Integrated Health Care Research Articles

Pioneering sustainable treatment delivery in childhood leukemia through synchronous telemedicine—A pilot study

AbstractCancer care places a heavy economic burden on families and health systems, driven by high treatment costs, lengthy hospital stays, and the necessity for extensive travel to specialized facilities. To address this challenge, an integrated health care network (IHCN) was implemented for maintenance treatment in acute leukemia. The IHCN encompassed outpatient services provided by local physicians and synchronous telemedicine consultation with pediatric oncologists. This study included twenty‐two pediatric patients (eleven [50.0%] females; twenty [90.9%] with B‐ALL and two [9.1%] with AML). The IHCN was offered to all rural patients (n = 17) with a one‐way driving distance more than 30 km, while urban patients (n = 5) received regular cancer care. Throughout the study, rural patients had a total of 510 routine clinical visits, with 367 (72%) conducted through the IHCN. Physical examinations revealed similar frequency of new abnormal findings for urban and rural patients (22.4% vs. 17.8%; p = .31). Laboratory tests indicated no significant difference in the frequency of abnormal values for various parameters between both groups. Similarly, there was no discrepancy of drug modifications or interruption in maintenance therapy between the two settings (p = .85). Moreover, patients' health‐related quality of life remained within the normative range, and user satisfaction with the IHCN was notably high. The implementation of the IHCN resulted in savings of 70,158 km, 950 h of travel, and 12,277 kg CO2 emissions. This pilot study underscores the efficacy of a telemedicine‐based IHCN, ensuring safety, quality of care, cost reduction, and satisfaction for both families and health care providers in pediatric leukemia management.

Examining Whether Patient Portal and Video Visit Use Differs by Race and Ethnicity Among Older Adults in a US Integrated Health Care Delivery System: Cross-Sectional Electronic Health Record and Survey-Based Study

Background Health care systems are increasingly encouraging patients to use patient portals and participate in video visits. However, there is limited information about how portal use differs among older adults. Objective This study aimed to understand how patient portal and video visit use differed by age, race, and ethnicity among older adult patients with access to the same digital health resources. Methods This cross-sectional study used electronic health record and survey data for adults aged 65 to 85 years who were members of a large Northern California health care delivery system throughout 2019 and 2020. The electronic health record cohort (N=471,152) included 320,686 White, 35,892 Black, 44,922 Latino, 20,786 Chinese, 28,732 Filipino, 8473 South Asian, 6716 Japanese, 2930 Vietnamese, and 2015 Korean adults. Racial and ethnic group and age group (65 to 75 years vs 76 to 85 years) differences in having a patient portal account by December 2020, the performance of 2 portal activities (sending ≥1 message to a clinician in 2019 or 2020 and viewing ≥1 laboratory test result in 2020), and having ≥1 video visit during 2020 were examined. Modified log-Poisson regression was used to examine prevalence ratios for portal and video visit use, comparing racial and ethnic groups to White adults and Asian ethnic groups to Chinese adults after adjusting for sex and age. Data from a 2020 member survey were used to compare internet use factors among 2867 White, 306 Black, 343 Latino, 225 Chinese, and 242 Filipino adults. Results Black, Latino, and Filipino adults were less likely to have a patient portal account than White adults, and Filipino adults were less likely to have a patient portal account than Chinese adults. Black, Latino, Filipino, Korean, Vietnamese, and South Asian adults were less likely to have sent messages and viewed test results than White adults, while Chinese and Japanese adults’ use of these features was similar to that of White adults. Filipino, Vietnamese, and Korean adults were less likely to have performed the aforementioned activities than Chinese adults. Video visit use was lower among Black and Latino adults and higher among Chinese and South Asian adults compared with White adults (aged 76 to 85 years) and lower among Filipino, Korean, and Vietnamese adults compared to Chinese adults. Survey data suggested that underlying differences in internet use may partially explain the lower use of messaging by Black, Latino, and Filipino adults compared with White and Chinese adults. Conclusions Patient portal and video visit use differed by race, ethnicity, and age group among older adult patients with access to the same patient portal. Internet use factors may contribute to these differences. Differences in patient portal and video visit use across Asian subgroups underscore the importance of disaggregating use data by Asian ethnicity.

Implementation of a High-Reliability Organization Framework in a Large Integrated Health Care System: A Pre-Post Quasi-Experimental Quality Improvement Project.

