A National Perspective of Telemedicine Use and Direct Medical Costs: Who Uses It and How Much It Costs.

BACKGROUND: Telemedicine has the potential to reduce medical costs among health systems. However, there is a limited understanding of the use of telemedicine and its association with direct medical costs. OBJECTIVES: Using nationally representative data, we investigated telemedicine use and the associated direct medical costs among respondents overall and stratified by medical provider type and patient insurance status. RESEARCH DESIGN, SUBJECTS, AND MEASURES: We used the 2020 Medical Expenditure Panel Survey full-year consolidated file, and outpatient department (OP) and office-based (OB) medical provider event files. Outcomes included total and out-of-pocket costs per visit for OP and OB. The primary independent variable was a binary variable indicating visits made through any telemedicine modality. We used multivariable generalized linear models and 2-part models, adjusting for types of providers and care, patient characteristics, and survey design. RESULTS: Among total OP (n = 2938) and OB (n = 20,204) visits, 47.6% and 24.7% of visits, respectively were made through telemedicine. For OP, telemedicine visits were associated with lower total costs (average marginal effect: -$228; 95% confidence interval -$362, -$95) and out-of-pocket costs for all visits and for visits to specialists and to nurse practitioners or physicians assistants. For OB, telemedicine visits were associated with lower total costs, but not with lower out-of-pocket costs, for visits to primary care physicians or nurse practitioners or physician assistants, and for visits by Medicare patients. CONCLUSION: Telemedicine was associated with lower direct medical costs. Its potential for cost curbing should be proactively identified and integrated into clinical practice and health policy design.

Multilevel predictors of guideline concordant needle biopsy use for non-metastatic breast cancer.

PURPOSE: Persistent breast cancer disparities, particularly geographic disparities, may be explained by diagnostic practice patterns such as utilization of needle biopsy, a National Quality Forum-endorsed quality metric for breast cancer diagnosis. Our objective was to assess the relationship between patient- and facility-level factors and needle biopsy receipt among women with non-metastatic breast cancer in the United States. METHODS: We examined characteristics of women diagnosed with breast cancer between 2004 and 2015 in the National Cancer Database. We assessed the relationship between patient- (e.g., race/ethnicity, stage, age, rurality) and facility-level (e.g., facility type, breast cancer case volume) factors with needle biopsy utilization via a mixed effects logistic regression model controlling for clustering by facility. RESULTS: In our cohort of 992,209 patients, 82.96% received needle biopsy. In adjusted models, the odds of needle biopsy receipt were higher for Hispanic (OR 1.04, Confidence Interval 1.01-1.08) and Medicaid patients (OR 1.04, CI 1.02-1.08), and for patients receiving care at Integrated Network Cancer Programs (OR 1.21, CI 1.02-1.43). Odds of needle biopsy receipt were lower for non-metropolitan patients (OR 0.93, CI 0.90-0.96), patients with cancer stage 0 or I (at least OR 0.89, CI 0.86-0.91), patients with comorbidities (OR 0.93, CI 0.91-0.94), and for patients receiving care at Community Cancer Programs (OR 0.84, CI 0.74-0.96). CONCLUSION: This study suggests a need to account for sociodemographic factors including rurality as predictors of utilization of evidence-based diagnostic testing, such as needle biopsy. Addressing inequities in breast cancer diagnosis quality may help improve breast cancer outcomes in underserved patients.

Evaluating the Impact of CenteringPregnancy Program Versus Individual Prenatal Care on Gestational Weight Gain.

