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BACKGROUND AND AIM: Pervasive disparities characterize sickle cell disease (SCD) care, including limited access to SCD specialists. Rapid deployment of remote healthcare provision and support during the COVID-19 pandemic provides an opportunity to understand telehealth barriers/facilitators for SCD. We aimed to evaluate telehealth experiences and satisfaction for routine visits among adults and caregivers of children with SCD within a US regional collaborative. METHODS: 151 adults ≥ 18 [median (IQR) = 36 (28, 43) years], and 94 caregivers [median child age (IQR) = 12 (7, 14) years] completed a 30-item online survey in 2021 assessing systems issues such as reliable Internet; health information sharing; and consumer focus (e.g., visit started on time). A multivariable logistic regression model was used to evaluate relations between independent variables and the outcome overall satisfaction with telehealth. RESULTS: Patients were primarily diagnosed with sickle cell anemia (60.8%) and prescribed hydroxyurea (57.6%). Satisfaction with telehealth was high (> 90%), but 60.6% of caregivers gave the highest rating compared with 44.9% of adults (p = 0.02). Few accessibility/technical issues were cited, however, caregivers reported more often having home support for telehealth (80.9% vs. 63.6%, p = 0.003). In multivariable analyses, participants seen in large centers (> 200) were more likely to give the highest satisfaction ratings compared with those in smaller centers (

BACKGROUND: Ambulatory access to academic medical centers (AMCs) for patients insured with Medi-Cal (i.e., Medicaid in California) is understudied, particularly among the 85% of beneficiaries enrolled in managed care plans. As more AMCs develop partnerships with these plans, data on patient experiences of access to care and quality are needed to guide patient-centered improvements in care delivery. METHODS: The authors conducted semi-structured, qualitative interviews with Medi-Cal-insured patients with initial visits at a large, urban AMC during 2022. Participant recruitment was informed by a database of ambulatory Medi-Cal encounters. The interview guide covered Medi-Cal enrollment, scheduling, and visit experience. Interviews were transcribed and inductively coded, then organized into themes across four domains: access, affordability, patient-provider interactions, and continuity. RESULTS: Twenty participant interviews were completed (55% female, 85% English speaking, 80% self-identified minority or other race, and 30% Hispanic or Latino) with primary and/or specialty care visits. Within the access domain, participants reported delays with Medi-Cal enrollment and access to specialist care or testing, though appointment scheduling was reported to be easy. Affordability concerns included out-of-pocket medical and parking costs, and missed income when patients or families skipped work to facilitate care coordination. Participants considered clear, bilateral communication with providers fundamental to positive patient-provider interactions. Some participants perceived discrimination by providers based on their insurance status. Participants valued continuity, but experienced frustration arising from frequent and unexpected health plan changes that disrupted care with their established AMC providers. CONCLUSIONS: The missions of AMCs typically focus on clinical care, education, research, and equity. However, reports from Medi-Cal insured patients receiving care at AMCs highlight their stress and confusion related to inconsistent provider access, uncompensated costs, variability in perceptions of quality, and fragmented care. Recommendations based upon patient-reported concerns suggest opportunities for AMC health system-level improvements that are compatible with AMC missions.

PURPOSE: To examine changes in rural and urban Veterans utilization of acute inpatient care in Veterans Health Administration (VHA) and non-VHA hospitals following access expansion from the Veterans Choice Act, which expanded eligibility for VHA-paid community hospitalization. METHODS: Using repeated cross-sectional data of VHA enrollees hospitalizations in 9 states (AZ, CA, CT, FL, LA, MA, NY, PA, and SC) between 2012 and 2017, we compared rural and urban Veterans probability of admission in VHA and non-VHA hospitals by payer over time for elective and nonelective hospitalizations using multinomial logistic regression to adjust for patient-level sociodemographic features. We also used generalized linear models to compare rural and urban Veterans travel distances to hospitals. FINDINGS: Over time, the probability of VHA-paid community hospitalization increased more for rural Veterans than urban Veterans. For elective inpatient care, rural Veterans probability of VHA-paid admission increased from 2.9% (95% CI 2.6%-3.2%) in 2012 to 6.5% (95% CI 5.8%-7.1%) in 2017. These changes were associated with a temporal trend that preceded and continued after the implementation of the Veterans Choice Act. Overall travel distances to hospitalizations were similar over time; however, the mean distance traveled decreased from 39.2 miles (95% CI 35.1-43.3) in 2012 to 32.3 miles (95% CI 30.2-34.4) in 2017 for rural Veterans receiving elective inpatient care in VHA-paid hospitals. CONCLUSIONS: Despite limited access to rural hospitals, these data demonstrate an increase in rural Veterans use of non-VHA hospitals for acute inpatient care and a small reduction in distance traveled to elective inpatient services.

BACKGROUND: While insurance is integral for accessing healthcare in the US, coverage alone may not ensure access, especially for those publicly insured. Access barriers for Medicaid-insured patients are rooted in social drivers of health, insurance complexities in the setting of managed care plans, and federal- and state-level policies. Elucidating barriers at the health system level may reveal opportunities for sustainable solutions. METHODS: To understand barriers to ambulatory care access for patients with Medi-Cal (Californias Medicaid program) and identify improvement opportunities, we performed a qualitative study using semi-structured interviews of a referred sample of clinicians and administrative staff members experienced with clinical patient encounters and/or completion of referral processes for patients with Medi-Cal (n = 19) at a large academic medical center. The interview guide covered the four process steps to accessing care within the health system: (1) scheduling, (2) referral and authorization, (3) contracting, and (4) the clinical encounter. We transcribed and inductively coded the interviews, then organized themes across the four steps to identify perceptions of barriers to access and improvement opportunities for ambulatory care for patients with Medi-Cal. RESULTS: Clinicians and administrative staff members at a large academic medical center revealed barriers to ambulatory care access for Medi-Cal insured patients, including lack of awareness of system-level policy, complexities surrounding insurance contracting, limited resources for social support, and poor dissemination of information to patients. Particularly, interviews revealed how managed Medi-Cal impacts academic health systems through additional time and effort by frontline staff to facilitate patient access compared to fee-for-service Medi-Cal. Interviewees reported that this resulted in patient care delays, suboptimal care coordination, and care fragmentation. CONCLUSIONS: Our findings highlight gaps in system-level policy, inconsistencies in pursuing insurance authorizations, limited resources for scheduling and social work support, and poor dissemination of information to and between providers and patients, which limit access to care at an academic medical center for Medi-Cal insured patients. Many interviewees additionally shared the moral injury that they experienced as they witnessed patient care delays in the absence of system-level structures to address these barriers. Reform at the state, insurance organization, and institutional levels is necessary to form solutions within Medi-Cal innovation efforts.

BACKGROUND AND AIMS: The extent of healthcare barriers and its association with acute care use among adults with chronic liver disease (CLD) relative to other chronic conditions remains understudied. We compared the probability of barriers and recurrent acute care use among persons with CLD and persons with chronic obstructive pulmonary disease (COPD) and/or cardiovascular disease (CVD). METHODS: We assembled a population-based, cross-sectional study using pooled self-reported National Health Interview Survey data (2011-2017) among community-dwelling persons. Probability of barriers by disease group (CLD vs COPD/CVD) was assessed using hurdle negative binomial regression. RESULTS: The sample included 47,037 adults (5062 with CLD, 41,975 with COPD/CVD). The CLD group was younger (median age 55 vs 62 years) and included more Hispanics (17.5% vs 8.6%) and persons with poverty (20.1% vs 15.3%) than the COPD/CVD group. More respondents with CLD vs COPD/CVD reported barriers (44.7% vs 34.4%), including unaffordability (27.5% vs 18.8%), transportation-related (6.1% vs 4.1%), and organizational barriers at entry to (17.6% vs 13.0%) and within healthcare (19.5% vs 14.2%). While adults with CLD were more likely to experience at least 1 barrier (adjusted incident rate ratio, 1.12 [1.01-1.24], P = .03), they were not associated with more (1.05 [1.00-2.71], P = .06). Probability of recurrent acute care use was associated with more healthcare barriers. CONCLUSION: Findings from this nationally representative sample of over 43 million US adults reveal that persons with CLD have increased probability of healthcare barriers, likely related to their higher prevalence of socioeconomic vulnerabilities compared to persons with COPD/CVD. CLD warrants attention as a priority condition in public policies that direct resources towards high-risk populations.

