Variation In Coverage Research Articles

A 50-Year Review of Congressional Membership by Health Care Professionals: Is Surgical Representation Adequate?

Although 100% of congressional legislators vote on health care policy, only a minority have a background in health care. A review of the participation of health care professionals (HCPs) in Congress, highlighting participation by surgeons, is critical to the future policy-making endeavors in health care. This article seeks to better understand the characteristics of HCPs who engage in advocacy and describe the trends in their representation in Congress, with commentary on participation by surgeons and its impact on current health advocacy efforts.A search of Congress.gov and the Biographical Directory of the United States Congress was performed to identify professional health care history for each congressperson, followed by review of official campaign websites for health advocacy work. Statistical analysis was performed using IBM SPSS Statistics Software for changes in representation of HCPs, physicians, and surgeons in Congress over time. Although there has been increasing representation of HCPs in Congress in the past 25 years, surgeons have the lowest increase in congressional membership. For health care reform to optimally address high costs, variable insurance coverage and reimbursement rates, and equal access to care, more physicians must make health care advocacy efforts an integral part of their careers. Incorporation of education in areas of health care advocacy and/or reform into undergraduate and graduate medical education curricula may help address deficiencies in knowledge of current health care-related events to further encourage involvement in health care legislation.

Validation of MUSES NH3 observations from AIRS and CrIS against aircraft measurements from DISCOVER-AQ and a surface network in the Magic Valley

Abstract. Ammonia is a significant precursor of PM2.5 particles and thus contributes to poor air quality in many regions. Furthermore, ammonia concentrations are rising due to the increase of large-scale, intensive agricultural activities, which are often accompanied by greater use of fertilizers and concentrated animal feedlots. Ammonia is highly reactive and thus highly variable and difficult to measure. Satellite-based instruments, such as the Atmospheric Infrared Sounder (AIRS) and the Cross-Track Infrared Sounder (CrIS), have been shown to provide much greater temporal and spatial coverage of ammonia distribution and variability than is possible with in situ networks or aircraft campaigns, but the validation of these data is limited. Here we evaluate MUSES (multi-spectra, multi-species, multi-sensors) ammonia retrievals from AIRS and CrIS against ammonia measurements from aircraft in the California Central Valley and in the Colorado Front Range. These are small datasets taken over high-source regions under very different conditions: winter in California and summer in Colorado. Direct comparisons of the surface values of the retrieved profiles are biased very low in California (∼ 40 ppbv) and slightly high in Colorado (∼ 4 ppbv). This bias appears to be primarily due to smoothing error, since applying the instrument operator effectively reduces the bias to zero; even after the smoothing error is accounted for, the average uncertainty at the surface is in the 20 %–30 % range. We also compare 3 years of CrIS ammonia against an in situ network in the Magic Valley in Idaho We show that CrIS ammonia captures both the seasonal signal and the spatial variability in the Magic Valley, although it is biased low here also. In summary, this analysis substantially adds to the validation record but also points to the need for more validation under many different conditions and at higher altitudes.

Health insurance coverage among incident cancer cases from population-based cancer registries in 49 US states, 2010-2019.

Having health insurance coverage is a strong determinant of cancer care access and survival in the United States. The expansion of Medicaid income eligibility under the Affordable Care Act has increased insurance coverage for working-age adults. Using data from the Cancer Incidence in North America (CiNA) in 2010-2019, we identified 6 432 117 incident cancer cases with known insurance status diagnosed at age 18-64 years from population-based registries of 49 states. Considerable variation in Medicaid coverage and uninsured rate exists across states, especially by Medicaid expansion status. Among expansion states, Medicaid coverage increased from 14.1% in 2010 to 19.9% in 2019, while the Medicaid coverage rate remained lower (range = 11.7% - 12.7%) in non-expansion states. The uninsured rate decreased from 4.9% to 2.1% in expansion states, while in non-expansion states, the uninsured rate decreased slightly from 9.5% to 8.1%. In 2019, 111 393 cancer cases (16.9%) had Medicaid coverage at diagnosis (range = 7.6%-37.9% across states), and 48 357 (4.4%) were uninsured (range = 0.5%-13.2%). These estimates suggest that many patients with cancer may face challenges with care access and continuity, especially following the unwinding of COVID-19 pandemic protections for Medicaid coverage. State cancer prevention and control efforts are needed to mitigate cancer care disparities among vulnerable populations.

