Breast and Cervical Cancer Screenings: A Systematic Economic Review of Patient Navigation Services.

INTRODUCTION: This paper examined the economic evidence of patient navigation services to increase breast and cervical cancer screenings among historically disadvantaged racial and ethnic populations and people with lower incomes. METHODS: The literature search strategy for this systematic review included English-language studies conducted in high-income countries that were published from database inception to December 2022. Studies on patients with existing cancer or without healthcare system involvement were excluded. Analysis was completed in January 2023. All monetary values reported are in 2022 U.S. dollars. RESULTS: The search yielded 3 breast cancer, 2 cervical cancer, and 2 multiple cancer studies that combined breast and cervical cancer with other cancer screenings. For breast cancer screening, the intervention cost per patient ranged from $109 to $10,245. Two studies reported $154 and $740 as intervention cost per additional person screened. Changes in healthcare cost per person from 2 studies were $202 and $2,437. Two studies reported cost per quality-adjusted life year (QALY) gained of $3,852 and $39,159 while one study reported cost per life year (LY) gained of $22,889. For cervical cancer, two studies reported intervention cost per person ($103 and $794) and per additional person screened ($56 and $533) with one study reporting a cost per QALY gained ($924). DISCUSSION: All estimates of cost per QALY/LY saved for breast cancer screening were below a conservative threshold of $50,000 indicating that patient navigation services for breast cancer screening were cost-effective. There is limited evidence to determine cost-effectiveness of patient navigation services for cervical cancer screening.

Parks, Trails, and Greenways for Physical Activity: A Community Guide Systematic Economic Review.

INTRODUCTION: This systematic economic review examined the cost-benefit and cost-effectiveness of park, trail, and greenway infrastructure interventions to increase physical activity or infrastructure use. METHODS: The search period covered the date of inception of publications databases through February 2022. Inclusion was limited to studies that reported cost-benefit or cost-effectiveness outcomes and were based in the U.S. and other high-income countries. Analyses were conducted from March 2022 through December 2022. All monetary values reported are in 2021 U.S. dollars. RESULTS: The search yielded 1 study based in the U.S. and 7 based in other high-income countries, with 1 reporting cost-effectiveness and 7 reporting cost-benefit outcomes. The cost-effectiveness study based in the United Kingdom reported $23,254 per disability-adjusted life year averted. The median benefit-to-cost ratio was 3.1 (interquartile interval=2.9-3.9) on the basis of 7 studies. DISCUSSION: The evidence shows that economic benefits exceed the intervention cost of park, trail, and greenway infrastructure. Given large differences in the size of infrastructure, intervention costs and economic benefits varied substantially across studies. There was insufficient number of studies to determine the cost-effectiveness of these interventions.

Food Environment Quality and Cardiovascular Disease Mortality in the United States: a County-Level Analysis from 2017 to 2019.

BACKGROUND: Upstream socioeconomic circumstances including food insecurity and food desert are important drivers of community-level health disparities in cardiovascular mortality let alone traditional risk factors. The study assessed the association between differences in food environment quality and cardiovascular mortality in US adults. DESIGN: Retrospective analysis of the association between cardiovascular mortality among US adults aged 45 and above and food environment quality, measured as the food environment index (FEI), in 2615 US counties. FEI was measured by equal weights of food insecurity (limited access to a reliable food source) and food desert (limited access to healthy food), ranging from 0 (worst) to 10 (best). Age-adjusted cardiovascular mortality rates per 100,000 adults aged 45 and above in the calendar year 2017-2019. County-level association between CVD mortality rate and FEI was modeled using generalized linear regression. Data were weighted using county population. RESULT: Median CVD deaths per 100,000 population were 645.4 (IQR 561.5, 747.0) among adults aged 45 years and above across US counties in 2017-2019. About 12.8% (IQR 10.7%, 15.1%) of residents were food insecure and 6.3% (IQR 3.6%, 9.9%) were living in food desert areas. Comparing counties by FEI quartiles, the CVD mortality rate was higher in the least healthy FE counties (704.3 vs 598.6 deaths per 100,000 population) compared to the healthiest FE counties. One unit increase in FEI was associated with - 12.95 CVD deaths/100,000 population. In the subgroup analysis of counties with higher income inequality, the healthiest food environment was associated with 46.4 lower CVD deaths/100,000 population than the least healthy food environment. One unit increase in FEI in counties with higher income inequality was associated with a fivefold decrease in CVD mortality difference in African American counties (- 18.4 deaths/100,000 population) when compared to non-African American counties (- 3.63 deaths/100,000 population). CONCLUSION: In this retrospective multi-county study in the USA, a higher food environment index was significantly associated with lower cardiovascular mortality.

