Visit Type Research Articles

Health status and health-care utilization among men recently released from a superjail: a matched prospective cohort study

PurposeContinuity of care and access to primary care have been identified as important contributors to improved health outcomes and reduced reincarceration among people who are justice-involved. While the disproportionate burden of health concerns among incarcerated populations is well documented, less is known about their health service utilization, limiting the potential for effective improvements to current policy and practice. This study aims to examine health status and health care utilization among men recently released from a superjail in a large metropolitan area to better understand patterns of use, risk factors and facilitators.Design/methodology/approachParticipants included adult men (n = 106) matched to a general population group (n = 530) in Ontario, Canada, linked to medical records (88.5% linkage) to examine baseline health status and health utilization three-months post-release. The authors compared differences between the groups in baseline health conditions and estimated the risk of emergency department, primary care, inpatient hospitalization and specialist ambulatory care visits.FindingsSuperjail participants had a significantly higher prevalence of respiratory conditions, mental illness, substance use and injuries. Substance use was a significant risk factor for all types of visits and emergency department visits were over three times higher among superjail participants.Originality/valueThis empirical case is illustrative of an emerging phenomenon in some regions of the world where emergency departments serve as de facto “walk-in clinics” for those with criminal justice involvement. Strategic approaches to health services are required to meet the complex social and health needs and disparities in access to care experienced by men released from custody.

Risk Factors for Missed Appointments at a Multisite Academic Urban Urogynecology Practice.

Missed appointments lead to decreased clinical productivity and poor health outcomes. The objectives of this study were to describe sociodemographic and clinical characteristics of patients who miss urogynecology appointments and identify risk factors for missed appointments. We conducted an institutional review board-approved case-control study of women 18 years or older scheduled for a urogynecology appointment at 1 of 4 sites associated with an urban academic tertiary care center over 4 months. Patients were included in the missed appointment group if they canceled their appointments the same day or did not show up for them. For comparison, we included a control group consisting of patients immediately preceding or following the ones who missed their appointments with the same visit type. Logistic regression was used to identify risk factors for missed appointments. Four hundred twenty-six women were included: 213 in the missed appointment group and 213 in the control group. Women who missed appointments were younger (60 years [interquartile range (IQR), 47-72 years] vs 69 years [IQR, 59-78 years], P < 0.0001). More women in the missed appointment group were Hispanic (24.4% vs 13.1%) and non-Hispanic Black (7.5% vs 3.8%, P = 0.009), had Medicaid (17.4% vs 6.57%, P = 0.0006), missed previous appointments (24.9% vs 11.7% P = 0.0005), waited longer for appointments (39 days [IQR, 23.5-55.5 days] vs 30.5 days [IQR, 12.8-47.0 days], P = 0.002), and made appointments for urinary incontinence (44.1% vs 26.8%, P = 0.0002). On multivariate logistic regression, women with Medicaid had significantly higher odds of missing appointments (adjusted OR, 2.11 [1.04-4.48], P = 0.044). Women with Medicaid were more likely to miss urogynecology appointments. Further research is needed to address barriers this group faces when accessing care.

Telehealth Utilization in Oral Medicine and Oral and Maxillofacial Surgery.

Objectives: The objectives of this retrospective study were to analyze telehealth utilization for two specialty care practices: oral medicine (OM) and oral and maxillofacial surgery (OMFS) during the first 2 years of the pandemic, its impact as a new treatment modality and on participating providers, as well as identify the type of patient visit that most readily adopted telehealth. Methods: Retrospective study of patients who sought specialty services, OM and OMFS, at an outpatient clinic in a university health system setting between March 1, 2019, and February 28, 2022. Source data were obtained from Epic, an electronic medical record application. Data were graphed using Tableau and Microsoft Excel software. Statistical analysis was performed utilizing chi-squared test and analysis of variance (ANOVA). Results: OMFS utilized telehealth 12% of the time, and OM 8% of the time. The majority (87%) of telehealth visits were for return patients (RPs). Compared with the first year of the pandemic, there was a decrease in the number of telehealth visits in the second year (p = 0.0001). As of August 2022, new patient (NP) telehealth encounters have largely returned to prepandemic levels (0-1.5%), whereas RP telehealth visits remained at an average level of 11.4% (9.4-12.4%). Surveyed providers consider telehealth as an effective complement to in-person care and will continue its use (4.2/5 Likert scale). Conclusions: Telehealth has become a viable pathway of care for OM and OMFS who previously did not utilize the remote platform to deliver healthcare. As a new treatment modality, telehealth is perceived as impactful in increasing access to specialty care by participating providers. NP visits are now almost completely in person, but telehealth continues for RPs. Ongoing demand for telehealth highlights urgency to develop appropriate standards and effective remote diagnostic/monitoring tools to maximize telehealth's capability to leverage finite health care resources and increase access to specialty care.

