Gender and Sexual Orientation Differences in Sexual Violence Knowledge, Prevention Behaviors, and Care-Seeking Behaviors.

Sexual violence (SV) on college campuses disproportionately affects cisgender (nontransgender) women, sexual minorities (e.g., gays/lesbians, bisexuals), and gender minority (e.g., transgender/nonbinary) people. This study investigates gender and sexual behavior differences in common SV intervention targets-SV-related knowledge, prevention behaviors, and care-seeking. We analyzed cross-sectional survey data, collected in 9/2015-3/2017, from 2202 students aged 18-24 years attending college health and counseling centers at 28 Pennsylvania and West Virginia campuses. Multivariable multilevel models tested gender and sexual behavior differences in SV history; recognition of SV; prevention behaviors (self-efficacy to obtain sexual consent, intentions to intervene, positive bystander behaviors); and care-seeking behaviors (knowledge of, self-efficacy to use, and actual use of SV services). Adjusting for lifetime exposure to SV, compared with cisgender men, cisgender women had higher recognition of SV and reproductive coercion, prevention behaviors, and care-seeking self-efficacy (beta range 0.19-1.36) and gender minority people had higher recognition of SV and intentions to intervene (beta range 0.33-0.61). Cisgender men with any same-gender sexual partners had higher SV knowledge (beta = 0.23) and self-efficacy to use SV services (beta = 0.52) than cisgender men with only opposite-gender partners. SV history did not explain these differences. Populations most vulnerable to SV generally have higher SV knowledge, prevention behaviors, and care-seeking behaviors than cisgender men with only opposite-gender sexual partners. Innovative SV intervention approaches are necessary to increase SV-related knowledge among heterosexual cisgender men and may need to target alternative mechanisms to effectively reduce inequities for sexual and gender minority people.

What Explains Inequalities in Telehealth Utilization Among North Carolina Medicaid Beneficiaries?

Background: Increased availability of telehealth can improve access to health care. However, there is evidence of persistent disparities in telehealth usage, as well as among people from minoritized racial and ethnic groups and rural residents. The objective of our work was to explore the degree to which disparities in telehealth use for behavioral health (BH) and musculoskeletal (MSK) related services during the COVID-19 pandemic are explained by observed beneficiary- and area-level characteristics. Methods: Using North Carolina Medicaid claims data of Medicaid beneficiaries with BH or MSK conditions, we apply nonlinear regression-based decomposition analysis-based models developed by Kitagawa, Oaxaca, and Blinder to determine which observed variables are associated with racial, ethnic, and rural inequalities in telehealth usage. Results: In the BH cohort, we found statistically significant differences in telehealth usage by race in the adult population, and by race, Hispanic ethnicity, and rurality in the pediatric population. In the MSK cohort, we found significant inequities by Hispanic ethnicity and rurality among adults, and by race and rurality among children. Inequalities in telehealth use between groups were small, ranging from 0.7 percentage points between urban and rural adults with MSK conditions to 3.8 percentage points between white adults and people of color among those with BH conditions. Overall, we found that racial and ethnic inequalities in telehealth use are not well explained by the observed variables in our data. Rural disparities in telehealth use are better explained by observed variables, particularly area-level broadband internet use. Conclusions: For inequalities between rural and urban residents, our analysis provides observational evidence that infrastructure such as broadband internet access is an important driver of differences in telehealth use. For racial and ethnic inequalities, the pathways may be more complex and difficult to measure, particularly when relying on administrative data sources in place of more detailed data on individual-level socioeconomic factors.

Opportunities for Integration in the Dual Medicare-Medicaid Population: North Carolina Landscape Analysis.

Background: NC Medicaid is amid a transformation to value-based care models. The transformation requires the consideration of models that may best serve the 1 in 5 NC Medicaid beneficiaries who are dually enrolled in Medicare. The lack of integration of Medicare and Medicaid administration, financing, and care may contribute to suboptimal health outcomes and care experiences. Integrating Medicare and Medicaid to improve care for dually enrolled individuals requires knowledge of the demographic, eligibility, and enrollment trends, as well as the medical needs of these individuals throughout North Carolina. Methods: We performed a cross-sectional analysis of 2019 NC Medicaid administrative enrollment data and 2015-2020 Medicare and Medicaid public use files. Results: Nearly half of North Carolina's full-benefit dual-eligible (FBDE) population was eligible for Medicare due to disability. About one-third of the FBDE population lost full Medicaid benefits at some point during 2019; of these, 65% were under age 65. Most FBDE beneficiaries were enrolled in Medicaid fee-for-service, with 3.5% enrolled in Community Alternatives Program (CAP) waivers, 2% in Medicaid waivers for beneficiaries with behavioral health or intellectual and developmental disabilities (BH/IDD) or traumatic brain injury (TBI), and 1% in the Program of All-Inclusive Care for the Elderly (PACE). Enrollment in Medicare Duals Special Needs Plans (D-SNPs) increased from 7.3% of the FBDE population in 2015 to 32.5% in 2021. Limitations: This descriptive, cross-sectional evaluation of North Carolina duals may not be generalizable to other time periods and contexts. Conclusion: Medicare-Medicaid integration presents an opportunity to improve the value of care for dual-eligible beneficiaries and aligns with the goals of NC Medicaid transformation. Integration strategies that leverage the current infrastructure may minimize disruption of services for beneficiaries and mitigate the impacts of unstable enrollment, particularly among working-age adults and disabled beneficiaries. The diversity within the dual-eligible populations requires a strategy designed to improve health equity across race, disability, eligibility, geography, and health care needs.

