Conectar
Background
Federally Qualified Health Centers (FQHC) provide services to individuals facing systemic barriers to health equity and are disproportionately affected by adverse social determinants of health. To better align healthcare services with the needs of those individuals experiencing health inequities, it is essential to screen for and document problematic social contributors to health in electronic health records, which health systems have been mandated to document by 2026.
Objectives
The aims of this study were to 1) determine the prevalence of documented social contributors to health Z-codes among patients receiving care through Colorado nurse-led FQHCs across urban, rural, and frontier settings; and 2) estimate healthcare utilization and expenditures associated with the presence of documented social contributors to health Z-codes compared to a matched sample of patients without that Z-code documentation.
Methods
We conducted a secondary analysis of the Colorado All Payers Claim Database. Social contributor of health ICD-10 Z-codes, reflecting problematic social structural circumstances as defined by Healthy People 2030, were extracted from patients receiving care in FQHCs. Social contributor of health-related charges were computed using propensity matching to compare individuals with and without documented social contributors of health.
Results
Documentation of social contributors of health Z-codes was notably low. Housing instability was the most common Z-code documented. Chronic pulmonary disease, diabetes, and heart disease were the most prevalent comorbidities among those with identified social contributors of health. The majority of patients with social contributors of health Z-codes were insured through Medicaid and lived in rural areas. Persons with documented social contributors of health had significantly higher predicted annual medical expenditures compared to those without documentation.
Discussion
The low prevalence of social contributors of health coding aligns with previous studies and represents a missed opportunity to provide targeted interventions for populations experiencing adverse social contributors. These findings underscore the need for strategizing and implementing plans to identify and code social contributors of health, especially in facilities serving those experiencing health inequities. Improved documentation of social contributors to health can facilitate data-driven resource allocation and tailored interventions to address adverse social determinants and promote health equity.
Background
In hospitals that serve disproportionately patients of Black race, here termed Black-serving hospitals (BSH), nurse staffing is worse, mortality rates are higher, and nursing-sensitive indicators may be worse than in other hospitals, but this evidence has not been compiled.
Objective
The study objective was to examine whether nursing-sensitive indicators, which measure changes in patient health status directly affected by nursing care, differ in hospitals where Black patients predominantly access their care, as compared to other hospitals.
Methods
To fulfill the objective, a cross-sectional design using publicly available 2019 to 2022 Hospital Compare, 2019 Medicare Provider Analysis and Review (MEDPAR), and case mix index (CMI) file databases were used. Four nursing-sensitive indicators were evaluated: pressure ulcer, postoperative sepsis, perioperative pulmonary embolus/deep vein thrombosis, and death rate among surgical inpatients with serious treatable complications (“failure to rescue”) in hospitals classified into high, medium, and low BSHs according to the percentage of patients of Black race in the MEDPAR data. Mean outcome differences across BSH categories were assessed through analyses of variance and regression models, which controlled for hospital CMI.
Results
The 3,101 hospitals were predominantly urban nonteaching hospitals in metropolitan areas. Although 12% of hospitals had Magnet designation, BSHs were disproportionately Magnet (14%). The outcome rates were 0.59 for pressure ulcers, 3.38 for perioperative pulmonary embolus/deep vein thrombosis, 143.58 for failure to rescue, and 4.12 for sepsis. Rates were significantly higher for pressure ulcers, perioperative pulmonary embolus/deep vein thrombosis, and sepsis in high BSHs. The mean failure to rescue rate was similar across low-to-high BSHs and did not show significant differences. These results were unchanged in models adjusting for CMI.
Discussion
The evidence suggests that several nursing-sensitive indicators are worse in high BSHs. Research linking nursing-sensitive indicators to nursing resources such as staffing is needed to explicate the mechanism underlying these findings. Poorer nursing-sensitive indicators in combination with poorer nurse staffing in high BSHs presents a priority for policy and management intervention.
Background
Females with autism often receive late diagnoses—especially those with average or above-average intellectual abilities—highlighting the need to explore the unique experiences of this population for better health care support.
