Faculty Bibliography

Importance/UNASSIGNED:Access to primary care clinicians, including primary care physicians and nonphysician clinicians (nurse practitioners and physician assistants) is necessary to improving population health. However, rural-urban trends in primary care access in the US are not well studied. Objective/UNASSIGNED:To assess the rural-urban trends in the primary care workforce from 2009 to 2017 across all counties in the US. Design, Setting, and Participants/UNASSIGNED:In this cross-sectional study of US counties, county rural-urban status was defined according to the national rural-urban classification scheme for counties used by the National Center for Health Statistics at the Centers for Disease Control and Prevention. Trends in the county-level distribution of primary care clinicians from 2009 to 2017 were examined. Data were analyzed from November 12, 2019, to February 10, 2020. Main Outcomes and Measures/UNASSIGNED:Density of primary care clinicians measured as the number of primary care physicians, nurse practitioners, and physician assistants per 3500 population in each county. The average annual percentage change (APC) of the means of the density of primary care clinicians over time was calculated, and generalized estimating equations were used to adjust for county-level sociodemographic variables obtained from the American Community Survey. Results/UNASSIGNED:The study included data from 3143 US counties (1167 [37%] urban and 1976 [63%] rural). The number of primary care clinicians per 3500 people increased significantly in rural counties (2009 median density: 2.04; interquartile range [IQR], 1.43-2.76; and 2017 median density: 2.29; IQR, 1.57-3.23; P < .001) and urban counties (2009 median density: 2.26; IQR. 1.52-3.23; and 2017 median density: 2.66; IQR, 1.72-4.02; P < .001). The APC of the mean density of primary care physicians in rural counties was 1.70% (95% CI, 0.84%-2.57%), nurse practitioners was 8.37% (95% CI, 7.11%-9.63%), and physician assistants was 5.14% (95% CI, 3.91%-6.37%); the APC of the mean density of primary care physicians in urban counties was 2.40% (95% CI, 1.19%-3.61%), nurse practitioners was 8.64% (95% CI, 7.72%-9.55%), and physician assistants was 6.42% (95% CI, 5.34%-7.50%). Results from the generalized estimating equations model showed that the density of primary care clinicians in urban counties increased faster than in rural counties (β = 0.04; 95% CI, 0.03 to 0.05; P < .001). Conclusions and Relevance/UNASSIGNED:Although the density of primary care clinicians increased in both rural and urban counties during the 2009-2017 period, the increase was more pronounced in urban than in rural counties. Closing rural-urban gaps in access to primary care clinicians may require increasingly intensive efforts targeting rural areas.

BACKGROUND:Epidemiological evidence on different classes of antihypertensives and risks of Alzheimer's disease and related dementias (ADRD) is inconclusive and limited. This study examined the association between antihypertensive use (including therapy type and antihypertensive class) and ADRD diagnoses among older adults with hypertension. METHODS:A retrospective, cross-sectional study was conducted, involving 539 individuals aged ≥ 65 years who used antihypertensives and had ADRD diagnosis selected from 2013 to 2018 Medical Expenditure Panel Survey (MEPS) data. The predictors were therapy type (monotherapy or polytherapy) and class of antihypertensives defined using Multum Lexicon therapeutic classification (with calcium channel blockers [CCBs] as the reference group). Weighted logistic regression was used to assess the relationships of therapy type and class of antihypertensives use with ADRD diagnosis, adjusting for sociodemographic characteristics and health status. RESULTS:We found no significant difference between monotherapy and polytherapy on the odds of ADRD diagnosis. As to monotherapy, those who used angiotensin-converting enzyme inhibitors (ACEIs) had significantly lower odds of developing AD compared to those who used CCBs (OR 0.36, 95 % CI 0.13-0.99). CONCLUSIONS:Findings of the study suggest the need for evidence-based drug therapy to manage hypertension in later adulthood and warrant further investigation into the mechanism underlying the protective effect of antihypertensives, particularly ACEIs, against the development of AD among older adults with hypertension.