The purpose of this quality improvement (QI) project was to evaluate outcomes across Veterans Health Administration (VHA) hospital facilities engaged in an enterprise-wide implementation of a high-reliability organization (HRO) framework. This QI project relied on primary data drawn from 139 facilities nationwide from 2019 to 2023. Data sources included the All Employee Survey Patient Safety Culture (PSC) Module and patient safety reporting data derived from the Joint Patient Safety Reporting system. The project design applied a pre-post quasi-experimental design that examined within-cohort changes at pre-intervention, intervention, and 2 post-intervention follow-up timepoints. HRO interventions included a combination of training, leadership coaching, site assessments, and experiential learning. HRO interventions were initiated at 18 facilities beginning in 2019 (Cohort 1), 54 facilities in 2020 (Cohort 2), and 67 facilities in 2021 (Cohort 3). For between-cohort analyses, the relative degree of change within Cohort 1 sites was compared with all other sites. There were broad positive within-group trends for PSC scores across all sites, and domain-specific between-group differences in PSC Dimension 2-Risk Identification and Just Culture-and Dimension 4-Error Transparency and Risk Mitigation. For patient safety reporting, total events reported, and close calls increased for Cohort 1. The ratio of close calls to adverse events also increased for both Cohort 1 and all other VHA sites at post-intervention year 2. The results of this QI project will inform further refinements to VHA's efforts to implement HRO principles and practices in the nation's largest integrated health system. In addition, the implementation practices may inform other large-scale, multi-level efforts to improve quality and patient safety.

A Tailored Postpartum eHealth Physical Activity Intervention for Individuals at High Risk of Postpartum Depression-the POstpartum Wellness Study (POW): Protocol and Data Overview for a Randomized Controlled Trial.

Postpartum depression (PPD) is associated with significant health consequences for the parent and child. Current recommendations for PPD prevention require intense health care system resources. Evidence-based interventions for PPD prevention that do not further burden the health care system are needed. Evidence suggests that physical activity (PA) can generally reduce depressive symptoms. Technology-based interventions may help decrease common barriers to PA. This study aims to report the protocol and provide a data overview of the POstpartum Wellness study (POW)-an effectiveness trial evaluating whether an eHealth PA intervention tailored for postpartum individuals increased PA and decreased depressive symptoms among individuals at high PPD risk. This remote parallel-group randomized controlled trial included postpartum individuals with a history of depression or at least moderate current depressive symptoms not meeting the PPD diagnostic threshold and with low PA levels from an integrated health care delivery system. Participants were randomized to an eHealth PA intervention or usual care. The intervention group received access to a library of web-based workout videos designed for postpartum individuals, which included interaction with their infants. At baseline and follow-up (3 and 6 months), PA was measured using questionnaires and a wrist-worn accelerometer. Depressive symptoms were measured using the Patient Health Questionnaire-8 (PHQ-8). Data were collected to assess exploratory outcomes of sleep, perceived stress, anxiety, parent-infant bonding, and infant development. The study was funded in January 2020. Participants were enrolled via REDCap (Research Electronic Data Capture) or telephonically between November 2020 and September 2022; data collection ended in April 2023. Randomized participants (N=99) were 4 months post partum at baseline with moderately severe depressive symptoms (mean PHQ-8 score 12.6, SD 2.2). Intervention (n=50) and usual care (n=49) groups had similar sociodemographic characteristics, months post partum, baseline depressive symptoms, number of children at home, and prepregnancy PA levels. Retention in assessments was ≥66% for questionnaires and ≥48% for accelerometry, with modest differences by group. At 3-month follow-up, 73 of 99 (74%) participants (intervention: 35/50, 70%; usual care: 38/49, 78%) completed questionnaires; 53 of 99 (54%) wore the accelerometer for 7 days (27 of 50 (54%) intervention, 26 of 49 (53%) usual care). At 6-month follow-up, 66 of 99 (67%) participants (30 of 50 (60%) intervention, 36 of 49 (73%) usual care) completed questionnaires and 43 of 99 (43%) wore the accelerometer for 7 days (21 of 50 (42%) intervention, 22 of 49 (45%) usual care). Data analysis is completed, and a manuscript with these findings is currently under review for publication. The POW trial evaluates the effectiveness of an eHealth PA intervention for improving depressive symptoms and increasing PA among postpartum individuals at high PPD risk. Results have implications for the design and delivery of behavioral interventions among vulnerable patients. ClinicalTrials.gov NCT04414696; https://clinicaltrials.gov/ct2/show/NCT04414696. DERR1-10.2196/56882.

Psychiatric comorbidity and hospitalization outcomes for AMI in portuguese public hospitals

Abstract Background Severe mental health disorders directly affect quality of life but may also indirectly relate to physical diseases and their prognosis. We test this hypothesis for the specific case of acute myocardial infarction (AMI), postulating a longer in-patient stay and an excess in-hospital mortality among patients suffering psychiatric comorbidities (PC). Methods A retrospective observational study was conducted using secondary data from public Portuguese hospitals, for all patients with a primary diagnosis of AMI (12,213 patients aged 18-80, for the years 2017-18). We used linear and logistic regression to model length of stay (LoS) and in-hospital mortality, respectively. Having at least one psychiatric comorbidity was the explanatory variable, and models were adjusted for age, sex, and the Charlson Comorbidity Index. Results The prevalence of PC was 12.95%. The in-hospital mortality rate was significantly higher in the group with PC (4.43%, OR = 1.372, 95%CI=1.041-1.784), than in the group without PC (3,38%). Stays were significantly longer among those with PC (mean=7.69 days), compared to those without PC (mean=6.87 days; adjusted β-coefficient=0.098, 95%CI=0.056-0.141). Conclusions Patients with AMI and comorbid mental disorders have poorer hospitalization outcomes than those without PC. This emphasizes the importance of promoting effective management strategies for comorbid psychiatric disorder, for instance, by improving the integration of mental health care in general hospitals, and empowering healthcare professionals to recognize and manage patients with PC. Key messages • Psychiatric comorbidity is related to longer inpatient stays and higher mortality risk among patients with AMI. • Efforts to integrate mental health care in general hospitals should be maintained.

