Food insecurity and quality of life in patients with sickle cell disease

Little is known about the relationship between quality of life (QOL) and food insecurity (FI) among patients with sickle cell disease (SCD). We hypothesized FI is associated with lower QOL in children and young adults with SCD. Overall (N = 99), 22% screened positive for FI. Supplemental Nutrition Assistance Program (SNAP) enrollment was 50 and 71% among people from food secure and FI households, respectively. A higher FI score was correlated with lower overall QOL (r = -0.22, p = .03), specifically lower QOL in worry and communication domains. Interventions for FI beyond SNAP may be important for QOL among people living with SCD.

Interventions addressing health-related social needs among patients with cancer

Health-related social needs are prevalent among cancer patients; associated with substantial negative health consequences; and drive pervasive inequities in cancer incidence, severity, treatment choices and decisions, and outcomes. To address the lack of clinical trial evidence to guide health-related social needs interventions among cancer patients, the National Cancer Institute Cancer Care Delivery Research Steering Committee convened experts to participate in a clinical trials planning meeting with the goal of designing studies to screen for and address health-related social needs among cancer patients. In this commentary, we discuss the rationale for, and challenges of, designing and testing health-related social needs interventions in alignment with the National Academy of Sciences, Engineering, and Medicine 5As framework. Evidence for food, housing, utilities, interpersonal safety, and transportation health-related social needs interventions is analyzed. Evidence regarding health-related social needs and delivery of health-related social needs interventions differs in maturity and applicability to cancer context, with transportation problems having the most maturity and interpersonal safety the least. We offer practical recommendations for health-related social needs interventions among cancer patients and the caregivers, families, and friends who support their health-related social needs. Cross-cutting (ie, health-related social needs agnostic) recommendations include leveraging navigation (eg, people, technology) to identify, refer, and deliver health-related social needs interventions; addressing health-related social needs through multilevel interventions; and recognizing that health-related social needs are states, not traits, that fluctuate over time. Health-related social needs-specific interventions are recommended, and pros and cons of addressing more than one health-related social needs concurrently are characterized. Considerations for collaborating with community partners are highlighted. The need for careful planning, strong partners, and funding is stressed. Finally, we outline a future research agenda to address evidence gaps.

Associations of Adolescent School Social Networks, Gender Norms, and Adolescent-to-Young Adult Changes in Male Gender Expression With Young Adult Substance Use

PURPOSE

Male gender expression (MGE), which is shaped by sociocultural pressures around masculinity, has been previously associated with health. This study examines associations of adolescent social network variables and school gender norms with MGE changes from adolescence to young adulthood, and associations of these changes with young adult substance use.

METHODS

Analyzing data from Waves I (1994-95, adolescents, aged 12-18) and IV (2008-09, young adults, 24-32) of a nationally representative longitudinal cohort study, male participants' MGE was assessed in each wave using a validated, empirically derived measure. Linear regression was used to evaluate associations of adolescent-to-young adult MGE changes between waves with adolescent social network characteristics and school gender norms. Logistic regression was used to examine associations between adolescent-to-young adult MGE changes and young adult substance uses (cigarette, marijuana, heavy alcohol, and recreational drug use, and prescription drug misuse).

RESULTS

Among 4,776 male participants, adolescent-to-young adult MGE changes were significantly associated with school gender norms such that adolescents whose MGE markedly departed from their schools' average exhibited greater MGE changes in the direction of their schools' average (β = -0.83, p < .01) relative to those who were more similar to school means. Adolescent-to-young adult increases in MGE were significantly associated with greater odds of all young adult substance use behaviors except prescription drug misuse.

DISCUSSION

Adolescents' MGE relative to other males at their school was associated with MGE changes toward school norms, with implications for young adult substance use. Adolescent gender norms may be an underexplored strategy for interventions to reduce substance misuse.

Screening for Financial Hardship: Comparing Patient Survey Responses Using Two Different Screening Tools

BACKGROUND

Healthcare delivery organizations are increasingly screening patients for social risks using tools that vary in content and length.

OBJECTIVES

To compare two screening tools both containing questions related to financial hardship.

DESIGN

Cross-sectional survey.

PARTICIPANTS

Convenience sample of adult patients (n = 471) in three primary care clinics.

MAIN MEASURES

Participants randomly assigned to self-complete either: (1) a screening tool developed by the Centers for Medicare & Medicaid Services (CMS) consisting of six questions on financial hardship (housing stability, housing quality, food security, transportation security, utilities security); or (2) social and behavioral risk measures recommended by the National Academy of Medicine (NAM), including one question on financial hardship (financial strain). We compared patient acceptability of screening, positive screening rates for financial hardship, patient interest in assistance, and self-rated health.

RESULTS

Ninety-one percent of eligible/interested patients completed the relevant survey questions to be included in the study (N = 471/516). Patient acceptability was high for both tools, though more participants reported screening was appropriate when answering the CMS versus NAM questions (87% vs. 79%, p = 0.02). Of respondents completing the CMS tool, 57% (132/232) reported at least one type of financial hardship; on the NAM survey, 52% (125/239) reported financial hardship (p = 0.36). Nearly twice as many respondents indicated interest in assistance related to financial hardship after completing items on the CMS tool than on the NAM question (39% vs. 21%, p < 0.01).

CONCLUSIONS

Patients reported high acceptability of both social risk assessment tools. While rates of positive screens for financial hardship were similar across the two measures, more patients indicated interest in assistance after answering questions about financial hardship on the CMS tool. This might be because the screening questions on the CMS tool help patients to appreciate the types of assistance related to financial hardship that may be available after screening. Future research should assess the validity and comparative validity of individual measures and measure sets. Tool selection should be based on setting and population served, screening goals, and resources available.

Effect of a Social Care Intervention on Health Care Experiences of Caregivers of Hospitalized Children: A Randomized Clinical Trial

Importance

Health-related social risks (HRSRs), like food and housing insecurity, are stigmatized conditions that, when addressed in clinical settings, could inadvertently compromise health care experiences.

Objective

To test the noninferiority hypothesis that a low-intensity, high-scale social care intervention does not promote experiences of discrimination or diminish satisfaction with care compared to usual care.

Design, Setting, and Participants

This was a double-blind randomized clinical trial conducted from November 2020 to June 2022 with 12-month follow-up analyzing data obtained 1 week after baseline intervention at a 155-bed academic urban children's hospital with 5300 annual admissions. Participants were recruited from their children's hospital rooms during their children's inpatient hospital stays. Inclusion criteria were identifying as the primary caregiver of a child younger than 18 years who was hospitalized in the general, intensive care, or transplant units; living in 1 of 42 target zip codes; and consenting to receive text messages. Caregivers of healthy newborns and caregivers of children expected to be hospitalized for less than 24 hours or greater than 30 days were excluded. A total of 637 eligible parents and caregivers were enrolled.

Interventions

Participants were randomized to usual care or usual care plus CommunityRx, a low-intensity, universally delivered, electronic medical record-integrated social care assistance intervention providing personalized information about local resources alongside education about HRSRs and how to access additional support. Usual care included an admission brochure about hospital-based free food options and nonsystematic provision of resource information.

Main Outcomes and Measures

Experiences of discrimination, measured using the Discrimination in Medical Settings Scale (range 7-35; higher scores indicate more frequent discrimination) and satisfaction with hospital discharge 1 week postdischarge using Child HCAHPS (range 0-100; higher scores indicate higher satisfaction). The a priori noninferiority margins (control minus intervention) were -0.9 (discrimination) and 1.6 (satisfaction).

Results

Of 637 eligible caregiver participants, most identified as female (n = 600 [94.3%]), Black (n = 505 [79.4%]), and had household income less than $50 000 per year (n = 488 [78.5%]). One-third were experiencing food insecurity (n = 223). Half of participants reported discrimination experiences during the pediatric hospitalization (n = 259). Discrimination experiences among the intervention group were noninferior to those among the control group (mean [SD] score: control, 10.3 [4.7] vs intervention, 10.0 [4.6]; difference, 0.2; 90% CI, -0.5 to 0.9). Mean (SD) satisfaction with discharge was high (control, 84.2 [23.8] vs intervention, 81.9 [24.8]), but evidence was insufficient to support intervention noninferiority for this end point (difference, 2.3; 90% CI, -1.2 to 5.8). Food security status did not moderate the relationship between intervention and either outcome.

Conclusions and Relevance

The findings suggest that a universally delivered social care assistance intervention did not promote caregiver experiences of discrimination during a child's hospitalization but were inconclusive regarding satisfaction.

Trial Registration

ClinicalTrials.gov Identifier: NCT04171999.

Food Insecurity and Experiences of Discrimination Among Caregivers of Hospitalized Children

BACKGROUND AND OBJECTIVES

Pediatric hospitals are adopting strategies to address food insecurity (FI), a stigmatizing condition, among families with children. We hypothesized that parents and other caregivers ("caregivers") from households with FI or marginal food security (MFS) are more likely to experience discrimination during their child's hospitalization.