Is health expenditure on immunisation associated with immunisation coverage in sub-Saharan Africa? A multicountry analysis, 2013–2017

ObjectivesThe designing of contextually tailored sustainable plans to finance the procurement of vaccines and the running of appropriate immunisation programmes are necessary to address the high burden of vaccine-preventable diseases...

Factors associated with full childhood vaccination coverage among young mothers in Northern Nigeria.

wide regional variation in immunization coverage still persists in Nigeria. Full Immunization Coverage (FIC) for more than 80% of all states in the northern region is lower than 40% relative to their southern counterpart. Studies focusing on young women in the north remain sparse, despite the high prevalence of early marriage and poor health-seeking behavior. This study examines FIC among young women in northern Nigeria. we performed a secondary analysis of the 2013 and 2018 Nigeria Demographic and Health Survey on 1,198 women of children aged 12-23 months in 2013 and 405 in the 2018 dataset. Analysis was limited to young women 15-24 years, residing in Northern Nigeria. We used logistics regression to predict factors associated with FIC. the proportion of fully immunized children was low, at 11% in 2013 and 18% in 2018. The coverage for most vaccines was low, except for the oral polio vaccine. The children of mothers who had health card [(aOR=18.1,95% C.I (8.1-40.7)], in 2013 and 2018 [(aOR=12.7, 95% C.I (5.9-27.1)], attended ANC [(aOR=8.6, 95% C.I (2.4-30.9)] in 2013 and had facility delivery [(aOR=2.0, 95% C.I (1.0-4.1)] in 2018 were more likely to be fully immunized. the study found FIC among children of young women in Northern Nigeria was abysmally low. Ownership of health care, antenatal attendance, and facility delivery significantly predicted the odds of FIC. These findings suggest the need for approaches that remove barriers to good health-seeking behavior, especially among young mothers in Northern Nigeria.

Elevational variations of leaf morphological traits and its responses to simulated climate warming in Tibetan alpine meadows

Both climate and environment changes can lead to variations in leaf morphological traits within or among herbaceous species. However, evidence for leaf morphological traits of alpine herbaceous species shifts with elevations, particularly under climate warming, is scarce. A field experimental warming experiment was conducted to address these questions in alpine meadows on the Tibetan Plateau. We measured the leaf morphological traits including leaf length, leaf width, leaf perimeter, leaf area of alpine herbaceous species along a slope of the Nyenqing-Tanggula Mountain (from 4600 m to 5200 m) on the Tibetan Plateau. Our results revealed that warming greatly decreased plant cover, species richness, and plant biomass of alpine meadows, but had no significant effects on soil carbon and nutrients. Leaf area across warming and control treatments was on average larger in low-elevation alpine meadows, and smaller toward the high-elevation alpine meadows, with leaf length and length/width ratio significantly decreased with increasing elevations. Leaf area and leaf length were positively corelated with growing season air temperature and soil temperature, but had no significant relationship with growing season precipitation, soil moisture, and photosynthetically active radiation. The decreasing elevational pattern in leaf size could be mainly attributed to the decreasing in leaf length. In response to experimental warming, our results further revealed that leaf size tended to be larger in warming plots than control plots along the elevational gradient, and the warming effects on leaf size varied greatly with herbaceous species. However, warming greatly decreased community-weighted means leaf area in mid-elevations, but increased that in both lower and higher elevations, which were mainly due to warming-induced variations in species richness and plant coverage. Our findings will fill the knowledge gap and provided valuable observational evidence in exploring elevational pattern of leaf size in Tibetan alpine meadows.

