Secret shopper studies: an unorthodox design that measures inequities in healthcare access

What's in a Lie? How Researchers Judge the Justifiability of Deception

Research ethics guidance on deception does not seem to provide extensive support to researchers and ethics reviewers on how to assess the justifiability of specific deceptive studies. One potential explanation for this shortcoming is that guidance does not offer precise and coherent descriptions of the ethically relevant characteristics of deceptive studies. To facilitate the development of improved guidance, we report on the findings of interviews with a diverse group of 24 researchers who use deception. Interviewees discussed how the interests of participants, society, and researchers can be affected by characteristics of the deceptive methods used. These characteristics pertained to the deceptive act (i.e., false, truthlike, or vague information; standardized or flexible deception), participants' belief formation (i.e., credibility and suspicions), and deception-induced behaviors and experiences (i.e., consent validity, negative value, and duration of induced study behaviors and experiences). In addition, researchers described as ethically relevant the characteristics of the social context in which deceptive studies were embedded. These characteristics related to the deceiver-participant relationship and the participants' community. Overall, our study contributes to a more coherent and precise, as well as complex and nuanced, understanding of the study characteristics that affect the justifiability of deception.

A mystery caller study on pain management options for intrauterine device placement

OBJECTIVES

To understand whether clinics present pain management options for intrauterine device (IUD) placement over the phone and whether these options align with current evidence for effective pain control during placement.

STUDY DESIGN

We used a mystery shopper approach and a standardized call script to collect information from a diverse, purposive sample of 100 clinics listed on www.bedsider.org.

RESULTS

We reached responsive personnel at 90 of the 100 selected clinics, of whom 32 (36%) would not provide information about pain control for IUD placement by phone or to non-established patients. Of the 58 clinics that provided information, four (6.9%) reported that they did not provide any options for pain management, and 54 (93.1%) presented at least one pharmaceutical option. The most common was ibuprofen, which was mentioned by 49 clinics (84.5%). Lidocaine, misoprostol, and naproxen were mentioned by 16 (27.6%), 14 (24.1%), and three (5.2%) clinics, respectively.

CONCLUSIONS

More than one third of clinics were unable to present pain control options over the phone. Among the 58 clinics that presented options to simulated patients calling to request an IUD placement, evidence-based pain control methods, such as lidocaine blocks, 10% lidocaine spray, or naproxen, were not often presented.

IMPLICATIONS

Given the barriers that pain and pre-procedure anxiety pose to uptake of IUDs, it is important for clinic staff to understand current guidelines for pain management during IUD placement as well as the pain control options offered for IUD placements at their clinic.

Bridging language barriers: Access to primary care for Medicaid Managed Care patients with limited English proficiency in three metropolitan areas

This secret shopper study compares the wait times for scheduling a first-time primary-care appointment among adults enrolled in Medicaid Managed Care who speak English, Spanish, or Mandarin in the Los Angeles, Houston, and New York Metropolitan Statistical Areas. Primary-care practices in Medicaid Managed Care Organization directories were randomized by language. The objective of the secret shoppers was to schedule first-time primary-care appointments, either in person or via telehealth. We found that the average wait times for Spanish and Mandarin speakers were greater than for English speakers by 3.73 and 14 days in Los Angeles and 7.29 and 2.55 days in Houston, respectively. The average wait time among Spanish and Mandarin speakers was 2.22 and 1.76 days less compared with English speakers in New York. We discuss the importance of policies and provide recommendations to address disparities in health access and use among adults with limited English proficiency.

Navigating the Orthopaedic Maze as a New Patient: A National Mystery Caller Study on Medicaid Coverage and Access to Specialized Surgeons

INTRODUCTION

Medicaid coverage is associated with longer appointment wait times, decreased access to care, and poorer health outcomes compared with private insurance across medical subspecialties. The purpose of this study was to evaluate new patient appointment wait times for subspecialty Orthopaedic care based on insurance type and to identify factors influencing these wait times.

