Health Visitors Research Articles

Race and Ethnicity and Diffusion of Telemedicine in Medicaid for Schizophrenia Care After Onset of the COVID-19 Pandemic

ImportanceDelivery of mental health care through telehealth (telemental health care) increased after the onset of the COVID-19 pandemic. Little is known about the speed of adoption (diffusion) of telemental health in the care in the care of individuals with schizophrenia.ObjectivesTo characterize telemental health care diffusion in mental health agencies serving Medicaid beneficiaries with schizophrenia and the beneficiary-level association of telemental health care use with race and ethnicity.Design, Setting, and ParticipantsThis retrospective cohort study used New York State Medicaid data from March 1, 2019, to February 29, 2020 (prepandemic period), and from March 11, 2020, to March 31, 2021 (pandemic period), from 261 agencies serving 30 990 beneficiaries with schizophrenia with 1 or more mental health visits during the pandemic period. Statistical analysis was performed from November 2021 through September 2024.ExposureAgency percentage of patients belonging to racial and ethnic minority groups among all Medicaid-covered patients between March 2019 and February 2020; agency type, categorized as freestanding, hospital affiliated, or state operated; beneficiary-level race and ethnicity, categorized as Asian or other (American Indian or Alaska Native; Native Hawaiian or Other Pacific Islander), Black, Latinx, White, and unknown; and pandemic severity, operationalized as COVID-19 hospitalization rates per 10 000 population in administratively defined catchment areas.Main Outcomes and MeasuresDays to 10% cumulative telemental health care use within agencies, as well as beneficiary-level time to first telemental health care visit and any telemental health care visit in catchment areas in times of varying pandemic severity.ResultsIn this cohort study of 261 agencies (18 [7%] state operated, 79 [30%] hospital affiliated, and 164 [63%] free standing) and 30 990 beneficiaries with schizophrenia (mean [SD] age, 43 [13] years; 59% male; 7% Asian or other, 38% Black, 20% Latinx, and 25% White), 6 agencies (2%) never adopted telemental health care, and 248 (95%) reached 10% cumulative telemental health care visits in a mean of 18 days. Mean (SD) agency prepandemic shares of beneficiaries belonging to racial or ethnic minority groups (56% [23%]) were not associated with telemental health care diffusion. Diffusion was faster in state-operated vs free-standing agencies (hazard ratio [HR], 2.44 [95% CI, 1.21-4.95]). Relative to White beneficiaries, time to first telemental health care visit was slower in every racial and ethnic minority group (Asian or other: HR, 0.93 [95% CI, 0.88-0.98]; Black: HR, 0.90 [95% CI, 0.87-0.93]; Latinx: HR, 0.95 [95% CI, 0.91-0.99]). Beneficiaries from at least 1 racial or ethnic minority group were less likely than White beneficiaries to have a telemental health care visit regardless of pandemic severity and area; differences narrowed when pandemic severity was higher (eg, in New York City, the odds ratio of Black beneficiaries having a telemental health care visit relative to White beneficiaries when the pandemic severity was high was 0.70 [95% CI, 0.63-0.79] but decreased to 0.59 [95% CI, 0.53-0.67] when the pandemic severity was low).Conclusions and RelevanceIn this cohort study of Medicaid beneficiaries with schizophrenia, telemental health care diffused rapidly after the onset of the COVID-19 pandemic, particularly in state-operated agencies. Together, agency-level and beneficiary-level race and ethnicity findings suggest within-agency racial and ethnic differences in diffusion of telemental health care. States should monitor the diffusion of innovations across vulnerable populations.

