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OBJECTIVES: This study examined dentists’ moving patterns in Iowa from 2000 to 2019 to identify potential trends in movement between urban and rural areas., METHODS: The source of data was the Iowa Dentist Tracking System (IDTS). All active dentists in Iowa in 2000 (n=1424) were used as a baseline. The final sample (n=616) included dentists who remained in private practice in Iowa during the study period. Movers were identified based on a change in the year 2000 street address as of 2019. Urbanicity of practice locations was measured at the county level using the 2013 Rural-Urban Continuum Codes (RUCC). Multivariable logistic regression was used to identify characteristics associated with relocation and subsequent change in urbanicity over the study period., RESULTS: Only 22.2% of the final sample moved during 2000-2019. Among dentists who moved (n=137), 74.5% moved with no change in urbanicity of their practice locations, 13.9% moved to more urban counties, and 11.7% moved to more rural counties. Eighty percent of those movers with no change in urbanicity relocated from one metro (RUCCs 1-3) location to another metro location. Younger (p, CONCLUSIONS: Iowa private practice dentists who moved during 2000-2019 tended to be younger and work part-time. Given that only two-tenths of the final sample of dentists moved and nearly three-quarters of those movers remained within the same urbanicity, the initial practice location may play an important role in geographic distribution of dentists across the state.

COVID-19 presented a public health emergency in the U.S., resulting in severe illness, hospitalizations, high mortality rates, and long-term adverse health care conditions. Several studies examined the disparities in transmission rates, barriers to care, and negative health outcomes for persons with disabilities, particularly people with intellectual and developmental disabilities (I/DD). While data revealed similar trends among Black, Hispanic or Latino/a/x/e, Native, Indigenous, and Asian people, outcomes are compounded for people of color with I/DD. Several historical, pervasive, systemic, structural, and attitudinal barriers have constrained healthcare access and adequate treatment, instigating feelings of distrust among those in systems of care. Although vaccination is effective in minimizing adverse outcomes, COVID-19 vaccine policies and rollouts have also followed inequitable patterns in distribution and accessibility. To better address the concerns and needs of communities, a multidisciplinary team at a University Center of Excellence in Developmental Disabilities (UCEDD) engaged in a generative, multistep, systematic process to explore factors that influence vaccine confidence among people with I/DD, their families, and support circles, particularly people of color with IDD. Garnering data and input from multiple sources, we uncovered several complexities around vaccination, which include (a) accessibility; (b) context, history, and sociocultural concerns; (c) policies; (d) communication and media; and (e) a continuum of vaccine confidence and supported decision-making. Findings from these efforts underscore the centrality of equity and trust, with implications for practitioners, institutions, policymakers, and public health strategists. Furthermore, our model can serve as a useful framework for people invested in promoting healthcare equity in vaccination for people with I/DD and with multiple marginalized identities.

Health literacy is related to different health-related outcomes. However, the nature of the relationship between health literacy and health outcomes is not well understood. One pathway may lead from health literacy to health outcomes by means of access to healthcare. The goal of the current study is to explore the association between health literacy and the particular measure of access to healthcare—unmet medical need—for the first time in Croatia and, to the best of our knowledge, for the first time in the EU context. We use data obtained from face-to-face interviews in a large nationally representative sample of the Croatian population (n = 1000) to estimate the level of health literacy and self-reported access to care and investigate the association between health literacy and self-perceived barriers to access. Our study showed that limited and problematic health literacy is prevalent and associated with higher rates of unmet medical need. Unmet need is largely caused by long waiting lists. It is therefore essential to design health services fitting the needs of those who have limited and/or problematic health literacy as well as enhance health education with the potential of improving the access to care and health outcomes as well as design policies that reduce waiting times.

Cadre de la recherche : En 1999, le CHU Sainte-Justine à Montréal a créé une offre de soins palliatifs pédiatriques (SPP) qui s’est déployée graduellement dans tous les secteurs de l’hôpital. Un programme de recherche rétrospectif et critique vise à comprendre l’évolution des pratiques et à circonscrire les enjeux actuels. Objectifs : Cet article présente un portrait des SPP en milieu de soins tertiaires afin de nourrir la réflexion sur l’évolution des pratiques en identifiant des priorités de recherche aux niveaux clinique, organisationnel et systémique. Méthodologie : L’approche des méthodes mixtes est utilisée pour cette recherche-intervention. Une base de données d’archives (1999-2021) et des comptes-rendus d’ateliers (2021-2022) font l’objet d’analyses statistiques descriptives, d’analyses conceptuelles et d’une narration collective. Résultats : Le déploiement des SPP s’est accru au fil des ans pour se stabiliser par la suite. Le nombre de requêtes n’est pas corrélé au nombre de décès pour un secteur donné. Les répondants ont décrit dix thèmes centraux pour la pratique, la formation et la recherche en SPP : (1) les besoins des patients en milieu hospitalier tertiaire, (2) les particularités pédiatriques des soins palliatifs et soins de fin de vie, (3) la centralité de l’enfant, (4) la douleur et la souffrance ou le bien-être et la qualité de vie, (5) les motivations et les besoins des soignants, (6) les pratiques interdisciplinaires et interprofessionnelles, (7) la formation et les compétences, (8) les normes et les indicateurs, (9) les dimensions éthique et systémique des SPP, et (10) l’espoir et les espoirs. Conclusion : Des outils conceptuels, procéduraux et pédagogiques sont essentiels pour améliorer la qualité et l’accessibilité des soins et des services en SPP. Contribution : Nous souhaitons enrichir la réflexion sur les SPP en décrivant notre perspective et en stimulant les interactions entre les différents milieux hospitaliers et communautaires concernés. Research Framework: In 1999, Montreal’s Sainte-Justine University Hospital created a pediatric palliative care (PPC) service that was gradually deployed in all sectors of the hospital. A retrospective and critical research program aims to understand the evolution of practices and to pinpoint current issues. Objectives: This article presents a portrait of PPC in tertiary care settings in order to fuel reflection on the evolution of practices by identifying research priorities at the clinical, organizational and systemic levels. Methodology: A mixed methods approach is used for this research intervention. An archive database (1999-2021) and workshop proceedings (2021-2022) were subjected to descriptive statistical analysis, conceptual analysis, and collective narration. Results: PPC interventions have increased over the year and then stabilized. The number of requests does not correlate with the number of deaths for a given area. Respondents described 10 central themes for PPC practice, training and research: (1) patient needs at the tertiary hospital setting, (2) pediatric specificities of palliative and end-of-life care, (3) child centredness, (4) pain and suffering or well-being and quality of life, (5) motivations and needs of caregivers, (6) interdisciplinary and interprofessional practices, (7) training and skills, (8) practice norms and indicators, (9) ethical and systemic dimensions of PPC, and (10) hope and high hopes. Conclusion: Conceptual, procedural, and educational tools are essential to improve quality and accessibility of care and PPC services. Contribution: We aim to contribute to the reflection on PPC by describing our perspective and by stimulating interactions among the various hospitals and communities involved. Marco de investigación: En 1999, el Hospital Universitario Sainte-Justine de Montreal creó un servicio de cuidados paliativos pediátricos (CPP) que se ha ido desplegando progresivamente en todos los sectores del hospital. Un programa de investigación retrospectiva y crítica pretende entender la evolución de estos cuidados e identificar los retos actuales. Objetivos: Este artículo presenta un retrato de los CPP en un entorno de atención terciaria, a fin de ofrecer elementos de reflexión sobre la evolución de estos cuidados identificando las prioridades de investigación a nivel clínico, organizacional y sistémico. Metodología: En el marco de esta intervención-investigación, se utiliza un enfoque de métodos mixtos. Una base de datos de archivos (1999-2021) y los informes de los talleres de reflexión (2021-2022) son objeto de análisis estadísticos descriptivos, de análisis conceptuales y de una narración colectiva. Resultados: El despliegue de los CPP ha aumentado con los años y se ha estabilizado después. El número de solicitudes por sector no se correlaciona con el número de muertes. Los participantes describieron diez temas centrales para la práctica, la formación y la investigación sobre los CPP: (1) las necesidades de los pacientes en un hospital de atención terciaria, (2) las especificidades pediátricas de los cuidados paliativos y al final de la vida, (3) la centralidad del niño, (4) el dolor y el sufrimiento o el bienestar y la calidad de vida, (5) las motivaciones y necesidades de los proveedores de atención médica, (6) las prácticas interdisciplinarias e interprofesionales, (7) la capacitación y las competencias, (8) las normas de práctica e indicadores de calidad, (9) las dimensiones ética y sistémica de los CPP y (10) la esperanza y las esperanzas. Conclusiones: Las herramientas conceptuales, procedimentales y pedagógicas son esenciales para mejorar la calidad y la accesibilidad a la atención y a los servicios en CPP. Contribución: Deseamos enriquecer la reflexión sobre los CPP describiendo nuestra perspectiva y estimulando las interacciones entre los diferentes entornos hospitalarios y comunitarios implicados en los CPP.