Linking Medicare-Medicaid Claims for Patient-Centered Outcomes Research Among Dual-Eligible Beneficiaries.

BACKGROUND: Evaluation of Medicare-Medicaid integration models' effects on patient-centered outcomes and costs requires multiple data sources and validated processes for linkage and reconciliation. OBJECTIVE: To describe the opportunities and limitations of linking state-specific Medicaid and Centers for Medicare & Medicaid Services administrative claims data to measure patient-centered outcomes for North Carolina dual-eligible beneficiaries. RESEARCH DESIGN: We developed systematic processes to (1) validate the beneficiary ID linkage using sex and date of birth in a beneficiary ID crosswalk, (2) verify dates of dual enrollment, and (3) reconcile Medicare-Medicaid claims data to support the development and use of patient-centered outcomes in linked data. PARTICIPANTS: North Carolina Medicaid beneficiaries with full Medicaid benefits and concurrent Medicare enrollment (FBDE) between 2014 and 2017. MEASURES: We identified need-based subgroups based on service use and eligibility program requirements. We calculated utilization and costs for Medicaid and Medicare, matched Medicaid claims to Medicare service categories where possible, and reported outcomes by the payer. Some services were covered only by Medicaid or Medicare, including Medicaid-only covered home and community-based services (HCBS). RESULTS: Of 498,030 potential dual enrollees, we verified the linkage and FBDE eligibility of 425,664 (85.5%) beneficiaries, including 281,174 adults enrolled in Medicaid and Medicare fee-for-service. The most common need-based subgroups were intensive behavioral health service users (26.2%) and HCBS users (10.8%) for adults under age 65, and HCBS users (20.6%) and nursing home residents (12.4%) for adults age 65 and over. Medicaid funded 42% and 49% of spending for adults under 65 and adults 65 and older, respectively. Adults under 65 had greater behavioral health service utilization but less skilled nursing facility, HCBS, and home health utilization compared with adults 65 and older. CONCLUSIONS: Linkage of Medicare-Medicaid data improves understanding of patient-centered outcomes among FBDE by combining Medicare-funded acute and ambulatory services with Medicaid-funded HCBS. Using linked Medicare-Medicaid data illustrates the diverse patient experience within FBDE beneficiaries, which is key to informing patient-centered outcomes, developing and evaluating integrated Medicare and Medicaid programs, and promoting health equity.

Evaluating Telehealth Uptake Among North Carolina Medicaid Beneficiaries With Musculoskeletal Conditions: Insights From the COVID-19 Pandemic.

BACKGROUND: The shift from in-person to virtual visits, known as telehealth (TH), during the COVID-19 pandemic was a significant change for North Carolina (NC) Medicaid beneficiaries seeking treatment for musculoskeletal (MSK) conditions, as remote care for these conditions was previously unavailable. We used this policy change to investigate factors associated with TH uptake and whether TH availability mitigated disparities in access to care or affected emergency department (ED) visits among these beneficiaries. RESEARCH DESIGN: Using 2019-2021 NC Medicaid claims, we identified beneficiaries receiving treatment for MSK conditions before COVID-19 (March 2019-February 2020) and analyzed uptake of newly available TH during COVID-19 (April 2020-March 2021). We used descriptive analysis and Poisson generalized estimating equations to quantify TH uptake, factors associated with TH uptake, and the association with ED visits during COVID-19. RESULTS: Black and Hispanic beneficiaries were less likely to use TH compared with White and non-Hispanic counterparts (10%, P <0.001 and 20%, P =0.03, respectively). Adults eligible for Tailored Plans, specialized NC Medicaid plans for those with significant behavioral health needs or intellectual/developmental disabilities, were less likely to use TH [adjusted risk ratio (ARR):0.83, 95% CI (0.78, 0.87)]; youth eligible for Tailored Plans were more likely to use TH [ARR:1.28, 95% CI (1.16, 1.42)]. Lower county-level internet access was associated with lower TH use [ARR: 0.85, 95% CI (0.82, 0.99)]. No statistical difference in ED utilization was observed between TH users and non-users. CONCLUSIONS: TH has the potential to deliver convenient care to beneficiaries with MSK conditions who can access it. Further research and policy changes should explore and address underlying factors driving disparities and improve equitable access to care for this population.

