Disparities in telemedicine use among Native Hawaiian and Pacific Islander individuals insured through Medicaid.

States have implemented policy changes to increase access to telemedicine services for individuals receiving Medicaid benefits. Native Hawaiian and Pacific Islander (NHPI) individuals experienced disproportionate harms from COVID-19 and have long experienced disparities in health care access compared with other racial and ethnic groups, making the issue of telemedicine access particularly salient for NHPI individuals on Medicaid. Utilizing 100% 2020-2021 Medicaid claims, we compared trends in telemedicine use between NHPI and non-Hispanic White individuals on Medicaid in Washington State and conducted a decomposition analysis to identify drivers of underlying disparities. In both years, NHPI individuals were 38%-39% less likely to use any telemedicine than White individuals after adjusting for patient- and area-level characteristics. Decomposition analysis revealed that most of this difference was due to differential effects of characteristics, rather than group differences in characteristics. Namely, several characteristics that were associated with increased telemedicine use had more muted associations for NHPI vs White individuals, such as English as the primary spoken language and female sex. These findings suggest the presence of limited acceptability of or group-specific barriers to telemedicine for NHPI individuals, including potential discrimination in being offered telemedicine visits. These issues should be understood and mitigated through close collaboration between health care leaders and NHPI communities.

"Advocates for Each Other": The creation and evaluation of a pragmatic peer navigation program for black patients in primary care with uncontrolled hypertension.

BACKGROUND: Black individuals in the U.S. and in our primary care clinic experience worse control of blood pressure compared to White individuals. OBJECTIVE: To address this inequity, our objectives were to (1) elicit from patients and community members their ideas for barriers and facilitators to blood pressure control; and (2) use their input to design and pilot a navigator program for Black patients in our clinic to improve blood pressure management. PATIENT INVOLVEMENT: We conducted three focus groups with 27 individuals and identified two main areas of need that informed the peer navigator program: (1) community-based services and (2) skill development for hypertension self-management. METHODS: Peer navigators from the Black community called participants at least monthly for 6-12 months and connected them with medical and social services. Available blood pressure data was used as the primary outcome to measure change pre- to post-peer navigation program. RESULTS: Among 499 eligible patients in the clinic, 53 (10.6%) enrolled in the peer navigation program. For those with baseline and follow-up blood pressure data, mean systolic blood pressure decreased from 155.9 to 142.4 mmHg after the program (change of -13.6, 95% CI -24.7 to -2.4) for the enrolled patients (N = 17) and from 139.1 to 137.1 mmHg (change of -2.5, -4.8 to 1.9) for unenrolled, comparison patients (N = 183). DISCUSSION: This community-informed peer navigation program to support Black patients with uncontrolled hypertension led to a 11.1 mmHg greater decrease in average systolic blood pressure for enrolled patients compared to the comparison group. However, the enrolled group started with a significantly higher systolic blood pressure at baseline with more room for improvement. While this study was conducted during the pandemic years, low uptake of this program needs to be addressed in expansion efforts. PRACTICAL VALUE: Clinic-based peer navigation for hypertension improved blood pressure control and was highly regarded by the subset of enrolled patients. Increasing uptake and sustainable funding for non-billable clinic roles remain areas of need. FUNDING: Grant from the Pacific Hospital Preservation & Development Authority.

Area-Level Socioeconomic Disadvantage and Health Care Spending: A Systematic Review.

Importance: Publicly available, US Census-based composite measures of socioeconomic disadvantage are increasingly being used in a wide range of clinical outcomes and health services research. Area Deprivation Index (ADI) and Social Vulnerability Index (SVI) are 2 of the most commonly used measures. There is also early interest in incorporating area-level measures to create more equitable alternative payment models. Objective: To review the evidence on the association of ADI and SVI with health care spending, including claims-based spending and patient-reported barriers to care due to cost. Evidence Review: A systematic search for English-language articles and abstracts was performed in the PubMed, Web of Science, Embase, and Cochrane databases (from inception to March 1, 2023). Peer-reviewed articles and abstracts using a cross-sectional, case-control, or cohort study design and based in the US were identified. Data analysis was performed in March 2023. Findings: This review included 24 articles and abstracts that used a cross-sectional, case-control, or cohort study design. In 20 of 24 studies (83%), ADI and SVI were associated with increased health care spending. No association was observed in the 4 remaining studies, mostly with smaller sample sizes from single centers. In adjusted models, the increase in spending associated with higher ADI or SVI residence was $574 to $1811 for index surgical hospitalizations, $3003 to $24 075 for 30- and 90-day episodes of care, and $3519 for total annual spending for Medicare beneficiaries. In the studies that explored mechanisms, postoperative complications, readmission risk, and poor primary care access emerged as health care system-related drivers of increased spending. Conclusions and Relevance: The findings of this systematic review suggest that both ADI and SVI can play important roles in efforts to understand drivers of health care spending and in the design of payment and care delivery programs that capture aspects of social risk. At the health care system level, higher health care spending and poor care access associated with ADI or SVI may represent opportunities to codesign interventions with patients from high ADI or SVI areas to improve access to high-value health care and health promotion more broadly.