RECEIPT OF GENDER-AFFIRMING SURGERY AMONG MEDICARE BENEFICIARIES

Abstract While transgender and gender diverse (TGD) people may never seek treatment related to their gender identity, many require access to gender-affirming treatments, including surgery. Starting in 2014, Medicare began covering gender-affirming surgery (GAS) on a case-by-case basis. In this study, we use national Medicare data to compare receipt of GAS by beneficiary characteristics. We classified TGD beneficiaries using an algorithm that combines diagnosis and procedure codes. Our study compared characteristics for all TGD identified beneficiaries and those who received GAS using a population-averaged logistic model using a generalized estimating equation (GEE) adjusting for dual status, age group, race/ethnicity, original reason for entitlement, and CMS region. Our sample accounted for 49,945 observations for 11,162 individuals, with a total of 290 identified records of GAS. In our adjusted analysis, we found that TGD beneficiaries in certain parts of the country had lower odds of GAS compared to their counterparts. Compared to CMS Region 1 (which includes Connecticut, Maine, Massachusetts, New Hampshire, Rhode Island, and Vermont), those living in Region 3 (Delaware, District of Columbia, Maryland, Pennsylvania, Virginia, and West Virginia), Region 4 (Alabama, Florida, Georgia, Kentucky, Mississippi, North Carolina, South Carolina, and Tennessee), and Region 6 (Arkansas, Louisiana, New Mexico, Oklahoma, and Texas) had a significantly lower odds of receiving GAS. Access to gender-affirming care may be influenced by CMS regional contractors, as well as state-by-state variation in Medicaid coverage for gender-affirming care. Further research is needed to explain why beneficiaries may have lower access to GAS to inform policy recommendations.

Coalescence-Induced Droplet Jumping on Superhydrophobic Surfaces with Annular Wedge-Shaped Micropillar Arrays.

The coalescence-induced droplet jumping on superhydrophobic surfaces has extensive application potential in water harvesting, thermal management of electronic devices, and microfluidics. The rational design of the surface structure can influence the interaction between the droplet and the surface, thereby controlling the velocity and direction of the droplet's jumping. In this study, we fabricate the superhydrophobic surface with annular wedge-shaped micropillar arrays, examine the dynamic behavior of condensate droplets on the surface, and measure the temporal and spatial variations of droplet density, average radius, and surface coverage with wedge-shaped micropillars of varying sizes. In addition, the energy analysis of the coalescence-induced droplet jumping reveals that the two primary factors influencing the jumping are the relative size and position of the droplets and micropillars. Further numerical simulations find that the wedge-shaped micropillars cause an asymmetric distribution of pressure within the droplet and at the solid-liquid contact surface, which generates an unbalanced force driving the droplet in the gradient direction of the wedge-shaped micropillar, causing the droplet to jump off the surface with both vertical and gradient-direction velocities. The capacity of the wedge-shaped micropillar surface to transport droplets in the gradient direction increases and then decreases as the relative size of the droplets and micropillars increases. The relative position of the droplet center-of-mass line perpendicular to the bottom edge of the wedge micropillars' trapezoidal shape is more favorable for droplet transport. This work reveals the influence mechanism of surface structure on the velocity and direction of droplet jumping, and the results can guide the microstructure design of superhydrophobic surfaces, which has significant implications for the application of droplet jumping.

Effect of unequal vaccination coverage and migration on long-term pathogen evolution in a metapopulation.

Worldwide inequalities in vaccine availability are expected to affect the spread and spatial distribution of infectious diseases. It is unclear, however, how spatial variation in vaccination coverage can affect the long-term evolution of pathogens. Here we use an analytical model and numerical simulations to analyse the influence of different imperfect vaccines on the potential evolution of pathogen virulence in a two-population model where vaccination coverage varies between populations. We focus on four vaccines, with different modes of action on the life cycle of a pathogen infecting two host populations coupled by migration. We show that, for vaccines that reduce infection risk or transmissibility, spatial heterogeneity has little effect on pathogen prevalence and host mortality, and no effect on the evolution of pathogen virulence. In contrast, vaccines that reduce pathogen virulence can select for more virulent pathogens and may lead to the coexistence of different pathogen strains, depending on the degree of spatial heterogeneity in the metapopulation. This heterogeneity is driven by two parameters: pathogen migration and the difference in the vaccination rate between the two populations. We show that vaccines that only reduce pathogen virulence select mainly for a single pathogen strategy in the long term, while vaccines that reduce both transmission and virulence can favor the coexistence of two pathogen genotypes. We discuss the implications and potential extensions of our analysis.

School-based vaccination program against HPV and Hepatitis B: A longitudinal analysis of vaccine coverage between 2015 and 2021 in Quebec