Machine Learning Big Data Analysis of the Impact of Air Pollutants on Rhinitis-Related Hospital Visits.

This study seeks to elucidate the intricate relationship between various air pollutants and the incidence of rhinitis in Seoul, South Korea, wherein it leveraged a vast repository of data and machine learning techniques. The dataset comprised more than 93 million hospital visits (n = 93,530,064) by rhinitis patients between 2013 and 2017. Daily atmospheric measurements were captured for six major pollutants: PM10, PM2.5, O3, NO2, CO, and SO2. We employed traditional correlation analyses alongside machine learning models, including the least absolute shrinkage and selection operator (LASSO), random forest (RF), and gradient boosting machine (GBM), to dissect the effects of these pollutants and the potential time lag in their symptom manifestation. Our analyses revealed that CO showed the strongest positive correlation with hospital visits across all three categories, with a notable significance in the 4-day lag analysis. NO2 also exhibited a substantial positive association, particularly with outpatient visits and hospital admissions and especially in the 4-day lag analysis. Interestingly, O3 demonstrated mixed results. Both PM10 and PM2.5 showed significant correlations with the different types of hospital visits, thus underlining their potential to exacerbate rhinitis symptoms. This study thus underscores the deleterious impacts of air pollution on respiratory health, thereby highlighting the importance of reducing pollutant levels and developing strategies to minimize rhinitis-related hospital visits. Further research considering other environmental factors and individual patient characteristics will enhance our understanding of these intricate dynamics.

Pediatric Fruit and Vegetable Prescriptions: Impact of Visit Type on Prescription Distribution and Redemption Rates

Pediatric Fruit and Vegetable Prescriptions: Impact of Visit Type on Prescription Distribution and Redemption Rates

Assessing changes in adolescent girls’ and young women’s sexual and reproductive health service utilisation following a COVID-19 lockdown in eSwatini

ABSTRACT The effects of COVID-19-associated restrictions on youth sexual and reproductive health (SRH) care during the pandemic remain unclear, particularly in sub-Saharan Africa. This study uses interrupted time series analyses to assess changes in SRH care utilisation (including visits for HIV testing and treatment, family planning, and antenatal care) adolescent girls’ and young women’s (AGYW; aged 15–24 years old) in eSwatini following COVID-19 lockdown beginning in March 2020. SRH utilisation data from 32 clinics in the Manzini region that remained open throughout the 2020 COVID-19 period were extracted from eSwatini’s electronic health record system. We tabulated and graphed monthly visits (both overall and by visit type) by AGYW during the two-year period between January 2019 and December 2020. Despite the March to September 2020 lockdown, we did not detect significant changes in monthly visit trends from 2019 to 2020. Our findings suggest little change to AGYW’s SRH utilisation in eSwatini during the 2020 COVID-19 lockdown period.

Comparison of clinical pharmacist visits based on language preference in an urban underserved clinic: A cross‐sectional analysis

AbstractBackgroundPersons who prefer a language other than English, termed Non‐English Language Preferred (NELP), experience lower health literacy and additional social determinants of health challenges when compared to English Language Preferred (ELP) patients. Non‐English Language Preferred persons have the potential to benefit from comprehensive medication management (CMM) services.MethodsThis was a cross‐sectional analysis of all patients seen by a clinical pharmacist (CP) at a single, urban family medicine clinic during 2021. Statistical analysis was completed to determine if there were differences between NELP and ELP patients in number of visits, visit type and duration, number and type of medication therapy problems (MTPs), and whether the patient was seen by a physician the same day.ResultsA total of 383 patients (57.7% ELP), resulting in 815 total visits (53.5% ELP) were seen by a CP in 2021. There was no difference in the mean number of CP visits per patient (2.0 for ELP, 2.3 for NELP; p = 0.104). There was no difference in the mean number of MTPs between groups (1.9 for ELP, 2.1 for NELP; p = 0.112); however, NELP patients were more likely to have a MTP of “dose too low” (12.9 vs. 21.1%; p = 0.003). Additionally, NELP patients had 11.2% fewer virtual visits than ELP patients (p &lt; 0.001). There were no significant differences in the type of visit (CMM vs. consult, p = 0.628), whether the visit occurred the same day as a physician visit (p = 0.064), or visit duration between groups (p = 0.740).ConclusionNon‐English Language Preferred patients were more likely to have an in‐person visit, and were more likely to have a MTP of “dose too low.” Understanding key differences in CP visits between ELP and NELP patients can help inform future CP care.

