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Inequitable access to healthy food has been associated with a variety of adverse health outcomes. In the United States, prior studies have suggested that low-income and racial minorities are more l...

Background: Devolution and integration of health and social care have placed increasing pressure on local statutory services, with a corresponding shift of health and social care to community organisations. The voluntary and charitable sector (VCS) is expected to make the case for increased funding by providing evidence of value and impact.\ud \ud \ud Aims and objectives: This paper explores the challenges of compiling evidence on health outcomes which do not reflect the holistic nature of VCS support. We document how knowledge brokering can be used to enable the VCS to generate evidence.\ud \ud \ud Key conclusions: Knowledge brokering (KB) may be an effective approach for developing community-generated evidence. Brokering is also needed to change perspectives on what counts as good evidence\ud \ud \ud \ud \ud Key messages\ud \ud Health outcome measures are not seen to be appropriate by the voluntary sector for social prescribing services.\ud \ud \ud A new evidence base is needed that reflects the social determinants of health.\ud \ud \ud Knowledge brokering may be an effective approach for developing community-generated evidence.\ud \ud \ud Brokering is also needed to change perspectives on what counts as good evidence.

Background Pharmacist-led transitions of care (TOC) interventions have been associated with improved health outcomes. Community pharmacists’ (CP) TOC communications have been described whereas limited evidence is available for hospital pharmacists (HP) and none for non-dispensing pharmacists, integrated into Family Medicine Groups (FMG). Objective To assess information needs and perceptions about TOC communications of HP, FMG pharmacists (FMG-P) and CP and to identify optimal TOC practices and their barriers. Methods In a cross-sectional design, a survey was distributed via email to the 70 pharmacists who participated in a multicenter, single group, longitudinal TOC intervention study for older adults at risk of medication-related harm. All pharmacists were surveyed on their TOC practices before the TOC study, as part of usual care. Pharmacists who followed TOC study patients were also surveyed on their TOC practices during the TOC study. Results Survey responses were received from 35 pharmacists (50%), including 8 HP, 6 FMG-P and 21 CP. The frequency of communication between pharmacists of different settings increased significantly during the TOC study, with more than 80% of pharmacists reporting satisfaction with the quality of the information provided. At hospital discharge, in optimal TOC, the FMG-P and CP reported that the most important information to transfer was the reasons of hospitalization, patient weight and height, and the therapeutic intent of the medications. The main barriers to TOC implementation were the lack of clinical information about patients for FMG-P and CP and understaffing for HP. FMG-P and CP reported a similar high degree of interest in assuming responsibility for the new extended scope of practice activities of medication adjustments according to therapeutic targets or laboratory results and the implementation of a plan for gradual dose increases or drug tapering. Conclusions The surveyed pharmacists reported an increased frequency of communication and satisfaction with the information exchanged between the pharmacists of different settings during the TOC study compared to usual care, before the study. The pharmacists extended scope of practice offers new opportunities to optimize TOC interventions.

Background Discrimination occurs in health care settings contributing to health inequities. Yet guidance on how best to measure discrimination in health care is still limited. Objectives We sought to (1) identify and describe the characteristics of published studies that used the Discrimination in Health Care Measure, a scale first published in 2001; (2) review how the measure has been used or adapted and summarize the measure’s published psychometric properties and its variations; and (3) summarize associations between the measure and health-related variables. Methods We performed a systematic search and review of the measure by searching PsycINFO, PubMed, Sociological Abstracts, and Web of Science from January 1, 2001 through January 31, 2017. We screened 260 unique articles, identified 22 eligible articles, and completed a narrative synthesis. Results Most studies measured race or ethnicity-based discrimination. All studies made minor revisions to the measure, and most reported high reliabilities. Discrimination in health care, using this measure, was associated with adverse health outcomes. Discussion and practice implications Study results indicate that the measure is easy to use and adapt. Researchers should consider using the Discrimination in Health Care Measure when designing studies that will examine individuals’ discriminatory experiences when receiving health care.

Frailty is associated with negative health outcomes, disability, and mortality. Physical activity is an effective intervention to improve functional health status. However, the effect of resistance training on multidimensional health in frail older adults remains unclear. This randomized controlled trial was conducted in a U.K. residential care home to assess feasibility with limited efficacy testing on health and functional outcomes and to inform a future definitive randomized controlled trial. Eleven frail older adults (>65 years) completed a 6-week machine-based resistance training protocol three times a week. Uptake and retention were greater than 80%. The measures and intervention were found to be acceptable and practicable. The analyses indicated large improvements in functional capacity, frailty, and strength in the intervention group compared with the controls. These findings support the feasibility of a definitive randomized controlled trial and reinforce the value of resistance training in this population. This trial was registered with ClinicalTrials.gov: NCT03141879.

Adverse childhood experiences (ACEs) are associated with poor treatment adherence and worse health outcomes among adults, but evidence among adolescents is less clear. The current systematic review identified and synthesized results from studies examining associations between ACEs and treatment adherence among adolescents. An expert medical librarian conducted searches in seven databases. Results were analyzed using a narrative synthesis framework. A total of six studies were eligible for review. Assessment strategies for ACEs and treatment adherence varied across studies. Most studies assessed for histories of maltreatment and neglect. Treatment adherence was most often defined as some form of attendance in a treatment program. Results support a relationship between ACEs and treatment nonadherence in adolescents. ACEs related to maltreatment, particularly emotional abuse, may be more predictive of treatment nonadherence than other types of ACEs. Specific qualities of ACEs (e.g., timing, intensity, frequency) may influence the relationship between ACEs and treatment nonadherence. [ Journal of Psychosocial Nursing and Mental Health Services, 60 (6), 11–18.]

