RESUMO
OBJECTIVES: The objective was to understand the characteristics of patients who used telemedicine for diabetes management to inform future implementation of telemedicine. METHODS: We examined patient characteristics associated with telemedicine use for diabetes mellitus (DM) care between March 1, 2020 and April 1, 2021 (the coronavirus disease 2019 pandemic period) in a large university health system when telemedicine visits increased rapidly. Logistic regression models assessed patient characteristics associated with telemedicine visits and delays in DM process measures (hemoglobin A1c checks, nephropathy, and retinopathy evaluations) during the pandemic period after adjusting for potential confounders and corresponding values before the pandemic period (March 1, 2019-February 29, 2020). RESULTS: A total of 45,159 patients were seen from 987,791 visits during the pandemic period. The number of visits averaged one visit less during the pandemic period than before the pandemic period. Approximately 5.4% of patients used telemedicine during the pandemic period from 42,750 visits. The mean (standard deviation) telemedicine visit was 1.28 (0.91). Men, Asian, Black, and other race (vs White), having Medicare or uninsured (vs private insurance), were less likely to use telemedicine. Patients with more visits before the pandemic period were more likely to use telemedicine and less likely to experience a delay in DM process measures during the pandemic period. Telemedicine users were 18% less likely to experience a delay in nephropathy visits than nonusers, but without difference for other process measures. CONCLUSIONS: Race, sex, insurance, and prepandemic in-person visits were associated with telemedicine use for DM management in a large health system. Telemedicine use was not associated with delays in hemoglobin A1c testing, nephropathy, and retinopathy assessments. Understanding reasons for not using telemedicine is important to be able to deliver equitable DM care.
Assuntos
Diabetes Mellitus , Doenças Retinianas , Telemedicina , Estados Unidos , Masculino , Humanos , Idoso , Medicare , Hemoglobinas Glicadas , Universidades , Diabetes Mellitus/epidemiologia , Diabetes Mellitus/terapiaRESUMO
OBJECTIVES: Equitable access to severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) testing is important for reducing disparities. We sought to examine differences in the health care setting choice for SARS-CoV-2 testing by race/ethnicity and insurance. Options included traditional health care settings and mobile testing units (MTUs) targeting communities experiencing disproportionately high coronavirus disease 2019 (COVID-19) rates. METHODS: We conducted a retrospective, observational study among patients in a large health system in the Southeastern US. Descriptive statistics and multinomial logistic regression analyses were employed to evaluate associations between patient characteristics and health care setting choice for SARS-CoV-2 testing, defined as: (1) outpatient (OP) care; (2) emergency department (ED); (3) urgent care (UC); and (4) MTUs. Patient characteristics included race/ethnicity, insurance, and the existence of an established relationship with the health care system. RESULTS: Our analytic sample included 105,386 adult patients tested for SARS-CoV-2. Overall, 55% of patients sought care at OP, 24% at ED, 12% at UC, and 9% at MTU. The sample was 58% White, 24% Black, 11% Hispanic, and 8% other race/ethnicity. Black patients had a higher likelihood of getting tested through the ED compared with White patients. Hispanic patients had the highest likelihood of testing at MTUs. Patients without a primary care provider had a higher relative risk of being tested through the ED and MTUs versus OP. CONCLUSIONS: Disparities by race/ethnicity were present in health care setting choice for SARS-CoV-2 testing. Health care systems may consider implementing mobile care delivery models to reach vulnerable populations. Our findings support the need for systemic change to increase primary care and health care access beyond short-term pandemic solutions.
