Receipt Of Services Research Articles

Vocational Rehabilitation Services and Labor Market Outcomes for Transition‐Age Youth with Disabilities in Maine

AbstractUsing administrative data from Maine to quantify the effect of vocational rehabilitation (VR) services on employment outcomes for transition‐age youth with disabilities, we exploited the variation in VR counselors’ propensity to develop Individualized Plans for Employment (IPEs) for VR youth as an instrument for service receipt. We found that among the estimated 36 percent of VR clients on the margin of service receipt, having an IPE implemented increases quarterly employment rate by 15.4 percentage points and quarterly earnings by $1,442 (2018 dollars). We found heterogeneous program effects with individuals 18 or younger benefiting significantly more than those older than age 18 at the time of VR application. We estimate the annual real rate of return to be 10.2 percent for two years after VR case closure.

Health related quality of life, service utilization and costs for patients with Huntington’s disease in Norway

BackgroundHuntington’s disease (HD) is a progressive genetic neurodegenerative disease accompanied by mental and neurocognitive disabilities, which requires long-term and comprehensive treatment and care. Information on the health and economic burden of HD is scarce, but essential for conducting health economic analyses, in light of the prospect of new therapies for HD. In this study, we aim to identify values for Health-Related Quality of Life (HRQoL), describe service utilization and costs, and their associations with clinical and socio-demographic variables across all phases of HD.MethodsA cross-sectional study including 86 patients across all phases of HD. Values of HRQoL were calculated based on EQ-5D-3L index scores. Additionally, health care and societal costs were estimated based on service utilization collected using the Client Service Receipt Inventory (CSRI) and data from the patients’ interviews. Total societal costs included costs of primary and secondary health care services, informal care and productivity loss of the patients. Multiple regression analyses were used to investigate associations between socio-demographic and clinical variables on HRQoL and costs.ResultsHRQoL values declined, while total costs increased across disease severity. Total six-month healthcare costs and total societal costs were € 18,538 and € 66,789 respectively. Healthcare and societal costs doubled from early to middle phase, and tripled from middle to advanced disease phase. Main six-month cost components for the three disease phases were informal care costs (€ 30,605) accounting for approximately half the total societal costs, and costs due to production loss (€ 18,907) being slightly higher than the total healthcare costs. Disease severity and gender were found to have the strongest effect on both values of HRQoL and costs.ConclusionsReported values of HRQoL and costs including costs for production loss may be used in modelling the cost-effectiveness of treatment for HD. Our results highlight the crucial role the informal caregivers play in the care provided to HD patients in all disease phases. Future research should focus on the estimation of productivity loss among informal caregivers.

Expanded access to OUD medication during pandemic proved beneficial

Several federal agencies in 2020 relaxed restrictions on medication treatments for opioid use disorder (OUD) to ensure continued access to treatment during the COVID‐19 pandemic. In order to examine the long‐term impacts of these measures, investigators conducted a longitudinal cohort study using Medicare data to compare use of OUD‐related telehealth services, use of medications to treat OUD, and incidence of overdose requiring medical treatment before and during the pandemic. Several Centers for Medicare & Medicaid Services data sources documenting behavioral health disorders and use of related treatment services were accessed. The cohort consisted of adult Medicare fee‐for‐service beneficiaries. Two mutually exclusive groups of individuals initiating OUD treatment before and after the pandemic were identified. The groups were followed for 6 months after their 6‐month index treatment periods in order to evaluate retention in OUD treatment. The primary outcomes were receipt of telehealth services, receipt of medication for OUD, and medically treated overdose. More individuals in the pandemic group compared with the pre‐pandemic group received telehealth services, with 19.6% of the pandemic group and 0.6% of the pre‐pandemic group receiving telehealth care related to OUD. Receipt of any medication for OUD was more prevalent in the pandemic group (7.5% vs. 4.4%). The percentages of patients receiving buprenorphine or medications from an opioid treatment program were higher in the pandemic cohort. Rates of medically treated overdose were similar in the two groups. Within the pandemic cohort, receipt of telehealth services was associated with increased retention in medication treatment. Those receiving OUD‐related telehealth services were also less likely to experience a medically treated overdose. The researchers suggested that future studies should examine the effect of telehealth availability on other outcomes, such as illicit opioid use and overdose deaths. [Jones C, et al. JAMA Psychiatry 2022; published online Aug 31; doi: 10.1001/jamapsychiatry.2022.2284]

Characteristics of Patients Served by a Statewide Child Psychiatry Access Program.

