Massachusetts Health Research Articles

Investigating a key structural determinant of health, racism, and related social determinants of health in Massachusetts during the COVID-19 pandemic.

A disproportionate burden of the ongoing COVID-19 pandemic is being shouldered by members of racial and ethnic minorities and socially disadvantaged communities. Structural and social determinants of health have been recognized as key contributors to the inequalities observed. Racism, a major structural determinant of health that patterns related social determinants of health, in the USA, warrants further investigation. In this perspective piece we provide an overview of the historical context of racism, followed by preliminary findings from the ongoing COVIDStory study-a cross-sectional study addressing perceptions of COVID-19 and COVID-19 research-that highlights the experiences of non-Hispanic Black and Hispanic identifying adult participants, residing in Worcester Massachusetts, during the COVID-19 pandemic. We then discuss these findings in the context of current and past research considering racism and relevant social determinants of health. Our study results suggest that racism and its residuals (residential segregation, economic insecurity, discrimination, bias, and vigilance) are modern challenges for non-Hispanic Black and Hispanic participants, and these findings are supported by the existing literature. It is our hope that this perspective piece provides additional evidence for action on structural and social determinants affecting the health of minoritized people, especially those living in Massachusetts.

The Evolution of CRISPR Technology from Editing to Diagnostics

The Evolution of CRISPR Technology from Editing to Diagnostics

Exploring How Public Health Partnerships with Community-Based Organizations (CBOs) can be Leveraged for Health Promotion and Community Health.

The Academic Public Health Corps (APHC) works to support local public health in Massachusetts through varying models of collaboration. In the setting of the COVID-19 pandemic, one initiative of the APHC has been to partner with community-based organizations (CBOs) to address vaccine hesitancy and improve overall community health. The purpose of this article is to share how the APHC partnered with CBOs in Massachusetts to address COVID-19 concerns within their respective communities, and present strategies to empower communities, share resources, and increase health promotion. The APHC partnered with 2 CBOs who received the Massachusetts COVID-19 Community Grants distributed by Health Resources in Action (HRiA). These CBOs include the Association of Islamic Charitable Projects Massachusetts (AICP) and the Somali Parents Advocacy Center for Education (SPACE). Culturally relevant educational and promotional materials were created and tailored toward the communities of interest within the CBOs. Additionally, in response to the community's desire for more informational events, the APHC hosted a virtual COVID-19 Q&A panel with Muslim health care professionals that included live Arabic translation. The model of outreach that the APHC has employed illustrates an intentional way of addressing key public health issues within local communities. The success of these partnerships highlights the importance of including CBOs in conversations about public health and health equity.

Estimating Land Cover-Based Soil Organic Carbon Values to Support Soil Health, Decarbonization, and Climate Resilience Planning in Massachusetts

Estimating Land Cover-Based Soil Organic Carbon Values to Support Soil Health, Decarbonization, and Climate Resilience Planning in Massachusetts

Massachusetts advocates receive grant to address older adult BH

The Massachusetts Association for Mental Health (MAMH) was awarded a three‐year grant of $225,000 from the Tufts Health Plan Foundation to highlight and elevate the importance of older adult behavioral health in Massachusetts, according to a July 9 press release. The grant will be used to strengthen existing networks related to older adults and behavioral health, beginning with supporting and expanding the work of the Massachusetts Aging and Mental Health Coalition. Grant activities will focus on supporting workforce development; educating older adults, caregivers and the public about the importance of addressing behavioral health in the context of aging; and informing state and local policy decisions that affect older adults. “Older people have been disproportionately affected by COVID‐19, and the prolonged impact of social isolation, financial stress, and grief may put them at increased risk for mental health and substance use concerns,” said Danna Mauch, MAMH president and CEO. “This generous grant from the Tufts Health Plan Foundation will allow us to work collaboratively with many community partners to elevate the importance of these issues and ensure that a broad range of diverse views are engaged in finding solutions.” The Tufts Health Plan Foundation is the only regional funder exclusively focused on healthy aging.