My STS research connects to my technical capstone work in that they both explore the impact of the Epic Electronic Health Record (EHR) in health systems. The STS research focuses on a specific case of Epic utilization and explores why it was unsuccessful. My technical work involves hands-on data collection and analysis utilizing many sources of information, one of which is Epic timestamp output. While my research focuses on the failure of Epic specifically, and my technical work is wider in scope with a greater objective of increasing efficiency, they both utilize Epic as a technology to improve provider workflows. My client for the technical project was UVA Health’s University Physicians Clinic (UPC). The project ranged in methods, including analysis of observational data and Epic EHR timestamps and the creation of a discrete-event simulation to explore various what-if scenarios. The observational data were cross-matched against the timestamps Epic would output and found several irrational results. These discrepancies indicated a significant gap in understanding what triggers these times, which makes it difficult to glean any information from this data for future analysis. The simulation used only accurate timestamps within a reasonable confidence level. The results from the simulation experiments supported providers and clinic leaders in advocating for more nursing staff. The analysis also showed that potential policies administrators want to explore would not be feasible in current workflows. My STS research paper uses the principles of Actor-Network theory (ANT) to argue that successful Epic workflow implementation requires synonymous goals across all levels of the health system. Administrators need to have goals aligned with front-line health workers and vice versa. The specific case I researched demonstrated the contentious relationship. The hierarchical programs put in place as part of the Epic implementation only exacerbated the antagonistic relationship between actors. The administration established these hierarchical programs to push their goals instead of shifting to have goals aligned with most other actors. Epic is a beneficial technology in health workflows and significantly increases efficiency, but only when fully utilizing its comprehensive capabilities. Epic's advantages were lost in the specific STS case I researched, and the EHR was not supporting the system's efficiency. Working on these projects concurrently improved how I viewed my technical client's problems. The STS research was on a specific case where there were many roadblocks due to the antagonistic relationship between physicians and the greater hospital administration. I noticed that same relationship in my real-world technical work. This disagreement framed our goal to generate data that would help support providers' calls for support in the inefficient clinic. It further showed that a strong, supportive relationship between health system administration and the field workers is critical for creating a successful network that serves patients with high access to quality care. The hands-on aspect of the technical project also served as context to understand the STS case study. Working on both my technical and STS project in parallel increased my ability to meet the project objectives of utilizing Epic EHR technology to improve workflows within health systems.

Cancer is one of the major socio-health problems in the world. The level of education, the profession and/or employment status of the patient and the family can influence the amount of household income, the additional expenditure, and the possible socio-economic impact of the disease. The main objective of the study is to analyse and evaluate the influence of the level of education, the employment status of the patient, and the need for care and how these factors influence the additional expenditure and the possible socio-economic impact. Methods: descriptive cross-sectional randomised observational epidemiological study without replacement at the Hospital Universitario de Salamanca (CAUSA). Results: total sample (n = 365) comprised 53.2% of patients with no education or primary education, 25.8% with secondary education and 21.1% with higher education. Overall, 36.4% of patients were employed, 10.1% were self-employed, 53.0% were not employed, and 38.9% were experiencing other conditions. Significant statistics were found for educational level, employment status of the patient and main caregivers in terms of financial expenditure. Conclusions: Oncology patients with more education spend more on home help and/or accompanying the patient and transfers to the hospital for treatment. Higher incomes are not synonymous with higher expenditure in the sample. The patient’s main caregivers are a fundamental pillar of the patient’s household income and additional spending on orthopaedic material.

Studies of health care access and use among historically resilient populations, while common, often field a limited sample size and rarely ask the groups most impacted by health inequities to weigh in. This is especially so for research and programs that focus on the American Indian and Alaska Native (AIAN) population. The present study addresses this gap by examining data from a cross-sectional survey of AIANs in Los Angeles County. To better interpret project findings and generate culturally relevant contexts, qualitative feedback was gathered at a community forum held in Spring 2018. Because recruitment of AIANs has historically been challenging, purposive sampling was employed to strategically identify a larger eligible pool. Among those who were eligible, 94% completed the survey (n = 496). AIANs who were enrolled in a tribe were 32% more likely to use the Indian Health Service (IHS), compared with those who were not enrolled (95% CI: 20.4%, 43.2%; p < .0001). In multivariable modeling, the strongest factors influencing IHS access and use were: tribal enrollment, preference for culturally-specific health care, proximity of the services to home or work, having Medicaid, and having less than a high school education. Feedback from the community forum indicated cost and trust (of a provider) were important considerations for most AIANs. Study findings reveal heterogeneous patterns of health care access and use in this population, suggesting a need to further improve the continuity, stability, and the image of AIANs' usual sources of care (e.g., IHS, community clinics).

Appointment wait times have increased nationally since 2014, especially in cardiology. At a mid-Atlantic academic medical center, access to care in the general cardiology clinic was below national standards, which can negatively affect patient outcomes and satisfaction. Adopting a Team-Based Care (TBC) model, advanced practice providers (APPs) were added to care teams with general cardiologists to provide timely outpatient management of cardiac conditions. This aimed to increase access to care, and consequently, patient satisfaction. A formative program evaluation using the Agency for Clinical Innovation framework assessed TBC’s impact on these outcomes. Access to care and patient satisfaction measures for TBC and non-team providers were compared to one another and national benchmarks. Nine months after implementation, the average time to new patient appointment for TBC providers was 31 days (47% decrease), and for non-team providers was 41 days (20% decrease). TBC had a higher percentage of new patient appointments within 14 days than non-team providers (39% and 20%, respectively). Patient satisfaction improved to the 98th percentile nationally for TBC but decreased to the 71st percentile for non-team. These findings suggest that a team-based care model utilizing APPs can improve access to care and patient satisfaction in the outpatient general cardiology setting.

Background Telemedicine expanded rapidly during the COVID-19 pandemic, including for contraceptive services. Data are needed to understand whether young people can access telemedicine for contraception, especially in underserved populations. Objective To compare young people’s perceived access to telemedicine visits for contraception during the COVID-19 pandemic by food and housing insecurity. Design Supplementary study to a cluster randomized controlled trial in 25 community colleges in California and Texas. Online surveys were administered May 2020 to April 2021. Mixed-effects logistic regression models with random effects for site were used to examine differences in access to contraception through telemedicine by food and housing insecurity status, controlling for key sociodemographic characteristics, including race/ethnicity, non-English primary language, health insurance status, and state of residence, and contraceptive method used. Participants 1,414 individuals assigned female at birth aged 18–28. Main Measures Survey measures were used to capture how difficult it would be for a participant to have a telemedicine visit (phone or video) for contraception. Key Results Twenty-nine percent of participants were food insecure, and 15% were housing insecure. Nearly a quarter (24%) stated that it would be difficult to have a phone or video visit for contraception. After accounting for sociodemographic factors and type of method used, food insecure (adjusted odds ratio [aOR], 2.17; 95% confidence interval [CI], 1.62–2.91) and housing insecure (aOR, 1.62; 95% CI, 1.13–2.33) participants were significantly more likely to report that it would be difficult to use telemedicine for contraception during the pandemic. Conclusions Underserved patients are those who could benefit most from the expansion of telemedicine services, yet our findings show that young people experiencing basic needs insecurity perceive the greatest difficulty accessing these services for essential reproductive care. Trial Registration ClinicalTrials.gov Identifier: NCT03519685

Social accountability is an important strategy towards ensuring that political leaders and actors implement the right policies in the interest of the entire society. In 2007, a community-based health insurance programme was implemented in selected rural communities in Kwara State, Nigeria, through collaboration between the Dutch Health Insurance Fund, PharmAccess Foundation, the Kwara State Government, and Hygeia Nigeria Limited to provide access to basic healthcare for the people. After operating for 9 years, the programme stopped in 2016. This paper describes how social and political accountability shaped the introduction, functioning, and stoppage of the CBHI programme. The study adopted a qualitative approach for data collection, particularly in-depth (n = 22) and key informant interviews (n = 32). Findings indicate that the community-based health insurance programme was proposed by the foreign agency and that the state government was instrumental in the stoppage of the programme. Also, the change in government (via voting against a political bloc that had been in power since 2003) in Kwara State during the 2019 general elections was among the accountability measures employed by the citizenry in reaction to the stoppage of the Community-Based Health Insurance programme. The implication of this is that the current government, expectedly, will not only draw up a more robust healthcare policy for implementation but will also ensure that the people are carried along through adequate social and political accountability mechanisms.

Background and ObjectivesStudies describing gaps in care for youth with congenital heart disease (CHD), focus on those who have returned to care, but rarely those actively missing from care. Our objective was to determine barriers for young adults with CHD actively missing from cardiac care and to re-engage them in care.MethodsRetrospective single-center cohort study of cardiology clinic patients ages 15-21 years with CHD between 2012-2019 for patients actively missing from care (≥12 months beyond requested clinic follow-up). We conducted prospective interviews, offered clinic scheduling information and recorded cardiac follow-up. Data was analyzed using descriptive statistics, univariable, and multivariable logistic regression.ResultsOf 1053 CHD patients, 33% (n=349) were actively missing. Of those missing, 58% were male and median age was 17 yrs (IQR 16-19). Forty-six percent were Non-Hispanic White, 33% Hispanic, and 9% Black. Moderately complex CHD was in 71%, and 62% had private insurance. Patients with simple CHD, older age at last encounter (18-21), and scheduled follow-up >12 months from last encounter were more likely to be actively missing. Interviews were completed by 125 patients/parents (36%). Lack of cardiac care was reported in 52%, and common barriers included: insurance (33%), appointment scheduling (26%), and unknown ACHD center care (15%). Roughly half (55%) accepted appointment information, yet only 3% successfully returned.ConclusionsMany patients require assistance beyond CHD knowledge to maintain and re-engage in care. Future interventions should include scheduling assistance, focused insurance maintenance, understanding where to obtain ACHD care, and educating on need for lifelong care.Article SummaryThere is a growing population of youth with congenital heart disease leaving cardiology care; we investigate patients actively missing from care and target their re-engagement.What’s Known on This Subject?Maintaining cardiac care is a problem for many patients with congenital heart disease, especially teens and young adults, and characteristics of both patients and their healthcare environment contribute to the maintenance and ability to continue appropriate cardiac care.What This Study AddsThis study uniquely investigates patients with congenital heart disease that are actively missing from care, and investigates if a simple intervention of contacting them while they are missing to re-engage them in care impacts their re-entry into cardiac care.Contributors’ Statement PageJudson Moore conceptualized and designed the study, designed data collection instruments, collected data, drafted the initial manuscript, and completed necessary revisions to final manuscript.Keila Lopez conceptualized and designed the study, designed data collection instruments, critically reviewed data, revised manuscript drafts, and provided content expertise.Shreya Sheth conceptualized and designed the study, critically reviewed data, and revised the manuscript.Wilson Lam contributed to study design, critically reviewed data for intellectual content, and revised the manuscript.Alexander Alexander, Andre Espaillat, and John Shabosky designed data collection instruments, collected data, and reviewed/revised the manuscript.Karla Dyer performed data extraction, data cleaning, and reviewed/revised the manuscript.Nicole Broussard and Donna Lovick provided expert knowledge for interpretation of data and reviewed/revised the manuscript.All authors approved the final manuscript as submitted and agree to be accountable for all aspects of the work.