A significant gap exists between high rates of antenatal care attendance and low uptake of intermittent preventive treatment in pregnancy with sulfadoxine-pyrimethamine (IPTp-SP) in Senegal. This study aims to investigate whether IPTp-SP is delivered per Senegal's national guidelines and to identify factors affecting the delivery of IPTp-SP at antenatal care visits. A secondary analysis was conducted using the 2014 and 2016 Senegal's Service Provision Assessment. The study sample consists of 1076 antenatal care across 369 health facilities. Multiple logit regression models were used to estimate the probability of receiving IPTp-SP during the antenatal care visit based on prior receipt of IPTp-SP and gestational age during the current pregnancy. At an antenatal care visit, the probability of receiving IPTp-SP is 84% (95% CI = [83%, 86%]) among women with no IPTp-SP history and 85% (95% CI = [79%, 92%]) among women with one prior dose. Women who visit a facility in the top quintile of the proportion of IPTp trained staff have a nearly 4-fold higher odds of receiving IPTp compared to those who visit a facility in the bottom quintile (95% CI = [1.54, 9.80]). The dose and timing of IPTp-SP provided in antenatal care settings in Senegal did not always conform with the national guideline. More training for providers and patient engagement is warranted to improve the uptake of IPTp-SP in antenatal care visits.

Background/UNASSIGNED:Though critical to primary care, continuity of care has rarely been examined in China. This study aims to assess the relationship between continuity of care and healthcare costs among patients with chronic diseases within primary care settings in China. Methods/UNASSIGNED:In this cross-sectional study, we used a social health insurance claims dataset of 1406 patients with hypertension and/or diabetes in Yuhuan City, Zhejiang Province collected in 2017-2019. We measured continuity of care using the Bice-Boxerman Continuity of Care (COC) Index, Herfindahl Index (HI), Sequential Continuity of Care (SECON) Index, Usual Provider of Care (UPC), and a binary variable indicating whether a patient's UPC was a primary care provider. We examined the associations between continuity of care and healthcare costs in the same period and the subsequent year, using ordinary least squares regression for the outpatient costs and two-part regression for the inpatient costs. Based on the regression coefficients, we predicted costs saved if each continuity measure was set to 1 from the status quo. Results/UNASSIGNED:When optimum continuity were to be achieved, 7.12-27.29% of total outpatient costs and 55.38-73.35% of total inpatient costs could be saved compared to the status quo during the two-year study period. If optimum continuity were to be achieved in the first year, 7.47%-21.78% of total outpatient costs and 8.84-40.22% of total inpatient costs could be saved in the second-year. Conclusions/UNASSIGNED:Care continuity indicators were consistently associated with reduced outpatient costs and hospitalization risks. Future health reform in China should further enhance continuity of care in primary care.

Introduction/UNASSIGNED:Generation 1.5, immigrants who moved to a different country before adulthood, are hypothesized to have unique cognitive and behavioral patterns. We examined the possible differences in cigarette smoking between Asian subpopulations who arrived in the United States at different life stages. Methods/UNASSIGNED:Using the Asian subsample of the 2015 Tobacco Use Supplement to the Current Population Survey, we tested this Generation 1.5 hypothesis with their smoking behavior. This dataset was chosen because its large sample size allowed for a national-level analysis of the Asian subsamples by sex, while other national datasets might not have adequate sample sizes for analysis of these subpopulations. The outcome variable was defined as whether the survey respondent had ever smoked 100 cigarettes or more, with the key independent variable operationalized as whether the respondent was: 1) born in the United States; 2) entered the United States before 12; 3) entered between 12 and 19; and 4) entered after 19. Logistic regressions were run to examine the associations with covariates including the respondent's age, educational attainment, and household income. Results/UNASSIGNED:Asian men who entered before 12 were less likely to have ever smoked 100 cigarettes than those who immigrated after 19; for Asian women, three groups (born in the United States, entered before 12, entered between 12 and 19) were more likely to have smoked 100 cigarettes than those who immigrated after 19. Conclusions/UNASSIGNED:While Asian men who came to the United States before 12 were less at risk for cigarette smoking than those who immigrated in adulthood, the pattern was the opposite among Asian women. Those who spent their childhood in the United States were more likely to smoke than those who came to the United States in adulthood. These patterns might result from the cultural differences between US and Asian countries, and bear policy relevance for the tobacco control efforts among Asian Americans.

