Offering extended use of the contraceptive implant via an implementation science framework: a qualitative study of clinicians' perceived barriers and facilitators.

BACKGROUND: The etonogestrel contraceptive implant is currently approved by the United States Food and Drug Administration (FDA) for the prevention of pregnancy up to 3 years. However, studies that suggest efficacy up to 5 years. There is little information on the prevalence of extended use and the factors that influence clinicians in offering extended use. We investigated clinician perspectives on the barriers and facilitators to offering extended use of the contraceptive implant. METHODS: Using the Consolidated Framework for Implementation Research (CFIR), we conducted semi-structured qualitative interviews. Participants were recruited from a nationwide survey study of reproductive health clinicians on their knowledge and perspective of extended use of the contraceptive implant. To optimize the diversity of perspectives, we purposefully sampled participants from this study. We used content analysis and consensual qualitative research methods to inform our coding and data analysis. Themes arose deductively and inductively. RESULTS: We interviewed 20 clinicians including advance practice clinicians, family medicine physicians, obstetrician/gynecologist and complex family planning sub-specialists. Themes regarding barriers and facilitators to extended use of the contraceptive implant emerged. Barriers included the FDA approval for 3 years and clinician concern about liability in the context of off-label use of the contraceptive implant. Educational materials and a champion of extended use were facilitators. CONCLUSIONS: There is opportunity to expand access to extended use of the contraceptive implant by developing educational materials for clinicians and patients, identifying a champion of extended use, and providing information on extended use prior to replacement appointments at 3 years.

Rural Hospital Closures: A Scoping Review of Studies Published Between 1990 and 2020.

Between 1990 and 2020, 334 rural hospitals closed in the United States, and since 2011 hospital closures have outnumbered new hospital openings. This scoping review evaluates peer-reviewed studies published since 1990 with a focus on rural hospital closures, synthesizing studies across six themes: 1) health care policy environment, 2) precursors to rural hospital closures, 3) economic impacts, 4) effects of rural hospital closures on access to care, 5) health and community impacts, and 6) definitions of rural hospitals and communities. In the 1990s, rural hospitals that closed were smaller, while rural hospitals that closed in the 2010s tended to have more beds. Many studies of the health impacts of rural hospital closures yielded null findings. However, these studies differed in their definitions of "rural hospital closure." Given the accelerated rate of hospital closures, more attention should be paid to hospitals that serve rural communities of color and low-income communities.

Food (in)security in relation to nutrition (in)security in a national cross-sectional sample of Supplemental Nutrition Assistance Program participants: considerations of an emerging construct.

BACKGROUND: Food insecurity, lack of access to sufficient food for an active, healthy life, is a persistent problem in the United States. Recently, nutrition security has emerged as a new concept. However, limited research exists examining how nutrition security relates to the established concept of food security. OBJECTIVES: This study assessed a recent metric of nutrition security and explored how well it describes the underlying construct among a sample of Supplemental Nutrition Assistance Program (SNAP) participants. We examined the correlation between food and nutrition security and demographic predictors of joint food and nutrition security status. METHODS: We conducted a national, web-based survey (Qualtrics; 30 September-19 October, 2022) in English and Spanish of adults aged ≥18 y (n = 1454) who reported receiving SNAP benefits in the past 12 mo. We measured food security using the US Department of Agriculture 6-item Food Security Survey and assessed nutrition security using the Gretchen Swanson Center for Nutrition Household Nutrition Security measure. We used multinominal logistic regression to examine demographic predictors of food and nutrition security. RESULTS: The majority (80.4%) of SNAP participants experienced food insecurity, and 59.1% reported experiencing nutrition insecurity. Food and nutrition security were moderately correlated (0.41); 55.6% of SNAP participants were both food and nutrition insecure, 3.5% were food secure but nutrition insecure, 24.8% were food insecure but nutrition secure, and 16.1% were both food and nutrition secure. Of SNAP participants, 24.8% reported experiencing food insecurity but not nutrition insecurity. Hispanic ethnicity and Southern residence were associated with joint food and nutrition insecurity. CONCLUSIONS: These findings raise questions about how nutrition security is conceptualized and measured and its added value beyond existing food security measurement scales. Further research is needed to understand differences in food and nutrition security experiences and risk factors and determine a validated definition and measure of nutrition security for future policy solutions.

A cross-sectional study of psoriasis hospitalizations in patients with cardiovascular comorbidities in patients under 60.

There is limited data assessing length of stay, cost of care, and differences in demographic data in hospitalized psoriasis patients with and without cardiovascular disease. Our study compares hospitalized psoriatic patients with and without comorbid cardiovascular disease for differences in length of stay and cost of care, as well as to assess differences in patient demographics. A cross-sectional study of hospital encounters of patients under the age of 60 with psoriasis in the National Inpatient Sample from 2016 to 2020 was performed using univariate analyses and a multivariable logistic regression model. A total of 2,485 psoriasis hospitalizations were included. 2,145 (86.3%) had psoriasis without cardiovascular disease and 340 (13.7%) had psoriasis with cardiovascular disease. Linear regression models identified significantly longer lengths of stay (Beta: 1.6; SE: 0.721; P = 0.030) and higher cost of care (Beta: 4,946; SE: 1,920; P = 0.011) in psoriasis patients with cardiovascular comorbidities.