METHODS

We analyzed data from 319 caregivers of children admitted to an urban, academic children's hospital and randomly assigned to the control arm of the double-blind randomized controlled CommunityRx-Hunger trial (November 2020 to June 2022, NCT R01MD012630). Household food security in the 30 days before admission and discrimination during hospitalization were measured with the US Household Food Security Survey and the Discrimination in Medical Settings Scale, respectively. We used logistic regression to model the relationship between food security status and discrimination, adjusting for gender, race, ethnicity, income, and partner status.

RESULTS

Most participants were African American or Black (81.5%), female (94.7%), and the parent of the hospitalized child (93.7%). FI and MFS were prevalent (25.1% and 15.1%, respectively). Experiences of discrimination during a child's hospitalization were prevalent (51.9%). Caregivers with FI had higher odds than caregivers with food security of experiencing discrimination (adjusted odds ratio = 2.0, 95% confidence interval 1.1-3.6, P = .03); MFS was not significantly associated with discrimination (P = .25). Compared with food secure caregivers, those with FI had higher odds of 5 of 7 experiences of discrimination assessed.

CONCLUSIONS

Among parents and other caregivers, household FI is associated with experiences of discrimination during a child's hospitalization.

Mystery Shopper Study of State Medicaid Coverage for Out-of-State Abortion Care

This cross-sectional study uses a mystery shopper survey to examine variation in state Medicaid agency responses to coverage questions on out-of-state abortion care.

CommunityRx, a social care assistance intervention for family and friend caregivers delivered at the point of care: two concurrent blinded randomized controlled trials

BACKGROUND

CommunityRx is an evidence-based social care intervention delivered to family and friend caregivers ("caregivers") at the point of healthcare to address health-related social risks (HRSRs). Two CommunityRx randomized controlled trials (RCTs) are being fielded concurrently on Chicago's South Side, a predominantly African American/Black community. CommunityRx-Hunger is a double-blind RCT enrolling caregivers of hospitalized children. CommunityRx-Dementia is a single-blind RCT enrolling caregivers of community-residing people with dementia. RCTs with caregivers face recruitment barriers, including caregiver burden and lack of systematic strategies to identify caregivers in clinical settings. COVID-19 pandemic-related visitor restrictions exacerbated these barriers and prompted the need for iteration of the protocols from in-person to remote operations. This study describes these protocols and methods used for successful iteration to overcome barriers.

METHODS AND FINDINGS

CommunityRx uses individual-level data to generate personalized, local community resource referrals for basic, health and caregiving needs. In early 2020, two in-person RCT protocols were pre-tested. In March 2020, when pandemic conditions prohibited face-to-face clinical enrollment, both protocols were iterated to efficient, caregiver-centered remote operations. Iterations were enabled in part by the Automated Randomized Controlled Trial Information-Communication System (ARCTICS), a trial management system innovation engineered to integrate the data collection database (REDCap) with community resource referral (NowPow) and SMS texting (Mosio) platforms. Enabled by engaged Community Advisory Boards and ARCTICS, both RCTs quickly adapted to remote operations. To accommodate these adaptations, launch was delayed until November (CommunityRx-Hunger) and December (CommunityRx-Dementia) 2020. Despite the delay, 65% of all planned participants (CommunityRx-Hunger n = 417/640; CommunityRx-Dementia n = 222/344) were enrolled by December 2021, halfway through our projected enrollment timeline. Both trials enrolled 13% more participants in the first 12 months than originally projected for in-person enrollment.

DISCUSSION

Our asset-based, community-engaged approach combined with widely accessible institutional and commercial information technologies facilitated rapid migration of in-person trials to remote operations. Remote or hybrid RCT designs for social care interventions may be a viable, scalable alternative to in-person recruitment and intervention delivery protocols, particularly for caregivers and other groups that are under-represented in traditional health services research.

TRIAL REGISTRATION

ClinicalTrials.gov: CommunityRx-Hunger (NCT04171999, 11/21/2019); CommunityRx for Caregivers (NCT04146545, 10/31/2019).

Childhood Parental Incarceration and Adult-Onset Hypertension and Cardiovascular Risk

Importance

Parental incarceration is an adverse childhood experience that disproportionately affects racially minoritized individuals and has been associated with long-term health risks. Although cardiovascular disease remains the primary cause of mortality differences between Black and White individuals in the US, the association between parental incarceration and cardiovascular risk remains poorly understood.

Objective

To examine the association between parental incarceration during childhood and incident cardiovascular risk in adulthood.

Design, Setting, and Participants

This population-based cohort study included data from waves IV (2008-2009) and V (2016-2018) of the US National Longitudinal Study of Adolescent to Adult Health. Participants represented US adults transitioning from young adulthood to adulthood. Data were analyzed from October 28, 2021, to May 1, 2023.

Main Outcomes and Measures

Parental incarceration was defined as a parent or parent-like figure going to jail or prison when participants were aged younger than 18 years. Outcome measures included self-reported diagnoses of obesity, hyperlipidemia, hypertension, diabetes, or heart disease as well as serum elevations in non-high-density lipoprotein cholesterol (≥160 mg/dL) and high-sensitivity C-reactive protein (hsCRP >3 mg/L), a marker of inflammation used to estimate risk of future coronary events. Using sampling weights, incident development of each outcome was modeled as a function of parental incarceration, adjusting for participant- and neighborhood-level characteristics.

Results

This study included 9629 participants representing 16 077 108 US adults. Approximately half of participants were women (5498 [weighted 50.3%]) and the majority (5895 [weighted 71.4%]) were White. The mean participant age was 37.8 years (95% CI, 37.5 to 38.0 years) in wave V compared with 28.9 years (95% CI, 28.6 to 29.1 years) in wave IV. In wave V, those with childhood exposure to parental incarceration had lower educational attainment (91 [weighted 8.2%] vs 245 [weighted 4.2%] completing less than high school), had higher rates of public insurance (257 [weighted 20.6%] vs 806 [weighted 11.0%]), and were disproportionately Black (374 [weighted 22.5%] vs 1488 [weighted 13.6%]). Parental incarceration was associated with 33% higher adjusted odds (95% CI, 1.05 to 1.68) of developing hypertension and 60% higher adjusted odds (95% CI, 1.03 to 2.48) of developing elevated hsCRP. Associations between childhood parental incarceration and other diagnoses (ie, obesity, hyperlipidemia, diabetes, or heart disease) and serum lipid levels were not observed.

Conclusions and Relevance

In this cohort study of US adults transitioning from young adulthood to adulthood, an increased incidence of hypertension and high-risk hsCRP, but not other cardiovascular risk factors, was observed among those exposed to parental incarceration during childhood. These findings suggest possible transgenerational health consequences of mass incarceration.

Social Risk and Smoking Among Women Smokers Early in the COVID-19 Pandemic: The Role of Mental Health

Background: We examined patterns of smoking in relation to health-related socioeconomic vulnerability (HRSV) among U.S. women early in the pandemic and whether mental health symptoms mediated these relationships. Materials and Methods: Data were obtained from the April 2020 National U.S. Women's Health COVID-19 Study (N = 3200). Among current smokers, adjusted odds of increased smoking since the start of the pandemic (vs. same or less) by incident and worsening HRSVs were modeled. Structural equation modeling was used to assess anxiety, depression, and traumatic stress symptoms as mediators of the relationship between six HRSVs (food insecurity; housing, utilities, and transportation difficulties; interpersonal violence; financial strain) and increased smoking early in the pandemic. Results: Nearly half (48%) of current smokers reported increased smoking since the pandemic started. Odds of increased smoking were higher among women with incident financial strain (aOR = 2.0, 95% CI 1.2-3.3), incident food insecurity (aOR = 2.9, 95% CI 1.7-5.1), any worsening HRSV (aOR = 2.2, 95% CI 1.5-3.0), and worsening food insecurity (aOR = 1.9, 95% CI 1.3-3.0). Anxiety symptoms were a significant, partial mediator of the relationship between increased smoking and any worsening HRSVs (proportion mediated = 0.17, p = 0.001) and worsening food insecurity (0.19, p = 0.023), specifically. Depression symptoms were a significant, partial mediator of the relationship between increased smoking and any worsening HRSVs (0.15, p = 0.004) and incident financial strain (0.19, p = 0.034). Traumatic stress was not a significant mediator of any tested relationship. Conclusions: Anxiety and depression symptoms partially explain the relationship between rising socioeconomic vulnerability and increased smoking among women early in the pandemic. Addressing HRSVs and mental health may help reduce increased smoking during a public health crisis.

Breast sensorisexual function: a novel patient-reported outcome measure of sexual sensory functions of the breast

BACKGROUND

A validated measure assessing sexual sensory functions of the breast is needed to optimize sexual and other health outcomes after breast procedures.

AIM

To describe the development of a patient-reported outcome measure (PROM) to assess breast sensorisexual function (BSF).

METHODS

We applied the PROMIS standards (Patient Reported Outcomes Measurement Information System) for measure development and evaluation of validity. An initial conceptual model of BSF was developed with patients and experts. A literature review yielded a pool of 117 candidate items that underwent cognitive testing and iteration. Forty-eight items were administered to an ethnically diverse, national panel-based sample of sexually active women with breast cancer (n = 350) or without (n = 300). Psychometric analyses were performed.