Assuntos
Teste para COVID-19/métodos , COVID-19/diagnóstico , COVID-19/etnologia , Instalações de Saúde/estatística & dados numéricos , Disparidades nos Níveis de Saúde , Adolescente , Adulto , Negro ou Afro-Americano/estatística & dados numéricos , Idoso , Idoso de 80 Anos ou mais , Etnicidade/estatística & dados numéricos , Feminino , Acessibilidade aos Serviços de Saúde/estatística & dados numéricos , Hispânico ou Latino/estatística & dados numéricos , Humanos , Masculino , Pessoa de Meia-Idade , Aceitação pelo Paciente de Cuidados de Saúde/etnologia , Estudos Retrospectivos , SARS-CoV-2 , Fatores Socioeconômicos , Estados Unidos , População Branca/estatística & dados numéricos , Adulto JovemRESUMO
BACKGROUND Although use of contraceptives has increased among young women in the United States, more than half of pregnancies remain unplanned. The goal of this study was to examine the association between insurance status and receipt of contraceptives among young women receiving care within a large integrated health care system in the Southeastern United States to better inform strategies for increasing access to contraception.METHODS This retrospective study used electronic medical record data from an integrated health care system based in Charlotte, North Carolina. Data were analyzed for 51,900 women aged 18-29 who lived in Mecklenburg County and had at least 1 primary care visit between 2014 and 2016. Contraceptive orders were identified by service and procedure codes and grouped into long-acting reversible contraceptives (LARC) and non-LARC categories. Adjusted multinomial logistic regression models were used to assess the association between receipt of contraceptives and insurance status.RESULTS Compared to non-Hispanic White women with commercial insurance, non-Hispanic Black (OR = 1.25; 95% CI, 1.13-1.38) and Hispanic (OR = 2.25; 95% CI, 1.93-2.61) women with Medicaid had higher odds of receiving LARC. Similar variations by insurance and race/ethnicity were observed for the non-LARC group.LIMITATIONS Data were limited to a single health care system and did not capture contraceptive orders by unaffiliated providers. Analyses used the most frequent payor and did not account for changes in insurance status.CONCLUSION Findings indicate an important role of race/ethnicity and insurance coverage in contraceptive care. Higher receipt of LARC among Black and Hispanic women also suggests that implicit biases may influence contraception counseling and promotion practices. Future study is warranted to further delineate these relationships.
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Anticoncepcionais , Etnicidade , Feminino , Humanos , Cobertura do Seguro , North Carolina , Gravidez , Estudos Retrospectivos , Estados UnidosRESUMO
PURPOSE: Contemporary trends and racial disparities in prostate cancer screening and referral to urology for prostate cancer risk are not well characterized, despite consensus that Black men are at higher risk for poor prostate cancer outcomes. The objective of this study was to characterize current racial disparities in prostate cancer screening and referral from primary care to urology for prostate cancer concern within our large, integrated health care system. MATERIALS AND METHODS: This retrospective cohort study used data from Atrium Health's enterprise data warehouse, which includes patient information from more than 900 care locations across North Carolina, South Carolina and Georgia. We included all men seen in the ambulatory or outpatient setting between 2014 and 2019 who were ≥40 years old. Clinical and demographic data were collected for all men, including age and race. Racial outcomes were reported for all groups with >2% representation in the population. Between-group comparisons were determined using chi-squared analysis, Wilcoxon rank sum testing and multivariable logistic regression, with significance defined as p <0.05. RESULTS: We observed a significant decrease in prostate specific antigen testing across all age and racial groups in a cohort of 606,985 men at Atrium Health, including 87,189 Black men, with an overall relative decline of 56%. As compared to White men, Black men were more likely to undergo prostate specific antigen testing (adjusted OR 1.24, 95% CI 1.22-1.26) and be referred to urology for prostate cancer (adjusted OR 1.94, 95% CI 1.75-2.16). CONCLUSIONS: There was a continued significant decline in prostate cancer screening between 2014 and 2019. Despite having modestly elevated odds of being screened for prostate cancer compared to White men, Black men are relatively underscreened when considering that those who undergo prostate specific antigen screening are more likely to be referred by primary care to urology for additional prostate cancer diagnostic evaluation.
Assuntos
Negro ou Afro-Americano/estatística & dados numéricos , Detecção Precoce de Câncer , Disparidades em Assistência à Saúde , Antígeno Prostático Específico/análise , Encaminhamento e Consulta/estatística & dados numéricos , População Branca/estatística & dados numéricos , Adulto , Idoso , Estudos de Coortes , Prestação Integrada de Cuidados de Saúde , Humanos , Masculino , Pessoa de Meia-Idade , Estudos Retrospectivos , Estados UnidosRESUMO
PURPOSE: To develop a valid reliable measurement tool that accurately quantifies postanesthesia recuperation in adult and pediatric patients. DESIGN: A descriptive factor-isolating design guided by measurement theory. METHODS: Instrument development was based on collaborative discussions of professional evidence. A five-person expert panel was consulted for content and face validity. Reliability testing took place in the adult and pediatric postanesthesia care units. FINDINGS: The expert panel's final review yielded a kappa statistic of 1 and scale content validity index based on universal agreement between raters of 1, suggesting high content validity. Reliability testing yielded a kappa statistic of 1, demonstrating complete agreement for all items. CONCLUSIONS: The Discerning Post Anesthesia Readiness for Transition measurement tool is a valid and reliable instrument that can be used in practice or future research to assess postanesthesia recuperation in pediatric and adult patients.