Volume of Care for Primary Care Physicians in Integrated vs Independent Practices Through the COVID-19 Pandemic.

This cohort study examines changes in volume of in-person vs virtual visits to independent and integrated practices during the COVID-19 pandemic.

Association of Social Isolation With Hospitalization and Nursing Home Entry Among Community-Dwelling Older Adults.

Importance: Social isolation is associated with adverse health outcomes, yet its implications for hospitalization and nursing home entry are not well understood. Objective: To evaluate whether higher levels of social isolation are associated with overnight hospitalization, skilled nursing facility stays, and nursing home placement among a nationally representative sample of community-dwelling older adults after adjusting for key health and social characteristics, including loneliness and depressive symptoms. Design, Setting, and Participants: This observational cohort study included 7 waves of longitudinal panel data from the Health and Retirement Study, with community-dwelling adults aged 65 years or older interviewed between March 1, 2006, and June 30, 2018 (11 517 respondents; 21 294 person-years). Data were analyzed from May 25, 2022, to May 4, 2023. Main Outcomes and Measures: Social isolation was measured with a multidomain 6-item scale (range, 0-6, in which a higher score indicates greater isolation). Multivariate logistic regressions were performed on survey-weighted data to produce national estimates for the odds of self-reported hospitalization, skilled nursing facility stays, and nursing home placement over time. Results: A total of 57% of this study's 11 517 participants were female, 43% were male, 8.4% were Black, 6.7% were Hispanic or Latino, 88.1% were White, 3.5% were other ("other" includes American Indian or Alaska Native, Asian or Pacific Islander, and other race, which has no further breakdown available because this variable was obtained directly from the Health and Retirement Study), and 58.2% were aged 65 to 74 years. Approximately 15% of community-dwelling older adults in the US experienced social isolation. Higher social isolation scores were significantly associated with increased odds of nursing home placement (odds ratio, 2.01; 95% CI, 1.21-3.32) and skilled nursing facility stays (odds ratio, 1.16; 95% CI, 1.06-1.28) during 2 years. With each point increase in an individual's social isolation score, the estimated probability of nursing home placement or a skilled nursing facility stay increased by 0.5 and 0.4 percentage points, respectively, during 2 years. Higher levels of social isolation were not associated with 2-year hospitalization rates. Conclusions and Relevance: This cohort study found that social isolation was a significant risk factor for nursing home use among older adults. Efforts to deter or delay nursing home entry should seek to enhance social contact at home or in community settings. The design and assessment of interventions that optimize the social connections of older adults have the potential to improve their health trajectories and outcomes.

Impact of County-level health infrastructure on participation in a reform effort to reduce the use of jail for individuals with mental health disorders.

BACKGROUND: The national Stepping Up Initiative has attracted over 500 counties interested in reducing the use of jail for individuals with mental health disorders. This paper identifies socioeconomic, criminal legal, and health care factors that predict the likelihood of counties joining Stepping Up. RESULTS: After performing variable selection, logistic regression models were performed on 3,141 U.S. counties. Counties designated as medically underserved and/or mental health staffing shortage areas were less likely to participate in this initiative. Logistic regression models showed that larger counties (populations over 250,000) with better health care infrastructure, more mental health providers per capita, higher percent of Medicaid funded drug treatment services, and at least one medical school, were more likely to join Stepping Up. These counties had lower per capita jail populations, higher concentration of police resources, and higher pretrial incarceration rate. CONCLUSIONS: County-level health care delivery factors are major contributors to a county's likelihood, or willingness, of engaging in Stepping Up reform efforts to reduce jail population with mental health disorders issues. Therefore, improving availability and accessibility of medical and behavioral health care in different communities, may facilitate efforts to address the unnecessary incarceration of individuals with mental health disorders.

