Patient perspectives of using reproductive autonomy to measure quality of care: a qualitative study.

BACKGROUND: Current measures of reproductive health care quality, such as rates of "unintended" pregnancies, neglect to incorporate patients' desires and center their reproductive autonomy. This study explores patients' perspectives on and receptivity to alternative metrics for measuring quality of such care. METHODS: An online research recruitment firm identified eligible participants living in New York, ages 18-45, self-identifying as women, and having visited a primary care provider in the last year. We conducted five virtual focus groups and eight in-depth interviews with participants (N = 30) in 2021. Semi-structured guides queried on ideal clinic interactions when preventing or attempting pregnancy and their perspectives on how to measure the quality of such encounters, including receptivity to using our definition of reproductive autonomy to develop one such metric: "whether the patient got the reproductive health service or counseling that they wanted to get, while having all the information about and access to their options, and not feeling forced into anything." We employed an inductive thematic analysis. RESULTS: Participants wanted care that was non-judgmental, respectful, and responsive to their needs and preferences. For pregnancy prevention, many preferred unbiased information about contraceptive options to help make their own decisions. For pregnancy, many desired comprehensive information and more provider support. There was considerable support for using reproductive autonomy to measure quality of care. CONCLUSIONS: Patients had distinct desires in their preferred approach to discussions about preventing versus attempting pregnancy. Quality of reproductive health care should be measured from the patient's perspective. Given participants' demonstrated support, future research is needed to develop and test a new metric that assesses patients' perceptions of reproductive autonomy during clinical encounters.

Collaborating With Student Parents as Participatory Researchers in a Qualitative Study.

When embarking on research within a community where little empirical research exists, the inclusion of a structured participant group-such as a steering committee or advisory board-can formalize the participant-research team partnership, increase community buy-in for action items, and reinforce the trustworthiness of research findings. These were among the aims of the multimethod design of the Student Parent Project, a qualitative study to determine the barriers and facilitators of academic achievement and well-being at six community colleges within a large, urban, public university system. The initial step of the study was to create a Student Advisory Board by recruiting one student parent from each of the participating campuses. The Student Advisory Board then met intermittently to review the research approach, data collection instruments, and preliminary findings at different stages. In this article, we describe the process of convening and collaborating with the advisory board and identify key areas in which their participation influenced the study design, findings, and recommendations. Based on lessons learned, we offer recommendations for the design and implementation of a participatory advisory board within qualitative studies.

"I totally didn't need to be there in person": New York women's preferences for telehealth consultations for sexual and reproductive healthcare in primary care.

BACKGROUND: Expanding telehealth in the United States during the COVID-19 pandemic supported patients with needed sexual and reproductive healthcare (SRH) for continuity of care and reproductive autonomy. While telehealth for SRH is feasible and acceptable, studies have not explored patient preferences towards telehealth SRH from primary care settings. OBJECTIVE: We explore New York women's preferences for telehealth SRH in primary care. METHODS: In 2021, we conducted 5 focus groups and 8 interviews with New York women of reproductive age who had a consultation with a primary care provider in the last year as part of a larger study on assessing SRH quality in primary care. We queried on experiences with telehealth for SRH and perceptions of measuring SRH quality in primary care telehealth consultations. We employed reflexive thematic analysis. RESULTS: We recruited 30 participants. They preferred telehealth for "basic" SRH conversations, such as contraceptive counselling, and desired in-person consultations for "complex" topics, like pregnancy and preconception, especially if nulliparous. Telehealth benefits included convenience, simplicity of some SRH needs, and alleviating power dynamics in patient-provider relationships. Challenges included lack of one-on-one connection, seriousness of pregnancy discussions, privacy, and internet access. Measuring quality of telehealth SRH should include fostering positive and engaging environments. CONCLUSION: Participants find telehealth SRH in primary care preferable, underscoring the importance of offering and expanding this care. As telehealth SRH expands, providers should strengthen quality by building rapport to facilitate conversations on "serious" topics and their ability to help patients remotely.