Can Automatic Retention Improve Health Insurance Market Outcomes?

There is growing interest in market design using default rules and other “choice architecture” principles to steer consumers toward desirable outcomes. Using data from Massachusetts's health insurance exchange, we study an “automatic retention” policy intended to prevent coverage interruptions among low-income enrollees. Rather than disenroll people who lapse in paying premiums, the policy automatically switches them to an available free plan until they actively cancel or lose eligibility. We find that automatic retention has a sizable impact, switching 14 percent of consumers annually and differentially retaining healthy, low-cost individuals. The results illustrate the power of defaults to shape insurance coverage outcomes.

Developing Statewide Violence Prevention Programs in Health Care: An Exemplar From Massachusetts.

Workplace violence is on the rise in health care. This problem contributes to medical errors, ineffective delivery of care, conflict and stress among health professionals, and demoralizing and unsafe work conditions. There is no specific federal statute that requires workplace violence protections, but several states have enacted legislation or regulations to protect health care workers. To address this problem in their state, the Massachusetts Health & Hospital Association developed an action plan to increase communication, policy development, and strategic protocols to decrease workplace violence. The purpose of this article is to report on the quality and safety improvement work that has been done statewide by the Massachusetts Health & Hospital Association and to provide a roadmap for other organizations and systems at the local, regional, or state level to replicate the improvement process.

Cognitive Health in Massachusetts, New Hampshire, and Rhode Island: Findings From the Healthy Aging Data Reports

Over time persons with Alzheimer’s disease (AD) have impaired health, lower quality of life, and increased mortality compared to those without AD. This study describes state and community rates of Alzheimer’s disease, self-rated cognitive difficulty, and the % of the population age 85+ in three New England states (MA, NH, RI). Data sources were the American Community Survey (2009-2013 RI, 2012-2016 MA/NH) and the CMS Medicare Current Beneficiary Summary File (2012-2013 RI, 2015 MA/NH). Small area estimation techniques were used to calculate age-sex adjusted community rates for Alzheimer’s disease and related dementias (ADRD), self-reported cognitive difficulties, percentage of older adults 85 years or older, and the percentage of adults age 65+ living alone. State rates (range) were: AD: RI 14.4% (8-23%), MA 13.6% (6-19.31%), and NH 12% (5.49-33.51%). Self-reported cognitive difficulty: MA 8.3% (0-25.16%), RI 7.8% (2-18%), and NH were 6.9% (0-34.21%). Adults 85 years and older: RI 17.6% (6-24%), MA 15.2% (0-32.23%), and NH 12.9% (0-27.91%). Living alone: RI 30.4% (12-45%), MA 30.2% (6.25-50%), and NH 26.1% (6.13-72.55%). While there was significant variation across states, Rhode Island had the highest state rate of ADRD, older adults 85 and older, and percentage of older adults living alone. Within-state disparities among AD rates, cognitive difficulties, and living alone was highest in NH, but MA had the largest variation for community rates of adults 85+. Understanding the prevalence of brain health is important to policy and practice efforts to promote age-friendly communities. This research was supported by the Tufts Health Plan Foundation.

A Pragmatic Controlled Trial of a Brief Yoga and Mindfulness-Based Program for Psychological and Occupational Health in Education Professionals

ObjectivesTo examine changes in psychological and occupational wellbeing in education professionals that attended a brief yoga and mindfulness-based program. DesignPragmatic controlled trial comparing education professionals that attended a yoga mindfulness-based program (n = 9) to a waitlist control group (n = 22). SettingThe 3-day program was delivered at the Kripalu Center for Yoga & Health in Massachusetts. Intervention: The 3-day yoga mindfulness program included 5 hours per day of yoga, mindfulness exercises, formal meditation, didactic, and experiential activities.Main Outcome Measures: Measures of psychological and occupational wellbeing were completed before (baseline), immediately after (post-program), and two months after the program (follow-up). Results: Relative to controls (n = 21), the RISE group (n = 9) showed significant improvements in positive affect (p = .033), negative affect (p = .044), mindfulness (p = .001), empowerment (p = .022), self-compassion (p = .001), and work engagement from baseline to post-program. From baseline to follow-up, the RISE group showed significant improvements in stress (p = .008), negative affect (p = .013), mindfulness (p = .001), empowerment (p = .007), and self-compassion (p = .001) compared to the control group. ConclusionsThe yoga mindfulness program was associated with improvements in educators’ psychological and occupational wellbeing immediately following and 2-months following the program. Future research with a larger sample size is needed to confirm these results.