METHODS

Orthopaedic physicians were identified using the American Academy of Orthopaedic Surgeons patient-facing database in the fields of Adult Reconstruction, Foot and Ankle, Hand, Sports Medicine, Spine, Pediatric, and General Orthopaedic surgery. Mystery callers, posing as patients with either Medicaid or Blue Cross/Blue Shield (BCBS) insurance, contacted physicians to request the next available new patient appointment. The business days until the first available new patient appointment were recorded and analyzed using a linear mixed Poisson model.

RESULTS

A total of 1,002 phone calls were made to 501 unique physicians in 47 states. Among the 349 physicians meeting inclusion criteria, 37% (n = 130) did not accept Medicaid. Medicaid patients experienced a 10% longer wait for a new patient appointment compared with patients with BCBS (incidence rate ratio: 1.10; CI: 1.05 to 1.15; P < 0.01) with mean wait times of 24.9 business days (SD ± 24) and 19.6 business days (SD ± 23), respectively. Increased waiting times were also associated with academic institutions ( P < 0.01), prolonged call times ( P < 0.01), and specific geographic regions ( P < 0.05). Our model achieved an R-squared value of 0.94, demonstrating strong explanatory power.

CONCLUSION

Patients with Medicaid experience longer wait times and decreased access to care when scheduling an appointment with an Orthopaedic surgeon compared with patients with private insurance. This may be due to reimbursement structures in Medicaid that do not cover the full cost of treatment. Aside from advocating for higher reimbursement rates, telehealth initiatives may help bridge this gap to ensure accessibility to orthopaedic surgery for all patients.

Access to Sudden Hearing Loss Care at Urgent Care Centers

OBJECTIVES

To compare patient access to urgent care centers (UCCs) with a diagnosis of sudden hearing loss based on insurance.

METHODS

One hundred twenty-five random UCCs in states with Medicaid expansion and 125 random UCCs in states without Medicaid expansion were contacted by a research assistant posing as a family member seeking care on behalf of a patient with a one-week history of sudden, unilateral hearing loss. Each clinic was called once as a Medicaid patient and once as a private insurance (PI) patient for 500 total calls. Each phone encounter was evaluated for insurance acceptance and self-pay price. Secondary outcomes included other measures of timely/accessible care. Chi-square/McNemar's tests and independent/paired sample t-tests were performed to determine whether there were statistically significant differences between expansion status and insurance type. Calls ended before answering questions were not included in the analysis.

RESULTS

Medicaid acceptance rate was significantly lower than PI (68.1% vs. 98.4%, p < 0.001). UCCs in Medicaid expansion states were significantly more likely to accept Medicaid (76.8% vs. 59.2%, p = 0.003). The mean wage-adjusted self-pay price was significantly greater in states with Medicaid expansion at $169.84 than in states without at $145.34 when called as a Medicaid patient (mean difference: $24.50, 95% Confidence Interval: $0.45-$48.54, p = 0.046). The rates of referral to an emergency department and self-pay price nondisclosure rates were greater for Medicaid calls than for private insurance calls (8.2% vs. 0.4% and 17.4% vs. 5.8%; p < 0.001 for both).

CONCLUSION

Medicaid patients with otologic emergencies face reduced access to care at UCCs.

LEVEL OF EVIDENCE

NA Laryngoscope, 134:5066-5072, 2024.

Evidence-based treatment for opioid use disorder is widely unavailable and often discouraged by providers of residential substance use services in North Carolina

INTRODUCTION

Opioid agonist treatment (OAT) is the only treatment for opioid use disorder (OUD) proven to reduce overdose mortality, yet access to this evidence-based treatment remains poor. The purpose of this cross-sectional audit study was to assess OAT availability at residential substance use services in North Carolina.

METHODS

We conducted a state-wide inventory of residential substance use service providers in North Carolina and subsequently called all providers identified, posing as uninsured persons who use heroin, seeking treatment services. Program characteristics, as reported in phone calls, were systematically recorded. We used Fisher's exact tests to assess what program characteristics were associated with OAT availability and with staff making discouraging comments about OAT. We used unsupervised agglomerative clustering to identify facilities with similar characteristics.