Introduction: The CenteringPregnancy (CP) program-proven to reduce preterm births-was modified to achieve more optimal gestational weight gain (GWG) by an intentional incorporation of nutrition education. We compared the effect of the modified CP program versus individual prenatal care (IPNC) on GWG. Methods: This observational study used linked birth certificate data and hospital discharge records of women who received prenatal care (PNC) in South Carolina Midlands' obstetric clinics between 2015 and 2019. Linear and multinomial logistic regressions were used to compare participants in CP (n = 568) versus IPNC on weight gain, measured by total GWG (delivery weight minus prepregnancy weight), weekly rate of weight gain, and meeting the Institute of Medicine's recommendations (inadequate, adequate, and excessive GWG). Nonrandom assignment to program was controlled by propensity scoring. Results: CP participants differed from IPNC participants in race, nulliparous, education, and type of health insurance, but not in parity or month PNC began (p-Value <0.05). CP and IPNC participants had a similar GWG experience: total GWG (coef(ß) = -0.054; 95% confidence interval [CI] -0.78 to 0.6), total weekly weight gain (coef(ß) = -0.004; 95% CI -0.03 to 0.03), total GWG category (inadequate GWG: RRR = 0.85, 95% CI 0.64-1.21, and excessive GWG: relative risk ratio (RRR) = 0.92, 95% CI 0.71-1.20 vs. adequate), and weekly weight gain category (inadequate GWG: RRR = 0.73, 95% CI 0.53-1.01, and excessive GWG: RRR = 0.83, 95% CI 0.61-1.13 vs. adequate). Conclusion: The CP program with an enhanced nutritional knowledge component was not associated with achieving recommended GWG. Further investigation is needed to explain the lack of impact.

Impact of functional disability on health-care use and medical costs among cancer survivors.

BACKGROUND: Cancer survivors with a disability are among the most vulnerable in health status and financial hardship, but no prior research has systematically examined how disability modifies health-care use and costs. This study examined the association between functional disability among cancer survivors and their health-care utilization and medical costs. METHODS: We generated nationally representative estimates using the 2015-2019 Medical Expenditure Panel Survey. Outcomes included use of 6 service types (inpatient, outpatient, office-based physician, office-based nonphysician, emergency department, and prescription) and medical costs of aggregate services and by each of 6 service types. The primary independent variable was a categorical variable for the total number of functional disabilities. We employed multivariable generalized linear models and 2-part models, adjusting for sociodemographics and health conditions and accounting for survey design. RESULTS: Among cancer survivors (n = 9359; weighted n = 21 046 285), 38.8% reported at least 1 disability. Compared with individuals without a disability, cancer survivors with 4 or more disabilities experienced longer hospital stays (adjusted average marginal effect = 1.14 days, 95% confidence interval [CI] = 0.55 to 1.73), more visits to an office-based physician (average marginal effect = 1.43 visits, 95% CI = 0.51 to 2.35), and a greater number of prescriptions (average marginal effect = 12.1 prescriptions, 95% CI = 9.27 to 15.0). Their total (average marginal effect = $9537, 95% CI = $5713 to $13 361) and out-of-pocket (average marginal effect = $639, 95% CI = $79 to $1199) medical costs for aggregate services were statistically significantly higher. By type, disability in independent living was most strongly associated with greater costs for aggregate services. CONCLUSIONS: Cancer survivors with a disability experienced greater health-care use and higher costs. Cancer survivorship planning for health care and financial stability should consider the patients' disability profile.

Integrating maternal depression care at primary private clinics in low-income settings in Pakistan: A secondary analysis.

Introduction: The prevalence of depression among women in Pakistan ranges from 28% to 66%. There is a lack of structured mental healthcare provision at private primary care clinics in low-income urban settings in Pakistan. This study investigated the effectiveness and processes of a facility-based maternal depression intervention at private primary care clinics in low-income settings. Materials and methods: A mixed-methods study was conducted using secondary data from the intervention. Mothers were assessed for depression using the Patient Health Questionnaire-9 (PHQ-9). A total of 1,957 mothers (1,037 and 920 in the intervention and control arms, respectively) were retrieved for outcome measurements after 1 year of being registered. This study estimated the effectiveness of the depression intervention through cluster adjusted differences in the change in PHQ-9 scores between the baseline and the endpoint measurements for the intervention and control arms. Implementation was evaluated through emerging themes and codes from the framework analysis of 18 in-depth interview transcriptions of intervention participants. Results: Intervention mothers had a 3.06-point (95% CI: -3.46 to -2.67) reduction in their PHQ-9 score at the endpoint compared with their control counterparts. The process evaluation revealed that the integration of structured depression care was feasible at primary clinics in poor urban settings. It also revealed gaps in the public-private care linkage system and the need to improve referral systems. Conclusions: Intervening for depression care at primary care clinics can be effective in reducing maternal depression. Clinic assistants can be trained to identify and deliver key depression counseling messages. The study invites policymakers to seize an opportunity to implement a monitoring mechanism toward standard mental health care.