Background There is a need for effective and cost-effective interprofessional care models that support older people to maintain their quality of life (QoL) and physical performance to live longer independently in their own homes. Objectives The objectives were to evaluate effectiveness, QoL and physical performance, and cost-utility of a people-centred care model (PCCM), including the contribution of clinically trained pharmacists, compared with that of usual care in primary care. Methods A randomised controlled trial (RCT) with a two-year follow-up was conducted. The participants were multimorbid community-living older people, aged ≥75 years. The intervention comprised an at-home patient interview, health review, pharmacist-led clinical medication review, an interprofessional team meeting, and nurse-led care coordination and health support. At the baseline and at the 1-year and 2-year follow-ups, QoL (SF-36, 36-Item Short-Form Health Survey) and physical performance (SPPB, Short Performance Physical Battery) were measured. Additionally, a physical dimension component summary in the SF-36 was calculated. The SF-36 data were transformed into SF-6D scores to calculate quality-adjusted life-years (QALYs). Healthcare resource use were collected and transformed into costs. A healthcare payer perspective was adopted. Incremental cost-effectiveness ratio (ICER) was calculated, and one-way sensitivity analysis was performed. Results No statistically or clinically significant differences were observed between the usual care (n = 126) and intervention group (n = 151) patients in their QoL; at the 2-year follow-up the mean difference was −0.02, (95 % CI -0.07; 0.04,p = 0.56). While the mean difference between the groups in physical performance at the 2-year follow-up was −1.02, (−1.94;-0.10,p = 0.03), between the physical component summary scores it was −7.3, (−15.2; 0.6,p = 0.07). The ICER was −73 638€/QALY, hence, the developed PCCM dominated usual care, since it was more effective and less costly. Conclusions The cost-utility analysis showed that the PCCM including pharmacist-led medication review dominated usual care. However, it had no effect on QoL and the effect towards physical performance remained unclear.

CONTEXT Accurate provider directories and whether consumers can schedule timely appointments are crucial determinants of health access and outcomes. We assessed whether consumers can rely on provider directories to find in-network primary care providers, cardiologists, endocrinologists, and gastroenterologists for 2018 and 2019 for all managed care plans in California and whether they can access these providers in a timely manner. METHOD We used large, random, and representative surveys of provider directories for all managed care plans in California for four specialties obtained from the California Department of Managed Health Care with a total of 657,012 observations (290,711 for 2018 and 475,524 for 2019). FINDINGS Surveys were able to verify provider directory entries for the four specialties for 59% to 76% of listings or 78% to 88% of providers reached. Moreover, we found that consumers were able to schedule urgent care appointments for 28% to 54% of listings or 44% to 72% of appropriately listed providers. For general care appointments, the percentages ranged from 35% to 64% of listed providers or 51% to 87% of appropriately listed providers. Differences across markets were generally small related to accuracy. Medi-Cal plans outperformed other markets with regards to timely access. Primary care consistently outperformed all other specialties. Timely access rates were higher for general appointments than for urgent care appointments. CONCLUSIONS Despite the fact that California is one of the most active and well-resourced regulators in the nation, we found concerning results for consumers when it comes to locating in-network providers and gaining timely access. This raises questions about the regulatory regime as well as consumer access and health outcomes.

Objectives Publications assessing health and economic outcomes of risk-sharing arrangements (RSAs) are limited. Better knowledge of these outcomes would shed light on the pertinence of such arrangements, informing design improvements for the future. The aim of the study is to describe the different types of RSAs implemented in Catalonia and their health and economic outcomes. Methods Retrospective descriptive analysis of RSAs implemented from January 2016 to December 2019 in the Catalan Health Service, CatSalut. Individual RSAs were reviewed and categorized according to standard RSA guidelines. Relevant health and economic outcomes pertaining to the RSAs were analyzed using aggregate data recorded in Catalan central registries. Results A total of 15 RSAs were implemented over the study period (10 of which are still ongoing). A total of 8 consisted of performance-linked reimbursements (PLRs) and 7 of cost-sharing arrangements (CSAs). The arrangements were implemented in the oncohematology (n = 11), rare disease (n = 3), and neurology (n = 1) areas. A total of 951 patients were included in PLR and 73% achieved the target health outcomes. Total medication costs were €9 295 755 of which 11% were refunded to CatSalut. CSAs involved 2066 patients and resulted in overall refunds of €1 349 564 (2.61%) for CatSalut. Conclusions Both PLRs and CSAs were used to manage the different uncertainties related to accessing innovative medicines in Catalonia. The data generated provide relevant information to inform decision-making, allowing an adaptation of the initial recommendation for use and access. Additional efforts are required to increase the RSA assessments and their publication.

Early prediction of significant morbidity or mortality in patients with acute ST-segment elevation myocardial infarction (STEMI) represents an unmet clinical need. In phenotypically matched population of 139 STEMI patients (72 cases, 67 controls) treated with primary percutaneous coronary intervention, we explored associations between a 24-h relative change from baseline in the concentration of 91 novel biomarkers and the composite outcome of death, heart failure, or shock within 90 days. Additionally, we used random forest models to predict the 90-day outcomes. After adjustment for false discovery rate, the 90-day composite was significantly associated with concentration changes in 14 biomarkers involved in various pathophysiologic processes including: myocardial fibrosis/remodeling (collagen alpha-1, cathepsin Z, metalloproteinase inhibitor 4, protein tyrosine phosphatase subunits), inflammation, angiogenesis and signaling (interleukin 1 and 2 subunits, growth differentiation factor 15, galectin 4, trefoil factor 3), bone/mineral metabolism (osteoprotegerin, matrix extracellular phosphoglycoprotein and tartrate-resistant acid phosphatase), thrombosis (tissue factor pathway inhibitor) and cholesterol metabolism (LDL-receptor). Random forest models suggested an independent association when inflammatory markers are included in models predicting the outcomes within 90 days. Substantial heterogeneity is apparent in the early proteomic responses among patients with acutely reperfused STEMI patients who develop death, heart failure or shock within 90 days. These findings suggest the need to consider synergistic multi-biomarker strategies for risk stratification and to inform future development of novel post-myocardial infarction therapies.

