Care Partner Engagement in Secure Messaging Between Patients With Diabetes and Their Clinicians: Cohort Study.

BACKGROUND: Patient engagement with secure messaging (SM) via digital patient portals has been associated with improved diabetes outcomes, including increased patient satisfaction and better glycemic control. Yet, disparities in SM uptake exist among older patients and racial and ethnic underserved groups. Care partners (family members or friends) may provide a means for mitigating these disparities; however, it remains unclear whether and to what extent care partners might enhance SM use. OBJECTIVE: We aim to examine whether SM use differs among older patients with diabetes based on the involvement of care partner proxies. METHODS: This is a substudy of the ECLIPPSE (Employing Computational Linguistics to Improve Patient-Provider Secure Emails) project, a cohort study taking place in a large, fully integrated health care delivery system with an established digital patient portal serving over 4 million patients. Participants included patients with type 2 diabetes aged ≥50 years, newly registered on the patient portal, who sent ≥1 English-language message to their clinician between July 1, 2006, and December 31, 2015. Proxy SM was identified by having a registered proxy. To identify nonregistered proxies, a computational linguistics algorithm was applied to detect words and phrases more likely to appear in proxy messages compared to patient-authored messages. The primary outcome was the annual volume of secure messages (sent or received); secondary outcomes were the length of time to the first SM sent by patient or proxy and the number of annual SM exchanges (unique message topics generating ≥1 reply). RESULTS: The mean age of the cohort (N=7659) at this study's start was 61 (SD 7.16) years; 75% (n=5573) were married, 15% (n=1089) identified as Black, 10% (n=747) Chinese, 12% (n=905) Filipino, 13% (n=999) Latino, and 30% (n=2225) White. Further, 49% (n=3782) of patients used a proxy to some extent. Compared to nonproxy users, proxy users were older (P<.001), had lower educational attainment (P<.001), and had more comorbidities (P<.001). Adjusting for patient sociodemographic and clinical characteristics, proxy users had greater annual SM volume (20.7, 95% CI 20.2-21.2 vs 10.9, 95% CI 10.7-11.2; P<.001), shorter time to SM initiation (hazard ratio vs nonusers: 1.30, 95% CI 1.24-1.37; P<.001), and more annual SM exchanges (6.0, 95% CI 5.8-6.1 vs 2.9, 95% CI 2.9-3.0, P<.001). Differences in SM engagement by proxy status were similar across patient levels of education, and racial and ethnic groups. CONCLUSIONS: Among a cohort of older patients with diabetes, proxy SM involvement was independently associated with earlier initiation and increased intensity of messaging, although it did not appear to mitigate existing disparities in SM. These findings suggest care partners can enhance patient-clinician telecommunication in diabetes care. Future studies should examine the effect of care partners' SM involvement on diabetes-related quality of care and clinical outcomes.

Evaluation of Changes in Prices and Purchases Following Implementation of Sugar-Sweetened Beverage Taxes Across the US.

Importance: Sugar-sweetened beverage (SSB) taxes are promoted as key policies to reduce cardiometabolic diseases and other conditions, but comprehensive analyses of SSB taxes in the US have been difficult because of the absence of sufficiently large data samples and methods limitations. Objective: To estimate changes in SSB prices and purchases following SSB taxes in 5 large US cities. Design, Setting, and Participants: In this cross-sectional study with an augmented synthetic control analysis, changes in prices and purchases of SSBs were estimated following SSB tax implementation in Boulder, Colorado; Philadelphia, Pennsylvania; Oakland, California; Seattle, Washington; and San Francisco, California. Changes in SSB prices (in US dollars) and purchases (volume in ounces) in these cities in the 2 years following tax implementation were estimated and compared with control groups constructed from other cities. Changes in adjacent, untaxed areas were assessed to detect any increase in cross-border purchases. Data used for this analysis spanned from January 1, 2012, to February 29, 2020, and were analyzed between June 1, 2022, and September 29, 2023. Main Outcomes and Measures: The main outcomes were the changes in SSB prices and volume purchased. Results: Using nutritional information, 5500 unique universal product codes were classified as SSBs, according to tax designations. The sample included 26 338 stores-496 located in treated localities, 1340 in bordering localities, and 24 502 in the donor pool. Prices of SSBs increased by an average of 33.1% (95% CI, 14.0% to 52.2%; P < .001) during the 2 years following tax implementation, corresponding to an average price increase of 1.3¢ per oz and a 92% tax pass-through rate from distributors to consumers. SSB purchases declined in total volume by an average of 33.0% (95% CI, -2.2% to -63.8%; P = .04) following tax implementation, corresponding to a -1.00 price elasticity of demand. The observed price increase and corresponding volume decrease immediately followed tax implementation, and both outcomes were sustained in the months thereafter. No evidence of increased cross-border purchases following tax implementation was found. Conclusions and Relevance: In this cross-sectional study, SSB taxes led to substantial, consistent declines in SSB purchases across 5 taxed cities following price increases associated with those taxes. Scaling SSB taxes nationally could yield substantial public health benefits.