OBJECTIVES: (1) Assess and compare the perceptions of pet owners and veterinary professionals pertaining to the extent of veterinary workforce and access to care challenges in 2023 in Colorado, and (2) Assess what programs, policies, and resources veterinary professionals and pet owners believe would be most effective at addressing access to care and workforce challenges in Colorado. SAMPLE: 736 veterinarians, veterinary technicians, or practice/owner manager (veterinary professionals) in Colorado. A total of 1,209 pet owners (919 from an online survey and 290 from in-person surveying). PROCEDURES: Distribution of an online anonymous survey to veterinary professionals in Colorado. Pet owners were surveyed both online and in-person at pet pantry or shelter events. RESULTS: Veterinary professionals reported significant workforce challenges, including having to frequently divert clients, clients forced to decline medical care or having to euthanize their pets due to cost. Veterinary professionals were especially supportive of policy efforts to enhance recruitment and retention of technicians, including through mechanisms such as clarifying their scope of practice, loan repayment programs, and enhancing career pathways. Colorado pet owners responses pertaining to the scope of access to care challenges were similar to prior national research. Pet owners reported particularly needing low-cost emergency clinics in their community as well as resources to reduce the cost of care. Pet owners were generally supportive of expanding veterinary care access through telemedicine; indicating they would feel comfortable seeing a veterinarian via telemedicine, even for the first time, and that expanded use of telemedicine would increase their ability to obtain care. CONCLUSIONS AND CLINICAL RELEVANCE: Colorado pet owners and veterinary professionals both identified numerous access to care challenges as well as indicated support for the development of several potential initiatives to address the problem. Low-cost clinics that provide sick and emergency care was the resource rated as being most helpful among pet owners. Further exploration of grants, voucher programs, expansion of telemedicine, increased utilization and title protection for CVTs, and the creation of the veterinary professional associate position are all initiatives that were noted to be worthy of further exploration.

Aim: Characterize the logistical challenges faced by healthcare professionals (HCPs), patients and caregivers during the chimeric antigen receptor T-cell (CAR T) treatment process for non-Hodgkin lymphoma patients. Materials & methods: HCPs in the US and UK experienced with CAR T administration participated in interviews and completed a web-based survey. Results: A total of 133 (80 US, 53 UK) HCPs participated. Two or more logistical challenges were identified by ≥60% of respondents across all stages of the CAR T process. Commonly reported challenges were lengthy waiting periods, administrative and payer-related barriers, limited healthcare capacity, caregiver support and (particularly in the US) patient out-of-pocket costs. Conclusion: The CAR T treatment process presents numerous challenges, highlighting an unmet need for more convenient therapies. Plain Language Summary Chimeric antigen receptor T-cell (CAR T) therapy is a new treatment for patients with non-Hodgkin lymphoma that have not responded to other types of treatment. CAR T therapy uses a person's own immune cells (T cells), which are modified in a laboratory to attack cancer cells. While CAR T therapy has the potential to be effective, there are challenges associated with the treatment process. In this study, we surveyed 133 healthcare professionals (HCPs) in the United States and United Kingdom to understand their experiences with logistical challenges involved in navigating the CAR T process. More than 60% of participants identified two or more logistical challenges at every stage of the CAR T treatment process. The most commonly reported challenges included long waiting periods, limited room at hospitals, availability of caregivers to support patients and issues related to out-of-pocket costs, travel and lodging for patients who are treated at specialized centers. In the United States, challenges related to insurance coverage and out-of-pocket costs for patients were highlighted. More than half of HCPs reported that patients' cancer getting worse while waiting to receive CAR T was a reason why patients may not proceed to treatment. While operational improvements might address some challenges in the CAR T treatment process, these findings highlight the need for more convenient, readily available and easily administered therapies for patients with non-Hodgkin lymphoma. Article highlights While chimeric antigen receptor T-cell (CAR T) therapy represents an advancement in the treatment of non-Hodgkin lymphoma, it is associated with a number of logistical challenges for patients, caregivers and healthcare professionals (HCPs). We surveyed physicians, nurses and other HCPs involved in the various stages of CAR T therapy administration in the US and UK to characterize logistical challenges at each stage of the CAR T process. Initial in-depth qualitative interviews (n = 25) of HCPs highlighted lack of caregiver support, time and administration, travel and accommodations and payer access as key themes. In a subsequent quantitative survey of HCPs (n = 133), more than 60% of respondents identified at least two logistical challenges faced at every stage of CAR T administration. Respondents most commonly reported challenges related to lengthy waiting periods, slow approval processes, limited capacity and availability of caregiver support. More than half of respondents reported rapid disease progression as a common reason why eligible patients do not proceed to CAR T infusion. The availability of caregiver support was selected as a logistical challenge present at every stage of the CAR T treatment process. Respondents highlighted out-of-pocket costs, travel and lodging challenges throughout the CAR T process, although out-of-pocket costs and insurance-related challenges were more pronounced in the US than in the UK. This study adds to the growing body of literature addressing the logistical challenges associated with CAR T therapy. Infographic [ABSTRACT FROM AUTHOR]

Objective: To estimate a causal relationship between mental health staffing and time to initiation of mental health care for new patients. Data Sources and Study Setting: As the largest integrated health care delivery system in the United States, the Veterans Health Administration (VHA) provides a unique setting for isolating the effects of staffing on initiation of mental health care where demand is high and out‐of‐pocket costs are not a relevant confounder. We use data from the Department of Defense and VHA to obtain patient and facility characteristics and health care use. Study Design: To isolate exogenous variation in mental health staffing, we used an instrumental variables approach—two‐stage residual inclusion with a discrete time hazard model. Our outcome is time to initiation of mental health care after separation from active duty (first appointment) and our exposure is mental health staffing (standardized clinic time per 1000 VHA enrollees per pay period). Data Collection/Extraction Methods: Our cohort consists of all Veterans separating from active duty between July 2014 and September 2017, who were enrolled in the VHA, and had at least one diagnosis of post‐traumatic stress disorder, major depressive disorder, and/or substance use disorder in the year prior to separation from active duty (N = 54,209). Principal Findings: An increase of 1 standard deviation in mental health staffing results in a higher likelihood of initiating mental health care (adjusted hazard ratio: 3.17, 95% confidence interval: 2.62, 3.84, p < 0.001). Models stratified by tertile of mental health staffing exhibit decreasing returns to scale. Conclusions: Increases in mental health staffing led to faster initiation of care and are especially beneficial in facilities where staffing is lower, although initiation of care appears capacity‐limited everywhere. [ABSTRACT FROM AUTHOR]

Subjective aging in older adults is associated with a decline in basic activities of daily living (bADL), although this is less well studied with increasing age cohorts by their healthcare resources (HCR) and healthcare access (HCA) controlling for sociodemographics. We aimed to address this gap in knowledge by analyzing the National Health and Aging Trends round 11 data set on 3303 older adults aged 70 to above 90, comprising 42% male and 58% female by age cohort (middle-old -70–79, n = 1409; older-old -80–89, n = 1432, oldest-old- 90 plus, n = 462). Results of mediation–moderation analysis show the subjective aging whole model comprising subjective cognitive decline, HCR, HCA, and sociodemographic to predict a decline in bADL with increasing age to be higher among the older-old age (80–89) compared to the middle-old age (70–79) or oldest-old (90 years +) cohorts. These findings suggest a "doughnut" effect by which the older-old age cohort of 80–89 may be coping less well with their bADL, while the oldest-old may have adapted to functional loss in their everyday living and/or comprises adults who may have passed a mortality selection despite a more significant burden of comorbidity. [ABSTRACT FROM AUTHOR]

ABSTRACT Aim Design Methods Results Conclusion Impact Reporting Methods To explore specialist homeless health professionals' perceptions of gaps in homeless health care and understand whether these might be addressed through existing nursing scopes of practice.Qualitative descriptive study.Semi‐structured interviews and focus groups with a purposive sample of 22 staff in nursing (11) and non‐nursing (11) roles, engaged with a Homeless Health Service. Data were collected via videoconferencing and recordings transcribed verbatim. An exploratory framework guided deductive and inductive thematic analysis.Service gap themes included the need for integration with mainstream health services, more specialised health professionals, and adaptations to the existing models of care. Addressing these gaps involved enhancements to the broad scope of nursing practice, workforce development by establishing homeless health as a nursing specialty and optimising organisational governance to minimise risk.The most pressing homeless health service delivery gap was lack of health service integration, and it was unclear how this could be resolved through nursing scopes of practice. Other service gaps could be addressed through skilling nurses to practice preventative health care, as well as crisis management. Enhancing nurses' capability in physical and mental health assessment skills including alcohol and other drugs and procedural skills would support wraparound care for people experiencing homelessness. We conclude that a homeless health nursing specialty could be established that formalises the scope of practice of nurses in this field to ensure future post‐graduate training aligns with service gaps.This study identifies opportunities to optimise nursing scopes of practice to address Homeless Health Service gaps through reviewing models of care and nursing practice. For example, enhancing nurses' capability to provide preventative and wraparound care. This research may inform a development pathway to enhance education and training for nurses working with vulnerable populations.COREQ 32‐item checklist.No patient or public contribution. [ABSTRACT FROM AUTHOR]