First Person: Howard Koh, MD, MPH: Physician devotes his career to improving public health on many fronts.

First Person: Howard Koh, MD, MPH: Physician devotes his career to improving public health on many fronts.

Validation of a risk stratification tool for fall-related injury in a state-wide cohort

ObjectiveA major preventable contributor to healthcare costs among older individuals is fall-related injury. We sought to validate a tool to stratify such risk based on readily available clinical data, including...

The Large Gaps in Transgender Medical Knowledge among Providers must be Measured and Addressed

Transgender or gender-incongruent individuals are those with gender identity or expression that differs from external sexual anatomy. Data suggest that 0.3 to 0.5% of the American population, or 900,000 individuals, are transgender ( 1. Conron K.J. Scott G. Stowell G.S. Landers S.J. Transgender health in Massachusetts: results from a household probability sample of adults. Am J Public Health. 2012; 102: 118-122 Crossref PubMed Scopus (298) Google Scholar , 2. Reisner S.L. Conron K.J. Tardiff L.A. Jarvi S. Gordon A.R. Austin S.B. Monitoring the health of transgender and other gender minority populations: validity of natal sex and gender identity survey items in a U.S. national cohort of young adults. BMC Public Health. 2014; 14: 1224 Crossref PubMed Scopus (129) Google Scholar ). Transgender persons have long suffered limited access to health care and, further, suffer significant health care disparities ( 3. Safer J.D. Coleman E. Feldman J. et al. Barriers to healthcare for transgender individuals. Curr Opin Endocrinol Diabetes Obes. 2016; 23: 168-171 Crossref PubMed Scopus (334) Google Scholar ). For example, multiple authors report increased incidence of human immunodeficiency virus infection, substance abuse, and depression among transgender individuals.

Influence of Health Insurance Expansion on Disparities in the Treatment of Acute Cholecystitis.

To evaluate the impact of the 2006 Massachusetts (MA) health reform on disparities in the management of acute cholecystitis (AC). Immediate cholecystectomy has been shown to be the optimal treatment for AC, yet variation in care persists depending upon insurance status and patient race. How increased insurance coverage impacts these disparities in surgical care is not known. A cohort study of patients admitted with AC in MA and 3 control states from 2001 through 2009 was performed using the Hospital Cost and Utilization Project State Inpatient Databases. We examined all nonelderly white, black, or Latino patients by insurance type and patient race, evaluating changes in the probability of undergoing immediate cholecystectomy and disparities in receiving immediate cholecystectomy before and after Massachusetts health reform. Data from 141,344 patients hospitalized for AC were analyzed. Before the 2006 reform, government-subsidized/self-pay (GS/SP) patients had a 6.6 to 9.9 percentage-point lower (P < 0.001) probability of immediate cholecystectomy in both MA control states. The MA insurance expansion was independently associated with a 2.5 percentage-point increased probability of immediate cholecystectomy for all GS/SP patients in MA (P = 0.049) and a 5.0 percentage-point increased probability (P = 0.011) for nonwhite, GS/SP patients compared to control states. Racial disparities in the probability of immediate cholecystectomy seen before health care reform were no longer statistically significant after reform in MA while persisting in control states. The MA health reform was associated with increased probability of undergoing immediate cholecystectomy for AC and reduced disparities in undergoing cholecystectomy by insurance status and patient race.