Maryland's Behavioral Health Integration in Pediatric Primary Care (BHIPP) is a child psychiatry access program offering child-adolescent psychiatry consultation, resource and referral networking, and direct-to-patient mental health intervention. This study investigated characteristics of patients for whom primary care providers sought BHIPP services. Data from 6,939 unique patient contacts between October 2012 and March 2020 were collected on service type, demographic characteristics, presenting concerns, clinical severity, clinicians' diagnostic impressions, current treatments, and BHIPP recommendations. Descriptive statistics and latent class analysis were used. Of the 6,939 patient contacts, 38.6% were for direct-to-patient mental health intervention, 27.3% for child-adolescent psychiatry consultation, and 34.2% for resource and referral networking. In total, 50.3% of patients were female, 58.7% were White, and 32.7% were already receiving mental health services. Latent class analysis identified four classes of presenting concerns: anxiety only (44.2%); behavior problems only (30.7%); mood and anxiety (17.1%); and attention, behavior, and learning problems (8.0%). Compared with patients in the anxiety-only class, those in the attention, behavior, and learning problems class were more likely to receive direct-to-patient mental health intervention (OR=3.59), and BHIPP clinicians were more likely to recommend in-office behavioral interventions for those in the mood and anxiety class (OR=1.62) and behavior problems-only class (OR=1.55). Patients supported through BHIPP varied in presenting concerns, condition severity and complexity, current receipt of services, and BHIPP utilization. Latent class analysis yielded more clinically useful information about the nature and complexity of patients' concerns than did consideration of individual presenting concerns.

Measuring the association between behavioural services and outcomes in young children with autism spectrum disorder

BackgroundChildren with autism spectrum disorder (ASD) receive a wide range of services. AimsTo examine the association between behavioural services received by children with ASD between ages 2 and 5 years and outcomes during primary school years. MethodsA total of 414 preschool-aged children diagnosed with ASD were enrolled at five Canadian sites and were assessed within four months of diagnosis (T1), six months later (T2), 12 months later (T3), at school entry (T4), and then annually (T5-T8) to 11 years of age. The association between the receipt of behavioural services during T1 to T3 and T8 outcomes related to adaptive behaviour and behavioural problems was modelled using linear regressions adjusted for immigrant status, family income, child’s age at diagnosis, site, sex assigned at birth, and baseline (T1) outcome. ResultsChildren who received behavioural services during at least one time period from T1 to T3 did not have significantly different outcomes at T8 than children who did not receive any behavioural services. ImplicationsPre-school use of behavioural services was not found to affect outcomes during later childhood. Numerous challenges accompany studies of the association between pre-school service use and later outcomes in a heterogeneous ASD sample. Recommendations for study design are provided.

Third-Grade Academic Performance and Episodes of Cardiac Care Among Children with Congenital Heart Defects.