Background: Stigma and discrimination towards people with mental health conditions by their communities are common worldwide. This can result in a range of negative outcomes for affected persons, including poor access to health care. However, evidence is still patchy from low- and middle-income countries (LMICs) on affordable, community-based interventions to reduce mental health-related stigma and to improve access to mental health care. Methods: This study aims to conduct a feasibility (proof-of-principle) pilot study that involves developing, implementing and evaluating a community-based, multi-component, awareness-raising intervention (titled Indigo-Local), designed to reduce stigma and discrimination and to increase referrals of people with mental health conditions for assessment and treatment. It is being piloted in seven sites in five LMICs—China, Ethiopia, India, Nepal and Tunisia—and includes several key components: a stakeholder group workshop; a stepped training programme (using a 'Training of Trainers' approach) of community health workers (or similar cadres of workers) and service users that includes repeated supervision and booster sessions; community engagement activities; and a media campaign. Social contact and service user involvement are instrumental to all components. The intervention is being evaluated through a mixed-methods pre-post study design that involves quantitative assessment of stigma outcomes measuring knowledge, attitudes and (discriminatory) behaviour; quantitative evaluation of mental health service utilization rates (optional, where feasible in sites); qualitative exploration of the potential effectiveness and impact of the Indigo-Local intervention; a process evaluation; implementation evaluation; and an evaluation of implementation costs. Discussion: The output of this study will be a contextually adapted, evidence-based intervention to reduce mental health-related stigma in local communities in five LMICs to achieve improved access to healthcare. We will have replicable models of how to involve people with lived experience as an integral part of the intervention and will produce knowledge of how intervention content and implementation strategies vary across settings. The intervention and its delivery will be refined to be feasible and ready for larger-scale implementation and evaluation. This study thereby has the potential to make an important contribution to the evidence base on what works to reduce mental health-related stigma and discrimination and improve access to health care. [ABSTRACT FROM AUTHOR]

Introduction Aim Methods Results Conclusion Rare coagulation disorders (RCDs) constitute an important health risk. Data on epidemiology, quality of life (QoL), access to care, and impact of the ongoing economic crisis on RCDs in Lebanon is limited.We aimed to address these gaps by evaluating effect of the crisis on the management of RCDs.We performed a retrospective chart review of RCD pediatric patients in a tertiary hospital between 2003 and 2023. Patients with deficiencies of fibrinogen, factor (F)II, FV, combined FV and FVIII, FVII, FXI, FXII, FXIII, and congenital deficiency of vitamin K‐dependent factors (VKCFDs) underwent a qualitative assessment of the impact of the economic crisis on care and quality of life by an interview aimed at investigating obstacles to diagnosis, disparities in access to treatment, impact of the crisis on QoL and disease management, and opinion on governmental efforts to solve the health crisis.46 patients were included. The response rate for the interview was 63%. Among the cohort, 21 (72.4%) reported difficulty accessing treatment since the start of the crisis and 18 (62%) reported “lack of healthcare coverage for necessary treatments” as the main issue. Most participants reported that the Lebanese government did not adequately address their needs during the crisis.Our study showcased that management of RCD patients in Lebanon has been severely affected by the economic crisis. Combined efforts by public and private sectors are needed to appropriately address this issue. Lessons can be learned from the Lebanese experience to appropriately screen for actionable factors in vulnerable populations. [ABSTRACT FROM AUTHOR]

Purpose: To investigate the prevalence and type of clinical pharmacy services offered within South Carolina Federally Qualified Health Centers (SC FQHCs) and identify existing implementation barriers. Methods: This study was a cross-sectional survey of pharmacists or Chief Medical Officers practicing in SC FQHCs. Organizations were identified utilizing the Health Resources and Services Administration (HRSA) database and were contacted to participate in a telephone survey. An electronic form was created in REDCap® software. Descriptive statistics were used to analyze and evaluate data. Results: Twenty-two SC FQHCs were eligible for the survey, with 16 (72.7%) participating. Of the respondents, 9 (56%) offered at least 1 service. The most common services offered were chronic disease state management, diabetes self-management education and support (DSMES), and tobacco cessation (43.8%, n = 7). The least common services offered were chronic care, Hepatitis C, and HIV management (18.9%, n = 3). The most common barriers to implementation were lack of personnel and provider interest (62.5%, n = 10). The least common barrier was a lack of pharmacist interest or time (25%, n = 4). Conclusion: Pharmacists offered at least 1 clinical service within most SC FQHCs. Barriers were identified that prevented expansion of services and further research is needed to overcome these. [ABSTRACT FROM AUTHOR]

Integrated and collaborative care models, in which mental/behavioral health providers work closely with primary care providers within a primary care setting, help support the quadruple aim of improved health outcomes, patient satisfaction, provider experience, and lower cost. In this paper, we describe patients' general perspectives of integrated care and their unique experiences accessing this care within one health system. Qualitative (interviews with patients) and quantitative (surveys with patients) methods were used to collect and analyze these results separately and together. The results highlight important features to the provision of integrated care from the perspective of patients using integrated care. They include the importance and experience of access, whole-person care and a team-based approach, the availability and use of telehealth when appropriate, having high quality mental health providers, scheduling and service usage suggestions, and means to connect with longer-term services for ongoing mental health care when needed. [ABSTRACT FROM AUTHOR]

Background: This study sought to identify factors that contribute to disparities in access to bariatric surgery in North Carolina (NC). Methods: Using the rate of bariatric surgery in the county with the best health outcome as the reference, we calculated the Surgical Equity Index (SEI) in the remaining counties in NC. Results: Approximately 2.95 million individuals (29%) were obese in NC. There were 992 (.5%) bariatric procedures performed on a population of 194 209 individuals with obesity in the Reference County (RC). The mean SEI for bariatric surgery in NC was .47 (SD .17, range .15-.95). A statistically significant difference was observed in 89 counties. Univariable analyses identified the following variables to be significantly associated with the SEI: percent of population living in rural areas (% rural) (relative rate change in SEI [RR] = .994, 95% CI .92-.997; <.0001), median household income (RR = 1.0, 95% CI = 1.0-1.0; P = .0002), prevalence of diabetes (RR = .947, 95% CI .917-.977; .0006), the primary care physician ratio (RR = .995, 95% CI .991-.998; P = .006), and percent uninsured adults (RR = .955, 95% CI .927-.985; P = .003). By multivariable hierarchical regression analysis, only the % rural remained statistically associated with a low SEI (RR = .995 per 1% increase in % rural, 95% CI = .992, .998; P = .0002). Discussion: The percent rural is the most significant predictor of disparities in access to bariatric surgery. For every 1% increase in % rural, the rate of surgery decreased by .5%. Understanding the characteristics of rurality that are barriers to access is crucial to mitigate disparities in bariatric surgical access in NC. [ABSTRACT FROM AUTHOR]

Introduction: The impact of socioeconomic inequalities on cancer care and outcomes has been well recognized and the underlying causes are likely multifactorial. Income is regarded as a cornerstone of socioeconomic status and has been assumed to correlate with access to care. We therefore sought to investigate whether income and changes in income would affect the rate of patients undergoing surgical resection for early-stage pancreatic cancer. Methods: Inflation-adjusted income data were obtained from the United States Census Bureau from 2010 to 2019. The cancer data were obtained from the SEER database. Counties present in both data sets were included in the analysis. Patients with stage I or II pancreatic cancer who underwent formal resection were deemed to have undergone appropriate surgical management. Patients were grouped into an early (2010-2014) and late (2015-2019) time period. Results: The final analysis included 23968 patients from 173 counties across 11 states. The resection rate was 45.1% for the entire study and rose from 42.8% to 47.4% from the early to late time periods (P < .001). The median change in income between the two time periods was an increase by $2387. The rate of resection was not dependent on income class or income change in our study population. Conclusion: Our surgical care of pancreatic cancer is improving with more patients undergoing resection. In addition, there are now fewer disparities between patients of lower-income and higher-income groups with respect to receiving surgical intervention. This implies that our access to care has improved over the past decade. This is an encouraging finding with regards to reducing health care disparities. [ABSTRACT FROM AUTHOR]