Assuntos
Anestesiologia/métodos , Transferência de Pacientes/classificação , Período Pós-Operatório , Humanos , Transferência de Pacientes/métodos , Transferência de Pacientes/normas , Enfermagem Perioperatória/métodos , Reprodutibilidade dos Testes , Inquéritos e QuestionáriosRESUMO
Objective: To compare three dissemination approaches for implementing an asthma shared decision-making (SDM) intervention into primary care practices. Methods: We randomized thirty practices into three study arms: (1) a facilitator-led approach to implementing SDM; (2) a one-hour lunch-and-learn training on SDM; and (3) a control group with no active intervention. Patient perceptions of SDM were assessed in the active intervention arms using a one-question anonymous survey. Logistic regression models compared the frequency of asthma exacerbations (emergency department (ED) visits, hospitalizations, and oral steroid prescriptions) between the three arms. Results: We collected 705 surveys from facilitator-led sites and 523 from lunch-and-learn sites. Patients were more likely to report that they participated equally with the provider in making the treatment decision in the facilitator-led sites (75% vs. 66%, p = 0.001). Comparisons of outcomes for patients in the facilitator-led (n = 1,658) and lunch-and-learn (n = 2,613) arms respectively vs. control (n = 2,273) showed no significant differences for ED visits (Odds Ratio [OR] [95%CI] = 0.77[0.57-1.04]; 0.83[0.66-1.07]), hospitalizations (OR [95%CI] = 1.30[0.59-2.89]; 1.40 [0.68-3.06]), or oral steroids (OR [95%CI] =0.95[0.79-1.15]; 1.03[0.81-1.06]). Conclusion: Facilitator-led dissemination was associated with a significantly higher proportion of patients sharing equally in decision-making with the provider compared to a traditional lunch-and-learn approach. While there was no significant difference in health outcomes between the three arms, the results were most likely confounded by a concurrent statewide asthma initiative and the pragmatic implementation of the intervention. These results offer support for the use of structured approaches such as facilitator-led dissemination of complex interventions into primary care practices.
Assuntos
Asma/terapia , Disseminação de Informação/métodos , Avaliação de Resultados em Cuidados de Saúde , Assistência Centrada no Paciente/organização & administração , Atenção Primária à Saúde/organização & administração , Adolescente , Adulto , Asma/diagnóstico , Análise por Conglomerados , Tomada de Decisão Compartilhada , Gerenciamento Clínico , Medicina Baseada em Evidências/métodos , Humanos , Modelos Logísticos , Masculino , Medicaid/estatística & dados numéricos , North Carolina , Estados Unidos , Adulto JovemRESUMO
OBJECTIVES: To examine racial/ethnic differences in healthcare use among patients classified as having controlled and uncontrolled diabetes. DESIGN: Data from the Carolinas HealthCare System electronic data warehouse were used. Glycemic control was defined as glycosylated hemoglobin (HbA1c) < 8% (64â mmol/mol) in 2012 (n = 9996). Patients with HbA1c ≥ 8% (64â mmol/mol) in 2012 were classified as uncontrolled (n = 2576). Race and ethnicity were jointly classified as non-Hispanic Black, non-Hispanic White or Other. Separate mixed effects negative binomial models estimated the independent effect of race/ethnicity on the number of emergency department (ED) visits, hospitalizations and physician office visits in 2013, in each patient group, adjusting for significant confounding variables. RESULTS: Rates of diabetes-related ED visits were two to three times higher for non-Hispanic Blacks compared to non-Hispanic Whites (uncontrolled rate ratio [RR]: 3.41 95% CI: 1.41-8.22; controlled RR: 2.95; 95% CI: 1.78-4.91). Similar differences were observed for all-cause ED visits (uncontrolled RR: 1.83, 95% CI: 1.50-2.24; controlled RR: 2.45, 95% CI: 2.17-2.77). Non-Hispanic Blacks with controlled and uncontrolled diabetes also had lower rates of all-cause physician office visits when compared to non-Hispanic Whites (uncontrolled RR: 0.84, 95% CI: 0.77-0.91; controlled RR: 0.81, 95% CI: 0.78-0.84). CONCLUSION: Notable racial/ethnic disparities exist in the use of emergency services and physician offices for diabetes care. Strategies such as patient education and care delivery changes that address healthcare access issues in racial/ethnic minorities should be considered to offer better diabetes management and address diabetes disparities.