Epidemiology, clinical characterization, and outcomes for heart failure with improved ejection fraction

Abstract Background Contemporary guidelines propose a new classification of heart failure with improved ejection fraction (HFimpEF). The prevalence of HFimpEF is expected to increase with the implementation of guideline-directed medical therapy (GDMT); however, there are limited data on the epidemiology of and outcomes for this novel clinical entity. Purpose We describe the prevalence, GDMT use and outcomes among patients with HFimpEF within a large, integrated healthcare delivery system. Methods We identified adults ≥18 years with incident HF with reduced EF (HFrEF ≤40%) between January 2013 and December 2018 from a large, integrated healthcare system serving >4.5 million members. HFimpEF was defined as known HFrEF with a follow-up EF measurement >40% within 12 months after incident HFrEF. Among HFimpEF patients, we examined GDMT use at discharge after incident HFrEF, incident HFimpEF, and at 6- and 12-months post-HFimpEF. From 12 months post initial HFrEF diagnosis, we calculated incidence rates of subsequent worsening HF (WHF) events (i.e., HF-related hospitalization, emergency department or urgent outpatient visits adjudicated using validated natural language processing-based algorithms) and all-cause death through December 31, 2019. We compared rates between patients with HFimpEF and those with persistent HFrEF (i.e., having all LVEF measurements within 12 months of incident HFrEF ≤40%) using Cox proportional hazards models adjusted for the EF value at incident HFrEF. Results Among 12,639 patients with incident HFrEF, 4,124 (33%) experienced HFimpEF within 12 months. Among patients with HFimpEF, use of β-blockers (82%) and angiotensin-converting enzyme inhibitor/angiotensin II receptor blockers (86%) was high, while angiotensin receptor-neprilysin inhibitor (1.2%) or mineralocorticoid receptor antagonist (28.2%) use was low. β-blockers, ACEi/ARB, and MRA use declined after incident HFimpEF (Figure, Panel A). Rates of WHF were 19.7 (95% Confidence Interval [CI]: 18.7 to 20.6) per 100 person-years among patients with HFimpEF vs. 40.0 (95% CI: 38.5 to 41.5) among patients with persistent HFrEF (hazard ratio [HR]: 0.55, 95% CI: 0.49 to 0.62; Figure, Panel B). Rates of death were 5.2 (95% CI: 4.7 to 5.7) and 8.4 (95% CI: 7.8 to 9.1) per 100 person-years among HFimpEF and persistent HFrEF, respectively (HR: 0.59, 95% CI: 0.52 to 0.67). Among patients with HFimpEF, those with an absolute EF improvement of ≥20% were less likely to experience WHF (HR: 0.82, 95% CI: 0.67 to 0.99) and death (HR: 0.85, 95% CI: 0.69 to 1.04) compared with those with <20% improvement. Conclusions One in three patients experienced improvement in EF within 12 months of initial HFrEF diagnosis. HFimpEF is associated with a reduced risk of WHF events and death, although these patients remain at significant clinical risk. Further research is necessary to assess the potential impact of sustained adherence to GDMT and therapeutic optimization on HFimpEF patient outcomes.

How to not revert to type: learnings from the pandemic response for universal health system reform

Abstract Background Understanding of the opportunities and learnings for health system change that have arisen during the pandemic is still emerging. Situated in the Irish health reform context of Sláintecare, the programme which aims to deliver universal, integrated healthcare, this study set out to generate evidence on the processes that impacted access to universal, integrated care during COVID-19, with a view to informing universal health system reform and implementation. Methods The study, which is qualitative, was underpinned by a co-production approach with Irish health system leadership. Semi-structured interviews were conducted with 16 health system professionals (including managers and frontline workers) from a range of responses to explore their experiences during the pandemic. Following thematic analysis, a complexity-informed approach guided the interpretation of the findings. Results A range of factors facilitated better access to integrated care during the crisis, falling under three key themes (1) nurturing whole-system thinking through a clear, common goal and shared information base; (2) harnessing, sharing and supporting innovation; and (3) prioritizing trust and relationship-building in a human-centred health system. Conclusions Alongside establishing health system structures, we must also incorporate alternative approaches to reform that recognise the value of shared sense-making in an interdependent system, while also allowing for innovation, exploration and learning; and acknowledging the role of social dynamics in driving change.