Establishing trust through home visits during pregnancy: a realist evaluation of a Danish breastfeeding support intervention

BackgroundBreastfeeding has numerous health benefits but social inequality in breastfeeding is documented in many high-income countries. The evidence for improving breastfeeding support through prenatal encounters is conflicting, but points towards a mechanism activated through a positive relationship between the families and their health care providers. A Danish intervention included a home visit by a health visitor during pregnancy to prolong breastfeeding and reduce social inequality in its rates. The purpose of this study was to investigate how this home visit affected breastfeeding support across socioeconomic groups with attention to how, and for whom, it activated a mechanism of improved relationship and trust between the health visitor and the family.MethodsOur study used a realist evaluation approach and was embedded in a cluster randomized trial carried out in 20 municipalities. In the intervention arm, we observed 35 home visits delivered by the health visitors, interviewed 16 mothers and conducted 6 focus groups with a total of 34 health visitors to examine the intervention mechanisms and contextual factors that influence the generation of outcomes. The analysis applied Luhmann’s, and Brown and Meyers’ concepts of trust as middle-range theories.ResultsThe pregnancy home visit helped early establishment of trust which enhanced the subsequent breastfeeding support postpartum in numerous ways. In realist terms, our central mechanism of change, the establishment of trust, had optimal conditions for success in the contextual setting of the pregnancy home visit where there was time, peace, undisturbed conversations, mental capacity to reflection, and a perceived more even power balance between the family and the health visitor which resulted in a range of positive outcomes. The mechanism resulted in improved tailored breastfeeding support postpartum, families reaching out to the health visitor sooner when experiencing breastfeeding difficulties, and families expressing a more positive experience of breastfeeding. The mechanism was activated across the different socioeconomic groups.ConclusionsThe circumstances of the pregnancy home visit helped to establish trust between the health visitor and the family. Especially for families in vulnerable positions, the pregnancy home visit seems to be a potent driver for enhancing the gains from breastfeeding support.

Practice examples: Baby observation tool supports interactions

IN SUMMARY Tool used by health visitors to observe babies' social behaviour helps promote stronger parent-infant interactions and identify emerging concerns that could impact on children's healthy development.

Perinatal mental health and risk of severe maternal morbidity in women with physical disabilities, Massachusetts 2003-2015.

Perinatal mental health and substance use disorders contribute to adverse maternal outcomes. Women with disabilities experience increased risk for severe maternal morbidity (SMM). No studies have examined the association between perinatal mental health and SMM risk in women with physical disabilities. To examine the association between perinatal mental health and substance use disorders and SMM risk in women with physical disabilities. We analyzed delivery hospitalizations from 2003 to 2015 from the Massachusetts Pregnancy to Early Life Longitudinal (PELL) data system. We identified physical disability using International Classification of Diseases, Ninth Revision codes. Perinatal mental health status was based on the presence of at least one emergency department visit, observational, or in-patient stay attributed to a mental health or substance use disorder anytime from gestation to delivery. We used modified Poisson regressions to obtain risk ratios (RR) for SMM in women with either a physical disability or no disability by perinatal mental health status. Non-disabled women with no perinatal mental health or substance use disorder visit served as the referent group. Deliveries in women with no physical disability and a perinatal mental health visit were not associated with risk of SMM. Compared to the referent group, women with a physical disability and a perinatal mental health or substance use disorder visit had greater risk of both SMM (RR=1.84, 95% CI:1.32-2.56), and nontransfusion SMM (RR=2.35 1.52, 3.64), after adjusting for demographic and socioeconomic characteristics. Increased attention should be paid to perinatal mental health status in women with physical disabilities.

Hospital and physician-based mental healthcare during 12 months of opioid agonist treatment for opioid use disorder: Exploring costs and factors associated with acute care.