Assuntos
Diabetes Mellitus/etnologia , Disparidades em Assistência à Saúde/etnologia , Aceitação pelo Paciente de Cuidados de Saúde/etnologia , Grupos Raciais/etnologia , Adulto , Idoso , Idoso de 80 Anos ou mais , Glicemia , Serviço Hospitalar de Emergência/estatística & dados numéricos , Feminino , Hemoglobinas Glicadas/análise , Humanos , Masculino , Pessoa de Meia-Idade , Aceitação pelo Paciente de Cuidados de Saúde/estatística & dados numéricos , Estados UnidosRESUMO
Although developing countries may find it difficult to provide adequate prenatal care, it is likely that they can provide at least some. We examined associations of prenatal care with infant mortality in West Africa. We used data from the Demographic and Health Surveys (n = 57,322) and proportional hazards regression models to estimate the risk of infant mortality. Having any prenatal care was associated with lower infant mortality risk in all but the poorest wealth quintile, with 56% lower risk in the wealthiest quintile (95% confidence interval [CI] 0.28-0.69). Even limited prenatal care may significantly reduce infant mortality in developing countries.
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Parto Obstétrico/métodos , Mortalidade Infantil , Cuidado Pré-Natal/estatística & dados numéricos , Adolescente , Adulto , África Ocidental/epidemiologia , Estudos Transversais , Feminino , Inquéritos Epidemiológicos , Humanos , Lactente , Mortalidade Infantil/tendências , Recém-Nascido , Pobreza , Gravidez , Fatores Socioeconômicos , Adulto JovemRESUMO
Objective: Although shared decision making (SDM) is a promising approach for improving outcomes for patients with chronic diseases, no evidence currently supports the use of SDM to delay asthma exacerbations. We evaluated the impact of an SDM intervention implemented by providers in a real-world setting on time to exacerbation in children with asthma. Methods: This study used a prospective cohort observed between 2011 and 2013 at five primary care practices that serve vulnerable populations (e.g., Medicaid and uninsured patients) in Charlotte, NC. Patients aged 2 to 17 receiving SDM were matched to those receiving usual care using propensity scores. Time to asthma exacerbation (asthma hospitalization, emergency department visit or oral steroid prescription in the outpatient setting) was compared between groups using Kaplan-Meier curves and conditional Cox proportional hazards models. Results: The cohort included 746 children, 60.5% male and 54.2% African American, with a mean age of 8.6 years. Of these, 625 received usual care and 121 received SDM. The final analysis included 100 matched pairs of children. Kaplan-Meier curves showed longer exacerbation-free time for patients in the SDM intervention compared to those in usual care (p = 0.005). The difference in risk of experiencing an exacerbation was marginally significant between the two groups (HR = 0.56, 95% C.I. = 0.29-1.08, p = 0.08). Conclusions: SDM was found to delay exacerbations among children with asthma. Clinicians should consider incorporating patient preferences in treatment decisions through SDM as a means for longer exacerbation-free time among children with poor asthma control.
Assuntos
Asma/tratamento farmacológico , Tomada de Decisão Clínica/métodos , Participação do Paciente , Preferência do Paciente , Atenção Primária à Saúde/métodos , Antiasmáticos/uso terapêutico , Asma/patologia , Criança , Pré-Escolar , Progressão da Doença , Feminino , Humanos , Masculino , Estudos Prospectivos , Fatores de Tempo , Populações VulneráveisRESUMO
OBJECTIVE: Few studies have examined the effectiveness of shared decision making (SDM) in clinical practice. This study evaluated the impact of SDM on quality of life and symptom control in children with asthma. METHODS: We conducted a prospective 3-year study in six community-based practices serving a low-income patient population. Practices received training on SDM using an evidence-based toolkit. Patients aged 2-17 with a diagnosis of asthma were identified from scheduling and billing data. At approximate 6-month intervals, patients completed a survey consisting of the Mini Pediatric Asthma Quality of Life Questionnaire (range 1-7) and the control domain of the Pediatric Asthma Therapy Assessment Questionnaire (range 0-7). We used propensity scores to match 46 children receiving SDM to 46 children receiving usual care with decision support. Included children had completed a baseline survey and at least one follow-up survey. Random coefficient models incorporated repeated measures to assess the effect of SDM on asthma quality of life and asthma control. RESULTS: The sample was primarily of non-White patients (94.6%) with Medicaid insurance (92.4%). Receipt of SDM using an evidence-based toolkit was associated with higher asthma quality of life [mean difference 0.9; 95% confidence interval (CI) 0.4-1.4] and fewer asthma control problems (mean difference -0.9; 95% CI -1.6--0.2) compared to usual care with decision support. CONCLUSIONS: Implementation of SDM within clinical practices using a standardized toolkit is associated with improved asthma quality of life and asthma control for low-income children with asthma when compared to usual care with decision support.