Knowledge about systemic lupus erythematosus (SLE) outcomes among US Asian patients is lacking. The present study was undertaken to examine SLE disease activity, severity, and damage among Asian patients of primarily Chinese and Filipino descent in a multiethnic cohort.California Lupus Epidemiology Study (n = 328) data were analyzed. Data were collected in English, Cantonese, Mandarin, or Spanish using validated instruments for disease activity (Systemic Lupus Erythematosus Disease Activity Index), disease severity (Lupus Severity Index [LSI]), and disease damage (Systemic Lupus International Collaborating Clinics/American College of Rheumatology Damage Index). We assessed differences in SLE outcomes among racial/ethnic groups using multivariable linear regression including interaction terms for age at diagnosis and race/ethnicity.Asian was the largest racial/ethnic group (38% [Chinese = 22%; Filipino = 9%; Other = 7%]). Average age at diagnosis was younger among Asian patients (27.9 years), particularly Filipino patients (22.2 years), compared with White (29.4 years) and Black patients (34.0 years). After adjustment, disease activity and damage were not significantly different across groups. Disease severity among Asian patients was significantly higher than among White patients (LSI score 7.1 versus 6.5; P 0.05) but similar among Black and Hispanic patients. Early age at diagnosis was associated with greater organ damage among Asian, Black, and Hispanic patients, but not White patients.SLE was more severe among US Asian patients compared to White patients. Filipinos were affected at strikingly young ages. Asian patients and non-White groups with younger age at diagnosis had greater organ damage than White patients. Such racial/ethnic distinctions suggest the need for heightened clinical awareness to improve health outcomes among Asian patients with SLE. Further study of SLE outcomes across a range of US Asian subgroups is important.

OBJECTIVE Evaluate injury patterns from wheeled recreational devices (WRD) in the public space and explore risk factors for hospital admission. METHOD A cross-sectional analysis of WRD injury prevalence and risk factors for hospital admissions was conducted using data from the Queensland Injury Surveillance Unit (QISU) database for 2007 to 2017. Descriptive statistics and a log-binomial regression model were used to calculate adjusted relative risk for hospital admission. RESULTS Most WRD injury in the public space was related to stand-alone WRD injury events such as falls, with few reported WRD users being hit by vehicles from 2007 to 2017. Stand-alone WRD injury events had a higher independent risk of hospital admissions when injured in the head/neck/face (RR 2.08, 95%CI 1.6 to 2.8, p

Background Opioid misuse continues to be a major concern in the United States, affecting both adults and adolescents. Unfortunately, even legitimate prescription opioid misuse in adolescence increases the risk for misuse later in life. Although adolescence is a critical period for learning, little is known about adolescents’ preferences for opioid safety education. One potential avenue for prescription opioid education is the use of serious games. Serious games can result in better health outcomes and understanding for adolescents and allow them to safely experience real-life scenarios. However, few studies have examined the use of serious games for adolescent opioid education. Objective This study explored adolescents’ preferences for prescription opioid education and design of a serious game focused on opioid safety education. Methods A focus group guide was adapted from 2 statewide surveys about participants’ perspectives on opioids. Recruitment packets with consent documents and an introduction to the study were sent home to eligible students. Ten focus groups were conducted with 68 middle and high school students in Wisconsin. Adolescents were asked to discuss their preferences for prescription opioid safety education and to design a serious game to educate teens about opioid safety. Focus groups were audio-recorded, professionally transcribed, and underwent content and thematic analyses using NVivo 12 software. Results Three preferred approaches for opioid safety education were identified, including the use of presentations, videos and websites, and serious games. Adolescents desired short presentations delivering personal stories to smaller audiences. They preferred websites and brief, engaging videos from reliable sources because of ease of access. Adolescents also preferred serious games for opioid education that were realistic and relatable. Conclusion When educating adolescents on prescription opioids, the use of presentations, particularly personal stories, brief and engaging websites and videos, or serious games with realistic and relatable scenarios should be incorporated.

Objective Recent World Health Organization (WHO) recommendations regarding uterotonics for the prevention of postpartum hemorrhage (PPH) state that carbetocin should be considered a first-line prophylactic agent for all births where its cost is comparable to other effective uterotonics. This study evaluated whether a room temperature stable formulation of carbetocin met this recommendation in a Canadian urban hospital setting. Methods A decision tree model was developed to assess the financial implications of replacing oxytocin with carbetocin as a first-line prophylactic agent for PPH prevention in a Greater Toronto Area (GTA) hospital. The analysis accounted for the mode of delivery, efficacies of carbetocin and oxytocin in PPH prevention, occurrence of PPH-related health outcomes, and health care resource costs for PPH interventions. Results This study found that a GTA hospital, with 3242 deliveries per year, could save over CAD $349 000 annually by switching to room temperature stable carbetocin for PPH prevention. Carbetocin was able to lower institution costs by reducing the use of health care resources for PPH management in low-risk and high-risk PPH patients. The cost-saving potential of carbetocin relative to oxytocin was largely attributed to its greater efficacy in preventing the consequences of PPH. Conclusion The use of room temperature stable carbetocin as a first-line prophylactic agent for PPH prevention meets WHO recommendations regarding uterotonics for PPH in a GTA hospital. The model from this study can be used to determine the financial impact of switching from oxytocin to carbetocin in other jurisdictions while diversifying a hospital's pool of PPH prophylactic agents.

Women's Health Centers (WHC) have evolved over the last few decades as comprehensive centers for women's health care. This article reviews the history and evaluation of WHC, as well as opportunities for women's health training. Prior studies comparing WHC with traditional primary care and obstetrics/gynecology clinics have found that WHC offer at least similar levels of preventative care, may increase access to care for a more diverse patient population, and improve patient/provider relationship satisfaction. WHC also increase women's health providers' education and research opportunities. There is still a gap in women's health education and training, although residency and fellowship programs have aimed to address this through women's health tracks and fellowships. The coronavirus disease 2019 (COVID-19) pandemic and its negative impact on women's access to care have further highlighted the potential of WHC to meet women's health care demands. WHC can provide comprehensive, convenient, and single-site care for women. The increased opportunities for women's health training through WHC give rise to more representation in leadership and investment in women's health. New research is needed to reassess and further evaluate health outcomes of WHC compared with traditional care models.