Pro- and Anti-Tax Framing in News Articles About California Sugar-Sweetened Beverage Tax Campaigns from 2014-2018.

Sugar-sweetened beverages (SSB) contribute to illness, especially among marginalized communities and children targeted by the beverage industry. SSB taxes can reduce consumption, illness burden, and health inequities, while generating revenue for health programs, and as one way to hold the industry responsible for their harmful products and marketing malpractices. Supporters and opponents have debated SSB tax proposals in news coverage - a key source of information that helps to shape public policy debates. To learn how four successful California-based SSB tax campaigns were covered in the news, we conducted a content analysis, comparing how SSB taxes were portrayed. We found that pro-tax arguments frequently reported data to expose the beverage industry's outsized campaign spending and emphasize the health harms of SSBs, often from health professionals. However, pro-tax arguments rarely described the benefits of SSB taxes, or how they can act as a tool for industry accountability. By contrast, anti-tax arguments overtly appealed to values and promoted misinformation, often from representatives from industry-funded front groups. As experts recommend additional SSB tax proposals, and as the industry mounts legislative counter-tactics to prevent them, advocates should consider harnessing community representatives as messengers and values-based messages to highlight the benefits of SSB taxes.

Visit and Between-Visit Interaction Frequency Before and After COVID-19 Telehealth Implementation.

Importance: Telehealth implementation associated with the COVID-19 public health emergency (PHE) affected patient-clinical team interactions in numerous ways. Yet, studies have narrowly examined billed patient-clinician visits rather than including visits with other team members (eg, pharmacists) or between-visit interactions. Objective: To evaluate rates of change over time in visits (in-person, telehealth) and between-visit interactions (telephone calls, patient portal messages) overall and by key patient characteristics. Design, Setting, and Participants: This retrospective cohort study included adults with diabetes receiving primary care at urban academic (University of California San Francisco [UCSF]) and safety-net (San Francisco Health Network [SFHN]) health care systems. Encounters from April 2019 to March 2021 were analyzed. Exposure: Telehealth implementation over 3 periods: pre-PHE (April 2019 to March 2020), strict shelter-in-place (April to June 2020), and hybrid-PHE (July 2020 to March 2021). Main Outcomes and Measures: The main outcomes were rates of change in monthly mean number of total encounters, visits with any health care team member, visits with billing clinicians, and between-visit interactions. Key patient-level characteristics were age, race and ethnicity, language, and neighborhood socioeconomic status (nSES). Results: Of 15 148 patients (4976 UCSF; 8975 SFHN) included, 2464 (16%) were 75 years or older, 7734 (51%) were female patients, 9823 (65%) self-identified as racially or ethnically minoritized, 6223 (41%) had a non-English language preference, and 4618 (31%) lived in the lowest nSES quintile. After accounting for changes to care delivery through an interrupted time-series analysis, total encounters increased in the hybrid-PHE period (UCSF: 2.3% per patient/mo; 95% CI, 1.6%-2.9% per patient/mo; SFHN: 1.8% per patient/mo, 95% CI, 1.3%-2.2% per patient/mo), associated primarily with growth in between-visit interactions (UCSF: 3.1% per patient/mo, 95% CI, 2.3%-3.8% per patient/mo; SFHN: 2.9% per patient/mo, 95% CI, 2.3%-3.4% per patient/mo). In contrast, rates of visits were stable during the hybrid-PHE period. Although there were fewer differences in visit use by key patient-level characteristics during the hybrid-PHE period, pre-PHE differences in between-visit interactions persisted during the hybrid-PHE period at SFHN. Asian and Chinese-speaking patients at SFHN had fewer monthly mean between-visit interactions compared with White patients (0.46 [95% CI, 0.42-0.50] vs 0.59 [95% CI, 0.53-0.66] between-visit interactions/patient/mo; P < .001) and English-speaking patients (0.52 [95% CI, 0.47-0.58] vs 0.61 [95% CI, 0.56-0.66] between-visit interactions/patient/mo; P = .03). Conclusions and Relevance: In this study, pre-PHE growth in overall patient-clinician encounters persisted after PHE-related telehealth implementation, driven in both periods by between-visit interactions. Differential utilization based on patient characteristics was observed, which may indicate disparities. The implications for health care team workload and patient outcomes are unknown, particularly regarding between-visit interactions. Therefore, to comprehensively understand care utilization for patients with chronic diseases, research should expand beyond billed visits.

