RESUMEN
Value-based care models, such as Medicaid accountable care organizations (ACOs), have the potential to improve access to and quality of care for pregnant and postpartum Medicaid enrollees. We leveraged a natural experiment in Massachusetts to evaluate the effects of Medicaid ACOs on quality-of-care-sensitive measures and care use across the prenatal, delivery, and postpartum periods. Using all-payer claims data on Medicaid-covered live deliveries in Massachusetts, we used a difference-in-differences approach to compare measures before (the first quarter of 2016 through the fourth quarter of 2017) and after (the third quarter of 2018 through the fourth quarter of 2020) Medicaid ACO implementation among ACO and non-ACO patients. After three years of implementation, the Medicaid ACO was associated with statistically significant increases in the probability of a timely postpartum visit, postpartum depression screening, and number of all-cause office visits in the prenatal and postpartum periods, with no changes in severe maternal morbidity, preterm birth, postpartum glucose screening, or prenatal or postpartum emergency department visits. Changes in cesarean deliveries were inconclusive. Results suggest that implementing Medicaid ACOs in the thirty-eight states without them could improve maternal health care outpatient engagement, but alone it may be insufficient to improve maternal health outcomes.
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Organizaciones Responsables por la Atención , Medicaid , Humanos , Femenino , Embarazo , Estados Unidos , Massachusetts , Organizaciones Responsables por la Atención/estadística & datos numéricos , Adulto , Calidad de la Atención de Salud , Periodo Posparto , Atención Prenatal/estadística & datos numéricos , Aceptación de la Atención de Salud/estadística & datos numéricos , Atención Posnatal/estadística & datos numéricos , Mejoramiento de la CalidadRESUMEN
Importance: In the US, infants born to non-Hispanic Black birthing parents are 50% more likely to be born preterm than those born to non-Hispanic White birthing parents, and individual-level factors do not fully account for this inequity. Neighborhood context, rooted in historic patterns of structural racism, may facilitate understanding patterns of inequity in preterm birth. Objective: To estimate the association between neighborhood opportunity level, measured by the Child Opportunity Index (COI), and preterm birth among infants in Massachusetts. Design, Setting, and Participants: In this cross-sectional, population-based study, Massachusetts birth certificates from 3 large metropolitan areas (Boston, Springfield, and Worcester) were linked to US Census tract-level data from the COI, and log binomial regression models and generalized estimating equations were fit to examine associations of different levels of opportunity with preterm birth. Singleton infants born in Massachusetts between February 1, 2011, and December 31, 2015, were included. Analyses were originally conducted in 2019 and updated in 2024. Exposure: Level of child opportunity (measured by the COI) at the US Census tract level. Race and ethnicity were ascertained from the birth certificate, as reported by the birthing parent. Main Outcomes and Measures: Live birth before 37 completed weeks' gestation. Results: The analytic dataset included 267â¯553 infants, of whom 18.9% were born to Hispanic, 10.1% to non-Hispanic Asian or Pacific Islander, 10.1% to non-Hispanic Black, and 61.0% to non-Hispanic White birthing parents. More than half of infants born to non-Hispanic Black and Hispanic birthing parents were born into very low opportunity neighborhoods, and in crude models, this was associated with greater prevalence of preterm birth relative to very high opportunity neighborhoods (prevalence ratio, 1.44; 95% CI, 1.37-1.52). After adjustment for covariates, infants born into very low opportunity neighborhoods still had a greater prevalence of preterm birth (prevalence ratio, 1.16; 95% CI, 1.10-1.23). Conclusions and Relevance: In this cross-sectional study of neighborhood opportunity and preterm birth, elevated risk associated with exposure to a very low opportunity neighborhood, coupled with the disproportionate exposure by race and ethnicity, points to a modifiable factor that may contribute to racial and ethnic inequities in preterm birth. Future research should investigate interventions that seek to address neighborhood opportunity.
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Nacimiento Prematuro , Humanos , Nacimiento Prematuro/etnología , Nacimiento Prematuro/epidemiología , Estudios Transversales , Femenino , Recién Nacido , Massachusetts/epidemiología , Adulto , Masculino , Embarazo , Características del Vecindario/estadística & datos numéricos , Etnicidad/estadística & datos numéricos , Características de la Residencia/estadística & datos numéricos , Población Blanca/estadística & datos numéricos , Negro o Afroamericano/estadística & datos numéricos , Grupos Raciales/estadística & datos numéricos , Hispánicos o Latinos/estadística & datos numéricosRESUMEN
Introduction: Food insecurity is defined as inconsistent access to enough food to meet nutritional needs. Discrimination is associated with food insecurity and poor health, especially among racial and ethnic minoritized and sexual or gender minoritized groups. We examined the demographic associations of perceived everyday discrimination and food pantry discrimination in Massachusetts. Methods: From December 2021 through February 2022, The Greater Boston Food Bank conducted a cross-sectional, statewide survey of Massachusetts adults. Of the 3,085 respondents, 702 were food pantry clients for whom complete data on food security were available; we analyzed data from this subset of respondents. We used the validated 10-item Everyday Discrimination Scale to measure perceived everyday discrimination and a 10-item modified version of the Everyday Discrimination Scale to measure perceived discrimination at food pantries. Logistic regression adjusted for race and ethnicity, age, gender identity, sexual orientation, having children in the household, annual household income, and household size assessed demographic associations of perceived everyday discrimination and discrimination at food pantries. Results: Food pantry clients identifying as LGBTQ+ were more likely than those identifying as non-LGBTQ+ to report perceived everyday discrimination (adjusted odds ratio [AOR] = 2.44; 95% CI, 1.24-4.79). Clients identifying as Hispanic (AOR = 1.83, 95% CI, 1.13-2.96) were more likely than clients identifying as non-Hispanic White to report perceived discrimination at food pantries. Conclusion: To equitably reach and serve households with food insecurity, food banks and pantries need to understand experiences of discrimination and unconscious bias to develop programs, policies, and practices to address discrimination and create more inclusive interventions for food assistance.