Healthcare Utilization for Medicaid-Insured Children with Medical Complexity: Differences by Sociodemographic Characteristics.

OBJECTIVE: To compare differences in healthcare utilization and costs for Medicaid-insured children with medical complexity (CMC) by race/ethnicity and rurality. METHODS: Retrospective cohort of North Carolina (NC) Medicaid claims for children 3-20 years old with 3 years continuous Medicaid coverage (10/1/2015-9/30/2018). Exposures were medical complexity, race/ethnicity, and rurality. Three medical complexity levels were: without chronic disease, non-complex chronic disease, and complex chronic disease; the latter were defined as CMC. Race/ethnicity was self-reported in claims; we defined rurality by home residence ZIP codes. Utilization and costs were summarized for 1 year (10/1/2018-9/30/2019) by complexity level classification and categorized as acute care (hospitalization, emergency [ED]), outpatient care (primary, specialty, allied health), and pharmacy. Per-complexity group utilization rates (per 1000 person-years) by race/ethnicity and rurality were compared using adjusted rate ratios (ARR). RESULTS: Among 859,166 Medicaid-insured children, 118,210 (13.8%) were CMC. Among CMC, 36% were categorized as Black non-Hispanic, 42.7% White non-Hispanic, 14.3% Hispanic, and 35% rural. Compared to White non-Hispanic CMC, Black non-Hispanic CMC had higher hospitalization (ARR = 1.12; confidence interval, CI 1.08-1.17) and ED visit (ARR = 1.17; CI 1.16-1.19) rates; Hispanic CMC had lower ED visit (ARR = 0.77; CI 0.75-0.78) and hospitalization rates (ARR = 0.79; CI 0.73-0.84). Black non-Hispanic and Hispanic CMC had lower outpatient visit rates than White non-Hispanic CMC. Rural CMC had higher ED (ARR = 1.13; CI 1.11-1.15) and lower primary care utilization rates (ARR = 0.87; CI 0.86-0.88) than urban CMC. DISCUSSION: Healthcare utilization varied by race/ethnicity and rurality for Medicaid-insured CMC. Further studies should investigate mechanisms for these variations and expand higher value, equitable care delivery for CMC.

Assessing feasibility of an adolescent relationship abuse prevention program for girls.

INTRODUCTION: Sexual violence and relationship abuse are prevalent among adolescents and programs promoting gender equity, reproductive justice, and healthy relationships are key strategies for prevention. While such "gender transformative" approaches appear promising for boys, they have not been evaluated among girls. This study assessed the feasibility of this community-based program, called Sisterhood 2.0, among girls in socially disadvantaged urban neighborhoods in Pittsburgh, Pennsylvania. METHODS: This quasi-experimental trial examined feasibility of Sisterhood 2.0 (n = 246), delivered through 8 weekly sessions, assessed through attendance, retention and satisfaction. Participants completed surveys at baseline and end of program assessing other relevant measures. Generalized linear mixed models estimated changes from baseline to follow up comparing intervention to control participants. RESULTS: Eleven neighborhoods were assigned to Sisterhood 2.0 (n = 5 neighborhoods) or job-readiness training (n = 6 neighborhoods). Girls were between the ages of 13 and 19, 8-10th graders (59%), and self-identified as Black (69%). Participants most often attended because they thought the program would be interesting (74%) and returned because of the women teaching the program (71%). Girls reported experiences with physical adolescent relationship abuse (ARA) (30% in both arms), emotional ARA (66% intervention; 56% control), or sexual ARA (11% intervention; 12% control). Physical ARA perpetration was high in both arms (intervention: 47%; control: 46%). Significant intervention effects were observed in recognition of abuse (ß = 0.41, 95% confidence interval 0.03-0.78). No other significant intervention effects were observed. CONCLUSIONS: Community-based gender-transformative programming for girls is feasible and may be a promising approach for addressing interpersonal violence and promoting sexual health.

Cases of Sexual Assault Prevented in an Athletic Coach-Delivered Gender Violence Prevention Program.