Integrated care in the Baltic states over a 5-year period: progress, challenges and future directions

Abstract Person-centered, multidisciplinary care is key to addressing evolving complex health needs. In Estonia, Latvia, and Lithuania, this pursuit of integrated care has gained momentum as an innovative approach to allocate resources more efficiently and improve patient outcomes. This study investigates the progress of integrating care in the Baltic countries from 2019 to 2024. It details key learnings, particularly for small European countries with limited resources. The Health Systems and Policy Monitor Network of the European Observatory on Health Systems and Policies undertook a cross-country study to better understand the progress in care integration in the Baltics. The Network’s Baltic country experts completed a 21-item questionnaire on the adoption of integrated care reforms. Responses were analyzed to capture reform characteristics and commonalities, countries’ political environments and their conduciveness to the uptake of integrated care. Country-specific experiences with the implementation of integrated care were further explored via case studies of pilot programs over the five years. The pace of implementing integrating care reforms varied in each country. Existing regulatory barriers, workforce challenges and payment schemes have impeded integration efforts across health and social care. Despite these obstacles, the political commitment to new and innovative service delivery and collaboration for chronic care management underscores an important prerequisite toward achieving more integrated and person-centered healthcare. The three case studies illustrate the hurdles that come with shifting care settings and expanding roles for some workers. Findings stress the role for integrated care to address organisational challenges in the Baltics. This study highlights innovative approaches and long-running efforts to provide multidisciplinary care for complex-needs patients and the implications of their results for broader health system adoption. Key messages • Small countries like the Baltics face structural challenges in integrating care to improve outcomes and efficiency. • Investment and innovative care approaches are key to further advancements.

Risk of Infection in Older Adults With Type 2 Diabetes With Relaxed Glycemic Control.

To compare the risk of hospitalization for infection among patients who achieve intensive versus relaxed glycemic control. This retrospective cohort study included adults age ≥65 years with type 2 diabetes from an integrated health care delivery system. Negative binomial models were used to estimate incidence rates and relative risk (RR) of hospitalization for infections (respiratory; genitourinary; skin, soft tissue, and bone; and sepsis), comparing two levels of relaxed (hemoglobin A1c [HbA1c] 7% to <8% and 8% to <9%) with intensive (HbA1c 6% to <7%) glycemic control from 1 January 2019 to 1 March 2020. Among 103,242 older patients (48.5% with HbA1c 6% to <7%, 35.3% with HbA1c 7% to <8%, and 16.1% with HbA1c 8% to <9%), the rate of hospitalization for infections was 51.3 per 1,000 person-years. Compared with HbA1c 6% to <7%, unadjusted risk of hospitalization for infections was significantly elevated among patients with HbA1c 8% to <9% (RR 1.25; 95% CI 1.13, 1.39) but not among patients with HbA1c 7% to <8% (RR 0.99; 95% CI 0.91, 1.08), and the difference became nonsignificant after adjustment. Across categories of infections, the adjusted RR of hospitalization was significantly higher among patients with HbA1c 8% to <9% only for skin, soft tissue, and bone infection (RR 1.33; 95% CI 1.05, 1.69). Older patients with type 2 diabetes who achieve relaxed glycemic control levels endorsed by clinical guidelines are not at significantly increased risk of hospitalization for most infections, but HbA1c 8% to <9% is associated with an increased risk of hospitalization for skin, soft tissue, and bone infections.

AUTOMEDICAÇÃO ENTRE ESTUDANTES UNIVERSITÁRIOS DA ÁREA DA SAÚDE NO BRASIL: UMA REVISÃO INTEGRATIVA DA LITERATURA

This study aimed to investigate, through an integrative review of the literature, the main reasons that lead undergraduate students in the health area to self-medicate, since they have the responsibility to guide society on the appropriate use and medicine insurance. After applying the inclusion and exclusion criteria, eleven studies were selected in which it was identified that, among the variables that influenced the practice of self-medication that were mentioned at least once in the productions, the most frequent were self-knowledge, advice from third parties, previous medical concession and ease of access. It is argued that undergraduate students in the health area are a portion of the population who self-medicate in an exacerbated manner, mainly because they believe they have sufficient theoretical, technical and scientific knowledge to carry out such practice. Thinking about this serious public health problem, we can see that there is a lack of data to promote effective measures in the rational use of medicines. It is necessary to understand that the idea of ​​integrated health care comprises knowledge developed collectively by professionals, teachers, managers and users/patients, co-responsible for the production of health, so that self-medication can be responsible for all segments of health. society.

Plan of Care Visits: Implementation During Hospitalization and Association With 30-Day Readmissions in a Large, Integrated Health Care System.