Assuntos
Asma/terapia , Tomada de Decisão Clínica/métodos , Serviços de Saúde Comunitária/organização & administração , Participação do Paciente , Qualidade de Vida , Adolescente , Asma/psicologia , Criança , Pré-Escolar , Serviços de Saúde Comunitária/métodos , Feminino , Implementação de Plano de Saúde , Humanos , Masculino , North Carolina , Pobreza , Avaliação de Programas e Projetos de Saúde , Estudos Prospectivos , Inquéritos e Questionários/estatística & dados numéricosRESUMO
BACKGROUND: Inappropriate prescribing of antibiotics poses an urgent public health threat. Limited research has examined factors associated with antibiotic prescribing practices in outpatient settings. The goals of this study were to explore elements influencing provider decisions to prescribe antibiotics, identify provider recommendations for interventions to reduce inappropriate antibiotic use, and inform the clinical management of patients in the outpatient environment for infections that do not require antibiotics. METHODS: This was a qualitative study using semi-structured interviews with key informants. Seventeen outpatient providers (10 medical doctors and 7 advanced care practitioners) within a large healthcare system in Charlotte, North Carolina, participated. Interviews were audio recorded, transcribed, and analyzed for themes. RESULTS: Primary barriers to reducing inappropriate antibiotic prescribing included patient education and expectations, system-level factors, and time constraints. Providers indicated they would be interested in having system-wide, evidence-based guidelines to inform their prescribing decisions and that they would also be receptive to efforts to improve their awareness of their own prescribing practices. Results further suggested that providers experience a high demand for antibiotic prescriptions; consequently, patient education around appropriate use would be beneficial. CONCLUSIONS: Findings suggest that antibiotic prescribing in the outpatient setting is influenced by many pressures, including patient demand and patient satisfaction. Training on appropriate antibiotic prescribing, guideline-based decision support, feedback on prescribing practices, and patient education are recommended interventions to improve levels of appropriate prescribing.
Assuntos
Antibacterianos/uso terapêutico , Atitude do Pessoal de Saúde , Tomada de Decisão Clínica , Prescrição Inadequada , Assistência Ambulatorial , Gestão de Antimicrobianos , Técnicas de Apoio para a Decisão , Medicina Baseada em Evidências , Feminino , Humanos , Masculino , Profissionais de Enfermagem , Educação de Pacientes como Assunto , Satisfação do Paciente , Pediatras , Assistentes Médicos , Médicos de Família , Pesquisa QualitativaRESUMO
Hispanic immigrant communities across the U.S. experience persistent health disparities and barriers to primary care. We examined whether community-based participatory research (CBPR) and geospatial modeling could systematically and reproducibly pinpoint neighborhoods in Charlotte, North Carolina with large proportions of Hispanic immigrants who were at-risk for poor health outcomes and health disparities. Using a CBPR framework, we identified 21 social determinants of health measures and developed a geospatial model from a subset of those measures to identify neighborhoods with large proportions of Hispanic immigrant populations at risk for poor health outcomes. The geospatial model included four measures-poverty, English ability, acculturation and violent crime-which comprised our Hispanic Health Risk Index (HHRI). We developed a Primary Care Barrier Index (PCBI) to determine (1) how well the HHRI correlated with a statistically derived composite measure incorporating all 21 measures identified through the CBPR process as being associated with access to primary care; (2) whether the HHRI predicted primary care access as well as the statistically-derived composite measure in a statistical model; and (3) whether the HHRI identified similar neighborhoods as the statistically derived composite measure. We collapsed 17 of the 21 social determinants using principal components analysis to develop the PCBI. We determined the correlation of each index with inappropriate emergency department (ED) visits, a proxy for primary care access, using logistic generalized estimating equations. Results from logistic regression models showed positive associations of both the HHRI and the PCBI with the use of the ED for primary care treatable conditions. Enhanced by the knowledge of the local community, the CBPR process with geospatial modeling can guide the multi-tiered validation of social determinants of health and identify neighborhoods that are at-risk for poor health outcomes and health disparities.