Individuals with opioid use disorder (OUD) have a high prevalence of co-occurring mental health disorders; however, there exists little information on mental health service use for this population. We aimed to determine the prevalence of non-substance use-related mental health emergency department (ED) visits, hospitalizations, and outpatient physician visits for individuals receiving treatment for OUD over one year. We also explored individual-level characteristics associated with mental health care service use and estimated the costs of this care. We linked observational cohort data collected from 3,430 individuals receiving treatment for OUD in Ontario, Canada, with health administrative records available for all individuals enrolled in Ontario's public health insurance program. Eligible participants were receiving medication treatment for OUD and were recruited between 2011 and 2021 Starting on the day of cohort enrolment, we included health service data for up to 12 months. We identified ED visits and hospitalizations for non-substance use-related mental health disorders using ICD-10-CA diagnostic codes. Outpatient mental health visits to primary care providers and psychiatrists were ascertained by examining the diagnostic codes of physician billing claims. We used logistic regression to explore the association between demographic and clinical factors of interest and mental health-related ED visits or hospitalizations. Mean one-year mental healthcare costs, calculated in 2022 Canadian dollars, were estimated. We fit a two-part zero-inflated negative binomial model to explore the association between factors of interest and healthcare costs. Altogether, 14.9% of individuals had mental health-related acute care ED visits or hospitalizations and 37.3% had outpatient mental health visits during the follow up period. For participants with at least one visit, we determined the mean number of ED visits (1.93, standard deviation [SD] = 2.15), hospitalizations (1.46, SD = 1.05), primary care visits (3.51, SD = 4.31), and psychiatry visits (4.04, SD = 4.73). Lower odds of ED use and hospitalization were associated with older age (46+ compared to less than 25 years: odds ratio [OR] 0.43, 95% confidence interval [CI]: 0.29, 0.63) and being employed (OR 0.48, 95% CI 0.37, 0.61). Higher odds of ED use and hospitalization was associated with positive opioid urine drug screens (50% positive urine drug screens compared to 0%: OR 1.45, 95% CI 1.05, 2.01), having more comorbid conditions (7+ health conditions compared to 0-2 health conditions: OR 3.76, 95% CI 2.60, 5.44), and receipt of outpatient mental healthcare (OR 2.38, 95% CI 1.95, 2.92) were associated with higher odds of ED visits or hospitalizations. Mean one-year mental healthcare costs for individuals receiving ED visits or hospitalizations totaled $9,117.80 (95% CI 7,372.90, 10,862.70) per person. Mean one-year costs for individuals with outpatient mental healthcare alone totaled $382.30 (95% CI 343.20, 421.30) per person. Individuals receiving treatment for OUD receive care in EDs, inpatient units, and outpatient clinics for mental health conditions other than substance use-related diagnoses. Healthcare costs were considerably higher for those receiving acute care treatment for mental health conditions. Studying integrated mental health and substance use disorder treatment in the outpatient setting should be a priority to bolster care for this population.

Patient and provider factors associated with follow-up for positive depression screens in adults: a retrospective review of University of Utah primary and specialty care clinics

ObjectiveTo identify patient and provider factors associated with lower rates of follow-up for positive depression screens in outpatient settings.DesignRetrospective cohort study with electronic health record analysis investigating factors associated with...

SYMPTOM OVERLAP BETWEEN SLEEP DISORDER AND DEPRESSIVE SYMPTOMS

Abstract Introduction The PHQ-9, a common screening tool for depression, asks about sleep and fatigue. An under-recognized concern is the overlap between sleep and fatigue depressive symptoms and sleep disturbances. We investigated whether elevated depression screening scores were due to sleep disorders rather than depression itself in older adults. Methods The study cohort included 2,257 adults (65+) with at least two outpatient primary care visits and at least one Medicare Annual Wellness Visit, who initially screened positive on the PHQ-2 (≥2) and completed the PHQ-9. A multiple indicator multiple cause (MIMIC) analysis was used to examine differential item functioning of the sleep and fatigue items of the PHQ-9, attributable to sleep disorders, based on diagnosis codes. Results The MIMIC analysis revealed a positive association between sleep disorders and depression (β = 0.19, p < 0.001), and a small positive effect on the “feeling tired” fatigue item of the PHQ-9 (β = 0.06, p < 0.001). No significant relationship was observed between sleep disorders and the PHQ-9 “sleep” item. The model exhibited a good fit, with RMSEA=0.040 (90% CI: 0.034-0.047), CFI=0.99, TLI=0.99, and SRMR=0.04. Discussion Sleep disorders and depressive symptoms are associated but no meaningful differential item functioning was detected in this sample of older adults. The PHQ-9 is an adequate screening tool for depression in older adults with sleep disorders.