Objective
To explore the experiences and perceptions of females who received a late diagnosis on the autism spectrum in terms of coping and managing their diagnosis.
Methods
A descriptive qualitative study was conducted from December 2022 to March 2023 using semistructured interviews with 14 late-diagnosed autistic female subjects. Purposive and snowball sampling were employed, and thematic analysis of the interview data was performed using ATLAS.ti v.9 software. Findings were reported following standards for reporting qualitative research guidelines.
Results
Two main themes emerged: (a) getting a diagnosis: fitting into the norm, and (b) navigating the distinct significance for autistic females. The findings indicated that masking strategies contribute to delayed diagnoses, and social and health care stigma surrounding autism in females was evident. Areas for improving access to resources and support programs were identified.
Discussion
The results show that masking and camouflaging are predominant strategies among autistic females, contributing to delayed diagnoses and exposing them to additional risks. Enhancing resources and training for health care professionals is necessary to address the specific needs of this population.
Background
In sub-Saharan Africa, the risk of obstetric complications remains high throughout the postpartum period.
Objective
We developed and tested a novel, integrated model of group postpartum care titled Focused-Postpartum Care (Focused-PPC) to improve outcomes. In this paper, we report clinical outcomes of participants in the intervention arm and differences in knowledge of postbirth warning signs among those in the intervention and control arms.
Methods
Focused-PPC encompassed recommended clinical assessments, targeted education, and peer support up to 1 year after birth. Focused-PPC was implemented as a parallel randomized controlled trial involving 192 postpartum women across four health centers in Tamale, Ghana, from February 2022 to August 2023. Eligible participants 18 years or older with a live birth were randomly assigned to either the Focused-PPC intervention arm or the control arm at a 1:1 allocation and were not blinded to their allocation. At each health center, 48 participants were allocated to either an intervention or control arm. Focused-PPC groups in the intervention arm consisted of eight participants per group. Participants in the intervention arm received the Focused-PPC integrated group model of care. Participants in the control arm received the standard of postnatal care already administered at each health center.
Results
Baseline analysis included 96 participants from the control arm and 91 participants from the intervention arm. We found that vital signs and clinical outcomes were relatively stable; however, incidences of hypertension substantially decreased among participants in the intervention arm. By 3 months postbirth, most participants in the intervention arm were able to identify all postbirth warning signs and retain this knowledge compared to the control arm. Those in the intervention arm were also knowledgeable of more warning signs at each time point compared to the control arm.
Discussion
An integrated, evidence-based approach to postpartum care, such as Focused-PPC, has potential to increase knowledge and improve clinical outcomes among mothers in Ghana.
Background
Tongue-tie is associated with nipple pain and early breastfeeding cessation. To date, research has been limited by small sample sizes and a dearth of evidence on the effects of tongue-tie on infant feeding symptoms and physiologic breastfeeding mechanics.
Objectives
In this article, we describe the protocol for our study exploring infant feeding, negative breastfeeding symptoms, maternal anatomy, and physiologic sucking data between infants with and without tongue-tie.
Methods
A prospective cohort study design is being employed. Over 8 weeks, three visits will be conducted with a sample of mothers and their infants without tongue-tie and a sample of mothers and their infants diagnosed with tongue-tie undergoing treatment via frenotomy. The aims of the study were to compare breastfeeding symptoms, breast anatomy, infant feeding symptoms, feeding efficiency, and nutritive sucking parameters between infants with and without tongue-tie, further comparing these metrics pretreatment and posttreatment via frenotomy with the non-tongue-tied age-matched counterparts.
Results
This study is currently ongoing.
Discussion
Tongue-tie is an everyday problem; clear guidelines are needed to decide whether to treat it. This novel, innovative, and multidisciplinary research study aims to fill critical gaps in understanding the physiological and functional effects of tongue-tie on breastfeeding, offering evidence to inform better clinical decisions and support effective interventions.
Background
Patients in hospitals that serve disproportionately patients of Black race have worse outcomes than patients in other hospitals, but the modifiable nursing factors that may contribute to such disparities have not been explored.