Use of New Audio-Only Telemedicine Claim Modifiers.

Importance: Policymakers at both the state and federal levels face decisions about coverage of audio-only telemedicine amid a dearth of reliable data due to changes and variation in billing practices. Objective: To describe early trends in the use of new audio-only telemedicine claims modifiers 93 and FQ in Washington State, which were introduced to improve the designation and identification of audio-only telemedicine claims. Design, Setting, and Participants: This retrospective cohort study analyzed claims data from the Washington All-Payer Claims Database from January to November 2022. Participants included 4.3 million children and adults insured for at least 6 months in 2021 through public or private insurance plans. Exposures: Use of audio-only telemedicine was compared by age, race, ethnicity, insurance type, rurality, and Social Vulnerability Index. Main Outcomes and Measures: Audio-only telemedicine services were identified by claims appended by Current Procedural Terminology (CPT) code modifiers 93 or FQ or that included telephone-only CPT codes. Modifiers 93 and FQ denote audio-only telemedicine services for any reason and for behavioral health concerns, respectively. Results: In 2022, there were a total of 917 589 audio-only telemedicine services, of which 345 941 (38%) were appended with modifier FQ and 55 352 (6%) with modifier 93. Audio-only telemedicine services with these modifiers were most frequent for behavioral health diagnoses or routine prenatal and postpartum care. Individuals who used telemedicine exclusively via audio-only modality were more likely to be older (mean [SD] age, 46.0 [22.5] vs 42.0 [21.4] years) and insured by Medicare (41 758 of 196 225 [21%] vs 95 962 of 707 626 [14%]) than those who used at least 1 audiovisual service. Conclusions and Relevance: In this cohort study of a statewide all-payer claims database, modifiers 93 and FQ offered the important capability to identify audio-only telemedicine services beyond telephone-only CPT codes, but their uptake remained low. Audio-only telemedicine appears to offer an important means for access to behavioral health and perinatal care access, but further work is needed to study outcomes and quality of care.

Association Between Capitated Payments and Preventive Care Among U.S. Adults.

Introduction: There is increasing interest in using capitation rather than fee for service to promote primary care and population health. The goal of this study was to examine the association between practice reimbursement mix (majority fee for service versus majority capitation versus other) and receipt of common preventive screening examinations and health counseling from 2012 to 2018. Methods: Using the National Ambulatory Medical Care Survey, a retrospective cross-sectional study of 24,864 visits with primary care clinicians among patients aged 18-75 years without a cancer diagnosis was conducted. The main dependent measures were age- and sex-appropriate receipt of breast cancer screening, osteoporosis screening, cervical cancer screening, chlamydia testing, colon cancer screening, diabetes screening, and hyperlipidemia screening as well as 3 health counseling items. Multivariable logistic regression was performed to assess the association between reimbursement mix and receipt of preventive care, adjusted for patient, visit, and practice characteristics. Results: Majority capitation reimbursement was associated with a greater likelihood of receiving breast cancer screening (AOR=2.11, 95% CI=1.16, 3.84, p=0.014) and osteoporosis screening (AOR=4.34, 95% CI=1.74, 10.8, p=0.0017) than majority fee-for-service or other reimbursement mixes. Reimbursement mix was not associated with the likelihood of receiving 9 other preventive care or health counseling services. Conclusions: Larger amounts of capitation reimbursement may improve some but not all aspects of preventive care compared with fee for service.

Reexamining the Impact of Insurance Type on Kidney Transplant Waitlist Status and Posttransplantation Outcomes in the United States After Implementation of the Affordable Care Act.