TESTING ERADAR: A NEW EHR-BASED ALGORITHM TO INCREASE DEMENTIA RECOGNITION IN HEALTH CARE SYSTEMS

Abstract Electronic health records (EHRs) hold potential for identifying individuals with undiagnosed dementia. Using machine learning, our team developed and externally validated a predictive algorithm called the EHR Risk of Alzheimers and Dementia Assessment Rule (eRADAR) that estimates the likelihood an individual has undiagnosed dementia with high accuracy (C statistics of 0.79 to 0.84). Through two embedded pragmatic trials, we are implementing eRADAR in 11 primary care clinics within Kaiser Permanente Washington and University of California, San Francisco. The target population is older adults age 65+ without a documented dementia diagnosis or medication. Primary care providers (PCPs) are randomized to intervention or usual care. The eRADAR algorithm is used to identify individuals with eRADAR scores in the top 15-20%, who are invited to a “brain health” visit that includes assessment of instrumental activities of daily living, depressive symptoms, and cognitive function (Montreal Cognitive Assessment). Results are shared with the patient and PCP, and the PCP is responsible for making the final diagnosis (with decision support provided through the EHR). To date, we have implemented the intervention in 9 clinics and conducted over 590 brain health visits. About 31% (658/2137) of high-risk individuals accept a brain health visit. Of these, about 18% have results suggesting dementia and another 30% mild cognitive impairment. Post-visit surveys show high acceptance of and satisfaction with the intervention. The primary study outcome is rate of dementia diagnosis over 12-month follow-up (completed by April 2025). We are also conducting semi-structured interviews to illuminate benefits and harms.

THE ROLE OF SOCIODEMOGRAPHIC FACTORS IN COMMUNITY-BASED REHABILITATION USE AFTER HIP ARTHROPLASTY

Abstract Community-based rehabilitation in the home health and outpatient settings is an important element of recovering function after total hip arthroplasty (THA). While there is ample evidence confirming sociodemographic differences in THA rates and short-term outcomes (e.g., post-operative complications), it is unclear whether there are differences in use of rehabilitation after THA. We analyzed 5 years of data (2017-2021) from a large health system on patients who received rehabilitation in the home health (n=6577) and/or outpatient setting (n=3,094) after THA. We estimated several regression models to examine the separate associations between sex, race, area deprivation, or rural residence with the number of visits and length of care in home health and outpatient settings, adjusting for age, hospital, hospital length of stay, non-home discharge, comorbidities, and marital status. Female sex was associated with greater rehabilitation use for 3 of 4 outcomes: number of home health visits (p<.001), number of outpatient visits (p=.04), and length of outpatient care (p<.001), but not length of home health care. High area deprivation was associated with higher use of home health visits (p<.001), but not length of the episode of home health care or outpatient rehabilitation use. Rural residence was associated with fewer home health visits (p=.04) and shorter outpatient episodes of care (p=.02). Race was not significantly associated with any of the outcomes. Overall, results were mixed, with rural residents generally receiving less post-arthroplasty rehabilitation, and women and those residing in more-deprived neighborhoods receiving more rehabilitation services.

Enrollment in Medicare is associated with fewer outpatient mental healthcare visits among those with mental health symptoms.

To test whether enrolling in traditional Medicare (TM) or Medicare Advantage (MA) at age 65 reduces mental healthcare utilization among individuals with mental health symptoms and low or moderate family incomes. We employ a fuzzy regression discontinuity design, comparing the likelihood of having an outpatient mental health visit or a psychotropic drug fill among individuals younger than or older than the age 65 Medicare eligibility threshold. We analyze 2014-2021 Medical Expenditure Panel Survey data. Our primary sample is restricted to individuals with probable mental health symptoms as indicated by their score on the Kessler K6 psychological distress scale (K6) and Patient Health Questionnaire-2 instrument (PHQ-2) and who have incomes less than 400% of the federal poverty level. Among individuals with probable mental health symptoms and low or moderate incomes, enrolling in Medicare (combining the effect of MA and TM) is associated with a 24.9 percentage point reduction (95% CI -49.1 to -0.8; p = 0.043) in the likelihood of having any type of outpatient mental health visit and a 31.3 percentage point reduction (95% CI -54.2 to -8.4; p = 0.008) in the likelihood of having a prescription drug fill for a psychotropic drug. Effects of MA and TM on mental healthcare utilization are not statistically different from each other. We observe no impact of enrolling in Medicare on the likelihood of having a visit to a primary care provider, having a visit to a non-mental healthcare specialist, or having a fill for a prescribed non-psychotropic drug. Enrolling in Medicare is associated with a reduction in the use of mental healthcare among individuals with probable mental health symptoms and low or moderate family incomes. Our findings suggest that the program poses access barriers specific to mental healthcare.