OUTCOMES

The main outcome was BSF, a measure that assesses affective (satisfaction, pleasure, importance, pain, discomfort) and functional (touch, pressure, thermoreception, nipple erection) sensorisexual domains.

RESULTS

A bifactor model fit to 6 domains-excluding 2 domains with only 2 items each and 2 pain-related domains-revealed a single general factor representing BSF that may be adequately measured by the average of the items. This factor, with higher values denoting better function and with the standard deviation set to 1, was highest among women without breast cancer (mean, 0.24), intermediate among women with breast cancer but not bilateral mastectomy and reconstruction (-0.01), and lowest among those with bilateral mastectomy and reconstruction (-0.56). Between women with and without breast cancer, the BSF general factor accounted for 40%, 49%, and 100% of the difference in arousal, ability to orgasm, and sexual satisfaction, respectively. Items in each of 8 domains demonstrated unidimensionality (ie, they measured 1 underlying BSF trait) and high Cronbach's alphas for the entire sample (0.77-0.93) and the cancer group (0.71-0.95). Correlations with sexual function, health, and quality of life were positive for the BSF general factor and mostly negative for the pain domains.

CLINICAL IMPLICATIONS

The BSF PROM can be used to assess the impact of breast surgery or other procedures on the sexual sensory functions of the breast in women with and without breast cancer.

STRENGTHS AND LIMITATIONS

The BSF PROM was developed by using evidence-based standards, and it applies to sexually active women with and without breast cancer. Generalizability to sexually inactive women and other women warrants further study.

CONCLUSION

The BSF PROM is a measure of women's breast sensorisexual function with evidence of validity among women affected and unaffected by breast cancer.

Perceived Appropriateness of Assessing for Health-related Socioeconomic Risks Among Adult Patients with Cancer

Cancer treatment can trigger or exacerbate health-related socioeconomic risks (HRSR; food/housing insecurity, transportation/utilities difficulties, and interpersonal violence). The American Cancer Society and National Cancer Institute recommend HRSR screening and referral, but little research has examined the perceptions of patients with cancer on the appropriateness of HRSR screening in healthcare settings. We examined whether HRSR status, desire for assistance with HRSRs, and sociodemographic and health care-related factors were associated with perceived appropriateness of HRSR screening in health care settings and comfort with HRSR documentation in electronic health records (EHR). A convenience sample of adult patients with cancer at two outpatient clinics completed self-administered surveys. We used χ 2 and Fisher exact tests to test for significant associations. The sample included 154 patients (72% female, 90% ages 45 years or older). Thirty-six percent reported ≥1 HRSRs and 27% desired assistance with HRSRs. Overall, 80% thought it was appropriate to assess for HRSRs in health care settings. The distributions of HRSR status and sociodemographic characteristics were similar among people who perceived screening to be appropriate and those who did not. Participants who perceived screening as appropriate were three times as likely to report prior experience with HRSR screening (31% vs. 10%, P = 0.01). Moreover, 60% felt comfortable having HRSRs documented in the EHR. Comfort with EHR documentation of HRSRs was significantly higher among patients desiring assistance with HRSRs (78%) compared with those who did not (53%, P < 0.01). While initiatives for HRSR screening are likely to be seen by patients with cancer as appropriate, concerns may remain over electronic documentation of HRSRs.

Significance

National organizations recommend addressing HRSRs such as food/housing insecurity, transportation/utilities difficulties, and interpersonal violence among patients with cancer. In our study, most patients with cancer perceived screening for HRSRs in clinical settings as appropriate. Meanwhile, concerns may remain over the documentation of HRSRs in EHRs.

"If you're in a community together, then you're basically a family": Perceptions of community among a predominantly African-American/Black youth cohort in a semi-rural region in the Southeastern United States

Geographic racism gives rise to health inequities that impact communities in detrimental ways. Southern ethnic minority groups, particularly African American/Black semi-rural communities, are subject to especially unjust outcomes in health, education, and wealth. Asset-based community development (ABCD) is a way of engaging with communities in participatory and positive ways that center community voices as expert. Youth can participate in ABCD, are sensitive to the ways in which their communities are structured, and have insights as to how to improve the places they live. We undertook a qualitative interview study which included a cognitive mapping exercise with 28 youth to understand how African American/Black youth who had participated in an ABCD-informed summer program conceptualized community and preferences about where they lived. Using a phenomenological approach to qualitative analysis, our study revealed that many youth defined community as a combination of people and place, enjoyed engaging with unique resources in their communities as well as seeking peace and quiet, experienced hardships as "something everybody knows" when observing constraints on their communities, and were committed to their communities and interested in seeing-and participating in-their flourishing. Our study provides a nuanced and contemporary understanding of the ways in which African American/Black semi-rural youth experience community which can contribute to cyclical asset-based development strategy aimed at empowering young people and improving health outcomes in resilient communities.

Two concurrent randomized controlled trials of CommunityRx, a social care intervention for family and friend caregivers delivered at the point of care

Background

CommunityRx is an evidence-based social care intervention delivered to family and friend caregivers ("caregivers") at the point of healthcare to address health-related social risks (HRSRs). CommunityRx-Hunger is a double-blind randomized controlled trial (RCT) that enrolls caregivers of hospitalized children. CommunityRx-Dementia is a single-blind RCT that enrolls caregivers of community-residing people with dementia. Clinical trials that enroll caregivers face recruitment barriers, including caregiver burden and lack of systematic strategies to identify and track caregivers. COVID-19 pandemic-related visitor restrictions exacerbated these barriers and prompted the need for iteration of the CommunityRx protocols from in-person to remote operations. This study describes the novel methods used to iterate existing RCT protocols and factors contributing to their successful iteration.

Methods

CommunityRx uses individual-level data to generate personalized community resource referrals for basic, health and caregiving needs. Our research program uses an asset-based, community-engaged approach including study-specific community advisory boards (CABs). In early 2020, both RCT protocols were pre-tested in-person. In March 2020, when pandemic conditions prohibited enrollment during clinical encounters, both protocols were iterated to efficient, caregiver-centered remote operations. Iterations were enabled in part by the Automated Randomized Controlled Trial Information-Communication System (ARCTICS), a trial management system innovation engineered to integrate the data collection database (REDCap) with community resource referral (NowPow) and SMS texting (Mosio) platforms.

Results

Enabled by engaged CABs and ARCTICS, both RCTs quickly adapted to remote operations. Designed before the pandemic, we had planned to launch both trials by March 2020 and complete enrollment by December 2021. The pandemic postponed launch until November (CommunityRx-Hunger) and December (CommunityRx-Dementia) 2020. Despite the delay, 65% of all planned participants (CommunityRx-Hunger n = 417/640; CommunityRx-Dementia n = 222/344) were enrolled by December 2021, halfway through our projected enrollment timeline. Both trials enrolled 13% more participants in 12 months than originally projected in-person.

Conclusions

Our asset-based, community-engaged approach combined with widely accessible institutional and commercial information technologies facilitated rapid migration to remote trial operations. Remote or hybrid RCT designs for social care interventions may be a viable, scalable alternative to in-person recruitment and intervention delivery protocols, particularly for caregivers and other groups that are under-represented in traditional health services research.

Trial Status

Both studies are registered on ClinicalTrials.gov: CommunityRx-Hunger (NCT04171999); CommunityRx for Caregivers (NCT04146545); My Diabetes My Community (NCT04970810).

Association of Hospital Quality and Neighborhood Deprivation With Mortality After Inpatient Surgery Among Medicare Beneficiaries

Importance

Although the hospital at which a patient is treated is a known source of variation in mortality after inpatient surgery, far less is known about how the neighborhoods from which patients come may also contribute.

Objective

To compare postoperative mortality among Medicare beneficiaries based on the level of neighborhood deprivation where they live and hospital quality where they received care.

Design, Setting, and Participants

This cross-sectional study examined outcomes among Medicare beneficiaries undergoing 1 of 5 common surgical procedures (colon resection, coronary artery bypass, cholecystectomy, appendectomy, or incisional hernia repair) between 2014 and 2018. Hospital quality was assigned using the Centers for Medicare & Medicaid Services Star Rating. Each beneficiary's neighborhood was identified at the census tract level and sorted in quintiles based on its Area Deprivation Index score, a composite measure of neighborhood quality, including education, employment, and housing quality. A risk matrix across hospital quality and neighborhood deprivation was created to determine the relative contribution of each to mortality after surgery. Data were analyzed from June 1 to December 31, 2021.

Exposures

Hospital quality and neighborhood deprivation.

Main Outcomes and Measures

The main outcome was risk-adjusted 30-day mortality after surgery using a multivariable logistic regression model taking into account patient factors and procedure type.