Assuntos
Pesquisa Participativa Baseada na Comunidade , Acessibilidade aos Serviços de Saúde , Necessidades e Demandas de Serviços de Saúde/estatística & dados numéricos , Disparidades em Assistência à Saúde , Hispânico ou Latino/estatística & dados numéricos , Atenção Primária à Saúde/estatística & dados numéricos , Melhoria de Qualidade , Determinantes Sociais da Saúde , Simulação por Computador , Humanos , North Carolina , Reprodutibilidade dos Testes , Populações VulneráveisRESUMO
OBJECTIVE: Patient/provider shared decision making (SDM) improves asthma control in a pragmatic clinical trial setting. This study evaluated the impact of an evidence-based SDM toolkit on outcomes for patients with asthma implemented by providers in a real world setting. We hypothesized that these patients with asthma would demonstrate improved outcomes such as reduced emergency department (ED) visits, hospitalizations, and oral steroid use in the 12 months following a SDM visit compared to those who did not receive the intervention. METHODS: Patients with asthma were identified within six primary care practices that serve vulnerable populations in Charlotte, NC (746 children; 718 adult patients). Propensity scores were used to match 200 children and 206 adults for analysis. The primary outcome variable was asthma exacerbation defined as an ED visit or hospitalization for asthma or outpatient prescription of an oral steroid. Patients were monitored at 3, 6, and 12 months after the intervention date. The outcome variables of ED visits, hospitalizations, and oral steroids were compared between intervention and matched control patients. RESULTS: The proportion of pediatric patients with one or more exacerbations was significantly lower in the SDM intervention group compared to controls during 12 months after exposure to the intervention (33% vs. 47%, p = 0.023). For adults, there was not a strong association between use of the SDM intervention and outcomes improvement. CONCLUSIONS: The evidence-based SDM intervention implemented in this study was associated with improved asthma outcomes for pediatric patients but not adult patients in a real world clinical setting.
Assuntos
Corticosteroides/administração & dosagem , Asma/terapia , Tomada de Decisões , Serviço Hospitalar de Emergência/estatística & dados numéricos , Promoção da Saúde/organização & administração , Atenção Primária à Saúde/organização & administração , Corticosteroides/uso terapêutico , Adulto , Criança , Uso de Medicamentos , Prática Clínica Baseada em Evidências , Feminino , Promoção da Saúde/estatística & dados numéricos , Humanos , Masculino , Pessoa de Meia-Idade , Planejamento de Assistência ao Paciente , Equipe de Assistência ao Paciente/organização & administração , Educação de Pacientes como Assunto/organização & administração , Pontuação de Propensão , Estudos Prospectivos , Fatores SocioeconômicosRESUMO
Social and health care context may influence prenatal care use. We studied associations of government health expenditures, supply of health care professionals, and country literacy rates with prenatal care use in ten West African countries, controlling for individual factors. We used data from Demographic and Health Surveys (n = 58,512) and random effect logistic regression models to estimate the likelihood of having any prenatal care and adequate prenatal care. Each percentage increase in the literacy rate was associated with 4% higher odds of having adequate prenatal care (p = .029). Higher literacy rates among women may help to promote adequate prenatal care.
Assuntos
Financiamento Governamental , Gastos em Saúde , Letramento em Saúde , Mão de Obra em Saúde , Aceitação pelo Paciente de Cuidados de Saúde , Cuidado Pré-Natal/estatística & dados numéricos , Adulto , África Ocidental , Atenção à Saúde/economia , Atenção à Saúde/organização & administração , Países em Desenvolvimento , Feminino , Pessoal de Saúde , Inquéritos Epidemiológicos , Humanos , Gravidez , Adulto JovemRESUMO
Objective To examine associations of household wealth and individual literacy with prenatal care in West Africa. Methods Data on women with recent births in Benin, Burkina Faso, Ghana, Guinea, Liberia, Mali, Nigeria, Niger, Senegal and Sierra Leone were obtained from 2006 to 2010 Demographic and Health Surveys (n = 58,512). Separate logistic regressions estimated associations of literacy and wealth quintiles with prenatal care, controlling for age, parity, marital status, rural/urban residence, religion, multiple births, pregnancy wantedness, and the woman's involvement in decision-making at home. Any prenatal care was defined by ≥1 prenatal care visit. Adequate prenatal care was defined as at least four prenatal care visits beginning in the first trimester, at least one with a skilled provider. Results Seventy-eight percent of women had any prenatal care; 23 % had adequate care. Women who were not literate had lower odds of having any prenatal care (odds ratio, OR 0.29; 95 % confidence interval, CI 0.26-0.33) and lower odds of adequate care (OR 0.73, CI 0.68-0.78). Women in the poorest wealth quintile were substantially less likely to have any prenatal care than women in the wealthiest quintile (OR 0.24, CI 0.11-0.18), and less likely to have adequate care (OR 0.31, CI 0.27-0.35). Conclusions for Practice A substantial percentage of women in West Africa have no prenatal care. Few have adequate care. Illiteracy and poverty are important risk factors for having little or no prenatal care. Increasing education for girls, promoting culturally appropriate messages about prenatal care, and building trust in providers may increase prenatal care.