BackgroundHPV vaccination prevents cancers, including 90% of cervical cancer. Since 2008, a school-based HPV vaccination program has been implemented in Quebec, but vaccine coverage is suboptimal. The COVID-19 pandemic disrupted school-based vaccination programs. This study aimed to assess variation in HPV vaccination coverage in the school-based program between 2015 and 2022 in Quebec and to identify sociodemographic characteristics associated with non-vaccination. MethodsHPV vaccine coverage data were extracted from the Quebec Immunization Registry for students in Grade 4 and matched to the 2016 Canadian census sociodemographic data. Descriptive analysis was conducted to explore individual-level vaccine coverage according to sociodemographic data. A Generalized Estimating Equations model assessed the independent association between non-vaccination and students’ sociodemographic characteristics. ResultsHPV vaccine coverage (at least one dose) was 84% in 2018–2019 and 85% in 2019–2020. A decrease was observed during the pandemic. In 2020–2021, the HPV vaccine coverage (at least one dose) was 52% (at the end of the school year) and rose to 84% with intense catch-up activities. In 2021–2022, the coverage was slightly lower than before the pandemic (81%). Factors in the dissemination area were statistically significantly associated with non-vaccination: material (p-value = 0.0001) and social deprivation index (p-value = 0.0048), the proportion of immigration (p-value < 0.0001), and the language spoken at home (English (p-value = 0.0318), other than French or English (p-value = 0.0001). ConclusionSchool-based vaccination programs offer equitable access to vaccination, and our analysis showed that some groups have consistently lower vaccine acceptance and uptake. Strategies to improve HPV vaccine coverage should target children living in areas with a higher proportion of immigrants, non-French speakers, and people from underprivileged backgrounds. Although it is too early to assess the full impact of COVID-19 on school-based programs in Quebec, it remains important to ensure that catch-up strategies are implemented for missed doses.

Abstract C023: Variations in clinical presentation and outcomes of rare ovarian cancers by race and nativity

Abstract Introduction: Disparities in the prevalence of disease, medical access, and survival rates have been well documented in women with epithelial ovarian cancer. Black women tend to develop more aggressive tumors and have worse overall survival. Aside from race, however, nativity (region of birth) has been associated with variations in treatment outcomes. There is a paucity of research specifically about rare ovarian cancer subtypes, including germ cell (GC) and stromal cell (SC) tumors. Our study aims to provide a comparative analysis of clinical presentation and outcomes among women of Caribbean and US origin with GC and SC tumors, stratified by race. Methods: Analyses were conducted using the Florida Cancer Data Service (FCDS), the statewide cancer registry. Women who were diagnosed with GC and SC ovarian cancer subtypes from 1987 to 2017 were identified, and categorized as either US-born (USB) White, USB Black, Caribbean-born (CB)White, or CB Black. Abstracted data included patient-level demographic data, treatment histories, and all-cause overall survival. Statistical analyses were performed using chi-square, ANOVA, log-rank test, and Kaplan-Meier method, with the threshold for statistical significance set at p &amp;lt; 0.05. Results: 691 women with GC and SC were identified. There was a significant difference in mean age at diagnosis by race and nativity. USB Black women were diagnosed at the youngest mean age (34.4 yr, SD 20.62), followed by USB White (38.6 yr, SD 20.97), CB Black (43.9 yr, SD 20.79), and CB White (45.9 yr, SD 18.66)(p=0.002). CB White patients had the highest utilization of Medicaid (23.5%), while CB Black had the highest proportion of uninsured patients (22.2%)(p&amp;lt;0.001). There were no differences in stage, tumor characteristics (grade, histology, lymph vascular invasion) or treatments (surgery, chemotherapy, radiation) administered among the groups. CB Black women had a much lower prevalence of smoking (2.8%) compared to the other subgroups (CB White 23.5%5; USB White 28.1%; USB Black 16.9%, p=0.003). There were no significant differences in median OS by race and nativity (USB White 184 months; USB Black USB 244 months; CB White 270 months; CB Black CB 204 months; log-rank p=0.8). Conclusion: Despite a younger age of diagnosis in USB versus CB women, and Black women vs White women, there were no differences in survival outcomes in women with GC and SC ovarian cancers, even when considering variations in insurance coverage and smoking histories. While the long survival is likely due to the natural history of these tumors, the variation in age at diagnosis suggests variable susceptibility to tumor initiation by race and place of birth. Citation Format: Maurice J. Chery, Alex P. Sanchez-Covarrubias, Sophia H.L. George, Matthew P. Schlumbrecht. Variations in clinical presentation and outcomes of rare ovarian cancers by race and nativity [abstract]. In: Proceedings of the 16th AACR Conference on the Science of Cancer Health Disparities in Racial/Ethnic Minorities and the Medically Underserved; 2023 Sep 29-Oct 2;Orlando, FL. Philadelphia (PA): AACR; Cancer Epidemiol Biomarkers Prev 2023;32(12 Suppl):Abstract nr C023.