Participation in the CenteringPregnancy Program and Pregnancy-Induced Hypertension.

INTRODUCTION: CenteringPregnancy emphasizes nutrition, learning, and peer support through a group meeting format in contrast to the standard of prenatal care that maximizes a pregnant patient's time with their provider. It was hypothesized that the program may yield a reduced risk of pregnancy-induced hypertension. In this observational study, authors examined the impacts of the CenteringPregnancy program versus those of standard of prenatal care on pregnancy-induced hypertension. METHODS: In 2021, birth certificate data were linked to hospital discharge records of women who delivered in obstetric clinics in the Midlands of South Carolina between 2015 and 2019. Logistic regression models were used to estimate the association between CenteringPregnancy participation (n=547) and any pregnancy-induced hypertension and specific pregnancy-induced hypertension diagnoses (gestational hypertension/unspecified hypertension, mild pre-eclampsia, and severe pre-eclampsia/eclampsia). Propensity score techniques (e.g., inverse probability of treatment weighting) were used to adjust for self-selection into the program versus into standard of prenatal care. RESULTS: CenteringPregnancy participants had higher odds of developing any pregnancy-induced hypertension under all specifications (OR=1.48, 95% CI=1.15, 1.92) and specifically gestational hypertension/unspecified hypertension (OR=1.76, 95% CI=1.28, 2.42) than those in standard of prenatal care. However, CenteringPregnancy participants did not experience significantly higher odds of mild pre-eclampsia (OR=1.06, 95% CI=0.65, 1.78) and severe pre-eclampsia/eclampsia (OR=1.21, 95% CI=0.78, 1.89) compared with standard of prenatal care participants. CONCLUSIONS: Participation in CenteringPregnancy was associated with higher odds of pregnancy-induced hypertension, particularly gestational hypertension, than participation in standard of prenatal care. Additional research is warranted to definitely rule out selection bias and identify contributing factor(s) that increased pregnancy-induced hypertension despite efforts to improve pregnancy-related health outcomes among CenteringPregnancy participants.

Patient Goals for Living with Rheumatoid Arthritis: A Qualitative Study.

Rheumatoid arthritis is highly individualized in terms of its flare ups and periods of remission. Each patient's unique experience requires a high level of personalization in terms of treatment making it necessary to understand what their goals for living are. This study explores patient perceptions on how the burden of RA shapes patients' goals for living and their preferences for symptom and side-effect management within the United States. Fifteen patients diagnosed with RA with varying lengths of diagnosis were interviewed. A thematic analysis was conducted to construct a conceptual framework. Emerging themes identified disease burdens as: (1) inability to perform essential needs, (2) negative feelings about disease, and (3) its influence on relationships. These burdens shaped desired goals for living which guided the symptom and side-effect priorities the patient wanted managed. Practitioners should consider patient goals and preferences in conjunction with disease progression when engaging in treatment decisions.

A conceptual model of physician work intensity: guidance for evaluating policies and practices to improve health care delivery.

BACKGROUND: Physician work intensity, although a major factor in determining the payment for medical services, may potentially affect patient health outcomes including quality of care and patient safety, and has implications for the redesign of medical practice to improve health care delivery. However, to date, there has been minimal research regarding the relationship between physician work intensity and either patient outcomes or the organization and management of medical practices. A theoretical model on physician work intensity will provide useful guidance to such inquiries. OBJECTIVE: To describe an initial conceptual model to facilitate further investigations of physician work intensity. RESEARCH DESIGN: A conceptual model of physician work intensity is described using as its theoretical base human performance science relating to work intensity. For each of the theoretical components, we present relevant empirical evidence derived from a review of the current literature. RESULTS: The proposed model specifies that the level of work intensity experienced by a physician is a consequence of the physician performing the set of tasks (ie, demands) relating to a medical service. It is conceptualized that each medical service has an inherent level of intensity that is experienced by a physician as a function of factors relating to the physician, patient, and medical practice environment. CONCLUSIONS: The proposed conceptual model provides guidance to researchers as to the factors to consider in studies of how physician work intensity impacts patient health outcomes and how work intensity may be affected by proposed policies and approaches to health care delivery.