Rethinking diabetes in the United States.

Despite the availability of effective medical treatments, the diabetes epidemic has accelerated in the United States, efforts to translate treatments into routine clinical practice have stalled, and health inequities have persisted. The National Clinical Care Commission (NCCC) was established by the Congress to make recommendations to better leverage federal policies and programs to more effectively prevent and control diabetes and its complications. The NCCC developed a guiding framework that incorporated elements of the Socioecological and Chronic Care Models. It gathered information from both health-related and non-health-related federal agencies, held 12 public meetings, solicited public comments, met with interested parties and key informants, and performed comprehensive literature reviews. The final report of the NCCC was transmitted to the Congress in January 2022. It called for a rethinking of the problem of diabetes in the United States, including the recognition that the lack of progress is due to a failure to confront diabetes as both a complex societal problem as well as a biomedical problem. To prevent and control diabetes, public policies and programs must be aligned to address both social and environmental determinants of health and health care delivery as they impact diabetes. In this article, we discuss the findings and recommendations of the NCCC as they relate to the social and environmental factors that influence the risk of type 2 diabetes and argue that the prevention and control of type 2 diabetes in the U.S. must begin with concrete population-level interventions to address social and environmental determinants of health.

Health Communication Science in the Balance.

Authors of this Viewpoint discuss the recent "pause" of the NIH Common Fund's research program that was designed to study the communication of science and the possible detrimental effect of not addressing scientific misinformation and disinformation.

The "Survival Pending Revolution" COVID-19 vaccination campaign: an example of critical communication theory in action.

Introduction: We carried out a two-phase, qualitative evaluation of a novel public health campaign to promote COVID-19 vaccination among youth and young adults of color (YOC), called Survival Pending Revolution. The campaign, commissioned by California's Department of Public Health, was created by YOC spoken word artists, under the direction of the organization, Youth Speaks. Methods: In phase 1, we describe the communication attributes of the campaign's nine video-poems, coded the content of the pieces, and applied thematic analysis to describe the themes conveyed. In phase 2, we carried out a comparative health communication study to assess the content's potential value. We exposed a sample of the target audience (YOC) to the content of Survival Pending Revolution and a widely viewed comparator campaign (The Conversation). Using a focus group, we solicited participants' views using a semi-structured approach. Using thematic analysis, we summarized the reactions that arose when participants reflected on the attributes of each campaign. Results: Findings from phase 1 reveal how engaging YOC artists who embrace Youth Speaks' philosophy of harnessing "life as primary text" resulted in content that is aligned with critical communication theory, focusing on structural determinants of health, including themes of overcoming oppressive systems, health and social inequities, and medical discrimination and mistrust. Findings from phase 2 reveal that this arts-based campaign based on such critical communication theory, when compared to a more traditional campaign, promotes message salience, fosters emotional engagement, and provides a form of validation among historically oppressed groups such that they may be more open to, and potentially act on, the COVID-19 vaccination communications to which they are exposed. Discussion: As an example of critical communication, the Survival Pending Revolution campaign encourages health-promoting behavioral decisions while calling out the structural determinants of health that shape risks of exposure and constrain free choice. Engaging uniquely gifted members of marginalized populations as creators and messengers of campaigns lead to content that is aligned with a critical communication approach, whose goal is to aid disparity populations in both resisting and navigating systems that continue to locate them on the margins of society. Our evaluation of this campaign suggests that it represents a promising formative and interventional approach to engendering trust in public health messaging and promoting health equity.