The expansion of phone- and video-based consultations in the United States for sexual and reproductive healthcare (SRH) during the COVID-19 pandemic supported patients with needed continuity of care, while minimizing virus exposure. As COVID-19 becomes endemic, medical organizations and providers recommend sustaining and expanding telehealth for SRH and other primary care needs. No studies to date have explored patient acceptability of telehealth for SRH services broadly in primary care settings. This brief report explores preferences for telehealth for SRH in primary care among New York women of reproductive age through focus groups and interviews. Overall, participants preferred telehealth for "basic" SRH conversations, such as contraceptive options, and in-person consultations for more "complex" topics, like pregnancy and preconception. Benefits of telehealth services included convenience, simplicity of some SRH needs, and being able to minimize uncomfortable power dynamics in the patient­provider relationship. Challenges included the lack of one-on-one connection with a provider, the perceived seriousness of pregnancy-related conversations, privacy, and internet access concerns. Patients find telehealth for SRH in primary care preferable, especially for simple SRH conversations, which suggests the importance of continuing to offer services in this manner.

Examining Women's and Men's Ideal Criteria Before Forming Families.

In the United States, family formation decision-making is more complex than the predominant models that have been used to capture this phenomenon. Understanding the context in which a pregnancy occurs requires a more nuanced examination. In-depth interviews were conducted with 60 men and women, aged 18-35, who had children or were pregnant. Using grounded theory analysis, themes emerged that revealed participants' ideal criteria desired before pregnancy. We stratified by those who met and did not meet these criteria. Almost universally, participants shared ideal criteria: to graduate, gain financial stability, establish a relationship, and then become pregnant. Many participants did not accomplish these goals. Those who had not met their criteria had experienced traumatic childhoods and suffered economic concerns. For this group, having children prompted positive changes within their control, but financial stability remained limited. Efforts should focus on improving circumstances for all individuals to fulfill their criteria before pregnancy.

Women's Perspectives on a Reproductive Health Services Screening Question: An Alternative to Pregnancy Intention Screening.

Background: Current efforts to integrate reproductive health care into primary care in the United States involve assessing pregnancy intentions and reproductive goals, which are often not meaningful or attainable for some. Alternatively, we designed a reproductive health services-based screening question: "Can I help you with any reproductive health services today, such as preventing pregnancy or planning a healthy pregnancy?" In this study, we describe women's interpretations of this question as part of a larger study, exploring perspectives on reproductive health care quality in primary care. Materials and Methods: We utilized a third-party research firm to recruit New York women of reproductive age (18-45), who visited a primary care provider in the past year. We conducted five focus groups and eight interviews (N = 30). Semistructured guides queried participants on interpretations of the screening question and preferences for raising reproductive health concerns during a primary care visit. We employed inductive thematic analysis. Results: Participants interpreted the question as offering contraception or pregnancy counseling and care, although younger participants also understood it as offering sexual and reproductive health services broadly. Participants also connected the question with discussions about their ability to conceive. Some participants described experiences with provider assumptions and implicit bias. Tensions emerged around accepting primary care as a setting for reproductive health due to a perceived lack of specialized training. Conclusions: Participants interpreted the screening question as intended, indicating face validity. Primary care settings should increase patients' awareness of reproductive health service availability, such as by routinely introducing a services-based screening question.

The association of pregnancy control, emotions, and beliefs with pregnancy desires: A new perspective on pregnancy intentions.