Study: Alcohol a leading preventable cause of cancer death

Alcohol is a leading preventable cause of cancer death in the United States, according to a study published in the American Journal of Public Health.1 The researchers, from the Boston University School of Medicine and the Boston University School of Public Health in Massachusetts, also demonstrated that reducing alcohol consumption is a key cancer prevention strategy as, even in small amounts, alcohol is a known carcinogen. Alcohol has been implicated consistently in previous studies as a significant risk factor for cancers of the mouth, throat, esophagus, and liver. It also has been shown to increase the risk of cancers of the colon, rectum, and female breast. Estimates indicate that it accounts for approximately 4% of all cancer-related deaths worldwide. Researchers, including senior author Timothy Naimi, MD, MPH, of the Boston University School of Medicine and colleagues from the National Cancer Institute, the Alcohol Research Group at the Public Health Institute, and Canada's Centre for Addiction and Mental Health, examined US data on alcohol consumption and cancer mortality. They found that alcohol consumption resulted in approximately 20,000 cancer deaths annually, or approximately 3.5% of all US cancer deaths. Breast cancer was the most common cause of alcohol-related deaths in women, accounting for approximately 6000 deaths, or 15% of all breast cancers, annually. Cancers of the mouth, throat, and esophagus were common causes of alcohol deaths in men, accounting for approximately 6000 annual deaths. Dr. Naimi and his colleagues also determined that each alcoholrelated death led to approximately 18 years of potential life lost. Furthermore, although higher levels of alcohol consumption led to a higher cancer risk, an average consumption of 1.5 drinks per day or less accounted for 30% of all alcohol-related cancer deaths. Dr. Naimi adds that although the relationship between alcohol and cancer is strong, it is not widely appreciated by the public and is underemphasized by physicians. In a news release issued by Boston University, he calls alcohol “a big preventable cancer risk factor that has been hiding in plain sight.”

Insurance expansion in Massachusetts did not reduce access among previously insured Medicare patients.

Critics of Massachusetts's health reform, a model for the Affordable Care Act, have argued that insurance expansion probably had a negative spillover effect leading to worse outcomes among already insured patients, such as vulnerable Medicare patients. Using Medicare data from 2004 to 2009, we examined trends in preventable hospitalizations for conditions such as uncontrolled hypertension and diabetes--markers of access to effective primary care--in Massachusetts compared to control states. We found that after Massachusetts's health reform, preventable hospitalization rates for Medicare patients actually decreased more in Massachusetts than in control states (a reduction of 101 admissions per 100,000 patients per quarter compared to a reduction of 83 admissions). Therefore, we found no evidence that Massachusetts's insurance expansion had a deleterious spillover effect on preventable hospitalizations among the previously insured. Our findings should offer some reassurance that it is possible to expand access to uninsured Americans without negatively affecting important clinical outcomes for those who are already insured.

Structural and Organizational Characteristics Associated With Performance of Essential Public Health Services in Small Jurisdictions

This study examined jurisdictional, organizational, and structural characteristics associated with capacity to deliver 10 essential public health services (EPHS) in Massachusetts, a state where a majority of local public health departments serve small municipalities. A survey was administered to local health directors or board of health chairs. The main outcome of the study was capacity to perform EPHS, measured by a 25-item screening tool. Seventy percent of the 351 boards of health in Massachusetts participated in the study. Greatest capacity was demonstrated in EPHS 2 (Diagnose and Investigate Health Problems) and EPHS 6 (Enforce Laws and Regulations). The capacity to perform the 8 other essential services was limited. Bivariate analysis indicates that overall capacity to perform EPHS is significantly associated with population size, poverty rate, annual municipal budget, and perceived understanding of the roles and responsibilities of local boards of health among elected municipal officials. The latter was the strongest predictor of overall capacity in multivariate analysis. Findings are aligned with studies examining factors associated with capacity to perform EPHS in large public health jurisdictions. The results suggest that one strategy for improving capacity to perform EPHS in smaller jurisdictions is to educate elected municipal leaders about the responsibilities of local health officials. Clarification regarding the role small jurisdictions with limited resources can play to ensure the equitable delivery of essential public health services and a strategy for measuring their contributions is important, especially as the national public health accreditation program gains momentum in the United States.