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Asistencia Alimentaria , Inseguridad Alimentaria , Humanos , Massachusetts , Femenino , Masculino , Estudios Transversales , Adulto , Asistencia Alimentaria/estadística & datos numéricos , Persona de Mediana Edad , Minorías Sexuales y de Género/psicología , Minorías Sexuales y de Género/estadística & datos numéricos , Adulto Joven , Discriminación Social/psicología , Abastecimiento de Alimentos/estadística & datos numéricos , Adolescente , AncianoRESUMEN
Introduction: The community health worker-led asthma home visiting model (CHW model) improved asthma outcomes and reduced health care costs among Massachusetts children with asthma. We projected cost savings associated with the expansion of the CHW model among pediatric Massachusetts Medicaid (MassHealth)-eligible patients with uncontrolled asthma (≥2 asthma-related emergency department visits per year). Methods: We estimated 2019 costs associated with asthma-related hospitalizations and emergency department visits for MassHealth pediatric patients with uncontrolled asthma who also had 365 days of Medicaid eligibility in 2019. We based estimated cost savings on previously published results from a study of a comparable patient population. Results: The projected asthma-related cost savings from expansion of the CHW model were $566.58 per patient, or $774,514.86 total, for the 1,367 MassHealth-eligible children with uncontrolled asthma in our analysis. Conclusion: Expansion of the CHW model is an effective way to increase asthma services and reduce Medicaid costs for MassHealth patients, a population made up disproportionately of Black and Hispanic residents with low incomes.
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Asma , Agentes Comunitarios de Salud , Ahorro de Costo , Visita Domiciliaria , Medicaid , Humanos , Asma/economía , Asma/terapia , Medicaid/economía , Massachusetts , Agentes Comunitarios de Salud/economía , Visita Domiciliaria/economía , Visita Domiciliaria/estadística & datos numéricos , Estados Unidos , Niño , Femenino , Masculino , Preescolar , Adolescente , Hospitalización/economía , Hospitalización/estadística & datos numéricos , Costos de la Atención en Salud/estadística & datos numéricosRESUMEN
Diverting food waste from landfills is crucial to reduce emissions and meet Paris Agreement targets. Between 2014 and 2024, nine US states banned commercial waste generators-such as grocery chains-from landfilling food waste, expecting a 10 to 15% waste reduction. However, no evaluation of these bans exists. We compile a comprehensive waste dataset covering 36 US states between 1996 and 2019 to evaluate the first five implemented state-level bans. Contrary to policy-makers' expectations, we can reject aggregate waste reductions higher than 3.2%, and we cannot reject a zero-null aggregate effect. Moreover, we cannot reject a zero-null effect for any other state except Massachusetts, which gradually achieved a 13.2% reduction. Our findings reveal the need to reassess food waste bans using Massachusetts as a benchmark for success.
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Alimento Perdido y Desperdiciado , Instalaciones de Eliminación de Residuos , Administración de Residuos , Massachusetts , Eliminación de Residuos/legislación & jurisprudencia , Estados Unidos , Administración de Residuos/legislación & jurisprudenciaRESUMEN
Freshwater turtles face numerous anthropogenic threats worldwide. Health assessments are a key component of chelonian population assessment and monitoring but are under reported in many species. The purpose of this study was to characterize the health of spotted turtles (Clemmys guttata; n = 30) and painted turtles (Chrysemys picta; n = 24) at Camp Edwards, a military base in Cape Cod, Massachusetts, using physical examinations, hematology, plasma heavy metal analyses, and pathogen surveillance via PCR. Spotted turtles had a high prevalence of carapace (n = 27, 90%) and plastron (n = 14, 46.7%) lesions, and a previously undescribed adenovirus was detected in three animals (proposed as Clemmys adenovirus-1). Female painted turtles had lower plasma copper (p = 0.012) and higher strontium (p = 0.0003) than males, and appeared to be in a similar plane of health to previous reports. This initial health assessment effort provides useful baseline data for future comparison in these species. Conservation efforts on Camp Edwards should incorporate continued health surveillance of these populations to identify intervention opportunities and determine the conservation threats, if any, of the novel adenovirus.