Results

A total of 1 898 829 Medicare beneficiaries (mean [SD] age, 74.8 [7.0] years; 961 216 [50.6%] male beneficiaries; 28 432 [1.5%] Asian, 145 160 [77%] Black, and 1 622 304 [86.5%] White beneficiaries) were included in analyses. Patients from all neighborhood deprivation group quintiles sought care at hospitals across hospital quality levels. For example, 9.1% of patients from the highest deprivation neighborhoods went to a hospital in the highest star rating of quality and 4.2% of patients from the lowest deprivation neighborhoods went to a hospital in the lowest star rating of quality. Thirty-day risk-adjusted mortality varied across high- and low-quality hospitals (4.3% vs 7.2%; adjusted odds ratio [aOR], 1.78; 95% CI, 1.66-1.92) and across the least and most deprived neighborhoods (4.5% vs 6.8%; aOR, 1.58; 95% CI, 1.53-1.64). When combined, comparing patients from the least deprived neighborhoods going to high-quality hospitals vs patients from the most deprived neighborhoods going to low-quality hospitals, the variation increased further (3.8% vs 8.1%; aOR, 2.20; 95% CI, 1.96-2.46).

Conclusions and Relevance

These findings suggest that characteristics of a patient's neighborhood and the hospital where they received treatment were both associated with risk of death after commonly performed inpatient surgical procedures. The associations of these factors on mortality may be additive. Efforts and investments to address variation in postoperative mortality should include both hospital quality improvement as well as addressing drivers of neighborhood deprivation.

Food Insecurity Among People With Cancer: Nutritional Needs as an Essential Component of Care

A cancer diagnosis can upend work and family life, leading patients to reallocate resources away from essentials such as food. Estimates of the percentage of people navigating a cancer diagnosis and food insecurity range between 17% and 55% of the cancer patient population. The complexity of addressing food insecurity among those diagnosed with cancer during different phases of treatment is multifactorial and often requires an extensive network of support throughout each phase. This commentary explores the issue of food insecurity in the context of cancer care, explores current mitigation efforts, and offers a call to action to create a path for food insecurity mitigation in the context of cancer. Three programs that address food insecurity among those with cancer at various stages of care are highlighted, drawing attention to current impact and actionable recommendations to make programs like these scalable and sustainable. Recommendations are grounded in the National Academies of Sciences, Engineering, and Medicine social care framework through 5 essential domain areas: awareness, adjustment, assistance, alignment, and advocacy. This commentary seeks to highlight opportunities for the optimization of cancer care and reframe food access as an essential part of treatment and long-term care plans.

Feed1st, No Questions Asked: How a Hospital-Based Food Pantry Program Grew Its Impact During the COVID-19 Pandemic

Feed1st, a no-questions-asked, self-serve food pantry program at a Chicago, Illinois, medical center, increased its impact during the COVID-19 pandemic, adding five new pantries and distributing 124% more food in March 2020 to November 2021 (42 970 pounds or 36 000 meals) than in the same period of 2018 to 2019 (19 220 pounds or 16 000 meals). Of 11 locations, distribution was highest in a phlebotomy waiting area and a cafeteria pantry. The community-engaged model enabled Feed1st to increase food access for patients, caregivers, and workers during the pandemic. (Am J Public Health. 2022;112(10):1394-1398. https://doi.org/10.2105/AJPH.2022.306984).

Caregiving in a Pandemic: Health-Related Socioeconomic Vulnerabilities Among Women Caregivers Early in the COVID-19 Pandemic

PURPOSE

Family and friends who provide regular care for a sick or dependent individual ("caregivers") are at increased risk of health-related socioeconomic vulnerabilities (HRSVs). This study examined pre-pandemic prevalence of and early pandemic changes in HRSVs among women caregivers compared with non-caregivers.

METHODS

A cross-sectional survey was conducted in April 2020 (early pandemic) with 3,200 English-speaking US women aged 18 years or older, 30% of whom identified as caregivers. We modeled adjusted odds of self-reported HRSVs (financial strain, food/housing insecurity, interpersonal violence, transportation/utilities difficulties) before and changes during the early pandemic by caregiving status. Models were adjusted for age, race/ethnicity, marital status, education, income, number of people in household, number of children in household, physical and mental health, and number of comorbidities.

RESULTS

Pre-pandemic, 63% of caregivers and 47% of non-caregivers reported 1 or more vulnerability (P <.01); food insecurity was most prevalent (48% of caregivers vs 33% of non-caregivers, P <.01). In the early pandemic, caregivers had higher odds than non-caregivers of financial strain, both incident (adjusted odds ratio [AOR] = 2.1; 95% CI, 1.6-2.7) and worsening (AOR = 2.0; 95% CI, 1.4-2.8); incident interpersonal violence (AOR = 2.0; 95% CI, 1.5-2.7); incident food insecurity (AOR = 1.6; 95% CI, 1.2-2.1); incident transportation difficulties (AOR = 1.9; 95% CI, 1.3-2.6); and incident housing insecurity (AOR = 1.6; 95% CI, 1.1-2.3).

CONCLUSION

The coronavirus disease 2019 (COVID-19) pandemic increased risk of incident and worsening HRSVs for caregivers more than for non-caregivers. COVID-19 response and recovery efforts should target caregivers to reduce modifiable HRSVs and promote the health of caregivers and those who depend on them.Annals Online First article.

A Framework for Cross-Sector Partnerships to Address Childhood Adversity and Improve Life Course Health

Childhood adversity and its structural causes drive lifelong and intergenerational inequities in health and well-being. Health care systems increasingly understand the influence of childhood adversity on health outcomes but cannot treat these deep and complex issues alone. Cross-sector partnerships, which integrate health care, food support, legal, housing, and financial services among others, are becoming increasingly recognized as effective approaches address health inequities. What principles should guide the design of cross-sector partnerships that address childhood adversity and promote Life Course Health Development (LCHD)? The complex effects of childhood adversity on health development are explained by LCHD concepts, which serve as the foundation for a cross-sector partnership that optimizes lifelong health. We review the evolution of cross-sector partnerships in health care to inform the development of an LCHD-informed partnership framework geared to address childhood adversity and LCHD. This framework outlines guiding principles to direct partnerships toward life course-oriented action: (1) proactive, developmental, and longitudinal investment; (2) integration and codesign of care networks; (3) collective, community and systemic impact; and (4) equity in praxis and outcomes. Additionally, the framework articulates foundational structures necessary for implementation: (1) a shared cross-sector theory of change; (2) relational structures enabling shared leadership, trust, and learning; (3) linked data and communication platforms; and (4) alternative funding models for shared savings and prospective investment. The LCHD-informed cross-sector partnership framework presented here can be a guide for the design and implementation of cross-sector partnerships that effectively address childhood adversity and advance health equity through individual-, family-, community-, and system-level intervention.

Why Add "Abolition" to the National Academies of Sciences, Engineering, and Medicine's Social Care Framework?

Abundant evidence demonstrates that enduring, endemic racism plays an important role in determining patient health. This commentary reviews a patient case about disease self-management and subsequent health outcomes that are shaped by social and economic circumstances. We analyze the case using a framework for social care developed in 2019 by the National Academies of Sciences, Engineering, and Medicine (NASEM). We then propose that the NASEM framework be adapted by adding the category abolition, which could make the other social care practices transformative for historically marginalized populations.

Toward a better measure of midlife sexual function: pooled analyses in nearly 1,000 women participating in MsFLASH randomized trials

OBJECTIVE

Evaluate appropriateness of the current Female Sexual Function Index (FSFI)-19 value of <26.6 to designate female sexual dysfunction (FSD) in postmenopausal women, using the Female Sexual Distress-Revised (FSDS-R) scale to measure distress.

METHODS

Participant-level data containing standardized measures from five completed Menopause Strategies: Finding Lasting Answers for Symptoms and Health trials was pooled. Baseline characteristics and FSFI-19 scores were compared across trials (F-test, homogeneity). FSFI-19 score associations with the FSDS-R were described. Receiver operating characteristic (ROC) curves were plotted to illustrate the choice of optimal FSFI-19 value to predict sexual distress. ROC curves were also estimated adjusting for trial number, clinical center, age, education, race, smoking, and BMI.

RESULTS

Nine hundred ninety eight women (79.2% postmenopausal), mean age 55.9 (SD 4.8) had complete FSFI-19, FSDS-R, and covariate data. Baseline mean FSFI-19 score among all participants and sexually active participants was 18.7 (SD 9.5) and 22.0 (SD 7.2), respectively. There was a consistent pattern across the trials of inverse association between poorer sexual function (FSFI-19) and greater sexual distress. Based on the ROC curve showing the likelihood of FSDS-R frequent or greater distress according to cut points of FSFI, the optimal cut point for FSD was FSFI-19 <21 for all participants. This cut point corresponded to sensitivity 87.2% (95% CI, 83.4-91.0), specificity 57.9% (95% CI, 54.3-61.6) and adjusted area under the ROC curve 78.8% (95% CI, 75.8-81.8).

CONCLUSIONS

A new FSFI-19 cut point of ≥21 should be considered to describe normal sexual function in periand postmenopausal women as opposed to the standard cut point of >26.6.

VIDEO SUMMARY

http://links.lww.com/MENO/A915.

Implementation of a multi-level community-clinical linkage intervention to improve glycemic control among south Asian patients with uncontrolled diabetes: study protocol of the DREAM initiative

BACKGROUND

A number of studies have identified patient-, provider-, and community-level barriers to effective diabetes management among South Asian Americans, who have a high prevalence of type 2 diabetes. However, no multi-level, integrated community health worker (CHW) models leveraging health information technology (HIT) have been developed to mitigate disease among this population. This paper describes the protocol for a multi-level, community-clinical linkage intervention to improve glycemic control among South Asians with uncontrolled diabetes.

