term care workers.

Patient reminder systems and asthma medication adherence: a systematic review.

OBJECTIVE: One of the most common reasons for medication non-adherence for asthma patients is forgetfulness. Daily medication reminder system interventions in the form of text messages, automated phone calls and audiovisual reminder devices can potentially address this problem. The aim of this review was to assess the effectiveness of reminder systems on patient daily asthma medication adherence. METHODS: We conducted a systematic review of the literature to identify randomized controlled trials (RCTs) which assessed the effect of reminder systems on daily asthma medication adherence. We searched all English-language articles in Pub Med (MEDLINE), CINAHL, EMBASE, PsychINFO and the Cochrane Library through May 2013. We abstracted data on the year of study publication, location, inclusion and exclusion criteria, patient characteristics, reminder system characteristics, effect on patient adherence rate and other outcomes measured. Descriptive statistics were used to summarize the characteristics and results of the studies. RESULTS: Five RCTs and one pragmatic RCT were included in the analysis. Median follow-up time was 16 weeks. All of the six studies suggested that the reminder system intervention was associated with greater levels of participant asthma medication adherence compared to those participants in the control group. None of the studies documented a change in asthma-related quality of life or clinical asthma outcomes. CONCLUSION: All studies in our analysis suggest that reminder systems increase patient medication adherence, but none documented improved clinical outcomes. Further studies with longer intervention durations are needed to assess effects on clinical outcomes, as well as the sustainability of effects on patient adherence.

Electronic health record availability among advanced practice registered nurses and physicians.

OBJECTIVES: To characterize availability of electronic health records (EHRs) at the primary practice locations of certified nurse midwives (CNMs), nurse practitioners (NPs), and physicians in California prior to the implementation of the state's Medicaid EHR incentive program. STUDY DESIGN AND METHODS: Cross-sectional mail surveys of samples of CNMs, NPs, and physicians who have active California licenses and reside in California. Descriptive statistics were calculated and multivariate regression analyses were estimated to identify characteristics associated with having an EHR. The following practice characteristics were included in the multivariate model: payer mix (% Medicaid), practice setting (hospital vs outpatient), and practice size. Variables for practitioner's age, sex, and practice location were also included. RESULTS: For both CNMs/NPs and physicians, practice size was the strongest predictor of EHR availability. Practicing in a large or mid-sized group was associated with higher odds of having a basic EHR or an advanced EHR. Having a high percentage of Medicaid patients was associated with lower odds of having an advanced EHR. Among physicians, but not CNMs/NPs, hospital-based practice was associated with higher odds of having an advanced EHR; being over age 45 years was associated with lower odds of having any EHR. CONCLUSIONS: The results suggest that prior to the launch of California's Medicaid EHR incentive program, similar characteristics predicted EHR availability among both CNMs/NPs and physicians, and that availability was concentrated among large practices with fewer Medicaid patients. Future studies should assess whether Medicaid and Medicare incentive payments attenuate these relationships.

Recent developments in asthma education.

PURPOSE OF REVIEW: Asthma education is a key component of the National Heart, Lung, and Blood Institute (NHLBI) asthma guidelines. Although the benefits and importance of asthma patient education are well documented, there are still many open questions regarding how to best provide asthma education. The following review highlights recent developments in this topic. RECENT FINDINGS: Recent innovations have applied asthma education in a variety of settings. Ensuring that health professionals within a community provide consistent educational messages about asthma can create synergy and leverage limited healthcare resources to improve outcomes. In addition, children seem to have greater responsibility for self-management of asthma at younger ages. SUMMARY: Further work is needed to understand how clinicians can best educate and give parents anticipatory guidance about how to best teach and transfer asthma self-management skills to young children. By developing teaching and mastering self-management skills at an early age, children may be able to carry such skills into adulthood. Finally, given the prevalence of healthcare disparities, there is a continued need for rigorously evaluated programs that are culturally appropriate and effective.

Financial impact of California's new law to increase HIV screening by mandating insurance coverage.

To increase HIV testing, in 2008 California's governor signed the first piece of legislation in the USA to require private health plans to cover the cost of HIV testing regardless of whether testing is related to a primary diagnosis. This study assesses the impacts of the bill on coverage, testing rate, and cost for 22,190,000 Californians. All targeted individuals had some form of coverage for HIV testing before the mandate. If minimum expansion of coverage occurs, overall expenditures on HIV testing are projected to increase by US$554,000 in the year following the adoption of the law. If testing broadens to comply with the Centers for Disease Control and Prevention (CDC) testing guidelines, annual expenditures are projected to increase by US$10,151,000. This policy change could serve as a step toward making HIV testing a routine screening test. However, the impact of this mandate largely depends on people's awareness and willingness to adopt the CDC guidelines.