Objective Children and adolescents with rare diseases face significant barriers when accessing healthcare. We aimed to assess and predict these barriers and investigate associations with health-related quality of life (HRQoL). Method We conducted a cross-sectional survey of Swiss parents (N  =   189) of children with rare diseases including the Barriers to Care Questionnaire (BCQ), containing six barriers and the Pediatric Quality of Life Inventory (PedsQL). Latent profile analysis (LPA) was used to uncover distinct classes, which were compared using chi-square tests and Mann–Whitney U tests. Relevant medical and sociodemographic class predictors were identified using Elastic Net regression, followed by regression analysis to investigate their role in predicting barriers to care and examine the effects of these classes on HRQoL. Results Two distinct groups were identified, a higher barriers class (59%) and a lower barriers class (41%). In the higher barriers class, participants showed elevated scores across all subscales and specifically on pragmatics and expectations. More barriers to care were linked to a nonstable disease course (OR = 2.27, p  =  .002) and a diagnosis after the age of 3 months (OR = 2.17, p  =  .006). Individuals in the higher barriers class exhibited more psychological comorbidities (p  =  .044), congenital malformations/deformations/chromosomal abnormalities (p =.042), and medical misdiagnoses (p  =  .006). Children in the higher barriers class had significantly lower PedsQL scores compared to the lower barriers class (p  <.05). Conclusion This study highlights the need for comprehensive assessment of barriers to pediatric care in rare diseases, offering potential entry points for targeted interventions. [ABSTRACT FROM AUTHOR]

This exploratory study examined the impact of physical activity education on health-related quality of life (HRQoL) and the physical performance of women experiencing homelessness. Twenty-seven women experiencing homelessness and residing in two women's shelters participated in a four-week physical activity education program. The program consisted of education in physical activity and exercise, activity tracking with wrist fitness trackers, and weekly reflections on personal goals. During the last session, focus group discussions on future program structure and content were held. The women participating in the physical activity educational program saw no statistically significant difference in physically unhealthy days during the program as compared to the preceding month. Participants reported a significant decrease in the number of mentally unhealthy days following the intervention (Healthy Days Core Module (HDCM3) [r (26) = 0.57, p = 0.03]). The results of this pilot study suggest a positive connection between physical education programs and HRQoL for women experiencing homelessness. The focus group discussion provided insight into program strengths, challenges, and future opportunities. [ABSTRACT FROM AUTHOR]

Introduction: Chronic kidney disease (CKD) affects a significant portion of the UK population and is a pressing public health issue. Current screening methods have a low patient uptake rate. This retrospective study explores the patient experience of remote diagnostic screening. Objective: This article retrospectively analyses patient-reported experiences, focusing on at-home urinary screening to detect CKD. Intervention: Our primary care network commissioned a remote diagnostic service for adult patients with diabetes (Types I and II) who had not taken urinary albumin: creatinine ratio test within 12 months. Patients were provided with an at-home kit and guided by a smartphone application. Qualitative clinical data was collected during screening, with a questionnaire capturing patients' experiences. Impact: A total of 60% of eligible patients performed testing, and 35% were detected to have abnormal results. A total of 80% of patients preferred remote screening. Conclusions: This study provides evidence for remote CKD screening and opens avenues for innovation. Most patients reported a positive experience, underscoring the potential of this approach to improve health outcomes, especially in higher-risk populations. [ABSTRACT FROM AUTHOR]

Objective Data Sources and Study Setting Study Design Data Collection/Extraction Methods Principal Findings Conclusions To characterize the landscape of policies that determine eligibility for family planning services through Medicaid programs and describe trends in eligibility and its determinants over time.Secondary data were collected for all states in the United States for the years 2008 through 2023. Data on economic and demographic characteristics came from the American Community Survey (ACS).Our descriptive study characterized state adoptions of Medicaid family planning section 1115 waivers and state plan amendments (SPA) and their eligibility criteria. We then estimated the proportion of women aged 19–44 years who were eligible for family planning services through Medicaid and identified the key determinants of changes in eligibility, by state and year.Information on state Medicaid policies was extracted from documentation on the Centers for Medicare & Medicaid Services website. When estimating the eligible population sizes, the denominator was women aged 19–44 years, the group most likely to be eligible for Medicaid family planning programs. Supplemental data on program enrollment or utilization were collected from states' websites and reports.Though eligibility limits for family planning through Medicaid generally increased over time, the proportion of women aged 19–44 years eligible for at least limited benefits decreased from 45.0% in 2012 to 39.4% in 2022, largely because of increases in household income. Trends varied considerably across states and by eligibility pathway. Among women with incomes below the poverty level, the proportion who were not eligible for Medicaid family planning services decreased from 6.3% in 2013 to 1.5% in 2022.Our data demonstrated substantial geographic and temporal variation in eligibility for family planning services through Medicaid. We identified key drivers of eligibility changes that may have important implications for health services analyses of means‐tested public programs. [ABSTRACT FROM AUTHOR]

ABSTRACT Background Purpose Method Results Conclusion Extant literature on transgender and gender‐diverse (TGD) people living in the United States is centered on bicoastal metropolitan cities. Little is known about the health status and health‐related barriers among TGD people living in the middle of the country. Minority Stress Theory (MST) provides a framework for understanding how TGD people experience stressors that shape their health‐related experiences.To describe health‐related experiences of TGD people living in Colorado using the MST framework.The scoping review was limited to peer‐reviewed, English‐language studies published between January 2018 and November 2023. Data abstraction and synthesis were performed using Thomas and Harden's approach to thematic synthesis.Twenty‐one articles were included in the review. Seventeen (80.9%) articles were quantitative studies, two (9.5%) were qualitative, and two (9.5%) were mixed methods. Most of the participants were transfeminine and 18 years old or younger. Three themes emerged (1) TGD Coloradans experience multiple health‐related stressors, (2) these stressors contribute to poor health outcomes, and (3) overcome with coping strategies and/or social support.TGD Coloradans experience multiple stressors related to their TGD identity that shape their health‐related experiences. Nurses play a critical role in intervening in these stressors and addressing care disparities. [ABSTRACT FROM AUTHOR]

Objective Study Setting and Design Data Sources and Analytical Sample Principal Findings Conclusion To examine differences in access to care and financial burden between Traditional Medicare (TM) and Medicare Advantage (MA) beneficiaries in rural and urban areas and then explore whether there were potential differences in MA benefits between urban and rural areas.We conducted a cross‐sectional study within the Medicare setting in the United States.Data from three distinct sources for 2017–2021: the Medicare Current Beneficiary Survey, the MA landscape data, and the Plan Benefit Package data. Our sample comprised 43,343 Medicare beneficiary‐years, including TM and MA beneficiaries in urban and rural areas.Our adjusted analysis showed that rural MA beneficiaries experienced higher rates of delayed care due to costs (10.0% [95% confidence interval (CI): 8.8–11.1]) compared with rural TM (9.5% [8.8–10.2]), urban MA (7.9% [7.4–8.4]), and urban TM (7.9% [7.5–8.2]) beneficiaries. Similarly, rural MA beneficiaries (11.4% [95% CI: 10.3–12.5]) reported more difficulty paying medical bills compared with rural TM (9.4% [8.7–10.1]), urban MA (8.1% [7.7–8.6]), and urban TM (7.8% [7.5–8.2]) beneficiaries. This disparity was associated with less generous financial structures in rural MA plans. Compared to urban MA plans, rural MA plans offered lower out‐of‐pocket maximums for in‐network care ($5918 vs. $5439), but required higher copayments ($1686 vs. $1724 for a 5‐day hospitalization, $37 vs. $41 for a specialist visit, and $35 vs. $38 for a mental health visit). However, differences in quality of care and provision of supplemental benefits were small.Rural Medicare beneficiaries reported a greater financial burden of care than urban Medicare beneficiaries, but the most significant burden was observed among MA beneficiaries in rural areas. One possible mechanism could be the less generous financial structures offered by rural MA plans. These findings suggest the need for policies addressing the affordability of care for rural MA beneficiaries. [ABSTRACT FROM AUTHOR]

Assess dog owners' concern levels and veterinary care decisions pertaining to behaviors that might signify pain before and after receiving brief pain-related educational information. Additionally, evaluate dog owners' perceptions of a modified version of the Colorado State University Canine Acute Pain Scale to identify their dog's pain level, determine whether they should take their dog to the veterinarian, and describe their dog's pain to their veterinarian. SAMPLE 367 survey respondents who resided in the US and were the primary caretaker of at least 1 dog. METHODS An electronic survey was created in Qualtrics and distributed via Prolific. Data were analyzed. RESULTS When assessing differences between participants' concern levels before and after educational pain-related information, significant differences were found for 2 of the 3 scenarios. Significant differences were also found between participants' veterinary-related behaviors before and after educational pain-related information for all 3 scenarios. The most common reasons for not seeking immediate veterinary care included elements related to cost, convenience, and dog-related stress during veterinary visits. Most participants reported finding the Canine Acute Pain Scale useful for identifying their dog's pain level (89%), determining whether they should take their dog to the veterinarian (84%), and describing their dog's pain to their veterinarian (89%). CLINICAL RELEVANCE Owners' interpretations of and subsequent actions (or inactions) to behaviors that might suggest pain carry great implications for companion animals' overall well-being. Following exposure to brief educational material about signs and symptoms of canine pain, owners in our study reported significant increases in stated concern related to their dog's change in behavior and intention to seek veterinary care. These findings suggest that even very brief pain related educational material can have a positive impact on owners' perceptions of canine behavioral changes and increase the possibility that they will seek veterinary care. [ABSTRACT FROM AUTHOR]