Economics of Team-Based Care for Blood Pressure Control: Updated Community Guide Systematic Review.

INTRODUCTION: This paper examined the recent evidence from economic evaluations of team-based care for controlling high blood pressure. METHODS: The search covered studies published from January 2011 through January 2021 and was limited to those based in the U.S. and other high-income countries. This yielded 35 studies: 23 based in the U.S. and 12 based in other high-income countries. Analyses were conducted from May 2021 through February 2023. All monetary values reported are in 2020 U.S. dollars. RESULTS: The median intervention cost per patient per year was $438 for U.S. studies and $299 for all studies. The median change in healthcare cost per patient per year after the intervention was -$140 for both U.S. studies and for all studies. The median net cost per patient per year was $439 for U.S. studies and $133 for all studies. The median cost per quality-adjusted life year gained was $12,897 for U.S. studies and $15,202 for all studies, which are below a conservative benchmark of $50,000 for cost-effectiveness. DISCUSSION: Intervention cost and net cost were higher in the U.S. than in other high-income countries. Healthcare cost averted did not exceed intervention cost in most studies. The evidence shows that team-based care for blood pressure control is cost-effective, reaffirming the favorable cost-effectiveness conclusion reached in the 2015 systematic review.

The role of discrimination and adverse childhood experiences in disordered eating.

BACKGROUND: In clinical research, there has been a call to move beyond individual psychosocial factors towards identifying cultural and social factors that inform mental health. Similar calls have been made in the eating disorders (ED) field underscoring the need to understand larger sociocultural influences on EDs. Discrimination is a social stressor that may influence mental health in similar ways to traumatic or adverse childhood experiences (ACEs). Given the high rates of EDs and discrimination among marginalized groups, it is vital to understand the role of discrimination and ACEs as predictors of ED symptoms in these populations. The aim of this study is to examine how perceived discrimination predicts ED pathology when statistically adjusting for gender, race, and ACEs. METHODS: The diverse study sample consisted of 331 undergraduate students from a longitudinal cohort study (ages 18-24; 66% female; 35% White/non-Hispanic). Participants completed measures of everyday discrimination, ACEs, and ED pathology. RESULTS: Following adjustment for multiple statistical comparisons, the frequency of daily discrimination predicted all ED symptoms above and beyond history of ACEs. In follow-up analyses, number of reasons for discrimination predicted cognitive restraint and purging. Differences in ED symptomatology were found based on the reason for discrimination, gender, and race. Specifically, those who experienced weight discrimination endorsed higher scores on all ED symptoms, and those experiencing gender discrimination endorsed higher body dissatisfaction, cognitive restraint, and restriction. People of color endorsed higher restriction, while female participants endorsed higher scores on all ED symptom with the exception of cognitive restraint. CONCLUSION: Discrimination is a salient risk factor for ED symptoms even when accounting for individuals' history of ACEs. Future research should utilize an intersectional approach to examine how perceived discrimination affects ED pathology over time. (Word count: 234).

Adverse childhood experiences (ACEs) increase risk for eating disorders (EDs). Discrimination based on race, gender, and gender and sexual identity is also linked to ED behaviors. This paper examined whether discrimination impacted ED behaviors when ACEs were considered to understand how they both might play a role in risk for EDs. Findings suggest that experiences of discrimination may have a greater impact on eating disorder symptoms in college students than a history of ACEs. More research is needed to understand the negative impacts of discrimination on eating disorders, in addition to history of trauma. Clinicians should attend to the ways discrimination may impact their clients' eating disorder behaviors, and whether individuals experience bias or discrimination when seeking eating disorder treatment.

A Quasi-Experimental Assessment of the Effect of the 2009 WIC Food Package Revisions on Breastfeeding Outcomes.