Objective To assess the recent trends, acceptability, and effectiveness of digital maternal patient education through summarizing the literature. Methods Articles published in 2010–2020 on patient education, digital tools, and maternal health were searched on PubMed. Abstract and full texts were reviewed to identify eligible studies and extract key information. Results Digital patient education studies covered various topics throughout pregnancy, with the greatest number of studies targeting the prenatal period. Among the 55 studies, 38 (69%) reported significant patient outcomes, with the main benefits of increased knowledge (83.3%), emotional benefits (73.7%), and behavioral changes (60.6%). The number of studies per year increased steadily over the past decade, with frequently utilized formats of texts with images (40%), SMS (30.9%), and videos (25.5%). Video produced the highest rate of positive patient outcomes; however, no statistical significance was found. Conclusion Our study presented evidence supporting the high effectiveness and prevalence of digital tools in maternal patient education, and analyzed the content, platforms, and formats utilized by digital tools of the past decade. Practice implications Digital tools are effective and feasible in conducting maternal patient education. No specific patient education format is found to be superior in improving patient’s health outcomes.

PURPOSE: Although there exists some literature on the psychosocial elements of health between patients with and without spiritual care, less information is available on hospital health outcomes. Hence, we aimed to describe and compare health care utilization and outcomes among medical oncology patients who received and did not receive spiritual care consultation during inpatient admission. METHODS: We conducted a retrospective chart review of medical oncology patients admitted to Yale New Haven Hospital between January 1, 2018, and December 31, 2020, to compare hospital outcomes between patients with and without spiritual care. RESULTS: Thirty-one thousand six hundred twenty-three patients were included, of whom 11,053 (35%) received a chaplain spiritual care visit and had a spiritual care note. Patients who received spiritual care were older and sicker. Readmission rates within 30 days were greater in the spiritual care group (OR = 1.07; P = .018). In addition, patients receiving spiritual care were at greater odds of increased length of stay (β = 4.92; P < .0001), intensive care unit admission (OR = 2.98; P < .0001), hospital death (OR = 1.46; P < .0001), and emergency department visit within 30 days of discharge (OR = 1.17; P < .0001). CONCLUSION: Patients who were older and sicker had greater spiritual care utilization than their younger and healthier counterparts. Spiritual care assessment of existential distress, complex grief, and faith-based support may be positively associated not only with patient care and quality of life but also with health care utilization and outcomes.

Objective/background Healthy sleep is vital for physical and psychological health, and poor sleep can result in a myriad of negative physical and psychological outcomes. Insomnia symptoms often manifest as a result of acute life stressors or changes, and COVID-19 experiences may be one such stressor. Other known predisposing factors to insomnia may moderate the impact of COVID-19 experiences on sleep. The present study aimed to determine current levels of insomnia severity in a US sample, to investigate the relation of COVID-19 experiences to insomnia symptoms, and to determine which individuals are most susceptible to this association. Methods Data were drawn from a larger online survey investigating sleep and health outcomes across the lifespan. COVID-19 experiences were assessed with the exposure and impact subscales of the CAIR Pandemic Impact Questionnaire (C-PIQ). The Insomnia Severity Index (ISI) measured insomnia symptoms. Biological, psychological, and social moderators were measured using other brief self-report measures. Results Insomnia symptoms prevalence was as follows: moderate-to-severe symptoms (25.5%), subthreshold symptoms (37.7%), and no symptoms (36.7%). Individuals’ COVID-19 experiences significantly predicted insomnia symptom severity [F(1,997) = 472.92, p Conclusions Although negative experiences with COVID-19 are associated with worse insomnia symptoms, this relationship is not the same for everyone.

Objective Test the hypothesis that a higher level of purpose in life is associated with an older age of Alzheimer's dementia onset and later mortality. Design Prospective cohort studies of aging and Alzheimer's dementia. Setting Community-based. Participants Two thousand five hundred fifty-eight older adults initially free of dementia underwent assessments of purpose in life and detailed annual clinical evaluations to document incident Alzheimer's dementia and mortality. General accelerated failure time models examined the relation of baseline purpose in life with age at Alzheimer's dementia diagnosis and mortality. Exposures Purpose in life was assessed at baseline. Main Outcomes Alzheimer's dementia diagnosis was documented annually based on detailed clinical evaluations and mortality was documented via regular contacts and annual evaluations. Results During a mean of 6.89 years of follow-up, 520 individuals were diagnosed with incident Alzheimer's dementia at a mean age of 88 (SD = 6.7; range: 64.1–106.5). They had a mean baseline level of purpose in life of 3.7 (SD = 0.47; range: 1–5). A higher level of purpose in life was associated with a considerably later age of dementia onset (estimate = 0.044; 95% CI: 0.023, 0.065); specifically, individuals with high purpose (90th percentile) developed Alzheimer's dementia at a mean age of about 95 compared to a mean age of about 89 for individuals with low purpose (10th percentile). Further, the estimated mean age of death was about 89 for individuals with high purpose compared to 85 for those with low purpose. Results persisted after controlling for sex and education. Conclusion and relevance Purpose in life delays dementia onset and mortality by several years. Interventions to increase purpose in life among older persons may increase healthspan and offer considerable public health benefit.

Aims To determine the level of glycemic control and cardiovascular (CVD) risk among adults with diabetes in the Eastern Caribbean. Methods Baseline data from the Eastern Caribbean Health Outcomes Research Network (ECHORN) Cohort Study (ECS) were used for the analysis. ECS participants were 40 years of age and older, residing in the US Virgin Islands, Puerto Rico, Trinidad, or Barbados. Participants completed a survey, physical exam, and laboratory studies. CVD risk was calculated using the Atherosclerotic CVD risk equation. Bivariate analysis followed by multinomial logistic regression was used to assess social and biological factors (education, lifestyle, access to care, medical history) associated with level of glycemic control. Results Twenty-three percent of participants with diabetes had an HbA1c ≥ 9% (>75 mmol/mol). Participants with diabetes had poorly controlled CVD risk factors: 70.2% had SBP ≥ 130 mmHg, 52.2% had LDL ≥ 100 mg/dl (2.59 mmol/L), and 73.2% had a 10-year CVD risk of more than 10%. Age and education level were significant, independent predictors of glycemic control. Conclusion There is a high prevalence of uncontrolled diabetes among adults in ECS. The high burden of elevated CVD risk explains the premature mortality we see in the region. Strategies are needed to improve glycemic control and CVD risk factor management among individuals with diabetes in the Caribbean.