Exploring Barriers and Bridging Gaps: Perspectives of Nurses, Midwives, and Lady Health Workers in the Implementation of Emergency Obstetric Care

Background & Objectives: Maternal mortality is a global concern primarily due to preventable obstetric complications. Challenges in implementing Emergency Obstetric Care (EmOC) in developing nations hinder effective reduction of these deaths. Our objective was to identify key challenges in EmOC practices among frontline healthcare providers, assess the severity and frequency of these barriers, and evaluate gaps in resources, training, and institutional support needed for effective resolution. Methods: This cross-sectional study assessed EmOC knowledge, practical skills, and challenges among Nurses, Lady Health Visitors (LHVs), and Lady Health Workers (LHWs) in Khyber Pakhtunkhwa, Pakistan from July 2017-June 2020. Participants were conveniently sampled from hospitals across eight districts, with data collected through a questionnaire on EmOC knowledge, practical interventions, and challenges faced. Results: Although most participants (91% of nurses, 90.2% of LHVs, 92.3% of LHWs, and 83.3% of midwives) expressed satisfaction with course content, important gaps emerged in the practical application of specific EmOC interventions. Nurses displayed 79% knowledge of the Partogram with only 60% utilization, while LHVs showed 80.5% knowledge but just 50.2% utilization. Assisted delivery knowledge and practice were particularly low among nurses (32% & 7%) & LHVs (17.1% & 2.4%) respectively. Significant gaps were found in retained placenta removal and manual vacuum aspiration, with only 12% of nurses and 3% of LHVs practicing the latter, with no utilization among LHWs or midwives. Key barriers included insufficient training and restrictive institutional policies. Conclusion: Despite high course content satisfaction, disparities in EmOC knowledge and practice persist among frontline healthcare-providers, with barriers like insufficient training and institutional limitations impacting maternal outcomes. doi: https://doi.org/10.12669/pjms.41.1.10269 How to cite this: Gul F, Mehsood R, Noor S. Exploring Barriers and Bridging Gaps: Perspectives of Nurses, Midwives, and Lady Health Workers in the Implementation of Emergency Obstetric Care. Pak J Med Sci. 2025;41(1):3-8. doi: https://doi.org/10.12669/pjms.41.1.10269 This is an Open Access article distributed under the terms of the Creative Commons Attribution License (http://creativecommons.org/licenses/by/3.0), which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.

Health care professionals’ views on a new postpartum contraception audiovisual animation: a survey

BackgroundThe postpartum period is a high-risk time for unintended pregnancy. We developed a 2-minute audiovisual animation on postpartum contraception (PPC) including the return of fertility after birth for patients. The...

Annual Wellness Visits for Police and Public Safety Officers: Current Practices Among Mental Health Professionals and Considerations for Future Program Development

Annual Wellness Visits for Police and Public Safety Officers: Current Practices Among Mental Health Professionals and Considerations for Future Program Development

User experience and perceived usability of nurse-led telemonitoring among women with gestational diabetes in Dhulikhel, Nepal