Children with congenital heart defects (CHDs) are at risk for poor academic performance. The degree to which receipt of health care services is associated with adverse academic outcomes is not known. We examined the association between episodes of cardiac care and third-grade performance in children with CHD. We identified subjects between 1/1/2008 and 4/30/2012 among 5 centers in North Carolina. We classified children by CHD type and linked subjects to the state educational records. Any inpatient or outpatient cardiac encounter on a date of service was considered an encounter. We calculated the number of encounters by adding the number of inpatient or outpatient cardiac visits prior to the date of the end-of-grade (EOG) tests. We estimated the odds of failing third-grade reading or math EOG tests by episodes of care stratified at the 50th percentile, controlling for CHD type, maternal education, sex, race/ethnicity, birth weight, and gestational age. A total of 184 children had third-grade EOG scores linked to health care records. The median number of episodes of care was 4 (range: 1-60). Those with visits ˃ 50th percentile (> 4 encounters/year over the 4.3year observation period) had 2.09 (95% CI 1.04, 4.21) greater odds of failing the math EOG compared to those ≤ 50th percentile (1-4 encounters). The third-grade math score declined by 1.5 points (P < 0.008) for every 10 episodes of care. There was no association of episodes of care on third-grade reading performance. Children with CHD with > 4 episodes of cardiac care/year may be at risk for delays in third-grade academic performance. Strategies to minimize school absenteeism may improve academic success in this population.

Symptom Management Experience of End-of-Life Family Caregivers: A Population-Based Study.

In the United States, 30% of all deaths occur at home. Effective symptom management is integral to quality end-of-life (EOL) care. Family caregivers play a major role in EOL symptom management. Recent federal policies emphasize the need to improve training and support for family caregivers. In a nationally representative sample: 1) Characterize the population of caregivers assisting with and reporting difficulty in symptom management at the end of life; and 2) Assess caregiver and care recipient characteristics associated with caregiver report of difficulty. Cross-sectional analysis of data from the National Health and Aging Trends Study and National Study of Caregiving. Multivariable logistic regression to assess association between care recipient and caregiver characteristics and caregiver report of difficulty. Caregivers (n = 214) were mean age 57.1 years, 74% female, and 86% white non-Hispanic. Over 2 million family caregivers provided assistance with symptom management in the last month of life in 2017; 78% reported difficulty. Non-Hispanic Black caregivers (aOR 0.24, 95% CI 0.08-0.75), Hispanic caregivers (0.13, 0.03-0.56), and caregivers with lower than high school education (0.26, 0.11-0.63) were less likely to report difficulty. Caregivers of care recipients who received paid care (3.37, 1.30-8.69) were more likely to report difficulty. Receipt of training and support services (1.80, 0.83-3.93) and hospice (1.83, 0.82-4.07) were not associated with caregiver report of difficulty. These findings underscore the need to improve training and support for family caregivers in EOL symptom management.

Health Status and Preventive Health Services Among Reproductive-Aged Women in Treatment for Opioid Use Disorder.

To assess the utilization of preventive health services and the prevalence of chronic health conditions among a cohort of women in treatment for opioid use disorder (OUD). Ninety-seven women who were receiving treatment for OUD from a single urban treatment program completed a self-administered anonymous online questionnaire that asked about demographics, health, receipt of preventive health services, and utilization of health care. Descriptive statistics were used to describe data. More than one-third of respondents reported that their health was fair or poor, whereas one-quarter were very concerned with their health. Most participants (59%) reported at least one chronic health condition; nearly 1 in 5 reported two or more conditions. Less than half of respondents had received a routine medical examination in the past year. Vaccine uptake was low; 56% received the coronavirus disease 2019 vaccine and 36% received the annual influenza vaccine. Women in treatment for OUD could benefit from enhanced health care to address the high rates of chronic diseases and risk factors and underutilization of recommended preventive health services. Interventions and models of care that aim to enhance utilization of such services, and ultimately improve the health of this vulnerable population, may be worth exploring.

Formal and Informal Costs of Care for People With Dementia Who Experience a Transition to Hospital at the End of Life: A Secondary Data Analysis.