Plan of Care of Visits (POCV), including the patient, nurse, and hospital provider were implemented across an integrated health system to improve provider-patient communication during hospitalization and patient outcomes. To assess POCV adoption after implementation, patient characteristics assosites were classified as teachsites were classified as teachsites were classified as teachsites were classified as ciated with POCV completion, and association of POCV with 30-day readmissions. This retrospective cohort study utilized electronic medical record (EMR) data of 237,430 adult patients discharged to home from 11 hospitals from January 2020 to December 2022. POCV completion was a discrete EMR variable. POCV adoption was estimated monthly by hospital as proportion of patients with at least 1 POCV during hospitalization, with variation among hospitals measured using the Variance Partition Coefficient (VPC). Multivariable logistic regressions assessed factors associated with POCV completion and POCV association with 30-day readmission. POCV adoption increased from 69% to 94% (2020-2022) and varied by 50% across hospitals (VPC 0.50, 95% CI: 0.29-0.70). Odds of a discharge-day POCV were lower among older patients (≥65 vs. 18-34y, OR 0.81, CI: 0.79-0.83), and higher among female (OR 1.06; CI: 1.04-1.07), Asian (vs. White, OR 1.13; CI: 1.06-1.21), Hispanic (OR 1.09; CI: 1.05-1.13), and surgical patients (vs. medical, OR 1.33; CI: 1.30-1.35). Patients completing discharge-day POCV had lower 30-day readmission odds (2022 OR 0.76, CI: 0.73-0.79). Patients with POCV on ≥75% of hospital days had similar readmission odds trends. POCV implementation was successful, and POCV completion was associated with fewer 30-day readmissions. Future work should focus on increasing POCV adoption while reducing hospital variation.

A Texting- and Internet-Based Self-Reporting System for Enhanced Vaccine Safety Surveillance With Insights From a Large Integrated Health Care System in the United States: Prospective Cohort Study.

SMS text messaging- and internet-based self-reporting systems can supplement existing vaccine safety surveillance systems, but real-world participation patterns have not been assessed at scale. This study aimed to describe the participation rates of a new SMS text messaging- and internet-based self-reporting system called the Kaiser Permanente Side Effect Monitor (KPSEM) within a large integrated health care system. We conducted a prospective cohort study of Kaiser Permanente Southern California (KPSC) patients receiving a COVID-19 vaccination from April 23, 2021, to July 31, 2023. Patients received invitations through flyers, SMS text messages, emails, or patient health care portals. After consenting, patients received regular surveys to assess adverse events up to 5 weeks after each dose. Linkage with medical records provided demographic and clinical data. In this study, we describe KPSEM participation rates, defined as providing consent and completing at least 1 survey within 35 days of COVID-19 vaccination. Approximately, 8% (164,636/2,091,975) of all vaccinated patients provided consent and completed at least 1 survey within 35 days. The lowest participation rates were observed for parents of children aged 12-17 years (1349/152,928, 0.9% participation rate), and the highest participation was observed among older adults aged 61-70 years (39,844/329,487, 12.1%). Persons of non-Hispanic White race were more likely to participate compared with other races and ethnicities (13.1% vs 3.9%-7.5%, respectively; P<.001). In addition, patients residing in areas with a higher neighborhood deprivation index were less likely to participate (5.1%, 16,503/323,122 vs 10.8%, 38,084/352,939 in the highest vs lowest deprivation quintiles, respectively; P<.001). Invitations through the individual's Kaiser Permanente health care portal account and by SMS text message were associated with the highest participation rate (19.2%, 70,248/366,377 and 10.5%, 96,169/914,793, respectively), followed by email (19,464/396,912, 4.9%) and then QR codes on flyers (25,882/2,091,975, 1.2%). SMS text messaging-based surveys demonstrated the highest sustained daily response rates compared with internet-based surveys. This real-world prospective study demonstrated that a novel digital vaccine safety self-reporting system implemented through an integrated health care system can achieve high participation rates. Linkage with participants' electronic health records is another unique benefit of this surveillance system. We also identified lower participation among selected vulnerable populations, which may have implications when interpreting data collected from similar digital systems.

Trends over time in oral anticoagulation and stroke rates in atrial fibrillation: A community-based study

ObjectivesOver the last decade, direct oral anticoagulants (DOAC) have become preferred over warfarin for stroke prevention in atrial fibrillation (AF). The objectives of this study were to quantify the shift over time from warfarin to DOACs and parallel changes in ischemic and hemorrhagic stroke rates in AF. Materials and methodsThis community-based retrospective study was undertaken within a single integrated health care network from 2011 to 2021. Changes over time in warfarin and DOAC use were quantified by year, both overall and stratified by CHA2DS2-VASc score. Ischemic and hemorrhagic stroke rate changes over time were evaluated by Poisson regression. Stroke rates were evaluated in different time eras: 2011–2015 and 2016–2021. ResultsAmong 31,978 AF patients followed an average of 5.5 years, any OAC use increased from 50.2 % (2011) to 59.4 % (2020) (p < 0.001). Warfarin use decreased from 49.3 % to 30.8 %, while DOAC use increased from 2.0 % to 30.8 % (both p < 0.001). In 2020, patients with CHA2DS2-VASc 0–1 and 2–5 were more likely to use DOACs than warfarin (18.6 % vs. 6.7 %; 33.0 % vs. 28.2 %), whereas in CHA2DS2-VASc 6–9 DOACs were used less frequently (30.0 % vs. 40.8 %). Ischemic stroke rates significantly increased by 19 % (95 % CI: 7 %, 32 %) from 2011 to 2015, but significantly decreased by 18 % (10 %, 26 %) from 2016 to 2021. Hemorrhagic stroke rates stabilized in 2016–2021 (+3 %; −18 %, 30 %) after increasing in 2011–2015 (+36 %; 4 %, 78 %). ConclusionImprovements in ischemic and hemorrhagic stroke rates coincided temporally with increased uptake of OACs and a shift toward increased uptake of DOACs relative to warfarin.