Absorbable Sutures and Telemedicine for Patients Undergoing Trigger Finger Release.

Background In the setting of the COVID-19 pandemic, the development of care processes that reduce the need for in-person clinic visits while maintaining low complication rates is needed. The purpose of this study is to assess the outcomes of patients undergoing trigger finger release with various suture and follow-up visit types to assess the feasibility of shifting towards telemedicine-based follow-up protocols. Methods A retrospective review of 329 patients undergoing trigger finger release was performed. Patients were classified based on whether or not they received in-office follow-ups; whether they received absorbable or non-absorbable sutures; and whether they were treated using a telemedicine and absorbable suture protocol or other combination of sutures and follow-ups. Univariate statistics were performed to compare outcomes between groups. Results Patients who did not undergo in-office follow-up were more likely to experience residual stiffness or contracture (11.4% vs. 4.1%; p=0.033) but had no significant differences in 30-day reoperation, emergency department (ED) returns, wound complaints, and Quick DASH (Disabilities of the Arm, Shoulder, and Hand) scores. When comparing chromic absorbable sutures to non-absorbable sutures, those with absorbable sutures were significantly more likely to have telemedicine visits but were also more likely to have wound complaints (17.9% vs. 8.5%; p=0.022). There was no significant difference in two- and six-week pain scores, 30-day reoperation, ED returns, residual symptoms, and Quick DASH scores. When comparing patients treated using the absorbable suture and telemedicine protocol with those receiving any other type of sutureand postoperative follow-up, no significant differences in any postoperative clinical outcome measures were observed. Conclusion The results of this study demonstrate that the use of an absorbable suture and telemedicine protocol for patients undergoing trigger finger release yields similar outcomes as traditional methods of care. However, the use of absorbable sutures may result in decreased patient satisfaction with surgical wound healing.

Preference for and impact of telehealth vs in-person asthma visits among Black and Latinx adults

BackgroundBlack and Latinx adults experience disproportionate asthma-related morbidity and limited specialty care access. The severe acute respiratory syndrome coronavirus 2 pandemic expanded telehealth use. ObjectiveTo evaluate visit type (telehealth [TH] vs in-person [IP]) preferences and the impact of visit type on asthma outcomes among Black and Latinx adults with moderate-to-severe asthma. MethodsFor this PREPARE trial ancillary study, visit type preference was surveyed by e-mail or telephone post-trial. Emergency medical record data on visit types and asthma outcomes were available for a subset (March 2020 to April 2021). Characteristics associated with visit type preferences, and relationships between visit type and asthma outcomes (control [Asthma Control Test] and asthma-related quality of life [Asthma Symptom Utility Index]), were tested using multivariable regression. ResultsA total of 866 participants consented to be surveyed, with 847 respondents. Among the participants with asthma care experience with both visit types, 42.0% preferred TH for regular checkups, which associated with employment (odds ratio [OR] = 1.61; 95% confidence interval [CI], 1.09-2.39; P = .02), lower asthma medication adherence (OR = 1.06; 95% CI, 1.01-1.11; P = .03), and having more historical emergency department and urgent care asthma visits (OR = 1.10 for each additional visit; 95% CI, 1.02-1.18; P = .02), after adjustment. Emergency medical record data were available for 98 participants (62 TH, 36 IP). Those with TH visits were more likely Latinx, from the Southwest, employed, using inhaled corticosteroid–only controller therapy, with lower body mass index, and lower self-reported asthma medication adherence vs those with IP visits only. Both groups had comparable Asthma Control Test (18.4 vs 18.9, P = .52) and Asthma Symptom Utility Index (0.79 vs 0.84, P = .16) scores after adjustment. ConclusionTH may be similarly efficacious as and often preferred over IP among Black and Latinx adults with moderate-to-severe asthma, especially for regular checkups. Trial RegistrationClinicalTrials.gov Identifier: NCT02995733.