CONTEXT: Standard pregnancy intentions measures do not always align with how people approach pregnancy. Studies that have investigated beyond a binary framework found that those with "ambivalent" feelings towards pregnancy are less likely to use contraception consistently, but the reasons for this are unclear. We sought to gain a nuanced understanding of pregnancy desires, and how perceptions about pregnancy are associated with contraceptive use. METHODS: We used non-probability quota sampling based on sex, age, and geographic region for a web-based survey of heterosexual men and women, aged 21-44 years, who could become pregnant/impregnate and were not currently pregnant (n = 1,477; 51% female). The survey was created using unique items informed by recent literature. Bivariate and multivariable analyses explored relationships between various perceptions about pregnancy with pregnancy desires categorized as: wanting a pregnancy, not wanting a pregnancy, and not trying but would be okay with a pregnancy. We conducted a sub-group analysis of those who were not trying but would be okay with a pregnancy (n = 460), using descriptive statistics to examine how consistent contraceptive use was associated with emotions and beliefs about avoiding pregnancy. RESULTS: After adjustment, those who felt that pregnancy may not always be avoidable, but instead determined by fate/higher power, or a natural process that happens when it is meant to, were significantly more likely (aOR: 1.83, 95% CI: 1.05-3.36; aOR: 2.21, 95% CI: 1.29-3.76, respectively) to report not trying but being okay with pregnancy, whereas those with negative feelings about a pregnancy were less likely to feel okay about a pregnancy (aOR: 0.11, 95% CI: 0.08-0.15), versus not wanting a pregnancy. In the sub-group analysis, those who felt pregnancy was determined by fate/higher power or a natural process were more likely to report not using contraception consistently (70%, 68%, respectively). CONCLUSIONS: Those who state they are not trying but would be okay with pregnancy may not use contraception consistently because of beliefs that pregnancy is predetermined. Our findings support less categorical and more multidimensional approaches to measuring fertility intentions, with important implications for reproductive health service provision.

Revisiting the Association between Race, Ethnicity, and Beliefs about Pregnancy.

Objective: Black and Latinx individuals are often the focus of health educational efforts to 'correct' perceived flawed beliefs about pregnancy, in order to increase contraceptive use and reduce unintended pregnancies. We sought to revisit the association between race, ethnicity, and beliefs about pregnancy. Methods: We administered a web-based survey to 2,099 heterosexual men and women aged 21-44 years, using non-probability quota sampling. We analyzed a subset who were not currently pregnant (n=1,884) and conducted chi-square tests to examine the association between race/ethnicity and beliefs about avoiding pregnancy (can be avoided, determined by fate/God, 'just happens,' and is a natural process). We then performed a two-stage multinomial logistic regression, modeling the belief that pregnancy can be avoided. The first model included sociodemographic characteristics and the second model added feelings about pregnancy. Results: Bivariate analyses revealed that, compared with Whites, those who identified as Black/African American or Latinx were significantly more likely to believe that pregnancy was determined by fate/God (15%,13% vs 9%, respectively) or a natural process (13%,13% vs 9%, respectively) and less likely to report that it can be avoided (57%,56% vs 67%, respectively; P=.001). In the first regression model, these differences persisted. However, in the second model, being Black/African American or Latinx was not significantly associated with beliefs about avoiding pregnancy. Conclusions: Our findings suggest that once more nuanced beliefs about pregnancy prevention are considered, Black and Latinx individuals do not hold strongly different beliefs than Whites. Efforts that exclusively focus on people of color to change beliefs about pregnancy appear unwarranted.

Women's Perspectives on Reproductive Health Services in Primary Care.

BACKGROUND AND OBJECTIVES: Primary care providers (PCPs) are increasingly offering reproductive health (RH) services to help address patients' unmet contraceptive needs and improve pregnancy outcomes. We sought to understand patient perspectives on receipt of RH services in primary care settings. METHODS: We used a purposeful stratified sampling approach to recruit women aged 21 to 40 years into focus groups (FGs) and in-depth interviews (IDIs). We held all four FGs in two New York City neighborhoods and all 18 IDIs in two upstate NY suburban/rural neighborhoods (each with half of the neighborhoods above and below the median county income in each setting type). We explored participants' preferences for RH services from PCPs, including their feelings about being asked about pregnancy intentions. We also asked their opinions on three distinct pregnancy intention screening and reproductive health needs assessment questions. Data analysis involved an iterative process of excerpt coding and interpretive analysis to identify key themes. RESULTS: We conducted four FGs and 18 IDIs with a total of 39 women. Participants were receptive to the availability of RH services in primary care and the benefits to streamlining this care, provided clinicians approach these services in a manner that respects patient autonomy and reproductive desires. They discussed a lack of preconception care counseling and concerns about primary care providers' training and/or comfort with RH, as well as time spent with patients. Participants had the most positive response to the proposed question "Can I help you with any reproductive health services today, such as birth control or planning for a healthy pregnancy?" based on its open-endedness, inclusiveness, and promotion of reproductive autonomy. CONCLUSIONS: The findings of this study support the continued expansion of RH services in primary care settings. Future research should test the preferred RH service needs question to understand how it may affect service delivery, patient satisfaction, reproductive autonomy, as well as unmet contraceptive need and indicators of maternal and child health.