Sexual violence (SV) is pervasive and economically burdensome in the USA. According to the CDC, SV prevention could avert $122,461 in costs per victim of rape, totaling an estimated $3.1 trillion. Coaching Boys into Men (CBIM) is an evidence-based dating abuse and SV prevention program found to reduce dating abuse and SV perpetration among male high school athletes and dating abuse among middle school athletes. This secondary data analysis of CBIM's high school (N = 1520) and middle school (N = 973) RCTs estimated the incidence of dating abuse, sexual harassment, and sexual assault that CBIM could prevent as well as the potential cost savings. Ten items measured dating abuse, with a subset measuring sexual assault and sexual harassment, among participants who had ever dated a female. Perpetration measures were dichotomized as present or absent. Maximum likelihood estimates of Poisson-distributed event rates allowed for possible multiple incidents of perpetration per athlete. Among high school athletes, CBIM was associated with a relative reduction of 85 incidents of dating abuse (95%CI 24, 146), 48 incidents of sexual harassment (95%CI 3.8, 92), and 20 incidents of sexual assault (95%CI 1.7, 38) per 1,000 athletes. Results among middle school athletes demonstrated similar, albeit non-significant, trends. Based on the reduction of sexual assaults among high school athletes alone, CBIM may have resulted in $2.4 million reduction in costs per 1000 athletes exposed. CBIM may be associated with significant sexual assault-related cost reductions. Given the low costs and time needed to implement the program, sexual and dating violence prevention programs like CBIM may result in substantial economic benefits.

Sexual Assault, Alcohol Use, and Gender of Sexual Partners Among Cisgender Women Seeking Care at US College Health Centers, 2015-2018.

Objectives. To assess differences by gender of sexual partner in the association between sexual assault and alcohol use among women seeking care in college health centers.Methods. This longitudinal study comprised 1578 women aged 18 to 24 years visiting 28 college health centers in Pennsylvania and West Virginia from 2015 to 2018. We used multilevel logistic regression and negative binomial regression, testing for interactions of gender of sexual partners, sexual assault, and prevalence and frequency of alcohol use and binge drinking.Results. Sexual assault was reported by 87.3% of women who had sex with women or with women and men (WSWM), 68.2% of women who had sex with men only (WSM), and 47.5% of women with no penetrative sexual partners. The relative associations between sexual assault and alcohol outcomes were smaller for WSWM (prevalence: odds ratios from 0.04 to 0.06; frequency: incidence rate ratios [IRRs] from 0.24 to 0.43) and larger for women who had no penetrative sexual partners (IRRs from 1.55 to 2.63), compared with WSM.Conclusions. Alcohol use patterns among women who have experienced sexual assault differ by gender of sexual partners.

Mechanisms Through Which a Family Caregiver Coaching Intervention Might Reduce Anxiety Among Children in Military Households.

OBJECTIVES: Children of injured or disabled veterans and service members may be at risk for mental health and adjustment problems due to household stress. Yet, there are few widely available interventions to address the needs of this population. Reducing distress and improving coping skills of the parent who cares for the injured or disabled adult may improve child outcomes. This paper examines whether changes in caregiver psychosocial outcomes after a caregiver coaching intervention are associated with decreases in child anxiety. METHODS: Using programmatic data collected between 2015 and 2019 from participants in a family caregiver coaching intervention (170 caregivers, 294 children), we apply linear mixed models to assess associations between changes in family caregiver well-being, including problem solving, depressive symptoms, burden, health complaints and quality of life, and changes in parent-reported child anxiety. RESULTS: The baseline median Spence Children's Anxiety Scale-Parent score was 17; children aged 6-11 had slightly higher scores. Child anxiety scores decreased on average 2.8 points (SD 8.4) between baseline and follow-up. In adjusted models, decreases in caregiver depressive symptoms and health complaints were associated with decreases in child anxiety. Caregiver problem-solving skills, quality of life, and subjective burden were not associated with changes in child anxiety. CONCLUSION: Family caregiver-focused interventions that decrease caregiver stress may positively affect children in the household. Few resources are directed at military children; therefore, practitioners should consider ways to leverage caregiver interventions to address child well-being, such as incorporating information on parenting strategies and addressing issues faced by military children.

Current practices in menstrual management in adolescents with cancer: A national survey of pediatric oncology providers.

