Characterizing Physical Intimate Partner Violence-Associated Injuries Among Adults in Low- and Middle-Income Countries: A Systematic Review.

Forty-two percent of women who experienced intimate partner violence (IPV) reported that their experience of IPV resulted in an injury. This review aims to review the existing literature from low- and middle-income countries (LMICs) on IPV-related injuries as well as identify IPV-related injury patterns and locations. A systematic electronic database search was conducted between August and September 2021 (Prospero ID: CRD42021281519). Five databases yielded 408 articles; 328 remained for title and abstract screening after duplicates were removed. Of the 59 eligible for full-text review, 19 articles were eligible for extraction. After quality assessment, 18 articles were included in the study. Most (56%) studies were observational studies. Studies represented 15 different countries. The majority of the studies (89%) had authors whose institutional affiliation was located in the country where the study took place. Soft tissue injuries were the most commonly reported injury type followed by fractures and burns. The most common injury locations were the head, neck, and face followed by both upper and lower limbs. The most commonly cited injury mechanism was bodily force. The findings of this study echo what has been written in the literature regarding IPV-related injury patterns from high-income countries (HICs). One limitation of this study is that the search only included literature published in English. The injury patterns identified in this article confirm the need for awareness and action on the part of both medical and surgical providers in order to best address IPV in LMICs.

Barriers to and Outcomes of Initiating Clinical Research at Two Trauma Centers in Mexico.

INTRODUCTION: Despite efforts to advance clinical research through collaboration between Latin and North American partners, there remains persistent barriers to performing investigative work. To overcome these obstacles, a team of over 100 surgeon-leaders from 18 Latin American countries founded the Asociación de Cirujanos Traumatólogos de las Américas (ACTUAR). One of ACTUAR's first major collaborative projects, initiated in 2018, was a prospective, observational, multicenter study evaluating quality of life after open tibia fracture management. The current study identified common barriers experienced during the initiation of this study, as exemplified through two sites in Mexico. The study aims to identify obstacles to proactively overcome these in future collaborative work. METHODS: Two research assistants from University of California, San Francisco and two research coordinators from Mexico were recruited to share their experiences, identify common barriers experienced during site enrollment and on-boarding for the ACTUAR open tibia study, and discuss possible solutions. RESULTS: Barriers were organized into three categories: structural, logistical, and intrapersonal. Structural barriers included differences in patient populations and resources between private and public hospitals. Logistical barriers included ambiguous ethical review processes, internet availability, and low patient follow-up. Primary enrollment as a resident responsibility led to some intrapersonal barriers. Potential solutions were identified for each barrier and agreed upon by all collaborators. CONCLUSIONS: Multiple barriers were identified by research personnel who initiated a prospective surgical clinical research study in Mexico. Through collaborative approaches, many potential solutions may help overcome these barriers and build locally led research capacity in Latin America.

Development of an Open-Access Webinar Series on Pathways for Global Surgery Engagement for Applicants to US Residency Programs.

BACKGROUND: Global surgery (GS) training pathways in residency are unclear and vary by specialty and program. Furthermore, information on these pathways is not always accessible. To address this gap, we produced a collection of open-access webinars for senior medical students focused on identifying GS training pathways during residency. METHODS: The Global Surgery Student Alliance (GSSA) is a national nonprofit that engages US students and trainees in GS education, research, and advocacy. GSSA organized nine one-hour, specialty-specific webinars featuring residents of surgical specialties, anesthesia, and OBGYN programs. Live webinars were produced via Zoom from August to October 2020, and all recordings were posted to the GSSA YouTube channel. Medical students moderated webinars with predetermined standardized questions and live questions submitted by attendees. Participant data were collected in mandatory registration forms. RESULTS: A total of 539 people were registered for 9 webinars. Among registrants, 189 institutions and 36 countries were represented. Registrants reported education/training levels from less than undergraduate education to attending physicians, while medical students represented the majority of registrants. Following the live webinars, YouTube recordings of the events were viewed 839 times. Webinars featuring otolaryngology and general surgery residents accrued the greatest number of registrations, while anesthesia accrued the least. CONCLUSIONS: Medical students at all levels demonstrated interest in both the live and recorded specialty-specific webinars on GS in residency. To address the gap in developing global surgery practitioners, additional online, open-access education materials and mentorship opportunities are needed for students applying to US residencies.

