Socioeconomic and Racial/Ethnic Inequalities in Infertility Prevalence, Help-Seeking, and Help Received Since 1995.

BACKGROUND: In the United States, infertility and treatment for infertility are marked by racial/ethnic and socioeconomic inequalities. Simultaneously, biomedical advances and increased public health attention toward preventing and addressing infertility have grown. It is not known, however, whether the racial/ethnic and socioeconomic inequalities observed in infertility prevalence, help-seeking, or help received have changed over time. METHODS: Using National Survey of Family Growth data (1995 through 2017-2019 cycles), this study applied multivariable logistic regression with interaction terms to investigate whether and how racial/ethnic and socioeconomic inequalities in 1) the prevalence of infertility, 2) ever seeking help to become pregnant, and 3) use of common types of medical help (advice, testing, medication for ovulation, surgery for blocked tubes, and artificial insemination) have changed over time. RESULTS: The results showed persisting, rather than narrowing or increasing, inequalities in the prevalence of infertility and help-seeking overall. The results showed persisting racial/ethnic inequalities in testing, ovulation medication use, and surgery for blocked tubes. By contrast, the results showed widening socioeconomic inequalities in testing and narrowing inequalities in the use of ovulation medications. CONCLUSIONS: There is little evidence to suggest policy interventions, biomedical advances, or increased public health awareness has narrowed inequalities in infertility prevalence, treatment seeking, or use of specific treatments.

Barriers to Postpartum Care: A Mixed Methods Study of Midwestern Postpartum Women.

PURPOSE: Postpartum care is an opportunity to provide essential follow-up care to people who have given birth, but inequalities in access by race and socioeconomic status (SES) are well-documented. The purpose of this study is to provide an in-depth description of the barriers to postpartum care using a mixed-methods design. METHODS: Mixed method analyses using convergent design with three stages including (1) bivariate logistic regression of survey data representative of postpartum women in Kalamazoo County, Michigan, (2) thematic qualitative analyses of focus group interviews of survey participants, and (3) bivariate logistic regression and logistic regression meditation analyses using themes operationalized with survey data measures. RESULTS: In Kalamazoo county, 82.0% of women attended their postpartum visit. White women and women with higher SES were 2.84 (SE = 1.35, p < .001) and 5.73 (SE = 3.10, p < .001) times more likely to attend postpartum visits than women of color and those with lower SES. Qualitative analyses identified four common barriers: (1) misaligned goals for appointments, (2) time and scheduling of appointments, (3) prioritization of children, and (4) material resources and health insurance coverage. The quantitative analyses found mixed support for these barriers and found limited evidence that these barriers mediated the relationship between race or SES and postpartum attendance. CONCLUSIONS FOR PRACTICE: The qualitative findings identify barriers that are amenable to practice-level interventions including changes to scheduling procedures and employing patient-centered care. The quantitative findings further suggest that although inequalities in postpartum care are present, interventions on these barriers may benefit women regardless of race and SES.

SIGNIFICANCE: What is Already Known on this Subject? Attendance at postpartum visits is lower for women of color and women with lower SES. Investigation of barriers to postpartum care is nascent, but prior research has shown common barriers include cost, transportation, scheduling, lack of provider continuity, and the fragmented nature of postpartum care in the U.S. Previous studies have tended to use only quantitative or qualitative data. What this Study adds? This mixed-methods study combines quantitative analyses of a county-level representative survey with qualitative focus group data to identify and statistically test for barriers to attendance and engagement at postpartum visits.

Geographic distribution of assisted reproductive technology clinics in the USA: a multilevel sociodemographic analysis.

PURPOSE: To investigate whether sociodemographic characteristics of US Census tracts and counties and state-level infertility insurance policy are associated with the presence of assisted reproductive technology (ART) clinics. METHODS: Multilevel logistic regression analyses using publicly available reports of ART clinic locations (2014-2018) matched with sociodemographic data from the US Census Bureau and state infertility insurance policy information. RESULTS: At the tract-level, multivariate multilevel logistic regression found significant associations with the likelihood of an ART clinic in a tract and the size of the tract population (adjusted odds ratio (aOR): 1.063, SE = 0.018, p < .001), the tract median household income (aOR = 0.990, SE = 0.002, p < 0.001), and the percentages of the population who were Hispanic (aOR = 0.975, SE = 0.007, p < 0.001), women over 25 with a bachelor's degree or higher (aOR: 1.052, SE = 0.004, p < 0.001), and foreign-born (aOR: 1.037, SE = 0.009, p < .001). At the county-level, significant associations were found with the county median household income (aOR: 1.016, SE = 0.006, p < .01) and the percentage of the population that identified as Black (aOR = 1.013, SE = 0.006, p < .05) and Hispanic (aOR = 1.028, SE = 0.009, p < .05). Multivariate models showed no associations between tract clinic counts and state infertility policy. CONCLUSION: There is mixed evidence that clinic concentration is associated with expected sociodemographics. In particular, physical proximity may not principally drive racial disparities in ART access. Furthermore, insurance mandates are not associated with the presence of an ART clinics in a tract, suggesting alternative policy levers may be needed to address differential access and utilization of ART services.