Reduced rates of substance use disorder in patients with alopecia: An all of us case-control study.

Alopecia areata (AA), depression, anxiety, and decreased quality of life are highly associated in the literature. It has been noted that there is an increased risk of substance use in those with AA to help cope with the psychological burdens and perceived stigmatization. This study aims to explore the relationship between substance use disorder (SUD) and scarring/non-scarring alopecia using the All of Us database. Of the 9,385 patients with alopecia, 8.4% had SUD of any kind. Multivariable regression revealed that alopecia is a potential protective factor against SUD when controlling for other covariates of significance, with a decreased odds of 0.73. Substance use disorder prevalence was not different between scarring and non-scarring alopecia. This may be the result of patients fearing exacerbation of hair loss, or due to increased mental health and community support in patients with alopecia. Dermatologists and primary care providers should continue to promote psychotherapy and community support to patients whose diagnosis of alopecia has a negative psychosocial impact.

Predictors of Incident Stroke and Subsequent Mortality Among a Sample of Veterans with Experience of Housing Instability.

Homelessness is associated with poor health outcomes and early development of cardiovascular disease. This study investigated the correlates of incident stroke and its association with mortality among Veterans experiencing housing instability. Using a national sample of Veterans (n=565,608) with incident housing instability between 2014-2018, we compared characteristics of Veterans who did and did not experience incident stroke and conducted logistic regressions to assess two outcomes: incident stroke and mortality. Almost four percent experienced a first stroke and were more frequently male, older than 55 years, Black, and non-Hispanic. A higher rate of mortality was observed among those with a first stroke compared with those with no stroke (17.6% vs. 10.8%), although the difference was not statistically significant. Incident stroke was associated with triple the odds of death among unstably-housed Veterans compared with those who did not have an incident stroke. Implications include the need to screen and monitor for stroke risk among Veterans with experience of housing instability, particularly for those who are older.

Prevalence and Impact of Adverse Social and Behavioral Determinants of Health in Heart Failure: Analysis of a Safety-Net Population.

OBJECTIVE: To determine the impact of adverse social and behavioral determinants of health (SBDH) on health care use in a safety-net community hospital (SNCH) heart failure (HF) population. METHODS: We performed a retrospective analysis of HF patients at a single SNCH between 2018-2019 (N= 4594). RESULTS: At least one adverse SBDH was present in 21% of the study population. Patients with at least one adverse SBDH were younger (57 vs. 68 years), more likely to identify as Black (50% vs. 36%), be male (68% vs. 53%), and have Medicaid insurance (48% vs. 22%), p<.001. Presence of at least one adverse SBDH (homelessness, substance use, or incarceration) correlated with increased hospitalizations (2.3 vs 1.4/patient) and ED visits (5.1 vs 2.1/patient), p<.0001. Adverse SBDH were independent predictors of HF readmissions. Prescribing of guideline-directed medical therapy was similar among all patients. CONCLUSIONS: In a SNCH HF cohort, adverse SBDH predominantly afflict younger Black men on Medicaid and are associated with increased utilization.

Prevalence of Diabetes Mellitus among Haitian Americans: A Hidden Epidemic.

The prevalence of diabetes mellitus in the Haitian American population remains an important question. A recent study revealed an alarming prevalence of 39.9%. To corroborate these data, between November 2021 and September 2023 a representative sample was collected among 401 Haitian Americans in Florida, Maryland, New Jersey, and New York. Results revealed a crude prevalence rate of 36.6% (95% CI 31.85, 41.55%). The age-adjusted prevalence was 29.7% (CI 19.71%, 39.63%). This study's prevalence is nearly double the 16.8% (Z=10.48, p<.0001) rate in non-Hispanic African Americans and nearly two and a half times the 12.0% (Z=14.99, p<.0001) rate in all Americans. The crude prevalence for undiagnosed diabetes mellitus was 13.38% (CI 10.19%, 17.14%), with 17.11% age-adjusted prevalence (CI 7.53%, 26.70%). The scope of the diabetes burden, especially the high rate of undiagnosed cases, indicates a need for better strategies for the prevention, screening, treatment, and management of diabetes among Haitian Americans.

Shallow Subsidies for Veterans Facing Housing Barriers in the VA Supportive Services for Veteran Families Program.