Racial Residential Segregation and Mental Health During Pregnancy

Research suggests the social, physical, and socioeconomic contexts of residing in segregated neighborhoods may negatively affect mental health. To assess the association between racial residential segregation and prenatal mental health among Asian, Black, Hispanic, and White individuals. This population-based cross-sectional study was conducted in Kaiser Permanente Northern California (KPNC), an integrated health care delivery system. Participants included self-identified Asian, Black, Hispanic, and White pregnant individuals who attended at least 1 prenatal care visit at KPNC between January 1, 2014, and December 31, 2019. Data were analyzed from January 14, 2023, to August 15, 2024. Racial residential segregation, defined by the local Getis-Ord Gi* statistic, was calculated in each racial and ethnic group and categorized as low (<0), medium (0-1.96), or high (>1.96). A positive Gi* statistic indicates overrepresentation (greater clustering or segregation) of the racial and ethnic group in an index census tract and neighboring tracts compared with the larger surrounding geographic area. Prenatal depression and anxiety defined by diagnoses codes documented in the electronic health record between the first day of the last menstrual period and the day prior to birth. Among the 201 115 participants included in the analysis (mean [SD] age, 30.8 [5.3] years; 26.8% Asian, 6.6% Black, 28.0% Hispanic, and 38.6% White), prenatal depression and anxiety were highest in Black individuals (18.3% and 18.4%, respectively), followed by White (16.0% and 18.2%, respectively), Hispanic (13.0% and 14.4%, respectively), and Asian (5.7% and 6.4%, respectively) individuals. Asian (40.8% vs 31.1%) and Black (43.3% vs 22.6%) individuals were more likely to live in neighborhoods with high vs low segregation, while Hispanic individuals were equally likely (34.3% vs 34.7%). High compared with low segregation was associated with greater odds of prenatal depression (adjusted odds ratio [AOR], 1.25 [95% CI, 1.10-1.42]) and anxiety (AOR, 1.14 [95% CI, 1.00-1.29]) among Black individuals. High segregation was associated with lower odds of prenatal depression among Asian (AOR, 0.75 [95% CI, 0.69-0.82]), Hispanic (AOR, 0.88 [95% CI, 0.82-0.94]), and White (AOR, 0.91 [95% CI, 0.86-0.96]) individuals. Similar associations were found for anxiety among Asian (AOR, 0.80 [95% CI, 0.73-0.87]) and Hispanic (AOR, 0.88 [95% CI, 0.82-0.93]) but not White (AOR, 0.95 [95% CI, 0.90-1.00]) individuals. In this cross-sectional study, racial and ethnic residential segregation was associated with worse prenatal mental health for Black individuals but better mental health for Asian, Hispanic, and White individuals. Policies reducing segregation and its impact may improve mental health outcomes in pregnant Black individuals.

Clinical Use of Mental Health Digital Therapeutics in a Large Health Care Delivery System: Retrospective Patient Cohort Study and Provider Survey.

While the number of digital therapeutics (DTx) has proliferated, there is little real-world research on the characteristics of providers recommending DTx, their recommendation behaviors, or the characteristics of patients receiving recommendations in the clinical setting. The aim of this study was to characterize the clinical and demographic characteristics of patients receiving DTx recommendations and describe provider characteristics and behaviors regarding DTx. This retrospective cohort study used electronic health record data from a large, integrated health care delivery system. Demographic and clinical characteristics of adult patients recommended versus not recommended DTx by a mental health provider between May 2020 and December 2021 were examined. A cross-sectional survey of mental health providers providing these recommendations was conducted in December 2022 to assess the characteristics of providers and recommendation behaviors related to DTx. Parametric and nonparametric tests were used to examine statistical significance between groups. Of 335,250 patients with a mental health appointment, 53,546 (16%) received a DTx recommendation. Patients recommended to DTx were younger, were of Asian or Hispanic race or ethnicity, were female, were without medical comorbidities, and had commercial insurance compared to those without a DTx recommendation (P<.001). More patients receiving a DTx recommendation had anxiety or adjustment disorder diagnoses, but less had depression, bipolar, or psychotic disorder diagnoses (P<.001) versus matched controls not recommended to DTx. Overall, depression and anxiety symptom scores were lower in patients recommended to DTx compared to matched controls not receiving a recommendation, although female patients had a higher proportion of severe depression and anxiety scores compared to male patients. Provider survey results indicated a higher proportion of nonprescribers recommended DTx to patients compared to prescribers (P=.008). Of all providers, 29.4% (45/153) reported using the suggested internal electronic health record-based tools (eg, smart text) to recommend DTx, and of providers recommending DTx resources to patients, 64.1% (98/153) reported they follow up with patients to inquire on DTx benefits. Only 38.4% (58/151) of respondents report recommending specific DTx modules, and of those, 58.6% (34/58) report following up on the impact of these specific modules. DTx use in mental health was modest and varied by patient and provider characteristics. Providers do not appear to actively engage with these tools and integrate them into treatment plans. Providers, while expressing interest in potential benefits from DTx, may view DTx as a passive strategy to augment traditional treatment for select patients.

