The Link Between Everyday Discrimination, Healthcare Utilization, and Health Status Among a National Sample of Women

Background: Research has not adequately examined the potential negative effects of perceiving routine discrimination on general healthcare utilization or health status, especially among reproductive-aged women. We sought to evaluate the association between everyday discrimination, health service use, and perceived health among a national sample of women in the United States. Materials and Methods: Data were drawn from the Women's Healthcare Experiences and Preferences survey, a randomly selected, national probability sample of 1078 U.S. women aged 18?55 years. We examined associations between everyday discrimination (via a standardized scale) on frequency of health service utilization and perceived general health status using chi-square and multivariable logistic regression modeling. Results: Compared with women who reported healthcare visits every 3 years or less (reference group), each one-point increase in discrimination score was associated with higher odds of having healthcare visits annually or more often (odds ratio [OR]?=?1.36, confidence interval [95% CI]?=?1.01?1.83). Additionally, each one-point increase in discrimination score was significantly associated with lower odds of having excellent/very good perceived health (OR?=?0.65; 95% CI?=?0.54?0.80). Conclusion: Perceived discrimination was associated with increased exposure to the healthcare setting among this national sample of women. Perceived discrimination was also inversely associated with excellent/very good perceived health status.Peer Reviewedhttps://deepblue.lib.umich.edu/bitstream/2027.42/140141/1/jwh.2015.5522.pd

Group Versus Individual Physical Therapy for Veterans With Knee Osteoarthritis: Randomized Clinical Trial

BACKGROUND: Efficient approaches are needed for delivering nonpharmacological interventions for management of knee osteoarthritis (OA). OBJECTIVE: This trial compared group-based versus individual physical therapy interventions for management of knee OA. DESIGN AND METHODS: Three hundred twenty patients with knee OA at the VA Medical Center in Durham, North Carolina, (mean age=60 years, 88% male, 58% nonwhite) were randomly assigned to receive either the group intervention (group physical therapy; six 1-hour sessions, typically 8 participants per group) or the individual intervention (individual physical therapy; two 1-hour sessions). Both programs included instruction in home exercise, joint protection techniques, and individual physical therapist evaluation. The primary outcome measure was the Western Ontario and McMaster Universities Osteoarthritis Index (WOMAC; range=0-96, higher scores indicate worse symptoms), measured at baseline, 12 weeks, and 24 weeks. The secondary outcome measure was the Short Physical Performance Battery (SPPB; range=0-12, higher scores indicate better performance), measured at baseline and 12 weeks. Linear mixed models assessed the difference in WOMAC scores between arms. RESULTS: At 12 weeks, WOMAC scores were 2.7 points lower in the group physical therapy arm compared with the individual physical therapy arm (95% confidence interval [CI]-5.9, 0.5; P=.10), indicating no between-group difference. At 24 weeks, WOMAC scores were 1.3 points lower in the group physical therapy arm compared with the individual physical therapy arm (95% CI-4.6, 2.0; P=.44), indicating no significant between-group difference. At 12 weeks, SPPB scores were 0.1 points lower in the group physical therapy arm compared with the individual physical therapy arm (95% CI-0.5, 0.2; P=.53), indicating no difference between groups. LIMITATIONS: This study was conducted in one VA medical center. Outcome assessors were blinded, but participants and physical therapists were not blinded. CONCLUSIONS: Group physical therapy was not more effective than individual physical therapy for primary and secondary study outcomes. Either group physical therapy or individual physical therapy may be a reasonable delivery model for health care systems to consider

Racial/ethnic and educational inequities in restrictive abortion policy variation and adverse birth outcomes in the United States