Police Interactions and the Mental Health of Black Americans: a Systematic Review.

Black Americans comprise 13% of the US population, yet data suggests that they represent 23% of those fatally shot by police officers. Data on non-lethal encounters with police in the Black community is less available but can understandably result in emotional trauma, stress responses, and depressive symptoms. The aim of this systematic literature review is to assess if interactions with the police are associated with mental health outcomes among Black Americans. Following pre-defined inclusion criteria, 11 articles were reviewed. Using a quality assessment tool, eight studies received a fair quality rating, two studies a poor rating, and one study received a good rating. The types of police interaction reported among study participants included police use of force during arrest, police stops, police searches, exposure to police killings, and interactions with police in the court system and varied mental health outcomes. Most of the studies (6 of 11) reviewed found statistically significant associations between police interactions and mental health (psychotic experiences, psychological distress, depression, PTSD, anxiety, suicidal ideation and attempts), indicating a nearly twofold higher prevalence of poor mental health among those reporting a prior police interaction compared to those with no interaction. Although better quality studies are needed, findings suggest an association between police interactions and negative mental health outcomes. Changes in law enforcement policy, development and implementation of a validated instrument for police experiences, improved community outreach, a federally mandated review of policy and practice in police departments, and expanded police training initiatives could reduce the potential negative mental health impact of police interactions on Black Americans.

Physician perspectives on routine pregnancy intention screening and counseling in primary care.

OBJECTIVES: To assess factors associated with routine pregnancy intention screening by primary care physicians and their support for such an initiative. STUDY DESIGN: We conducted a cross-sectional survey study of 443 primary care physicians in New York State. We performed multivariable logistic regression analyses of physician support for routine pregnancy intention screening and implementation of screening in the last year. Predictors included in the models were physician age, sex, specialty, clinic setting, and, for the outcome of support for screening, experience with screening in the last year. RESULTS: In this convenience sample, the vast majority of respondents from all specialties (88%) felt pregnancy intention screening should be routinely included in primary care, with 48% reporting that they routinely perform such screening. The preferred wording for this question was one which assessed reproductive health service needs. In multivariable analyses, internal medicine physicians were less likely than family medicine physicians to have provided routine pregnancy intention screening (aOR = 0.15, 95% CI 0.09, 0.25). Only 8% of the sample reported they required more training to implement pregnancy intention screening, but more reported needing training prior to contraceptive provision (17%), contraceptive counseling (16%), and preconception care (15%). More internal medicine and other types of doctors cited a need for this additional training than family medicine physicians. CONCLUSIONS: Most responding primary care physicians supported routine integration of pregnancy intention screening. Incorporating additional training, especially for internal medicine physicians, in contraception and preconception care counseling is key to ensuring success. IMPLICATIONS STATEMENT: Responding primary care physicians supported routine inclusion of reproductive health needs assessment in primary care. Primary care may become increasingly important for ensuring access to a full range of reproductive health services. Providing necessary training, especially for internal medicine physicians, is needed prior to routine inclusion.

A qualitative assessment of perspectives on getting pregnant: the Social Position and Family Formation study.