Patient satisfaction with telemedicine and in-person visits in reproductive endocrinology and infertility clinics

Is patient satisfaction higher with telemedicine visits or in-person visits for an initial consultation in the ambulatory fertility setting? A survey study of fertility patients who had an initial consultation visit between January 2018 and September 2022 was conducted using a nationally distributed survey. Patient satisfaction and other outcomes pertaining to patient experience were compared between telemedicine and in-person visits. In total, 682 participants completed the survey nationwide; of these, 425 respondents had an in-person visit and 257 respondents had a telemedicine visit. Age, geographic region, race, education level, employment status, income level and marital status did not differ between the groups. Overall, 69.6% of participants were satisfied with telemedicine visits, with improvement in partner participation. More patients were satisfied with in-person visits compared with telemedicine visits (82.6% versus 69.6%, P<0.001), and more patients preferred in-person visits to telemedicine visits regardless of the type of appointment they had for their initial visit. In a subgroup analysis of patients seen during the coronavirus disease 2019 pandemic, patients who had telemedicine visits were younger, more likely to be White, more educated and had a higher income compared with patients who had in-person visits. Previously, the impact of telemedicine in the fertility setting was largely unknown. This study demonstrated that the majority of patients were satisfied with health care through telemedicine visits. However, patients were more satisfied with in-person visits, and preferred in-person visits to telemedicine visits. Further studies are needed to help clarify the differences in patient satisfaction with visit type, and to assess the role of telemedicine in future fertility care.

Discipline-level differences in mental health provider perceptions of video and phone telehealth.

COVID-19 led to a rapid increase in telemental health care via video or phone. It is important to examine contributors to the choice of video versus phone, as video may be more effective and preferred by patients. Medical mental health (MH) providers (e.g., psychiatrists) may conduct more phone and less video visits than nonmedical MH providers (e.g., psychologists). This study examined whether medical and nonmedical providers' perceptions of the quality and complexity of phone and video MH care may contribute to differences in use. A 32-item survey of 414 providers (79.5% response rate) assessed perceptions of care quality, factors contributing to modality choice, and telehealth challenges. The types of visits completed by providers in the months prior to the survey were extracted from administrative data. Medical and nonmedical providers generally viewed video care as higher quality and more preferred than phone, although to a lesser extent among medical providers. Nonmedical providers' decision making was more impacted by research regarding the modalities' relative effectiveness. Medical providers more frequently endorsed video challenges, including patient technical difficulties and lack of patient training. Administrative data demonstrated that medical providers conducted fewer video appointments than nonmedical providers. Medical providers may be less aware of research demonstrating that video care is effective and preferred by patients, and the complexity of video visits may be a barrier to use. Streamlining video processes, increasing technical support, and disseminating research that compares the quality of video and phone care may increase video use among medical providers. (PsycInfo Database Record (c) 2024 APA, all rights reserved).

Apremilast Adherence and Persistence in Patients with Psoriasis and Psoriatic Arthritis in the Telehealth Setting Versus the In-person Setting During the COVID-19 Pandemic.

Limited access to healthcare during the COVID-19 pandemic prompted patients to seek care using telehealth. In this study, we assessed whether treatment patterns differed for patients with psoriasis (PsO) or psoriatic arthritis (PsA) initiating apremilast by either a telehealth or an in-person visit. We estimated adherence and persistence among US patients in the Merative© MarketScan© Commercial and Supplemental Medicare Databases who newly initiated apremilast between April and June 2020, categorized by the type of visit (telehealth or in-person) when apremilast was first prescribed. Adherence was defined as the proportion of days covered (PDC), with PDC ≥ 0.80 considered to indicate high adherence. Persistence was defined as having apremilast available to take without a 60-day gap during follow-up. Factors associated with high adherence and persistence were estimated with logistic and Cox regression. Among apremilast initiators (n = 505), the mean age was 47.6years, 57.8% were female, and the majority had PsO (79.6%). Telehealth index visits were more likely among patients residing in Northeast USA (odds ratio [OR] 3.31, 95% confidence interval [CI] 1.63-6.71) and Western USA (OR 2.52, 95% CI 1.07-5.93]), those with a prescribing rheumatologist (OR 2.27, 95% CI 1.10-4.68), and those with any baseline telehealth visit (OR 1.91, 85% CI 1.20-3.04). Those initiating apremilast with a telehealth visit (n = 141) had similar mean PDC to those initiating apremilast with an in-person visit (n = 364) (0.695 vs. 0.728; p = 0.272). At the end of the 6-month follow-up, 54.3% of the overall population had high adherence (PDC ≥ 0.80) and 65.1% were persistent. After adjusting for potential confounders, patients initiating apremilast via telehealth had similar full adherence (OR 0.80, 95% CI 0.52-1.21) and persistence as those initiating apremilast in-person. Patients with PsO and patients with PsA initiating apremilast via telehealth or in-person during the COVID-19 pandemic had similar medication adherence and persistence during the 6-month follow-up period. These data suggest that patients initiating apremilast can be as effectively managed with telehealth visits as with in-person visits.