The article "Leveraging Technology to Transform Sexual and Reproductive Health Services" in the Bangladesh Journal of Medical Science examines how technology, including telemedicine and mobile health apps, is reshaping the delivery of sexual and reproductive health services. It underscores the advantages of these innovations in enhancing access, care quality, and patient empowerment, while also addressing concerns about data privacy, digital literacy, and equity. The document delves into ethical considerations, disparities in digital access, and the significance of health equity in telemedicine and e-health services, emphasizing the need for collaboration among stakeholders for a safe and inclusive integration of technology in SRH services. [Extracted from the article]

Introduction: Transgender and gender diverse (TGD) people are disproportionately negatively impacted by gaps in several social determinants of health (SDH) domains. Methods: Using an SDH lens, this commentary leverages and reflects upon the expertise and experience of practitioners in the largest adult gender identity clinic in Canada providing services to TGD patients by facilitating access to gender-affirming healthcare. Results: Perceived needs across SDH domains, efforts to address these needs, and recommendations for improving services and increasing access for TGD patients are shared. Conclusion: We argue that addressing SDH needs is a necessary and critical component of both comprehensive primary and mental healthcare for TGD individuals in particular, given the inequity many of them face across SDH domains. [ABSTRACT FROM AUTHOR]

In the Brazilian Amazon, snakebite envenomations (SBEs) disproportionately affect Indigenous populations, and have a significantly higher incidence and lethality than in non‐Indigenous populations. This qualitative study describes the Indigenous and biomedical healthcare domains for SBE care from the perspective of the Indigenous medical and nursing students in Manaus, Western Brazilian Amazon. In‐depth interviews were conducted with five Indigenous students from the Amazonas State University, between January and December 2021. The interviews were analyzed using inductive content analysis. We organized an explanatory model with five themes: (1) participants' identities; (2) causality levels in Indigenous and biomedical systems; (3) therapeutic itineraries in Indigenous and biomedical systems; (4) ideological implications of adding biomedical devices to Indigenous healing systems; and (5) therapeutic failure in and efficacy of Indigenous and biomedical systems. From a noncolonial perspective and seeking to increase the quality and acceptability of health care for the Indigenous populations of the Brazilian Amazon, the training of Indigenous health professionals presents itself as a promising strategy. For this goal, universities should serve as empowering settings for Indigenous health students that support them in their growth and development, raise their awareness of injustice, and catalyze change toward a culturally adapted and effective service for the users. [ABSTRACT FROM AUTHOR]

Background Many patients present to their family medicine clinic with more than one health concern, placing an increased demand on family physicians. Research into the average number of concerns per regular family medicine visit is limited. Recognition of the frequency that family physicians address more than one concern per visit and adapting practices accordingly is important for improving patient care. Objective To examine whether family physicians routinely address multiple different patient concerns during a single visit and if this is influenced by patient demographics. Methods This study was conducted at a multi-physician family medicine clinic in Regina, Saskatchewan, Canada. Five physicians contributed their 500 most recent charts, extending retrospectively from 1 June 2023, from in-person visits by patients over 18 years of age and billed as regular appointments without billed procedures. Each chart was reviewed for the number of concerns addressed in the visit. Results Fifty percent of visits addressed more than 1 concern (range = 1–8). A generalized linear mixed model using Poisson distribution showed certain physicians (incident rate ratio [IRR]: 1.192, 95% CI: 1.087–1.307, P  < 0.001) and adults older than 65 years compared to adults less than 40 years (IRR 1.151, 95% CI: 1.069–1.239, P  < 0.001) were more likely to present with multiple concerns, but patient sex was not a significant predictor. Conclusions Family physicians routinely address more than one concern per visit. Standard visit length and billing practices should be adapted to reflect this complexity. [ABSTRACT FROM AUTHOR]

Background: Cervical cancer is the fourth most common cancer in women worldwide, and women with human immunodeficiency virus (HIV) are particularly at risk of developing it. Regular screening effectively prevents morbidity and mortality. This mixed-methods study quantitatively assessed cervical cancer screening uptake and qualitatively explored the process of undergoing cervical cancer screening to understand possible reasons for delayed screening among women with HIV in Lesotho. Methods: Between October 2020 and March 2022, the Viral load Triggered ART care in Lesotho (VITAL) trial enrolled women aged 18 years and older with HIV who were taking antiretroviral therapy (ART). Cervical cancer screening delay was defined as reporting a screening that occurred more than two years ago or never having been screened. Cervical cancer screening uptake and the association between screening delay and sociodemographic variables were assessed using a multivariable mixed-effects logistic regression model accounting for clustering at clinic level. In-depth interviews were conducted with 16 women to obtain information on awareness, perceptions, and barriers to cervical cancer screening and were analyzed using thematic analysis. Results: Quantitative data were available for 3790 women. Among them, cervical cancer screening was delayed in 1814 (47.9%), including 1533 (40.5%) who were never screened. Compared to women aged 25 to 39 years, women aged 18 to 24 years (adjusted odds ratio (aOR) 2.8; 95% confidence interval (CI) 2.1–3.7), women aged 40 to 59 years (aOR 1.3; CI 1.1–1.6), and women older than 60 years (aOR 3.9; CI 3.0-5.1) were at higher risk of screening delay. Furthermore, time on ART below 6 months (aOR 1.6; CI 1.1–2.3) compared to above 6 months was associated with screening delay. Qualitative data identified limited awareness of cervical cancer risks and screening guidelines, misconceptions and fears created by the influence of other women's narratives, and low internal motivation as the main barriers to screening uptake. Conclusions: Cervical cancer screening delay was common. Limited personal awareness and motivation as well as the negative influence of other women were the primary internal barriers to cervical cancer screening. Awareness and screening campaigns in Lesotho should consider these factors. Trial registration: clinicaltrials.gov, NCT04527874, August 27, 2020. [ABSTRACT FROM AUTHOR]

Pediatric home-based hospice and palliative care is a growing and important sub-field within the larger pediatric palliative care landscape. Despite research demonstrating the clinical and systemic efficacy of pediatric home-based hospice and palliative care, there remain barriers to its optimal development, implementation, and dissemination as well as best clinical practice knowledge gaps. This case series presents specific examples of ubiquitous challenges in pediatric home-based hospice and palliative care in hopes of guiding future research, education, advocacy, and program development efforts. [ABSTRACT FROM AUTHOR]

Objective: The aim of this study was to assess health insurance acquisition awareness, knowledge, and associated emotions among college students preparing to enter the workforce. Methods: A 21-item survey was developed to gather data on knowledge, awareness, and emotions associated with health insurance acquisition conversations with future employers. Results: Most respondents (91.1%), indicated they have thought about obtaining their own health insurance. The study found that participants rated acquiring health insurance more important the closer the respondent was to graduation; F(4,96) = 3.84, p =.006. An increase in stress emotions was indicated (F(4,96)=14.41, p =.000) and a reduction in positive emotions (F(4,96) = 2.99, p =.035) regarding health insurance acquisition post-graduation. Conclusions: College students identify low knowledge and indicate high levels of stress regarding health insurance conversations with future employers post-graduation. These findings are important for developing self-efficacy-based health education content preparing students for engaging in these conversations confidently and effectively. [ABSTRACT FROM AUTHOR]

Homelessness in the United States is a significant public health issue, with dermatologic disease being the most prevalent health concern among the undomiciled and sheltered populations. Despite a growing need for dermatologic care, the supply of dermatologists remains insufficient, contributing to disparities in healthcare access for this vulnerable group. This review aims to detail the spectrum of dermatologic conditions experienced by homeless individuals, identify barriers to adequate care, and explore teledermatology as a potential solution to bridge these gaps. A comprehensive literature review was conducted, analyzing studies and reports on dermatologic issues prevalent among the homeless population and the efficacy of teledermatology in addressing these concerns. Homeless individuals face a wide range of dermatologic problems, from common conditions like acne and eczema to severe issues such as cellulitis, leg ulcers, and skin cancer. Drug abuse, domestic and sexual abuse, and parasitic infestations further complicate the dermatologic health of this population. Teledermatology has emerged as a promising tool to enhance access to dermatologic care, showing significant improvements in clinical outcomes and accessibility, especially in underserved urban settings. However, challenges remain, such as the digital divide affecting the elderly and low-income populations, which could potentially exacerbate disparities. Addressing the dermatologic needs of the homeless population requires a multifaceted approach. Teledermatology offers a viable solution to improve care access and efficiency, but additional efforts are necessary to ensure inclusivity and avoid further marginalization. Volunteer-driven multidisciplinary clinics also play a crucial role in providing care, though they face challenges in continuity and resource availability. Future strategies should focus on integrating teledermatology with other supportive services to create a comprehensive care model for this underserved population. [ABSTRACT FROM AUTHOR]