RESULTS

Of the 94 treatment providers identified, we successfully contacted and collected data from 66. Of those, only 7 (10.6 %) provide OAT on site; an additional 9 (13.6 %) allow OAT through an outside or community-based prescriber. Only 8 (12.1 %) providers were licensed to provide residential substance use treatment. Staff from 33 (50.0 %) providers made negative, discouraging, or stigmatizing remarks about OAT-for example, that OAT substitutes one addiction for another or does not constitute "true recovery." OAT availability was positively associated with a provider holding a state license for any substance use-related service (41.9 % vs 8.6 %, p = 0.002) and offering 12-step programming (36.1 % vs. 10/0 %, p = 0.020). OAT availability was negatively associated with faith-based programming (6.1 % vs 42.4 %, p = 0.001), dress codes (5.3 % vs 50.0 %, p < 0.001), and mandates that residents work in a provider-owned and -operated commercial enterprise (5.0 % vs 32.6 %, p = 0.026). Cluster analysis revealed that the most common (n = 21) type of service provider in North Carolina is an unlicensed, faith-based organization that prohibits OAT, imposes a dress code, and mandates that residents work, often in provider-owned and -operated commercial enterprises.

CONCLUSION

Evidence-based treatments for OUD are largely unavailable at providers of residential substance use services in North Carolina. The prohibition of OAT occurs most often among providers who are unlicensed and impose labor and/or 12-step mandates on residents. Changes to state licensure requirements and exemptions may help improve OAT availability.

Pharmacist supply of non-prescription sildenafil in Norway: a simulated patient mixed-method study

BACKGROUND

Pharmacist supply of non-prescription sildenafil was initiated in Norway in 2019, and continuous evaluation of the service is warranted.

OBJECTIVES

To map how the service checklist is used, evaluate the counselling and information given in consultations, get an insight into pharmacist assessments during consultations, and explore the pharmacists' experiences with the service.

METHODS

A mixed-method approach of simulated patient visits with feedback combined with qualitative interviews was used. One 24-year-old simulated patient visited pharmacies requesting sildenafil in a scenario that ended before purchase. Visits were audio-recorded and evaluated. Post-visit, pharmacists were invited to get feedback and participate in an audio-recorded interview. Visits, feedback, and interviews were transcribed and analysed by descriptive statistics and systematic text condensation.

KEY FINDINGS

Of 39 visits, 26 were analysed and 13 were excluded because the pharmacists did not give consent. Six (23%) pharmacists asked all the checklist questions, while 15 (58%) asked some of them. None of the pharmacists provided all the guideline counselling points. The counselling most provided was 'See your general practitioner within 6 months for a health check' (N = 7, 27%). Interviews (N = 19) elicited that pharmacists assessed the patients, with adaptations in the use of the checklist. Several barriers affecting the service were identified, including time pressure, pharmacist competence, and the task being uncomfortable and challenging.

CONCLUSIONS

Most pharmacists did not completely adhere to the mandatory checklist on non-prescription sildenafil and the counselling and information given were limited. The pharmacy sector must increase awareness of how best to assess and manage patients requesting non-prescription sildenafil.

Post Hoc Bias in Treatment Decisions

Importance

A goal of health care is to reduce symptoms and improve health status, whereas continuing dubious treatments can contribute to complacency, discourage the search for alternatives, and lead to shortfalls in care.

Objective

To test a potential bias in intuitive reasoning following a marginal improvement in symptoms after a dubious treatment (post hoc bias).

Design, Setting, and Participants

Surveys eliciting treatment recommendations for hypothetical patients were sent to community members throughout North America recruited via an online survey platform in the early winter months of 2023 and 2024 and presented to health care professionals (pharmacists who were approached in person using a secret shopper technique) in the summer months of 2023.

Exposure

Respondents received randomized versions of surveys that differed according to whether vague symptoms improved or remained unchanged after a dubious treatment.