Republication of "Cross-Sectional Assessment of Orthopedic Foot and Ankle Patient Knowledge".

Individuals with limited health literacy often struggle in effectively communicating with their physicians and may lack the skills needed to make informed health decisions. It is therefore important that providers have insight into patients' baseline medical knowledge, as this can help physicians customize their approach to, and conversations with, each patient. As such, this study evaluated the foot and ankle-specific knowledge of patients seeking care for various foot and ankle ailments. An unvalidated survey developed by our study group was distributed to 206 patients, assessing their knowledge of foot and ankle anatomy, terminology, conditions, treatment, and perioperative issues. Performance was evaluated as a function of participants' demographic factors. Participants performed significantly worse on the conditions and treatment questions as compared to the anatomy, terminology, and perioperative considerations subsections. Significantly better performance correlated with education (≥college), visit type (preoperative evaluation), a current or previous health care occupation, and prior orthopedic surgeon evaluation. Patients' knowledge of foot and ankle anatomy, terminology, conditions, treatment, and perioperative issues correlates with certain patient characteristics and demographics. With enhanced insight into the risk factors for limited knowledge, education campaigns can be designed to target those most in need.

Patient Experience and Clinical Outcomes after Same-day Outpatient Mastectomy and Immediate Breast Reconstruction Protocol during the Global Pandemic.

This is a retrospective single-institution study of consecutive patients who underwent mastectomy and immediate alloplastic reconstruction between July 2019 and November 2020. A postoperative survey was completed by patients to evaluate satisfaction with perioperative communications, recovery, and their overall experience. A total of 302 patients (100% women) underwent mastectomy and immediate alloplastic reconstruction (174 pre-COVID-19, 128 during COVID-19). During COVID-19, 71% of patients were scheduled for a same-day discharge, among which 89% were successfully discharged the same day. Compared with pre-COVID-19, there were no differences in type of surgery, operative times, pain scores, 30-day readmission, or unplanned visits (all P > 0.05) during the COVID-19 pandemic. Compared with pre-COVID-19, patients during the pandemic reported comparable satisfaction with their care experience and postoperative recovery (56% survey response rate). Patient satisfaction was also similar between those discharged the same day (n = 81) versus the next day (n = 47) during COVID-19. Same-day discharge is feasible, safe, and can provide similar patient-reported satisfaction and outcomes compared with traditional overnight stay. These data highlight the ability to deliver adaptable, high-quality breast cancer care, within the constraints of a global pandemic.

A time-motion study of community health workers delivering community-based primary health care in Neno District, Malawi

IntroductionCommunity health workers (CHWs) are vital resources in delivering community-based primary health care, especially in low-and-middle-income countries (LMIC). However, few studies have investigated detailed time and task assessments of CHW's work. We conducted a time-motion study to evaluate CHWs' time on health conditions and specific tasks in Neno District, Malawi.MethodsWe conducted a descriptive quantitative study utilizing a time observation tracker to capture time spent by CHWs on focused health conditions and tasks performed during household visits. We observed 64 CHWs between 29 June and 20 August 2020. We computed counts and median to describe CHW distribution, visit type, and time spent per health condition and task. We utilized Mood’s median test to compare the median time spent at a household during monthly visits with the program design standard time. We used pairwise median test to test differences in median time duration for health conditions and assigned tasks.ResultsWe observed 660 CHW visits from 64 CHWs, with 95.2% (n = 628) of the visits as monthly household visits. The median time for a monthly household visit was 34 min, statistically less than the program design time of 60 min (p < 0.001). While the CHW program focused on eight disease areas, pretesting with the observation tool showed that CHWs were engaged in additional health areas like COVID-19. Of the 3043 health area touches by CHWs observed, COVID-19, tuberculosis, and non-communicable diseases (NCDs) had the highest touches (19.3%, 17.6%, and 16.6%, respectively). The median time spent on sexually transmitted infections (STIs) and NCDs was statistically higher than in other health areas (p < 0.05). Of 3813 tasks completed by CHWs, 1640 (43%) were on health education and promotion. A significant difference was observed in the median time spent on health education, promotion, and screening compared to other tasks (p < 0.05).ConclusionThis study demonstrates that CHWs spend the most time on health education, promotion, and screening per programmatic objectives but, overall, less time than program design. CHWs deliver care for a broader range of health conditions than the programmatic design indicates. Future studies should examine associations between time spent and quality of care delivery.