BACKGROUND: Adolescents and young adult (AYA) women with cancer are at risk of heavy menstrual bleeding (HMB) due to thrombocytopenia, coagulopathy, and/or disruption of the hypothalamic-pituitary-gonadal axis. Currently, little is known about current practices to help prevent and treat HMB in AYA women with cancer. METHODS: We surveyed providers from 100 pediatric oncology centers. Face and content validity were assessed prior to distribution. Descriptive statistics, Chi-squared and Fisher exact tests were used for analysis. RESULTS: Ninety-four percent of respondents have recommended preventative menstrual suppression. More than half of respondents agreed that patients with the following types of cancers should receive preventative menstrual suppression: sarcomas, acute leukemias, lymphomas, and germ cell tumors. The most preferred form of menstrual suppression was GnRH agonists. Almost 95% of respondents felt that it is important to consider menstrual suppression and that a formal guideline about initiation of menstrual suppression would be helpful. Only 46% felt comfortable personally managing menstrual suppression. CONCLUSIONS: The vast majority of pediatric oncologists who responded to this national survey have used preventative menstrual suppression and feel that it is important to consider in many types of AYA cancers. Although pediatric oncologists are most often managing menstrual suppression, they do not feel comfortable doing so and desire guidelines to help with management. Future studies to assess which patients require menstrual suppression and which menstrual suppression is best tolerated and efficacious is needed.

Updates on adolescent dating and sexual violence prevention and intervention.

PURPOSE OF REVIEW: Dating and sexual violence victimization are not uncommon in early adolescence and increase in prevalence throughout adolescence into young adulthood with profound health and social consequences. Greater attention to what works in prevention is needed to inform current policies and practices. RECENT FINDINGS: Adolescent dating violence (ADV) and sexual violence victimization, including cyber dating abuse, are highly prevalent among adolescents. Studies have found sex category differences, with adolescent girls reporting more victimization than boys, particularly sexual violence. Sexual and gender minority youth also experience a higher prevalence of violence victimization than their heterosexual counterparts. Studies on risk factors include examinations of childhood adversities, exposure to sexually explicit material and substance use as well as the role of gender inequitable attitudes on violence perpetration. Recent prevention research includes examining the impact of bystander interventions and transforming gender norms. SUMMARY: Recent ADV/ sexual violence research highlights both prevalence and modifiable risk and protective factors that may help reduce such violence. Practitioners caring for youth should consider ADV/ sexual violence when seeing patients (including those struggling with substance use and other behaviours that contribute to poor health) and not simply rely on screening tools to identify those suffering from ADV/ sexual violence.

Cluster randomized controlled trial protocol: addressing reproductive coercion in health settings (ARCHES).

BACKGROUND: Women ages 16-29 utilizing family planning clinics for medical services experience higher rates of intimate partner violence (IPV) and reproductive coercion (RC) than their same-age peers, increasing risk for unintended pregnancy and related poor reproductive health outcomes. Brief interventions integrated into routine family planning care have shown promise in reducing risk for RC, but longer-term intervention effects on partner violence victimization, RC, and unintended pregnancy have not been examined. METHODS/DESIGN: The 'Addressing Reproductive Coercion in Health Settings (ARCHES)' Intervention Study is a cluster randomized controlled trial evaluating the effectiveness of a brief, clinician-delivered universal education and counseling intervention to reduce IPV, RC and unintended pregnancy compared to standard-of-care in family planning clinic settings. The ARCHES intervention was refined based on formative research. Twenty five family planning clinics were randomized (in 17 clusters) to either a three hour training for all family planning clinic staff on how to deliver the ARCHES intervention or to a standard-of-care control condition. All women ages 16-29 seeking care in these family planning clinics were eligible to participate. Consenting clients use laptop computers to answer survey questions immediately prior to their clinic visit, a brief exit survey immediately after the clinic visit, a first follow up survey 12-20 weeks after the baseline visit (T2), and a final survey 12 months after the baseline (T3). Medical record chart review provides additional data about IPV and RC assessment and disclosure, sexual and reproductive health diagnoses, and health care utilization. Of 4009 women approached and determined to be eligible based on age (16-29 years old), 3687 (92 % participation) completed the baseline survey and were included in the sample. DISCUSSION: The ARCHES Intervention Study is a community-partnered study designed to provide arigorous assessment of the short (3-4 months) and long-term (12 months) effects of a brief, clinician-delivered universal education and counseling intervention to reduce IPC, RC and unintended pregnancy in family planning clinic settings. The trial features a cluster randomized controlled trial design, a comprehensive data collection schedule and a large sample size with excellent retention. TRIAL REGISTRATION: ClinicialTrials.gov NCT01459458. Registered 10 October 2011.

Gestational diabetes diagnostic methods (GD2M) pilot randomized trial.