Assuntos
Conhecimentos, Atitudes e Prática em Saúde , Alfabetização , Mães/psicologia , Pobreza , Cuidado Pré-Natal/estatística & dados numéricos , Adolescente , Adulto , África Ocidental , Feminino , Inquéritos Epidemiológicos , Humanos , Pessoa de Meia-Idade , Gravidez , Características de Residência , Fatores Socioeconômicos , Adulto JovemRESUMO
BACKGROUND: Metabolic syndrome (MetS) is a cluster of conditions--including abdominal obesity, dyslipidemia, hypertension, and hyperglycemia--that are associated with a significantly increased risk of developing diabetes and cardiovascular diseases. No information currently exists regarding the prevalence of MetS in North Carolina. This study determined the prevalence of MetS among adults receiving care in a large integrated health care system in North Carolina. METHODS: This study used data from the Carolinas HealthCare System's electronic medical record system and included adults receiving care during 2014. The association between patient demographic characteristics and MetS was determined using multivariable logistic regression. RESULTS: The prevalence of MetS was approximately 22.5%. Individuals aged 18-29 years were less likely to have MetS compared with those aged 80 years and older (odds ratio [OR], 0.61; 95% confidence interval [CI], 0.56-0.67). Groups that were more likely to have MetS included women (OR, 1.07; 95% CI, 1.05-1.10), Hispanics (OR, 1.14; 95% CI, 1.05-1.23), individuals with Medicare (OR, 1.38; 95% CI, 1.33-1.42), and those with Medicaid (OR, 1.68; 95% CI, 1.58-1.78) compared with men, whites, and those with commercial insurance, respectively. LIMITATIONS: We excluded individuals with missing data for any of the conditions that define MetS, which may underestimate the actual prevalence of this condition. CONCLUSIONS: The considerable prevalence of MetS in our North Carolina sample suggests that interventions are needed to achieve the state's population health goals.
Assuntos
Síndrome Metabólica/epidemiologia , Adolescente , Adulto , Idoso , Idoso de 80 Anos ou mais , Feminino , Humanos , Masculino , Pessoa de Meia-Idade , North Carolina/epidemiologia , Prevalência , Adulto JovemRESUMO
Cancer clinical trial (CCT) accrual and retention rates remain disproportionately low among African Americans. Awarenesss and access to trials are crucial facilitators of trial participation. Strategies developed within a community-based participatory framework (CBPR) are potential solutions to increase awareness and access to CCTs. In this study, we describe the pilot phase of three innovative community-centered modules to improve basic CCT knowledge, awareness of locations to access CCT information, and opportunities to participate in CCTs. Four community organizations completed Community Bridges to CCT training-of-the-trainer and recruited adult African American volunteers to participate in one of three CCT education modules: a workshop about CCTs, a role play describing one person's experience with CCTs, or a call and response session reviewing myths and facts about CCTs. Pre- and post-test surveys were collected and analyzed using McNemar agreement statistic to evaluate changes in knowledge and attitudes regarding trials. Trainers enrolled 125 participants in the call and response (n = 22), role play (n = 60), and workshop (n = 43) modules. Module participants were mostly African American, female, and with a mean age of 53 years. Comparison of pre- and post-test responses demonstrates favorable changes in awareness of CCTs and where to access CCTs across the sample. Analysis by module type indicates significant increases for participants in the call and response (p < 0.01) and role play modules (p < 0.001), but not the workshop module. Despite measures taken to increase the participation and retention rate of African Americans in clinical trials, little advancement has been made. Developing tailored community education modules on CCTs within the CBPR framework is a promising innovation to increase knowledge about CCTs and favorable attitudes about participation that are known precursors to trial enrollment.