Main Outcomes and Measures

The primary outcome was a recommendation to continue treatment.

Results

In total, 1497 community members (mean [SD] age, 38.1 [12.5] years; 663 female [55.3%]) and 100 health care professionals were contacted. The first scenario described a patient with a sore throat who took unprescribed antibiotics; respondents were more likely to continue antibiotics after initial treatment if there was a marginal improvement in symptoms vs when symptoms remained unchanged (67 of 150 respondents [45%] vs 25 of respondents [17%]; odds ratio [OR], 3.98 [95% CI, 2.33-6.78]; P < .001). Another scenario described a patient with wrist pain who wore a copper bracelet; respondents were more likely to continue wearing the copper bracelet after initial care was followed by a marginal improvement in symptoms vs when symptoms remained unchanged (78 of 100 respondents [78%] vs 25 of 99 respondents [25%]; OR, 16.19 [95% CI, 5.32-19.52]; P < .001). A third scenario described a patient with fatigue who took unprescribed vitamin B12; respondents were more likely to continue taking vitamin B12 when initial treatment was followed by a marginal improvement in symptoms vs when symptoms remained unchanged (80 of 100 respondents [80%] vs 33 of 100 respondents [33%]; OR, 7.91 [95% CI, 4.18-14.97]; P < .001). Four further scenarios involving dubious treatments found similar results, including when tested on health care professionals.

Conclusions and Relevance

In this study of clinical scenarios, a marginal improvement in symptoms led patients to continue a dubious and sometimes costly treatment, suggesting that clinicians should caution patients against post hoc bias.

Wait times for scheduling appointments with hospital affiliated dermatologists in New York City

Patients' experience accessing dermatologic care is understudied. The purpose of this cross-sectional study was to examine current wait times for new patients to receive dermatological care in NYC. Websites at 58 accredited private and public hospitals in the five boroughs of NYC were reviewed to identify dermatology practices. Office telephone numbers listed on each website were called to collect information pertaining to whether the physician was accepting new patients, type of insurance accepted (public, private, both, or none), and the number of days until a new patient could be seen for an appointment. Data pertaining to the time kept on hold and availability of web-based booking were also collected. Mean waiting time for an appointment was 50 days [standard deviation, SD 66] - nearly 2 months, but the distribution was considerably skewed. The median waiting time was 19.5 days [Interquartile range, IQR 4-60]. The time kept on hold to make the appointment was negligible at about 1 min (63 s, SD = 77) but could take up to ~ 7 min. Two-thirds of dermatologists accepted private, Medicare, and Medicaid insurance (n = 228, 66%); a small number accepted only private insurance (n = 12, 4%) or no insurance at all (n = 16, 5%). The median waiting time for an appointment for the 228 providers that accepted Medicaid was 30.5 days (IQR = 5.0-73.25) while for providers who did not accept Medicaid (n = 116) the median wait time for an appointment was 13.0 days (IQR = 3.0-38.0). Just over half (56%) of the dermatologists allowed for appointments to be booked on their website (n = 193). This research highlights the necessity of incorporating new strategies into routine dermatology appointments in order to increase treatment availability and decrease healthcare inequality.

Pre-exposure and postexposure prophylaxis access in rural versus urban pharmacies in Georgia and Pennsylvania

BACKGROUND

Pre-exposure prophylaxis (PrEP) and postexposure prophylaxis (PEP) prevent HIV among individuals at high risk for acquisition. Pre-existing structural barriers to PrEP/PEP access among rural patients may be exacerbated further if pharmacies do not keep PrEP/PEP in stock, constituting a significant barrier to mitigating the HIV epidemic.

OBJECTIVES

To compare PrEP/PEP availability for same-day pickup in rural vs urban Georgia and Pennsylvania pharmacies.

