The Implementation of the Tennessee Fetal Assault Law and Its Association With Out-of-State Births Among Residents of Tennessee.

INTRODUCTION: This study analyzed the association between the implementation of the Tennessee Fetal Assault Law (TFAL), which allowed prosecutors to incarcerate people who used substances during pregnancy, and out-of-state births among residents of Tennessee. METHODS: The main data source is vital records on singleton births in hospitals to people aged 15-44 years during the period January 2010 to June 2016. We include data from 33 states and the District of Columbia where birth certificate data are comparable over this time period. The statistical significance of the difference in outcomes observed before and after TFAL implementation was tested using a difference-in-differences analysis between Tennessee and the comparison group. RESULTS: After TFAL implementation, the odds of having an out-of-state birth increased by 13% for residents of Tennessee (odds ratio, 1.13; 95% confidence interval, 1.09-1.16) relative to residents of the comparison states. When we adopted different thresholds for travel distances to the birth hospital, the odds of residents of Tennessee having an out-of-state birth more than 75 miles away increased by 17% (odds ratio, 1.17; 95% confidence interval, 1.13-1.21) after TFAL implementation. CONCLUSION: The results of this study suggest that the implementation of a policy allowing incarceration of people who use substances during pregnancy is associated with an increase in out-of-state births, potentially putting pregnant people and their infants at greater risk.

Medicaid Expansion: Effects On Hospital Finances And Implications For Hospitals Facing COVID-19 Challenges.

States' decisions to expand Medicaid may have important implications for their hospitals' financial ability to weather the coronavirus disease 2019 (COVID-19) pandemic. This study estimated the effects of the Affordable Care Act (ACA) Medicaid expansion on hospital finances in 2017 to update earlier findings. The analysis also explored how the ACA Medicaid expansion affects different types of hospitals by size, ownership, rurality, and safety-net status. We found that the early positive financial impact of Medicaid expansion was sustained in fiscal years 2016 and 2017 as hospitals in expansion states continued to experience decreased uncompensated care costs and increased Medicaid revenue and financial margins. The magnitude of these impacts varied by hospital type. As COVID-19 has brought hospitals to a time of great need, findings from this study provide important information on what hospitals in states that have yet to expand Medicaid could gain through expansion and what is at risk should any reversal of Medicaid expansions occur.

A Mixed Methods Examination of Health Care Provider Behaviors That Build Patients' Trust.

OBJECTIVE: Patient trust in health care providers is associated with better health behaviors and utilization, yet provider trust has not been consistently conceptualized. This study uses qualitative methods to identify the key health provider behaviors that patients report build their trust, and data from a national U.S. survey of adults to test the robustness of the qualitative findings. METHODS: In this mixed methods study, we conducted 40 semi-structured interviews with a diverse sample to identify the provider behaviors that build trust. We then analyzed a nationally representative survey (n = 6,517) to examine the relationship between respondents' trust in their usual provider and the key trust-related behaviors identified in the qualitative interviews. RESULTS: Interviewees reported that health providers build trust by communicating effectively (listening and providing detailed explanations), caring about their patients (treating them as individuals, valuing their experience, and showing commitment to solving their health issues), and demonstrating competence (being knowledgeable, thorough, and solving their health issues). Trust in one's provider was highly correlated with all eight survey items measuring communication, caring, and competence. CONCLUSIONS: To build trust with patients, health providers should actively listen, provide detailed explanations, show caring for patients, and demonstrate their knowledge.

The Association of Racial and Ethnic Social Networks with Mental Health Service Utilization Across Minority Groups in the USA.