BACKGROUND: Intentions-oriented approaches to measuring pregnancy do not necessarily align with how people view and approach pregnancy. Our objective was to obtain an in-depth understanding of the notions women and men hold regarding pregnancy. METHODS: We conducted semi-structured in-depth interviews with 176 heterosexual women and men ages 18-35, in the United States. Data were analyzed using grounded theory methodology. RESULTS: Participants described notions of getting pregnant in one of three ways. One group of participants used language that solely described pregnancy as a deliberate process, either premeditated or actively avoided. Another described pregnancy as a predetermined phenomenon, due to fate or something that 'just happens.' The third group represented a blending of both notions. CONCLUSIONS: Our findings underscore the need to shift the current paradigm of deliberate intentions to one that recognizes that pregnancy can also be viewed as predetermined. These findings can be used to improve measurement, health services, and better direct public health resources.

A systematic review of the effect of reproductive intention screening in primary care settings on reproductive health outcomes.

Purpose: No recommendations exist for routine reproductive intention screening in primary care. The objective of this systematic review is to assess the effect of reproductive intention screening in primary care on reproductive health outcomes (PROSPERO CRD42015019726). Methods: We performed a systematic search in Ovid Medline, PubMed, CINAHL, Embase, CDR/DARE databases, Web of Science, ISRCTN registry, Clinicaltrials.gov and Cochrane Library. Studies published in English between 2000 and 2017 and whose population was patients of reproductive age (15-49) were included. Studies without a comparison group were excluded. Two independent reviewers assessed eligibility, study quality and abstracted data. Results: Of 24 780 titles and/or abstracts reviewed, nine studies met inclusion criteria: four randomized controlled trials (RCTs) and five observational studies. Two RCTs and one quasi-experimental cohort study showed a statistically significant increase in knowledge related to healthier pregnancy, such as the benefits of folic acid supplementation, and increased risk profiles for those with chronic conditions. Among studies measuring contraceptive use, only one cohort study showed any increase while the RCT and retrospective cohort did not show a statistically significant effect. Neither of the two RCTs that assessed the provision of contraception by primary care providers for those not desiring pregnancy found increased access to contraception, although one found increased documentation of contraception in electronic medical records. Acceptability of reproductive intention screening was measured in seven studies, and participant satisfaction was high in all seven studies. Conclusions: More research is needed to determine whether routine inclusion of reproductive intention screening in primary care is warranted.

Impact of Massachusetts Health Reform on Inpatient Care Use: Was the Safety-Net Experience Different Than in the Non-Safety-Net?

OBJECTIVE: Most inpatient care for the uninsured and other vulnerable subpopulations occurs in safety-net hospitals. As insurance expansion increases the choice of hospitals for the previously uninsured, we examined if Massachusetts health reform was associated with shifts in the volume of inpatient care from safety-net to non-safety-net hospitals overall, or among other vulnerable sociodemographic (racial/ethnic minority, low socioeconomic status, high uninsured rate area) and clinical subpopulations (emergent status, diagnosis). DATA SOURCES/STUDY SETTING: Discharge records for adults discharged from all nonfederal acute care hospitals in Massachusetts, New Jersey, New York, and Pennsylvania 2004-2010. STUDY DESIGN: Using a difference-in-differences design, we compared pre-/post-reform changes in safety-net and non-safety-net hospital discharge outcomes in Massachusetts among adults 18-64 with corresponding changes in comparisons states with no reform, overall, and by subpopulations. PRINCIPAL FINDINGS: Reform was not associated with changes in inpatient care use at safety-net and non-safety-net hospitals across all discharges or in most subpopulations examined. CONCLUSIONS: Demand for inpatient care at safety-net hospitals may not decrease following insurance expansion. Whether this is due to other access barriers or patient preference needs to be explored.

The perceived role of clinicians in pregnancy prevention among young Black women.