Breastfeeding rates among infants participating in the Special Supplemental Nutrition Program for Women, Infants, and Children (WIC) are consistently lower than those of WIC nonparticipants. The 2009 WIC food package revisions were intended to incentivize breastfeeding among the WIC population. To examine the effectiveness of this policy change, we estimated an intent-to-treat regression-adjusted difference-in-difference model with propensity score weighting, an approach that allowed us to control for both secular trends in breastfeeding and selection bias. We used novel data from the Feeding Infants and Toddlers Survey from 2008 and 2016. We defined our treatment group as infants eligible for WIC based on household income and our control group as infants in households with incomes just above the WIC eligibility threshold. The breastfeeding outcomes we analyzed were whether the infants were ever breastfed, breastfed through 6 months, and breastfed exclusively through 6 months. We observed significant increases in infants that were ever breastfed in both the treatment group (10 percentage points; p < 0.01) and the control group (15 percentage points; p < 0.05); however, we did not find evidence that the difference between the two groups was statistically significant, suggesting that the 2009 revisions may not have had an effect on any of these breastfeeding outcomes.

Associations between use of specific social media sites and electronic cigarette use among college students.

OBJECTIVE: To examine dose-response associations between use of specific social media sites and the use of electronic cigarettes (e-cigarettes) and traditional cigarettes. METHODS: This was a cross-sectional study of 298 first-year college students enrolled in the fall 2019 semester at a large state university. Heckman selection and Probit model were used to estimate associations between use of specific social media sites and e-cigarette/traditional cigarette use. RESULTS: Each additional hour per day spent on Snapchat was associated with a 4.61% increase in the probability of lifetime e-cigarette use. In addition, among current e-cigarette users, more time spent on Snapchat was associated with more frequent e-cigarette use (marginal effects: 0.13, p = 0.001). Facebook, Twitter, Snapchat and Instagram were not associated with traditional cigarette smoking. CONCLUSION: Snapchat was the only major social media platform associated with both lifetime and current e-cigarette use.

Community Guide Methods for Systematic Reviews of Economic Evidence.

INTRODUCTION: Community Guide systematic economic reviews provide information on the cost, economic benefit, cost-benefit, and cost-effectiveness of public health interventions recommended by the Community Preventive Services Task Force on the basis of evidence of effectiveness. The number and variety of economic evaluation studies in public health have grown substantially over time, contributing to methodologic challenges that required updates to the methods for Community Guide systematic economic reviews. This paper describes these updated methods. METHODS: The 9-step Community Guide economic review process includes prioritization of topic, creation of a coordination team, conceptualization of review, literature search, screening studies for inclusion, abstraction of studies, analysis of results, translation of evidence to Community Preventive Services Task Force economic findings, and dissemination of findings and evidence gaps. The methods applied in each of these steps are reported in this paper. RESULTS: Two published Community Guide reviews, tailored pharmacy-based interventions to improve adherence to medications for cardiovascular disease and permanent supportive housing with housing first to prevent homelessness, are used to illustrate the application of the updated methods. The Community Preventive Services Task Force reached a finding of cost-effectiveness for the first intervention and a finding of favorable cost-benefit for the second on the basis of results from the economic reviews. CONCLUSIONS: The updated Community Guide economic systematic review methods provide transparency and improve the reliability of estimates that are used to derive a Community Preventive Services Task Force economic finding. This may in turn augment the utility of Community Guide economic reviews for communities making decisions about allocating limited resources to effective programs.

The EvidenceNOW Practice Support Initiative: The Heart of Virginia Healthcare.