Automated Strategy Feedback Can Improve the Readability of Physicians' Electronic Communications to Simulated Patients.

Modern communication between health care professionals and patients increasingly relies upon secure messages (SMs) exchanged through an electronic patient portal. Despite the convenience of secure messaging, challenges include gaps between physician and patient expertise along with the asynchronous nature of such communication. Importantly, less readable SMs from physicians (e.g., too complicated) may result in patient confusion, non-adherence, and ultimately poorer health outcomes. The current simulation trial synthesizes work on patient-physician electronic communication, message readability assessments, and feedback to explore the potential for automated strategy feedback to improve the readability of physicians' SMs to patients. Within a simulated secure messaging portal featuring multiple simulated patient scenarios, computational algorithms assessed the complexity of SMs written by 67 participating physicians to patients. The messaging portal provided strategy feedback for how physician responses might be improved (e.g., adding details and information to reduce complexity). Analyses of changes in SM complexity revealed that automated strategy feedback indeed helped physicians compose and refine more readable messages. Although the effects for any individual SM were slight, the cumulative effects within and across patient scenarios showed trends of decreasing complexity. Physicians appeared to learn how to craft more readable SMs via interactions with the feedback system. Implications for secure messaging systems and physician training are discussed, along with considerations for further investigation of broader physician populations and effects on patient experience.

Evaluation of the sugar-sweetened beverage tax in Oakland, United States, 2015-2019: A quasi-experimental and cost-effectiveness study.

BACKGROUND: While a 2021 federal commission recommended that the United States government levy a sugar-sweetened beverage (SSB) tax to improve diabetes prevention and control efforts, evidence is limited regarding the longer-term impacts of SSB taxes on SSB purchases, health outcomes, costs, and cost-effectiveness. This study estimates the impact and cost-effectiveness of an SSB tax levied in Oakland, California. METHODS AND FINDINGS: An SSB tax ($0.01/oz) was implemented on July 1, 2017, in Oakland. The main sample of sales data included 11,627 beverage products, 316 stores, and 172,985,767 product-store-month observations. The main analysis, a longitudinal quasi-experimental difference-in-differences approach, compared changes in beverage purchases at stores in Oakland versus Richmond, California (a nontaxed comparator in the same market area) before and 30 months after tax implementation (through December 31, 2019). Additional estimates used synthetic control methods with comparator stores in Los Angeles, California. Estimates were inputted into a closed-cohort microsimulation model to estimate quality-adjusted life years (QALYs) and societal costs (in Oakland) from 6 SSB-associated disease outcomes. In the main analysis, SSB purchases declined by 26.8% (95% CI -39.0 to -14.7, p < 0.001) in Oakland after tax implementation, compared with Richmond. There were no detectable changes in purchases of untaxed beverages or sweet snacks or purchases in border areas surrounding cities. In the synthetic control analysis, declines in SSB purchases were similar to the main analysis (-22.4%, 95% CI -41.7% to -3.0%, p = 0.04). The estimated changes in SSB purchases, when translated into declines in consumption, would be expected to accrue QALYs (94 per 10,000 residents) and significant societal cost savings (>$100,000 per 10,000 residents) over 10 years, with greater gains over a lifetime horizon. Study limitations include a lack of SSB consumption data and use of sales data primarily from chain stores. CONCLUSIONS: An SSB tax levied in Oakland was associated with a substantial decline in volume of SSBs purchased, an association that was sustained more than 2 years after tax implementation. Our study suggests that SSB taxes are effective policy instruments for improving health and generating significant cost savings for society.