OBJECTIVES: The aims of this study are to (1) create clusters of joint temporal patterns of diet and physical activity (PA), and (2) determine the association of these clusters with health status indicators including body mass index (BMI), waist circumference (WC), fasting plasma glucose, hemoglobin A1c, triglyceride, high-density lipoprotein cholesterol, total cholesterol, blood pressure and health outcomes including obesity, Type 2 Diabetes (T2DM) and metabolic syndrome (MS) in U.S. adults 20–65 years. METHODS: A random day of PA from accelerometry data and the first day 24 hour dietary recall collected in the National Health and Nutrition Examination Survey 2003–2006 were used to determine absolute PA intensity, absolute energy intake, and the time of these activities. Dietary and PA data from 1,627 U.S. adults were Z-normalized. Dynamic time warping (DTW) coupled with kernel-k means clustering algorithm was used to develop joint temporal dietary and PA patterns that maximally partition individuals with similar temporal behaviors into mutually exclusive clusters derived from the data rather than predefined standards. Multivariate regression models adjusted for ptential confounders, multiple comparisons and survey design factors determined associations between joint temporal patterns and health status indicators along with health outcomes (P

This study aimed to comprehensively evaluate whether income affects long-term health outcomes for older patients who underwent percutaneous coronary intervention (PCI) provided by a universal health coverage system. Data were from the Latter Stage Elderly Healthcare Insurance database in Fukuoka Prefecture, Japan. A total of 5625 individuals aged ≥65 years who underwent PCI in 2014-2016 were included. Cox proportional hazards models were used to assess the association between income status and the incidence of health outcomes. With a median follow-up of 1095 days, 554 acute myocardial infarction (AMI) cases, 1075 stroke cases, 1690 repeat revascularization cases, and 1094 deaths were observed. Risk of all-cause mortality decreased significantly with increasing income level in both unadjusted and adjusted Cox regression models. Patients in the low-income level had a significantly higher rate of AMI (log-rank

Hereditary thrombotic thrombocytopenic purpura (hTTP) is a rare disorder caused by severe ADAMTS13 deficiency. Major morbidities and death at a young age are common. Although replacement of ADAMTS13 can prevent morbidities and death, current regimens of plasma prophylaxis are insufficient. We identified 226 patients with hTTP in 96 reports published from 2001 through 2020. Age at diagnosis was reported for 202 patients; 117 were female and 85 were male. The difference was caused by diagnosis of 34 women during pregnancy, suggesting that many men and nulliparous women are not diagnosed. Eighty-three patients had severe jaundice at birth; hTTP was suspected and effectively treated in only 3 infants. Of the 217 patients who survived infancy, 73 (34%) had major morbidities defined as stroke, kidney injury, or cardiac injury that occurred at a median age of 21 years. Sixty-two patients had stroke; 13 strokes occurred in children age 10 years or younger. Of the 54 patients who survived their initial major morbidity and were subsequently observed, 37 (69%) had sustained or subsequent major morbidities. Of the 39 patients who were observed after age 40 years, 20 (51%) had experienced a major morbidity. Compared with an age- and sex-matched US population, probability of survival was lower at all ages beginning at birth. Prophylaxis was initiated in 45 patients with a major morbidity; in 11 (28%), a major morbidity recurred after prophylaxis had begun. Increased recognition of hTTP and more effective prophylaxis started at a younger age are required to improve health outcomes.

Supplemental Digital Content is available in the text., It remains debated whether pulse pressure is associated with left ventricular traits and adverse outcomes over and beyond mean arterial pressure (MAP) in patients with heart failure (HF) with preserved ejection fraction. We investigated these associations in 3428 patients with HF with preserved ejection fraction (51.5% women; mean age, 68.6 years) enrolled in the TOPCAT trial (Treatment of Preserved Cardiac Function Heart Failure With an Aldosterone Antagonist). We computed association sizes and hazards ratios with 1-SD increase in MAP and pulse pressure. In multivariable-adjusted analyses, association sizes (P≤0.039) for MAP were 0.016 cm and 0.014 cm for septal and posterior wall thickness, −0.15 for E/A ratio, −0.66 for E/e′, and −0.64% for ejection fraction, independent of pulse pressure. With adjustment additionally applied for MAP, E/A ratio and longitudinal strain increased with higher pulse pressure with association sizes amounting to 0.067 (P=0.026) and 0.40% (P=0.023). In multivariable-adjusted analyses of both placebo and spironolactone groups, lower MAP and higher pulse pressure predicted the primary composite end point (P≤0.028) and hospitalized HF (P≤0.002), whereas MAP was also significantly associated with total mortality (P≤0.007). Sensitivity analyses stratified by sex, median age, and region generated confirmatory results with exception for the association of adverse outcomes with pulse pressure in patients with age ≥69 years. In conclusion, the clinical application of MAP and pulse pressure may refine risk estimates in patients with HF with preserved ejection fraction. This finding may help further investigation for the development of HF with preserved ejection fraction preventive strategies targeting pulsatility and blood pressure control.

Population health management (PHM) is the holistic process of improving health outcomes of groups of individuals through the support of appropriate financial and care models. Radiologists' presence...

The Carolina Abecedarian Project helped to establish the understanding that early care and education experiences can have long-term positive impacts on educational, social-emotional, and health outcomes into adulthood. This article uses an antiracist lens to reexamine this research, concluding that whereas the study has many strengths, the study's “colorblind” approach and deficit-model orientation limit its ability to inform practice and policy for promoting positive developmental outcomes in the population of Black children represented in the sample. As these limitations remain prevalent in contemporary early care and education research, implications for future research are discussed. Specifically, we propose that studies that focus on race and are based on strength-based perspectives will further understanding of developmental science. This in turn will enable researchers to better inform practice that supports and promotes positive outcomes for all children and public policy that addresses structural racism and its consequences in systems serving Black, Latine, Indigenous, and other minoritized families and communities.