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Infecciones por Adenoviridae , Adenoviridae , Tortugas , Animales , Tortugas/virología , Femenino , Masculino , Massachusetts/epidemiología , Infecciones por Adenoviridae/veterinaria , Infecciones por Adenoviridae/epidemiología , Infecciones por Adenoviridae/virología , Adenoviridae/aislamiento & purificación , Adenoviridae/genéticaRESUMEN
BACKGROUND: Incarceration provides an opportunity for health interventions, including opioid use disorder (OUD) treatment and prevention of opioid-related overdoses post-release. All FDA-approved forms of medication for OUD (MOUD) treatment were mandated in several Massachusetts jails in 2019, with some jails offering extended-release buprenorphine (XR-Bup). Little is known about patient perspectives on and experiences with XR-Bup in carceral settings. METHODS: We conducted semi-structured interviews in 2022 with community-dwelling people who received MOUD during a recent incarceration in a Massachusetts jail. We asked participants about their experiences with and perspectives on XR-Bup while in jail. Qualitative data were double-coded deductively and reviewed inductively to identify emergent themes, which were structured using the Theoretical Framework of Acceptability (TFA). RESULTS: Participants (n = 38) had a mean age of 41.5 years, were 86% male, 84% White, 24% Hispanic, and 95% continued to receive MOUD at the time of their interview, including 11% receiving XR-Bup. Participants who viewed XR-Bup favorably appreciated avoiding the taste of sublingual buprenorphine; avoiding procedural difficulties and indignities associated with daily dosing in carceral settings (e.g., mouth checks, stigmatizing treatment from correctional staff); avoiding daily reminders of their addiction; experiencing less withdrawal; having extra time for other activities, such as work; and reduction of diversion of MOUD within the jail setting. Participants who viewed XR-Bup less favorably preferred to maintain their daily dosing routine; liked daily time out of their housing unit; wanted to know what was "going into my body everyday"; and feared needles and adverse events. Participants also reported that jail clinicians used XR-Bup for patients who were previously caught diverting sublingual buprenorphine, suggesting limited patient participation in decision-making around XR-Bup initiation in some jails. CONCLUSION: People who received MOUD in Massachusetts jails had both favorable and unfavorable views and experiences with XR-Bup. Understanding these preferences can inform protocols in jails that are considering implementation of XR-Bup treatment.
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Buprenorfina , Preparaciones de Acción Retardada , Tratamiento de Sustitución de Opiáceos , Trastornos Relacionados con Opioides , Investigación Cualitativa , Humanos , Buprenorfina/administración & dosificación , Buprenorfina/uso terapéutico , Trastornos Relacionados con Opioides/tratamiento farmacológico , Masculino , Femenino , Adulto , Persona de Mediana Edad , Tratamiento de Sustitución de Opiáceos/métodos , Massachusetts , Cárceles Locales , Prisioneros , Entrevistas como Asunto , Antagonistas de Narcóticos/administración & dosificación , Antagonistas de Narcóticos/uso terapéuticoRESUMEN
BACKGROUND: In recent years, overdoses involving illicit cocaine, methamphetamine, and other stimulants have increased in the U.S. The unintentional consumption of stimulants containing illicit fentanyl is a major risk factor for overdoses, particularly in Massachusetts and Rhode Island. Understanding the drug use patterns and strategies used by people who use stimulants (PWUS) to prevent overdose is necessary to identify risk and protective factors for stimulant and opioid-involved overdoses. Mixed-methods research with people who distribute drugs (PWDD) can also provide critical information into the mechanisms through which fentanyl may enter the stimulant supply, and the testing of drug samples can further triangulate PWUS and PWDD perspectives regarding the potency and adulteration of the drug supply. These epidemiological methods can inform collaborative intervention development efforts with community leaders to identify feasible, acceptable, and scalable strategies to prevent fatal and non-fatal overdoses in high-risk communities. METHODS: Our overall objective is to reduce stimulant and opioid-involved overdoses in regions disproportionately affected by the overdose epidemic. To meet this long-term objective, we employ a multi-pronged approach to identify risk and protective factors for unintentional stimulant and opioid-involved overdoses among PWUS and use these findings to develop a package of locally tailored intervention strategies that can be swiftly implemented to prevent overdoses. Specifically, this study aims to [1] Carry out mixed-methods research with incarcerated and non-incarcerated people who use or distribute illicit stimulants to identify risk and protective factors for stimulant and opioid-involved overdoses; [2] Conduct drug checking to examine the presence and relative quantity of fentanyl and other adulterants in the stimulant supply; and [3] Convene a series of working groups with community stakeholders involved in primary and secondary overdose prevention in Massachusetts and Rhode Island to contextualize our mixed-methods findings and identify multilevel intervention strategies to prevent stimulant-involved overdoses. DISCUSSION: Completion of this study will yield a rich understanding of the social epidemiology of stimulant and opioid-involved overdoses in addition to community-derived intervention strategies that can be readily implemented and scaled to prevent such overdoses in two states disproportionately impacted by the opioid and overdose crises: Massachusetts and Rhode Island.