ObjectiveTo assess the usability and acceptability of nurse-led telemonitoring in managing gestational diabetes among Nepalese women.MethodsWe conducted a convergent mixed-method study among 91 pregnant women diagnosed with gestational diabetes at Dhulikhel Hospital, Nepal. Participants received glucometers and blood pressure monitors, along with training and instructions to measure and record their blood pressure and glucose levels at home once a week. Starting from the 28th gestational week, the study nurse reviewed measurements obtained at home during the biweekly telemonitoring follow ups, alternating with hospital visits. We used the System Usability Scale (SUS) to assess perceived usability and conducted in-depth interviews to understand participants’ experiences with telemonitoring and related technologies, including feasibility, acceptability, satisfaction with treatment, usability, as well as any difficulties or unmet needs. The quantitative analysis included descriptive statistics to summarize participant characteristics and System Usability Scale (SUS) responses, while a framework analysis was applied to examine the qualitative data.ResultsThe mean SUS score for telemonitoring services was 72.1 ± 7.6, indicating good usability (a score ≥ 68 indicates good usability). 93% of participants wanted to use the service frequently; 88% found it easy to use; 81% considered it well-integrated with their typical prenatal care. Participants acknowledged the benefits of virtual health visits, such as frequent health monitoring, facilitation of communication with healthcare providers, appointment reminders, added motivation for home monitoring, increased access to health information, and prevention of unnecessary anxiety. Overall, participants expressed satisfaction with the quality and features of the nurse-led telemonitoring for managing gestational diabetes, emphasizing its role in ensuring uninterrupted prenatal care.ConclusionsTelemonitoring is a feasible and acceptable tool to facilitate close monitoring of pregnant women with gestational diabetes in peri-urban hospital settings in Nepal.

Use of emergency services in response to a flood: an account of the aftermath of the May 2023 flood in Romagna, Italy

BackgroundExtreme weather events due to human activities have significantly increased the frequency and severity of hydrological disasters like floods, impacting human health and healthcare systems worldwide. This study analyses the...

Differences in Mental Health Symptoms and Inequities in Mental Health Service Use Among Black and White Populations and Asian and Latine Subpopulations.

While studies have observed mental health inequities across aggregated Asian and Latine populations, a critical gap exists in our understanding of inequities within and across Asian and Latine subpopulations. We examined the prevalence of mental health symptoms and variations in mental health service use across Black and White populations and Asian and Latine subpopulations at a more granular level. We conducted a cross-sectional study using data from the 2016-2021 Medical Expenditure Panel Survey. Outcomes included mental health symptoms (mild and serious) and mental health service use (outpatient mental health visits and psychotropic medication fills). The primary independent variable was the category of 13 racial/ethnic groups: Black and non-Latine White individuals and Asian (Asian Indian, Chinese, Filipino, and Other Asian) and Latine (Central/South American, Cuban, Dominican, Mexican, Other Latine, and Puerto Rican) subpopulation individuals. We found modest differences in mental health symptoms by race/ethnicity. However, significant differences were observed in mental health service use among individuals with mental health symptoms. These differences were pronounced across Asian subpopulations with serious mental health symptoms. The likelihood of having any outpatient mental health visit was lower among Asian Indian (- 12.2 percentage points [95% CI - 18.2, - 6.2], Chinese (- 11.7 [- 21.6, - 1.7]), and Filipino individuals (- 16.1 [- 22.5, - 9.8]) than White individuals. The likelihood of having psychotropic medication fill was lower among Asian Indian (- 23.3 [- 34, - 12.7]), Chinese (- 19.8 [- 30.7, - 8.9]), Filipino (- 27.6 [- 40.2, - 14.9]), and other Asian individuals (- 22.5 [- 29.4, - 15.6]) than White individuals. On the other hand, some of these differences were observed in certain Latine subpopulations but not in others. There is a heterogeneity in inequities in mental health service use among Asian and Latine subpopulation groups. These findings underscore the importance of studying granular categories of race/ethnicity for targeting mental health inequities.

Predictors of recent mental health service utilization among firearm-owning US service members with high levels of psychological distress.

Service members with mental health difficulties and access to a firearm are at an increased risk for suicide. Mental healthcare providers are well-positioned to discuss firearms and create safety plans; however, many service members do not seek treatment. This study aims to identify potential sociodemographic predictors of recent mental healthcare utilization among firearm-owning service members who report past month distress. The sample included 268 US military service members. Participants reported whether they attended at least one behavioral health visit in the 3 months prior to participation. Females, individuals of a racial background other than Black or White, older individuals, and those who have never been active-duty were more likely to have attended a session. Additionally, the likelihood of utilization was higher among those who reported past week wish to die and suicidal behaviors in the past year. While certain service members are less likely to have utilized mental healthcare, findings suggest that those with suicidal ideation and access to a firearm are likely to engage in at least one appointment. As such, providing mental healthcare providers with training and resources for promoting secure firearm storage is an important avenue for suicide prevention.