Background The number of Californians covered by Medi-Cal increased more than 50% between 2013 and 2018, largely due to expansion under the Affordable Care Act (ACA). This rapid expansion of Medicaid rolls prompted concerns that Medi-Cal enrollees would face greater difficulty accessing health care. Objective Examine whether gaps in access to care between Medi-Cal and employer-sponsored insurance (ESI) present in 2013 (prior to ACA implementation) had changed by 2018 (several years post implementation). Design Secondary analysis of data from the 2013 and 2018 California Health Interview Survey. The sample included adults of ages 18–64 insured all year and covered by ESI or Medi-Cal at time of interview. Logistic regressions were used to examine variation across years in the association between access to care and insurance type. Main Measures Five access to care outcomes were assessed: no usual source of care, not accepted as new patient in past year, insurance not accepted in past year, delayed medical care in past year, and difficulty getting timely appointment. The main predictors of interest were type of insurance (Medi-Cal or ESI) and survey year (2013 or 2018). Key Results The association between insurance type and access to care changed significantly over time for three outcomes: not accepted as new patient in past year (OR = 0.55, 95% CI = 0.32–0.97), delayed medical care in past year (OR = 1.55, 95% CI = 1.06–2.25), and difficulty getting timely appointment (OR = 0.41, 95% CI = 0.23–0.74). Predicted probabilities indicate gaps between Medi-Cal and ESI narrowed for not accepted as new patient in past year and difficulty getting timely appointment, but widened for delayed medical care. Conclusions Despite the rapid expansion in the number of Californians covered by Medi-Cal, most gaps in access to care between Medi-Cal and ESI enrollees improved or did not significantly change between 2013 and 2018.

Background Despite guidelines, poor access to appropriate care for juvenile idiopathic arthritis (JIA) patients remains a global issue. Prompt referral to a pediatric rheumatology (PR) center and effective care is known to be critical for changing the natural history of the disease and improving long-term prognosis. This project assesses socio-economic factors of delayed referral to a pediatric rheumatologist (PRst) for JIA patients in France and Switzerland within the Juvenile Inflammatory Rheumatism (JIR) Cohort. Methods All patients diagnosed with JIA, presenting at one center of the JIRcohort in France or Switzerland with additional data on referral pathway were included. Patient characteristics at first visit to the PR center, dates of visits to healthcare providers during referral, and parent characteristics were extracted from the JIRcohort database. Results Two hundred fifty children were included. The overall median time to first PR assessment was 2.4 months [1.3; 6.9] and ranged widely across the JIA subtypes, from 1.4 months [0.6; 3.8] for children with systemic juvenile idiopathic arthritis (sJIA) to 5.3 months [2.0; 19.1] for children with enthesitis-related arthritis (ERA). A diagnosis of ERA and an appointment with an orthopedist during the referral pathway were significantly associated with a longer time before the first PR visit (hazard ratio HR 0.50 [95% CI: 0.29; 0.84]) and HR 0.68 [95% CI: 0.49; 0.93], respectively) in multivariable analysis. Having a mother with a post-graduate educational attainment level was tendentially associated with a shorter time before the first PR visit, (HR 1.32 [95% CI: 0.99; 1.78]). Conclusions Time to first PRst visit was most often short compared to other studies and close to the British recommendations. However, this time remained too long for many patients. We observed no social inequities in access to a PRst, but we show the need to improve effective pathway and access to a PR center for JIA patients.

Access to hepatitis C (HCV) testing and treatment is still limited globally. To address this, the Government of Rwanda launched a voluntary mass screening and treatment campaign in 2017. We studied the progression of patients through the cascade of HCV care during this campaign. We conducted a retrospective cohort study and included all patients screened at 46 hospitals between April 2017 and October 2019. We used hierarchical logistic regression to assess factors associated with HCV positivity, gaps in care, and treatment failure. A total of 860,801 people attended the mass screening during the study period. Some 5.7% tested positive for anti-HCV, and 2.9% were confirmed positive. Of those who were confirmed positive, 52% initiated treatment, and 72% of those initiated treatment, completed treatment and returned for assessment 12 weeks afterward. The cure rate was 88%. HCV positivity was associated with age, socio-economic status, sex, marital status, and HIV coinfection. Treatment failure was associated with cirrhosis, baseline viral load, and a family history of HCV. Our results suggest that future HCV screening and testing interventions in Rwanda and other similar settings should target high-risk groups. High dropout rates suggest that more effort should be put into patient follow-up to increase adherence to care.

Objective: Lung lobectomy is the standard of care for early-stage lung cancer. Studies have suggested improved outcomes associated with lobectomy performed by specialized thoracic surgery providers. We hypothesized that disparities would exist regarding access to thoracic surgeons among patients receiving lung lobectomy for cancer. Methods: The Premier Hospital Database was used to identify adult inpatients receiving lung lobectomy from 2009 to 2019. Patients were categorized as receiving their lobectomy from a thoracic surgeon, cardiovascular surgeon, or general surgeon. Sample-weighted multivariable analysis was performed to identify factors associated with provider type. Results: When adjusted for sampling, 121,711 patients were analyzed, including 71,709 (58.9%) who received lobectomy by a thoracic surgeon, 36,630 (30.1%) by a cardiovascular surgeon, and 13,373 (11.0%) by a general surgeon. Multivariable analysis showed that thoracic surgeon provider type was less likely with Black patients, Medicaid insurance, smaller hospital size, in the western region, and in rural areas. In addition, non-thoracic surgery specialty was less likely to perform minimally-invasive (MIS) lobectomy (cardiovascular OR 0.80, p < 0.001, general surgery OR 0.85, p = 0.003). Conclusions: In this nationally representative analysis, smaller, rural, non-teaching hospitals, and certain regions of the United States are less likely to receive lobectomy from a thoracic surgeon. Thoracic surgeon specialization is also independently associated with utilization of minimally invasive lobectomy. Combined, there are significant disparities in access to guideline-directed surgical care of patients receiving lung lobectomy.

La e-santé participe à la démocratisation de la connaissance de l’accès aux soins des populations. Dans une volonté de démocratie sanitaire, un site internet interactif gratuit permet à chaque usager d’interroger les différents indicateurs liés à la démographie médicale de son propre « territoire vécu ». Ce site propose d’interroger le recours aux soins de première ligne (accès aux services des urgences) pour identifier les inadéquations de l’offre de soins aux « besoins » réels des populations. En 2015, la France métropolitaine comptait 557 services officiels d’accueil des urgences qui accueillaient plus de 17 millions primo-passages pour des soins d’urgences. Afin d’apporter un éclairage objectif à destination des usagers (citoyens, pouvoirs publics), il est nécessaire de disposer d’un territoire pertinent reflétant le plus fidèlement de la pratique spatiale des usagers, c’est-à-dire, un « territoire vécu ». Une projection à l’horizon 2025 et 2030, cible les besoins théoriques en termes de démographie médicale des médecins généralistes au niveau de ces territoires opérationnels. E-health contributes to the democratisation of knowledge regarding the access to healthcare among populations. In this sense, a free interactive website enables each user to question various medical demography indicators of his own "lived territory". This website highlights the use of first-line care (access to emergency services) to identify the inadequacies between the care supply and the real care "needs" of the populations. In 2015, five hundred fifty-seven official emergency services operated in metropolitan France and received more than 17 million first-time visitors for emergency care. However, it is necessary to have a relevant territory reference shaping as closely as possible the spatial practice of users in order to provide the users (citizens, public authorities) with the objective view. The relevant territory reference is represented in this research by the « lived territory ». This research paper also proposes a projection for 2025 and 2030 of the theoretical needs in medical demography of general practitioners in these operational territories, i.e., « lived territories », in metropolitan France.

Background Disparities in oral health and distinct patterns in service use related to socio-economic status have been shown to exist in the United Kingdom. A number of studies have used the Andersen behavioural model to better understand the factors that influence utilization and thereby inform policies aimed at improving service uptake. As the nature of need may differ across distinct types of patients, however, so too may the distribution of enabling and pre-disposing factors and observed relationships between need, other factors and service use. In this study we compare samples with distinct self-assessed needs in terms of their characteristics and patterns of service use to compare application of the Andersen model to dental services among respondents to a population based survey. Materials and methods Data were taken from the Scottish Health Survey, for 2019. Data on service use, oral hygiene habits, perceived treatment need, and socio-demographic characteristics were extracted. Data were analysed using descriptive statistics, t-tests and ordered logistic regression analyses. Results Two thousand one hundred forty-eight usable responses were obtained from the survey, 74.95% of the sample had visited the dentist less than a year ago, 11.82% between 1 year and up to 2 years ago, 7.12% between 2 and 5 years ago and 6.10% more than 5 years. Descriptive statistics, t-tests and ordered logistic regression analyses revealed distinct patterns of service use when the sample was partitioned based on perceived treatment need. Specifically those with self-assessed treatment need were older, more likely to smoke, be male and be less likely to have a degree than those who did not. While service use was positively related to age (predisposing) among those who did not have self-assessed treatment need, it was negatively related for those with perceived treatment need. Distinct patterns were also evident with respect to sugar exposure (need) and ease with which time off work could be organised (enabling). Discussion The study shows common and distinct patterns of service use related to enabling and predisposing factors across groups differentiated by self-perceived treatment need. If inequalities in health and healthcare use are to be addressed, it is important to understand their origins. Conflation of distinct types of need that may correlate with predisposing and enabling factors complicates this. Conclusion In applying the Andersen model, it is important to take account of potential differences in the types of need expressed where possible to understand the role of other variables in service use.