MkLTG: a command-line tool for taxonomic assignment of metabarcoding sequences using variable identity thresholds.

Metabarcoding is now a widely used method for biodiversity studies. Taxonomic assignment of environmental sequences is one of the key steps of metabarcoding. Assignments based on lowest common ancestor (LCA) method generally rely on fixed arbitrary thresholds, and this is generally not well adapted for assignment of taxonomically diverse groups with variable coverage in reference databases. The mkLTG is a LCA-based method that uses a series of percentage of identity thresholds starting from stringent parameters and decreasing it if necessary. All parameters can be set separately for each percentage of identity threshold, which makes this tool adaptable for different databases, genetic markers and diverse taxonomic groups. The optimization step was included using the COI marker and a comprehensive, non-redundant database. The mkLTG tool is a command-line application with few dependencies that runs in all operating systems, therefore, it is easy to include into complex pipelines. All scripts are freely available including the benchmarking at https://github.com/meglecz/mkLTG .

Role of Metal Nanoparticles in the Fabrication of Porous Silicon: A Material for Solar Cell Applications

Metal-Assisted Chemical Etching method (MACE) has emerged as an effective tool to fabricate silicon nanostructures. This technique requires a catalytic mask that is commonly composed of a metal. In the present work, the role of Silver nanoparticles (AgNPs) in the etching mechanism of Porous Silicon (PS) is investigated by studying the effect of AgNP coverage on the surface porosity and the different properties of PS. XRD spectra consist of the two peaks corresponding to silicon and AgNPs respectively and the peak intensity of Ag decreased with an increase in etching time which indicates that as the etching time increases the dissolution of silver metal also increases. Thus, the pore depth depends on the dissolution of AgNP. The pore depth and porosity are calculated at different etching times by SEM analysis. It is observed that porosity is modifiable with the variation of AgNP coverage which in turn modifies the optical properties of PS. The porosity increased with the increase of etching time and the highest porosity obtained was 78% after 240 minutes. The refractive index of PS decreased with increasing porosity in the visible region. The variation of the refractive index results in the tuning of optical energy gap which is more essential in increasing the efficiency of solar cells.

Analyzing variation in state newspaper coverage of climate change

Analyzing variation in state newspaper coverage of climate change

Impacts of climate change on fractional vegetation coverage of temperate grasslands in China from 1982 to 2015

The vegetation coverage of temperate grasslands in China has changed substantially due to climate change during the past decades, which significantly affects the function of grassland ecosystems. To appropriately carry out adaptive management and protect temperate grassland vegetation, it is important to understand the variations in fractional vegetation coverage (FVC) of China's temperate grasslands and how they are responding to climate change. Using the GIMMS NDVI and climatic datasets, this study explored the dynamics of FVC and their climatic drivers across the temperate grassland region of China during 1982∼2015. The results showed that the growing season mean FVC increased by 0.12% per year during 1982∼2015. The increases in precipitation and minimum temperature in the growing-season (especially in spring) could enhance the FVC of various vegetation types. In summer, the FVC of temperate steppe and desert steppe could drastically increase with increasing precipitation. In addition, this study found that the impacts of daytime and night-time warming on the FVC of temperate grasslands were asymmetric. Daytime warming can moderately increase FVC of temperate grasslands, while night-time warming could significantly increase it. Furthermore, the increase in summer daytime and night-time temperatures leads to a weak decrease and a moderate increase in FVC, respectively. This asymmetric effect was more evident for the temperate steppe and desert steppe in the central area. In autumn, the temperatures increase had significant positive impacts on the FVC of temperate meadows and steppes. This study highlights the differences in the impacts of climate change at different time scales on the FVC of grasslands with various vegetation types, and indicates that the asymmetric influences of daytime and night-time temperatures in different seasons on FVC must be included in calculating the vegetation coverage of China's temperate grasslands. The results could provide information for maintaining grassland ecosystem functions and managing environmental systems.

Modeling of sputter-based atomic layer deposition with altered parameters

Computational modeling of the sputtering process forming atomic layers of some technologically significant materials was performed based on sputter rate relation. Bismuth atomic layer deposition at different polar angles and ion fluence were shown. The atomic layers getting deposited were studied as a function of incident Argon ion energy at different pressure and a curve analogous to the Bragg curve was obtained. The sputtering parameters were varied to get different atomic layers of TiOx films and the variation of coverage with sticking coefficient was shown. The rate of change of partial sputtering yield with coverage was depicted in the sputter-based deposition of TiN films. The deposition pressure and time were varied to get films of different thicknesses. All the simulated results were correlated with experimental findings with features like variation of reactive gas pressure, electron aided momentum transfer in Bi, multilayer anatase and rutile formation in TiO2 and effect of process parameters on TiN.