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Sobredosis de Droga , Humanos , Sobredosis de Droga/prevención & control , Sobredosis de Droga/epidemiología , Rhode Island/epidemiología , Estimulantes del Sistema Nervioso Central/análisis , Massachusetts/epidemiología , Factores de Riesgo , Fentanilo/envenenamiento , Fentanilo/análisisRESUMEN
OBJECTIVE: Many surgical residencies have passed along attendings preferences and procedural knowledge as a highly utilized but informal resource. The objective was to assess the effect of providing operative steps and attending preferences on surgical resident performance. DESIGN: This was a prospective observational study with a survey-based design. SETTING: We created and shared vascular surgery operative steps including institutional and attending preferences with junior residents at the Massachusetts General Hospital. PARTICIPANTS: There were a total of 31 residents who completed a survey to assess self-perception of performance in operative knowledge and Accreditation Council for Graduate Medical Education (ACGME) Milestone criteria. RESULTS: Advice from colleagues was the most utilized resource, followed by web-based materials. Of the web-based materials, almost all residents utilized Google searches over other web-based resources designed to specifically help surgical trainees. The vascular surgery resource was used by 90% of residents more than 3 times per week to prepare for operative cases. There was significant improvement in patient positioning, instrument selection, operative field exposure, anatomy, sequence of procedure, procedure choices, and peri-operative care knowledge. CONCLUSIONS: Development of institutional resources that specifically capture attending surgeon procedural variations can improve resident performance, encourage resident autonomy, and provide a catalog of approaches to challenging operative situations.
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Competencia Clínica , Internado y Residencia , Procedimientos Quirúrgicos Vasculares , Estudios Prospectivos , Procedimientos Quirúrgicos Vasculares/educación , Proyectos Piloto , Humanos , Educación de Postgrado en Medicina/métodos , Femenino , Masculino , Massachusetts , Adulto , Encuestas y CuestionariosRESUMEN
Importance: Decisions about whether to stop colorectal cancer (CRC) screening tests in older adults can be difficult and may benefit from shared decision-making (SDM). Objective: To evaluate the effect of physician training in SDM and electronic previsit reminders (intervention) vs reminders only (comparator) on receipt of the patient-preferred approach to CRC screening and on overall CRC screening rates of older adults at 12 months. Design, Setting, and Participants: This was a secondary analysis of the Promoting Informed Decisions About Colorectal Cancer Screening in Older Adults (PRIMED) cluster randomized clinical trial. In the PRIMED trial, primary care physicians (PCPs) from 36 primary care practices in Massachusetts and Maine were enrolled between May 1 and August 30, 2019, and were randomized to the intervention group or the comparator group. Patients aged 76 to 85 years who were overdue for CRC screening and did not have a prior diagnosis of CRC enrolled between October 21, 2019, and April 8, 2021. Data analysis was performed between May 24, 2022, and May 10, 2023. Interventions: Primary care physicians in the intervention group completed an SDM training course and received previsit reminders of patients eligible for CRC testing discussion, whereas PCPs in the comparator group received reminders only. Main Outcomes and Measures: The primary outcome was concordance, or the percentage of patients who received their preferred screening approach. Postvisit surveys were administered to assess patient preference for testing, and electronic health record review was used to assess CRC testing at 12 months. Heterogeneity of treatment effect analyses examined interaction between study groups and different factors on concordance rates. Results: This study included 59 physicians and 466 older adults. Physicians had a mean (SD) age of 52.7 (9.4) years and a mean (SD) of 21.6 (10.2) years in practice; 30 (50.8%) were women and 16 (27.1%) reported prior training in SDM. Patients had a mean (SD) age of 80.3 (2.8) years; 249 (53.4%) were women and 238 (51.1%) reported excellent or very good overall health. Patients preferred stool-based tests (161 [34.5%]), followed by colonoscopy (116 [24.8%]) or no further screening (97 [20.8%]); 75 (16.1%) were not sure. The distribution of patient preferences was similar across groups (P = .36). At 12 months, test uptake was also similar for both the intervention group (29 [12.3%] for colonoscopy, 62 [26.3%] for stool-based tests, and 145 [61.4%] for no testing) and the comparator group (32 [13.9%] for colonoscopy, 35 [15.2%] for stool-based tests, and 163 [70.9%] for no testing; P = .08). Approximately half of patients in the intervention group received their preferred approach vs the comparator group (115 of 226 [50.9%] vs 103 of 223 [46.2%]; P = .47). Heterogeneity of treatment effect analyses found significantly higher rates with the intervention vs the comparator for patients with a strong intention to follow through with the preferred approach (adjusted odds ratio [AOR], 1.79 [95% CI, 1.11-2.89]; P = .02, P = .05 for interaction) and for patients who reported more than 5 minutes (AOR, 3.27 [95% CI, 1.25-8.59]; P = .02, P = .05 for interaction) of discussion with their PCP regarding screening. Higher rates were also observed among patients who reported 2 to 5 minutes of discussion with their PCP, although this finding was not significant (AOR, 1.89 [95% CI, 0.93-3.84]; P = .08, P = .05 for interaction). Conclusions and Relevance: In this secondary analysis of a cluster randomized clinical trial, approximately half of older patients received their preferred approach to CRC screening. Physician training in SDM did not result in higher concordance rates overall but may have benefitted some subgroups. Future work to refine and evaluate clinical decision support (in the form of an electronic advisory or reminder) as well as focused SDM skills training for PCPs may promote high-quality, preference-concordant decisions about CRC testing for older adults. Trial Registration: ClinicalTrials.gov Identifier: NCT03959696.