BACKGROUND:Young adult cancer survivors face medical financial hardships that may lead to delaying or forgoing medical care. This study describes the medical financial difficulties experienced by young adult cancer survivors in the United States in the post Affordable Care Act (ACA) period. METHOD/METHODS:We identified 1,009 cancer survivors aged 18-39 years from the National Health Interview Survey 2015-2022 and matched 963 (95%) cancer survivors to 2,733 controls using nearest neighbor matching. We used conditional logistic regression to examine the association between cancer history and medical financial hardship and assess whether this association varied by age, sex, race/ethnicity, and region of residence. RESULTS:Compared to those without a cancer history, young adult cancer survivors were more likely to report material financial hardship (22.8% vs 15.2%; odds ratio (OR) 1.65, 95% confidence interval (CI):1.50-1.81) and behavioral medical financial hardship (34.3% vs 24.4%; OR 1.62, 95% CI: 1.49-1.76), but not psychological financial hardship (526% vs 50.9%; OR 1.07, 95% CI: 0.99-1.16). Young adult cancer survivors who were Hispanic, or lived in the Midwest and South were more likely to report psychological financial hardship than their counterparts. CONCLUSIONS:We found that young adult cancer survivors were more likely to experience material and behavioral medical financial hardship than young adults without a cancer history. We also identified specific subgroups of young adult cancer survivors that may benefit from targeted policies and interventions to alleviate medical financial hardship.

IMPORTANCE/UNASSIGNED:Economic policies have the potential to impact management and control of hypertension. OBJECTIVES/UNASSIGNED:To review the evidence on the association between economic policies and hypertension management and control among adults with hypertension in the US. EVIDENCE REVIEW/UNASSIGNED:A search was carried out of PubMed/MEDLINE, Cochrane Library, Embase, PsycINFO, CINAHL, EconLit, Sociological Abstracts, and Scopus from January 1, 2000, through November 1, 2023. Included were randomized clinical trials, difference-in-differences, and interrupted time series studies that evaluated the association of economic policies with hypertension management. Economic policies were grouped into 3 categories: insurance coverage expansion such as Medicaid expansion, cost sharing in health care such as increased drug copayments, and financial incentives for quality such as pay-for-performance. Antihypertensive treatment was measured as taking antihypertensive medications or medication adherence among those who have a hypertension diagnosis; and hypertension control, measured as blood pressure (BP) lower than  140/90 mm Hg or a reduction in BP. Evidence was extracted and synthesized through dual review of titles, abstracts, full-text articles, study quality, and policy effects. FINDINGS/UNASSIGNED:In total, 31 articles were included. None of the studies examined economic policies outside of the health care system. Of these, 16 (52%) assessed policies for insurance coverage expansion, 8 (26%) evaluated policies related to patient cost sharing for prescription drugs, and 7 (22%) evaluated financial incentive programs for improving health care quality. Of the 16 studies that evaluated coverage expansion policies, all but 1 found that policies such as Medicare Part D and Medicaid expansion were associated with significant improvement in antihypertensive treatment and BP control. Among the 8 studies that examined patient cost sharing, 4 found that measures such as prior authorization and increased copayments were associated with decreased adherence to antihypertensive medication. Finally, all 7 studies evaluating financial incentives aimed at improving quality found that they were associated with improved antihypertensive treatment and BP control. Overall, most studies had a moderate or low risk of bias in their policy evaluation. CONCLUSIONS AND RELEVANCE/UNASSIGNED:The findings of this systematic review suggest that economic policies aimed at expanding insurance coverage or improving health care quality successfully improved medication use and BP control among US adults with hypertension. Future research is needed to investigate the potential effects of non-health care economic policies on hypertension control.