Methods for Identification of Blood Product Transfusions in a Cohort of Myelofibrosis Patients: An Assessment of Data Capture Using Insurance Claims and Electronic Health Record Abstraction

Introduction Transfusion data completeness is critical in assessing real-world response and progression in myeloid malignancies. In the real-world setting transfusion data can be collected via insurance claims or by Electronic Health Record (EHR) abstraction. Transfusion events captured from claims have previously been shown to be 71% sensitive and 92% specific compared to EHR abstraction in the community hospital setting, however this has not been evaluated in outpatient community oncology setting (Howard DH, et al. Transfusion Medicine. 2016;26:457-459). Our objective was to assess the completeness of transfusion data from claims in the The Komodo Healthcare Map™(KHM) to EHR abstraction in the Flatiron Health Research Database (FHRD) in a group of patients with myelofibrosis (MF). Methods This study used the nationwide Flatiron Health EHR-derived de-identified database and The Komodo Healthcare Map™, a database of de-identified claim-based healthcare encounters from insured patients in the US (2015-2022).This is a cross-sectional study of a cohort of patients with MF that underwent EHR abstraction (EHRC) (n = 507) from FHRD, capturing transfusion dates, and number of units from date of diagnosis up to data cutoff on 30 November 2022 (observation window). Those patients were linked to KHM to create a Linked Claims Cohort (LCC), and a sub-cohort of patients with any closed claims during the observation window to make a Closed Claims Cohort (CCC), where transfusions were assessed by reviewing transfusion-related HCPCS and ICD codes. Analyses were performed on the matched patients in the LCC and CCC, respectively. To assess the level of concordance between claims and EHR data sources on the number of transfusions per patient the intraclass correlation coefficient (ICC) was used. Also, percent overlap and sensitivity, specificity, and positive and negative predictive values were calculated. Results Out of a total of 507 in the EHRC, 498 were found in KHM and included in the LCC, and 245 had closed claims and comprised the CCC. Demographics are listed below (Table 1) and are similar between groups, however the CCC had a higher percentage of patients with more recent diagnosis. A total of 319 (64%) vs 168 (34%) in the LCC, and 143 (58%) vs 95 (39%) patients in the CCC had at least one transfusion identified by EHR and claims data sources, respectively (Table 2). In the LCC, there was 64.1% agreement of having a transfusion across data sources, with a kappa of 0.34 (p = 0), and in the CCC, there was 72.24% agreement, with a kappa of 0.47 (p = 0). The unweighted kappa for the number of transfusions recorded during the observation period was 0.11 (p = 0) in the LCC and 0.18 (p = 0) in the CCC. Treating the EHR source as the source of truth, the claims data source in LCC had a sensitivity of 48.28%, specificity of 92.18%, PPV of 91.67%, and NPV of 50% to identify transfusion events, while the claims in CCC had a sensitivity of 59.44%, specificity of 90.20%, PPV of 89.47%, and NPV of 61.33% Conclusions There was an observed low agreement between transfusions identified via EHR abstraction and Claims data sources, with the EHR having more transfusions identified, but a moderate agreement when selecting for patients with closed claims. As a source for transfusion data EHR provided more data points during the observation window for this group of patients. Future investigation of transfusions in patients with continuous closed claims during the observation window is warranted to determine if it improves data capture. This study demonstrates that EHR abstraction may have higher utility for identifying transfusions with lower attrition in a cohort of MF patients with long observation periods, and with variable insurance coverage in the outpatient oncology setting.