Testing the effectiveness of narrative messages using critical health communication.

BACKGROUND: Latinos suffer from health disparities associated with excessive consumption of sugar-sweetened beverages. This study aimed to test the effectiveness of messaging using critical health communication approaches and delivered by two narrative modalities (video and comic book) with similar content that aims to empower Latinos to advocate for social change and to make individual behavior change related to sugary beverage consumption. METHODS: Participants (N = 129 Mexican American women between 18 and 29 years) completed an online survey before and after exposure to an embedded stimulus. Participants were randomly assigned to a stimulus, a narrative message in video or comic book format, both developed using critical health communication approaches that focused on individual harms and social causes of sugary beverage consumption. RESULTS: Paired sample t-test results showed that both narrative messages increased intentions to reduce sugary beverage consumption (Video: P < 0.01; d = 0.43; Comic: P = 0.03; d = 0.28). Both groups also demonstrated significant improvements in sugary beverage-related media literacy (Video: P = 0.01, d = 0.34; Comic: P = 0.05, d = 0.25), public health literacy (Video: P = 0.05, d = 0.24; Comic: P = 0.01, d = 0.32), and empowerment to engage in sugary beverage-related community movements (Video: P = 0.003, d = 0.38; Comic: P = 0.034, d = 0.27). CONCLUSIONS: This study provides initial evidence indicating the effectiveness of narrative messages in two modalities using critical health communication for promoting individual behavioral intention and social activation in reducing sugary beverage consumption.

The National Clinical Care Commission Report to Congress: Summary and Next Steps.

The U.S. is experiencing an epidemic of type 2 diabetes. Socioeconomically disadvantaged and certain racial and ethnic groups experience a disproportionate burden from diabetes and are subject to disparities in treatment and outcomes. The National Clinical Care Commission (NCCC) was charged with making recommendations to leverage federal policies and programs to more effectively prevent and control diabetes and its complications. The NCCC determined that diabetes cannot be addressed simply as a medical problem but must also be addressed as a societal problem requiring social, clinical, and public health policy solutions. As a result, the NCCC's recommendations address policies and programs of both non-health-related and health-related federal agencies. The NCCC report, submitted to the U.S. Congress on 6 January 2022, makes 39 specific recommendations, including three foundational recommendations that non-health-related and health-related federal agencies coordinate their activities to better address diabetes, that all federal agencies and departments ensure that health equity is a guiding principle for their policies and programs that impact diabetes, and that all Americans have access to comprehensive and affordable health care. Specific recommendations are also made to improve general population-wide policies and programs that impact diabetes risk and control, to increase awareness and prevention efforts among those at high risk for type 2 diabetes, and to remove barriers to access to effective treatments for diabetes and its complications. Finally, the NCCC recommends that an Office of National Diabetes Policy be established to coordinate the activities of health-related and non-health-related federal agencies to address diabetes prevention and treatment. The NCCC urges Congress and the Secretary of Health and Human Services to implement these recommendations to protect the health and well-being of the more than 130 million Americans at risk for and living with diabetes.

The National Clinical Care Commission Report to Congress: Recommendations to Better Leverage Federal Policies and Programs to Prevent and Control Diabetes.

The National Clinical Care Commission (NCCC) was established by Congress to make recommendations to leverage federal policies and programs to more effectively prevent and treat diabetes and its complications. The NCCC developed a guiding framework that incorporated elements of the Socioecological and Chronic Care Models. It surveyed federal agencies and conducted follow-up meetings with representatives from 10 health-related and 11 non-health-related federal agencies. It held 12 public meetings, solicited public comments, met with numerous interested parties and key informants, and performed comprehensive literature reviews. The final report, transmitted to Congress in January 2022, contained 39 specific recommendations, including 3 foundational recommendations that addressed the necessity of an all-of-government approach to diabetes, health equity, and access to health care. At the general population level, the NCCC recommended that the federal government adopt a health-in-all-policies approach so that the activities of non-health-related federal agencies that address agriculture, food, housing, transportation, commerce, and the environment be coordinated with those of health-related federal agencies to affirmatively address the social and environmental conditions that contribute to diabetes and its complications. For individuals at risk for type 2 diabetes, including those with prediabetes, the NCCC recommended that federal policies and programs be strengthened to increase awareness of prediabetes and the availability of, referral to, and insurance coverage for intensive lifestyle interventions for diabetes prevention and that data be assembled to seek approval of metformin for diabetes prevention. For people with diabetes and its complications, the NCCC recommended that barriers to proven effective treatments for diabetes and its complications be removed, the size and competence of the workforce to treat diabetes and its complications be increased, and new payment models be implemented to support access to lifesaving medications and proven effective treatments for diabetes and its complications. The NCCC also outlined an ambitious research agenda. The NCCC strongly encourages the public to support these recommendations and Congress to take swift action.