Suicide Prevention and Telehealth in Children's Hospital Emergency Departments.

Suicide is a leading cause of death among adolescents. Emergency department (ED) visits for mental health concerns are rising, and telehealth is increasingly used to provide emergency mental health care. We conducted a national survey to describe suicide prevention practices and tele-mental health care in children's hospital EDs. We conducted a cross-sectional survey of leaders at all 52 US EDs affiliated with dedicated children's hospitals (ie, hospitals that provide care only to children) to describe use of tele-mental health care and suicide prevention practices. Leaders from 41 EDs completed the survey (79% response rate). Tele-mental health care was used in 23 EDs (56%); there were no differences in ED structural characteristics between institutions with telehealth versus without telehealth. Among responding EDs, 40 (98%) reported they screen for suicide risk, and 29 (71%) reported they use a standardized approach to suicide prevention discharge planning. Risk reduction practices conducted at many but not all EDs included assessment of access to lethal means (n = 31, 86%), counseling on reduction of access to lethal means (n = 30, 73%) and providing patients with a list of professionals or agencies that they can contact in a crisis (n = 35, 85%). There were no differences in use of suicide prevention practices at EDs with versus without telehealth (P > 0.1 for all). Approximately half of children's hospital EDs use tele-mental health care, and hospitals with versus without tele-mental health care report similar rates of suicide prevention practice use. Opportunities exist to increase use of discharge safety practices.

Doing More with Less: Predicting Primary Care Provider Effectiveness

Abstract We use data from the Veterans Administration to examine the efficacy of primary care providers (PCPs). Leveraging quasi-random assignment of veterans to PCPs, we measure effectiveness using ambulatory care sensitive conditions (ACSC) and hospitalizations/emergency department (ED) visits for mental health or circulatory conditions. PCPs’ variation along these dimensions predicts future outcomes. For example, a 1 standard deviation improvement in mental health effectiveness reduces patient risk of death by 3.8% and lowers costs by 4.4% over the next three years. More effective PCPs do more with less: their patients have fewer primary care visits, specialist referrals, lab panels, or imaging tests.

Inequality in modern contraceptive use and unmet need for contraception among women of reproductive age in Zambia. A trend and decomposition analysis 2007–2018

BackgroundAccess to contraception can be a transformational intervention towards advancement of education, health, and freedom of choice. Countries have committed to improving access to contraception enshrined in the sustainable development goals (SDGs), indicator 3.7.1. Our study seeks to investigate the level of inequality in current use of modern contraception and unmet need for contraception among sexually active women of reproductive age in Zambia during 2007, 2013/14 and 2018 to inform family planning policy.MethodsWe use three rounds of Zambia demographic and health survey datasets for the years 2007, 2013/14 and 2018, which are nationally representative surveys. We included a total of 19,973 sexually active women of reproductive age from 15 to 49 years living in Zambia. The level of inequality was assessed using concentration curves, and indices. The concentration indices were decomposed to identify the causes of the inequality.ResultsOur analysis shows that there was inequality in the current use of modern contraception across the years 2007, 2013/14 and 2018. The concentration curves showed that current use of modern contraception was higher among the wealthy than the poor. This pro-rich trend was consistent throughout the study period. Erreygers concentration Index (EI) values were 0.2046 in 2007, 0.1816 in 2013/14, and 0.1124 in 2018. The inequality in current use of modern contraception was significantly influenced by having access to contraceptive counselling, education level and being in a union (living with a partner). In addition, there was inequality in unmet need for contraception with concentration curves showing that unmet need for modern contraception was experienced more among the poor compared to the wealthy. Unmet need was thus pro poor. The EI values were – 0.0484 in 2007, – 0.0940 in 2013/14 and – 0.0427 in 2018. This inequality was significantly influenced by education, employment status, being in a union, and having health insurance.ConclusionInequality in modern contraceptive use and unmet need for contraception exists and has persisted over the years in Zambia. Such inequality can be addressed through a multipronged approach that includes encouraging women to visit health facilities, access to contraceptive counselling, and promoting formal education.