Though they have comparable prevalence of mental illness, American racial and ethnic minorities are less likely to receive mental health services than white Americans. Minorities are often part of racial and ethnic social networks, which may affect mental health service utilization in two ways. While these networks can encourage service utilization by working as a channel of knowledge spillover and social support, they can also discourage utilization by stigmatizing mental illness. This study examined the association of racial and ethnic social networks with mental health service utilization and depression diagnosis in the USA. Using the 2012 Behavioral Risk Factor Surveillance System (BRFSS) data, a multilevel mixed-effect generalized linear model was adopted, controlling for predisposing, need, and enabling factors of mental health service utilization. The association of racial and ethnic social networks with mental health service utilization and depression diagnosis was significant and negative among African Americans. Despite having a comparable number of bad mental health days, the association was insignificant among Hispanic, Asian, and non-Hispanic white respondents. An African American living in a county where all residents were African American was less likely to utilize mental health services by 84.3-86.8% and less likely to be diagnosed with depression by 76.0-84.8% than an African American living in a county where no residents were African American. These results suggest racial and ethnic social networks can discourage mental health service utilization and should be engaged in efforts to improve mental health, particularly among African American communities in the USA.

Drivers of Racial and Ethnic Disparities in Cardiac Rehabilitation Use: Patient and Provider Perspectives.

Cardiac rehabilitation (CR) use is lower for racial and ethnic minorities than White patients. The purpose of this study was to identify factors that drive this disparity at the system, provider, and patient levels. A mixed methods study combined descriptive analysis of 2007 Medicare claims data and thematic analysis of 19 clinician interviews, 8 minority patient focus groups and 8 one-on-one interviews with minority heart patients across three communities. The disparity between White and non-White CR use ranged from 7 to 11 percentage points among study sites (p < .05). Key themes suggest disparities are driven by (a) flawed financing and reimbursement that creates disincentives to invest in CR programs, (b) a health care system whose priorities are misaligned with the needs of patients, and (c) subjective decision-making around referral processes. These findings suggest that the health care system needs to address multiple levels of problems to mitigate disparities in CR use.

The characteristics of clinically active older physician assistants.

OBJECTIVE: To prepare for future health workforce requirements, planners need an understanding of the clinical activity of physician assistants (PAs) and their career trajectory. We compared the characteristics of clinically active older PAs to younger PAs. METHOD: PAs were identified from all respondents aged 60 years or older at the time they participated in the annual census of the AAPA from 2005 through 2009. The most recent year of census participation was selected for analysis. This cadre of older PAs was compared with PAs younger than 60 years. Variables included age, gender, year of PA graduation, duration of being a PA, and clinical activity by self-identified work location and specialty. RESULT: A total of 48,692 PAs participated in at least one census from 2005 through 2009. Approximately 5% (2,340) met the age criteria and were clinically active. Clinically active older PAs reported working a mean of 39 hours per week and were employed in a rural setting more often than their younger counterparts. Nearly one-half of older respondents reported their specialty to be primary care. CONCLUSION: Although the career span of a PA is only vaguely understood, a small but significant portion of clinicians appear to remain in the workforce into their seventh decade. They distinguish themselves by working proportionally more in primary care and nonurban areas than younger PAs. Older PAs may represent an American trend by remaining employed longer than historically observed. Gaps in the understanding of role behavior of PAs could be improved with longitudinal databases.

Barriers to effective self-management in cardiac patients: the patient's experience.

OBJECTIVE: This paper identifies common obstacles impeding effective self-management among patients with heart disease and explores how for disadvantaged patients access barriers interfere with typical management challenges to undermine patients' efforts to care for their illnesses. METHODS: We convened 33 focus group discussions with heart patients in 10 U.S. communities. Using content analysis, we identified and grouped the most common barriers that emerged in focus group discussions. RESULTS: We identified nine major themes reflecting issues related to patients' ability to care for and manage their heart conditions. We grouped the themes into three domains of interest: (1) barriers that interfere with getting necessary services, (2) barriers that impede the monitoring and management of a heart condition on a daily basis, and (3) supports that enable self-management and improve care. CONCLUSION: For disadvantaged populations, typical problems associated with self-management of a heart condition are aggravated by substantial obstacles to accessing care. PRACTICE IMPLICATIONS: Ensuring disadvantaged patients with chronic heart conditions are linked to formal systems of care, such as cardiac rehabilitation programs, could better develop patients' self-management skills, reduce barriers to receiving care and improve the overall health outcomes of these patients.