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Neoplasias Colorrectales , Toma de Decisiones Conjunta , Detección Precoz del Cáncer , Humanos , Neoplasias Colorrectales/diagnóstico , Anciano , Femenino , Masculino , Detección Precoz del Cáncer/métodos , Detección Precoz del Cáncer/estadística & datos numéricos , Anciano de 80 o más Años , Sistemas Recordatorios , Massachusetts , Atención Primaria de Salud , Médicos de Atención Primaria/educación , Médicos de Atención Primaria/estadística & datos numéricos , MaineRESUMEN
Introduction: The Massachusetts Academic Health Department Consortium (AHD) established the Academic Public Health Volunteer Corps (APHVC) to support Local Health Departments (LHDs, n = 351) to meet rapidly emerging needs during the COVID-19 pandemic through engaging student volunteers. A program evaluation captured lessons learned and informed recommendations for sustainability and future replication. Methods: The mixed-methods evaluation leveraged the Consolidated Framework for Implementation Research (CFIR). Data were stratified by LHD engagement with APHVC. Quantitative surveys informed probes for qualitative focus groups and interviews; findings were categorized into CFIR constructs using a deductive approach. Results: One-fifth of LHDs (n = 76, 27 used APHVC services, 45 did not) completed the survey. Eleven employees participated in follow-up focus groups or interviews. APHVC filled resource gaps, built capacity, and provided high-quality deliverables. LHDs experienced issues with reliability and communication of volunteers and lacked time to train volunteers. Conclusions: CFIR aided in evaluating APHVC in real time, producing actionable recommendations for best practices, dissemination, and future iterations of the program. Results are being used to enhance program effectiveness and sustainability, community health, and health equity across Massachusetts, and may help inform academic practice-based programs across the United States.
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COVID-19 , Creación de Capacidad , Evaluación de Programas y Proyectos de Salud , Salud Pública , Voluntarios , Humanos , Massachusetts , Grupos Focales , SARS-CoV-2 , Encuestas y CuestionariosRESUMEN
Importance: Local-level data are needed to understand whether the relaxation of X-waiver training requirements for prescribing buprenorphine in April 2021 translated to increased buprenorphine treatment. Objective: To assess whether relaxation of X-waiver training requirements was associated with changes in the number of clinicians waivered to and who prescribe buprenorphine for opioid use disorder and the number of patients receiving treatment. Design, Setting, and Participants: This serial cross-sectional study uses an interrupted time series analysis of 2020-2022 data from the HEALing Communities Study (HCS), a cluster-randomized, wait-list-controlled trial. Urban and rural communities in 4 states (Kentucky, Massachusetts, New York, and Ohio) with a high burden of opioid overdoses that had not yet received the HCS intervention were included. Exposure: Relaxation of X-waiver training requirements (ie, allowing training-exempt X-waivers) on April 28, 2021. Main Outcomes and Measures: The monthly number of X-waivered clinicians, X-waivered buprenorphine prescribers, and patients receiving buprenorphine were each summed across communities within a state. Segmented linear regression models to estimate pre- and post-policy change by state were used. Results: The number of individuals in 33 participating HCS communities included 347â¯863 in Massachusetts, 815â¯794 in Kentucky, 971â¯490 in New York, and 1â¯623â¯958 in Ohio. The distribution of age (18-35 years: range, 29.4%-32.4%; 35-54 years: range, 29.9%-32.5%; ≥55 years: range, 35.7%-39.3%) and sex (female: range, 51.1%-52.6%) was similar across communities. There was a temporal increase in the number of X-waivered clinicians in the pre-policy change period in all states, which further increased in the post-policy change period in each state except Ohio, ranging from 5.2% (95% CI, 3.1%-7.3%) in Massachusetts communities to 8.4% (95% CI, 6.5%-10.3%) in Kentucky communities. Only communities in Kentucky showed an increase in the number of X-waivered clinicians prescribing buprenorphine associated with the policy change (relative increase, 3.2%; 95% CI, 1.5%-4.9%), while communities in other states showed no change or a decrease. Similarly, only communities in Massachusetts experienced an increase in patients receiving buprenorphine associated with the policy change (relative increase, 1.7%; 95% CI, 0.8%-2.6%), while communities in other states showed no change. Conclusions and Relevance: In this serial cross-sectional study, relaxation of X-waiver training requirements was associated with an increase in the number of X-waivered clinicians but was not consistently associated with an increase in the number of buprenorphine prescribers or patients receiving buprenorphine. These findings suggest that training requirements may not be the primary barrier to expanding buprenorphine treatment.