Background: The purpose of this study was to evaluate potential predictors of no-shows and late cancellations in an outpatient clinic within a large healthcare system serving vulnerable communities. Methods: Demographic data and appointment status were recorded for 537 consecutive patients scheduled for neuropsychological evaluation in an outpatient psychiatry clinic. Patients include 220 males and 317 females with an average formal education of 11.01 years (SD = 3.87) and age of 55.64 years (SD = 16.20). Results: The overall rate of no-shows or late cancellations was 20%. Of the 106 patients who no-showed/late cancelled, 41% rescheduled, and of those, 23% missed or late cancelled their second appointment. No-shows and late cancellations were associated with historical/prior no-show rate, while race/ethnicity and activation of MyChart had slight impacts. Conclusions: These data suggest that prior no-show rates and MyChart access may be targets for interventions to improve show rates. This is important for the patients' gaining access to care as well as minimizing financial strains for the system and increasing wait times/delays to care for other patients. [ABSTRACT FROM AUTHOR]

The Health Resources and Services Administration's (HRSA) Health Center Program provides health care to vulnerable persons across theUS, regardless of their ability to pay for health care.We examined characteristics of populations living within and outside a 30-minute drive-time to HRSA-supported health centers to establish a baseline to better understand the differences in these populations. Using a descriptive, cross-sectional study design and geographic information systems, we found that 94% of persons in the US live within a 30-minute drive-time of a health center. Of those outside a 30-minute drive-time to a health center, 11.7 million (60.11%) are rural and over 1.5 million households (20.32%) lack broadband internet access. [ABSTRACT FROM AUTHOR]

Background: Dominant conceptualisations of access to health care are limited, framed in terms of speed and supply. The Candidacy Framework offers a more comprehensive approach, identifying diverse influences on how access is accomplished. Aim: To characterise how the Candidacy Framework can explain access to general practice — an increasingly fraught area of public debate and policy. Design and setting: Qualitative review guided by the principles of critical interpretive synthesis. Method: We conducted a literature review using an author-led approach, involving iterative analytically guided searches. Articles were eligible for inclusion if they related to the context of general practice, without geographical or time limitations. Key themes relating to access to general practice were extracted and synthesised using the Candidacy Framework. Results: A total of 229 articles were included in the final synthesis. The seven features identified in the original Candidacy Framework are highly salient to general practice. Using the lens of candidacy demonstrates that access to general practice is subject to multiple influences that are highly dynamic, contingent, and subject to constant negotiation. These influences are socioeconomically and institutionally patterned, creating risks to access for some groups. This analysis enables understanding of the barriers to access that may exist, even though general practice in the UK is free at the point of care, but also demonstrates that a Candidacy Framework specific to this setting is needed. Conclusion: The Candidacy Framework has considerable value as a way of understanding access to general practice, offering new insights for policy and practice. The original framework would benefit from further customisation for the distinctive setting of general practice. [ABSTRACT FROM AUTHOR]

Cincinnati Children's Hospital Medical Center (CCHMC) implemented a Genetic Counseling Clinic (GCC), where the appointment for a general genetics indication is conducted solely by a genetic counselor (GC). We conducted a retrospective chart review of 211 patient encounters scheduled in the GCC between January 1, 2022 and June 30, 2022 and collected patient demographics, wait time, appointment characteristics, referral indication, and clinical recommendations. To study impact on patient access, we compared patient demographics and appointment characteristics with 912 patient encounters scheduled in the General Genetics Clinic with a geneticist during the same time period. We found that there were not significant differences in patient demographics scheduled in the GCC as compared with the General Genetics Clinic with the exception of insurance type, where patients scheduled in the GCC were more likely to have private insurance. Patients scheduled in the GCC had a significantly shorter wait time, were more likely to complete their appointment, were more often new to the genetics division, and were more likely to be seen via telehealth (audio plus video or audio‐only) as compared with patients scheduled in the General Genetics Clinic. The most common indications for patients scheduled in the GCC were post‐test counseling (36.0%) followed by pre‐test counseling and coordination of testing (22.3%), and first‐line testing for autism, intellectual disability, and developmental delay (13.7%). Completed appointments in the GCC often resulted in the GC ordering genetic testing (67.5%). After genetic testing results were received, most patients (72.7%) did not require subsequent follow‐up with the genetics division, thereby reducing burden to the medical genetics team. Our GCC increased access to genetic services and allowed GCs and clinical geneticists to better work at the top of their scope of practice. [ABSTRACT FROM AUTHOR]

Black men in the United States have higher rates of prostate cancer and worse outcomes compared to White men. The causes of these disparities have been debated, with some attributing them to genetic and biological differences ("nature") and others to environmental factors ("nurture"). Recent research suggests that both factors contribute to the disparities. Biological differences include genetic and chromosomal variations, differences in signaling pathways, and other factors such as immunobiology and epigenetics. However, access-related issues and systemic racism also play a significant role in the disparities. When access to care is equalized, Black men have similar or better outcomes compared to White men. Efforts to address these disparities include targeted treatments based on biological differences and improving access to care through legislative changes, provider education, and community outreach. While progress has been made, there is still work to be done to further improve outcomes for Black men with prostate cancer. [Extracted from the article]

Native Hawaiians and Pacific Islanders (NHPIs) are peoples diverse in culture and history who are too often represented as a monolithic entity, a tendency that undermines efforts to ameliorate health inequities. The current study represents a partnership between academic researchers and a community organization serving NHPIs, in which space was held for five multigenerational NHPI families (N = 15 family members) to share their experiences with educational and healthcare systems, including issues of discrimination and barriers to accessing services. Qualitative analysis of the interviews identified four themes: Cultural Values and Strengths; Mental Health—Past, Present, and Future Directions; Systemic Racism and Discrimination; and Need for Culturally Informed and Linguistically Accessible Healthcare. These results, including the importance of family systems within NHPI cultures, positive intergenerational shifts in mental health, and the pervasive impacts of colonization on health, are discussed in terms of implications for the health of NHPI communities. [ABSTRACT FROM AUTHOR]

Individually, the COVID-19 and HIV pandemics have differentially impacted minoritized groups due to the role of social determinants of health (SDoH) in the U.S. Little is known how the collision of these two pandemics may have exacerbated adverse health outcomes. We evaluated county-level SDoH and associations with hospitalization after a COVID-19 diagnosis among people with (PWH) and without HIV (PWOH) by racial/ethnic groups. We used the U.S. National COVID Cohort Collaborative (January 2020-November 2023), a nationally-sampled electronic health record repository, to identify adults who were diagnosed with COVID-19 with HIV (n = 22,491) and without HIV (n = 2,220,660). We aggregated SDoH measures at the county-level and categorized racial/ethnic groups as Non-Hispanic (NH) White, NH-Black, Hispanic/Latinx, NH-Asian and Pacific Islander (AAPI), and NH-American Indian or Alaskan Native (AIAN). To estimate associations of county-level SDoH with hospitalization after a COVID-19 diagnosis, we used multilevel, multivariable logistic regressions, calculating adjusted relative risks (aRR) with 95% confidence intervals (95% CI). COVID-19 related hospitalization occurred among 11% of PWH and 7% of PWOH, with the highest proportion among NH-Black PWH (15%). In evaluating county-level SDoH among PWH, we found higher average household size was associated with lower risk of COVID-19 related hospitalization across racial/ethnic groups. Higher mean commute time (aRR: 1.76; 95% CI 1.10–2.62) and higher proportion of adults without health insurance (aRR: 1.40; 95% CI 1.04–1.84) was associated with a higher risk of COVID-19 hospitalization among NH-Black PWH, however, NH-Black PWOH did not demonstrate these associations. Differences by race and ethnicity exist in associations of adverse county-level SDoH with COVID-19 outcomes among people with and without HIV in the U.S. [ABSTRACT FROM AUTHOR]

Abstract Background Coronary artery angiography (CAG) and percutaneous coronary intervention (PCI) are superior to non-invasive approaches in reducing mortality in patients with ST-segment elevation myocardial infarction (STEMI). However, their efficacy remains uncertain in non-ST-elevation acute coronary syndromes (NSTE-ACS) and limited in low-resource settings. This study aimed to compare in-hospital and 5-year mortality rates between patients with a first event of STEMI and NSTE-ACS who underwent CAG and PCI and those with similar severity who did not undergo CAG and PCI. Methods A propensity-matched retrospective cohort study was conducted using population-based claims data of national universal coverage of Thailand for identification of patients with acute coronary syndromes. The mortality of recruited patients was additionally linked to the national database of vital registration. Patients aged ≥ 40 years who were hospitalized for STEMI and NSTE-ACS in 2017, with a focus on access to CAG and PCI were included. For each condition either STEMI or NSTE-ACS, patients who underwent CAG and PCI were matched to those who did not undergo using propensity score matching (PSM) to balance measured confounders, such as age, sex, and underlying conditions. In-hospital mortality rate ratio and 5-year mortality were analyzed as measures. Results Through PSM, 2,702 non-intervention STEMI patients were paired with an equal number of intervention patients, and similarly, 5,072 non-intervention NSTE-ACS patients were matched with an equivalent group who received interventions. For patients with STEMI, the in-hospital mortality rate ratio (95% confidence interval (CI)) for those who underwent CAG and PCI compared to those who did not was 30.1% (30.0%, 30.2%). Similar trends were observed in patients with NSTE-ACS with a mortality rate of 34.7% (34.6%, 34.8%). For the five-year mortality comparison, the hazard ratios (95% CI) of mortality after discharge were 0.55 (0.50, 0.62) for STEMI and 0.57 (0.54, 0.61) for NSTE-ACS cases. Conclusions Access to CAG and PCI was significantly associated with lower in-hospital and 5-year mortality rates in patients who experienced their first event of ACS, despite the limited availability of some unmeasured or residual confounders. Healthcare systems should expand their resources for CAG and PCI in Thailand and other countries to equitably enhance longevity.