Health outcomes associated with military deployment: mild traumatic brain injury, blast, trauma, and combat associations in the Florida National Guard.

OBJECTIVES: To determine the association between specific military deployment experiences and immediate and longer-term physical and mental health effects, as well as examine the effects of multiple deployment-related traumatic brain injuries (TBIs) on health outcomes. DESIGN: Online survey of cross-sectional cohort. Odds ratios were calculated to assess the association between deployment-related factors (ie, physical injuries, exposure to potentially traumatic deployment experiences, combat, blast exposure, and mild TBI) and current health status, controlling for potential confounders, demographics, and predeployment experiences. SETTING: Nonclinical. PARTICIPANTS: Members (N=3098) of the Florida National Guard (1443 deployed, 1655 not deployed). INTERVENTIONS: Not applicable. MAIN OUTCOME MEASURES: Presence of current psychiatric diagnoses and health outcomes, including postconcussive and non-postconcussive symptoms. RESULTS: Surveys were completed an average of 31.8 months (SD=24.4, range=0-95) after deployment. Strong, statistically significant associations were found between self-reported military deployment-related factors and current adverse health status. Deployment-related mild TBI was associated with depression, anxiety, posttraumatic stress disorder (PTSD), and postconcussive symptoms collectively and individually. Statistically significant increases in the frequency of depression, anxiety, PTSD, and a postconcussive symptom complex were seen comparing single to multiple TBIs. However, a predeployment TBI did not increase the likelihood of sustaining another TBI in a blast exposure. Associations between blast exposure and abdominal pain, pain on deep breathing, shortness of breath, hearing loss, and tinnitus suggested residual barotrauma. Combat exposures with and without physical injury were each associated not only with PTSD but also with numerous postconcussive and non-postconcussive symptoms. The experience of seeing others wounded or killed or experiencing the death of a buddy or leader was associated with indigestion and headaches but not with depression, anxiety, or PTSD. CONCLUSIONS: Complex relationships exist between multiple deployment-related factors and numerous overlapping and co-occurring current adverse physical and psychological health outcomes. Various deployment-related experiences increased the risk for postdeployment adverse mental and physical health outcomes, individually and in combination. These findings suggest that an integrated physical and mental health care approach would be beneficial to postdeployment care.

Mobile Health Apps for Patient-Centered Care: Review of United States Rheumatoid Arthritis Apps for Engagement and Activation.

BACKGROUND: Rheumatoid arthritis (RA) is a highly dynamic and individualized disease in terms of its patterns of symptomatic flare-ups and periods of remission. Patient-centered care (PCC) aligns patients' lifestyle goals with their preferences for managing symptoms and side effects through the selection of therapies appropriate for disease management. Mobile health (mHealth) apps have the potential to engage and activate patients in PCC. mHealth apps can provide features that increase disease knowledge, collect patient-generated health indicators and behavioral metrics, and highlight goals for disease management. However, little evidence-based guidance exists as to which apps contain functionality essential for supporting the delivery of PCC. OBJECTIVE: The objective of this study was to evaluate the patient-centeredness of United States-based rheumatoid arthritis mobile apps in terms of patient engagement and activation. METHODS: A search of mobile apps on 2 major United States app stores (Apple App Store and Google Play) was conducted from June 2020 to July 2021 to identify apps designed for use by patients with RA by adapting the PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-analyses) guidelines for mobile health app screening based on the literature. Reviewers conducted a content analysis of mobile app features to evaluate their functionality for patient engagement and activation. Engagement and activation were assessed using the Mobile Application Rating Scale (MARS) and social cognitive theory, respectively. Apps were ranked by their ability to facilitate PCC care along 2 dimensions: engagement and activation. RESULTS: A total of 202 mobile apps were initially identified, and 20 remained after screening. Two apps emerged with the greatest ability to facilitate PCC. Both apps were scored as having acceptable or good patient engagement according to the MARS. These 2 apps also had high patient activation according to social cognitive theory, with many features within those apps representing theoretical constructs such as knowledge, perceived self-efficacy, and expectations about outcomes that support behavioral management of RA. CONCLUSIONS: We found very few mobile apps available within the United States that have functionality that both engages and activates the patient to facilitate PCC. As the prevalence of mobile apps expands, the design of mobile apps needs to integrate patients to ensure that their functionality promotes engagement and activation. More research is needed to understand how mobile app use impacts patient engagement and activation, and ultimately, treatment decisions and disease trajectory.