Background & Aims We aimed to compare safety and effectiveness of vedolizumab to tumor necrosis factor (TNF)-antagonist therapy in ulcerative colitis in routine practice. Methods A multicenter, retrospective, observational cohort study (May 2014 to December 2017) of ulcerative colitis patients treated with vedolizumab or TNF-antagonist therapy. Propensity score weighted comparisons for development of serious adverse events and achievement of clinical remission, steroid-free clinical remission, and steroid-free deep remission. A priori determined subgroup comparisons in TNF-antagonist–naive and –exposed patients, and for vedolizumab against infliximab and subcutaneous TNF-antagonists separately. Results A total of 722 (454 vedolizumab, 268 TNF antagonist) patients were included. Vedolizumab-treated patients were more likely to achieve clinical remission (hazard ratio [HR], 1.651; 95% confidence interval [CI], 1.229-2.217), steroid-free clinical remission (HR, 1.828; 95% CI, 1.135-2.944), and steroid-free deep remission (HR, 2.819; 95% CI, 1.496-5.310) than those treated with TNF antagonists. Results were consistent across subgroup analyses in TNF-antagonist–naive and −exposed patients, and for vedolizumab vs infliximab and vs subcutaneous TNF-antagonist agents separately. Overall, there were no statistically significant differences in the risk of serious adverse events (HR, 0.899; 95% CI, 0.502-1.612) or serious infections (HR, 1.235; 95% CI, 0.608-2.511) between vedolizumab-treated and TNF-antagonist−treated patients. However, in TNF-antagonist−naive patients, vedolizumab was less likely to be associated with serious adverse events than TNF antagonists (HR, 0.192; 95% CI, 0.049-0.754). Conclusions Treatment of ulcerative colitis with vedolizumab is associated with higher rates of remission than treatment with TNF-antagonist therapy in routine practice, and lower rates of serious adverse events in TNF-antagonist−naive patients.

Living in a culture of poverty challenges people when they seek healthcare. Attitudes of healthcare workers caring for the poor can affect both return to care and subsequent health outcomes. This quality improvement project at a U.S. Midwestern hospital employed a quasi-experimental design to examine the effect of a voluntary educational intervention on nurses' attitudes toward the culture of poverty. Findings indicated a significant positive change in attitude dealing with stigmatizing statements about people living in the culture of poverty.

Sexually transmitted infections (STIs) have created a significant health burden in the United States. Prevalence and incidence estimates of STIs help portray the magnitude of the burden. These estimates also underscore the need for increased STI screening. Because STIs are often asymptomatic, diagnosis and treatment may be delayed, and a person who is infected may transmit the infection to others unknowingly. Untreated STIs can lead to severe, irreversible health outcomes. Following the United States Preventive Services Task Force and the HIV Medicine Association of the Infectious Diseases Society of America’s screening and testing recommendations will help reduce the burden.

We explored gender diverse youth’s experiences seeking and receiving gender-affirming care in various health system locations. Results provide evidence for system-, clinic-, and provider-level improvements to promote the development of affirming environments and to improve health outcomes for gender diverse youth.

OBJECTIVE The utility of endovascular thrombectomy (EVT) in patients with acute ischemic stroke, large vessel occlusion (LVO), and low Alberta Stroke Program Early CT Scores (ASPECTS) remains uncertain. The objective of this study was to determine the health outcomes and cost-effectiveness of EVT versus medical management in patients with ASPECTS < 6. METHODS A decision-analytical study was performed with Markov modeling to estimate the lifetime quality-adjusted life-years (QALYs) and associated costs of EVT-treated patients compared to medical management. The study was performed over a lifetime horizon with a societal perspective in the US setting. RESULTS The incremental cost-effectiveness ratios were $412,411/QALY and $1,022,985/QALY for 55- and 65-year-old groups in the short-term model. EVT was the long-term cost-effective strategy in 96.16% of the iterations and resulted in differences in health benefit of 2.21 QALYs and 0.79 QALYs in the 55- and 65-year-old age groups, respectively, equivalent to 807 days and 288 days in perfect health. EVT remained the more cost-effective strategy when the probability of good outcome with EVT was above 16.8% or as long as the good outcome associated with the procedure was at least 1.6% higher in absolute value than that of medical management. EVT remained cost-effective even when its cost exceeded $100,000 (threshold was $108,036). Although the cost-effectiveness decreased with age, EVT was cost-effective for 75-year-old patients as well. CONCLUSIONS This study suggests that EVT is the more cost-effective approach compared to medical management in patients with ASPECTS < 6 in the long term (lifetime horizon), considering the poor outcomes and significant disability associated with nonreperfusion.

Corruption is pervasive, but we know little about its effects on individual lives. Using individual-level data from 28 post-communist countries, we demonstrate that bribing for public services worsens self-assessed health. We account for endogeneity of bribery and show that bribing for any type of public service, not just for health services, has an adverse impact. We also find that bribery lowers the quality of services received. Moreover, there are potentially high indirect costs of bribery since, as we show, it comes at the expense of cutting food consumption. These findings suggest that corruption is a potentially important source behind the poor health outcomes in many developing countries.

Adverse childhood experiences such as abuse, neglect, and poverty, profoundly alter neurobehavioral development in a manner that negatively impacts health across the lifespan. Adults who have been exposed to such adversities exhibit premature and more severe age-related declines in brain health. Unfortunately, it remains unclear whether the negative effects of early life adversity (ELA) on brain health can be remediated through intervention in adulthood. Physical activity may represent a low-cost behavioral approach to address the long-term consequences of ELA on brain health. However, there has been limited research examining the impact of physical activity on brain health among adults with a history of ELA. Accordingly, the purpose of this review is to (1) review the influence of ELA on brain health in adulthood and (2) highlight evidence for the role of neurotrophic factors, hypothalamic-adrenal-pituitary axis regulation, inflammatory processes, and epigenetic modifications in mediating the effects of both ELA and physical activity on brain health outcomes in adulthood. We then propose a theoretical framework to guide future research in this area.