Comparative effectiveness of generic commercial versus locally customized clinical decision support tools to reduce prescription of nonsteroidal anti-inflammatory drugs for patients with heart failure.

To compare the effectiveness of 2 clinical decision support (CDS) tools to avoid prescription of nonsteroidal anti-inflammatory drugs (NSAIDs) in patients with heart failure (HF): a "commercial" and a locally "customized" alert. We conducted a retrospective cohort study of 2 CDS tools implemented within a large integrated health system. The commercial CDS tool was designed according to third-party drug content and EHR vendor specifications. The customized CDS tool underwent a user-centered design process informed by implementation science principles, with input from a cross disciplinary team. The customized CDS tool replaced the commercial CDS tool. Data were collected from the electronic health record via analytic reports and manual chart review. The primary outcome was effectiveness, defined as whether the clinician changed their behavior and did not prescribe an NSAID. A random sample of 366 alerts (183 per CDS tool) was evaluated that represented 355 unique patients. The commercial CDS tool was effective for 7 of 172 (4%) patients, while the customized CDS tool was effective for 81 of 183 (44%) patients. After adjusting for age, chronic kidney disease, ejection fraction, NYHA class, concurrent prescription of an opioid or acetaminophen, visit type (inpatient or outpatient), and clinician specialty, the customized alerts were at 24.3 times greater odds of effectiveness compared to the commercial alerts (OR: 24.3 CI: 10.20-58.06). Investing additional resources to customize a CDS tool resulted in a CDS tool that was more effective at reducing the total number of NSAID orders placed for patients with HF compared to a commercially available CDS tool.

A Qualitative Study of Barriers and Facilitators to Integrating Medications for Opioid Use Disorder and HIV Preexposure Prophylaxis for Adolescents and Young Adults.

The syndemic of substance use and human immunodeficiency virus (HIV) is a well-recognized global phenomenon that threatens to undermine the priorities outlined by the National Institutes of Health "Ending the HIV Epidemic" initiative. There are few published studies on preexposure prophylaxis (PrEP) for adolescents and young adults (AYAs) with opioid use disorder (OUD) despite increasing availability of biomedical prevention options and Centers for Disease Control and Prevention recommendations to offer PrEP to this group. Healthcare providers who previously prescribed medications for OUD (MOUDs) and/or PrEP for AYA were purposively sampled. Audio-recorded in-depth individual interviews were conducted using chart-stimulated recall to explore barriers and facilitators to integrated MOUD and HIV prevention services. Interviews were double-coded, and qualitative analysis was performed using a modified grounded theory. Of 19 providers sampled, most were physicians (63%). All recommended HIV screening at varying intervals; however, few counseled on (19%) or prescribed (11%) PrEP to patients on MOUD. Barriers to PrEP prescriptions included patient-level (ie, stigma surrounding PrEP use, adherence challenges, and competing social or mental healthcare needs), provider (perception of low risk, lack of training/experience), and system-level factors (including restricted visit types). Facilitators of PrEP prescriptions included patient-initiated requests, electronic health record system reminders, and the availability of consistent support staff (ie, navigators, certified recovery specialists). Our study confirms that discussions about HIV prevention and PrEP prescriptions may be rare for AYA patients receiving MOUD. Further research is needed to develop interventions that increase the integration of PrEP delivery within the context of OUD care among this key AYA population.