Background To examine racial/ethnic and educational inequities in the relationship between state-level restrictive abortion policies and adverse birth outcomes from 2005 to 2015 in the United States. Methods Using a state-level abortion restrictiveness index comprised of 18 restrictive abortion policies, we conducted a retrospective longitudinal analysis examining whether race/ethnicity and education level moderated the relationship between the restrictiveness index and individual-level probabilities of preterm birth (PTB) and low birthweight (LBW). Data were obtained from the 2005–2015 National Center for Health Statistics Period Linked Live Birth-Infant Death Files and analyzed with linear probability models adjusted for individual- and state-level characteristics and state and year fixed-effects. Results Among 2,250,000 live births, 269,253 (12.0%) were PTBs and 182,960 (8.1%) were LBW. On average, states had approximately seven restrictive abortion policies enacted from 2005 to 2015. Black individuals experienced increased probability of PTB with additional exposure to restrictive abortion policies compared to non-Black individuals. Similarly, those with less than a college degree experienced increased probability of LBW with additional exposure to restrictive abortion policies compared to college graduates. For all analyses, inequities worsened as state environments grew increasingly restrictive. Conclusion Findings demonstrate that Black individuals at all educational levels and those with fewer years of education disproportionately experienced adverse birth outcomes associated with restrictive abortion policies. Restrictive abortion policies may compound existing racial/ethnic, socioeconomic, and intersecting racial/ethnic and socioeconomic perinatal and infant health inequities

STepped exercise program for patients with knee OsteoArthritis (STEP-KOA): protocol for a randomized controlled trial

Background: Physical therapy (PT) and other exercise-based interventions are core components of care for knee osteoarthritis (OA), but both are underutilized, and some patients have limited access to PT services. This clinical trial is examining a STepped Exercise Program for patients with Knee OsteoArthritis (STEP-KOA). This model of care can help to tailor exercise-based interventions to patient needs and also conserve higher resource services (such as PT) for patients who do not make clinically relevant improvements after receiving less costly interventions. Methods / Design: Step-KOA is a randomized trial of 345 patients with symptomatic knee OA from two Department of Veterans Affairs sites. Participants are randomized to STEP-KOA and Arthritis Education (AE) Control groups with a 2:1 ratio, respectively. STEP-KOA begins with 3 months of access to an internet-based exercise program (Step 1). Participants not meeting response criteria for clinically meaningful improvement in pain and function after Step 1 progress to Step 2, which involves bi-weekly physical activity coaching calls for 3 months. Participants not meeting response criteria after Step 2 progress to in-person PT visits (Step 3). Outcomes will be assessed at baseline, 3, 6 and 9 months (primary outcome time point). The primary outcome is the Western Ontario and McMasters Universities Osteoarthritis Index (WOMAC), and secondary outcomes are objective measures of physical function. Linear mixed models will compare outcomes between the STEP-KOA and AE control groups at follow-up. We will also evaluate patient characteristics associated with treatment response and conduct a cost-effectiveness analysis of STEP-KOA. Discussion: STEP-KOA is a novel, efficient and patient-centered approach to delivering exercise-based interventions to patients with knee OA, one of the most prevalent and disabling health conditions. This trial will provide information on the effectiveness of STEP-KOA as a novel potential model of care for treatment of OA

System-level factors influencing refugee women's access and utilization of sexual and reproductive health services: A qualitative study of providers’ perspectives

Refugee women have poor outcomes and low utilization of sexual and reproductive health (SRH) services, which may be driven by access to and quality of SRH services at their resettled destinations. While healthcare providers offer valuable insights into these topics, little research has explored United States (U.S.) providers' experiences. To fill this literature gap, we investigate U.S. providers' perspectives of healthcare system-related factors influencing refugee women's access and utilization of SRH services. Between July and December 2019, we conducted in-depth, semi-structured interviews with 17 providers serving refugee women in metropolitan Atlanta in the state of Georgia (United States). We used convenience and snowball sampling for recruitment. We inquired about system-related resources, facilitators, and barriers influencing SRH services access and utilization. Two coders analyzed the data using a qualitative thematic approach. We found that transportation availability was crucial to refugee women's SRH services access. Providers noted a tension between refugee women's preferred usage of informal interpretation assistance (e.g., family and friends) and healthcare providers’ desire for more formal interpretation services. Providers reported a lack of funding and human resources to offer comprehensive SRH services as well as several challenges with using a referral system for women to get SRH care in other systems. Culturally and linguistically-concordant patient navigators were successful at helping refugee women navigate the healthcare system and addressing language barriers. We discussed implications for future research and practice to improve refugee women's SRH care access and utilization. In particular, our findings underscore multilevel constraints of clinics providing SRH care to refugee women and highlight the importance of transportation services and acceptable interpretation services. While understudied, the use of patient navigators holds potential for increasing refugee women's SRH care access and utilization. Patient navigation can both effectively address language-related challenges for refugee women and help them navigate the healthcare system for SRH. Future research should explore organizational and external factors that can facilitate or hinder the implementation of patient navigators for refugee women's SRH care