Optimizing enteral nutrition for premature infants may help mitigate extrauterine growth restriction and adverse chronic health outcomes. Previously, we showed in neonatal pigs born at term that lean growth is enhanced by intermittent bolus compared with continuous feeding. The objective was to determine if prematurity impacts how body composition, muscle protein synthesis, and myonuclear accretion respond to feeding modality. Following preterm delivery, pigs were fed equivalent amounts of formula delivered either as intermittent boluses (INT

Contains fulltext : 244759.pdf (Publisher’s version ) (Closed access) PURPOSE: Secondary findings (SFs) are present in 1-4% of individuals undergoing genome/exome sequencing. A review of how SFs are disclosed and what outcomes result from their receipt is urgent and timely. METHODS: We conducted a systematic literature review of SF disclosure practices and outcomes after receipt including cascade testing, family and provider communication, and health-care actions. Of the 1,184 nonduplicate records screened we summarize findings from 27 included research articles describing SF disclosure practices, outcomes after receipt, or both. RESULTS: The included articles reported 709 unique SF index recipients/families. Referrals and/or recommendations were provided 647 SF recipients and outcome data were available for 236. At least one recommended evaluation was reported for 146 SF recipients; 16 reports of treatment or prophylactic surgery were identified. We found substantial variations in how the constructs of interest were defined and described. CONCLUSION: Variation in how SF disclosure and outcomes were described limited our ability to compare findings. We conclude the literature provided limited insight into how the American College of Medical Genetics and Genomics (ACMG) guidelines have been translated into precision health outcomes for SF recipients. Robust studies of SF recipients are needed and should be prioritized for future research.

Adherence may be an important factor to consider when interpreting the results of an exercise intervention. This article will discuss the importance of measuring and reporting adherence to exercise interventions that are designed to improve targeted health outcomes. Additionally, we will propose and describe a universal method to measure and report adherence to exercise interventions.

Background Insertable cardiac monitors (ICMs) are a clinically effective means of detecting atrial fibrillation (AF) in high-risk patients, and guiding the initiation of non-vitamin K oral anticoagulants (NOACs). Their cost-effectiveness from a US clinical payer perspective is not yet known. The objective of this study was to evaluate the cost-effectiveness of ICMs compared to standard of care (SoC) for detecting AF in patients at high risk of stroke (CHADS2 ≥ 2), in the US. Methods Using patient data from the REVEAL AF trial (n = 393, average CHADS2 score = 2.9), a Markov model estimated the lifetime costs and benefits of detecting AF with an ICM or with SoC (specifically intermittent use of electrocardiograms and 24-h Holter monitors). Ischemic and hemorrhagic strokes, intra- and extra-cranial hemorrhages, and minor bleeds were modelled. Diagnostic and device costs, costs of treating stroke and bleeding events and medical therapy—specifically costs of NOACs were included. Costs and health outcomes, measured as quality-adjusted life years (QALYs), were discounted at 3% per annum, in line with standard practice in the US setting. One-way deterministic and probabilistic sensitivity analyses (PSA) were undertaken. Results Lifetime per-patient cost for ICM was $31,116 versus $25,330 for SoC. ICMs generated a total of 7.75 QALYs versus 7.59 for SoC, with 34 fewer strokes projected per 1000 patients. The model estimates a number needed to treat of 29 per stroke avoided. The incremental cost-effectiveness ratio was $35,528 per QALY gained. ICMs were cost-effective in 75% of PSA simulations, using a $50,000 per QALY threshold, and a 100% probability of being cost-effective at a WTP threshold of $150,000 per QALY. Conclusions The use of ICMs to identify AF in a high-risk population is likely to be cost-effective in the US healthcare setting.

Recent estimates have reiterated that non-fatal causes of disease, such as low back pain, headaches and depressive disorders, are amongst the leading causes of disability-adjusted life years (DALYs). For these causes, the contribution of years lived with disability (YLD) – put simply, ill-health – is what drives DALYs, not mortality. Being able to monitor trends in YLD closely is particularly relevant for countries that sit high on the socio-demographic spectrum of development, as it contributes more than half of all DALYs. There is a paucity of data on how the population-level occurrence of disease is distributed according to severity, and as such, the majority of global and national efforts in monitoring YLD lack the ability to differentiate changes in severity across time and location. This raises uncertainties in interpreting these findings without triangulation with other relevant data sources. Our commentary aims to bring this issue to the forefront for users of burden of disease estimates, as its impact is often easily overlooked as part of the fundamental process of generating DALY estimates. Moreover, the wider health harms of the COVID-19 pandemic have underlined the likelihood of latent and delayed demand in accessing vital health and care services that will ultimately lead to exacerbated disease severity and health outcomes. This places increased importance on attempts to be able to differentiate by both the occurrence and severity of disease.

BACKGROUND There is a lack of simple tools that could allow members of the general population to estimate their own dietary patterns and to associate them with unfavourable health outcomes. The present study aimed to develop and validate a simple self-administered tool, called the Easy Diet Screener (EDS), that would identify healthy and unhealthy dietary patterns and evaluate their association with unfavourable blood and anthropometric parameters (i.e. values outside the recommended values). METHODS In total, 259 adult people (31-50 years of age) participated in this observational study. They filled out an online version of the EDS questionnaire; those who scored highly were assigned to the healthy dietary pattern (HDP) group, whereas those with a low score were assigned to the western dietary pattern (WDP) group. The dietary records, anthropometric and biochemical parameters were evaluated in a subset of 200 participants who obtained similar score in the repeated EDS (paper version). RESULTS People assigned to HDP on the basis of EDS had significantly better diet quality than those assigned to WDP, with values of the Healthy Eating Index being 76.9 ± 9.2 and 58.7 ± 10.5, respectively. People classed as WDP had a higher risk of too high serum low-density lipoproteins [odds ratio (OR) = 2.65], triglycerides (OR = 3.67), body mass index (OR = 2.87) and percentage of fat tissue (OR = 3.98) than did people in the HDP. CONCLUSIONS EDS is an easy tool for quickly identifying healthy and western dietary patterns that are associated with lipid profile and body adiposity.