In early 2022 in the U.S., rural adults were the least likely to vaccinate against COVID-19 due to vaccine hesitancy and reduced healthcare access. This study explored the factors influencing rural adults’ COVID-19 vaccine perceptions and their acceptance of pharmacist-administered vaccination. We utilized phone-based semi-structured interviews with 30 adults living in rural regions of one southwestern state and analyzed the data using a team-based thematic analysis approach. Vaccine-willing participants described knowing other people affected by the virus and their desired protection from the virus. They reported trusting scientific institutions and the government to provide safe vaccines. Vaccine-hesitant populations, however, feared that the COVID-19 vaccine development process had been rushed, compromising the safety of these newer vaccines. Although they differed in the news sources they preferred for receiving COVID-19 vaccine information, both vaccine-willing and vaccine-hesitant participants described trusting local authorities, such as healthcare providers and county government officials, to provide accurate COVID-19 vaccine information. Regarding the acceptability of pharmacist-administered COVID-19 vaccinations, all but one participant described their acceptance of this healthcare delivery approach. Future outreach should leverage rural adults’ trust in local sources, including community pharmacists, deemed more convenient access points to healthcare, when addressing vaccine hesitancy.

Investigating the experiences of healthcare providers affected by infertility in the United States: a scoping review protocol

Background The collateral damage of SARS-CoV-2 is a serious concern in the Emergency Medicine (EM) community, specifically in relation to delayed care increasing morbidity and mortality in attendances unrelated to COVID-19. The objectives of this study are to describe the profile of patients attending an Irish ED prior to, and during the pandemic, and to investigate the factors influencing ED utilisation in this cohort. Methods This was a cross-sectional study with recruitment at three time-points prior to the onset of COVID-19 in December 2019 (n = 47) and February 2020 (n = 57) and post-Lockdown 1 in July 2020 (n = 70). At each time-point all adults presenting over a 24 h period were eligible for inclusion. Clinical data were collected via electronic records and a questionnaire provided information on demographics, healthcare utilisation, service awareness and factors influencing the decision to attend the ED. Data analysis was performed in SPSS and included descriptive and inferential statistics. Results The demographic and clinical profile of patients across time-points was comparable in terms of age (p = 0.904), gender (p = 0.584) and presenting complaint (p = 0.556). Median length of stay in the ED decreased from 7.25 h (IQR 4.18–11.22) in February to 3.86 h (IQR 0.41–9.14) in July (p ≤ 0.005) and differences were observed in disposition (p ≤ 0.001). COVID-19 influenced decision to attend the ED for 31% of patients with 9% delaying presentation. Post-lockdown, patients were less likely to attend the ED for reassurance (p ≤ 0.005), for a second opinion (p ≤ 0.005) or to see a specialist (p ≤ 0.05). Conclusions Demographic and clinical presentations of ED patients prior to the first COVID-19 lockdown and during the reopening phase were comparable, however, COVID-19 significantly impacted health-seeking behaviour and operational metrics in the ED at this phase of the pandemic. These findings provide useful information for hospitals with regard to pandemic preparedness and also have wider implications for planning of future health service delivery.

Investigating the experiences of healthcare providers affected by infertility in the United States: a scoping review

In April 2020, the Department of Veterans Affairs responded to the COVID-19 pandemic and escalating unsheltered homelessness in Los Angeles by sanctioning a tent turned tiny shelter encampment at the West Los Angeles Veterans Affairs medical center. Initially, staff offered linkages to on-campus VA healthcare. However, as many Veterans living in the encampment struggled to avail themselves of these services, our "encampment medicine" team was launched to provide on-site care coordination and healthcare at the tiny shelters. This case study showcases the team's engagement with a Veteran experiencing homelessness struggling with opioid use disorder and depicts how this co-located, comprehensive care team allowed for trusting care relationships formed with, and empowerment of the Veterans living in the encampment. The piece highlights a healthcare model that engages with persons experiencing homelessness on their own terms while building trust and solidarity, focuses on the sense of community that formed in the tiny shelter encampment, and gives recommendations for how homeless services might adapt to use the strengths of this unique community.

Background Antenatal care and skilled childbirth services are important interventions to improve maternal health and lower the risk of poor pregnancy outcomes and mortality. A growing body of literature has shown that geographic distance to clinics can be a disincentive towards seeking care during pregnancy. On the Thailand-Myanmar border antenatal clinics serving migrant populations have found high rates of loss to follow-up of 17.4%, but decades of civil conflict have made the underlying factors difficult to investigate. Here we perform a comprehensive study examining the geographic, demographic, and health-related factors contributing to loss to follow-up. Methods Using patient records we conducted a spatial and epidemiological analysis looking for predictors of loss to follow-up and pregnancy outcomes between 2007 and 2015. We used multivariable negative binomial regressions to assess for associations between distance travelled to the clinic and birth outcomes (loss to follow-up, pregnancy complications, and time of first presentation for antenatal care.) Results We found distance travelled to clinic strongly predicts loss to follow-up, miscarriage, malaria infections in pregnancy, and presentation for antenatal care after the first trimester. People lost to follow-up travelled 50% farther than people who had a normal singleton childbirth (a ratio of distances (DR) 1.5; 95% confidence interval (CI): 1.4 – 1.5). People with pregnancies complicated by miscarriage travelled 20% farther than those who did not have miscarriages (DR: 1.2; CI 1.1–1.3), and those with Plasmodium falciparum malaria in pregnancy travelled 60% farther than those without P. falciparum (DR: 1.6; CI: 1.6 – 1.8). People who delayed antenatal care until the third trimester travelled 50% farther compared to people who attended in the first trimester (DR: 1.5; CI: 1.4 – 1.5). Conclusions This analysis provides the first evidence of the complex impact of geography on access to antenatal services and pregnancy outcomes in the rural, remote, and politically complex Thailand-Myanmar border region. These findings can be used to help guide evidence-based interventions to increase uptake of maternal healthcare both in the Thailand-Myanmar region and in other rural, remote, and politically complicated environments.

Purpose Rectal bleeding is a common symptom of colorectal cancer. In this paper, we describe and evaluate the operation of a central access and triage system for patients with rectal bleeding, which uses a “high-risk”/ “low-risk” designation based on the referring doctor’s subjective designation and a 10-item symptom checklist. Methods A total of 1846 patients, referred between February 1, 2016, and December 31, 2018, were included. Exclusion criteria were the following: incorrect patient identification number, duplicate records, and pre-diagnosed gastrointestinal cancer. Data was obtained by chart review. Sensitivity, specificity, and positive and negative predictive values were calculated for each item on the symptom checklist. Results Eight hundred seventy-nine (48%) patients received endoscopy, and 37 (2%) were found to have cancer. Five hundred eighty-two (32%) patients were deemed high-risk. Twenty-nine (78%) of the patients with cancer were in the high-risk group. Patients in the high-risk group had a higher incidence of cancer (5.0% vs 0.6%, p

Background: Patients with heart failure (HF) are often cared for by non-cardiologists. The implications are unknown. Methods: In a nationwide HF cohort with reduced ejection fraction (HFrEF), we compared demographics, clinical characteristics, guideline-based therapy use and outcomes in non-cardiology vs. cardiology in-patient and outpatient care. Results: Between 2000 and 2016, 36,076 patients with HFrEF were enrolled in the Swedish HF registry (19,337 [54%] in-patients overall), with 44% of in-patients and 45% of out-patients managed in non-cardiology settings. Predictors of treatment in non-cardiology were age > 75 years (adjusted odds ratio for non-cardiology 1.20; 95% confidence interval 1.14-1.27), lower education level (0.71; 0.66-0.76 for university vs. compulsory), valve disease (1.24; 1.18-1.31) and systolic blood pressure (SBP) >120 mmHg (1.05; 1.00-1.10). Non-cardiology care was significantly associated with lower use of beta-blockers (0.80; 0.74-0.86) and devices (intracardiac defibrillator [ICD] and/or cardiac resynchronization therapy [CRT]: 0.63; 0.56-0.71), and less frequent specialist follow-up (0.61; 0.57-0.65). Over 1-year follow-up the risk of all-cause mortality (adjusted hazard ratio 1.09; 1.03-1.15) was higher but the risk of first HF (re-) hospitalization was lower (0.93; 0.89-0.97) in non-cardiology vs. cardiology care. Conclusions: In HFrEF, non-cardiology care was independently associated with older ageand lower education. After covariate adjustment, non-cardiology care was associated with lower use of beta-blockers and devices, higher mortality, and lower risk of HF hospitalization. Access to cardiology care may not be equitable and this may have implications for use of guideline-based care and outcomes. Funding Agencies|Karolinska InstitutetKarolinska Institutet; Swedish Research CouncilSwedish Research CouncilEuropean Commission [523-2014-2336]; Swedish Heart Lung FoundationSwedish Heart-Lung Foundation [20150557, 20190310]; Stockholm County CouncilStockholm County Council [20170112, 20190525]

Background Unmet oral health needs routinely affect low-income communities. Lower-income adults suffer a disproportionate share of dental disease and often cannot access necessary oral surgery services. The Affordable Care Act (ACA) Medicaid expansion created new financial opportunities for community health centers (CHCs) to provide mission-relevant services in low-income areas. However, little is understood in the literature about how the ACA Medicaid expansion impacted oral surgery delivery at CHCs. Using a large sample of CHCs, we examined whether the ACA Medicaid expansion increased the likelihood of oral surgery delivery at expansion-state CHCs compared to non-expansion-state CHCs. Methods Exploiting a natural experiment, we estimated Poisson regression models examining the effects of the Medicaid expansion on the likelihood of oral surgery delivery at expansion-state CHCs relative to non-expansion-state CHCs. We merged data from multiple sources spanning 2012–2017. The analytic sample included 2054 CHC-year observations. Results Compared to the year prior to expansion, expansion-state CHCs were 13.5% less likely than non-expansion-state CHCs to provide additional oral surgery services in 2016 (IRR = 0.865; P = 0.06) and 14.7% less likely in 2017 (IRR = 0.853; P = 0.02). All else equal, and relative to non-expansion-state CHCs, expansion-state CHCs included in the analytic sample were 8.7% less likely to provide oral surgery services in all post-expansion years pooled together (IRR = 0.913; P = 0.01). Conclusions Medicaid expansions can provide CHCs with opportunities to expand their patient revenue and services. However, whether because of known dental treatment capacity limitations, new competition, or coordination with other providers, expansion-state CHCs in our study sample were less likely to provide oral surgery services on the margin relative to non-expansion-state CHCs following Medicaid expansion.