Overview of the Hepatitis B Epidemiology and Vaccination among Healthcare Workers

Introduction: Healthcare workers (HCWs) who are at high risk for HBV infection, have been recommended to receive the HB vaccine for over 20 years. This review aimed to highlight the enablers and obstacles facing the universal coverage of hepatitis B epidemiology and vaccination among healthcare workers. Methods: A search was conducted using the following terms related to hepatitis B, vaccination, and healthcare workers in Africa: hepatitis B, hepatitis B virus, vaccination, immunization, healthcare workers, health workers, and health personnel. This review included cross-sectional, case-control, and cohort studies. Studies in English or French from any location were selected. A search was conducted for articles published from 1970 to 2022 in PubMed and the Excerpta Medica Database (Embase) using search terms related to hepatitis B and healthcare workers. Results: This study analyzed 25 cross-sectional studies on healthcare workers (HCWs) in African countries to determine the prevalence of hepatitis B vaccination. The majority of the studies were conducted in hospitals and included HCWs from West and East Africa. After assessing the quality of the studies, 5 (14.3%) were found to be of high quality, 17 (77.1%) were of moderate quality, and 3 (8.6%) were of low quality. The proportion of HCWs who were fully vaccinated against hepatitis B varied widely, ranging from 0.8% in Rwanda to 72.0% in Libya. The overall pooled full vaccination coverage among HCWs in Africa was 24.7%. Subgroup analyses showed significant variation in vaccination coverage among HCWs in different regions of Africa and Asia, with the highest coverage in North Africa and the lowest in Central and East Africa. Conclusions: Healthcare workers (HCWs) are at higher risk of infection with Hepatitis B virus (HBV) compared to individuals who do not work in hospitals, with frequencies of infection up to 4 times higher. HBV can be transmitted between patients and HCWs, as well as between HCWs and their relatives, contributing to the ongoing chain of transmission.

Geographic Variation in Qualified Health Plan Coverage and Prior Authorization Requirements for HIV Preexposure Prophylaxis

HIV preexposure prophylaxis (PrEP) is a key component of the Ending the HIV Epidemic (EHE) Initiative to curb new HIV diagnoses. In October 2019, emtricitabine/tenofovir alafenamide was added as an approved formulation for PrEP in addition to emtricitabine/tenofovir disoproxil fumarate; despite availability of another formulation with a similar prevention indication, variations in coverage may limit access. To assess qualified health plan (QHP) coverage, prior authorization (PA) requirements, and specialty tiering for emtricitabine/tenofovir disoproxil fumarate and emtricitabine/tenofovir alafenamide following emtricitabine/tenofovir alafenamide approval as a PrEP treatment. This cross-sectional study analyzed QHPs in the US that were compliant with the Patient Protection and Affordable Care Act from 2018 to 2020. QHPs were categorized by region and EHE priority jurisdictions. Data analysis occurred from March 2022 to March 2023. Enrollment in a qualified health plan certified by the Patient Protection and Affordable Care Act. Annual variation in QHP coverage and PA requirement for emtricitabine/tenofovir disoproxil fumarate and/or emtricitabine/tenofovir alafenamide. Descriptive statistics were reported for all outcomes. A secondary outcome was whether the PrEP formulation was determined by the QHP to be placed on a specialty drug tier. A total of 58 087 QHPs (19 533 for 2018; 17 007 for 2019; and 21 547 for 2020) were analyzed. QHPs covered emtricitabine/tenofovir disoproxil fumarate (19 165 QHPs [98.1%] in 2018; 16 970 QHPs [99.8%] in 2019; 20 045 QHPs [94.8%] in 2020) at a higher rate than emtricitabine/tenofovir alafenamide (17 391 QHPs [91.9%] in 2018; 15 757 QHPs [92.7%] in 2019; 18 836 QHPs [87.4%] in 2020). QHPs in the South required exclusive PA (ie, PA for 1 of the formulations even if the QHP covered both) for emtricitabine/tenofovir disoproxil fumarate and emtricitabine/tenofovir alafenamide at the highest rates in all 3 years. In the South, the rate of PA for emtricitabine/tenofovir disoproxil fumarate increased from 806 of 8023 QHPs (10.0%) in 2018 to 3466 of 7401 QHPs (46.8%) in 2020. QHPs with exclusive PA requirement for emtricitabine/tenofovir disoproxil fumarate were higher in EHE jurisdictions than non-EHE jurisdictions (difference: 2018, 0.9 percentage points; 2019, 3.5 percentage points; 2020, 29.1 percentage points). QHPs were more likely to place emtricitabine/tenofovir disoproxil fumarate on a specialty tier compared with emtricitabine/tenofovir alafenamide (difference: 2018, 1.8 percentage points; 2019, 3.7 percentage points; 2020, 4.1 percentage points). In this cross-sectional study, despite similar indications for biomedical prevention, QHPs were more likely to cover emtricitabine/tenofovir disoproxil fumarate than emtricitabine/tenofovir alafenamide, and QHPs were also more likely to subject emtricitabine/tenofovir disoproxil fumarate to PA or place it on a specialty tier despite the broader clinical indication. QHP PA requirements of emtricitabine/tenofovir disoproxil fumarate following emtricitabine/tenofovir alafenamide approval does not reflect clinical guidelines. The requirements could reflect differences in clinical indication, manufacturer discounts, or anticipation of a changing regulations and emerging generics. High rates of exclusive PA for emtricitabine/tenofovir disoproxil fumarate in areas where rates of HIV diagnoses are highest and PrEP is most needed (eg, the South and EHE priority jurisdictions) is concerning; policy solutions to address the growing PrEP health equity crisis could include regulator actions and a national PrEP program.