PURPOSE: HHS' Million Hearts campaign focused the delivery system on ABCS clinical quality measures (appropriate Aspirin use, Blood pressure control, Cholesterol control, and Smoking cessation counseling). AHRQ's Evidence Now project funded 7 collaboratives to test different ways to improve performance and outcomes on ABCS within small primary care practices. The Heart of Virginia Health care (HVH) collaborative designed 1 of the approaches in Evidence Now. METHODS: Two hundred sixty-four eligible practices were recruited to participate and randomized to 3 cohorts in a stepped wedge design, and 173, employing 16 different EHRs, remained for the duration of the initiative. The practice support curriculum was delivered by trained practice coaches to enhance overall practice function and improve performance on the ABCS metrics. The intervention consisted of a kickoff meeting, 3 months of intensive support, 9 months of ongoing support, and access to online learning materials and expert faculty. The mean practice contact time with coaches was 428 minutes, but the standard deviation was 426 minutes. RESULTS: Overall, the short HVH intervention had a small but statistically significant positive average effects on appropriate use of aspirin and other antithrombotics, small negative effects on blood pressure control, except for those practices which did not attend the kickoff, and small negative effects on smoking cessation counseling. CONCLUSIONS: The intervention phase was truncated due to difficulty in recruiting a sufficient number of practices. This undoubtedly contributed to the lack of substantial improvements in the ABCS. Other likely contributing factors were our inability to provide real time feedback on metrics and the frequency with which major practice disruptions occurred. Future efforts to improve primary care practice function should allow adequate time for both practice recruitment and external support.

Where It Really Counts: Feasibility and Potential of the Peer Engaged Empowered Recovery Program for Substance-Dependent Jail Inmates.

OBJECTIVE: The Peer Engaged Empowered Recovery (PEER) program is a county collaboration between specialty behavioral health and probation departments to address substance use and related problems by providing team-based peer recovery specialist (PRS) services. The study aimed to assess the feasibility and potential effectiveness of PEER and propose recommendations. METHOD: Eligible clients released from jail had suspected substance use disorder and were assigned to the local drug court, on pretrial probation, or considered of high risk of recidivism. Clients were offered PRS support for 6 months. Client-reported data, administrative data on services, and survey data from program stakeholders were assessed. RESULT: The program successfully identified clients with substance use disorder who had high to very high levels of need for social determinants of health, comorbid mental illness and other chronic conditions, and a high recidivism risk. Clients were served predominantly by phone despite complex needs. The sustainability of the PEER program was rated as stable along many dimensions except funding stability. CONCLUSION: The PEER pilot program was well targeted. The average level of health and social need among clients was high, and many were difficult for PRS to contact. PRS services, which are currently undifferentiated in the state, may need to be risk-stratified in the future to take into account health and social factors and to align caseloads, reimbursement, and training.

The relationship between community public health, behavioral health service accessibility, and mass incarceration.

BACKGROUND: The relationship between healthcare service accessibility in the community and incarceration is an important, yet not widely understood, phenomenon. Community behavioral health and the criminal legal systems are treated separately, which creates a competing demand to confront mass incarceration and expand available services. As a result, the relationship between behavioral health services, demographics and community factors, and incarceration rate has not been well addressed. Understanding potential drivers of incarceration, including access to community-based services, is necessary to reduce entry into the legal system and decrease recidivism. This study identifies county-level demographic, socioeconomic, healthcare services availability/accessibility, and criminal legal characteristics that predict per capita jail population across the U.S. More than 10 million individuals pass through U.S. jails each year, increasing the urgency of addressing this challenge. METHODS: The selection of variables for our model proceeded in stages. The study commenced by identifying potential descriptors and then using machine learning techniques to select non-collinear variables to predict county jail population per capita. Beta regression was then applied to nationally available data from all 3,141 U.S. counties to identify factors predicting county jail population size. Data sources include the Vera Institute's incarceration database, Robert Wood Johnson Foundation's County Health Rankings and Roadmaps, Uniform Crime Report, and the U.S. Census. RESULTS: Fewer per capita psychiatrists (z-score = -2.16; p = .031), lower percent of drug treatment paid by Medicaid (-3.66; p < .001), higher per capita healthcare costs (5.71; p < .001), higher number of physically unhealthy days in a month (8.6; p < .001), lower high school graduation rate (-4.05; p < .001), smaller county size (-2.66, p = .008; -2.71, p = .007; medium and large versus small counties, respectively), and more police officers per capita (8.74; p < .001) were associated with higher per capita jail population. Controlling for other factors, violent crime rate did not predict incarceration rate. CONCLUSIONS: Counties with smaller populations, larger percentages of individuals that did not graduate high school, that have more health-related issues, and provide fewer community treatment services are more likely to have higher jail population per capita. Increasing access to services, including mental health providers, and improving the affordability of drug treatment and healthcare may help reduce incarceration rates.