METHODS

We conducted a cross-sectional simulated patient caller study, calling pharmacists in Georgia and Pennsylvania to see whether PrEP/PEP was available for same-day pickup. We identified retail pharmacies through state pharmacy boards and categorized rurality using state-based definitions. We used multivariable logistic regression to assess PrEP availability by rurality and Ending the HIV Epidemic (EHE) designation, accounting for chain pharmacy status and county-level racial composition.

RESULTS

Among 481 pharmacies contacted (304 in Pennsylvania and 177 in Georgia), only 30.77% had PrEP for same-day pickup and only 10.55% had PEP for same-day pickup. PrEP availability did not differ significantly by state. Urban pharmacies had 2.02 (95% CI: 1.32-3.09) greater odds of PrEP same-day availability compared to rural pharmacies. Pharmacies in EHE counties had 3.45 (95% CI: 1.9-6.23) times higher odds of carrying PrEP compared to non-EHE counties.

CONCLUSIONS

Pharmacies were unlikely to carry PrEP or PEP. Pharmacies in rural compared to urban, and non-EHE compared to EHE locations were less likely to carry PrEP. Addressing pharmacy barriers to PrEP/PEP may enhance access to HIV prevention for those living at high risk of HIV.

Access to Sudden Sensorineural Hearing Loss Care at Private Equity-Owned Otolaryngology Clinics

OBJECTIVE

Characterizing access to sudden sensorineural hearing loss (SSNHL) care at private practice otolaryngology clinics of varying ownership models.

STUDY DESIGN

Cross-sectional prospective review.

SETTING

Private practice otolaryngology clinics.

METHODS

We employed a Secret Shopper study design with private equity (PE) owned and non-PE-owned clinics within 15 miles of one another. Using a standardized script, researchers randomly called 50% of each clinic type between October 2021 and January 2022 requesting an appointment on behalf of a family member enrolled in either Medicaid or private insurance (PI) experiencing SSNHL. Access to timely care was assessed between clinic ownership and insurance type.

RESULTS

Seventy-eight total PE-owned otolaryngology clinics were identified across the United States. Only 40 non-PE clinics could be matched to the PE clinics; 39 PE and 28 non-PE clinics were called as Medicaid patients; 39 PE and 25 non-PE clinics were called as PI patients; 48.7% of PE and 28.6% of non-PE clinics accepted Medicaid. The mean wait time to new appointment ranged between 9.55 and 13.21 days for all insurance and ownership types but did not vary significantly (P > .480). Telehealth was significantly more likely to be offered for new Medicaid patients at non-PE clinics compared to PE clinics (31.8% vs 0.0%, P = .001). The mean cost for an appointment was significantly greater at PE clinics than at non-PE clinics ($291.18 vs $203.75, P = .004).

CONCLUSIONS

Patients seeking SSNHL care at PE-owned otolaryngology clinics are likely to face long wait times prior to obtaining an initial appointment and reduced telehealth options.

Dialing for doctors: Secret shopper study of Arizona methadone and buprenorphine providers, 2022

INTRODUCTION

Methadone and buprenorphine are effective and safe treatments for opioid use disorder (OUD) and also reduce overdose and all-cause mortality. Identifying and reaching providers of medication for opioid use disorder (MOUD) has proven difficult for prospective patients and researchers.

OBJECTIVES

To assess the accuracy of government-maintained lists of Arizona (AZ) providers prescribing MOUD, and the extent to which these providers are accessible for treatment.

METHODS

A two-phase study used a listing of 2376 AZ MOUD providers obtained from the U.S. Drug Enforcement Administration and the Substance Abuse and Mental Health Services Administration. Phase 1 assessed the accuracy of the listing using internet confirmatory research from May-October 2022. Phase 2 used the resulting list of 838 providers to assess provider availability, type of MOUD treatment provided, and accepted payment through secret shopper calls between November 16 and 30, 2022.