Adverse events in the treatment of motorcycle-related isolated limb injuries at a regional hospital in Uganda: a prospective clinical analysis.

PURPOSE: Although motorcycle accidents are a leading cause of limb injury in Uganda, little is known about injury care quality at regional hospitals. This study measured the incidence of clinical adverse events (CAEs) and identified associated treatment barriers surrounding motorcycle-related isolated limb injuries at a regional hospital. METHODS: A prospective descriptive study was conducted among patients with motorcycle-related isolated limb injuries at a Ugandan regional hospital between September 2017 and February 2018. Patients were surveyed upon admission and monitored throughout their course of treatment. Weight-bearing status and quality of life measures (EQ-5D) were assessed at four and 12 weeks. RESULTS: One hundred twenty-four participants enrolled. Of the total participants, 12% refused definitive treatment. Among 108 treated patients, six experienced CAEs: four wound infections, one amputation, and one death. At 12 weeks follow-up, the majority of patients had no difficulty with mobility, pain/discomfort, or self-care, but 51% endorsed challenges completing certain daily chores, and 40% of patients could ambulate without an assistive device with restoration of pre-fracture gait. Both longer hospital stays and poorer 12-week functional recovery were seen among patients sustaining open fracture (p < 0.001). CONCLUSION: Treatment of isolated limb injuries at a Ugandan Regional Hospital was associated with minimal short-term CAEs. However, patients with more severe injuries may be at risk for delayed post-operative recovery. Future studies measuring long-term functional outcomes should be performed to better understand and optimize injury care in this population.

Understanding the Role of Past Health Care Discrimination in Help-Seeking and Shared Decision-Making for Depression Treatment Preferences.

As a part of a larger, mixed-methods research study, we conducted semi-structured interviews with 21 adults with depressive symptoms to understand the role that past health care discrimination plays in shaping help-seeking for depression treatment and receiving preferred treatment modalities. We recruited to achieve heterogeneity of racial/ethnic backgrounds and history of health care discrimination in our participant sample. Participants were Hispanic/Latino (n = 4), non-Hispanic/Latino Black (n = 8), or non-Hispanic/Latino White (n = 9). Twelve reported health care discrimination due to race/ethnicity, language, perceived social class, and/or mental health diagnosis. Health care discrimination exacerbated barriers to initiating and continuing depression treatment among patients from diverse backgrounds or with stigmatized mental health conditions. Treatment preferences emerged as fluid and shaped by shared decisions made within a trustworthy patient-provider relationship. However, patients who had experienced health care discrimination faced greater challenges to forming trusting relationships with providers and thus engaging in shared decision-making processes.

The impact of a comprehensive electronic patient portal on the health service use: an interrupted time-series analysis.

BACKGROUND: There is little empirical research on the potential benefit that electronic patient portals (EPP) can have on the care quality and health outcomes of diverse multi-ethnic international populations. The purpose of this study is to determine the extent to which an EPP was associated with improvements in health service use. METHODS: Using a quasi-experimental interrupted time-series approach, we assessed health service use before (April 2012-September 2015) and after (October 2015-December 2016) the implementation of a comprehensive EPP at four hospitals in Madrid, Spain. Primary outcomes were number of outpatient visits, any hospital admission, any 30-day all-cause readmission and any emergency department visit. RESULTS: Implementation of the EPP was associated with a significant decline in readmissions. Among patients with chronic heart failure, EPP implementation was associated with a significant decline for all outcome measures, and among patients with COPD, a decline in all outcomes except readmissions. Among patients diagnosed with malignant hematological diseases, no significant changes were identified. CONCLUSIONS: EPPs hold promise for reducing hospital readmissions. Certain patient populations with chronic conditions may differentially benefit from portal use depending on their needs for communication with their providers.