Quantifying the Digital Divide: Associations of Broadband Internet with Tele-mental Health Access Before and During the COVID-19 Pandemic

BackgroundDuring the COVID-19 pandemic, telemedicine quickly expanded. Broadband speeds may impact equitable access to video-based mental health (MH) services.ObjectiveTo identify access disparities in Veterans Health Administration (VHA) MH services based on broadband speed availability.DesignInstrumental variable difference-in-differences study using administrative data to identify MH visits prior to (October 1, 2015–February 28, 2020) and after COVID-19 pandemic onset (March 1, 2020–December 31, 2021) among 1176 VHA MH clinics. The exposure is broadband download and upload speeds categorized as inadequate (download ≤25 Megabits per second - Mbps; upload ≤3 Mbps), adequate (download ≥25 Mbps and <100 Mbps; upload ≥5 Mbps and <100 Mbps), or optimal (download and upload ≥100/100 Mbps) based on data reported to the Federal Communications Commission at the census block and spatially merged to each veteran’s residential address.ParticipantsAll veterans receiving VHA MH services during study period.Main MeasuresMH visits were categorized as in-person or virtual (i.e., telephone or video). By patient, MH visits were counted quarterly by broadband category. Poisson models with Huber-White robust errors clustered at the census block estimated the association between a patient’s broadband speed category and quarterly MH visit count by visit type, adjusted for patient demographics, residential rurality, and area deprivation index.Key ResultsOver the 6-year study period, 3,659,699 unique veterans were seen. Adjusted regression analyses estimated the change after pandemic onset versus pre-pandemic in patients’ quarterly MH visit count; patients living in census blocks with optimal versus inadequate broadband increased video visit use (incidence rate ratio (IRR) = 1.52, 95% CI = 1.45–1.59; P < 0.001) and decreased in-person visits (IRR = 0.92, 95% CI = 0.90–0.94; P < 0.001).ConclusionsThis study found patients with optimal versus inadequate broadband availability had more video-based and fewer in-person MH visits after pandemic onset, suggesting broadband availability is an important determinant of access-to-care during public health emergencies requiring remote care.

Linkages between women's empowerment, religion, marriage type, and uptake of antenatal care visits in 13 West African countries.

Characteristics which reflect a particular context and unique to individuals, households, and societies have been suggested to have an impact on the association between women's empowerment and women's well-being indicators. However, there is limited empirical evidence of this effect. We used access to antenatal care (ANC) to examine the main and interaction effects of women's empowerment, religion, marriage type, and uptake of services in 13 West African countries. Data was extracted from Phase 6 and 7 of the Demographic and Health Survey, and we measured women's empowerment using the survey-based women's empowerment (SWPER) index for women's empowerment in Africa. ANC visits as the outcome variable was analyzed as a count variable and the SWPER domains, religion, and marriage type were the key independent variables. We utilised ordinary least square (OLS) and Poisson regression models where appropriate to examine main and interaction effects and analyses were appropriately weighted and key control variables were applied. Statistical significance was established at 95% confidence interval. Findings suggest that being Muslim or in a polygynous household was consistently associated with disempowerment in social independence, attitude toward violence, and decision-making for women. Although less consistent, improved social independence and decision-making for women were associated with the probability of increased ANC visits. Polygyny and Islamic religion were negatively associated with increased number of ANC visits. Decision-making for Muslim women appear to increase the probability of increased number of ANC visits. Improving the conditions that contribute towards women's disempowerment especially for Muslim women and to a lesser extent for those who reside in polygynous households is key towards better uptake of antenatal care services. Furthermore, targeting of interventions and polices that could empower women towards better access to health services should be tailored on existing contextual factors including religion and marriage type.

Official Visits and Economic Freedom

This study examines the effect of U.S. Presidents and Secretaries of State visits to a country on institutional quality, particularly on economic freedom. Hence, the study develops a model that predicts the conditions under which official visits can enhance the quality of institutions. We compile variables on official visits from 1960 to 2019 from the archives of the U.S. State Department to test the predictions of our model. In addition, we use the endogenous treatment model estimation to deal with potential endogeneity. The estimation results show that the official visits have a statistically significant negative effect on economic freedom, particularly in non-democratic countries with less political freedom. The estimation results are robust with different types of visits and samples. The study presents multiple explanations for these results, including the possibility of the following: First, some American administrations adopt a pragmatic approach aimed at achieving strategic objectives while overlooking practices that do not enhance institutional quality. Second, these official visits may improve other aspects of institutional quality that are more observable to the international community than economic freedoms. Third, American policymakers care more about achieving short-term objectives from their visits that can be presented as accomplishments to their electorate rather than institutional reforms that will only yield benefits to the United States in the long run. Finally, economic freedoms are associated with political freedoms per the Hayek-Friedman hypothesis.