RESULTS

Just over half (52.2 %, n = 1240) of providers were removed from the original listing during Phase 1. One quarter (25.9 %) were no longer in practice. Among the 833 eligible for the secret shopper Phase 2 study, 36.6 % (n = 307) were reached and identified as providing MOUD. A vast majority (88.1 %) of MOUD providers indicating treatment type were accepting new patients, however methadone was identified far more frequently than was likely permitted or provided for OUD. Providers were 5.5 times more likely to accept new patients if they accepted cash payment for services, and 4.9 times more likely if they accepted Medicaid. Rural areas remained underserved.

CONCLUSIONS

The active population of MOUD providers is far smaller than surmised. DEA and SAMHSA provider listings are not sufficiently accurate for survey research sampling. Other means of representative sampling will need to be devised, and trusted lists of providers for prospective patients should be promoted, publicly available, and regularly maintained for accuracy. Providers that offer treatment should assure that public-facing staff have basic information about the practice, the treatment offered, and conditions for taking new patients. Concerted efforts must assure rural access at the most local levels to reduce patient travel burden.

Financial assistance and payment plans for underinsured patients shopping for "shoppable" hospital services

Recent price transparency laws are designed to better inform patients as they compare hospital options and "shop" for health care services. In addition to prices, underinsured patients seeking care need information on financial assistance, discounts, payment plans, and upfront payment requirements to compare the affordability of care across hospitals. Little is known about the availability of this information and the experience of prospective patients seeking it. We contacted a random sample of 10% of general short-term hospitals across the United States in this "secret shopper" telephone study to assess financial options and navigation challenges faced by underinsured patients in need of a non-emergency procedure. The administrative friction was substantial. Most hospitals have 3 siloed offices for (1) financial assistance, (2) payment plans and discounts, and (3) upfront payment requirements. All relevant offices were unreachable in 3 attempted calls at 18.1% of hospitals. Among hospitals with available information, the majority have financial options for patients: 86.7% of hospitals offer financial assistance and 97.0% of hospitals offer payment plans to underinsured patients for non-emergency care. The length and terms of payments plans varied widely for hospital-administered and third-party financing arrangements. Upfront payments were sometimes required, potentially posing barriers for patients without cash or credit access.

County-level neonatal opioid withdrawal syndrome rates and real-world access to buprenorphine during pregnancy: An audit ("secret shopper") study in Missouri

Background

Amid rising rates of neonatal opioid withdrawal syndrome (NOWS) worldwide and in many regions of the USA, we conducted an audit study ("secret shopper study") to evaluate the influence of county-level buprenorphine capacity and rurality on county-level NOWS rates.

Methods

In 2019, up to three phone calls were made to buprenorphine prescribers in the state of Missouri (USA). County-level buprenorphine capacity was defined as the number of clinicians (across all specialties) accepting pregnant people divided by the number of births. Multivariable negative binomial regression models estimated associations between buprenorphine capacity, rurality, and county-level NOWS rates, controlling for potential confounders (i.e., poverty, unemployment, and physician shortages) that may correspond to higher rates of NOWS and lower rates of buprenorphine prescribing. Analyses were stratified using tertiles of county-level overdose rates (top, middle, and lowest 1/3 of overdose rates).

Results

Of 115 Missouri counties, 81(70 %) had no buprenorphine capacity, 17(15 %) were low-capacity (<0.5-clinicians/1,000 births), and 17(15 %) were high-capacity (≥0.5/1,000 births). The mean NOWS rate was 6.5/1,000 births. In Missouri counties with both the highest and lowest opioid overdose rates, higher buprenorphine capacity did not correspond to decreases in NOWS rates (incidence rate ratio[IRR]=1.23[95 %-confidence-interval[CI]=0.65-2.32] and IRR=1.57[1.21-2.03] respectively). Rurality did not correspond to greater NOWS burden in both Missouri counties with highest and lowest opioid overdose rates.

Conclusions

The vast majority of counties in Missouri have no capacity for buprenorphine prescribing during pregnancy. Rurality and lower buprenorphine capacity did not significantly predict elevated rates of NOWS.

Come back when you're infected: pharmacy access to sterile syringes in an Arizona Secret Shopper Study, 2023

BACKGROUND

Pharmacies are critical healthcare partners in community efforts to eliminate bloodborne illnesses. Pharmacy sale of sterile syringes is central to this effort.