Trends in smoking among adults with mental illness and association between mental health treatment and smoking cessation.

IMPORTANCE: Significant progress has been made in reducing the prevalence of tobacco use in the United States. However, tobacco cessation efforts have focused on the general population rather than individuals with mental illness, who demonstrate greater rates of tobacco use and nicotine dependence. OBJECTIVES: To assess whether declines in tobacco use have been realized among individuals with mental illness and examine the association between mental health treatment and smoking cessation. DESIGN, SETTING, AND PARTICIPANTS: Use of nationally representative surveys of noninstitutionalized US residents to compare trends in smoking rates between adults with and without mental illness and across multiple disorders (2004-2011 Medical Expenditure Panel Survey [MEPS]) and to compare rates of smoking cessation among adults with mental illness who did and did not receive mental health treatment (2009-2011 National Survey of Drug Use and Health [NSDUH]).The MEPS sample included 32,156 respondents with mental illness (operationalized as reporting severe psychological distress, probable depression, or receiving treatment for mental illness) and 133,113 without mental illness. The NSDUH sample included 14,057 lifetime smokers with mental illness. MAIN OUTCOMES AND MEASURES: Current smoking status (primary analysis; MEPS sample) and smoking cessation, operationalized as a lifetime smoker who did not smoke in the last 30 days (secondary analysis; NSDUH sample). RESULTS: Adjusted smoking rates declined significantly among individuals without mental illness (19.2% [95% CI, 18.7-19.7%] to 16.5% [95% CI, 16.0%-17.0%]; P < .001) but changed only slightly among those with mental illness (25.3% [95% CI, 24.2%-26.3%] to 24.9% [95% CI, 23.8%- 26.0%]; P = .50), a significant difference in difference of 2.3% (95% CI, 0.7%-3.9%) (P = .005). Individuals with mental illness who received mental health treatment within the previous year were more likely to have quit smoking (37.2% [95% CI, 35.1%-39.4%]) than those not receiving treatment (33.1% [95% CI, 31.5%-34.7%]) (P = .005). CONCLUSIONS AND RELEVANCE: Between 2004 and 2011, the decline in smoking among individuals with mental illness was significantly less than among those without mental illness, although quit rates were greater among those receiving mental health treatment. This suggests that tobacco control policies and cessation interventions targeting the general population have not worked as effectively for persons with mental illness.

Disproportionate increase in cannabis use among people with serious psychological distress and associations with psychiatric service use in the United States, 2009-2019.

BACKGROUND: Cannabis use is on the rise, but it is unclear how use is changing among individuals with serious psychological distress (SPD) compared to the general population as well as what associations this may have with mental health service use. METHODS: Retrospective cohort study using the National Survey on Drug Use and Health (NSDUH) 2009-19 public use files of 447,228 adults aged ≥ 18 years. Multivariable logistic regression and predictive margin methods were used to estimate linear time trends in any and greater-than-weekly levels of cannabis use by year and SPD status and rates of psychiatric hospitalization and outpatient mental health care. FINDINGS: Rates of any and weekly-plus cannabis use increased similarly among individuals with SPD compared to those without from 200 to 2014 but more rapidly in SPD every year from 2015 to 2019 (p < 0.001). Among individuals with SPD, no use was associated with a 4.2 % probability of psychiatric hospitalization, significantly less than less-than-weekly (5.0 %, p = 0.037) and weekly-plus cannabis use (5.1 %, p = 0.028). For outpatient mental health care, no use was associated with a 27.4 % probability (95 % CI 26.7-28.1 %) of any outpatient care, significantly less than less than weekly use (32.6 % probability, p < 0.001) and weekly-plus use (29.9 % probability, p = 0.01). CONCLUSIONS: Cannabis use is increasing more rapidly among individuals with SPD than the general population, and is associated with increased rates of psychiatric hospitalization and outpatient service use. These findings can inform policy makers looking to tailor regulations on advertising for cannabis and develop public health messaging on cannabis use by people with mental illness.