To explore formal and informal care costs in the last 3months of life for people with dementia, and to evaluate the association between transitions to hospital and usual place of care with costs. Cross-sectional study using pooled data from 3 mortality follow-back surveys. People who died with dementia. The Client Service Receipt Inventory survey was used to derive formal (health, social) and informal care costs in the last 3months of life. Generalized linear models were used to explore the association between transitions to hospital and usual place of care with formal and informal care costs. A total of 146 people who died with dementia were included. The mean age was 88.1years (SD 6.0), and 98 (67.1%) were female. The usual place of care was care home for 85 (58.2%). Sixty-five individuals (44.5%) died in a care home, and 85 (58.2%) experienced a transition to hospital in the last 3months. The mean total costs of care in the last 3months of life were £31,224.7 (SD 23,536.6). People with a transition to hospital had higher total costs (£33,239.2, 95% CI 28,301.8-39,037.8) than people without transition (£21,522.0, 95% CI 17,784.0-26,045.8), mainly explained by hospital costs. People whose usual place of care was care homes had lower total costs (£23,801.3, 95% CI 20,172.0-28,083.6) compared to home (£34,331.4, 95% CI 27,824.7-42,359.5), mainly explained by lower informal care costs. Total care costs are high among people dying with dementia, and informal care costs represent an important component of end-of-life care costs. Transitions to hospital have a large impact on total costs; preventing these transitions might reduce costs from the health care perspective, but not from patients' and families' perspectives. Access to care homes could help reduce transitions to hospital as well as reduce formal and informal care costs.

Implementation and Mental Health Outcomes of a Service Cascade Linking Child Welfare and Children’s Mental Health Systems: A Case Study of the Gateway CALL Demonstration

The mental health needs of children and youth involved in the child welfare system remain largely unmet. Service cascades are an emerging approach to systematizing mental health screening, assessment, and treatment referral processes. However, evidence is minimal and inconsistent regarding the effectiveness of such approaches for improving mental health service access and outcomes. In an effort to address this gap, this study presents a case-study of the implementation fidelity and treatment outcomes of the Gateway CALL service cascade. Study analyses involved longitudinal data collected as part of a larger evaluation of Gateway CALL. Specifically, descriptive and linear mixed model analyses were conducted to assess the implementation of service cascade components, and changes in mental health outcomes (behavior problems) among 175 children placed out-of-home during the study. Study analyses found that although fidelity was strong early in the service cascade, implementation began to break down once components involved more than one service system (child welfare, mental health). However, results also indicated that parent-reported child behavior problems decreased significantly over time, despite later cascade components being implemented with poor fidelity to the Gateway CALL service model. For children and youth involved in child welfare systems, service cascades like Gateway CALL have the potential to significantly improve both mental health service receipt and outcomes. To maximize the effectiveness of such approaches, later phases of implementation may require increased attention and support, particularly regarding processes and outcomes that cross child welfare and mental health service systems.

Philosophical and Pedagogical Discourse in the Postmodern Educational Space: Peculiarities of Distance Learning

The article presents a philosophical understanding and real interpretation of the existence and evolution of pedagogical (educational) discourse in the postmodern space. The results of scientific research are analyzed and the structural-semantic relationship of the concepts, terms and categories associated with the terminological field “discourse” is defined. The authors raise the problem of the postmodern significance of discourse in the period of the global transformation of the educational environment, caused by the pandemic COVID-19, which has put humanity before the fact of actualization of remote communication and receipt of educational services. The authors believe that distance learning should be provided with strong technical and technological support on the one hand and the use of this vector set of educational, pedagogical, learning and development technologies in the preparation of future specialists in the system of higher education on the other. The article deals with new approaches to the application of discourse-supporting technologies and methods. Thus, the emphasis is placed on the relevance of an open informational and educational environment of higher education institutions in the postmodern space where the role of discourse as a constructive tool of postmodernism is determined by the new interpretation, and the teacher becomes a generator of innovations in this context.