The National Clinical Care Commission Report to Congress: Background, Methods, and Foundational Recommendations.

Since the first Federal Commission on Diabetes issued its report in 1975, the diabetes epidemic in the U.S. has accelerated, and efforts to translate advances in diabetes treatment into routine clinical practice have stalled. In 2021, the National Clinical Care Commission (NCCC) delivered a report to Congress that provided recommendations to leverage federal policies and programs to more effectively prevent and treat diabetes and its complications. In the five articles in this series, we present the NCCC's evidence-based recommendations to 1) reduce diabetes-related risks, prevent type 2 diabetes, and avert diabetes complications through changes in federal policies and programs affecting the general population; 2) prevent type 2 diabetes in at-risk individuals through targeted lifestyle and medication interventions; and 3) improve the treatment of diabetes and its complications to improve the health outcomes of people with diabetes. In this first article, we review the successes and limitations of previous federal efforts to combat diabetes. We then describe the establishment of and charge to the NCCC. We discuss the development of a hybrid conceptual model that guided the NCCC's novel all-of-government approach to address diabetes as both a societal and medical problem. We then review the procedures used by the NCCC to gather information from federal agencies, stakeholders, key informants, and the public and to conduct literature reviews. Finally, we review the NCCC's three foundational recommendations: 1) improve the coordination of non-health-related and health-related federal agencies to address the social and environmental conditions that are accelerating the diabetes epidemic; 2) ensure that all Americans at risk for and with diabetes have health insurance and access to health care; and 3) ensure that all federal policies and programs promote health equity in diabetes.

The National Clinical Care Commission Report to Congress: Leveraging Federal Policies and Programs for Population-Level Diabetes Prevention and Control: Recommendations From the National Clinical Care Commission.

The etiology of type 2 diabetes is rooted in a myriad of factors and exposures at individual, community, and societal levels, many of which also affect the control of type 1 and type 2 diabetes. Not only do such factors impact risk and treatment at the time of diagnosis but they also can accumulate biologically from preconception, in utero, and across the life course. These factors include inadequate nutritional quality, poor access to physical activity resources, chronic stress (e.g., adverse childhood experiences, racism, and poverty), and exposures to environmental toxins. The National Clinical Care Commission (NCCC) concluded that the diabetes epidemic cannot be treated solely as a biomedical problem but must also be treated as a societal problem that requires an all-of-government approach. The NCCC determined that it is critical to design, leverage, and coordinate federal policies and programs to foster social and environmental conditions that facilitate the prevention and treatment of diabetes. This article reviews the rationale, scientific evidence base, and content of the NCCC's population-wide recommendations that address food systems; consumption of water over sugar-sweetened beverages; food and beverage labeling; marketing and advertising; workplace, ambient, and built environments; and research. Recommendations relate to specific federal policies, programs, agencies, and departments, including the U.S. Department of Agriculture, the Food and Drug Administration, the Federal Trade Commission, the Department of Housing and Urban Development, the Environmental Protection Agency, and others. These population-level recommendations are transformative. By recommending health-in-all-policies and an equity-based approach to governance, the NCCC Report to Congress has the potential to contribute to meaningful change across the diabetes continuum and beyond. Adopting these recommendations could significantly reduce diabetes incidence, complications, costs, and inequities. Substantial political resolve will be needed to translate recommendations into policy. Engagement by diverse members of the diabetes stakeholder community will be critical to such efforts.