Examining Racial/Ethnic Differences in Patterns of Opioid Prescribing: Results from an Urban Safety-Net Healthcare System.

Prescription opioids still account for a large proportion of overdose deaths and contribute to opioid use dependence (OUD). Studies earlier in the epidemic suggest clinicians were less likely to prescribe opioids to racial/ethnic minorities. As OUD-related deaths have increased disproportionately amongst minority populations, it is essential to understand racial/ethnic differences in opioid prescribing patterns to inform culturally sensitive mitigation efforts. The purpose of this study is to estimate racial/ethnic differences in opioid medication use among patients prescribed opioids. Using electronic health records and a retrospective cohort study design, we estimated multivariable hazard models and generalized linear models, assessing racial/ethnic differences in OUD diagnosis, number of opioid prescriptions, receiving only one opioid prescription, and receiving ≥18 opioid prescriptions. Study population (N=22,201) consisted of adult patients (≥18years), with ≥3 primary care visits (ensuring healthcare system linkage), ≥1 opioid prescription, who did not have an OUD diagnoses prior to the first opioid prescription during the 32-month study period. Relative to racial/ethnic minority patients, White patients, in both unadjusted and adjusted analyses, had a greater number of opioid prescriptions filled, a higher proportion received ≥18 opioid prescriptions, and a greater hazard of having an OUD diagnosis subsequent to receiving an opioid prescription (all groups p<0.001). Although opioid prescribing rates have declined nationally, our findings suggest White patients still experience a high volume of opioid prescriptions and greater risk of OUD diagnosis. Racial/ethnic minorities are less likely to receive follow-up pain medications, which may signal low care quality. Identifying provider bias in pain management of racial/ethnic minorities could inform interventions seeking balance between adequate pain treatment and risk of opioid misuse/abuse.

Self-Pay Outpatient Mental Health Care for Children and Adolescents, by Socioeconomic Status.

OBJECTIVE: Many parents struggle to find mental health care for their children, and many mental health clinicians do not accept insurance payments. The authors aimed to estimate the frequency and cost of self-pay psychotherapy and psychotropic medication management visits for youths and to determine how service use varies by family income. METHODS: A descriptive cross-sectional analysis was performed among youths ages 5-17 years in the 2018-2020 Medical Expenditure Panel Survey. Specialist visits included those with psychiatrists, psychologists, social workers, and mental health counselors or family therapists. RESULTS: Approximately one in five of 13,639 outpatient mental health specialist visits were self-pay, with psychologists (23% of visits) and social workers (24% of visits) most likely to see youths on a self-pay basis. Use of self-pay care was strongly associated with higher income, but even families earning <$28,000 per year utilized some self-pay care, at a median cost of $95 per visit. Self-pay visits were associated with slightly lower clinical need than insurance-covered visits, although this measure varied by income. CONCLUSIONS: The self-pay market for child mental health care potentially exacerbates inequities in access to care by burdening low-income families with high costs. Incentivizing mental health providers to participate in insurance for larger portions of their patient panels, for example, by increasing reimbursement rates and reducing paperwork, may help improve equitable access to mental health care. To the extent that reimbursement rates drive insurance acceptance, the frequency of self-pay mental health visits suggests that mental health services are underreimbursed relative to their benefit to patients and families.

Examining Racial/Ethnic Disparities in Tobacco Dependence Treatment Among Medicaid Beneficiaries Using Fifty State Medicaid Claims, 2009-2014.