METHODS

A mixed methods "secret shopper" syringe purchase study was conducted in the fall of 2022 with 38 community pharmacies in Maricopa and Pima Counties, Arizona. Pharmacies were geomapped to within 2 miles of areas identified as having a potentially high volume of illicit drug commerce. Daytime venue sampling was used whereby separate investigators with lived/living drug use experience attempted to purchase syringes without a prescription. Investigator response when prompted for purchase rationale was "to protect myself from HIV and hepatitis C." A 24-item instrument measured sales outcome, pharmacy staff interaction (hostile/neutral/friendly), and the buyer's subjective experience.

RESULTS

Only 24.6% (n = 28) of 114 purchase attempts across the 38 pharmacies resulted in syringe sale. Less than one quarter (21.1%) of pharmacies always sold, while 44.7% never sold. Independent and food store pharmacies tended not to sell syringes. There emerged distinct pharmacy staff interactions characterized by body language, customer query, normalization or othering response, response to purchase request and closure. Pharmacy discretion and pharmacy policy not to sell syringes without a prescription limited sterile syringe access. Investigators reported frequent and adverse emotional impact due to pharmacy staff negative and stigmatizing interactions.

CONCLUSIONS

Pharmacies miss opportunities to advance efforts to eliminate bloodborne infections by stringent no-sale policy and discretion about syringe sale. State regulatory policy facilitating pharmacy syringe sales, limiting pharmacist discretion for syringe sales, and targeting pharmacy-staff level education may help advance the achievement of public health goals to eliminate bloodborne infections in Arizona.

Evaluating the network adequacy of vision care services for children in Arizona: A cross sectional study

Background

Vision challenges are among the most prevalent disabling conditions in childhood, affecting up to 28% of school-age children. These issues can impact the development, learning, and literacy skills of affected children. While vision problems are correctable with timely diagnosis and treatment, insufficient networks can impede children's access to comprehensive, and high-quality care.

Objective

The study aims to determine where pediatric vision care network adequacy exists in the state of Arizona and where there are gaps in receiving vision care for children.

Methods

This cross-sectional study assessed the adequacy of pediatric vision care networks in Arizona through a "secret shopper" phone survey. Calls were made to practices that accept Arizona's Medicaid program, Arizona Health Care Cost Containment System (AHCCCS) and/or commercial insurance. Providers were contacted following a standardized script to schedule routine appointments on behalf of 10 and 3-year-old patients enrolled in either Medicaid or commercial health insurance plans. The study examined various components of children's access to vision care services, including the reliability of provider directory information, time until the next available appointment, bilingual service offerings, ages served, region of practice and types of care available.

Results

A total of 556 practices in Arizona were evaluated through simulations as patients on AHCCCS, and 510 practices were assessed through simulations as patients with commercial health insurance plans. The average wait time for the next available appointment was 13 days for both insurance types. Alarmingly, up to 74% of vision care practices in Arizona do not serve children covered by AHCCCS. Furthermore, only 41% provide services to children 5 years and younger.

Conclusions

Our findings underscore the need to improve access to vision care services for children in Arizona, especially racial/ethnic minorities, low-income groups, and rural residents.

Potential demand for and access to medication abortion among North Carolina college students

OBJECTIVE

To estimate demand for medication abortion (MAB) among North Carolina (NC) college students and describe access to nearest clinics offering MAB to each campus.

METHODS

We calculated demand using 2019-2020 campus demographics and NC abortion statistics. We used a mystery client technique to gather MAB cost and appointment wait times at the closest clinics and calculated travel distances and times.

RESULTS

We estimated that 2,517 NC students seek MAB annually. Twenty-one clinics were closest to NC's 111 colleges and universities, including five in neighboring states. Mean cost was $450, with an average wait time of six days to appointment. The average round-trip travel distance was 58 miles and time to the nearest clinic was 84 min by car.