Purpose: Since the start of the coronavirus disease 2019 (COVID-19) pandemic in March 2020, ∼40% of U.S. adults have experienced delayed medical care. Rates of uninsurance, delayed care, and utilization of mental health services during the course of the pandemic have not been analyzed in detail. We examined monthly trends and disparities in access to care by household income levels in the United States. Methods: Using Census Bureau's nationally representative pooled 2020 Household Pulse Survey from April to December, 2020 (N=778,819), logistic regression models were used to analyze trends and inequalities in various access to care measures. Results: During the COVID-19 pandemic, the odds of being uninsured, having a delayed medical care due to pandemic, delayed care of something other than COVID-19, or delayed mental health care were, respectively, 5.54, 1.50, 1.85, and 2.18 times higher for adults with income

In France, self-employers physicians are mainly paid on a fee-for-service basis with regulated prices (for sector 1 physicians) or extra fees (sector 2 physicians). This remuneration scheme, which, by definition, encourages physicians to perform more procedures to increase their income, impacts the way they provide care. More generally, it influences the organization and efficiency of the healthcare system. Based on administrative and exhaustive databases of all French self-employed physicians, this thesis aims to understand better how physicians react when faced with changes in their remuneration. In particular, when a "pay-for-performance" (P4P) scheme is introduced in addition to fee-for-service payment (chapter 1), or when the practice of overbilling is prohibited (chapter 2) or limited (chapter 3). P4P was introduced in 2009 through the "Contrat d’Amélioration des Pratiques Individuelles" (CAPI). The first chapter shows that the CAPI has significantly influenced the GPs' activity who have joined it in a way that is compatible with an improvement in the quality of care. Unlike other GPs, CAPI members did not reduce their number of consultations per patient or the amount of prescriptions per patient. They have also increased, to a greater extent than others, the proportion of their patients whom they treat as the primary care doctor (i.e. the "médecin traitant"). Finally, CAPI led to an increase in the fees per patient, with, as a consequence, a higher cost for the National Health Insurance.The second line of research focuses mainly on specialists, who often practice in sector 2 and can therefore charge higher fees. Extra fees, which are high and charged to patients, can generate inequalities in access to care. The first attempt to regulate the practice of extra fees was the "sector 2 freeze" reform in 1990. Using discontinuity regressions, Chapter 2 evaluates the causal effect of this regulation of fees. It shows that specialists whose activity is more "technical" in nature increase their activity significantly when constrained to practice in sector 1, mainly their technical activity. Two-thirds of this increase in activity is associated with the arrival of new patients, a sign of improved accessibility to care; the remaining third can be assimilated to strategic behavior, aiming to compensate for the fall in their tariffs by an increase in the content of the procedures provided. On the other hand, specialists whose activity is mainly composed of office visits have no room for maneuver to increase their activity when they are forced to practice in sector 1. Chapter 3 estimates, using difference-in-differences, the causal effect of two financial incentive programs to reduce the practice of overbilling and improve access to care: the "Contrat d'accès aux soins" (CAS) introduced in 2014, replaced by the "Option Pratique Tarifaire Maîtrisée" (OPTAM) in 2017. The results indicate that restricting the practice of overbilling has improved access to care for the population; however, the OPTAM has been more effective than the CAS. Specialists joining the CAS and then the OPTAM have, in parallel with the reduction in their fees, increased their activity (number of consultations, technical acts) due to an increase in the number of patients followed, and in particular, an increase in the number of low-income patients (CMU-C beneficiaries). However, this improvement in access to care generates a high cost for the National Health Insurance.; En France, les médecins libéraux sont principalement payés à l'acte avec des tarifs fixés (pour les médecins de secteur 1) ou des dépassements d’honoraires (médecins de secteur 2). Ce mode de rémunération, qui, par définition, incite les médecins à multiplier les actes pour augmenter leurs revenus, impacte leurs comportements d'offre de soins. Il influence donc plus généralement l'organisation et l'efficience du système de santé. À partir de bases de données administratives et exhaustives de l’ensemble des médecins libéraux exerçant en France, cette thèse a pour objet de mieux comprendre comment les médecins réagissent lorsqu'ils font face à des modifications de leur rémunération. Plus particulièrement, lorsqu’un système de « paiement à la performance » est introduit en complément du paiement à l’acte (chapitre 1), ou lorsque la pratique des dépassements d’honoraires est interdite (chapitre 2) ou limitée (chapitre 3). Le paiement à la performance a été introduit en 2009 par le biais du « Contrat d’Amélioration des Pratiques Individuelles » (CAPI). Le premier chapitre montre que le CAPI a significativement infléchi les pratiques des médecins généralistes qui y ont adhéré dans un sens compatible avec une amélioration de la qualité des soins : contrairement à l'ensemble de leurs collègues, les adhérents du CAPI n’ont pas diminué le nombre de consultations par patient ni le montant des prescriptions par patient. Ils ont également augmenté, plus fortement que les autres, la proportion de leurs patients suivis en tant que médecin traitant. Finalement, le CAPI a conduit à une augmentation des honoraires perçus par patient, avec, en conséquence, un coût de prise en charge plus élevé pour la Sécurité sociale.Le deuxième axe de recherche s'intéresse principalement aux médecins spécialistes, qui sont souvent conventionnés en secteur 2 et peuvent ainsi pratiquer des dépassements d’honoraires. Ces dépassements, élevés et à la charge des patients, peuvent générer des inégalités dans l’accès aux soins. La première tentative de régulation de la pratique des dépassements d’honoraires est la réforme du « gel du secteur 2 », en 1990. À l’aide de régressions par discontinuité, le chapitre 2 évalue l’effet causal de cette régulation des tarifs. Il montre que les médecins spécialistes ayant une activité de nature plutôt « technique » augmentent fortement leur activité lorsqu’ils sont contraints d’exercer en secteur 1 et principalement leur activité technique. Les deux-tiers de ce surcroit d’activité sont associés à l’accueil de nouveaux patients, signe d’une amélioration de l’accessibilité aux soins ; le tiers restant est assimilable à des comportements stratégiques, visant à compenser la baisse de leurs tarifs par une augmentation du contenu des actes délivrés. En revanche, les spécialistes qui ont une activité principalement composée de consultations en cabinet n’ont pas de marge de manœuvre pour augmenter leur activité lorsqu’ils sont contraints d’exercer en secteur 1. Le chapitre 3 estime, à l’aide de différence de différences, l’effet causal de deux programmes d’incitations financières à la réduction de la pratique des dépassements d’honoraires et à l’amélioration de l’accès aux soins : le « Contrat d’accès aux soins » (CAS) introduit en 2013, remplacé par l’« Option Pratique Tarifaire Maîtrisée » (OPTAM) en 2017. Les résultats indiquent que la restriction de la pratique des dépassements a permis d’améliorer l’accès aux soins de la population ; l’OPTAM a cependant été plus efficace que le CAS. Les médecins spécialistes adhérant au CAS puis à l’OPTAM ont, parallèlement à la baisse de leurs tarifs, augmenté leur activité (nombre de consultations, actes techniques), en raison d’une augmentation du nombre de patients suivis, et en particulier d’une hausse du nombre de patients à bas revenus (bénéficiaires de la CMU-C). Cette amélioration à l’accès aux soins génère cependant un coût important pour la Sécurité sociale.

La e-santé participe à la démocratisation de la connaissance de l’accès aux soins des populations. Dans une volonté de démocratie sanitaire, un site internet interactif gratuit permet à chaque usager d’interroger les différents indicateurs liés à la démographie médicale de son propre « territoire vécu ». Ce site propose d’interroger le recours aux soins de première ligne (accès aux services des urgences) pour identifier les inadéquations de l’offre de soins aux « besoins » réels des populations. En 2015, la France métropolitaine comptait 557 services officiels d’accueil des urgences qui accueillaient plus de 17 millions primo-passages pour des soins d’urgences. Afin d’apporter un éclairage objectif à destination des usagers (citoyens, pouvoirs publics), il est nécessaire de disposer d’un territoire pertinent reflétant le plus fidèlement de la pratique spatiale des usagers, c’est-à-dire, un « territoire vécu ». Une projection à l’horizon 2025 et 2030, cible les besoins théoriques en termes de démographie médicale des médecins généralistes au niveau de ces territoires opérationnels. E-health contributes to the democratisation of knowledge regarding the access to healthcare among populations. In this sense, a free interactive website enables each user to question various medical demography indicators of his own "lived territory". This website highlights the use of first-line care (access to emergency services) to identify the inadequacies between the care supply and the real care "needs" of the populations. In 2015, five hundred fifty-seven official emergency services operated in metropolitan France and received more than 17 million first-time visitors for emergency care. However, it is necessary to have a relevant territory reference shaping as closely as possible the spatial practice of users in order to provide the users (citizens, public authorities) with the objective view. The relevant territory reference is represented in this research by the « lived territory ». This research paper also proposes a projection for 2025 and 2030 of the theoretical needs in medical demography of general practitioners in these operational territories, i.e., « lived territories », in metropolitan France.