To test the feasibility of conducting a pragmatic randomized controlled trial (RCT) comparing the International Association of Diabetes in Pregnancy Study Groups (IADPSG) versus Carpenter-Coustan diagnostic criteria for gestational diabetes (GDM), and to examine patient and provider views on GDM screening. A single-blinded pragmatic pilot RCT. Participants with a singleton pregnancy between 24 and 28 weeks gestation received a 50 g oral glucose challenge test and if the value was <200 mg/dL were randomized to either the 2 h 75 g OGTT using the IADPSG criteria or the 3 h 100 g OGTT using the Carpenter-Coustan criteria. Primary outcome was the feasibility of randomization and screening. Secondary outcomes included patient and provider views (or preferences) on GDM testing. Sixty-eight women were recruited, 48 (71 %) enrolled and 47 (69 %) were randomized. Participants in both study arms identified the main challenges to GDM testing to be: drinking the glucola, fasting prior to testing, waiting to have blood drawn, and multiple venipuntures. Women in both study arms would prefer the 2 h 75 g OGTT or whichever test is recommended by their doctor in a future pregnancy. Physicians and nurse midwives endorsed screening and were comfortable with being blinded to the GDM testing strategy and results values. Both pregnant women and providers value GDM screening, and pregnant women can be recruited to a blinded, randomized GDM screening trial with minimal attrition and missing data.

Nurse-Led Strategy to Improve Blood Pressure and Cholesterol Level Among People With HIV: A Randomized Clinical Trial.

Importance: Despite higher atherosclerotic cardiovascular disease (ASCVD) risk, people with HIV (PWH) experience unique barriers to ASCVD prevention, such as changing models of HIV primary care. Objective: To test whether a multicomponent nurse-led strategy would improve systolic blood pressure (SBP) and non-high-density lipoprotein (HDL) cholesterol level in a diverse population of PWH receiving antiretroviral therapy (ART). Design, Setting, and Participants: This randomized clinical trial enrolled PWH at 3 academic HIV clinics in the US from September 2019 to January 2022 and conducted follow-up for 12 months until January 2023. Included patients were 18 years or older and had a confirmed HIV diagnosis, an HIV-1 viral load less than 200 copies/mL, and both hypertension and hypercholesterolemia. Participants were stratified by trial site and randomized 1:1 to either the multicomponent EXTRA-CVD (A Nurse-Led Intervention to Extend the HIV Treatment Cascade for Cardiovascular Disease Prevention) intervention group or the control group. Primary analyses were conducted according to the intention-to-treat principle. Intervention: The EXTRA-CVD group received home BP monitoring guidance and BP and cholesterol management from a dedicated prevention nurse at 4 in-person visits (baseline and 4, 8, and 12 months) and frequent telephone check-ins up to every 2 weeks as needed. The control group received general prevention education sessions from the prevention nurse at each of the 4 in-person visits. Main Outcomes and Measures: Study-measured SBP was the primary outcome, and non-HDL cholesterol level was the secondary outcome. Measurements were taken over 12 months and assessed by linear mixed models. Prespecified moderators tested were sex at birth, baseline ASCVD risk, and trial site. Results: A total of 297 PWH were randomized to the EXTRA-CVD arm (n = 149) or control arm (n = 148). Participants had a median (IQR) age of 59.0 (53.0-65.0) years and included 234 males (78.8%). Baseline mean (SD) SBP was 135.0 (18.8) mm Hg and non-HDL cholesterol level was 139.9 (44.6) mg/dL. At 12 months, participants in the EXTRA-CVD arm had a clinically significant 4.2-mm Hg (95% CI, 0.3-8.2 mm Hg; P = .04) lower SBP and 16.9-mg/dL (95% CI, 8.6-25.2 mg/dL; P < .001) lower non-HDL cholesterol level compared with participants in the control arm. There was a clinically meaningful but not statistically significant difference in SBP effect in females compared with males (11.8-mm Hg greater difference at 4 months, 9.6 mm Hg at 8 months, and 5.9 mm Hg at 12 months; overall joint test P = .06). Conclusions and Relevance: Results of this trial indicate that the EXTRA-CVD strategy effectively reduced BP and cholesterol level over 12 months and should inform future implementation of multifaceted ASCVD prevention programs for PWH. Trial Registration: ClinicalTrials.gov Identifier: NCT03643705.

Feasibility of Implementation of a Mobile Digital Personal Health Record to Coordinate Care for Children and Youth With Special Health Care Needs in Primary Care: Protocol for a Mixed Methods Study.