In the USA, low-income racial/ethnic minority groups experience higher smoking rates and greater smoking-related disease burden than their White counterparts. Despite the adverse effects, racial/ethnic minorities are less likely to access tobacco dependence treatment (TDT). Medicaid is one of the largest payers of TDT in the USA and covers predominantly low-income populations. The extent of TDT use among beneficiaries from distinct racial/ethnic groups is unknown. The objective is to estimate racial/ethnic differences in TDT use among Medicaid fee-for-service beneficiaries. Using a retrospective study design and 50 state (including the District of Columbia) Medicaid claims (2009-2014), we employed multivariable logistic regression models and predictive margin methods to estimate TDT use rates among adults (18-64) enrolled (≥ 11 months) in Medicaid fee-for-service programs (January 2009-December 2014) by race/ethnicity. The population included White (n = 6,536,004), Black (n = 3,352,983), Latinx (n = 2,264,647), Asian (n = 451,448), and Native American/Alaskan Native (n = 206,472) beneficiaries. Dichotomous outcomes reflected service use in the past year. Any TDT use was operationalized as any smoking cessation medication fill, any smoking cessation counseling visit, or any smoking cessation outpatient visit. In secondary analyses, we disaggregated TDT use into three separate outcomes. Results suggested that Black (10.6%; 95% CI = 9.9-11.4%), Latinx (9.5%; 95% CI = 8.9-10.2%), Asian (3.7%; 95% CI = 3.4-4.1%), and Native American/Alaskan Native (13.7%; 95% CI = 12.7-14.7%) beneficiaries had lower TDT use rates compared to White beneficiaries (20.6%). Similar racial/ethnic treatment disparities were identified across all outcomes. By identifying significant racial/ethnic disparities in TDT use between 2009 and 2014, this study provides a benchmark against which to measure recent interventions in state Medicaid programs improving equity in smoking cessation interventions.

Estimating the economic impact of complications after open tibial fracture: A secondary analysis of the pilot Gentamicin Open Tibia trial (pGO-Tibia).

Objectives: To estimate the indirect economic impact of tibial fractures and their associated adverse events (AEs) in Tanzania. Design: A secondary analysis of the pilot Gentamicin Open (pGO)-Tibia randomized control trial estimating the indirect economic impact of suffering an AE, defined as a fracture-related infection (FRI) and/or nonunion, after an open tibial fracture in Tanzania. Setting: The pGO-Tibia trial was conducted from November 2019 to August 2021 at the Muhimbili Orthopaedic Institute in Dar es Salaam, Tanzania. Patients/Participants: One hundred adults with open tibial shaft fractures participated in this study. Intervention: Work hours were compared between AE groups. Cost data were analyzed using a weighted-average hourly wage and converted into purchasing power parity-adjusted USD. Main Outcome Measurements: Indirect economic impact was analyzed from the perspective of return to work (RTW), lost productivity, and other indirect economic and household costs. RTW was analyzed using a survival analysis. Results: Half of patients returned to work at 1-year follow-up, with those experiencing an AE having a significantly lower rate of RTW. Lost productivity was nearly double for those experiencing an AE. There was a significant difference in the mean outside health care costs between groups. The total mean indirect cost was $2385 with an AE, representing 92% of mean annual income and an increase of $1195 compared with no AE. There were significantly more patients with an AE who endorsed difficulty affording household expenses postinjury and who borrowed money to pay for their medical expenses. Conclusions: This study identified serious economic burden after tibial fractures, with significant differences in total indirect cost between those with and without an AE. Level of Evidence: II.

Ethnoracial Differences in Social Determinants of Health and Acute Mental Health Symptoms Among Adults Hospitalized After Emergency Care.

Research has established relationships between social determinants of health (SDOH) and mental health, with mixed findings on which ethnoracial groups are most vulnerable to deleterious outcomes. The current study examines ethnoracial differences in SDOH and their associations with acute mental health symptoms among patients hospitalized after emergency care. Using data collected in a multi-site study of 1,318 diverse adults admitted to inpatient units, we performed analyses using linear regression models. Findings show that Multiracial/Indigenous and Black adults had significantly higher discrimination and financial stress scores. However, compared with White adults, the positive association between extreme discrimination and acute mental health symptoms was diminished among Latinx (B=-2.3; p=.02) and Black individuals (B=-1.6; p=.05) as was the positive association between financial insecurity and acute mental health symptoms for Black adults (B=-2.3; p=.04). This study provides evidence of differential experiences of SDOH and mental health challenges that may warrant tailored interventions.