Insurance type, a marker of socioeconomic status, has been associated with poor access to kidney transplant (KT) and worse KT outcomes before the implementation of the Affordable Care Act (ACA) and the revised Kidney Allocation System (KAS). In this study, we assessed if insurance type remained a risk marker for worse waitlist and transplant outcomes after ACA and KAS. Methods: Using Scientific Registry of Transplant Recipients data, we assessed insurance type of waitlisted candidates pre- (2008-2014) versus post- (2014-2021) KAS/ACA using chi-square tests. Next, we performed a competing risk analysis to study the effect of private versus public (Medicare, Medicaid, or government-sponsored) insurance on waitlist outcomes and a Cox survival analysis to study posttransplant outcomes while controlling for candidate, and recipient and donor variables, respectively. Results: The proportion of overall KT candidates insured by Medicaid increased from pre-KAS/ACA to post-KAS/ACA (from 12 667 [7.3%] to 21 768 [8.8%], P < 0.0001). However, KT candidates with public insurance were more likely to have died or become too sick for KT (subdistribution hazard ratio [SHR] = 1.33, confidence interval [CI], 1.30-1.36) or to receive a deceased donor KT (SHR = 1.57, CI, 1.54-1.60) but less likely to receive a living donor KT (SHR = 0.87, CI, 0.85-0.89). Post-KT, KT recipients with public insurance had greater risk of mortality (relative risks = 1.22, CI, 1.15-1.31) and allograft failure (relative risks = 1.10, CI, 1.03-1.29). Conclusions: Although the implementation of ACA marginally increased the proportion of waitlisted candidates with Medicaid, publicly insured KT candidates remained at greater risk of being removed from the waitlist, had lower probability of living donor kidney transplantation, and had greater probability of dying post-KT and allograft failure. Concerted efforts to address factors contributing to these inequities in future studies are needed, with the goal of achieving equity in KT for all.

Chief Residency Selection in Internal Medicine: Who Is Left Out?

Little progress has been made in improving racial, gender, or intersectional diversity within academic internal medicine (IM). Chief Residency fulfills a unique opportunity to target diversity efforts; Chief Residents (CR) are integral in creating an inclusive environment and support system for IM trainees, and the position serves as a steppingstone for future leadership positions within academia. However, the CR selection process often lacks transparency and includes steps that are fraught with bias, thereby disadvantaging underrepresented minority groups from gaining important experience needed to climb the academic ladder. We describe a more standardized selection process that will improve recruitment and selection of more diverse CRs and ultimately improve the recruitment, retention, and promotion of more diverse faculty within academic internal medicine. Key recommendations include an open call for applications, the use of standardized and structured interviews, and the formation of a diverse selection committee to conduct a transparent selection process based on explicitly defined criteria.

Effectiveness of a school-based intervention in Guatemala to increase knowledge of sexual and reproductive health.

OBJECTIVES: Adolescent pregnancy in Guatemala is a multifactorial issue contributing to maternal and child mortality as well as negative social and economic outcomes. While multiple organizations have identified this as an important area for improvement, little has been published on methods for reducing rates of adolescent pregnancy in resource-limited settings. We characterized the effects of a brief intervention on the knowledge and attitudes towards sexual health of high schoolers in a rural Guatemalan community. METHODS: We created a condensed, 2-h sexual education course, which was taught to over 500 high school students in San Juan Sacatepequez, Guatemala. Students completed pre- and post-intervention surveys assessing their knowledge about pregnancy prevention and attitudes toward contraception use. Chi-square tests were used to assess the difference between the pre- and post-intervention responses as well as the responses between male and female participants. RESULTS: Analysis of the survey results revealed significant improvements in all questions assessing knowledge regarding pregnancy prevention (p<0.01). Our pre-intervention survey revealed that male participants possessed greater knowledge regarding pregnancy prevention (p<0.01). Following the intervention, several areas of initial difference between male and female students' knowledge disappeared, including knowledge of what a contraceptive is, awareness that one sexual relation is sufficient for pregnancy, and recognition that condoms can prevent sexually transmitted infections. CONCLUSIONS: This study demonstrates that brief, school-based sexual health courses are low-resource, feasible interventions to significantly increase knowledge about contraception and sexual health in resource-limited settings and improve the disparities in knowledge between male and female participants.

A Blueprint for Planning and Implementing a Transgender Health Program.

Transgender and gender-diverse people face multiple barriers to accessing appropriate health care, including denial of service, harassment, and lack of clinician knowledge. This article presents a blueprint for planning and implementing a transgender health program within a primary care practice in order to enhance the capacity of the health care system to meet the medical and mental health needs of this underserved population. The steps described, with emphasis on elements specific to transgender care, include conducting a community needs assessment, gaining commitment from leadership and staff, choosing a service model and treatment protocols, defining staff roles, and creating a welcoming environment.

A 36-Year-Old Moroccan Man Presenting with Widespread Papules and Pustules.

Cutaneous manifestations of tuberculosis are uncommon, can be nonspecific, and may demonstrate a wide variety of morphologies, including ulcerative papules, verrucous plaques, or nodules. We report the case of a 36-year-old Moroccan man who presented with nearly 2 years of generalized folliculocentric pustules and nodules, night sweats, and weight loss. Workup revealed necrotic right axillary lymphadenopathy, multiple ill-defined hepatic lesions, and a positive interferon-γ release assay. These findings were most consistent with papulonecrotic tuberculosis.

Evaluation of Barriers to Telehealth Programs and Dermatological Care for American Indian Individuals in Rural Communities.