Outpatient Care Among Users and Nonusers of Direct-to-Patient Telehealth: Observational Study.

BACKGROUND: Expansion of telehealth insurance coverage is hampered by concerns that such coverage may encourage excessive use and spending. OBJECTIVE: The aim of this paper is to examine whether users of telehealth services rely more on other forms of outpatient care than nonusers, and to estimate the differences in payment rates. METHODS: We examined claims data from a large national insurer in 2017. We limited our analysis to patients with visits for 3 common diagnoses (N=660,546). We calculated the total number of visits per patient, overall, and by setting, and adjusted for patient- and county-level factors. RESULTS: After multivariable adjustment, telehealth-visit users, compared to nonusers, had 0.44 fewer visits to primary care, 0.11 fewer visits to emergency departments, and 0.17 fewer visits to retail and urgent care. All estimates are statistically significant at P<.001. Average payment rates for telehealth visits were lower than all other settings. CONCLUSIONS: These findings suggest that telehealth visits may substitute rather than add to in-person care for some types of care. Our study suggests that telehealth visits may offer an efficient and less costly alternative.

Substance use and firearm access among college freshmen.

OBJECTIVE: Examine the proportion of students with rapid firearm access and associations with recent alcohol and marijuana use. PARTICIPANTS: Cross-sectional data from college freshmen (n = 183) in 2020 who participated in the Mason: Health Starts Here study. METHODS: Using logistic regression, associations were examined between past 30-day substance use and access to firearms within 15-min. RESULTS: More than 10% of students could rapidly access a firearm, 53% of whom were current binge drinkers, compared to 13% of those who could not rapidly access firearms. Non-Hispanic White students (AOR = 4.1, 95%CI = 1.3,12.7) and past 30-day binge drinkers (AOR = 6.4, 95%CI = 2.1,19.7) had greater odds of having rapid firearm access. Age, sex, and past 30-day marijuana use were not associated with rapid access. CONCLUSIONS: A notable proportion of students had rapid firearm access, which was strongly associated with recent binge drinking. Campus prevention programs should consider how their alcohol and firearm policies could be enhanced to prevent violence/self-harm.

Food insecurity and housing instability as determinants of cardiovascular health outcomes: A systematic review.

AIMS: The primary objective of this study is to conduct a systematic review of existing literature on the association between food insecurity and housing instability with CVD and its subtypes-related outcomes. Summarizing the comprehensive evidence for independent/interchangeable relationship of food and housing instability with CVD outcomes may inform specific interventions strategies to reduce CVD-risk. DATA SYNTHESIS: The search focused on English-language articles in PubMed/Medline, from January 1, 2010, to June 1, 2021, with restriction to the US adult population. We included studies estimating the association between food insecurity or/and housing instability(exposure) and CVD-subtypes-related health outcomes (outcome). The study methodological quality was assessed using the Study Quality Assessment Tools (SQAT). Nineteen studies met eligibility criteria, consisted of 15 cross-sectional and 4 cohort studies. Of total studies, 7 examined housing instability, 11 studies focused on food insecurity, and one examined both. Food insecurity/housing instability was associated with increased overall CVD-mortality rate and greater healthcare cost utilization, while evidence were mixed for hospital readmission rate. By subtype, stroke mortality was greater with food insecurity but not with housing instability. The likelihood of myocardial infarction, coronary heart disease, and congestive heart failure was greater with food insecurity. Although mortality with MI was higher with housing instability, readmission and surgical procedure rates were significantly lower than housing stable adults. CONCLUSION: Findings from this review suggest an urgent need to test the impact of screening for food and housing insecurities, referral services, and community engagement for CV health, within clinical and public health settings. PROTOCOL REGISTRATION: Prospero CRD4202123352.