METHODS

The study includes three components: 1) building the capacity of primary care practices (PCPs) to utilize electronic health record (EHR) registries to identify patients with uncontrolled diabetes; 2) delivery of a culturally- and linguistically-adapted CHW intervention to improve diabetes self-management; and 3) HIT-enabled linkage to culturally-relevant community resources. The CHW intervention component includes a randomized controlled trial consisting of group education sessions on diabetes management, physical activity, and diet/nutrition. South Asian individuals with type 2 diabetes are recruited from 20 PCPs throughout NYC and randomized at the individual level within each PCP site. A total of 886 individuals will be randomized into treatment or control groups; EHR data collection occurs at screening, 6-, 12-, and 18-month. We hypothesize that individuals receiving the multi-level diabetes management intervention will be 15% more likely than the control group to achieve ≥0.5% point reduction in hemoglobin A1c (HbA1c) at 6-months. Secondary outcomes include change in weight, body mass index, and LDL cholesterol; the increased use of community and social services; and increased health self-efficacy. Additionally, a cost-effectiveness analysis will focus on implementation and healthcare utilization costs to determine the incremental cost per person achieving an HbA1c change of ≥0.5%.

DISCUSSION

Final outcomes will provide evidence regarding the effectiveness of a multi-level, integrated EHR-CHW intervention, implemented in small PCP settings to promote diabetes control among an underserved South Asian population. The study leverages multisectoral partnerships, including the local health department, a healthcare payer, and EHR vendors. Study findings will have important implications for the translation of integrated evidence-based strategies to other minority communities and in under-resourced primary care settings.

TRIAL REGISTRATION

This study was registered with clinicaltrials.gov: NCT03333044 on November 6, 2017.

Building and experimenting with an agent-based model to study the population-level impact of CommunityRx, a clinic-based community resource referral intervention

CommunityRx (CRx), an information technology intervention, provides patients with a personalized list of healthful community resources (HealtheRx). In repeated clinical studies, nearly half of those who received clinical "doses" of the HealtheRx shared their information with others ("social doses"). Clinical trial design cannot fully capture the impact of information diffusion, which can act as a force multiplier for the intervention. Furthermore, experimentation is needed to understand how intervention delivery can optimize social spread under varying circumstances. To study information diffusion from CRx under varying conditions, we built an agent-based model (ABM). This study describes the model building process and illustrates how an ABM provides insight about information diffusion through in silico experimentation. To build the ABM, we constructed a synthetic population ("agents") using publicly-available data sources. Using clinical trial data, we developed empirically-informed processes simulating agent activities, resource knowledge evolution and information sharing. Using RepastHPC and chiSIM software, we replicated the intervention in silico, simulated information diffusion processes, and generated emergent information diffusion networks. The CRx ABM was calibrated using empirical data to replicate the CRx intervention in silico. We used the ABM to quantify information spread via social versus clinical dosing then conducted information diffusion experiments, comparing the social dosing effect of the intervention when delivered by physicians, nurses or clinical clerks. The synthetic population (N = 802,191) exhibited diverse behavioral characteristics, including activity and knowledge evolution patterns. In silico delivery of the intervention was replicated with high fidelity. Large-scale information diffusion networks emerged among agents exchanging resource information. Varying the propensity for information exchange resulted in networks with different topological characteristics. Community resource information spread via social dosing was nearly 4 fold that from clinical dosing alone and did not vary by delivery mode. This study, using CRx as an example, demonstrates the process of building and experimenting with an ABM to study information diffusion from, and the population-level impact of, a clinical information-based intervention. While the focus of the CRx ABM is to recreate the CRx intervention in silico, the general process of model building, and computational experimentation presented is generalizable to other large-scale ABMs of information diffusion.

Racial and Ethnic Disparities in Health-Related Socioeconomic Risks During the Early COVID-19 Pandemic: A National Survey of U.S. Women

Background: Nearly half of U.S. women experienced new or worsening health-related socioeconomic risks (HRSRs) (food, housing, utilities and transportation difficulties, and interpersonal violence) early in the COVID-19 pandemic. We sought to examine racial/ethnic disparities in pandemic-related changes in HRSRs among women. Materials and Methods: We conducted a cross-sectional survey (04/2020) of 3200 women. Pre- and early pandemic HRSRs were described by race/ethnicity. Weighted, multivariable logistic regression models generated odds of incident and worsening HRSRs by race/ethnicity. Results: The majority of Black, East or Southeast (E/SE) Asian, and Hispanic women reported ≥1 prepandemic HRSR (51%-56% vs. 38% of White women, p < 0.001). By April 2020, 68% of Black, E/SE Asian, and Hispanic women and 55% of White women had ≥1 HRSR (p < 0.001). For most HRSRs, the odds of an incident or worsening condition were similar across racial/ethnic groups, except Black, E/SE Asian and Hispanic women had 2-3.6 times the odds of incident transportation difficulties compared with White women. E/SE Asian women also had higher odds of worsening transportation difficulties compared with White women (adjusted odds ratios = 2.5, 95% confidence interval 1.1-5.6). In the early pandemic, 1/19 Hispanic, 1/28 E/SE Asian, 1/36 Black and 1/100 White women had all 5 HRSRs (extreme health-related socioeconomic vulnerability). Conclusions: Prepandemic racial/ethnic disparities in HRSRs persisted and prevalence rates increased for all groups early in the pandemic. Disparities in transportation difficulties widened. White women were much less likely than others to experience extreme health-related socioeconomic vulnerability. An equitable COVID-19 response requires attention to persistent and widening racial/ethnic disparities in HRSRs among women.

Domestic Violence Police Reporting and Resources During the 2020 COVID-19 Stay-at-Home Order in Chicago, Illinois

IMPORTANCE

Domestic violence (DV) has become a growing public health concern during the COVID-19 pandemic because individuals may be sheltering in place with abusers and facing mounting economic and health-related stresses.

OBJECTIVE

To analyze associations of the 2020 COVID-19 stay-at-home (SH) order with DV police reporting and resource availability, including differences by community area racial/ethnic composition.

DESIGN, SETTING, AND PARTICIPANTS

This longitudinal cohort study assessed DV police reports (January-June 2020) obtained from the Chicago, Illinois, Police Department and DV resource availability (March and August 2020) obtained from the NowPow community resource database, both for 77 community areas in Chicago. Data were analyzed July through December 2020.

EXPOSURES

The COVID-19 SH order effective March 21, 2020.

MAIN OUTCOMES AND MEASURES

Monthly rates of DV police reports and DV resource availability per 100 000 persons.

RESULTS

Of 77 community areas in Chicago, 28 (36.4%) were majority Black, 19 (24.7%) majority Hispanic/Latinx, 18 (23.4%) majority White, and 12 (15.6%) a different or no majority race/ethnicity, representing an estimated population of 2 718 555 individuals. For each community area, the SH order was associated with a decrease in the rate of DV police reports by 21.8 (95% CI, -30.48 to -13.07) crimes per 100 000 persons per month relative to the same months in 2019. Compared with White majority community areas, Black majority areas had a decrease in the rate of DV police reports by 40.8 (95% CI, -62.93 to -18.75) crimes per 100 000 persons per month relative to the same months in 2019. The SH order was also associated with a decrease in DV resource availability at a rate of 5.1 (95% CI, -7.55 to -2.67) resources per 100 000 persons, with the largest decreases for mental health (-4.3 [95% CI, -5.97 to -2.66] resources per 100 000 persons) and personal safety (-2.4 [95% CI, -4.40 to -0.41] resources per 100 000 persons). The Black majority south side of Chicago had a larger decrease in resource availability (-6.7 [95% CI, -12.92 to -0.46] resources per 100 000 persons) than the White majority north side.

CONCLUSIONS AND RELEVANCE

In this longitudinal cohort study, the rate of DV police reports decreased after the SH order was implemented in Chicago. This decrease was largely observed in Black majority communities, whereas there was no significant change in White majority communities. These findings may reflect decreased DV incidence but may also reflect an exacerbation of underreporting. In addition, DV resource availability decreased disproportionately on the predominantly Black south side of Chicago.

Screening for Interpersonal Violence: Missed Opportunities and Potential Harms

INTRODUCTION

Screening for interpersonal violence is used in healthcare settings to identify patients experiencing violence. However, using unvalidated screening tools may misclassify patients' experience with violence. The Center for Medicare & Medicaid Innovation adapted a previously validated intimate partner violence screening tool for use in assessing interpersonal violence and retained the tool's original scoring rubric, despite the new tool's broader scope. This study evaluates the scoring system for detecting safety concerns.

METHODS

This was a cross-sectional survey of a convenience sample of adult patients and caregivers of pediatric patients at 7 primary care clinics and 4 emergency departments (2018-2019). Surveys included the adapted 4-item Hurt Insult Threat Scream tool. Questions are scored by frequency on a Likert scale (1=never; 5=frequently). Scores of 11-20 are considered positive for safety concerns. Two-sided Fisher's exact tests were used for descriptive analyses. Data analyses occurred in 2019-2020.