Translating medical effectiveness research into policy: lessons from the California Health Benefits Review Program.

CONTEXT: Legislatures and executive branch agencies in the United States and other nations are increasingly using reviews of the medical literature to inform health policy decisions. To clarify these efforts to give policymakers evidence of medical effectiveness, this article discusses the California Health Benefits Review Program (CHBRP). This program, based at the University of California, analyzes the medical effectiveness of health insurance benefit mandate bills for the California legislature, as well as their impact on cost and public health. METHODS: This article is based on the authors' experience reviewing benefit mandate bills for CHBRP and findings from evaluations of the program. General observations are illustrated with examples from CHBRP's reports. Information about efforts to incorporate evidence into health policymaking in other states and nations was obtained through a review of published literature. FINDINGS: CHBRP produces reports that California legislators, legislative staff, and other major stakeholders value and use routinely in deliberations about benefit mandate bills. Where available, the program relies on previously published meta-analyses and systematic reviews to streamline the review of the medical literature. Faculty and staff responsible for the medical effectiveness sections of CHBRP's reports have learned four major lessons over the course of the program's six-year history: the need to (1) recognize the limitations of the medical literature, (2) anticipate the need to inform legislators about the complexity of evidence, (3) have realistic expectations regarding the impact of medical effectiveness reviews, and (4) understand the consequences of the reactive nature of mandated benefit reviews. CONCLUSIONS: CHBRP has demonstrated that it is possible to produce useful reviews of the medical literature within the tight time constraints of the legislative process. The program's reports have provided state legislators with independent analyses that allow them to move beyond sifting through conflicting information from proponents and opponents to consider difficult policy choices and their implications.

Do school-based asthma education programs improve self-management and health outcomes?

CONTEXT: Asthma self-management education is critical for high-quality asthma care for children. A number of studies have assessed the effectiveness of providing asthma education in schools to augment education provided by primary care providers. OBJECTIVE: To conduct a systematic review of the literature on school-based asthma education programs. METHODS: As our data sources, we used 3 databases that index peer-reviewed literature: MEDLINE, the Cochrane Central Register of Controlled Trials, and the Cumulative Index to Nursing and Allied Health Literature. Inclusion criteria included publication in English and enrollment of children aged 4 to 17 years with a clinical diagnosis of asthma or symptoms consistent with asthma. RESULTS: Twenty-five articles met the inclusion criteria. Synthesizing findings across studies was difficult because the characteristics of interventions and target populations varied widely, as did the outcomes assessed. In addition, some studies had major methodologic weaknesses. Most studies that compared asthma education to usual care found that school-based asthma education improved knowledge of asthma (7 of 10 studies), self-efficacy (6 of 8 studies), and self-management behaviors (7 of 8 studies). Fewer studies reported favorable effects on quality of life (4 of 8 studies), days of symptoms (5 of 11 studies), nights with symptoms (2 of 4 studies), and school absences (5 of 17 studies). CONCLUSIONS: Although findings regarding effects of school-based asthma education programs on quality of life, school absences, and days and nights with symptoms were not consistent, our analyses suggest that school-based asthma education improves knowledge of asthma, self-efficacy, and self-management behaviors.

Physician communication regarding cost when prescribing asthma medication to children.

Children with asthma require multiple medications, and cost may be a barrier to care. The purpose of this study was to determine how often physicians ask about cost when prescribing new asthma medication and to identify factors influencing queries. We surveyed pediatricians and family physicians and asked whether they asked about cost when prescribing new asthma medication and if cost was a barrier to prescribing. One third of physicians (35%) reported that concern for cost to the family was a barrier to prescribing. Half reported not asking their patients about drug costs. Pediatricians were less likely to ask about cost (odds ratio [OR] = 0.43; 95% confidence interval [CI] = 0.20-0.92) when compared with family physicians. For every 10% increase in the number of privately insured patients, a physician was less likely to ask about cost (OR = 0.83; 95% CI = 0.74-0.94). Communication about medication costs should be included in childhood asthma management.

Effects of asthma education on children's use of acute care services: a meta-analysis.