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Buprenorfina , Tratamiento de Sustitución de Opiáceos , Trastornos Relacionados con Opioides , Pautas de la Práctica en Medicina , Buprenorfina/uso terapéutico , Humanos , Estudios Transversales , Pautas de la Práctica en Medicina/estadística & datos numéricos , Massachusetts , Tratamiento de Sustitución de Opiáceos/métodos , Trastornos Relacionados con Opioides/tratamiento farmacológico , Ohio , Masculino , Femenino , New York , Adulto , Análisis de Series de Tiempo Interrumpido , Kentucky , Persona de Mediana Edad , Analgésicos Opioides/uso terapéutico , Antagonistas de Narcóticos/uso terapéuticoRESUMEN
INTRODUCTION: At-home colorectal cancer (CRC) screening is an effective way to reduce CRC mortality, but screening rates in medically underserved groups are low. To plan the implementation of a pragmatic randomized trial comparing two population-based outreach approaches, we conducted qualitative research on current processes and barriers to at-home CRC screening in 10 community health centers (CHCs) that serve medically underserved groups, four each in Massachusetts and California, and two tribal facilities in South Dakota. METHODS: We conducted 53 semi-structured interviews with clinical and administrative staff at the participating CHCs. Participants were asked about CRC screening processes, categorized into eight domains: patient identification, outreach, risk assessment, fecal immunochemical test (FIT) workflows, FIT-DNA (i.e., Cologuard) workflows, referral for a follow-up colonoscopy, patient navigation, and educational materials. Transcripts were analyzed using a Rapid Qualitative Analysis approach. A matrix was used to organize and summarize the data into four sub-themes: current process, barriers, facilitators, and solutions to adapt materials for the intervention. RESULTS: Each site's process for stool-based CRC screening varied slightly. Interviewees identified the importance of offering educational materials in English and Spanish, using text messages to remind patients to return kits, adapting materials to address health literacy needs so patients can access instructions in writing, pictures, or video, creating mailed workflows integrated with a tracking system, and offering patient navigation to colonoscopy for patients with an abnormal result. CONCLUSION: Proposed solutions across the three regions will inform a multilevel intervention in a pragmatic trial to increase CRC screening uptake in CHCs.
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Neoplasias Colorrectales , Centros Comunitarios de Salud , Detección Precoz del Cáncer , Área sin Atención Médica , Humanos , Neoplasias Colorrectales/diagnóstico , Detección Precoz del Cáncer/métodos , Femenino , Masculino , Colonoscopía , Massachusetts , Sangre Oculta , Persona de Mediana Edad , California , South Dakota , Investigación Cualitativa , Anciano , Tamizaje Masivo/métodos , Navegación de PacientesRESUMEN
OBJECTIVE: To develop an Artificial Intelligence (AI)-based anomaly detection model as a complement of an "astute physician" in detecting novel disease cases in a hospital and preventing emerging outbreaks. METHODS: Data included hospitalized patients (n = 120,714) at a safety-net hospital in Massachusetts. A novel Generative Pre-trained Transformer (GPT)-based clinical anomaly detection system was designed and further trained using Empirical Risk Minimization (ERM), which can model a hospitalized patient's Electronic Health Records (EHR) and detect atypical patients. Methods and performance metrics, similar to the ones behind the recent Large Language Models (LLMs), were leveraged to capture the dynamic evolution of the patient's clinical variables and compute an Out-Of-Distribution (OOD) anomaly score. RESULTS: In a completely unsupervised setting, hospitalizations for Severe Acute Respiratory Syndrome Coronavirus 2 (SARS-CoV-2) infection could have been predicted by our GPT model at the beginning of the COVID-19 pandemic, with an Area Under the Receiver Operating Characteristic Curve (AUC) of 92.2 %, using 31 extracted clinical variables and a 3-day detection window. Our GPT achieves individual patient-level anomaly detection and mortality prediction AUC of 78.3 % and 94.7 %, outperforming traditional linear models by 6.6 % and 9 %, respectively. Different types of clinical trajectories of a SARS-CoV-2 infection are captured by our model to make interpretable detections, while a trend of over-pessimistic outcome prediction yields a more effective detection pathway. Furthermore, our comprehensive GPT model can potentially assist clinicians with forecasting patient clinical variables and developing personalized treatment plans. CONCLUSION: This study demonstrates that an emerging outbreak can be accurately detected within a hospital, by using a GPT to model patient EHR time sequences and labeling them as anomalous when actual outcomes are not supported by the model. Such a GPT is also a comprehensive model with the functionality of generating future patient clinical variables, which can potentially assist clinicians in developing personalized treatment plans.