An Analysis of Participant Preferences Regarding Virtual Versus In-person Format of Orthopaedic Surgery Educational Materials in Low- and Middle-Income Countries.

INTRODUCTION: The University of California, San Francisco Institute for Global Orthopaedics and Traumatology Surgical Management and Reconstructive Training (SMART) course has instructed orthopaedic surgeons from low-resource countries on soft-tissue reconstruction. Before the COVID-19 pandemic, the course was conducted in-person; however, it was transitioned to a virtual format during the pandemic. The aim of this study was to determine participant preferences regarding a virtual or in-person SMART course format. METHODS: Survey data were collected via e-mail after each SMART course using RedCap or Qualtrics. Statistical analyses were conducted using Stata. RESULTS: There were 247 survey respondents from 44 countries representing all world regions, with Africa (125, 51%) the most represented. Of those who attended both an in-person and virtual course, most (82%) preferred the in-person format. In addition, all measured course outcomes were significantly better for participants attending the in-person course. The most common reason for not attending an in-person course was the cost of travel (38, 51%). DISCUSSION: This study demonstrated a preference toward in-person learning for the SMART course. In addition, those surgeons participating in the in-person course endorsed increased positive outcomes from the course. Increased emphasis should be placed on in-person surgical skills training for low-resource surgeons.

Critical elements of international academic partnerships in orthopaedic surgery: a modified Delphi approach.

Background: Despite the recent emphasis on promoting international collaborations within orthopaedic surgery, criteria for determining the strengths of such partnerships has not been established. The purpose of this study was to evaluate orthopaedic experts' perceptions of the most valuable characteristics of international academic partnerships. Methods: This study was conducted using a modified Delphi methodology. Experts were identified through the Consortium of Orthopaedic Academic Traumatologists (COACT). Responses were collected from February to September 2022. Three rounds of surveys listing possible topics on a 5-point Likert scale were used to develop consensus among a group of experts. Consensus criteria for topic inclusion in the final scale was determined as a rating of "strongly agree" or "agree" by ≥70% of the participants in the third survey. Results: The Round 1 survey was distributed to 96 invited participants within the COACT network, of which 50 experts (52.1%) completed the first survey. Consensus was reached on 54 topics organized into the following 5 categories: Research, Advocacy/Leadership, Training/Surgical Skills, Education/Knowledge Exchange, and Sustainability and Safety (RATES Criteria). Conclusions: Determining the most valuable characteristics of successful international academic partnerships can lead to more sustainable, mutually beneficial collaborations. The criteria identified in this study can provide the foundation for developing new partnerships and assessing existing ones.

The Current State of International Academic Partnerships in Orthopaedic Surgery Between High-Income and Low and Middle-Income Countries: A Systematic Review.

Background: Orthopaedic academic partnerships between high-income countries (HICs) and low and middle-income countries (LMICs) are an effective method to increase research and scholarly support. The purpose of this study was to perform a systematic literature review of the current state of partnerships worldwide and assess the quality, quantity, and content of their research output. Methods: A systematic review was conducted using 4 academic databases: PubMed, MEDLINE, Embase, and CENTRAL. Article eligibility criteria included articles published between January 2017 and 2022, with orthopaedic authors from at least 1 HIC and LMIC. Articles related to global orthopaedic surgery with exclusively HIC or LMIC authors were excluded. Results: The database search yielded 25,928 articles, and after deduplication, 21,145 articles were included in the screening. After title and abstract screening, 408 articles underwent full-text review for eligibility. The final list of eligible articles for extraction included 310 publications in 127 journals. Published articles increased over time (46 in 2017 to 88 in 2021) and were most commonly published in the Journal of Bone and Joint Surgery (20, 6.5%). Open-access articles (203, 65.5%) had a significantly greater Journal Citation Indicator (p = 0.024) than non-open-access articles. Most studies (40.7%) were observational, with few (3.6%) randomized controlled trials. Orthopaedic trauma (38.1%) was the most common subspecialty, followed by spine (14.8%) and pediatrics (14.2%). Most partnerships were sponsored by North American authors in 65 LMICs, primarily China, India, and the sub-Saharan African region. Conclusion: This study identified 310 articles published by orthopaedic international academic partnerships in 106 countries over the past 5 years, demonstrating that collaborations between LMIC/HIC partners nearly doubled over the study period. Sixty-five percent of the articles were published in open-access journals.