OBJECTIVE: National Heart, Lung, and Blood Institute clinical practice guidelines strongly recommend that health professionals educate children with asthma and their caregivers about self-management. We conducted a meta-analysis to estimate the effects of pediatric asthma education on hospitalizations, emergency department visits, and urgent physician visits for asthma. PATIENTS AND METHODS: Inclusion criteria included enrollment of children aged 2 to 17 years with a clinical diagnosis of asthma who resided in the United States. Pooled standardized mean differences and pooled odds ratios were calculated. Random-effects models were estimated for all outcomes assessed. RESULTS: Of the 208 studies identified and screened, 37 met the inclusion criteria. Twenty-seven compared educational interventions to usual care, and 10 compared different interventions. Among studies that compared asthma education to usual care, education was associated with statistically significant decreases in mean hospitalizations and mean emergency department visits and a trend toward lower odds of an emergency department visit. Education did not affect the odds of hospitalization or the mean number of urgent physician visits. Findings from studies that compared different types of asthma education interventions suggest that providing more sessions and more opportunities for interactive learning may produce better outcomes. CONCLUSIONS: Providing pediatric asthma education reduces mean number of hospitalizations and emergency department visits and the odds of an emergency department visit for asthma, but not the odds of hospitalization or mean number of urgent physician visits. Health plans should invest in pediatric asthma education or provide health professionals with incentives to furnish such education. Additional research is needed to determine the most important components of interventions and compare the cost-effectiveness of different interventions.

Social networks and their relationship to mental health service use and expenditures among Medicaid beneficiaries.

OBJECTIVE: This study examined the relationship between social networks and mental health services utilization and expenditures. METHODS: A sample of 522 Medicaid mental health consumers was randomly selected from the administrative records of Colorado's Department of Health Care Policy and Financing. The administrative records contain information on utilization of services and expenditures of Medicaid beneficiaries within Colorado's Mental Health Services. In addition to the administrative records, social network and psychosocial data were gathered through longitudinal survey interviews. The interviews were conducted at six-month intervals between 1994 and 1997. Measures used in the regression analysis included demographic characteristics, clinical diagnoses, the social network index, expenditures, and utilization variables. RESULTS: The social network index was positively associated with utilization of and expenditures for inpatient services in local hospitals but negatively associated with expenditures for inpatient services in state hospitals or outpatient services. Relationships with family were negatively related to expenditures for outpatient services. Relationships with friends were positively associated with utilization of and expenditures for psychiatric inpatient services in local hospitals. CONCLUSIONS: Consumers who had higher social network index scores utilized more inpatient psychiatric services in local hospitals and had higher expenditures than those who had lower scores. Consumers who had higher social network index scores also had lower expenditures for inpatient services in state hospitals and outpatient services than those who have lower scores. Findings suggest that social network is associated with mental health utilization and expenditures in various ways, associations that need to be researched further.

Do physicians always flee from HMOs? New results using dynamic panel estimation methods.

OBJECTIVE: To assess the impact of changes in relative health maintenance organization (HMO) penetration on changes in the physician-to-population ratio in California counties when changes in the economic conditions in California counties relative to the U.S. average are taken into account. DATA SOURCES: Data on physicians who practiced in California at any time from 1988 to 1998 were obtained from the AMA Masterfile. The analysis was restricted to active, patient care physicians, excluding medical residents. Data on other covariates in the model were obtained from the Bureau of Economic Analysis, InterStudy, the Area Resource File, and the California state government. Data were merged using county FIPS codes. STUDY DESIGN: Changes in the physician-to-population ratio in California counties include the effects of both intrastate migration and interstate migration. A reduced-form model was estimated using the Arellano-Bond dynamic panel estimator. Economic conditions in California relative to the U.S. were measured as the ratio of county-level real per capita income to national-level real per capita income. Relative HMO penetration in California was measured as the ratio of county-level HMO penetration to HMO penetration in the U.S. relative HMO penetration was instrumented using five identifying variables to address potential endogeneity. Omitted-variable bias was controlled for by first differencing the model. The model also incorporated eight other covariates that may be associated with the demand for physicians: the percentage of the population enrolled in Medicaid, beds in short-term hospitals per 100,000 population, the percentage of the population that is black, the percentage of the population that is Hispanic, the percentage of the population that is Asian, the percentage of the population that is below age 18, the percentage of the population that is aged 65 and older, and the percentage of the population that are new legal immigrants in a given year. All of the above variables were lagged one period. The lagged physician-to-population ratio was also included to control for the supply of physicians. Separate equations were estimated for primary care physicians and specialist physicians. PRINCIPAL FINDINGS: Changes in lagged relative HMO penetration are negatively associated with changes in specialist physicians per 100,000 population. However, this effect of HMO penetration is attenuated and at times reversed in areas where the magnitude of the difference in relative economic conditions is sufficiently large. We did not find any statistically significant effects for primary care physicians. CONCLUSIONS: Consistent with prior studies, we find that changes in physician supply are associated with changes in relative HMO penetration. Relative economic conditions are an important moderator of the effect of changes in relative HMO penetration on physician migration.