Abstract Background Stigma and discrimination towards people with mental health conditions by their communities are common worldwide. This can result in a range of negative outcomes for affected persons, including poor access to health care. However, evidence is still patchy from low- and middle-income countries (LMICs) on affordable, community-based interventions to reduce mental health-related stigma and to improve access to mental health care. Methods This study aims to conduct a feasibility (proof-of-principle) pilot study that involves developing, implementing and evaluating a community-based, multi-component, awareness-raising intervention (titled Indigo-Local), designed to reduce stigma and discrimination and to increase referrals of people with mental health conditions for assessment and treatment. It is being piloted in seven sites in five LMICs—China, Ethiopia, India, Nepal and Tunisia—and includes several key components: a stakeholder group workshop; a stepped training programme (using a ‘Training of Trainers’ approach) of community health workers (or similar cadres of workers) and service users that includes repeated supervision and booster sessions; community engagement activities; and a media campaign. Social contact and service user involvement are instrumental to all components. The intervention is being evaluated through a mixed-methods pre-post study design that involves quantitative assessment of stigma outcomes measuring knowledge, attitudes and (discriminatory) behaviour; quantitative evaluation of mental health service utilization rates (optional, where feasible in sites); qualitative exploration of the potential effectiveness and impact of the Indigo-Local intervention; a process evaluation; implementation evaluation; and an evaluation of implementation costs. Discussion The output of this study will be a contextually adapted, evidence-based intervention to reduce mental health-related stigma in local communities in five LMICs to achieve improved access to healthcare. We will have replicable models of how to involve people with lived experience as an integral part of the intervention and will produce knowledge of how intervention content and implementation strategies vary across settings. The intervention and its delivery will be refined to be feasible and ready for larger-scale implementation and evaluation. This study thereby has the potential to make an important contribution to the evidence base on what works to reduce mental health-related stigma and discrimination and improve access to health care.

Abstract Background African, Caribbean, and Black im/migrant women experience a disproportionate burden of HIV relative to people born in Canada, yet there is scarce empirical evidence about the social and structural barriers that influence access to HIV care. The objectives of this study is to estimate associations between African, Caribbean, and Black background and stigma and non-consensual HIV disclosure outcomes, and to understand how experiences of stigma and im/migration trajectories shape access to HIV care and peer supports among African, Caribbean, and Black im/migrant women living with HIV in Canada. Methods This mixed-methods analysis draws on interviewer-administered questionnaires and semi-structured interviews with self-identifying African, Caribbean, and Black women living with HIV in the community-based SHAWNA (Sexual Health and HIV/AIDS: Women’s Longitudinal Needs Assessment) cohort. Bivariate and multivariable logistic regression using generalized estimating equations (GEE) were performed to estimate associations between African, Caribbean, and Black background and stigma and non-consensual HIV disclosure outcomes. Drawing on a social and structural determinants of health framework, qualitative analysis of interviews elucidated the interplay between migration trajectories, stigma, racialization, and HIV. Results Amongst our participants (n = 291), multivariable GEE analysis revealed that African, Caribbean, and Black participants (n = 15) had significantly higher odds of recently being outed without consent as living with HIV (AOR 2.34, 95% CI 0.98–5.57). Additionally, African, Caribbean, and Black participants had higher odds of recent verbal or physical abuse due to their HIV status (AOR 2.11, 95% CI 0.65–6.91). Reflecting on their im/migration trajectories, participants’ narratives (n = 9) highlighted experiences of political violence and conflict, trauma, stigma, and discrimination associated with HIV in their place of origin and the racialization and stigmatization of HIV in Canada. Fear of disclosure without consent was linked to barriers of accessing care and peer-based supports. Conclusion Our findings indicate that im/migration trajectories of African, Caribbean, and Black women living with HIV are critically related to accessing HIV care and supports in Canada and compound HIV stigma and discrimination. HIV disclosure without consent complicates access to care and social/peer support, underscoring the need for privacy, confidentiality, and the importance of building trust in the context of clinical encounters. The results of this study emphasize the critical need for culturally sensitive trauma-informed care models rooted in peer-based approaches.

Despite the considerable global burden of urologic malignancies, Low- and middle-income countries (LMICs) often encounter significant challenges in caring for patients with urologic malignancies. Several interrelated factors impact cancer care in LMICs, which face significant challenges that hinder effective diagnosis, treatment, and management of disease. Socioeconomic and healthcare infrastructure limitations are fundamental issues leading to the disparity observed in cancer care across the globe. This review aims to evaluate the challenges and disparities in access to comprehensive urologic care in LMICs, emphasizing the impact of such global disparities on incidence rates, timely diagnoses, and access to comprehensive care as it relates to prostate, kidney, and bladder cancers.

Abstract Background Cervical cancer is the fourth most common cancer in women worldwide, and women with human immunodeficiency virus (HIV) are particularly at risk of developing it. Regular screening effectively prevents morbidity and mortality. This mixed-methods study quantitatively assessed cervical cancer screening uptake and qualitatively explored the process of undergoing cervical cancer screening to understand possible reasons for delayed screening among women with HIV in Lesotho. Methods Between October 2020 and March 2022, the Viral load Triggered ART care in Lesotho (VITAL) trial enrolled women aged 18 years and older with HIV who were taking antiretroviral therapy (ART). Cervical cancer screening delay was defined as reporting a screening that occurred more than two years ago or never having been screened. Cervical cancer screening uptake and the association between screening delay and sociodemographic variables were assessed using a multivariable mixed-effects logistic regression model accounting for clustering at clinic level. In-depth interviews were conducted with 16 women to obtain information on awareness, perceptions, and barriers to cervical cancer screening and were analyzed using thematic analysis. Results Quantitative data were available for 3790 women. Among them, cervical cancer screening was delayed in 1814 (47.9%), including 1533 (40.5%) who were never screened. Compared to women aged 25 to 39 years, women aged 18 to 24 years (adjusted odds ratio (aOR) 2.8; 95% confidence interval (CI) 2.1–3.7), women aged 40 to 59 years (aOR 1.3; CI 1.1–1.6), and women older than 60 years (aOR 3.9; CI 3.0-5.1) were at higher risk of screening delay. Furthermore, time on ART below 6 months (aOR 1.6; CI 1.1–2.3) compared to above 6 months was associated with screening delay. Qualitative data identified limited awareness of cervical cancer risks and screening guidelines, misconceptions and fears created by the influence of other women’s narratives, and low internal motivation as the main barriers to screening uptake. Conclusions Cervical cancer screening delay was common. Limited personal awareness and motivation as well as the negative influence of other women were the primary internal barriers to cervical cancer screening. Awareness and screening campaigns in Lesotho should consider these factors. Trial registration clinicaltrials.gov, NCT04527874, August 27, 2020.

BACKGROUND: Literature evaluating the management of abnormal uterine bleeding in premenopausal patients prior to endometrial malignancy diagnosis is lacking. OBJECTIVE: To evaluate predictors and consequences of inadequate evaluation and management of abnormal uterine bleeding and time to endometrial sampling in premenopausal patients prior to endometrial malignancy diagnosis.Study Design.This was a retrospective cohort study of premenopausal individuals with endometrioid endometrial cancer or atypical hyperplasia at a single institution from 2015 to 2020.. Complete noninvasive management encompassed pelvic exam, ultrasound, and progestin treatment before or in conjunction with the endometrial sampling of diagnosis. Multivariable logistic and ordinal odds models were used to evaluate predictors and outcomes. RESULTS: 152 subjects were included, 80.3 % with cancer and 19.7 % with atypical hyperplasia. The majority of patients had anovulatory bleeding, obesityand recent health care. Only 20.4 % had complete nonvinvasive management, and only 12.5 % had complete noninvasive management or endometrial sampling within 2 months of presentation with abnormal bleeding. Class III obesity reduced the likelihood of complete assessment and increased time to sampling, while age 45 and up and parity reduced time to sampling. Most patients had partial workup but no progestin treatment and long intervals before endometrial sampling after presentation to a provider with abnormal bleeding. Incomplete workup correlated to worse cancer grade and stage. CONCLUSION: Despite high clinical risk and health care contact, most patients had insufficient gynecologic management preceding a diagnosis of endometrial malignancy. Inadequate care correlated to worse oncologic outcomes and demonstrates missed opportunities for early detection and prevention of endometrial cancer.