Racial and Ethnic Disparities in the Time to Ovarian Cancer Surgery in Patients at an Integrated Health Care Delivery System.

Disparities in ovarian cancer survival for African American women are multifactorial. We evaluated racial and ethnic differences in time to ovarian cancer surgery in members of an integrated health care system. In this retrospective cohort study, we identified women diagnosed with invasive epithelial-type ovarian cancer between January 1, 2008, through December 31, 2014, at an integrated health care system in the United States. We extracted data on cancer-related variables and sociodemographic variables from the health care system's cancer registry and electronic health records. We included patients who received ovarian cancer surgery without neoadjuvant chemotherapy. We defined time to surgery as the number of days between diagnostic imaging study and surgery. We used Cox proportional hazards regression to evaluate crude and adjusted association of race and ethnicity with time to surgery. Of 872 patients included, 55.1% were non-Hispanic White (hereafter, White), 24.9% were Hispanic, 14.6% were Asian/Pacific Islander (PI)/Native American, and 5.5% were African American. Median age at diagnosis was 59.0 years. African American patients were diagnosed at an older age and were more likely to come from deprived neighborhoods than other racial and ethnic groups. Median time to surgery was longer for African American patients compared with White, Hispanic, and Asian/PI/Native American patients (median days: 27.5 vs 21.0, 24.5, and 26.0, respectively; P<.0001). In adjusted models, the likelihood of having received surgery at any given time post diagnostic imaging was 31% lower for African American patients compared with White patients (HR, 0.69; 95% CI, 0.51-0.93). This likelihood was also lower for Hispanic and Asian/PI/Native American patients, but not statistically significant. Our findings showed that patients with ovarian cancer from racial and ethnic minorities had a lower likelihood of having received surgery at any given time post diagnostic imaging compared with White patients, demonstrating that racial and ethnic differences exist in time to ovarian cancer surgery in patients with relatively equal access to care.

Exploring the experience of participants in a pilot scheme to recognise teaching excellence in healthcare: A mixed methods approach.

BackgroundWithin healthcare settings, practice-based healthcare professionals are expected to teach, supervise, assess and/or support learners in their respective disciplines. Ongoing development opportunities focusing specifically on teaching skills and support of students are varied and there are no mandatory requirements for practice-based healthcare professionals to develop formal teaching qualifications, despite their direct involvement with learners. ObjectiveTo explore the experience of participants in a pilot scheme to recognise teaching excellence in healthcare. DesignA mixed methods approach was used. Setting(s)One inner-city integrated health care system in the UK. ParticipantsThis study involved eleven participants in total: seven applicants who successfully completed the award and four mentors who supported them throughout the application process. Mentors were all Advance HE Fellowship holders employed within one National Health Service (NHS) organisation and one Higher Education Institution situated within the Northwest of England. MethodsData collection methods included an online anonymised survey followed by individual semi- structured interviews. Quantitative data were analysed descriptively, and qualitative data were analysed using framework analysis principles. ResultsThe findings indicated that participants (applicants and mentors) found the overall experience positive and rewarding. The main positive aspects of taking part were:I. Increased confidence and sharing of teaching experienceII. Increased reflection and use of pedagogyIII. Formation of a teaching community of practiceIV. Perceived teaching career progression opportunitiesThe application process appeared to act as a catalyst towards re-engagement with underpinning pedagogy when considering the suitability and utility of effective teaching approaches for learners in practice. It also helped to promote a teaching community of practice where mentors were able to ‘pay forward’ and support practice colleagues to be recognised for their teaching roles.The main challenges were the competing demands on applicants’ time and the self-directed approach required to complete the award application. ConclusionGaining recognition of teaching excellence through an award scheme such as Advance HE Fellowship can foster a sense of empowerment, recognition and reward for educators who work with learners undertaking Higher Education Programmes, irrespective of the setting where teaching and learning takes place. However, without wider organisation support and resources, the benefits of such schemes can be diminished. RegistrationN/A Tweetable abstractWith institutional support, Advance HE Fellowships offer accessible recognition for healthcare educator's commitment to teaching excellence @AdvanceHE @NHSE_WTE