Background: Cancer is one of the most relevant social and health problems in the world. The disease entails additional costs for cancer patients and their families that are not covered by the public part of our welfare state, and which they assume themselves simply because they are ill. The main objective of this study is to identify and analyse the additional cost and socioeconomic impact of cancer disease on patients diagnosed with cancer disease and their families. Methods: Descriptive cross-sectional randomised observational epidemiological study without replacement with prevalence of cancer disease in the study base, carried out in the Medical Oncology Service of the Complejo Asistencial Universitario de Salamanca (CAUSA), Spain. Results: The study variable has been the additional cost of the cancer disease for cancer patients and their families that is not covered by our autonomous health system. Conclusions: Cancer disease entails an additional cost for the patient and family; more specifically, for 55% of the patients in the study sample, the diagnosis of cancer represents extra expenditure of between 8.38–9.67% of their annual income. Furthermore, the disability and dependence of patients does not represent an additional cost due to their levels of functionality, but it can have repercussions on the future cost of the evolution of the disease, in addition to the fact of having cancer.

(1) Background: While inequalities in the prevalence of cancer, access to care, and survival have been well documented, less research has focused on inequalities in the uptake of supportive oncology care. Given its contribution to improving the quality of life of people affected by cancer, access to such care is a major public health issue. The present study focuses on the access and uptake of those supportive oncology care services. (2) Methods: This study is based on qualitative research methodology, using a thematic analysis tree on NVivo© analysis software. First, an exploratory survey was conducted with users of oncology services, and professionals from these services and supportive oncology care. Then, individual interviews were conducted in June 2022 among people who are currently being treated or have been treated for cancer. (3) Results: The experiences of the 33 respondents revealed that significant variations in the uptake of supportive oncology care are underpinned by identifiable disparities in their healthcare pathways: in their assimilation of information, difficulties in accessing oncology care, personal reluctance and motivations, perceived needs and benefits, and use of other medicines. (4) Conclusion: This study aims to gain some insight into disparities in the uptake of supportive care in the Centre-Val de Loire region (France). Thus, it provides a better understanding of the complex ways in which these inequalities in supportive oncology care uptake are constructed.

Background: The objective of this retrospective study was to assess the oral health status and treatment needs of children with ASD and to explore the differences in risk factors and oral health care status and the risk factors for treatment under GA. Methods: Dental charts of children between 6 and 14 years of age who were examined at a dental facility associated with the College of Dentistry, University of Saskatchewan between 2016 to 2019 were assessed. Children who were identified as having ASD, as well as an age- and gender-matched control group consisting of otherwise healthy children were included in the study. Results: The sample included 346 dental records, with 173 children having a diagnosis of ASD. Children diagnosed with ASD had significantly higher experience with caries (91.3% vs. 65.9%, p = 0.003) and severity (mean DMFT/dmft = 8.18 ± 1.62 vs. 4.93 ± 0.58 p = 0.007). Children with ASD were also older when visiting the dentist for the first time (age of 5.97 ± 1.18 vs. 2.79 ± 1.09, p = 0.02)). Children with ASD were less likely to brush once a day (66.5% vs. 88.4%, p = 0.02), were more likely to have bruxism (35.8% vs. 10.4%, p = 0.003) and were less likely to have class I occlusion (64.7% vs. 80.9%, p = 0.03). Findings from the logistic regression analysis revealed that children with ASD were also 2.13 times more likely to receive a referral for general anesthesia when all other variables were held constant (p = 0.03). Conclusions: This research demonstrates that children diagnosed with ASD may face more barriers with access to oral health care, leading to poorer outcomes and greater treatment dental needs.

This dissertation work contributes to the comprehension of the impact of complementary health insurance policies on healthcare utilization and coverage decision among the poorest in France, it ambitions to highlight how such policies shape the equity level of the French health system.The first chapter present the context in which the thesis in embedded. It describes the level of inequities of access to healthcare in France, details the policies implemented to reduce it and reviews the existing knowledge about the effectiveness of these policies.The second part is interested in the impact of subsidizing complementary health insurance on the utilization of healthcare. The second chapter studies the case of a fully subsidized complementary health insurance. We show that taking up the program has a positive and important impact on health services utilization. The third chapter focuses on a program offering incomplete subsidy for complementary health insurance. We show that the program also has a positive impact on health services utilization.The third part analyses the demand for complementary health insurance for poor individuals. The fourth chapter shows that the demand for complementary health insurance is premium elastic: demand for higher coverage increase when the premium level decreases. In the fifth chapter, we analyse low income insurance choices when individuals are required to pay a higher premium but also get a higher level of coverage. We show that, despite being premium elastic, individuals are willing to pay more in order to remain insured instead of losing their complementary health insurance coverage.; Cette thèse contribue à la compréhension de l’impact des politiques d’assurance complémentaire en santé sur l’utilisation du système de soins et les décisions d’assurance des ménages pauvres en France.Le premier chapitre présente le contexte dans lequel cette thèse s’inscrit. Il décrit les inéquités d’accès aux soins en France, détaille les politiques mises en place pour les réduire et présente l’état des connaissances sur l’efficacité de ces politiques.Une seconde partie de cette thèse s’intéresse à l’impact des politiques qui subventionnent l’accès à l’assurance complémentaire santé. Le second chapitre étudie le cas d’une subvention complète. Nous montrons que le recours à ce programme subventionné a un impact positif et de forte magnitude sur l'utilisation du système de santé. Le troisième chapitre s’intéresse au cas où l’assurance est subventionnée partiellement. Nous montrons que la subvention partielle a également un impact positif sur l'utilisation du système de santé.Dans une troisième partie, nous analysons la demande d’assurance complémentaire en santé des ménages pauvres en France. Le quatrième chapitre montre que la demande pour différentes qualités d’assurance complémentaire est sensible au niveau des primes : la demande pour une meilleure qualité augmente quand le niveau de prime diminue. Dans un cinquième chapitre, nous analysons les choix de couverture des ménages à bas revenu quand le prix et la qualité de l'assurance augmentent de façon simultanée. Nous montrons que les assurés acceptent, en moyenne, de payer une prime plus importante afin de conserver leur couverture par une assurance complémentaire.

The success of the Australian COVID-19 vaccination strategy rested on access to primary healthcare. People experiencing or at risk of homelessness are less likely to access primary healthcare services. Therefore, leaders in homeless health service delivery in Sydney identified the need to develop a vaccine hub specifically for this vulnerable population. The aim of this study was to develop an evidenced based model of care to underpin the Vaccine Hub and optimize access to vaccination for people experiencing or at risk of homelessness. A mixed methods study was conducted that included interviews with key stakeholders involved in establishing and delivering the Inner City COVID-19 Vaccine Hub, and a survey with people receiving COVID-19 vaccination. Over the 6-month period of this study, 4305 COVID-19 vaccinations were administered. Participants receiving vaccination reported feeling safe in the Vaccine Hub and would recommend it to others. Stakeholders paid tribute to the collective teamwork of the Vaccine Hub, the collaboration between services, the ‘no wrong door’ approach to increasing access and the joy of being able to support such a vulnerable population in challenging times. The study findings have been populated into a Vaccination Hub Blueprint document that can be used as a template for others to improve access to vaccinations for vulnerable populations.

BackgroundA baseline of hepatitis C virus (HCV) burden and other HCV epidemiological profiles is necessary for HCV micro-elimination in Ho Chi Minh City (HCMC), Viet Nam. This study aimed to determine HCV exposure and prevalence of HCV viremia as well as the proportion of HCV testing and treatment uptake among participants.MethodsFrom 2019 to 2020, the probability proportionate to size sampling method was deployed to representatively invite approximately 20,000 adults (18 or older) throughout HCMC to free screening and linkage to care for HCV.FindingsIn HCMC, the weighted prevalence of anti-HCV was 1·3% (95% CI, 1·1%-1·6%). Individuals born from 1945 to 1964 had the anti-HCV prevalence of 3·6% (95% CI, 3·0%-4·2%) and represented 40·4% of all HCV cases. There were wide variations in anti-HCV prevalence in HCMC, including variations between districts, risk factors, and socioeconomic statuses. A baseline HCV continuum of care for the city demonstrated that only 28·5% (85/298, 95%CI 23·4-33·7%) of persons with anti-HCV (+) were aware of their HCV status, with 77.6% (66/85, 95%CI 68·8-86·5%) diagnosing HCV incidentally, 82·7% (62/75, 95%CI 74·1-91·2%) initiating anti-HCV therapy, and 53.6% (30/56, 95%CI 40·5-66·6%) achieving HCV cures.InterpretationThere remains a considerable disease burden of HCV in HCMC of which a significant proportion was in the age group born between 1945 to 1964. Additionally, there were significant gaps in HCV awareness, screening, and access to care in the community in Viet Nam. Thus, future interventions must have pragmatic targets, be tailored to the local needs, and emphasise screening.FundingThis work was supported by investigator-sponsored research grants from Gilead Sciences Inc. (Grant No: IN-US-987-5382); Roche Diagnostic International Ltd. (Grant No. SUB-000196); and in-kind donations from Abbott Diagnostic Viet Nam; Hepatitis B Foundation; Medic Medical Center, Viet Nam; Johns Hopkins University School of Medicine's Center of Excellence for Liver Disease in Viet Nam; and the Board of Directors, Viet Nam Viral Hepatitis Alliance (V-VHA).