PURPOSE: Telemedicine care dramatically expanded during the COVID-19 pandemic. We characterized facilitators and barriers to telemedicine implementation among safety-net primary care clinics serving patients with limited English proficiency (LEP). METHODS: We collected data on telemedicine volume and patient demographics among safety-net clinics participating in a telemedicine learning collaborative. Data on various metrics were reported to the collaborative from February 2019 through August 2021. We conducted semi-structured interviews with clinical and quality leaders, purposively sampling clinics serving high proportions of patients with LEP. We analyzed interviews with a mixed inductive-deductive approach applying the Consolidated Framework for Implementation Research. RESULTS: By September 2020, the 23 sites served 121,589 unique patients with in-person and 120,338 with telephone visits; 47% of these patients had LEP. Of 10,897 unique patients served by video visits, 38% had LEP. As a proportion of total visits, telemedicine (telephone and video) visits increased from 0-17% in October 2019-March 2020 to 10-98% in March-August 2020. We conducted 14 interviews at 11 sites. Themes included (1) existing telemedicine platforms and interpreter services were not optimized to support patients with LEP; (2) clinics invested significant labor iterating workflows; (3) sites with technological infrastructure and language-concordant staff were best suited to serve patients; (4) patients speaking less-represented languages or experiencing intersecting literacy barriers were underserved with telemedicine. Interviewees recommended innovations in telemedicine platforms and community-based access. CONCLUSIONS: Safety-net sites relied on existing resources to accommodate patients with LEP, but struggled providing access for the most marginalized. Proactive, data-driven strategies to address patient and community barriers as well as optimize clinical workflows with high-quality, certified medical interpreters are needed to ensure equitable access.

Background and Objectives: Evidence indicates significant disparities in access to health care for immigrants, but few studies have focused on changes in patterns of access to care by immigration status over time. We examined patterns of change in access and health indicators before and after the Affordable Care Act (ACA) for the undocumented and compared to US-born, naturalized, and documented residents. Methods: We examined indicators of usual source of care, service use, delays and self-reported health from 2005 to 2018 using a California Health Interview Survey sample of non-elderly adults (n = 207,652). We used multinomial and logistic regression models to assess changes in access and health status within each immigration category and across ACA periods. Results: From early- to post-ACA periods, we found a widening gap in insurance coverage of undocumented vs. US-born residents, and a shift toward use of public settings as usual source of care for both groups. From the pre- to early-ACA periods, there was a greater reduction of delayed medical care, and an increase in any mental health visits for US-born vs. undocumented residents. Discussion: Findings portend exacerbation of disparities in access for undocumented residents due to the economic consequences of events such as the pandemic and continued exclusion of undocumented residents from federally-funded coverage. [ABSTRACT FROM AUTHOR]

Abstract Background Many older people from minority ethnic groups experience inequalities towards the end of life, including barriers to accessing palliative care. With levels of international migration increasing, there is a need to understand these differences and consider the needs of minority ethnic groups in healthcare policies. This review aimed to map evidence on how older people from minority ethnic groups access and utilise palliative and end of life care, preferences for palliative and end of life care, experiences of palliative and end of life care, and how this varies between minority ethnic groups in different countries, and with different health conditions. Methods Scoping review, following Joanna Briggs Institute (JBI) guidance. Searches of eight online databases (MEDLINE, Embase, Web of Science, CINAHL, PsycInfo, Assia, Scopus, and the Cochrane Library) and grey literature were undertaken in 2024. Qualitative sources that focused on older people from minority ethnic groups’ and carers’ access to and use of palliative and end of life care were included, as well as those focusing on healthcare professionals’ experiences. Results Twenty-three sources were included in the review, the majority of which were interview studies from the USA. Findings reflect a range of preferences, inequalities, facilitators and barriers to accessing palliative and end of life care, with themes relating to: (1) Knowledge of hospice and palliative care, (2) societal and structural issues, (3) language and health literacy, (4) migratory experiences, (5) trust in healthcare services and professionals, (6) religion and hope, and (7) cultural values. Conclusions This review identified areas for healthcare providers to consider developing more culturally appropriate palliative and end of life care practice, including building trust and improving communication, sharing information, reducing language barriers, addressing stigma, and, if relevant, acknowledging the importance of culture and religion. Further qualitative research from an intersectional perspective, such as geographical location or socio-economic status, rather than race, ethnicity, and culture alone, is needed in more diverse geographical settings and on specific health conditions.

Abstract Background Ambulatory access to academic medical centers (AMCs) for patients insured with Medi-Cal (i.e., Medicaid in California) is understudied, particularly among the 85% of beneficiaries enrolled in managed care plans. As more AMCs develop partnerships with these plans, data on patient experiences of access to care and quality are needed to guide patient-centered improvements in care delivery. Methods The authors conducted semi-structured, qualitative interviews with Medi-Cal-insured patients with initial visits at a large, urban AMC during 2022. Participant recruitment was informed by a database of ambulatory Medi-Cal encounters. The interview guide covered Medi-Cal enrollment, scheduling, and visit experience. Interviews were transcribed and inductively coded, then organized into themes across four domains: access, affordability, patient-provider interactions, and continuity. Results Twenty participant interviews were completed (55% female, 85% English speaking, 80% self-identified minority or “other” race, and 30% Hispanic or Latino) with primary and/or specialty care visits. Within the access domain, participants reported delays with Medi-Cal enrollment and access to specialist care or testing, though appointment scheduling was reported to be easy. Affordability concerns included out-of-pocket medical and parking costs, and missed income when patients or families skipped work to facilitate care coordination. Participants considered clear, bilateral communication with providers fundamental to positive patient-provider interactions. Some participants perceived discrimination by providers based on their insurance status. Participants valued continuity, but experienced frustration arising from frequent and unexpected health plan changes that disrupted care with their established AMC providers. Conclusions The missions of AMCs typically focus on clinical care, education, research, and equity. However, reports from Medi-Cal insured patients receiving care at AMCs highlight their stress and confusion related to inconsistent provider access, uncompensated costs, variability in perceptions of quality, and fragmented care. Recommendations based upon patient-reported concerns suggest opportunities for AMC health system-level improvements that are compatible with AMC missions.

Abstract Background Many patients with post COVID-19 condition (PCC) require healthcare services. However, qualitative studies indicate that patients with PCC encounter many barriers to healthcare access. This cross-sectional study aimed to determine how many PCC patients report barriers to healthcare access and which barriers are reported, and to explore differences between subgroups. Methods Data were collected via an online survey from 10,462 adult patients with a confirmed or suspected COVID-19 infection in the Netherlands, who experienced persisting symptoms ≥ 3 months after the initial infection. To study self-perceived barriers, a list of eleven possible barriers was used, covering multiple aspects of healthcare access. Differences between subgroups based on sociodemographic characteristics, medical characteristics, PCC symptoms (fatigue, dyspnoea, cognitive problems, anxiety and depression), and healthcare use (general practitioner, paramedical professional, medical specialist, occupational physician and mental health professional) were studied through multivariable multinomial (0 vs. 1 vs. > 1 barrier) and binomial regression analyses (for each individual barrier). Results A total of 83.2% of respondents reported at least one barrier to healthcare access. Respondents reported a median of 2.0 (IQR = 3.0) barriers. The barriers “I didn’t know who to turn to for help” (50.9%) and “No one with the right knowledge/skills was available” (36.8%) were most frequently reported. Respondents with younger age, higher educational level, not hospitalized during acute COVID-19 infection, longer disease duration, who had more severe PCC symptoms, and who did not consult an occupational physician or paramedical professional, were more likely to report barriers. Analyses per barrier showed that women were more likely to report financial and help-seeking barriers, while men were more likely to report barriers related to availability of care. Hospitalized respondents were less likely to report barriers related to availability of care, but not less likely to report financial or help-seeking barriers. Conclusions This study shows that the majority of patients with PCC experiences barriers to healthcare access. Particular attention should be paid to younger, non-hospitalized patients with a long disease duration and severe PCC symptoms. Efforts to remove barriers should focus not only on improving availability of care, but also on helping patients navigate care pathways.