OBJECTIVE: The purpose of this study is to identify young Black women's attitudes toward clinicians and understand how they affect contraceptive behavior. STUDY DESIGN AND MAIN OUTCOME MEASURES: We conducted semi-structured qualitative interviews with women aged 18-23 who self-identified as Black or African-American and analyzed data using techniques informed by grounded theory. Initial codes were grouped thematically, and these themes into larger concepts. RESULTS: Participants discussed two salient concepts related to pregnancy prevention: (1) sexual responsibility and self-efficacy and (2) the perceived limited role of health care clinicians. Women portrayed themselves as in control of their contraceptive decision-making and practices. Many viewed their life plan, to finish school and gain financial stability, as crucial to their resolve to use contraception. Participants gathered information from various sources to make their own independent decision about which method, if any, was most appropriate for their needs. Most had limited expectations of clinicians and considered in-depth conversations about details of contraceptive use to be irrelevant and unnecessary. CONCLUSION: These findings help understand factors contributing to contraceptive decision-making. The patient-clinician interaction is a necessary focus of future research to improve sexual health discussions and understand if and what aspects of this interaction can influence behavior.

Effect of Massachusetts healthcare reform on racial and ethnic disparities in admissions to hospital for ambulatory care sensitive conditions: retrospective analysis of hospital episode statistics.

OBJECTIVES: To examine the impact of Massachusetts healthcare reform on changes in rates of admission to hospital for ambulatory care sensitive conditions (ACSCs), which are potentially preventable with good access to outpatient medical care, and racial and ethnic disparities in such rates, using complete inpatient discharge data (hospital episode statistics) from Massachusetts and three control states. DESIGN: Difference in differences analysis to identify the change, overall and according to race/ethnicity, adjusted for secular changes unrelated to reform. SETTING: Hospitals in Massachusetts, New York, New Jersey, and Pennsylvania, United States. PARTICIPANTS: Adults aged 18-64 (those most likely to have been affected by the reform) admitted for any of 12 ACSCs in the 21 months before and after the period during which reform was implemented (July 2006 to December 2007). MAIN OUTCOME MEASURES: Admission rates for a composite of all 12 ACSCs, and subgroup composites of acute and chronic ACSCs. RESULTS: After adjustment for potential confounders, including age, race and ethnicity, sex, and county income, unemployment rate and physician supply, we found no evidence of a change in the admission rate for overall composite ACSC (1.2%, 95% confidence interval -1.6% to 4.1%) or for subgroup composites of acute and chronic ACSCs. Nor did we find a change in disparities in admission rates between black and white people (-1.9%, -8.5% to 5.1%) or white and Hispanic people (2.0%, -7.5% to 12.4%) for overall composite ACSC that existed in Massachusetts before reform. In analyses limited to Massachusetts only, we found no evidence of a change in admission rate for overall composite ACSC between counties with higher and lower rates of uninsurance at baseline (1.4%, -2.3% to 5.3%). CONCLUSIONS: Massachusetts reform was not associated with significantly lower overall or racial and ethnic disparities in rates of admission to hospital for ACSCs. In the US, and Massachusetts in particular, additional efforts might be needed to improve access to outpatient care and reduce preventable admissions.

Massachusetts health reform and disparities in joint replacement use: difference in differences study.

OBJECTIVE: To estimate the impact of the insurance expansion in 2006 on use of knee and hip replacement procedures by race/ethnicity, area income, and the use of hospitals that predominantly serve poor people ("safety net hospitals"). DESIGN: Quasi-experimental difference in differences study examining change after reform in the share of procedures performed in safety net hospitals by race/ethnicity and area income, with adjustment for patients' residence, demographics, and comorbidity. SETTING: State of Massachusetts, United States. PARTICIPANTS: Massachusetts residents aged 40-64 as the target beneficiaries of reform and similarly aged residents of New Jersey, New York, and Pennsylvania as the comparison (control) population. MAIN OUTCOMES MEASURES: Number of knee and hip replacement procedures per 10 000 population and use of safety net hospitals. Procedure counts from state discharge data for 2.5 years before and after reform, and multivariate difference in differences. Poisson regression was used to adjust for demographics, economic conditions, secular time, and geographic factors to estimate the change in procedure rate associated with health reform by race/ethnicity and area income. RESULTS: Before reform, the number of procedures (/10 000) in Massachusetts was lower among Hispanic people (12.9, P<0.001) than black people (28.1) and white people (30.1). Overall, procedure use increased 22.4% during the 2.5 years after insurance expansion; reform in Massachusetts was associated with a 4.7% increase. The increase associated with reform was significantly higher among Hispanic people (37.9%, P<0.001) and black people (11.4%, P<0.05) than among white people (2.8%). Lower income was not associated with larger increases in procedure use. The share of knee and hip replacement procedures performed in safety net hospitals in Massachusetts decreased by 1.0% from a level of 12.7% before reform. The reduction was larger among Hispanic people (-6.4%, P<0.001) than white people (-1.0%), and among low income residents (-3.9%, p<0.001) than high income residents (0%). CONCLUSIONS: Insurance expansion can help reduce disparities by race/ethnicity but not by income in access to elective surgical care and could shift some elective surgical care away from safety net hospitals.