Introduction Eliminating points in the continuum of care that do not change management is a safe strategy for cost containment and workflow efficiency in health systems. As a process improvement initiative, we sought to identify whether routine, outpatient follow-up changes management in laparoscopic appendectomy in a military hospital. Methods We performed a retrospective chart review of adult patients undergoing laparoscopic appendectomy during a one-year period. The primary outcome was identification of a change in management during routine in person follow-up. Secondary outcomes included location of patient presentation with a post-operative event (clinic, emergency department, primary care provider), and if those visits changed management. Events were defined as any deviation from the typical post-operative course within 6 weeks of surgery, including abnormal specimen pathology. Results One-hundred and seventy-six appendectomies were performed over one year, and 148 patients met inclusion criteria (median age = 27, 66.9% male). Perforation was identified in 10.1% of patients. Seventeen-point-five percent of patients had a post-operative event, of which persistent pain was the most common. Only 2.0% of all patients saw a change in management at their routine in person follow-up appointment. Eighty percent of patients with any post-operative events sought care outside of their routine in person follow up appointments. No variable was independently associated with a change in management. Conclusion Routine in-person clinical follow-up for laparoscopic appendectomy almost never changes management. Perforated appendicitis may be an indication for in-person follow-up. Considering a telemedicine model for post-operative follow-up of laparoscopic appendectomy patients will provide a safe and effective alternative to in-person clinic visits, while saving patients time and allowing providers the clinic freedom to prioritize more urgent and new patients.

Background The Affordable Care Act (ACA) enabled millions of people to gain coverage that was expected to improve access to healthcare services. However, it is unclear the extent of the policy’s impact on Federally Qualified Health Centers (FQHC) and the patients they served. This study sought to understand FQHC administrators’ views on the ACA’s impact on their patient population and organization. It specifically explores FQHC administrators’ perspective on 1) patients’ experience with gaining coverage 2) their ability to meet patients’ healthcare needs. Methods Twenty-two semi-structured interviews were conducted with administrators from FQHCs in urban counties in 2 Medicaid-expanded states (Arizona and California) and 1 non-expanded state (Texas). An inductive thematic analysis approach was used to analyze the interview data. Results All FQHC administrators reported uninsured patients were more likely to gain coverage from Medicaid than from private health insurance. Insured patients generally experienced an improvement in accessing healthcare services but depended on their plan’s covered services, FQHCs’ capacity to meet demand, and specialist providers’ willingness to accept their coverage type. Conclusion Gaining coverage helped improved newly insured patients’ access to care, but limitations remained. Additional policies are required to better address the gaps in the depth of covered services in Medicaid and the most affordable PHI plans and capacity of providers to meet demand to ensure beneficiaries can fully access the health care services they need.

Purpose To examine the benefits and feasibility of a mobile, real-time, community-based, teleophthalmology program for detecting eye diseases in the New York metro area. Design Single site, nonrandomized, cross-sectional, teleophthalmologic study. Methods Participants underwent a comprehensive evaluation in a Wi-Fi-equipped teleophthalmology mobile unit. The evaluation consisted of a basic anamnesis with a questionnaire form, brief systemic evaluations and an ophthalmologic evaluation that included visual field, intraocular pressure, pachymetry, anterior segment optical coherence tomography, posterior segment optical coherence tomography, and nonmydriatic fundus photography. The results were evaluated in real-time and follow-up calls were scheduled to complete a secondary questionnaire form. Risk factors were calculated for different types of ophthalmological referrals. Results A total of 957 participants were screened. Out of 458 (48%) participants that have been referred, 305 (32%) had glaucoma, 136 (14%) had narrow-angle, 124 (13%) had cataract, 29 had (3%) diabetic retinopathy, 9 (1%) had macular degeneration, and 97 (10%) had other eye disease findings. Significant risk factors for ophthalmological referral consisted of older age, history of high blood pressure, diabetes mellitus, Hemoglobin A1c measurement of ≥6.5, and stage 2 hypertension. As for the ocular parameters, all but central corneal thickness were found to be significant, including having an intraocular pressure >21 mm Hg, vertical cup-to-disc ratio ≥0.5, visual field abnormalities, and retinal nerve fiber layer thinning. Conclusions Mobile, real-time teleophthalmology is both workable and effective in increasing access to care and identifying the most common causes of blindness and their risk factors.

Background The role of an advanced practice physiotherapist has been introduced in many countries to improve access to care for patients with hip and knee arthritis. Traditional models of care have shown a gender bias, with women less often referred and recommended for surgery than men. This study sought to understand if patient gender affects access to care in the clinical encounter with the advanced practice provider. Our objectives were: (1) To determine if a gender difference exists in the clinical decision to offer a consultation with a surgeon; (2) To determine if a gender difference exists in patients’ decisions to accept a consultation with a surgeon among those patients to whom it is offered; and, (3) To describe patients’ reasons for not accepting a consultation with a surgeon. Methods This was a prospective study of 815 patients presenting to a tertiary care centre for assessment of hip and knee arthritis, with referral onward to an orthopaedic surgeon when indicated. We performed a multiple logistic regression analysis adjusting for severity to address the first objective and a simple logistic regression analysis to answer the second objective. Reasons for not accepting a surgical consultation were obtained by questionnaire. Results Eight hundred and fifteen patients (511 women, 304 men) fulfilled study eligibility criteria. There was no difference in the probability of being referred to a surgeon for men and women (difference adjusted for severity = − 0.02, 95% CI: − 0.07, 0.02). Neither was there a difference in the acceptance of a referral for men and women (difference = − 0.05, 95% CI: − 0.09, 0.00). Of the 14 reasons for declining a surgical consultation, 5 showed a difference with more women than men indicating a preference for non-surgical treatment along with fears/concerns about surgery. Conclusions There is no strong evidence to suggest there is a difference in proportion of males and females proceeding to surgical consultation in the model of care that utilizes advanced practice orthopaedic providers in triage. This study adds to the evidence that supports the use of suitably trained alternate providers in roles that reduce wait times to care and add value in contexts where health human resources are limited. The care model is a viable strategy to assist in managing the growing backlog in orthopaedic care, recently exacerbated by the COVID-19 pandemic.

Background The individual factors associated to Frequent Users (FUs) in Emergency Departments are well known. However, the characteristics of their geographical distribution and how territorial specificities are associated and intertwined with ED use are limited. Investigating healthcare use and territorial factors would help targeting local health policies. We aim at describing the geographical distribution of ED’s FUs within the Paris region. Methods We performed a retrospective analysis of all ED visits in the Paris region in 2015. Data were collected from the universal health insurance’s claims database. Frequent Users (FUs) were defined as having visited ≥3 times any ED of the region over the period. We assessed the FUs rate in each geographical unit (GU) and assessed correlations between FUs rate and socio-demographics and economic characteristics of GUs. We also performed a multidimensional analysis and a principal component analysis to identify a typology of territories to describe and target the FUs phenomenon. Results FUs accounted for 278,687 (11.7%) of the 2,382,802 patients who visited the ED, living in 232 GUs. In the region, median FUs rate in each GU was 11.0% [interquartile range: 9.5–12.5]. High FUs rate was correlated to the territorial markers of social deprivation. Three different categories of GU were identified with different profiles of healthcare providers densities. Conclusion FUs rate varies between territories and is correlated to territorial markers of social deprivation. Targeted public policies should focus on disadvantaged territories.

BACKGROUND: Concerns exist about the ability of safety net health care organizations to participate in US health care reform. Primary care practices are key to several efforts, but little is known about how capabilities of primary care practices serving a high share of disadvantaged patients compare to other practices. OBJECTIVE: To assess capabilities around access to and quality of care among primary care practices serving a high share of Medicaid and uninsured patients compared to practices serving a low share of these patients. DESIGN: We analyzed data from the National Survey of Healthcare Organizations and Systems (response rate 46.8%), conducted 2017–2018. PARTICIPANTS: A total of 2190 medical practices with at least three adult primary care physicians. MAIN MEASURES: Our key exposures are payer mix and federally qualified health center (FQHC) designation. We classified practices as safety net if they reported a combined total of at least 25% of annual revenue from uninsured or Medicaid patients; we then further classified safety net practices into those that identified as an FQHC and those that did not. KEY RESULTS: FQHCs were more likely than other safety net practices and non-safety net practices to offer early or late appointments (79%, 55%, 62%; p=0.001) and weekend appointments (56%, 39%, 42%; p=0.03). FQHCs more often provided medication-assisted treatment for opioid use disorders (43%, 27%, 25%; p=0.004) and behavioral health services (82%, 50%, 36%; p

Introduction:/Aims Patients with neuromuscular disorders (NMDs), including many elderly, immunosuppressed, and disabled individuals, may have been particularly affected during the coronavirus disease 2019 (COVID‐19) pandemic in Lombardy, a COVID‐19 high‐incidence area between February and May 2020. We aimed to evaluate the effects of the COVID‐19 pandemic on the quality of life (QoL) and perceived disease burden of this group of patients. Methods We conducted a cross‐sectional phone‐based survey study between June 1 and June 14, 2020, on a sample of 240 NMD patients followed at our clinic in Milan, Italy. We asked about perceived NMD burden and QoL before and during the COVID‐19 pandemic. We collected responses on access to outpatient care and ancillary services. We investigated the presence of symptoms suggestive of COVID‐19 infection and confirmed cases. Results We collected 205 responses: 53 patients (25.9%) reported a subjective worsening of the underlying NMD. QoL measures showed a significant worsening between pre and pandemic time frames (odds ratio, 2.14 95%; confidence interval, 1.82–2.51). Outpatient visits were postponed in more than half of cases (57.1%), with 104 patients (50.7%) experiencing a cancellation of scheduled diagnostic tests. 79 patients (38.5%) reported at least one symptom attributable to COVID‐19 infection. Among the 10 patients tested with nasopharyngeal swabs, 6 tested positive and 3 died from respiratory failure, including 2 patients on corticosteroid/ immunosuppressive therapy. Discussion The COVID‐19 pandemic affected QoL and limited access to outpatient care and ancillary services of NMD patients in Lombardy between February and May 2020.