Socio-demographic disparities in receipt of clinical health care services during the COVID-19 pandemic for Canadian children with disability

BackgroundLittle is known about the experience of receiving in-person and virtual clinical health care services during the COVID-19 pandemic for Canadian children with developmental disabilities and delays facing multiple layers of vulnerability (e.g., low income, low educational attainment families). We examined the relationship between socio-demographic factors and the receipt of these services (physical and mental health services) during COVID-19 for Canadian children with these conditions.MethodsData collected in Canada for the Global Report on Developmental Delays, Disorders and Disabilities were used. The survey: (1) was developed and disseminated in collaboration with caregivers of children with disabilities, (2) included topics such as response to the pandemic and receipt of services and supports, and (3) documented the experiences of a non-random convenience sample of caregivers of children (any age) with these conditions during and prior to the pandemic. We used four logistic regression models to assess the association between socio-demographic factors and receipt of services.ResultsBeing a single parent, having low educational attainment (high school or less), having low income (making less than $40,000 per year), working less than full time (working part-time, working reduced hours due to COVID, retired, stay home parent or student), as well as male gender and older age of the child with disability were factors associated with decreased likelihood of receiving services.ConclusionOur findings point to the need for tailoring services for families of children with disabilities, particularly low socioeconomic status families, to ensure continuity of care during public health emergencies.

Does Adult-Directed Early Behavioral Intervention Improve Family Quality of Life? A Systematic Review and Meta-Analysis

For decades, researchers and providers of adult-directed early behavioral intervention services have made conceptual arguments linking the receipt of such services to improvements in family and family member quality of life. To date, there has not been a review of the literature to empirically evaluate this claim. Therefore, we conducted a systematic review and identified 15 studies contributing 40 effect sizes to evaluate the relationship between the receipt of early behavioral intervention and family quality of life. Our analyses did not detect that there was a robust and meaningful difference in the quality of life of families with a child that did and did not receive early behavioral intervention. Considerations to inform future research are presented; and implications are discussed with respect to parents, pediatricians, providers, and those involved in the public dissemination of evidence-based treatments for individuals with autism.

Associations between sociodemographic factors and receiving "ask and advise" services from healthcare providers in India: analysis of the national GATS-2 dataset

BackgroundIndia is home to about 12% of the world's tobacco users, with about 1.35 million tobacco-related deaths each year. The morbidity and mortality rates are socially patterned based on gender, rural vs. urban residence, education, and other factors. Following the World Health Organization's guidance, it is critical to offer tobacco users support for cessation as a complement to policy and environmental changes. Such guidance is typically unavailable in low-resource systems, despite the potential for population-level impact. Additionally, service delivery for tobacco control tends to be patterned by sociodemographic factors. To understand current activity in this area, we assessed the percentage of daily tobacco users being asked about tobacco use and advised to quit by a healthcare provider. We also examined social patterning of receipt of services (related to by rural vs. urban residence, age, gender, education, caste, and wealth).MethodsWe analyzed cross-sectional data from India's 2016-2017 Global Adult Tobacco Survey (GATS-2), a nationally representative survey. Among 74,037 respondents, about 25% were daily users of smoked and/or smokeless tobacco. We examined rates of being asked and advised about tobacco use overall and based on rural vs. urban residence, age, gender, education, caste, and wealth. We also conducted multivariate logistic regression to assess the association of demographic and socioeconomic conditions with participants' receipt of “ask and advise” services.ResultsNationally, among daily tobacco users, we found low rates of individuals reporting being asked about tobacco use or advised to quit by a healthcare provider (22% and 19%, respectively). Being asked and advised about tobacco use was patterned by age, gender, education, caste, and wealth in our final regression model.ConclusionsThis study offers a helpful starting point in identifying opportunities to address a critical service delivery gap in India. Given the existing burden on the public health and health systems, scale-up will require innovative, resource-appropriate solutions. The findings also point to the need to center equity in the design and scale-up of tobacco cessation supports so that marginalized and underserved groups will have equitable access to these critical services.