BACKGROUND: Electronic health record (EHR)-integrated digital personal health records (PHRs) via Fast Healthcare Interoperability Resources (FHIR) are promising digital health tools to support care coordination (CC) for children and youth with special health care needs but remain widely unadopted; as their adoption grows, mixed methods and implementation research could guide real-world implementation and evaluation. OBJECTIVE: This study (1) evaluates the feasibility of an FHIR-enabled digital PHR app for CC for children and youth with special health care needs, (2) characterizes determinants of implementation, and (3) explores associations between adoption and patient- or family-reported outcomes. METHODS: This nonrandomized, single-arm, prospective feasibility trial will test an FHIR-enabled digital PHR app's use among families of children and youth with special health care needs in primary care settings. Key app features are FHIR-enabled access to structured data from the child's medical record, families' abilities to longitudinally track patient- or family-centered care goals, and sharing progress toward care goals with the child's primary care provider via a clinician dashboard. We shall enroll 40 parents or caregivers of children and youth with special health care needs to use the app for 6 months. Inclusion criteria for children and youth with special health care needs are age 0-16 years; primary care at a participating site; complex needs benefiting from CC; high hospitalization risk in the next 6 months; English speaking; having requisite technology at home (internet access, Apple iOS mobile device); and an active web-based EHR patient portal account to which a parent or caregiver has full proxy access. Digital prescriptions will be used to disseminate study recruitment materials directly to eligible participants via their existing EHR patient portal accounts. We will apply an intervention mixed methods design to link quantitative and qualitative (semistructured interviews and family engagement panels with parents of children and youth with special health care needs) data and characterize implementation determinants. Two CC frameworks (Pediatric Care Coordination Framework; Patient-Centered Medical Home) and 2 evaluation frameworks (Consolidated Framework for Implementation Research; Technology Acceptance Model) provide theoretical foundations for this study. RESULTS: Participant recruitment began in fall 2022, before which we identified >300 potentially eligible patients in EHR data. A family engagement panel in fall 2021 generated formative feedback from family partners. Integrated analysis of pretrial quantitative and qualitative data informed family-centered enhancements to study procedures. CONCLUSIONS: Our findings will inform how to integrate an FHIR-enabled digital PHR app for children and youth with special health care needs into clinical care. Mixed methods and implementation research will help strengthen implementation in diverse clinical settings. The study is positioned to advance knowledge of how to use digital health innovations for improving care and outcomes for children and youth with special health care needs and their families. TRIAL REGISTRATION: ClinicalTrials.gov NCT05513235; https://clinicaltrials.gov/study/NCT05513235. INTERNATIONAL REGISTERED REPORT IDENTIFIER (IRRID): DERR1-10.2196/46847.

Telehealth Utilization Among Adult Medicaid Beneficiaries in North Carolina with Behavioral Health Conditions During the COVID-19 Pandemic.

OBJECTIVE: We examined factors associated with telehealth utilization during COVID-19 among adult Medicaid beneficiaries with behavioral health conditions. DATA SOURCES AND STUDY SETTING: NC Medicaid 2019-2021 beneficiary and claims data. STUDY DESIGN: This retrospective cohort study examined and compared behavioral health service use pre-COVID-19 (03/01/2019 to 02/28/2020) and during COVID-19 (04/01/2020 to 03/31/2021). Telehealth users included those with at least one behavioral health visit via telehealth during COVID-19. Descriptive statistics were calculated for overall sample and by telehealth status. Multilevel modified Poisson generalized estimating equation examined associations between telehealth use and patient- and area-level characteristics. DATA COLLECTION/EXTRACTION METHODS: We identified individuals ages ≥ 21-64, diagnosed with a behavioral health condition, and had at least one behavioral-health specific visit before COVID-19. PRINCIPAL FINDINGS: Almost two-thirds of the cohort received behavioral health services during COVID-19, with half of these beneficiaries using telehealth. Non-telehealth users had steeper declines in service use from pre- to during COVID-19 compared to telehealth users. Beneficiaries identifying as Black, multiracial or other were significantly less likely to use telehealth (ARR = 0.86; 95% CI: (0.83, 0.89)); (ARR = 0.92; 95% CI: (0.87, 0.96)) compared to White beneficiaries. Those eligible for Medicaid through the blind/disabled programs and who qualified for a state-specific specialized behavioral health plan were more likely to use telehealth (17% and 20%, respectively). CONCLUSIONS: During the pandemic, telehealth facilitated continuity of care for beneficiaries with behavioral health conditions. Future research should aim to investigate how to reduce the digital divide and ensure equitable access to telehealth.

Health Care Use and Spending Among Need-Based Subgroups of Medicare Beneficiaries With Full Medicaid Benefits.