Extent of Follow-Up on Abnormal Cancer Screening in Multiple California Public Hospital Systems: A Retrospective Review.

BACKGROUND: Inequitable follow-up of abnormal cancer screening tests may contribute to racial/ethnic disparities in colon and breast cancer outcomes. However, few multi-site studies have examined follow-up of abnormal cancer screening tests and it is unknown if racial/ethnic disparities exist. OBJECTIVE: This report describes patterns of performance on follow-up of abnormal colon and breast cancer screening tests and explores the extent to which racial/ethnic disparities exist in public hospital systems. DESIGN: We conducted a retrospective cohort study using data from five California public hospital systems. We used multivariable robust Poisson regression analyses to examine whether patient-level factors or site predicted receipt of follow-up test. MAIN MEASURES: Using data from five public hospital systems between July 2015 and June 2017, we assessed follow-up of two screening results: (1) colonoscopy after positive fecal immunochemical tests (FIT) and (2) tissue biopsy within 21 days after a BIRADS 4/5 mammogram. KEY RESULTS: Of 4132 abnormal FITs, 1736 (42%) received a follow-up colonoscopy. Older age, Medicaid insurance, lack of insurance, English language, and site were negatively associated with follow-up colonoscopy, while Hispanic ethnicity and Asian race were positively associated with follow-up colonoscopy. Of 1702 BIRADS 4/5 mammograms, 1082 (64%) received a timely biopsy; only site was associated with timely follow-up biopsy. CONCLUSION: Despite the vulnerabilities of public-hospital-system patients, follow-up of abnormal cancer screening tests occurs at rates similar to that of patients in other healthcare settings, with colon cancer screening test follow-up occurring at lower rates than follow-up of breast cancer screening tests. Site-level factors have larger, more consistent impact on follow-up rates than patient sociodemographic traits. Resources are needed to identify health system-level factors, such as test follow-up processes or data infrastructure, that improve abnormal cancer screening test follow-up so that effective health system-level interventions can be evaluated and disseminated.

CRANIUM: a quasi-experimental study to improve metabolic screening and HIV testing in community mental health clinics compared to usual care.

BACKGROUND: Individuals with serious mental illness often do not receive guideline-concordant metabolic screening and human immunodeficiency virus (HIV) testing, contributing to increased morbidity and premature mortality. This study evaluates the effectiveness of CRANIUM (Cardiometabolic Risk Assessment and treatment through a Novel Integration model for Underserved populations with Mental illness), an intervention to increase metabolic screening and HIV testing among patients with serious mental illness in a community mental health clinic compared to usual care. METHODS: The study used a quasi-experimental design, prospectively comparing a preventive care screening intervention at one community mental health clinic (n = 536 patients) to usual care at the remaining clinics within an urban behavioural health system (n = 4,847 patients). Psychiatrists at the intervention site received training in preventive health screening and had access to a primary care consultant, screening and treatment algorithms, patient registries, and a peer support specialist. Outcomes were the change in screening rates of A1c, lipid, and HIV testing post-intervention at the intervention site compared to usual care sites. RESULTS: Rates of lipid screening and HIV testing increased significantly at the intervention site compared to usual care, with and without multivariable adjustment [Lipid: aOR 1.90, 95% CI 1.32-2.75, P = .001; HIV: aOR 23.42, 95% CI 5.94-92.41, P < .001]. While we observed a significant increase in A1c screening rates at the intervention site, this increase did not persist after multivariable adjustment (aOR 1.37, 95% CI .95-1.99, P = .09). CONCLUSIONS: This low-cost, reverse integrated care model targeting community psychiatrist practices had modest effects on increasing preventive care screenings, with the biggest effect seen for HIV testing rates. Additional incentives and structural supports may be needed to further promote screening practices for individuals with serious mental illness.

Impact of an Arts-based Public Health Literacy Program Delivered Online to High School Students during the COVID-19 Pandemic.