Overcoming the Obstacles That Prevent Identification and Treatment of Women Who Have Iron Deficiency

Background: Iron deficiency (ID) is the most common nutritional deficiency in pregnancy, in women who have menstrual periods, and among people who have had bariatric surgery. In pregnant women, iron deficiency anemia (IDA) has been associated with maternal morbidity, peripartum complications, and impaired infant development. Among all populations with IDA, common symptoms include severe fatigue, shortness of breath, and impaired concentration, with consequences including diminished work productivity and reduced quality of life. Because women have ID more frequently than men do, ID may be viewed as a driver of gender inequality. It has been a challenge to identify and treat women who have ID. The barriers to identifying these women have included (1) lack of awareness about low iron among women and their physicians, (2) lack of understanding about the difference between hemoglobin testing and iron testing, (3) inability of women to get tested without a lab test order from their physician, (4) variation in interpretation of iron saturation and ferritin test results among providers, and (5) variation in interpretability of iron saturation and ferritin tests in different patient populations. The obstacles that prevent treatment of ID with iron infusions have included (1) lack of understanding about limited efficacy and tolerability of oral iron supplements, (2) lack of awareness about the safety, efficacy, and tolerability of iron infusions, (3) lack of patient access to infusion clinics that are capable of doing iron infusions promptly and safely, (4) lack of physician comfort writing iron infusion orders, and (5) variation in health plan coverage of iron infusion costs. Methods: We developed a system to overcome the barriers to identifying women who have ID and the obstacles that prevent women from receiving iron infusions. Our system included education of women's health physician practices, delivered by a clinician-led education team, as well as print and social media advertisements. Patients who were referred to our practice were promptly evaluated online in telemedicine hematology consults provided by one hematologist physician and a well-trained team of advanced practice providers (APP's). This enabled consistent interpretation of patients' symptoms and lab test results, as well as thorough explanations about ID and iron infusions. To overcome the obstacle of health plan coverage, we created a team of well-trained iron infusion coordinators to promptly obtain health plan authorization and troubleshoot lack of coverage. To do the infusions, we created a network of dedicated iron infusion centers with well-trained nurses and supervising APP's. We established protocols to address infusion reactions, and workflows to enable several women to safely receive iron infusions at the same time. Results: 6,101 patients were evaluated online in hematology telemedicine consults between June 2020 and June 2023, with a 5-10% month-to-month increase in referrals. Of these patients, 3,076 patients who had iron deficiency received a total of 7,246 iron infusions over two years. 1,383 (45%) of these were pregnant women. The iron formulations infused were partly determined by the patient's health plan coverage. These included Ferric Derisomaltose (1,055 infusions), Ferumoxytol (1,481 infusions), Iron Sucrose 200 mg doses (n=3,962 infusions), Iron Sucrose 400 mg doses (n=723 infusions), and Ferric Carboxymaltose (20 infusions). Our system enabled prompt patient evaluations because of the flexibility of doing telemedicine patient visits. Some patients were seen online the day after they were referred. The average time from a televisit to an iron infusion was nine days, with some patients receiving iron infusions the day after their televisit. Our retrospective chart review demonstrated that 94% of patients who received iron infusions reported improvement of one or more ID-related symptoms (shortness of breath, fatigue, or ice craving/ice chewing). The overall incidence of adverse reactions occurring during infusions was 4.5%, with some variation among the iron formulations. Conclusions: Our hematology practice has overcome barriers to identifying women who have iron deficiency, and obstacles that prevent treatment with iron infusions. The solution to this problem involves educating women and women's health providers, and creating a system to plan and perform iron infusions promptly and safely.