Accounting for past patient composition in evaluations of quality reporting.

OBJECTIVE: To investigate whether accounting for past patient composition in evaluations of the association between public quality reports and patient selectivity changes findings and conclusions. DATA SOURCES: Secondary data analysis of public reports of Assisted Reproductive Technology Clinic success rates between 2011 and 2018. STUDY DESIGN: Two sets of fixed effects models, (1) a standard fixed-effects model (FE) and (2) a dynamic panel model using structural equation modeling estimated with maximum-likelihood (ML-SEM) with one- and two-year lagged patient characteristics, are compared. The outcome variables are patient composition features associated with success rates, including two age categories and eight diagnoses of infertility. Two-year lagged success rates for any live birth and a singleton live birth are central predictor variables. DATA COLLECTION/EXTRACTION METHODS: Clinics with complete records for the 2011-2018 period were included (N = 303). PRINCIPAL FINDINGS: For live birth success rates, the two models show increases in the two-year lagged success rate is associated with a reduction in (1) the transformed percentage of patients with endometriosis (FE: ß = -0.006, SE = 0.002, p < 0.01; ML-SEM: ß = -0.005, SE = 0.002, p < 0.01) and (2) the percentage of patients with tubal diagnoses (FE: ß = -0.090, SE = 0.017, p < 0.001; ML-SEM: ß = -0.064, SE = 0.027, p < 0.05). For singleton birth success rates, the models show positive associations between the two-year lagged success rate and the percent of patients over 35 years old (FE: ß = 0.219, SE = 0.033, p < 0.001; ML-SEM: ß = 0.095, SE = 0.047, p < 0.05). Overall, the FE models show numerous significant associations with the two-year lagged success rate not observed in the ML-SEM models. Thus, the preferred and theoretically appropriate model (ML-SEM) and the more commonly used model (FE) yield different results. CONCLUSIONS: Researchers and policymakers should use models that account for past patient composition when evaluating the associations between quality reports and patient selectivity.

Care Transformation Strategies and Approaches of Accountable Care Organizations.

Although accountable care organizations (ACOs) proliferate, little is known about the activities and strategies ACOs are pursuing to meet goals of reducing costs and improving quality. We use semistructured interviews with executives at 16 ACOs to understand ACO approaches. We identified two overarching ACO approaches to changing clinical care: a practice-based transformation approach, working to overhaul care processes and teams from the inside out; and an overlay approach, where ACO activities were centralized and delivered external to physician practices. We additionally identified four methods ACOs were using to achieve their aims: using patient support roles; targeted clinics, events, programs, and interventions; clinical process standardization; and tracking and identifying patients on which to focus resources. We expect that ACOs using either of the major approaches can succeed under current ACO programs, but that as value-based payment programs mature, ACOs will need to undertake practice-based approaches to be successful in the long term.

The new frontier of strategic alliances in health care: New partnerships under accountable care organizations.

Accountable care organizations (ACOs) and similar reforms aim to improve coordination between health care providers; however, due to the fragmented nature of the US health care system, successful coordination will hinge in large part on the ability of health care organizations to successfully partner across organizational boundaries. Little is known about new partnerships formed under the ACO model. We use mixed methods data from the National Survey of ACOs, Medicare ACO performance data and interviews with executive leaders across 31 ACOs to examine the prevalence, characteristics, and capabilities of partnership ACOs and why and how ACO partnerships form. We find that a striking percentage of ACOs - 81% - involve new partnerships between independent health care organizations. These "partnership ACOs" generally report lower capabilities on care management, care coordination, and health information technology. Additionally, under Medicare ACO programs partnership ACO achieved somewhat lower quality performance. Qualitative interviews revealed that providers are motivated to partner for resource complementarity, risk reduction, and legislative requirements, and are using a variety of formal and informal accountability mechanisms. Most partnership ACOs were formed out of existing, positive relationships, but a minority of ACOs formed out of previously competitive or conflictual relationships. Our findings suggests that the success of the ACO model will hinge in large part upon the success of new partnerships, with important implications for understanding ACO readiness and capabilities, the relatively small savings achieved to date by ACO programs, and the path to providers bearing more risk for population health management. In addition, ACO partnerships may provide an important window to monitor a potential wave of health care consolidation or, in contrast, a new model of independent providers successfully coordinating patient care.