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COVID-19 , Registros Electrónicos de Salud , Humanos , COVID-19/epidemiología , COVID-19/diagnóstico , SARS-CoV-2 , Inteligencia Artificial , Massachusetts/epidemiología , Curva ROC , Hospitalización/estadística & datos numéricos , Femenino , Masculino , Persona de Mediana Edad , Pandemias , AlgoritmosRESUMEN
STUDY OBJECTIVE: A low dynamic driving pressure during mechanical ventilation for general anesthesia has been associated with a lower risk of postoperative respiratory complications (PRC), a key driver of healthcare costs. It is, however, unclear whether maintaining low driving pressure is clinically relevant to measure and contain costs. We hypothesized that a lower dynamic driving pressure is associated with lower costs. DESIGN: Multicenter retrospective cohort study. SETTING: Two academic healthcare networks in New York and Massachusetts, USA. PATIENTS: 46,715 adult surgical patients undergoing general anesthesia for non-ambulatory (inpatient and same-day admission) surgery between 2016 and 2021. INTERVENTIONS: The primary exposure was the median intraoperative dynamic driving pressure. MEASUREMENTS: The primary outcome was direct perioperative healthcare-associated costs, which were matched with data from the Healthcare Cost and Utilization Project-National Inpatient Sample (HCUP-NIS) to report absolute differences in total costs in United States Dollars (US$). We assessed effect modification by patients' baseline risk of PRC (score for prediction of postoperative respiratory complications [SPORC] ≥ 7) and effect mediation by rates of PRC (including post-extubation saturation < 90%, re-intubation or non-invasive ventilation within 7 days) and other major complications. MAIN RESULTS: The median intraoperative dynamic driving pressure was 17.2cmH2O (IQR 14.0-21.3cmH2O). In adjusted analyses, every 5cmH2O reduction in dynamic driving pressure was associated with a decrease of -0.7% in direct perioperative healthcare-associated costs (95%CI -1.3 to -0.1%; p = 0.020). When a dynamic driving pressure below 15cmH2O was maintained, -US$340 lower total perioperative healthcare-associated costs were observed (95%CI -US$546 to -US$132; p = 0.001). This association was limited to patients at high baseline risk of PRC (n = 4059; -US$1755;97.5%CI -US$2495 to -US$986; p < 0.001), where lower risks of PRC and other major complications mediated 10.7% and 7.2% of this association (p < 0.001 and p = 0.015, respectively). CONCLUSIONS: Intraoperative mechanical ventilation targeting low dynamic driving pressures could be a relevant measure to reduce perioperative healthcare-associated costs in high-risk patients.
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Anestesia General , Costos de la Atención en Salud , Complicaciones Posoperatorias , Humanos , Estudios Retrospectivos , Femenino , Masculino , Persona de Mediana Edad , Anciano , Complicaciones Posoperatorias/economía , Complicaciones Posoperatorias/etiología , Complicaciones Posoperatorias/epidemiología , Complicaciones Posoperatorias/prevención & control , Anestesia General/economía , Anestesia General/efectos adversos , Costos de la Atención en Salud/estadística & datos numéricos , Respiración Artificial/estadística & datos numéricos , Respiración Artificial/economía , Respiración Artificial/efectos adversos , Atención Perioperativa/métodos , Atención Perioperativa/economía , Atención Perioperativa/estadística & datos numéricos , Adulto , Cuidados Intraoperatorios/métodos , Cuidados Intraoperatorios/economía , Cuidados Intraoperatorios/estadística & datos numéricos , Estudios de Cohortes , Massachusetts/epidemiologíaRESUMEN
Microplastics are fast-emerging as another potential threat to already globally declining seagrass ecosystems, but there is a paucity of in situ surveys showing their accumulations. Here, we surveyed multiple Zostera marina L. meadows in 2020 and 2021 across Massachusetts, USA, for microplastic contamination, as well as identified factors related to patterns of accumulation. We found that microplastics were ubiquitous throughout all sites regardless of proximity to human development, with fibers being the most common microplastic type. In addition, we showed that accumulation of microplastics within seagrass meadows was related to epiphytic cover on leaves, plant morphology, and bulk-density in sediments. The results of this study provide the first in situ baseline microplastic concentrations on Z. marina plants and sediments for the temperate western North Atlantic. Additionally, we identify specific biotic and abiotic factors related to patterns of microplastic accumulation in these ecosystems.