Brief provider communication skills training fails to impact patient hypertension outcomes.

OBJECTIVES: Hypertension remains a prevalent risk factor for cardiovascular disease, and improved medication adherence leads to better blood pressure (BP) control. We sought to improve medication adherence and hypertension outcomes among patients with uncontrolled BP through communication skills training targeting providers. METHODS: We conducted a randomized controlled trial to assess the effects of a communication skills intervention for primary care doctors compared to usual care controls, on the outcomes of BP (systolic, diastolic), patient self-reported medication adherence, and provider counseling, assessed at baseline and post-intervention. We enrolled 379 patients with uncontrolled BP; 203 (54%) with follow-up data comprised our final sample. We performed random effects least squares regression analyses to examine whether the provider training improved outcomes, using clinics as the unit of randomization. RESULTS: In neither unadjusted nor multivariate analyses were significant differences in change detected from baseline to follow-up in provider counseling, medication adherence or BP, for the intervention versus control groups. CONCLUSION: The intervention did not improve the outcomes; it may have been too brief and lacked sufficient practice level changes to impact counseling, adherence or BP. PRACTICE IMPLICATIONS: Future intervention efforts may require more extensive provider training, along with broader systematic changes, to improve patient outcomes.

The effect of Massachusetts health reform on 30 day hospital readmissions: retrospective analysis of hospital episode statistics.

OBJECTIVES: To analyse changes in overall readmission rates and disparities in such rates, among patients aged 18-64 (those most likely to have been affected by reform), using all payer inpatient discharge databases (hospital episode statistics) from Massachusetts and two control states (New York and New Jersey). DESIGN: Difference in differences analysis to identify the post-reform change, adjusted for secular changes unrelated to reform. SETTING: US hospitals in Massachusetts, New York, and New Jersey. PARTICIPANTS: Adults aged 18-64 admitted for any cause, excluding obstetrical. MAIN OUTCOME MEASURE: Readmissions at 30 days after an index admission. RESULTS: After adjustment for known confounders, including age, sex, comorbidity, hospital ownership, teaching hospital status, and nurse to census ratio, the odds of all cause readmission in Massachusetts was slightly increased compared with control states post-reform (odds ratio 1.02, 95% confidence interval 1.01 to 1.04, P<0.05). Racial and ethnic disparities in all cause readmission rates did not change in Massachusetts compared with control states. In analyses limited to Massachusetts only, there were minimal overall differences in changes in readmission rates between counties with differing baseline uninsurance rates, but black people in counties with the highest uninsurance rates had decreased odds of readmission (0.91, 0.84 to 1.00) compared with black people in counties with lower uninsurance rates. Similarly, white people in counties with the highest uninsurance rates had decreased odds of readmission (0.96, 0.94 to 0.99) compared with white people in counties with lower uninsurance rates. CONCLUSIONS: In the United States, and in Massachusetts in particular, extending health insurance coverage alone seems insufficient to improve readmission rates. Additional efforts are needed to reduce hospital readmissions and disparities in this outcome.