IMPORTANCE: Understanding geographic and financial barriers to health care is an important step toward creating more accessible health care systems. Yet, the barriers to dermatological care access for American Indian populations in rural areas have not been studied extensively. OBJECTIVE: To evaluate the driving distances and insurance coverage for dermatological care and the current availability of teledermatological programs within the Indian Health Service (IHS) or tribal hospitals system. DESIGN, SETTING, AND PARTICIPANTS: This mixed-methods study was conducted from May 7, 2018, to September 1, 2018, and did not take place in any IHS or tribal health care facility in the continental United States. The study design involved a geographic analysis and a cross-sectional telephone survey with brick-and-mortar dermatology clinics (n = 27) and teledermatological programs (n = 49). Brick-and-mortar clinics were selected for their proximity to a rural IHS or tribal hospital. MAIN OUTCOMES AND MEASURES: Mean driving distance from rural IHS or tribal hospital to nearest dermatology clinic, number of dermatology clinics within a 35-mile or 90-mile radius of IHS or tribal hospitals, insurance and referral types accepted by dermatology clinics, and number of teledermatological programs collaborating with IHS or tribal hospitals or health centers. RESULTS: In total, 27 brick-and-mortar dermatology clinics and 49 teledermatological programs were identified and contacted for the survey. The median (interquartile range [IQR]) driving distance between rural IHS or tribal hospitals and the nearest dermatology clinic was 68 (30-104) miles. Of the 27 dermatology clinics in closest proximity to rural IHS or tribal hospitals (median [IQR] driving distance, 82.4 [31-114] miles), 25 (93%) responded to the survey, 6 (22%) did not accept patients with Medicaid, and 6 (22%) did not accept IHS referrals for patients without insurance. Of the 49 teledermatological programs, 45 (92%) responded and 14 (29%) were no longer active. Ten (20%) teledermatology programs were currently partnering (n = 6), previously partnered (n = 2), or were setting up services (n = 2) with an IHS or tribal site. Only 9% (n = 27) of the 303 rural IHS or facility in the continental United States reported receiving teledermatological services. CONCLUSIONS AND RELEVANCE: Substantial geographic and insurance coverage barriers to dermatological care exist for American Indian individuals in rural communities; teledermatological innovations could represent an important step toward minimizing the disparities in dermatological care access and outcomes.

Fostering Student-Faculty Partnerships for Continuous Curricular Improvement in Undergraduate Medical Education.

PROBLEM: A number of medical schools have used curricular reform as an opportunity to formalize student involvement in medical education, but there are few published assessments of these programs. Formal evaluation of a program's acceptability and use is essential for determining its potential for sustainability and generalizability. APPROACH: Harvard Medical School's Education Representatives (Ed Reps) program was created in 2015 to launch alongside a new curriculum. The program aimed to foster partnerships between faculty and students for continuous and real-time curricular improvement. Ed Reps, course directors, and core faculty met regularly to convey bidirectional feedback to optimize the learning environment in real time. OUTCOMES: A survey to assess the program's impact was sent to students and faculty. The majority of students (202/222; 91.0%) reported Ed Reps had a positive impact on the curriculum. Among faculty, 35/37 (94.6%) reported making changes to their courses as a result of Ed Reps feedback, and 34/37 (91.9%) agreed the program had a positive impact on the learning environment. Qualitative feedback from students and faculty demonstrated a change in school culture, reflecting the primary goals of partnership and continuous quality improvement (CQI). NEXT STEPS: This student-faculty partnership demonstrated high rates of awareness, use, and satisfaction among faculty and students, suggesting its potential for local sustainability and implementation at other schools seeking to formalize student engagement in CQI. Next steps include ensuring the feedback provided is representative of the student body and identifying new areas for student CQI input as the curriculum becomes more established.

Conformational properties of cardiolipin-bound cytochrome c.

Interactions of cytochrome c (cyt c) with cardiolipin (CL) are important for both electron transfer and apoptotic functions of this protein. A sluggish peroxidase in its native state, when bound to CL, cyt c catalyzes CL peroxidation, which contributes to the protein apoptotic release. The heterogeneous CL-bound cyt c ensemble is difficult to characterize with traditional structural methods and ensemble-averaged probes. We have employed time-resolved FRET measurements to evaluate structural properties of the CL-bound protein in four dansyl (Dns)-labeled variants of horse heart cyt c. The Dns decay curves and extracted Dns-to-heme distance distributions P(r) reveal a conformational diversity of the CL-bound cyt c ensemble with distinct populations of the polypeptide structures that vary in their degree of protein unfolding. A fraction of the ensemble is substantially unfolded, with Dns-to-heme distances resembling those in the guanidine hydrochloride-denatured state. These largely open cyt c structures likely dominate the peroxidase activity of the CL-bound cyt c ensemble. Site variations in P(r) distributions uncover structural features of the CL-bound cyt c, rationalize previous findings, and implicate the prime role of electrostatic interactions, particularly with the protein C terminus, in the CL-induced unfolding.