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Monitoreo del Ambiente , Microplásticos , Contaminantes Químicos del Agua , Zosteraceae , Zosteraceae/metabolismo , Massachusetts , Contaminantes Químicos del Agua/análisis , Microplásticos/análisis , Sedimentos Geológicos/química , EcosistemaRESUMEN
OBJECTIVE: To understand how Long COVID is impacting the health and social conditions of the Black and Latinx communities. BACKGROUND: Emerging research on Long COVID has identified three distinct characteristics, including multi-organ damage, persistent symptoms, and post-hospitalization complications. Given Black and Latinx communities experienced significantly higher COVID rates in the first phase of the pandemic they may be disproportionately impacted by Long COVID. METHODS: Eleven focus groups were conducted in four languages with diverse Black and Latinx individuals (n = 99) experiencing prolonged symptoms of COVID-19 or caring for family members with prolonged COVID-19 symptoms. Data was analyzed thematically. RESULTS: Most participants in non-English language groups reported they were unfamiliar with the diagnosis of long COVID, despite experiencing symptoms. Long COVID impacts spanned financial and housing stability to physical and mental health impacts. Participants reported challenging encounters with health care providers, a lack of support managing symptoms and difficulty performing activities of daily living including work. CONCLUSIONS: There is a need for multilingual, accessible information about Long COVID symptoms, improved outreach and healthcare delivery, and increased ease of enrollment in long-term disability and economic support programs.
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Negro o Afroamericano , COVID-19 , Grupos Focales , Hispánicos o Latinos , Humanos , Hispánicos o Latinos/psicología , Hispánicos o Latinos/estadística & datos numéricos , COVID-19/etnología , COVID-19/psicología , COVID-19/epidemiología , Masculino , Femenino , Persona de Mediana Edad , Massachusetts , Adulto , Negro o Afroamericano/psicología , Negro o Afroamericano/estadística & datos numéricos , Síndrome Post Agudo de COVID-19 , Anciano , SARS-CoV-2RESUMEN
BACKGROUND: There is limited evaluation of approaches to identify patients with new onset bipolar affective disorder (BPAD) when using administrative datasets. METHODS: Using the Massachusetts All-Payer Claims Database (APCD), we identified individuals with a 2016 diagnosis of bipolar disorder with mania and examined patterns of psychiatric and medical care over the preceding 48 months. RESULTS: Among 4806 individuals aged 15-35 years with a 2016 BPAD with mania diagnosis, 3066 had 48 months of historical APCD data, and of those, 75 % involved information from ≥2 payors. After excluding individuals with historical BPAD or mania diagnoses, there were 583 individuals whose 2016 BPAD with mania diagnosis appeared to be new (i.e., 34 new diagnoses per 100,000 individuals aged 15-35 years). Most individuals received medical care, e.g., 98 % had outpatient visits, 76 % had Emergency Department (ED) visits, and 50 % had mental health-related ED visits during the 48 months prior to their first mania diagnosis. One-third (37.2 %) had a depressive episode before their initial BPAD with mania diagnosis. LIMITATIONS: Study was conducted in one state among insured individuals. We used administrative data, which permits evaluation of large populations but lacks rigorous, well-validated claims-based definitions for BPAD. There could be diagnostic uncertainty during illness course, and clinicians may differ in their diagnostic thresholds. CONCLUSIONS: Careful examination of multiple years of patient history spanning all payors is essential for identifying new onset BPAD diagnoses presenting with mania, which in turn is critical to estimating population rates of new disease and understanding the early course of disease.
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Trastorno Bipolar , Manía , Aceptación de la Atención de Salud , Humanos , Adulto , Femenino , Masculino , Adolescente , Trastorno Bipolar/diagnóstico , Trastorno Bipolar/epidemiología , Adulto Joven , Aceptación de la Atención de Salud/estadística & datos numéricos , Massachusetts/epidemiología , Manía/diagnóstico , Servicio de Urgencia en Hospital/estadística & datos numéricos , Bases de Datos Factuales , Servicios de Salud Mental/estadística & datos numéricosRESUMEN
BACKGROUND: Involuntary civil commitment (ICC) is a court-mandated process to place people who use drugs (PWUD) into substance use treatment. Research on ICC effectiveness is mixed, but suggests that coercive drug treatment like ICC is harmful and can produce a number of adverse outcomes. We qualitatively examined the experiences and outcomes of ICC among PWUD in Massachusetts. METHODS: Data for this analysis were collected between 2017 and 2023 as part of a mixed-methods study of Massachusetts residents who disclosed illicit drug use in the past 30-days. We examined the transcripts of 42 participants who completed in-depth interviews and self-reported ICC. Transcripts were coded and thematically analysed using inductive and deductive approaches to understand the diversity of ICC experiences. RESULTS: Participants were predominantly male (57 %), white (71 %), age 31-40 (50 %), and stably housed (67 %). All participants experienced ICC at least once; half reported multiple ICCs. Participants highlighted perceptions of ICC for substance use treatment in Massachusetts. Themes surrounding ICC experience included: positive and negative treatment experience's, strategies for evading ICC, disrupting access to medications for opioid use disorder (MOUD), and contributing to continued substance use and risk following release. CONCLUSIONS: PWUD experience farther-reaching health and social consequences beyond the immediate outcomes of an ICC. Findings suggest opportunities to amend ICC to facilitate more positive outcomes and experiences, such as providing sufficient access to MOUD and de-criminalizing the ICC processes. Policymakers, public health, and criminal justice professionals should consider possible unintended consequences of ICC on PWUD.