CONCLUSIONS

Many NC college students likely obtain MAB every year and face high costs, long wait times and distances to care, which has likely worsened after the overturning of Roe v. Wade.

Adolescent Residential Addiction Treatment In The US: Uneven Access, Waitlists, And High Costs

Drug overdose deaths among adolescents are increasing in the United States. Residential treatment facilities are one treatment option for adolescents with substance use disorders, yet little is known about their accessibility or cost. Using the Substance Abuse and Mental Health Services Administration's treatment locator and search engine advertising data, we identified 160 residential addiction treatment facilities that treated adolescents with opioid use disorder as of December 2022. We called facilities while role-playing as the aunt or uncle of a sixteen-year-old child with a recent nonfatal overdose, to inquire about policies and costs. Eighty-seven facilities (54.4 percent) had a bed immediately available. Among sites with a waitlist, the mean wait time for a bed was 28.4 days. Of facilities providing cost information, the mean cost of treatment per day was $878. Daily costs among for-profit facilities were triple those of nonprofit facilities. Half of facilities required up-front payment by self-pay patients. The mean up-front cost was $28,731. We were unable to identify any facilities for adolescents in ten states or Washington, D.C. Access to adolescent residential addiction treatment centers in the United States is limited and costly.

Assessing suboxone access in community pharmacies: Secret shopper model

Objective

To assess whether Maryland community pharmacies had Suboxone available for dispensing.

Methods

This cross-sectional study used a secret shopper model to contact public-facing community pharmacies in Maryland. The secret shopper, guided by a script, asked whether a prescription for Suboxone was available for the same or next day pick-up. A small convenience sample of pharmacies who did not have Suboxone available received an in-person visit to inquire about medication availability and dispensing barriers.

Results

After contacting 99% (n = 1046) of Maryland public-facing pharmacies, Suboxone was confirmed available for immediate pick-up in 31% (n = 326). The remaining did not have, would not disclose, or had limited access (existing patients or specific providers only). Significant differences in Suboxone availability were found for National Capital vs. Baltimore metro region and when pharmacist asked questions vs. no questions. Of the 11 pharmacy visits completed, 10 said they had Suboxone currently in stock, with one clarifying medication was for existing patients only.

Conclusion

About 69% of patients may face challenges when calling to find out whether they can obtain Suboxone in Maryland pharmacies. Better patient education and more thorough pharmacy-level investigation of system and workflow barriers could offer solutions.

Treatment access for opioid use disorder among women with medicaid in Florida

INTRODUCTION

Opioid use disorder (OUD) remains prevalent. Medications for OUD (MOUD) are standard care for pregnant and non-pregnant women. Previous research has identified barriers to MOUD for women with Medicaid but did not account for the type of MOUD (methadone vs. buprenorphine) or pregnancy status. We examined access to MOUD by treatment type for pregnant and non-pregnant women with Medicaid in Florida.

METHODS

A secondary analysis of Florida "secret-shopper" data was conducted. Calls were made to clinicians from the 2018 Substance Abuse and Mental Health Services Administration provider list by women posing as either a pregnant or non-pregnant woman with OUD and Medicaid. We examined 546 calls to buprenorphine-waivered providers (BWP) and 139 to opioid treatment programs (OTP). Counts and percentages were used to describe caller success by type of treatment and pregnancy status. Chi-square tests were used to identify statistical differences.

RESULTS

Only 42 % of calls reached a treatment provider in Florida. Pregnant and non-pregnant women were less likely to obtain an appointment with Medicaid coverage by a BWP than an OTP (p < 0.01). Nearly 40 % of OTPs offered appointments to callers with Medicaid compared to only 17 % of BWPs. Both types of providers denied appointments more often for pregnant women. Thirty-eight percent of BWP's and 12 % of OTP's denied appointments to pregnant women using cash or Medicaid payment.

CONCLUSIONS

Our study demonstrates logistical and financial barriers to treatment for OUD among pregnant and non-pregnant women with Medicaid in Florida and highlights the need for improved systems of care.