Reasons For The Wide Variation In Medicaid Participation Rates Among States Hold Lessons For Coverage Expansion In 2014

The Affordable Care Act will expand Medicaid eligibility in 2014 to adults with incomes of up to 133 percent of the federal poverty level. To maximize this opportunity, policy makers need to ensure that participation, or "take-up," among eligible adults exceeds current rates. Using the Current Population Survey 2005-10, we estimated that the nationwide Medicaid participation rate was 62.6 percent among eligible adults ages 19-64 without private insurance. Take-up varied widely by state, from 43.0 percent in Arkansas and Louisiana to 82.8 percent in Massachusetts, after adjusting for population demographics. Participation was highest among disabled adults, 75.8 percent, and lowest among childless adults, 38.3 percent. Factors linked to higher take-up rates included low cost sharing for beneficiaries; more generous benefits; and greater use of managed care programs for Medicaid populations. Factors associated with lower take-up rates included the existence of asset tests in some states. Massachusetts's health reform was associated with a major increase in Medicaid participation. Our results suggest that when Medicaid is expanded in 2014, take-up may be less than anticipated because new enrollees will be offered a more restrictive set of benefits--known as "benchmark coverage"--compared to those in traditional Medicaid, and the majority of newly eligible adults will be in groups with traditionally low take-up (primarily nondisabled adults). To encourage high participation in the expanded Medicaid program, states will need to offer comprehensive coverage of needed benefits; provide community-based outreach; and consider more dramatic changes to their enrollment processes, such as automatically enrolling people in Medicaid based on their participation in other public programs.

Transgender Health in Massachusetts: Results From a Household Probability Sample of Adults

Despite higher rates of unemployment and poverty among transgender adults (n = 131; 0.5% weighted) than among nontransgender adults (n = 28,045) in our population-based Massachusetts household sample, few health differences were observed between transgender and nontransgender adults. Transgender adults who are stably housed and participated in a telephone health survey may represent the healthiest segment of the transgender population. Our findings demonstrate a need for diverse sampling approaches to monitor transgender health, including adding transgender measures to population-based surveys, and further highlight economic inequities that warrant intervention.

Abstract P98: Change in Racial and Ethnic Disparities in Use of Inpatient Cardiovascular Surgeries in Postreform Massachusetts

BACKGROUND The 2006 Massachusetts (MA) health reform increased insurance coverage to near-universal levels, but its impact on access to care is not known. We examined post-reform change in racial/ethnic differences in use of two cardiovascular procedures - percutaneous transluminal coronary angioplasty (PTCA) and coronary artery bypass graft (CABG) - and two non-cardiovascular procedures (knee and hip replacements) documented to be underutilized by minorities. METHODS Using discharge data on all MA hospitalizations for 21 months preceding and following implementation of the reform, we identified all PTCA, CABG and joint (knee, hip) replacement procedures performed for patients aged &gt;=40. Stratifying census population by race/ethnicity, we estimated pre- and post-reform population-based procedure rates, and their changes, for those aged 40-64, adjusting for secular changes unrelated to reform by capturing corresponding changes for those aged &gt;= 65, whose coverage (Medicare) was unaffected by reform. RESULTS There was a secular decrease in use of PTCA and CABG for all groups (of 18% or more); use of joint replacement increased (&gt;=20%). Post-reform, Black/White ratio of combined PTCA &amp; CABG procedure rate improved from 0.77 to 0.82, with a smaller decrease for Blacks (18%) than Whites (24%). Difference in Hispanic/White PTCA &amp; CABG procedure rate was not significant pre- and post-reform. Post-reform change associated with reform was not significant. Use of joint replacement increased for both minorities vs. Whites; change associated with reform was sizable for all groups (&gt;=7%; significant for Whites only). CONCLUSIONS Use of inpatient PTCA and CABG shows a largely secular decrease, with little change associated with reform. While Black-White difference in PTCA and CABG rate decreased marginally, the rate among Blacks remained significantly lower than for Whites and Hispanics. Limitation: clinical appropriateness of the procedures could not be confirmed. Table 1. Differences in Procedure Rates and Post-Reform Change in Massachusetts: Age 40-64 PTCA &amp; CABG Knee &amp; Hip Replacement Whites Blacks Hispanics Whites Blacks Hispanics Pre-reform Procedure Rate/10,000 pop. c 38 29 38 30 31 13 Procedure Rate Ratio, Non-White/White (p-value for test of ratio=1) 0.77*** 0.99 1.03 0.42*** Post-reform Procedure Rate/10,000 pop. c 29 24 31 35 41 18 Procedure Rate Ratio, Non-White/White (p-value for test of ratio=1) 0.82*** 1.04 1.18** 0.52*** Total Post-reform Change, % d -24%*** -18%*** -19%*** 20%*** 36%*** 40%*** Difference, Non-White -White (p-value for test of difference=0) 5.2% 5.1% 16%* 20%** Net Post-reform Change, % e (p-value for test of change=0) -0.9% -2.2% 2.9% 7%*** 12% 18% a) ***, ** and * denote p-value &lt;=0.001, &lt;=0.01 and &lt;=0.05 respectively b) Pre-reform period=(Oct 2004 to Jun 2006) and post-reform period=(Jan 2008 to Sept 2009) are 21 months each c) Procedure rates, adjusted for sex and age differences, are estimated by direct standardization method d) Total post-reform change in procedure rate is the simple % change in the pre-and post-reform procedure rates. e) Net post-reform change is the estimate of change in procedure rate associated with the health reform. To separate the impact of health reform from secular temporal effects that may be unrelated to health reform, we used a difference-in-difference specification of a hierarchical Poisson regression model to estimate the net change among the 40-64 age group by contrasting the corresponding change for those among patients aged ≥65, assuming they had continuous Medicare coverage that was unaffected by the reform