The COVID-19 pandemic, coupled with the domestic socio-political unrest of 2020, provides a critical opportunity to reframe how we engage with youth around health and disease risk. The Bigger Picture (TBP), a spoken word, arts-based public health literacy campaign, uses a social justice and racial equity frame to activate youth around social determinants of health, including salient topics such as type 2 diabetes, COVID-19, climate change, and police violence. This quasi-experimental study determined the impact of providing an online adaptation of TBP during the COVID-19 pandemic to urban, low-income, diverse high school students (3 intervention schools assigned to receive TBP-based spoken word program; 3 comparison schools received a non-health focused spoken word program). We used outcomes derived from the Culture of Health framework, including: (1) health-related mind-sets and expectations; (2) sense of belonging; and (3) civic engagement. Students completed pre/post surveys; a subset of adults and youth from all 6 schools completed semi-structured interviews. TBP participation resulted in measurable shifts in students' mind-sets around structural drivers of health and health inequity and increases in plans for future civic engagement. Arts-based programming with an intentional focus on the social ecological model and health equity appears to impact young people, even when delivered online.

Evaluating Natural Experiments that Impact the Diabetes Epidemic: an Introduction to the NEXT-D3 Network.

PURPOSE OF REVIEW: Diabetes is an ongoing public health issue in the USA, and, despite progress, recent reports suggest acute and chronic diabetes complications are increasing. RECENT FINDINGS: The Natural Experiments for Translation in Diabetes 3.0 (NEXT-D3) Network is a 5-year research collaboration involving six academic centers (Harvard University, Northwestern University, Oregon Health & Science University, Tulane University, University of California Los Angeles, and University of California San Francisco) and two funding agencies (Centers for Disease Control and Prevention and National Institutes of Health) to address the gaps leading to persisting diabetes burdens. The network builds on previously funded networks, expanding to include type 2 diabetes (T2D) prevention and an emphasis on health equity. NEXT-D3 researchers use rigorous natural experiment study designs to evaluate impacts of naturally occurring programs and policies, with a focus on diabetes-related outcomes. NEXT-D3 projects address whether and to what extent federal or state legislative policies and health plan innovations affect T2D risk and diabetes treatment and outcomes in the USA; real-world effects of increased access to health insurance under the Affordable Care Act; and the effectiveness of interventions that reduce barriers to medication access (e.g., decreased or eliminated cost sharing for cardiometabolic medications and new medications such as SGLT-2 inhibitors for Medicaid patients). Overarching goals include (1) expanding generalizable knowledge about policies and programs to manage or prevent T2D and educate decision-makers and organizations and (2) generating evidence to guide the development of health equity goals to reduce disparities in T2D-related risk factors, treatment, and complications.

Family caregivers navigating the health care system: Evolving roles during the COVID-19 pandemic.

INTRODUCTION: The COVID-19 pandemic has altered access to health care; it remains unclear how patients with chronic illness and disability and their family caregivers are adapting to these changes. In this study, we examined changes in family caregiver roles helping care recipients with chronic illness and disability navigate health care needs during the COVID-19 pandemic. METHODS: From April 15 to May 27, 2020, we distributed online and telephone surveys to family caregiver members of a population-based regional research registry. Caregivers reported whether they were helping "more," "less," or the "same" with ten health care activities (e.g., filling prescriptions, attending medical appointments) now, compared to before the coronavirus pandemic. Using multivariable logistic regression models, we examined caregiver and caregiving context characteristics associated with helping more with 1 or more health care activities. RESULTS: Of 561 caregiver respondents, mean age was 59 years, 76% were women, and 56% co-resided with care recipients. Many caregivers (59%) reported increased help with 1 or more health care activities since the pandemic. Caregivers reported greater help getting medical supplies (31%) and attending care recipients' phone (21%) and video (16%) medical appointments. Women (OR 1.55; 95% CI 1.02-2.36) and caregivers assisting with short-term physical conditions were more likely to help more with 1 or more health care activities (OR 2.81; 95% CI 1.20-6.59). DISCUSSION: Family caregivers reported their responsibilities helping care recipients with chronic conditions and disabilities stay engaged with health care increased since the pandemic. Providers and health systems should consider targeted strategies to support caregivers helping vulnerable patients access necessary care. (PsycInfo Database Record (c) 2022 APA, all rights reserved).