The economic impact of infection and/or nonunion on long-bone shaft fractures: a systematic review.

Background: Long-bone fractures are a major cause of morbidity worldwide. These injuries are often complicated by infection or nonunion, which significantly affect patient quality of life and economic costs. Although studies have quantified the impact of these fractures, there is not a comprehensive review summarizing their economic and lifestyle costs. Study Objective: This review summarized the impact of long-bone fracture infection and nonunion on health-related quality of life, as measured by utility scores, and both direct and indirect economic costs. Methods: A systematic review was conducted using the following databases: PubMed, EMBASE, Web of Science, and the Cochrane Library. The search included terms related to long-bone fractures, infection, nonunion, cost, and utility. The search yielded 1267 articles, and after deduplication, 1144 were screened, yielding 116 articles for full-text review. Screening was conducted using Covidence and extraction using REDCap. Results: Twenty-two articles met inclusion criteria, with the majority being from the United States and Europe. Most articles were retrospective studies, predominantly regarding the tibia. Fifteen articles contained cost data and 8 contained utility data, with 1 article containing both. Ten cost articles and 1 utility article contained infection data. 8 cost and all utility articles contained nonunion data. Infection ranged from 1.5 to 8.0 times the cost of an uncomplicated fracture. Nonunion ranged from 2.6 to 4.3 times the cost of an uncomplicated fracture. Utility data were variable and ranged from 0.62 to 0.66 for infection and 0.48-0.85 for nonunion. Conclusions: Infection and nonunion after long-bone fractures are associated with large decreases in health-related quality of life and incur substantial costs to both patients and health care systems. The data presented in this review quantify these impacts and may serve useful for future economic analyses. In addition, this study highlights the dearth of high-quality literature on this important topic.

Eliciting patient past experiences of healthcare discrimination as a potential pathway to reduce health disparities: A qualitative study of primary care staff.

OBJECTIVE: To understand whether and how primary care providers and staff elicit patients' past experiences of healthcare discrimination when providing care. DATA SOURCES/STUDY SETTING: Twenty qualitative semi-structured interviews were conducted with healthcare staff in primary care roles to inform future interventions to integrate data about past experiences of healthcare discrimination into clinical care. STUDY DESIGN: Qualitative study. DATA COLLECTION/EXTRACTION METHODS: Data were collected via semi-structured qualitative interviews between December 2018 and January 2019, with health care staff in primary care roles at a hospital-based clinic within an urban safety-net health system that serves a patient population with significant racial, ethnic, and linguistic diversity. PRINCIPAL FINDINGS: Providers did not routinely, or in a structured way, elicit information about past experiences of healthcare discrimination. Some providers believed that information about healthcare discrimination experiences could allow them to be more aware of and responsive to their patients' needs and to establish more trusting relationships. Others did not deem it appropriate or useful to elicit such information and were concerned about challenges in collecting and effectively using such data. CONCLUSIONS: While providers see value in eliciting past experiences of discrimination, directly and systematically discussing such experiences with patients during a primary care encounter is challenging for them. Collecting this information in primary care settings will likely require implementation of multilevel systematic data collection strategies. Findings presented here can help identify clinic-level opportunities to do so.