Survey Finds CE, IT Departments View One Another Warily

While technological advances are forcing clinical engineering (CE) and healthcare information technology (IT) professionals to collaborate more than ever, a new survey reveals some striking disparities in the way each group perceives its own priorities and the priorities of the other. For example, while IT professionals list “patient care” as their highest priority, CE professionals perceive patient care to be the least of IT’s priorities. Additionally, whereas CE professionals consider “network management” to be a fairly significant departmental priority, IT professionals perceive network management to be, by far, the lowest of all possible priorities for CE departments. The survey was conducted by the CE-IT Community—a collaboration among AAMI, the American College of Clinical Engineering (ACCE), and the Healthcare Information and Management Systems Society (HIMSS). The effort is intended to help ease the myriad challenges related to the convergence of medical and information technologies. The survey sought to get a snapshot of the working relationships between CE and IT departments in healthcare facilities, and to identify obstacles that may hinder their ability to work well together. The responses suggest there is a long way to go in helping each group better understand the other. One portion of the survey asked respondents to rate 19 different departmental priorities on a scale of 1–5, with five being the highest priority. IT professionals’ listed “end-user education” and “safety” as high priorities, with CE perceiving those areas as very low priorities for IT. “Technology assessment” was another point of contention, with CE calling it a high priority, and IT perceiving technology assessment as a low CE priority. Ken Olbrish, a system administrator with Main Line Health near Philadelphia and a member of the CE-IT Community’s Steering Committee, says that the survey results “are an illustration of why the work of the CE-IT Community is needed—to try to bring both sides closer together and have a better understanding of one another. There have been these anecdotal perceptions for years from each side about the other, but the survey puts numbers on it.” Steve Merritt, infrastructure engineer with Baystate Health in Massachusetts and a leader of the CE-IT Community, says that some discrepancies in responses about priorities could be the result of differing vocabularies. For example, do words like “maintenance” or “safety” mean the same things to both a clinical engineer and an IT professional? “Making sure both departments are using the same terminology and vocabulary could be one way of smoothing out communication issues between the two,” says Merritt. “Developing a shared vocabulary between CE Patrick Bernat is director of Healthcare Technology Management at AAMI. E-mail: pbernat@aami.org Survey Finds CE, IT Departments View One Another Warily