Importance: Beneficiaries dual eligible for Medicare and Medicaid account for a disproportionate share of expenditures due to their complex care needs. Lack of coordination between payment programs creates misaligned incentives, resulting in higher costs, fragmented care, and poor health outcomes. Objective: To inform the design of integrated programs by describing the health care use and spending for need-based subgroups in North Carolina's full benefit, dual-eligible population. Design, Setting, and Participants: This cross-sectional study using Medicare and North Carolina Medicaid 100% claims data (2014-2017) linked at the individual level included Medicare beneficiaries with full North Carolina Medicaid benefits. Data were analyzed between 2021 and 2022. Exposure: Need-based subgroups: community well, home- and community-based services (HCBS) users, nursing home (NH) residents, and intensive behavioral health (BH) users. Measures: Medicare and Medicaid utilization and spending per person-year (PPY). Results: The cohort (n = 333 240) comprised subgroups of community well (64.1%, n = 213 667), HCBS users (15.0%, n = 50 095), BH users (15.2%, n = 50 509), and NH residents (7.5%, n = 24 927). Overall, 61.1% reported female sex. The most common racial identities included Asian (1.8%), Black (36.1%), and White (58.7%). Combined spending for Medicare and Medicaid was $26 874 PPY, and the funding of care was split evenly between Medicare and Medicaid. Among need-based subgroups, combined spending was lowest among community well at $19 734 PPY with the lowest portion (38.5%) of spending contributed by Medicaid ($7605). Among NH residents, overall spending ($68 359) was highest, and the highest portion of spending contributed by Medicaid (70.1%). Key components of spending among HCBS users' combined total of $40 069 PPY were clinician services on carrier claims ($14 523) and outpatient facility services ($9012). Conclusions and relevance: Federal and state policy makers and administrators are developing strategies to integrate Medicare- and Medicaid-funded health care services to provide better care to the people enrolled in both programs. Substantial use of both Medicare- and Medicaid-funded services was found across all need-based subgroups, and the services contributing a high proportion of the total spending differed across subgroups. The diversity of health care use suggests a tailored approach to integration strategies with comprehensive set benefits that comprises Medicare and Medicaid services, including long-term services and supports, BH, palliative care, and social services.

Inequities in Receipt of the North Carolina Medicaid Waiver Among Individuals with Intellectual Disability or Autism Spectrum Disorder.

OBJECTIVE: We examined characteristics associated with receiving the North Carolina Home and Community-Based Services Waiver for intellectual and developmental disabilities (I/DDs) and its association with emergency department (ED) utilization. METHOD: Through analysis of the North Carolina 2017 to 2018 Medicaid claims and enrollment data, we examined characteristics (age, sex, race and ethnicity, geography, diagnosis (intellectual disability [ID] with or without autism spectrum disorders or autism spectrum disorder without ID) associated with receiving the NC I/DD Waiver and the association of this Wavier with ED utilization. We identified patients with at least 1 International Classification of Diseases-10-CM diagnosis code for an ID or autism spectrum disorder. We excluded patients with missing county information and whose enrollment in the NC I/DD Waiver program began after October 1, 2017. RESULTS: Only 22% of 53,531 individuals with I/DD in North Carolina received the Waiver. Non-Hispanic Blacks and Hispanic individuals were less likely to receive the Waiver than non-Hispanic White individuals. Adults (>21 years old), men, and urban residents were more likely to receive the Waiver. Individuals who received the Waiver were 31% less likely to use the ED. CONCLUSION: Innovative strategies are needed to provide equitable access to the NC I/DD Waiver and provide services to the 14,000 people with I/DD currently waiting to receive the Waiver. Through the Waiver, those with I/DD can access preventative and therapeutic outpatient services and decrease their need for ED care. These findings highlight the need for policy reform to address inequities in access to the Waiver for individuals with I/DD.

Individual and program Characteristics May Drive Variability in Outcomes After Caregivers Participate in a Tailored Support Intervention.

Critically needed programs designed to support family caregivers have shown inconsistent reductions in stress and burden. To explore drivers of improvement in caregiver outcomes after participation in a support intervention we analyzed data from a one-on-one, tailored problem-solving intervention targeting caregiver wellbeing (2015-2019, n = 503). We explored data patterns across 21 individual, household, and program-level variables using elastic net regression to identify drivers of improvements, and their relative importance. Baseline subjective burden, baseline depressive symptom scores, baseline caregiver problem solving, African American race, and site and coach fixed effects were the most consistent drivers of changes across the explored caregiver outcomes. Caregiver and program characteristics may be promising avenues to target to decrease distress and burden during intervention design. Interventions focusing on highly distressed caregivers may lead to greater improvements. More research is needed to identify how site or interventionists characteristics drive positive intervention effects.