Generalized anxiety disorder symptoms during COVID-19 pandemic in Jazan, Saudi Arabia.

The aim of this study was to measure anxiety levels and many co-factors that might influence the levels of anxiety during the COVID-19 outbreak in southern Saudi Arabia (KSA). A cross-sectional self-reporting survey was conducted to determine the level of generalized anxiety disorder (GAD) symptoms related to COVID-19 and quarantining. We selected a convenience sample of eligible participants who had been invited online through social media apps. The survey instrument was distributed, and 981 participants responded. Of the total sample, almost 90% were under the age of 40, 75% were women, and 77% had an educational level beyond high school. Just over half were single, with nearly all participants Saudi nationals. The overall prevalence of anxiety related to COVID-19 was 27%. Factors most strongly related to reporting anxiety included having a diagnosis of COVID-19, spending 1- ≥ 3 h focused on COVID-19, having a previous mental illness history, being a current or former smoker, being female, having a previous diagnosis of chronic or respiratory illness, being below age 40, having a limited standard of living, and being a student. Our study reveals how critical it is to emphasize preventive mental health care during pandemics and what factors may make some individuals most vulnerable to anxiety. Further research is recommended to examine GAD levels pre, during and post pandemic. Additional research to explore the long-term impact of the pandemic on mental health is also needed. being a student, and a limited standard of living.

Needlestick and sharps injuries among secondary and tertiary healthcare workers, Saudi Arabia.

AIM: The study aimed to assess the incidence of needlestick and sharps injuries among healthcare workers (HCWs) in the Jazan region of Saudi Arabia, as well as to determine whether there exists an association between hospital level and needlestick and sharps injuries rate. DESIGN: A cross-sectional survey was conducted among 609 randomly selected HCWs from nine general hospitals. METHODS: A self-administered questionnaire, which covered the structure and process of injection safety, was used for data collection. RESULTS: The overall needlestick and sharps injuries incidence rate was 24%. The needlestick and sharps injuries rates were 30% and 14% in secondary and tertiary hospitals, respectively. HCWs working in tertiary hospitals were 61% less likely to have needlestick and sharps injuries than those employed in secondary hospitals. This was mainly the impact of better and continuous training. High safety level maintenance and health education provision are vital in such settings.

Clinical work intensity among physician specialties: how might we assess it? What do we find?

BACKGROUND: The level of work intensity associated with patient encounters has implications for quality of care, patient safety, practice management, and reimbursement. The utility of available instruments for clinical work intensity assessment is unknown. OBJECTIVE: We assessed, in the clinical setting, the performance of existing measures of work intensity that are valid for nonclinical contexts. RESEARCH DESIGN: A cross-sectional, multimeasure design involving work intensity assessments for the last patient encounter and for an entire half-day clinic session. SUBJECTS: A convenience sample of 14 providers from the following 4 specialties: family medicine, general internal medicine, neurology, and surgery. MEASURES: Perceived clinical work intensity was measured by the following 3 instruments: National Aeronautic and Space Administration-Task Load Index, Subjective Workload Assessment Technique, and Multiple Resources Questionnaire; stress was measured by the Dundee Stress State Questionnaire. Convergent validity was assessed by correlation among the instruments. RESULTS: For the last patient encounter, there was a moderate to high correlation between the work intensity instruments' scores (Pearson's r ranged from 0.41 to 0.73) and low to moderate correlation with the distress subscale of the Dundee Stress State Questionnaire (Pearson's r ranged from -0.11 to 0.46), reflecting their stress dimension. Provider personality was associated with reported levels of work intensity and stress. Similar results were obtained when the entire clinic session was the unit of reference. CONCLUSION: Existing measures of work intensity and stress appear to be valid for use in the clinical setting to generate evidence on perceived intensity and stress experienced by providers in the performance of medical services.