Assuntos
Negro ou Afro-Americano , Ensaios Clínicos como Assunto/estatística & dados numéricos , Pesquisa Participativa Baseada na Comunidade , Neoplasias/prevenção & controle , Participação do Paciente , Seleção de Pacientes , Adulto , Idoso , Idoso de 80 Anos ou mais , Defesa do Consumidor , Intervenção Educacional Precoce , Feminino , Conhecimentos, Atitudes e Prática em Saúde , Humanos , Masculino , Pessoa de Meia-Idade , Educação de Pacientes como Assunto , Projetos Piloto , Projetos de Pesquisa , Adulto JovemRESUMO
BACKGROUND: Although churches are an important partner for improving health within the African American community, it is not known how congregants are best reached by health promotion activities and thus how best to target members in recruitment. This study examined how characteristics of churches and congregants' beliefs and interests in faith-based health promotion related to their willingness to attend church-based health promotion activities. METHOD: We surveyed adult congregants (n = 1,204) of 11 predominately African American churches in North Carolina. Surveys collected data within four domains: demographics (age, sex, education), behavioral (church attendance, respondent food choices, and physical activity), cognitive (church-based health promotion belief, Bible-based healthy living interest, healthy living resource interest), or environmental (family health, church travel distance, church health ministry activity, church members' food choices). Analyses used a dichotomous outcome, interest in attending programs offered by the health ministry. Domain-specific models were constructed. Logistic generalized estimating equations adjusted for clustering. RESULTS: Of the 1,204 congregants, 72% were female, 57% were 50 years or older, 84% had a high school education or more, and 77% had a chronic health condition. In bivariate analyses and in models adjusting for all four domains, cognitive factors had the highest odds of willingness to attend. CONCLUSION: Congregants' belief in the church's role in health promotion and their desire to learn about healthy behaviors highlight the role of the African American church as a partner in addressing health disparities and the need to capitalize on this expectation through stronger partnerships between medical and faith communities.
Assuntos
Negro ou Afro-Americano/estatística & dados numéricos , Promoção da Saúde/estatística & dados numéricos , Religião , Adolescente , Adulto , Negro ou Afro-Americano/psicologia , Fatores Etários , Meio Ambiente , Feminino , Comportamentos Relacionados com a Saúde , Nível de Saúde , Humanos , Estilo de Vida , Masculino , Pessoa de Meia-Idade , North Carolina , Características de Residência , Fatores Socioeconômicos , Adulto JovemRESUMO
The coronavirus disease 2019 (COVID-19) pandemic raised new considerations for social disparities in critical illness including hospital capacity and access to personal protective equipment, access to evolving therapies, vaccinations, virtual care, and restrictions on family visitation. This narrative review aims to explore evidence about racial/ethnic and socioeconomic differences in critical illness during the COVID-19 pandemic, factors driving those differences and promising solutions for mitigating inequities in the future. We apply a patient journey framework to identify social disparities at various stages before, during, and after patient interactions with critical care services and discuss recommendations for policy and practice.
Assuntos
COVID-19 , Estado Terminal , Disparidades em Assistência à Saúde , Humanos , COVID-19/epidemiologia , COVID-19/terapia , Cuidados Críticos , Fatores Socioeconômicos , Pandemias , SARS-CoV-2 , Acessibilidade aos Serviços de SaúdeRESUMO
BACKGROUND: The optimal approach to implementing telemedicine hypertension management in the United States is unknown. METHODS: We examined telemedicine hypertension management versus the effect of usual clinic-based care on blood pressure (BP) and patient/clinician-related heterogeneity in a systematic review/meta-analysis. We searched United States-based randomized trials from Medline, Embase, CENTRAL, CINAHL, PsycINFO, Compendex, Web of Science Core Collection, Scopus, and 2 trial registries. We used trial-level differences in BP and its control rate at ≥6 months using random-effects models. We examined heterogeneity in univariable metaregression and in prespecified subgroups (clinicians leading pharmacotherapy [physician/nonphysician], self-management support [pharmacist/nurse], White versus non-White patient predominant trials [>50% patients/trial], diabetes predominant trials [≥25% patients/trial], and White patient predominant but not diabetes predominant trials versus both non-White and diabetes patient predominant trials]. RESULTS: Thirteen, 11, and 7 trials were eligible for systolic and diastolic BP difference and BP control, respectively. Differences in systolic and diastolic BP and BP control rate were -7.3 mmâ Hg (95% CI, -9.4 to -5.2), -2.7 mmâ Hg (-4.0 to -1.5), and 10.1% (0.4%-19.9%), respectively, favoring telemedicine. Greater BP reduction occurred in trials where nonphysicians led pharmacotherapy, pharmacists provided self-management support, White patient predominant trials, and White patient predominant but not diabetes predominant trials, with no difference by diabetes predominant trials. CONCLUSIONS: Telemedicine hypertension management is more effective than clinic-based care in the United States, particularly when nonphysicians lead pharmacotherapy and pharmacists provide self-management support. Non-White patient predominant trials achieved less BP reduction. Equity-conscious, locally informed adaptation of telemedicine interventions is needed before wider implementation.