Host Genetic Factors and Vaccine-Induced Immunity to HBV Infection: Haplotype Analysis

Hepatitis B virus (HBV) infection remains a significant health burden world-wide, although vaccines help decrease this problem. We previously identified associations of single nucleotide polymorphisms in several candidate genes with vaccine-induced peak antibody level (anti-HBs), which is predictive of long-term vaccine efficacy and protection against infection and persistent carriage; here we report on a haplotype-based analysis. A total of 688 SNPs from 117 genes were examined for a two, three and four sliding window haplotype analysis in a Gambian cohort. Analysis was performed on 197 unrelated individuals, 454 individuals from 174 families, and the combined sample (N = 651). Global and individual haplotype association tests were carried out (adjusted for covariates), employing peak anti-HBs level as outcome. Five genes (CD44, CD58, CDC42, IL19 and IL1R1) had at least one significant haplotype in the unrelated or family analysis as well as the combined analysis. Previous single locus results were confirmed for CD44 (combined global p = 9.1×10−5 for rs353644-rs353630-rs7937602) and CD58 (combined global p = 0.008 for rs1414275-rs11588376-rs1016140). Haplotypes in CDC42, IL19 and IL1R1 also associated with peak anti-HBs level. We have identified strong haplotype effects on HBV vaccine-induced antibody level in five genes, three of which, CDC42, IL19 and IL1R1, did not show evidence of association in a single SNP analyses and corroborated the majority of these effects in two datasets. The haplotype analysis identified associations with HBV vaccine-induced immunity in several new genes

Study protocol for the Innovative Support for Patients with SARS-COV-2 Infections Registry (INSPIRE): A longitudinal study of the medium and long-term sequelae of SARS-CoV-2 infection

Background: Reports on medium and long-term sequelae of SARS-CoV-2 infections largely lack quantification of incidence and relative risk. We describe the rationale and methods of the Innovative Support for Patients with SARS-CoV-2 Registry (INSPIRE) that combines patient-reported outcomes with data from digital health records to understand predictors and impacts of SARS-CoV-2 infection. Methods: INSPIRE is a prospective, multicenter, longitudinal study of individuals with symptoms of SARS-CoV-2 infection in eight regions across the US. Adults are eligible for enrollment if they are fluent in English or Spanish, reported symptoms suggestive of acute SARS-CoV-2 infection, and if they are within 42 days of having a SARS-CoV-2 viral test (i.e., nucleic acid amplification test or antigen test), regardless of test results. Recruitment occurs in-person, by phone or email, and through online advertisement. A secure online platform is used to facilitate the collation of consent-related materials, digital health records, and responses to self-administered surveys. Participants are followed for up to 18 months, with patient-reported outcomes collected every three months via survey and linked to concurrent digital health data; follow-up includes no in-person involvement. Our planned enrollment is 4,800 participants, including 2,400 SARS-CoV-2 positive and 2,400 SARS-CoV-2 negative participants (as a concurrent comparison group). These data will allow assessment of longitudinal outcomes from SARS-CoV-2 infection and comparison of the relative risk of outcomes in individuals with and without infection. Patient-reported outcomes include self-reported health function and status, as well as clinical outcomes including health system encounters and new diagnoses. Results: Participating sites obtained institutional review board approval. Enrollment and follow-up are ongoing. Conclusions: This study will characterize medium and long-term sequelae of SARS-CoV-2 infection among a diverse population, predictors of sequelae, and their relative risk compared to persons with similar symptomatology but without SARS-CoV-2 infection. These data may inform clinical interventions for individuals with sequelae of SARS-CoV-2 infection