Functional Status and Mortality Among Older Adults with Multiple Myeloma

Introduction Multiple myeloma (MM) is disproportionately a disease of older adults, with a median age at diagnosis of 69. Prior single-center studies and therapeutic trials have demonstrated that aging-related functional impairments in activities of daily living (ADLs - e.g., bathing, toileting) are common among this population and predict treatment intolerance, healthcare utilization, and mortality. However, the prevalence and impact of functional impairments among broader, more generalizable populations of older adults with MM is less well understood. Methods We utilized cancer registry data from the Surveillance, Epidemiology, and End Results (SEER) program linked with Medicare enrollment and claims data from 2008-2019 and the Outcome and Assessment Information Set (OASIS) from 2008-2018 to construct a retrospective cohort of adults aged ≥66 diagnosed with MM between 2009 and 2017. OASIS data capture functional assessments for Medicare beneficiaries who are home health care recipients (HHRs). Individuals were deemed home health recipients if they had at least one OASIS assessment in the 12 months prior to MM diagnosis (inclusive of month of diagnosis). The primary exposures were (1) receipt of home health services prior to MM diagnosis and (2), degree of functional disability, a composite score derived from individual items related to ADLs contained in the OASIS data for HHRs and categorized by tertile as mild (composite score 0-11), moderate (12-17) or severe disability (18-40). The primary outcome was overall mortality within 5 years from diagnosis. Associations between primary exposures and outcomes were assessed via cumulative risk ratios (RRs) at 6, 12, and 36 months from diagnosis, with bootstrapped 95% confidence intervals. The association between receipt of any home health services and mortality was unadjusted; the association between degree of functional disability and mortality among those receiving home health services was adjusted for age, sex, race, and SEER region via inverse probability weighting. Results Among 41,635 beneficiaries with MM, 6,850 (16.4%) received home health services and had an OASIS assessment in the year prior to diagnosis. When compared to non-recipients, HHRs were older (38.6% in highest quartile vs 22.5%), more likely to be non-Hispanic Black (19.9%% vs 17.2%), and more likely to live in counties with greater rates of poverty (25.2% in highest quartile vs 21.7%). HHRs had similar rates of rural residence (10.5% vs 10.8%). Among HHRs, 79% required assistance with at least one ADL. Median number of activities with which HHRs required assistance was 3 (range 0-7). HHRs had higher all-cause mortality at all assessed time points compared to non-HHRs with MM (Figure 1); RRs were 1.91 (95% CI 1.83-1.99) at 6 months from diagnosis, 1.80 (1.74-1.86) at 12 months, and 1.50 at 36 months (1.47-1.53). Among HHRs, mortality was higher among those with severe functional disabilities compared to those with mild disability; RR for the severe versus mild disability groups was 1.38 (1.17-1.62) at 6 months, 1.29 (1.17-1.43) at 12 months, and 1.13 (1.08-1.19) at 36 months. In contrast, those with mild and moderate degrees of disability had similar survival (Figure 2), with non-significant differences in mortality at all assessed time points. Conclusions In this large nationwide study of older adults with MM, we describe the association between physical disability/activity dependence and 5-year mortality. These findings corroborate results of prior, smaller studies based on data from academic centers or therapeutic clinical trials. Our study is novel for its use of a large, diverse, and generalizable data source and the recent linkage with OASIS records. In this cohort, home health recipients had higher 5-year mortality compared to non-home health recipients. Additionally, mortality was most profoundly impacted among those with severe disabilities. In contrast, those with moderate degrees of disability had mortality rates that did not differ significantly from those individuals with mild disability. This moderate disability group, who had a median survival measured in years, may be at risk for undertreatment if their prognosis is underestimated. Future research will characterize the impact of physical disability on MM therapy receipt among this population. Figure 1View largeDownload PPTFigure 1View largeDownload PPT Close modal

Impact of oral health integration training on children's receipt of oral assessment, fluoride varnish and dental services.

To evaluate the impact of an oral health integration training program on children's receipt of oral health and dental services in Southern Oregon. Children under 19 years with at least 6months of Medicaid enrolment and at least one healthcare visit from 2014 to 2018 were included. The treatment group included children with at least one visit with a trained provider (n=5541); children with no visits with trained providers (n=8273) were the control group. The percentage of the treatment group who received oral health assessments was calculated, and regression models were developed to estimate the difference in likelihood of receiving fluoride varnish and dental services between treatment and control groups. The percentage of children receiving oral health assessments increased over time. Visiting a trained provider was consistently associated, each year, with a greater likelihood of receipt of fluoride varnish and preventive and diagnostic dental services but was not associated with treatment dental services or dental sealants. This study reports evidence for the overall impact of an oral health integration training on children's receipt of oral and dental services. Health systems implementing these types of training strategies should consider how to reach specific underserved subgroups, increase paediatric dentists, and expand efforts to include older children.