Depression and Anxiety Among US Children and Young Adults

Data from surveys show increased mental health disorders in youths. However, little is known about clinical diagnosis over time. To assess the incidence, prevalence, and changes from 2017 to 2021 for depression and anxiety diagnosed clinically among children, adolescents, and young adults and to identify potential disparities. This cohort study included approximately 1.7 million individuals aged 5 to 22 years in Southern California. Data were extracted from electronic medical records; International Statistical Classification of Diseases, Tenth Revision (ICD-10), codes were used to identify depression and/or anxiety diagnosis for each study year from January 1, 2017, to December 31, 2021. Rates were stratified by age, gender, race and ethnicity, estimated household income, weight status, and comorbidity history. Changes over time and association with these variables were assessed using Poisson regression. Data were analyzed between June 1, 2022, and November 29, 2023. Clinical diagnosis of (1) depression and (2) anxiety without a depression diagnosis using ICD-10 codes. Among the 1.7 million participants, mean (SD) age was approximately 14 (5) years, and 51% were male. In terms of race and ethnicity for each study year, approximately 50% of participants were Hispanic; 8%, non-Hispanic Asian; 8%, non-Hispanic Black; and 23%, non-Hispanic White. From 2017 to 2021, depression diagnosis increased by 55.6% (from 1.35% to 2.10%) for incidence and 60.0% (from 2.55% to 4.08%) for prevalence; anxiety without depression diagnosis increased by 31.1% (from 1.77% to 2.32%) for incidence and 35.2% (from 3.13% to 4.22%) for prevalence (P < .001 for trend). The increases in rates were higher during the COVID-19 pandemic (2020-2021) than before the pandemic (2017-2019), except for depression incidence. Rates increased across all subgroups. Rates were highest for subgroups aged 14 to 17 and 18 to 22 years; female participants; those of non-Hispanic American Indian or Alaska Native, non-Hispanic White, or multiple races or ethnicities; and subgroups with higher household income, obesity (and underweight for anxiety without depression), or comorbidities. Among these factors, age was the most important factor for depression diagnosis, whereas weight status was the most important factor for anxiety without depression diagnosis. This cohort study, using electronic medical record data from a large integrated health care system, found an increase in clinically diagnosed depression from 2017 to 2021, with a higher increase during the COVID-19 pandemic and higher rates in some subgroups. Equally important, this study identified high rates and an increase in clinical diagnosis of anxiety without a depression diagnosis. These results support the increased need in public health and health care effort to combat the mental health crisis in youths.

Patient assignment and quality performance: a misaligned system.

To assess the congruence between patient assignment and established patients as well as their association with Healthcare Effectiveness Data and Information Set (HEDIS) quality performance. A retrospective cross-sectional analysis from January 2020 to February 2022. The study setting is a fully integrated health care delivery system in Phoenix, Arizona. The study population includes Medicaid patients who received primary care services or were assigned to a primary care physician (PCP) at the study setting by 5 Medicaid managed care organizations (MCOs). We identified 4 possible relationships between the established patients (2 primary care visits) and the assigned patients (assigned by the MCO to the study setting): true-positive, false-positive, true-negative, and false-negative classifications. Precision and recall measures were used to assess congruence (or incongruence). Outcome measures were HEDIS quality metrics. A total of 100,030 Medicaid enrollees (adults and children) were established and/or assigned to the study setting from 5 separate payers. Only 15% were congruently established and assigned to the physician (true-positive). The overall precision was 21%, and the overall recall was 37%. The HEDIS quality performance was significantly higher (P < .05) for established patients for 5 of 6 metrics compared with patients who were not established. The vast majority of assigned patients were not treated by the assigned PCP, yet better patient outcomes were seen with an established patient. As the health system rapidly adopts value-based payments, more rigorous methodologies are essential to identify physician-patientrelationships.

Trends in Adolescent Depression Screening Outcomes Over the COVID-19 Pandemic at a Large, Integrated Health Care System in Southern California

PurposeLittle is known about changes in depression screening outcomes among adolescents in primary healthcare across the COVID-19 pandemic. We describe trends in depression screening outcomes within a large integrated health care system in Southern California. MethodsRetrospective electronic health record data from preventative healthcare visits of 11–12-year-olds and 13–17-year-olds screened for depression from March 1, 2017, to August 31, 2022, were extracted in 6-month blocks. The percentages of screens meeting “threshold depression” were reported overall, and by sex, race or ethnicity, and median household income quintiles. We used Poisson regression to estimate rate ratios of threshold depression in 3 winter blocks (September to February) comparing lockdown (2020), reopening (2021) to a pre-COVID (2019) period, and reopening relative to lockdown. Disparities in trends by sex, race, or ethnicity and household income were tested using interaction terms. ResultsOf 735,333 visits with complete screening (183,550 for 11–12-year-olds and 551,783 for 13–17-year-olds), 4.6%, 6.5%, and 7.4% of 11–12-year-olds had “threshold depression” during winter blocks of pre-COVID, lockdown and reopening, respectively. The corresponding rates were 5.8%, 8.5%, and 9.8% for 13–17-year-olds. The rates were higher during lockdown and reopening relative to pre-COVID and higher during reopening relative to lockdown for both age groups (all p-values <.001). Trends differed by sex in both age groups (p-values <.001) and by race or ethnicity (p = .001) in the 13–17-year age group. DiscussionCalifornian adolescents demonstrated an increase in threshold depression since COVID lockdown starting March 2020 with further increase observed during reopening in September 2021. Future studies are needed to determine the long-term trends.