Patients with persistent Lyme disease/chronic Lyme disease (PLD/CLD) encounter significant barriers to accessing medical care. Although this health inequity has been explored from the patient perspective, the obstacles clinicians encounter when providing care to this group of patients have not been examined. The primary goal of this study was to identify the challenges faced by clinicians who provide care for patients with PLD/CLD. Clinicians who treat PLD/CLD were surveyed regarding their professional backgrounds, general challenges to providing care, supply and demand constraints, insurance restrictions, and regulatory and legal challenges. Clinicians treating patients with PLD/CLD have developed substantial clinical expertise but encounter multiple clinical, regulatory and financial impediments to providing care. Clinician-encountered barriers may be powerful disincentives for providing care patients with PLD/CLD and make it difficult to retain and recruit clinicians who will care for the rapidly expanding PLD/CLD populations. Understanding these barriers and identifying potential solutions is essential to resolving the current supply/demand imbalance that makes it difficult for patients to receive the care they need to become well.

PurposeNearly one-fifth of Americans live in rural areas and experience multiple socioeconomic and health disparities. Health Resources and Services Administration (HRSA)-funded health centers (HCs) provide comprehensive primary care in rural communities. However, no prior research has examined trends in access to care in rural HC patients. We examined the change in access to care among patients served at rural HRSA-funded HCs in the United States between 2009 and 2014.MethodsWe compared patients by year to examine measures of access using multilevel generalized structural equation logistic regression models with random effects. We used the 2009 and 2014 cross-sectional Health Center Patient Surveys and identified 2,625 adult rural HC patients. Dependent variables were subjective (unmet need/delay in medical care, mental health, dental care, and prescription medications) and objective measures (preventive care and other health care utilization) in access to care. Our independent variable of interest was time, comparing access in 2009 and 2014.ResultsRural HC patients reported higher predicted probability of influenza vaccine receipt (37% vs 51%), and lower unmet (25% vs 14%) and delayed medical care (36% vs 18%) between 2009 and 2014. Any emergency department visits in the last year increased (32% vs 46%) and mammogram (70% vs 55%) and Pap test (83% vs 72%) screening rates decreased.ConclusionsObserved increases in access to care among rural HC patients are positive developments but the challenges to access care still persist. Remote services, such as telehealth, could be cost-effective means of improving access to care among rural patients with limited provider supply.

This scoping review will support a technical brief providing an overview of the existing research on disparities in and barriers to pediatric cancer survivorship care. The brief is funded by the Agency for Healthcare Research and Quality (AHRQ) and commissioned by the National Cancer Institute.

The literature on outcomes associated with recovery housing is in its infancy due to the unregulated nature of the RH industry lending to various RH models that exist and outcomes assessed. The research that has been conducted on RH outcomes, although limited, indicates the RH model to be effective. Secondary analysis of demographic data from a validation study conducted to develop a measure of therapeutic alliance for the context of RH with recovery housing residents in the state of Kentucky, indicated that among 272 residents, the majority (92%) report to be Caucasian (data unpublished). Additionally, Fletcher Group Inc., is a nonprofit dedicated to the expansion and quality improvement of RH across the United States through the provision of technical assistance. Through their work, anecdotal evidence via the provision of over 3,000 technical assistance encounters with RH owners and operators indicates that a racial disparity may exist in terms of populations accessing RH. There is minimal oversight of the RH industry. Consequently, no formal agency at the national level is tasked with tracking the RH and who is served by them. Recent research aimed to identify the numbers of RH nationwide, estimates that there are between 10,358 to 17,900 (Jason et al., 2020; Mericle et al., 2021). It’s imperative to begin developing an understanding of who is using recovery housing, in efforts to design strategies to engage populations underrepresented in RH, in order to ensure they have their needs met. The intent of this scoping review is to assess the literature that pertains to RH outcomes and determine which populations are primarily represented and underrepresented in these studies. Although the literature assessing RH outcomes does not translate to an accurate understanding of RH utilization, it is a proxy and starting point. Further, it’s important to assess which populations are represented in the RH research that has been conducted, given findings of RH related outcomes, if only assessed with specific populations, presents issues with generalizability of those outcomes.

The objective of this work was to validate the content of a scale formulated in Spanish for older adults in Mexico, with the aim of comprehensively measuring the access of this population group to outpatient primary-care services. To this end, we carried out a methodological content-validity study in four stages: (1) construction of the scale; (2) evaluation of item legibility; (3) quantitative content evaluation by two groups of judges selected by convenience: participant-judges including older adults with adequate reading comprehension, surveyed in person (n = 23), and expert-judges comprised of researchers specialized in the fields of health services, psychometrics and aging, surveyed online (n = 7); and (4) collection of qualitative feedback from several of the participant-judges (older adults, n = 4). The content was validated both by sequentially examining the level of consensus in the responses of both groups of judges, using the Tastle and Wierman method, and by calculating Aiken’s Validity Coefficient with a 90% confidence interval. The scale contained 65 items pertaining to 10 dimensions of two major constructs: accessibility (n = 39) and personal abilities (n = 26). Five items were eliminated in accordance with the minimum-consensus criterion (0.5). This is the first psychometric scale to be developed in Mexico with the view of integrating the characteristics of health-care services and the abilities of the older adults in a single questionnaire designed to measure the access of this population group to outpatient primary-care services.

Epilepsy is a common comorbidity among children with autism spectrum disorder (ASD). There is a lack of understanding of the inequality in access to care for children with co-occurring ASD and epilepsy (ASD-EP). The purpose of this study is to examine key indicators for access to care and care coordination for children with ASD-EP in the US National Survey of Children’s Health (NSCH). Data were collected from the 2017–2019 NSCH. Our analytic sample included children with ASD without epilepsy (N = 2150), children with both ASD and epilepsy (N = 143), and children with epilepsy without ASD (N = 711). The dependent variables included important access to care indicators such as having usual sources of care, having adequate coverage, being frustrated in efforts to get service, and receiving care coordination. The independent variables included ASD-EP status, child demographics, and an intellectual disability (ID) diagnosis. Our results show that demographic characteristics such as sex, race, income level, and insurance type affect access to care. Inadequate access to healthcare was significantly higher among female children, children from low-income families, and children with ID. The access barriers among children with ASD-EP were more likely due to the interplay of multiple clinical and individual factors.

Background: Arthroscopic rotator cuff repair is an effective treatment for patients with symptomatic rotator cuff tears. Ensuring timely and appropriate postoperative access to physical therapy (PT) is paramount to the achievement of optimal patient outcomes. Extended immobility due to a lack of formal rehabilitation can lead to decreased range of motion, continued pain, and potential reoperation for stiffness. The purpose of this study is to evaluate national disparities in access to PT services after rotator cuff repair between patients with private vs. Medicaid insurance. This study will further evaluate differences in access to PT services between states that have previously undergone Medicaid expansion as compared with those states which have not. Methods: The American Physical Therapy Association Website was used to identify 10 physical therapy practices from the capital city in every state. Each physical therapy practice was contacted using a mock-patient script for a patient with Medicaid insurance or private (Blue Cross Blue Shield) insurance. To maintain anonymity, calls were made by two separate investigators. Univariate analysis included independent sample t-test for differences between the study groups for continuous variables. Chi square or Fisher's exact test assessed differences in discrete variables between the study groups. Results: Contact was made with 465 of 510 (91.2%) physical therapy practices. Overall, 52.7% accepted Medicaid insurance, while 94.9% accepted private insurance (P < .001). Medicaid insurance was more likely to be accepted in a Medicaid expansion state than a nonexpansion state (56.1% vs. 46.3%, P = .05). Private insurance was also more likely to be accepted in a Medicaid expansion state than a nonexpansion state (96.7% vs. 91.3%, P = .01). The time to first appointment varied more in Medicaid expansion states (private range: 0-43 days, Medicaid range: 0-72 days) than in nonexpansion states (private range: 0-11 days, medicaid range: 0-10 days). Conclusion: Significantly fewer PT practices accepted Medicaid insurance nationally compared with private insurance, which suggests that patients with Medicaid insurance have greater difficulty accessing PT after rotator cuff repair in the United States compared with patients with private insurance. While Medicaid insurance was more likely to be accepted in a Medicaid expansion state, this finding was only borderline significant, which indicates that patients in Medicaid expansion states are still having difficulty accessing PT, despite efforts to expand government insurance coverage to improve access to care. Orthopedic surgeons should counsel their patients with Medicaid insurance to seek out PT as early as possible in the postoperative period to avoid delays in rehabilitation.

Background The COVID-19 pandemic has affected mental health and created barriers to healthcare. In this study, we sought to elucidate the pandemic's effects on mental health and access to care for perinatal individuals. Methods This cross-sectional study of individuals in Massachusetts who were pregnant or up to three months postpartum with a history of depressive symptoms examined associations between demographics and psychiatric symptoms (via validated mental health screening instruments) and the COVID-19 pandemic's effects on mental health and access to care. Chi-square associations and multivariate regression models were used. Results Of 163 participants, 80.8% perceived increased symptoms of depression and 88.8% of anxiety due to the pandemic. Positive screens for depression, anxiety, and/or PTSD at time of interview, higher education, and income were associated with increased symptoms of depression and anxiety due to the pandemic. Positive screens for depression, anxiety, and/or PTSD were also associated with perceived changes in access to mental healthcare. Compared to non-Hispanic White participants, participants of color (Black, Asian, Multiracial, and/or Hispanic/Latinx) were more likely to report that the pandemic changed their mental healthcare access (aOR:3.25, 95%CI:1.23, 8.59). Limitations Limitations included study generalizability, given that participants have a history of depressive symptoms, and cross-sectional design. Conclusions The pandemic has increased symptoms of perinatal depression and anxiety and impacted perceived access to care. Self-reported increases in depression and anxiety and changes to healthcare access varied by education, race/ethnicity, income, and positive screens. Understanding these differences is important to address perinatal mental health and provide equitable care.