Factors Associated with Revision Surgery after Internal Fixation of Hip Fractures

Background: Femoral neck fractures are associated with high rates of revision surgery after management with internal fixation. Using data from the Fixation using Alternative Implants for the Treatment of Hip fractures (FAITH) trial evaluating methods of internal fixation in patients with femoral neck fractures, we investigated associations between baseline and surgical factors and the need for revision surgery to promote healing, relieve pain, treat infection or improve function over 24 months postsurgery. Additionally, we investigated factors associated with (1) hardware removal and (2) implant exchange from cancellous screws (CS) or sliding hip screw (SHS) to total hip arthroplasty, hemiarthroplasty, or another internal fixation device. Methods: We identified 15 potential factors a priori that may be associated with revision surgery, 7 with hardware removal, and 14 with implant exchange. We used multivariable Cox proportional hazards analyses in our investigation. Results: Factors associated with increased risk of revision surgery included: female sex, [hazard ratio (HR) 1.79, 95% confidence interval (CI) 1.25-2.50; P = 0.001], higher body mass index (fo

Increasing frailty is associated with higher prevalence and reduced recognition of delirium in older hospitalised inpatients: results of a multi-centre study

Purpose: Delirium is a neuropsychiatric disorder delineated by an acute change in cognition, attention, and consciousness. It is common, particularly in older adults, but poorly recognised. Frailty is the accumulation of deficits conferring an increased risk of adverse outcomes. We set out to determine how severity of frailty, as measured using the CFS, affected delirium rates, and recognition in hospitalised older people in the United Kingdom. Methods: Adults over 65 years were included in an observational multi-centre audit across UK hospitals, two prospective rounds, and one retrospective note review. Clinical Frailty Scale (CFS), delirium status, and 30-day outcomes were recorded. Results: The overall prevalence of delirium was 16.3% (483). Patients with delirium were more frail than patients without delirium (median CFS 6 vs 4). The risk of delirium was greater with increasing frailty [OR 2.9 (1.8–4.6) in CFS 4 vs 1–3; OR 12.4 (6.2–24.5) in CFS 8 vs 1–3]. Higher CFS was associated with reduced recognition of delirium (OR of 0.7 (0.3–1.9) in CFS 4 compared to 0.2 (0.1–0.7) in CFS 8). These risks were both independent of age and dementia. Conclusion: We have demonstrated an incremental increase in risk of delirium with increasing frailty. This has important clinical implications, suggesting that frailty may provide a more nuanced measure of vulnerability to delirium and poor outcomes. However, the most frail patients are least likely to have their delirium diagnosed and there is a significant lack of research into the underlying pathophysiology of both of these common geriatric syndromes

Types of combined oral contraceptives used by US women

Background: We sought to estimate the prevalence of types of combined oral contraceptives (COCs) used among US women. Study Design: We analyzed interview-collected data from 12,279 women aged 15-44 years participating in the National Survey of Family Growth, 2006-2010. Analyses focused on COC use overall, by pill type, across sociodemographics and health factors. Results: The prevalence of current COC use (88 different brands) was 17%. The majority of COC users used earlier-formulation COCs: >= 30 mcg (67%) versus <30 mcg estrogen (33%), monophasic (67%) versus multiphasic (33%) dosages and traditional 21/7 (88%) versus extended/other cycle regimens (12%) regimens. Norgestimate (32%) and norethindrone (20%) were the most commonly used progestins. Sociodemographic, gynecological and health risk factors were associated with type of COC use. Conclusion: Further investigation of specific COC use and of the factors associated with types of pills used among US women at the population level is needed