BACKGROUND:Previous studies have demonstrated the association between food security and cardiometabolic diseases (CMDs), yet none have investigated trends in prevalence of CMDs by food security status in the United States (US). METHODS:Serial cross-sectional analysis of the US nationally representative data from National Health and Nutrition Examination Survey (1999-2018) was conducted among adults aged 20 years or older. Food security status was defined by the US Household Food Security Survey Module (full, marginal, low, and very low food security). We estimated the age-adjusted prevalence of CMDs including obesity, hypertension, diabetes, and coronary heart disease by food security status. Racial and ethnic disparities in age-adjusted prevalence of CMDs by food security status were also assessed. RESULTS:A total of 49,738 participants were included in this analysis (weighted mean age 47.3 years; 51.3% women). From 1999 to 2018, the age-adjusted prevalence of CMDs was lower in full food secure group as compared with other groups. For example, trends in hypertension decreased from 49.7% (47.5-51.8%) to 45.9% (43.8-48.0%) (P-trend = 0.002) among the full and from 54.2% (49.9-58.5%) to 49.7% (46.8-52.6%) (P-trend = 0.02) among the marginal but remained stable among the low at 49.7% (47.9-51.6%) and among the very low at 51.1% (48.9-53.3%) (P-interaction = 0.02). Prevalence of diabetes increased from 8.85% (8.15-9.60%) to 12.2% (11.1-13.5%) among the full (P-trend < 0.001), from 16.5% (13.2-20.4%) to 20.9% (18.6-23.5%) (P-trend = 0.045) among the marginal and from 14.6% (11.1-19.0%) to 20.9% (18.8-23.3%) (P-trend = 0.001) among the low but remained stable at 18.8% (17.0-20.9) among the very low (P-trend = 0.35) (P-interaction = 0.03). Racial and ethnic differences in prevalence of CMD by food security status were observed. For example, among individuals with full food secure status, the prevalence of diabetes was 9.08% (95% CI, 8.60-9.59%) for non-Hispanic whites, 17.3% (95% CI, 16.4-18.2%) for non-Hispanic blacks, 16.1% (95% CI, 15.0-17.4%) for Hispanics and 14.9% (95% CI, 13.3-16.7%) for others. CONCLUSIONS AND RELEVANCE/CONCLUSIONS:Prevalence of CMDs was greatest among those experiencing food insecurity, and food insecurity disproportionately affected racial/ethnic minorities. Disparities in CMD prevalence by food security status persisted or worsened, especially among racial/ethnic minorities.

OBJECTIVE:Examine user perceptions of the Mind Your Heart (MYH) program, a mindful eating and nutrition education program delivered via an eHealth system. METHODS:Sixteen participants (41.5 ± 13.1 years) completed sample MYH lessons over 3 weeks. We examined changes in mindfulness from the State Mindfulness Scale via text messages sent 3 times per week. We assessed MYH user perceptions in a semistructured interview after 3 weeks. Analyses included Spearman's correlation, repeated measures ANOVA, and thematic analysis. RESULTS:State Mindfulness Scale scores were significantly improved (F[1,15] = 5.35, P = 0.01) from week 1 (M = 2.28 ± 0.80) to week 3 (M = 2.75 ± 1.04). Four themes emerged: (1) MYH is supportive of health goals, (2) text messages act as an intervention, (3) facilitators or inhibitors of use, and (4) enhancing engagement. CONCLUSIONS AND IMPLICATIONS/CONCLUSIONS:Based on participant feedback, the final version of MYH should include example-based learning to translate abstract concepts like mindful eating into action.