RESULTS

Of 1,014 participants, 66 (6.5%) reported any frequency of physical violence. Of these, 54 (81.8%) did not reach the threshold score of 11. Of the 1,014 participants, 93 (9.2%) reported any frequency of physical violence or being threatened with harm; 76 of 93 participants (81.7%) scored <11.

CONCLUSIONS

Using the original scoring criteria for the adapted Hurt Insult Threat Scream, >80% of participants reporting physical violence did not screen positive for potential safety concerns. The scoring criteria did not reliably identify participants experiencing or at high risk for violence. To improve patient safety, the adapted Hurt Insult Threat Scream scoring rubric should be updated on the basis of stakeholder input and additional validation studies.

Patient Experiences with Screening and Assistance for Social Isolation in Primary Care Settings

BACKGROUND

Social isolation is a known predictor of mortality that disproportionately affects vulnerable populations in the USA. Although experts began to recognize it as a public health crisis prior to 2020, the novel coronavirus pandemic has accelerated recognition of social isolation as a serious threat to health and well-being.

OBJECTIVE

Examine patient experiences with screening and assistance for social isolation in primary care settings, and whether patient experiences with these activities are associated with the severity of reported social isolation.

DESIGN

Cross-sectional survey conducted in 2018.

PARTICIPANTS

Adults (N = 251) were recruited from 3 primary care clinics in Boston, Chicago, and San Francisco.

MAIN MEASURES

A modified version of the Berkman-Syme Social Network Index (SNI), endorsed by the National Academies of Sciences, Engineering, and Medicine; items to assess for prior experiences with screening and assistance for social isolation.

KEY RESULTS

In the sample population, 12.4% reported the highest levels of social isolation (SNI = 0/1), compared to 36.7%, 34.7%, and 16.3% (SNI = 2-4, respectively). Most patients had not been asked about social isolation in a healthcare setting (87.3%), despite reporting no discomfort with social isolation screening (93.9%). Neither discomfort with nor participation in prior screening for social isolation was associated with social isolation levels. Desire for assistance with social isolation (3.2%) was associated with a higher level of social isolation (AOR = 6.0, 95% CI, 1.3-28.8), as well as poor or fair health status (AOR = 9.1; 95% CI, 1.3-64.1).

CONCLUSIONS

In this study, few patients reported being screened previously for social isolation in a primary care setting, despite low levels of discomfort with screening. Providers should consider broadening social isolation screening and referral practices in healthcare settings, especially among sicker and more isolated patients who express higher levels of interest in assistance with social isolation.

CommunityRx: Optimizing a Community Resource Referral Intervention for Minority Dementia Caregivers

Community resource referral systems have been implemented into care settings that serve persons with dementia but with little input from caregivers. Focus groups were conducted with African American, Hispanic, and Asian caregivers to describe their preferences for community resource referral information. Caregivers discussed the significance of a community resource list for dementia caregiving and self-care and articulated strategies for effective information delivery during a medical visit. Most caregivers acknowledged that resource needs change with progression of dementia, but no patterns emerged with regard to preference for information delivered incrementally based on disease stage or all at once. Hispanic and Asian caregivers felt that resource information should specify service providers' language and cultural capabilities. All caregivers agreed that delivery by a member of the care team with knowledge of dementia-specific resources would be most effective. Optimal delivery of community resource referrals is caregiver-centered and customizable to individual and subgroup preferences.

Change in Health-Related Socioeconomic Risk Factors and Mental Health During the Early Phase of the COVID-19 Pandemic: A National Survey of U.S. Women

Background: During a pandemic, women may be especially vulnerable to secondary health problems driven by its social and economic effects. We examined the relationship between changes in health-related socioeconomic risks (HRSRs) and mental health. Materials and Methods: A cross-sectional survey of 3,200 women aged 18-90 years was conducted in April 2020 using a quota-based sample from a national panel (88% cooperation rate). Patterns of change in HRSRs (food insecurity, housing instability, interpersonal violence, and difficulties with utilities and transportation) were described. Weighted, multivariate logistic regression was used to model the odds of depression, anxiety, and traumatic stress symptoms among those with and without incident or worsening HRSRs. Results: More than 40% of women had one or more prepandemic HRSRs. In the early pandemic phase, 49% of all women, including 29% with no prepandemic HRSRs, had experienced incident or worsening HRSRs. By April 2020, the rates of depression and anxiety were twice that of prepandemic benchmarks (29%); 17% of women had symptoms of traumatic stress. The odds of depression, anxiety, and posttraumatic stress symptoms were two to three times higher among women who reported at least one incident or worsening HRSR; this finding was similar for women with and without prepandemic HRSRs. Conclusions: Increased health-related socioeconomic vulnerability among U.S. women early in the coronavirus disease 2019 (COVID-19) pandemic was prevalent and associated with alarmingly high rates of mental health problems. Pandemic-related mental health needs are likely to be much greater than currently available resources, especially for vulnerable women.

Implementation of Community-Based Resource Referrals for Cardiovascular Disease Self-Management

PURPOSE

Describe primary care practices' implementation of CommunityRx-H3, a community resource referral intervention that utilized practice facilitators to support cardiovascular disease (CVD) prevention quality improvement.

METHODS

Qualitative focus groups were conducted with practice facilitators to elicit perceptions of practices' experiences with CommunityRx-H3, practice-level factors affecting, and practice facilitator strategies to promote implementation. Qualitative data were analyzed using directed content analysis. The Consolidated Framework for Implementation Research was applied deductively to organize and interpret findings.

RESULTS

Fourteen of all 19 practice facilitators participated. Practice facilitators perceived that staff attitudes about connecting patients to community resources for CVD were largely positive. Practices were already using a range of non-systematic strategies to refer to community resources. Practice-level factors that facilitated CommunityRx-H3 implementation included clinician "champions," engaged practice managers, and a practice culture that valued community resources. Implementation barriers included a practice's unwillingness to integrate the intervention into existing workflows, limited staff capacity to complete the resource inventory, and unavailability or cost of materials needed to print the resource referral list ("HealtheRx-H3"). Practice facilitator strategies to promote implementation included supporting ongoing customization of the HealtheRx-H3 and material support. Practice facilitators felt implementation would be improved by integration of CommunityRx-H3 with electronic medical record workflows and alternative methods for engaging practices in the implementation process.

CONCLUSIONS

Practice facilitators are increasingly being utilized by primary care practices to support quality improvement interventions and, as shown here, can also play an important role in implementation science. This study yields insights to improve implementation of community resource referral solutions to support primary care CVD prevention efforts.

Impact of a Low-Intensity Resource Referral Intervention on Patients' Knowledge, Beliefs, and Use of Community Resources: Results from the CommunityRx Trial

BACKGROUND

Connecting patients to community-based resources is now a cornerstone of modern healthcare that supports self-management of health. The mechanisms that link resource information to behavior change, however, remain poorly understood.

OBJECTIVE

To evaluate the impact of CommunityRx, an automated, low-intensity resource referral intervention, on patients' knowledge, beliefs, and use of community resources.

DESIGN

Real-world controlled clinical trial at an urban academic medical center in 2015-2016; participants were assigned by alternating week to receive the CommunityRx intervention or usual care. Surveys were administered at baseline, 1 week, 1 month, and 3 months.

PARTICIPANTS

Publicly insured adults, ages 45-74 years.

INTERVENTION

CommunityRx generated an automated, personalized list of resources, known as HealtheRx, near each participant's home using condition-specific, evidence-based algorithms. Algorithms used patient demographic and health characteristics documented in the electronic health record to identify relevant resources from a comprehensive, regularly updated database of health-related resources in the study area.

MAIN MEASURES

Using intent-to-treat analysis, we examined the impact of HealtheRx referrals on (1) knowledge of the most commonly referred resource types, including healthy eating classes, individual counseling, mortgage assistance, smoking cessation, stress management, and weight loss classes or groups, and (2) beliefs about having resources in the community to manage health.

KEY RESULTS

In a real-world controlled trial of 374 adults, intervention recipients improved knowledge (AOR = 2.15; 95% CI, 1.29-3.58) and beliefs (AOR = 1.68; 95% CI, 1.07-2.64) about common resources in the community to manage health, specifically gaining knowledge about smoking cessation (AOR = 2.76; 95% CI, 1.07-7.12) and weight loss resources (AOR = 2.26; 95% CI 1.05-4.84). Positive changes in both knowledge and beliefs about community resources were associated with higher resource use (P = 0.02).

CONCLUSIONS

In a middle-age and older population with high morbidity, a low-intensity health IT intervention to deliver resource referrals promoted behavior change by increasing knowledge and positive beliefs about community resources for self-management of health.

NIH TRIAL REGISTRY

NCT02435511.

Part I: A Quantitative Study of Social Risk Screening Acceptability in Patients and Caregivers

INTRODUCTION

Despite recent growth in healthcare delivery-based social risk screening, little is known about patient perspectives on these activities. This study evaluates patient and caregiver acceptability of social risk screening.