The global burden of chronic disease has forced health systems to focus on improved care. This has led to improved health outcomes for some populations, but not for all people or for all conditions. The rising prevalence of chronic disease has also significantly increased demands on healthcare systems, with unsustainable costs to funders. To improve health and social outcomes for all people with chronic disease, it is critical to embrace allied health professionals as key members of primary healthcare teams. The recognised efficacy and cost-effectiveness of many allied health interventions suggest that implementation into usual care would result in enhanced outcomes for people accessing healthcare, their families and communities, and for health systems. Our aim is to highlight the current unacceptable lack of allied health integration into primary healthcare teams, and illustrate the potential value of improved and equitable access to allied health professionals for managing chronic conditions and multimorbidity.

Recreational use of natural freshwater bodies poses a risk to human health, although the risks associated with different types of exposure in freshwater are not clear. A systematic review was carried out to identify the risks of adverse health outcomes among individuals exposed through primary contact recreation compared to minimal contact recreation in different types of freshwater bodies. Among 5858 potentially relevant titles and abstracts, 35 were eligible for final inclusion. We included studies that reported the type of freshwater exposure and health outcomes, were peer-reviewed, and had full-text articles available in English. Across all studies, general gastrointestinal illness was the most commonly reported (77.1%), followed by skin (37.1%) and ear-related infection (34.3%), respiratory illness (31.4%), and eye-related illness (25.7%). Most studies reported adverse health outcomes from primary contact recreation (85.7%) in comparison to secondary contact activities (17.1%) and no-contact recreation (2.9%). More than half of the included studies (54.3%) focussed on lakes. The continued focus on primary contact recreation in lakes is a concern, given the growing global trend in secondary and non-contact recreation associated with urban wetlands. A better understanding of risks associated with recreational contact with freshwater in these settings is needed.

Atmospheric carbon dioxide (CO2 ) levels are currently at 418 parts per million (ppm), and by 2100 may exceed 900 ppm. The biological effects of lifetime exposure to CO2 at these levels is unknown. Previously we have shown that mouse lung function is altered by long-term exposure to 890 ppm CO2 . Here, we assess the broader systemic physiological responses to this exposure. Mice were exposed to either 460 or 890 ppm from preconception to 3 months of age, and assessed for effects on developmental, renal and osteological parameters. Locomotor, memory, learning and anxiety-like behaviours of the mice were also assessed. Exposure to 890 ppm CO2 increased birthweight, decreased female body weight after weaning, and, as young adults, resulted in reduced engagement in memory/learning tasks, and hyperactivity in both sexes in comparison to controls. There were no clear anxiety, learning or memory changes. Renal and osteological parameters were minimally affected. Overall, this study shows that exposure of mice to 890 ppm CO2 from preconception to young adulthood alters growth and some behaviours, with limited evidence of compensatory changes in acid-base balance. These findings highlight the potential for a direct effect of increased atmospheric CO2 on mammalian health outcomes. KEY POINTS: Long-term exposure to elevated levels of atmospheric CO2 is an uncontrolled experiment already underway. This is the first known study to assess non-respiratory physiological impacts of long-term (conception to young adulthood) exposure of mice to CO2 at levels that may arise in the atmosphere due to global emissions. Exposure to elevated CO2 , in comparison to control mice, altered growth patterns in early life and resulted in hyperactive behaviours in young adulthood. Renal and bone parameters, which are important to balance acid-base levels to compensate for increased CO2 exposure, remained relatively unaffected. This work adds to the body of evidence regarding the effects of carbon emissions on mammalian health and highlights a potential future burden of disease.

Background and objectiveNeonatal outcome research and clinical follow-up principally focus on neurodevelopmental impairment (NDI) after extremely preterm birth, as defined by the scientific community, without parental input. This survey aimed to investigate parental perspectives about the health and development of their preterm children.MethodsParents of children aged 18 months to 7 years born Results248 parents of 213 children (mean gestational age 26.6±1.6 weeks, 20% with severe NDI) were recruited. Parents evaluated their children’s health at a median of 9/10. Parental priorities for health improvements were (1) development, mainly behaviour, emotional health and language/communication (55%); (2) respiratory heath and overall medical fragility (25%); and (3) feeding/growth issues (14%). Nineteen per cent explicitly mentioned ‘no improvements’. Parents were more likely to state ‘no improvements’ if child had no versus severe NDI OR 4.33 (95% CI 1.47 to 12.75)) or if parents had no versus at least a high school diploma (OR 4.01 (95% 1.99 to 8.10)).ConclusionsParents evaluate the health of their preterm children as being very good, with positive perspectives. Parental concerns outside the developmental sphere should also be addressed both in clinical follow-up and research.

Purpose: Global collaboration to accelerate development and equitable access to COVID-19 tests, treatments, and vaccines was launched with the name of the Access to COVID-19 Tools Accelerator (ACT-A), and this initiative owes its expertise to the lessons learned of the global health organizations. To date, the comprehensive mechanisms and potential effects of the initiative remain largely unknown. Methods: This study reviewed the programs of Gavi, the Global Fund, Unitaid, and ACT-A, which mitigating barriers to greater use of health technology with an analytic framework. Results and conclusion: The study findings are as follows. First, programs to alleviate the absence of necessary technology include the International Finance Facility for Immunization and Covax Facility. Second, Pooled Procurement Mechanism and Accelerated Order Mechanism are examples of mitigating the inability to access technology. Third, programs to overcome reluctance to adopt accessible technology include health system strengthening efforts such as the capacity-building health workforces. Further actions of Korea are needed to collaborate with the initiatives to enhance health outcomes.