Supporting Parents' Services Access During the COVID-19 Pandemic Through the Infant-Toddler Court Team Program.

Infant-Toddler Court Teams (ITCTs) are a collaborative practice designed to improve timely identification and receipt of needed services for families of infants and toddlers involved in the child welfare system and their families. The goal of the study was to explore the impact of the first year of COVID compared to the previous year, in the context of ITCT support, on: (1) parents' access to services; (2) parents' services receipt and access within 30 days and within 14 days from referral; and (3) predictors of services access and receipt. Overall, 897 instances of services needs were analyzed, 411 pre-COVID and 486 during COVID. Logistic regression models were used to test for differences pre- and during COVID, controlling for covariates. A reduction in service access was found across all services during COVID (OR = 0.2, CI: 0.1-0.3, p < .0001). Nevertheless, if a service was still available, parents were able to maintain similar levels of receipt within 30 days and within 14 days as before COVID. Moreover, a higher percentage of parents in need received mental health services in 30 or fewer days and substance use disorder services in both 14 and 30 or fewer days during COVID compared to pre-COVID. This success is notable given the significant disruption to the availability of services and barriers to accessing services caused by the pandemic. ITCTs provided a robust platform for supporting the health and well-being of families with very young children in the face of a severely reduced service landscape due to COVID-19.

Drive Time and Receipt of Guideline-Recommended Screening, Diagnosis, and Treatment

Many patients do not receive recommended services. Drive time to health care services may affect receipt of guideline-recommended care, but this has not been comprehensively studied. To assess associations between drive time to care and receipt of guideline-recommended screening, diagnosis, and treatment interventions. This cohort study used administrative data from the National Veterans Health Administration (VA) data merged with Medicare data. Eligible participants were patients using VA services between January 2016 and December 2019. Women ages 65 years or older without underlying bone disease were assessed for osteoporosis screening. Patients with new diagnosis of chronic obstructive pulmonary disease (COPD) indicated by at least 2 encounter codes for COPD or at least 1 COPD-related hospitalization were assessed for receipt of diagnostic spirometry. Patients hospitalized for ischemic heart disease were assessed for cardiac rehabilitation treatment. Drive time from each patient's residential address to the closest VA facility where the service was available, measured using geocoded addresses. Binary outcome at the patient level for receipt of osteoporosis screening, spirometry, and cardiac rehabilitation. Multivariable logistic regression models were used to assess associations between drive time and receipt of services. Of 110 780 eligible women analyzed, 36 431 (32.9%) had osteoporosis screening (mean [SD] age, 66.7 [5.4] years; 19 422 [17.5%] Black, 63 403 [57.2%] White). Of 281 130 patients with new COPD diagnosis, 145 249 (51.7%) had spirometry (mean [SD] age, 68.2 [11.5] years; 268 999 [95.7%] men; 37 834 [13.5%] Black, 217 608 [77.4%] White). Of 73 146 patients hospitalized for ischemic heart disease, 11 171 (15.3%) had cardiac rehabilitation (mean [SD] age, 70.0 [10.8] years; 71 217 [97.4%] men; 15 213 [20.8%] Black, 52 144 [71.3%] White). The odds of receiving recommended services declined as drive times increased. Compared with patients with a drive time of 30 minutes or less, patients with a drive time of 61 to 90 minutes had lower odds of receiving osteoporosis screening (adjusted odds ratio [aOR], 0.90; 95% CI, 0.86-0.95) and spirometry (aOR, 0.90; 95% CI, 0.88-0.92) while patients with a drive time of 91 to 120 minutes had lower odds of receiving cardiac rehabilitation (aOR, 0.80; 95% CI, 0.74-0.87). Results were similar in analyses restricted to urban patients or patients whose primary care clinic was in a tertiary care center. In this retrospective cohort study, longer drive time was associated with less frequent receipt of guideline-recommended services across multiple components of care. To improve quality of care and health outcomes, health systems and clinicians should adopt strategies to mitigate travel burden, even for urban patients.