METHODS

This was a cross-sectional survey of 969 adult patients and adult caregivers of pediatric patients recruited from 6 primary care clinics and 4 emergency departments across 9 states. Survey items included the Center for Medicare and Medicaid Innovation Accountable Health Communities' social risk screening tool and questions about appropriateness of screening and comfort with including social risk data in electronic health records. Logistic regressions evaluated covariate associations with acceptability measures. Data collection occurred from July 2018 to February 2019; data analyses were conducted in February‒March 2019.

RESULTS

Screening was reported as appropriate by 79% of participants; 65% reported comfort including social risks in electronic health records. In adjusted models, higher perceived screening appropriateness was associated with previous exposure to healthcare-based social risk screening (AOR=1.82, 95% CI=1.16, 2.88), trust in clinicians (AOR=1.55, 95% CI=1.00, 2.40), and recruitment from a primary care setting (AOR=1.70, 95% CI=1.23, 2.38). Lower appropriateness was associated with previous experience of healthcare discrimination (AOR=0.66, 95% CI=0.45, 0.95). Higher comfort with electronic health record documentation was associated with previously receiving assistance with social risks in a healthcare setting (AOR=1.47, 95% CI=1.04, 2.07).

CONCLUSIONS

A strong majority of adult patients and caregivers of pediatric patients reported that social risk screening was appropriate. Most also felt comfortable including social risk data in electronic health records. Although multiple factors influenced acceptability, the effects were moderate to small. These findings suggest that lack of patient acceptability is unlikely to be a major implementation barrier.

SUPPLEMENT INFORMATION

This article is part of a supplement entitled Identifying and Intervening on Social Needs in Clinical Settings: Evidence and Evidence Gaps, which is sponsored by the Agency for Healthcare Research and Quality of the U.S. Department of Health and Human Services, Kaiser Permanente, and the Robert Wood Johnson Foundation.

Part II: A Qualitative Study of Social Risk Screening Acceptability in Patients and Caregivers

INTRODUCTION

This study aimed to better understand patient and caregiver perspectives on social risk screening across different healthcare settings.

METHODS

As part of a mixed-methods multisite study, the authors conducted semistructured interviews with a subset of adult patients and adult caregivers of pediatric patients who had completed the Center for Medicare and Medicaid Innovation Accountable Health Communities social risk screening tool between July 2018 and February 2019. Interviews, conducted in English or Spanish, asked about reactions to screening, screening acceptability, preferences for administration, prior screening experiences that informed perspectives, and expectations for social assistance. Basic thematic analysis and constant comparative methods were used to code and develop themes.

RESULTS

Fifty interviews were conducted across 10 study sites in 9 states, including 6 primary care clinics and 4 emergency departments. There was broad consensus among interviewees across all sites that social risk screening was acceptable. The following 4 main themes emerged: (1) participants believed screening for social risks is important; (2) participants expressed insight into the connections between social risks and overall health; (3) participants emphasized the importance of patient-centered implementation of social risk screening; and (4) participants recognized limits to the healthcare sector's capacity to address or resolve social risks.

CONCLUSIONS

Despite gaps in the availability of social risk-related interventions in healthcare settings, patient-centered social risk screening, including empathy and attention to privacy, may strengthen relationships between patients and healthcare teams.

SUPPLEMENT INFORMATION

This article is part of a supplement entitled Identifying and Intervening on Social Needs in Clinical Settings: Evidence and Evidence Gaps, which is sponsored by the Agency for Healthcare Research and Quality of the U.S. Department of Health and Human Services, Kaiser Permanente, and the Robert Wood Johnson Foundation.

Association of Rising Violent Crime With Blood Pressure and Cardiovascular Risk: Longitudinal Evidence From Chicago, 2014-2016

BACKGROUND

The purpose of this study was to examine the longitudinal association between rising violent crime and elevated blood pressure (BP).

METHODS

We analyzed 217,816 BP measurements from 17,783 adults during a temporal surge in violent crime in Chicago (2014-2016). Serial observations were abstracted from the electronic health record at an academic medical center and paired to the City of Chicago Police Data Portal. The violent crime rate (VCR) was calculated as the number of violent crimes per 1,000 population per year for each census tract. Longitudinal multilevel regression models were implemented to assess elevated BP (systolic BP ≥ 140 mm Hg or diastolic BP ≥ 90 mm Hg) as a function of the VCR, adjusting for patient characteristics, neighborhood characteristics, and time effects. Secondary dependent measures included elevated heart rate, obesity, missed outpatient appointments, all-cause hospital admissions, and cardiovascular hospital admissions.

RESULTS

At baseline, the median VCR was 41.3 (interquartile range: 15.2-66.8), with a maximum rise in VCR of 59.1 over the 3-year surge period. A 20-unit rise in the VCR was associated with 3% higher adjusted odds of having elevated BP (95% confidence interval [CI]: 1.01-1.06), 8% higher adjusted odds of missing an outpatient appointment (95% CI: 1.03-1.13), and 6% higher adjusted odds of having a cardiovascular-related hospital admission (95% CI: 1.01-1.12); associations were not significant for elevated heart rate and obesity.

CONCLUSION

Rising violent crime was associated with increased BP during a temporal crime surge.

Community resource referral needs among African American dementia caregivers in an urban community: a qualitative study

BACKGROUND

African American caregivers of community-residing persons with dementia are mostly unpaid and have high rates of unmet basic and health needs. The National Alzheimer's Project Act (NAPA) mandates improved coordination of care for persons with dementia and calls for special attention to racial populations at higher risk for Alzheimer's Disease or related dementias (ADRD) to decrease health disparities. The purpose of this study is to describe the perceptions of African American caregivers of people with dementia about community resources needed to support caregiving as well as their own self-care.

METHODS

Using a qualitative study design, in-depth, semi-structured qualitative interviews were conducted with caregivers (N = 13) at an urban geriatric clinic to elicit community resource needs, barriers to and facilitators of resource use and how to optimize clinical referrals to community resources. Caregivers were shown a community resource referral list ("HealtheRx") developed for people with dementia and were queried to elicit relevance, gaps and insights to inform delivery of this information in the healthcare setting. Data were iteratively coded and analyzed using directed content analysis. Results represent key themes.

RESULTS

Most caregivers were women (n = 10, 77%) and offspring (n = 8, 62%) of the person with dementia. Community resource needs of these caregivers included social, entertainment, personal self-care and hospice services. Main barriers to resource use were the inability to leave the person with dementia unsupervised and the care recipient's disinterest in participating in their own self-care. Facilitators of resource use included shared caregiving responsibility and learning about resources from trusted sources. To optimize clinical referrals to resources, caregivers wanted specific eligibility criteria and an indicator of dementia care capability.

CONCLUSIONS

African American caregivers in this study identified ways in which community resource referrals by clinicians can be improved to meet their caregiving and self-care needs.

Embedding research recruitment in a community resource e-prescribing system: lessons from an implementation study on Chicago's South Side

OBJECTIVE

The study sought to implement and assess the CommunityRx e-prescribing system to recruit research participants from a predominantly non-Hispanic Black community on Chicago's South Side.

MATERIALS AND METHODS

CommunityRx integrates with electronic medical record systems to generate a personalized list of health-promoting community resources (HealtheRx). Between December 2015 and December 2016, HealtheRxs distributed at outpatient visits to adults with asthma or chronic obstructive pulmonary disease also incentivized participation in a pulmonary research registry. Usual practices for registry recruitment continued in parallel.

RESULTS

Focus groups established acceptability and appropriateness among the target population. Pulmonary research registry recruitment information was included on 13 437 HealtheRxs. Forty-one (90% non-Hispanic Black) patients responded with willingness to participate and 9 (8 non-Hispanic Black) returned a signed consent required to enroll. Usual recruitment practices enrolled 4 registrants (1 non-Hispanic Black).

DISCUSSION

Automating research recruitment using a community e-prescribing system is feasible.

CONCLUSIONS

Implementation of an electronic medical record-integrated, community resource referral tool promotes enrollment of eligible underrepresented research participants; however, enrollment was low.

Literature Review of Vaginal Stenosis and Dilator Use in Radiation Oncology

PURPOSE

Guidelines for the care of women undergoing pelvic radiation therapy (RT) recommend vaginal dilator therapy (VDT) to prevent radiation-induced vaginal stenosis (VS); however, no standard protocol exists. This review seeks to update our current state of knowledge concerning VS and VDT in radiation oncology.

METHODS AND MATERIALS

A comprehensive literature review (1972-2017) was conducted using search terms "vaginal stenosis," "radiation," and "vaginal dilator." Information was organized by key concepts including VS definition, time course, pathophysiology, risk factors, and interventions.

RESULTS

VS is a well-described consequence of pelvic RT, with early manifestations and late changes evolving over several years. Strong risk factors for VS include RT dose and volume of vagina irradiated. Resultant vaginal changes can interfere with sexual function and correlational studies support the use of preventive VDT. The complexity of factors that drive noncompliance with VDT is well recognized. There are no prospective data to guide optimal duration of VDT, and the consistency with which radiation oncologists monitor VS and manage its consequences is unknown.