Estimates of Major Depressive Disorder and Treatment Among Adolescents by Race and Ethnicity.

Importance: The COVID-19 pandemic has contributed to poorer mental health and a greater need for treatment. Nationally representative estimates of major depressive disorder (MDD) and mental health treatment among US adolescents during the pandemic are needed. Objective: To estimate MDD prevalence among adolescents, evaluate mental health treatment use among adolescents with MDD, and assess differences by race and ethnicity. Design, Setting, and Participants: This cross-sectional analysis of the nationally representative 2021 National Survey on Drug Use and Health included noninstitutionalized US adolescents between the ages of 12 and 17 years (n = 10 743). Analytic weights were applied to all rates and model estimates to be nationally representative and account for sample design and survey nonresponse. Data were collected from January 14 to December 20, 2021, and analyzed from February 11 to April 3, 2023. Exposures: Self-reported race and ethnicity. Main Outcomes and Measures: Dichotomous outcomes of MDD as defined by the Diagnostic and Statistical Manual of Mental Disorders (Fifth Edition), MDD-specific mental health treatment, any type of mental health treatment, telehealth visits, and delays in mental health treatment. Results: The sample included 10 743 adolescents (51.1% male). Self-reported race and ethnicity included 5.1% Asian, 14.1% Black, 23.3% Latinx, 51.2% White, and 6.3% more than 1 race. Ages were evenly distributed: 34.0% aged 12 to 13 years; 33.3% aged 14 to 15 years; and 32.7% aged 16 to 17 years. Adolescents of more than 1 race or ethnicity had the highest MDD rate (26.5%). Compared with White adolescents, the lowest rates of any MDD treatment overall were found among Latinx adolescents (29.2% [95% CI, 22.2%-36.2%]) and those of more than 1 race or ethnicity (21.1% [95% CI, 11.6%-30.7%]). Similar results were found for treatment by any clinician (Latinx, 25.6% [95% CI, 18.8%-32.4%]; >1 race or ethnicity, 19.1% [95% CI, 9.7%-28.6%]), treatment by a mental health specialist (Latinx, 22.9% [95% CI, 16.9%-28.9%]; >1 race or ethnicity, 16.7% [95% CI, 7.1%-26.3%]), treatment by a nonspecialist clinician (Latinx, 7.3% [95% CI, 3.3%-11.3%]; >1 race or ethnicity, 4.8% [95% CI, 1.9%-7.7%]), and use of any psychotropic medication prescription (Latinx, 11.6% [95% CI, 7.3%-15.9%]; >1 race or ethnicity, 8.3% [95% CI, 2.8%-13.7]). Compared with White adolescents, Black adolescents had lower rates of MDD treatment by any clinician (31.7% [95% CI, 23.7%-39.8%]) and by nonspecialist clinicians (8.4% [95% CI, 3.8%-13.2%]) and experienced lower prescription rates for any psychotropic medication (12.6 [95% CI, 4.6%-20.6%]). Asian (16.0% [95% CI, 5.0%-27.2%]) and Latinx (17.8% [95% CI, 12.6%-23.0%]) adolescents had lower rates of virtual mental health treatment compared with White adolescents. Black (19.1% [95% CI, 14.1%-24.2%]) and Latinx (17.9% [95% CI, 15.0%-21.1%]) adolescents had lower rates of appointments transition to telehealth, while Black adolescents (14.1% [95% CI, 10.7%-17.4%]) experienced delays getting their prescriptions. Conclusions and Relevance: During the first full calendar year of the pandemic, approximately 1 in 5 adolescents had MDD, and less than half of adolescents who needed treatment had any mental health treatment. Adolescents in racial and ethnic minority groups, particularly Latinx, experienced the lowest treatment rates. Federal policy should target adolescents as a whole, and minority populations in particular, to ensure equitable treatment access. Efforts should consider the social, racial, ethnic, and cultural determinants of health.