The association between chiropractic integration in an Ontario community health centre and continued prescription opioid use for chronic non-cancer spinal pain: a sequential explanatory mixed methods study

Background:Emerging evidence suggests that access to chiropractic care may reduce the likelihood of initiating an opioid prescription for spinal pain; however, the impact of chiropractic care for patients already prescribed opioids is uncertain. We undertook a sequential explanatory mixed methods study to evaluate the association between initiating chiropractic care and continued opioid use among adult patients attending an Ontario community health centre (CHC) and receiving opioid therapy for chronic non-cancer spinal pain.Methods:We conducted a retrospective cohort study of 210 patient records between January 1, 2014 and December 31, 2020. We used generalized estimating equations, adjusted for patient demographics, co-morbidities, visit frequency, and calendar year, to evaluate the association between receipt versus non-receipt of chiropractic services and continued opioid use (e.g., unique opioid fills, number of refills, and dosages) up to one year following the index chiropractic visit. We also completed follow-up interviews with 14 patients and nine general practitioners from the CHC and integrated these data with our quantitative findings.Results:Over 12-month follow-up, there were lower rates of opioid fills (incidence rate ratio [IRR] = 0.66; 95% confidence interval [CI], 0.52–0.83) and refills (IRR = 0.27; 95% CI, 0.17–0.42) among chiropractic recipients (n = 49) versus non-recipients (n = 161). Although patients who did and did not receive chiropractic care began the study with the same dose of opioids, recipients were less likely to be prescribed higher-dose opioids (i.e., ≥ 50 mg morphine equivalents daily) compared to non-recipients at three months (odds ratio [OR] = 0.14; 95% CI, 0.04–0.47), six months (OR = 0.14; 95% CI, 0.05–0.40), nine months (OR = 0.19; 95% CI, 0.07–0.57), and 12 months (OR = 0.22; 95% CI, 0.08–0.62). Interviews suggested that patient self-efficacy, limited effectiveness of opioids for chronic pain, stigma regarding use of opioids, and access to chiropractic treatment were important influencing factors.Conclusion:We found that continued prescription opioid use among patients with chronic non-cancer spinal pain who received chiropractic care was lower than in patients who did not receive chiropractic care. Four themes emerged in our qualitative interviews to help provide a richer understanding of this association. Randomized controlled trials are needed to establish the effect of chiropractic care on opioid use for chronic spinal pain.

Among Children Placed in Kinship Care: Exit to Reunification, Adoption, or Foster Care

This study examined factors related to children’s exit from kinship care to reunification, adoption, and foster care. Data describing 498 parents of children placed in kinship care were extracted from a national survey. Results showed that the likelihood of reunification was increased with other maltreatment type, parent receipt of mental health services, number of alcoholic drinks consumed, having other health insurance, and family income; such likelihood was reduced by parent nonmedical use of medication, receipt of health-care services, and education. Number of alcoholic drinks consumed, number of IPV episodes reported, receipt of domestic-violence services, caseworker turnover, and family income increased the likelihood of exit to adoption; receipt of legal services, having other health insurance, parent of other minority race/ethnicity, and being employed diminished such likelihood. Likelihood of exit to foster care was reduced by other maltreatment, nonmedical use of medication, mental health, receipt of employment services, receipt of health-care services, having other health insurance, parent–caseworker shared race/ethnicity, Hispanic parent, other non-Black minority parent, and education. Such likelihood was increased with physical maltreatment, receipt of financial assistance, difficulty in accessing services, perceived caseworker engagement, and caseworker turnover. Implications and future research for facilitating unification, case plans, and working alliance are discussed.