CONCLUSIONS

This review provides information concerning VS definition, pathophysiology, and risk factors and identifies domains of VDT practice that are understudied. Prospective efforts to monitor and measure outcomes of patients who are prescribed VDT are needed to guide practice.

Literature Review of Vaginal Stenosis and Dilator Use in Radiation Oncology

PURPOSE

Guidelines for the care of women undergoing pelvic radiation therapy (RT) recommend vaginal dilator therapy (VDT) to prevent radiation-induced vaginal stenosis (VS); however, no standard protocol exists. This review seeks to update our current state of knowledge concerning VS and VDT in radiation oncology.

METHODS AND MATERIALS

A comprehensive literature review (1972-2017) was conducted using search terms "vaginal stenosis," "radiation," and "vaginal dilator." Information was organized by key concepts including VS definition, time course, pathophysiology, risk factors, and interventions.

RESULTS

VS is a well-described consequence of pelvic RT, with early manifestations and late changes evolving over several years. Strong risk factors for VS include RT dose and volume of vagina irradiated. Resultant vaginal changes can interfere with sexual function and correlational studies support the use of preventive VDT. The complexity of factors that drive noncompliance with VDT is well recognized. There are no prospective data to guide optimal duration of VDT, and the consistency with which radiation oncologists monitor VS and manage its consequences is unknown.

CONCLUSIONS

This review provides information concerning VS definition, pathophysiology, and risk factors and identifies domains of VDT practice that are understudied. Prospective efforts to monitor and measure outcomes of patients who are prescribed VDT are needed to guide practice.

CommunityRx: A Real-World Controlled Clinical Trial of a Scalable, Low-Intensity Community Resource Referral Intervention

OBJECTIVES

To test the effect of CommunityRx, a scalable, low-intensity intervention that matches patients to community resources, on mental health-related quality of life (HRQOL) (primary outcome), physical HRQOL, and confidence in finding resources.

METHODS

A real-world trial assigned publicly insured residents of Chicago, Illinois, aged 45 to 74 years to an intervention (n = 209) or control (n = 202) group by alternating calendar week, December 2015 to August 2016. Intervention group participants received usual care and an electronic medical record-generated, personalized list of community resources. Surveys (baseline, 1-week, 1- and 3-months) measured HRQOL and confidence in finding community resources to manage health.

RESULTS

At 3 months, there was no difference between groups in mental (-1.03; 95% confidence interval [CI] = -3.02, 0.96) or physical HRQOL (0.59; 95% CI = -0.98, 2.16). Confidence in finding resources was higher in the intervention group (odds ratio = 2.08; 95% CI = 1.18, 3.63); the effect increased at each successive time point. Among intervention group participants, 65% recalled receiving the intervention; 48% shared community resource information with others.

CONCLUSIONS

CommunityRx did not increase HRQOL, but its positive effect on confidence in finding resources for self-care suggests that this low-intensity intervention may have a role in population health promotion.

TRIAL REGISTRATION

ClinicalTrials.gov Identifier: NCT02435511.

Geospatial patterns of access to self-care resources for obesity among endometrial cancer survivors in a high poverty urban community

OBJECTIVE

To examine endometrial cancer survivors' access to recommended obesity-related self-care resources.

METHODS

Participants included women treated 2010-2015 for endometrial cancer at an academic medical center who lived in the surrounding 16 ZIP code area on Chicago's South Side. Demographic and health data were abstracted from medical records. A socioeconomic status (SES) score (SES-1 = low, SES-5 = high) was generated for each patient using census block group-level data. Self-care resources for exercise, healthy weight, and diet were obtained from a community resource census. Geospatial techniques assessed "walkable access" (~½-mile radius around a patient's home) to obesity-related resources. Multivariable logistic regression investigated associations between access to obesity-related resources and patient characteristics.

RESULTS

Of 195 endometrial cancer survivors, 81% identified as Black/African American and 34% lived in an SES-1 census block. Two thirds (68%) had Stage I or II endometrial cancer. Nearly two thirds (62%) were obese (BMI ≥ 30 kg/m²). Obesity was inversely associated with SES (p = 0.05). Two thirds of survivors had access to at least one of all three recommended resource types. Access was lower in low SES regions and among Black/African American women. Lower SES was associated with lower odds of walkable access to recommended resources (AOR for access to two of each resource type 0.75, 95%CI 0.59, 0.97; AOR for access to three or more of each 0.44, 95%CI 0.32, 0.61).

CONCLUSIONS

Obesity rates were higher and access to recommended resources was lower for Black/African American endometrial cancer survivors living in high poverty areas in Chicago.

Cross-Sector Collaboration in the High-Poverty Setting: Qualitative Results from a Community-Based Diabetes Intervention

OBJECTIVE

To characterize the motivations of stakeholders from diverse sectors who engaged in cross-sector collaboration with an academic medical center.

DATA SOURCE

Primary qualitative data (2014-2015) were collected from 22 organizations involved in a cross-sector diabetes intervention on the South Side of Chicago.

STUDY DESIGN

In-depth, semistructured interviews; participants included leaders from all stakeholder organization types (e.g., businesses, community development, faith-based) involved in the intervention.

DATA COLLECTION METHODS

Data were transcribed verbatim from audio and video recordings. Analysis was conducted using the constant comparison method, derived from grounded theory.

PRINCIPAL FINDINGS

All stakeholders described collaboration as an opportunity to promote community health in vulnerable populations. Among diverse motivations across organization types, stakeholders described collaboration as an opportunity for: financial support, brand enhancement, access to specialized skills or knowledge, professional networking, and health care system involvement in community-based efforts. Based on our findings, we propose a framework for implementing a working knowledge of stakeholder motivations to facilitate effective cross-sector collaboration.

CONCLUSIONS

We identified several factors that motivated collaboration across diverse sectors with health care systems to promote health in a high-poverty, urban setting. Understanding these motivations will be foundational to optimizing meaningful cross-sector collaboration and improving diabetes outcomes in the nation's most vulnerable communities.

Sexuality and Cognitive Status: A U.S. Nationally Representative Study of Home-Dwelling Older Adults

OBJECTIVES

To determine patterns and prevalence of sexual behavior, problems, and attitudes in individuals with different cognitive status.

DESIGN

We used data from the National Social Life, Health, and Aging Project to describe the relationship between sexual behavior, function, and cognitive status (normal, mild cognitive impairment, dementia), classified using an adapted Montreal Cognitive Assessment (MoCA) (0-30 points).

SETTING

U.S. home-dwelling older adults.

PARTICIPANTS

Nationally representative probability sample of 3,196 adults (1,682 women, 1,514 men) aged 62 to 91 (mean 72).

MEASUREMENTS

Cognitive status and sexual activity, problems, and attitudes.

RESULTS

The weighted response rate was 74%. Mean MoCA score was 22.7. Of partnered people with dementia, 59% of men and 51% of women were sexually active, including 41% of those aged 80 to 91; 46% of all men (95% confidence interval (CI)=37.8-53.2%) and 18% of all women (95% CI=13.6-21.5%) with dementia were sexually active. The rate of sexual function problems was high across gender and cognitive groups (77%). Having sex primarily out of obligation was similar across cognitive groups for women (12%) and higher in men with dementia (17%) than other men (2-5%; P <.001). The majority of people were having sex less often than they would like. Few men (17%) or women (1%) with dementia talked with a doctor about sex.

CONCLUSION

Many home-dwelling men and women with dementia are sexually active. Although the rate of sexual function problems was uniformly high, people with lower cognitive function infrequently discussed sex with a physician.

Prescription Medication Use Among Children and Adolescents in the United States

BACKGROUND AND OBJECTIVES

Information on the use of prescription medications among children and adolescents in the United States is lacking. We estimate the prevalence of prescription medication use, concurrent use, and potential major drug-drug interactions (DDIs) in this population.

METHODS

We conducted descriptive analyses using nationally representative data for people ≤19 years old from NHANES. Data were derived from a medication log administered by direct observation during in-home interviews. Acute medications were used for ≤30 days. Concurrent use was defined as use of ≥2 prescription medications. Micromedex was used to identify potentially major DDIs.

RESULTS

During 2013-2014, 19.8% of children and adolescents used at least 1 prescription medication, and 7.1% used acute medications. Concurrent use of prescription medications was 7.5% overall and was highest among boys 6 to 12 years old (12%) and among boys and girls ages 13 to 19 years old (10% for both). Using pooled 2009-2014 data, we found that 8.2% of concurrent users of prescription medications were at risk for a potentially major DDI. The vast majority of interacting regimens involved antidepressants and were more common among adolescent girls than boys (18.1% vs 6.6%; P < .05), driven largely by greater rates of use of acute medications.

CONCLUSIONS

Many US children and adolescents use prescription medications with nearly 1 in 12 concurrent users of prescription medications potentially at risk for a major DDI. Efforts to prevent adverse drug events in children and adolescents should consider the role of interacting drug combinations, especially among adolescent girls.

Prevalence of Dietary Supplement Use in US Children and Adolescents, 2003-2014

This study uses NHANES data to estimate the prevalence of dietary supplement use, including both nutritional products and alternative medicines, among US children and adolescents between 2003 and 2014.