The Department of Veterans Affairs provides a shallow subsidy (i.e., subsidizing 50% of an individual's rent for two years) to Veterans experiencing housing instability. We sought to describe the characteristics of Veterans who received these subsidies. Methods. We conducted a retrospective cohort study of Veterans between 10/2019-9/2021. We identified Veteran-level characteristics associated with receiving a shallow subsidy using a multivariable two-part regression model. We also conducted qualitative interviews to identify how shallow subsidies are allocated. Results Black race, higher income, more education, and older age were positively associated with receiving a shallow subsidy; previous homelessness, prior VA outpatient cost, and participating in permanent supportive housing were negatively associated with receiving a shallow subsidy. Interviews revealed that income was the most influential determinant of whether to give shallow subsidies. Discussion Our mixed methods findings were consistent, indicating that socioeconomic stability is an important driver of shallow subsidy allocation decisions.

A Social-ecological Perspective on Understanding Facilitators to Access Primary Health Care Services among Ethiopian Immigrant Women in the United States.

Using a social-ecological model (SEM), this qualitative study explored the facilitators of access to primary health care (PHC) among Ethiopian immigrant women in the U.S. Data were collected through in-depth interviews (N=21, ≥18 years) and analyzed thematically using Nvivo12. At the individual level, stable employment, insurance, immigration status, proactivity, education, communication skills, and internet usage were identified as facilitators of PHC access. Interpersonal support from family and friends was highlighted as a key facilitator. Institutional facilitators included interpretation services and the sociocultural background of health care providers. On the community level, support from community organizations and residing in certain locations were recognized as facilitators of PHC access. No policy-level facilitators were identified. The findings underscore the importance of strengthening individual and interpersonal capacities, including job opportunities, social support, legal assistance for immigration status, and education and communication skills. Further research is needed to analyze policy gaps and suggest viable solutions.

Special Considerations for Brazilian Transgender Patients in the United States: A Commentary.

Despite facing many social and structural challenges inside and outside of health systems, transgender and gender diverse (TGD) Brazilian immigrants in the U.S. are understudied, and their barriers to care are largely unnamed. In this commentary, we build on existing literature and our experiences at a safety-net community health system that sees a high volume of Brazilian patients to discuss challenges facing TGD Brazilian immigrant populations. We highlight that while Brazilian TGD populations face discrimination in Brazil, major challenges persist upon immigrating to the U.S., and include: difficulty updating identity documents and changing immigration status, barriers seeking general and specialized health care (including finding bilingual and bicultural providers), challenges navigating complex health and insurance systems, and a lack of community supports. We end by recommending more coordinated efforts between health care and community organizations to help ensure the health and wellness of TGD Brazilian immigrants in the United States.

The Ryan White HIV/AIDS Program: Thirty Years of Addressing Health Disparities.

The Ryan White HIV/AIDS Program is a unique federal program to provide HIV care, treatment, and support services for people living with HIV in the United States. Through the distinctive structure of the program that allows for addressing both medical needs and some of the social determinants of health that can pose barriers to accessing care, the program has been instrumental in improving outcomes for people with HIV with documented improvement in HIV viral suppression and decreased disparities in that outcome over the past decade. To reach the goal of ending the HIV epidemic in the U.S., the program must expand services to people with HIV who are not regularly engaged in medical care.

Ethical and Equity Guidance for Transplant Programs Considering Thoracoabdominal Normothermic Regional Perfusion (TA-NRP) for Procurement of Hearts.

Donation after circulatory determination of death (DCDD) is an accepted practice in the United States, but heart procurement under these circumstances has been debated. Although the practice is experiencing a resurgence due to the recently completed trials using ex vivo perfusion systems, interest in thoracoabdominal normothermic regional perfusion (TA-NRP), wherein the organs are reanimated in situ prior to procurement, has raised many ethical questions. We outline practical, ethical, and equity considerations to ensure transplant programs make well-informed decisions about TA-NRP. We present a multidisciplinary analysis of the relevant ethical issues arising from DCDD-NRP heart procurement, including application of the Dead Donor Rule and the Uniform Definition of Death Act, and provide recommendations to facilitate ethical analysis and input from all interested parties. We also recommend informed consent, as distinct from typical "authorization," for cadaveric organ donation using TA-NRP.

The Unified Brain-Based Determination of Death Conceptually Justifies Death Determination in DCDD and NRP Protocols.

Organ donation after the circulatory determination of death requires the permanent cessation of circulation while organ donation after the brain determination of death requires the irreversible cessation of brain functions. The unified brain-based determination of death connects the brain and circulatory death criteria for circulatory death determination in organ donation as follows: permanent cessation of systemic circulation causes permanent cessation of brain circulation which causes permanent cessation of brain perfusion which causes permanent cessation of brain function. The relevant circulation that must cease in circulatory death determination is that to the brain. Eliminating brain circulation from the donor ECMO organ perfusion circuit in thoracoabdominal NRP protocols satisfies the unified brain-based determination of death but only if the complete cessation of brain circulation can be proved. Despite its medical and physiologic rationale, the unified brain-based determination of death remains inconsistent with the Uniform Determination of Death Act.