Objective
The study objective was to examine whether nurse staffing differs in hospitals that serve predominantly patients of Black race (Black-serving hospitals) as compared to other hospitals.
Methods
A cross-sectional correlational design using a nurse survey in a national hospital sample was used to fulfill the study objective. Nurse staffing was measured as the maximum number of patients cared for on the last shift from the 2015 annual registered nurse survey conducted in National Database of Nursing Quality Indicators hospitals. Hospitals were classified into subgroups of low, medium, and high percentages of patients of Black race using the 2019 Medicare Provider Analysis and Review database.
Results
In survey data from 179,336 registered nurses in 574 hospitals, nurse staffing was significantly worse in high-Black-serving hospitals as compared to medium- and low-Black-serving hospitals. In Poisson regression models that adjusted for nursing unit type and hospital characteristics, nurses in high-Black-serving hospitals and medium-Black-serving hospitals had more patients-per-nurse than did nurses in low-Black-serving hospitals.
Discussion
Small, statistically significant differences in nurse staffing that are worse in hospitals where Black patients disproportionately access their care were found using nurse survey data accounting for nursing unit type. The poorer nurse staffing in Black-serving hospitals may compromise the care and outcomes of the seven in 10 hospitalized Black older adults who receive care in Black-serving hospitals. The consequences for patient outcome disparities of poorer nurse staffing in Black-serving hospitals deserve investigation. Policies to increase nurse staffing in hospitals serving a higher proportion of patients of Black race are needed to contribute to efforts to reduce health disparities.
Background
In the United States, Black adults have the highest prevalence of obesity and hypertension, increasing their risk of morbidity and mortality. Caregivers of persons with dementia are also at increased risk of morbidity and mortality due to the demands of providing care. Thus, Black caregivers—who are the second largest group of caregivers of persons with dementia in the United States—have the highest risks for poor health outcomes among all caregivers. However, the physiological changes associated with multiple chronic conditions in Black caregivers are poorly understood.
Objectives
In this study, metabolomics were compared to the metabolic profiles of Black caregivers with obesity, with or without hypertension. Our goal was to identify metabolites and metabolic pathways that could be targeted to reduce obesity and hypertension rates in this group.
Methods
High-resolution, untargeted metabolomic assays were performed on plasma samples from 26 self-identified Black caregivers with obesity, 18 of whom had hypertension. Logistic regression and pathway analyses were employed to identify metabolites and metabolic pathways differentiating caregivers with obesity only and caregivers with both obesity and hypertension.
Results
Key metabolic pathways discriminating caregivers with obesity only and caregivers with obesity and hypertension were butanoate and glutamate metabolism, fatty acid activation/biosynthesis, and the carnitine shuttle pathway. Metabolites related to glutamate metabolism in the butanoate metabolism pathway were more abundant in caregivers with hypertension, while metabolites identified as butyric acid/butanoate and R-(3)-hydroxybutanoate were less abundant. Caregivers with hypertension also had lower levels of several unsaturated fatty acids.
Discussion
In Black caregivers with obesity, multiple metabolic features and pathways differentiated among caregivers with and without hypertension. If confirmed in future studies, these findings would support ongoing clinical monitoring and culturally tailored interventions focused on nutrition (particularly polyunsaturated fats and animal protein), exercise, and stress management to reduce the risk of hypertension in Black caregivers with obesity.
Background
Fatigue is a highly prevalent symptom for individuals with polycystic ovary syndrome (PCOS); however, characterization of fatigue and investigation into the gut microbiome—a pathway that may contribute to fatigue—remains inadequately explored in Black women with PCOS.
Objectives
The purpose of this cross-sectional study was to examine fatigue and its relationship to the gut microbiome in adult Black women with PCOS.
Methods
Adult Black women with a diagnosis of PCOS were recruited for this cross-sectional study. The Multidimensional Fatigue Inventory-20 (MFI-20) and the PROMIS Fatigue Short Form were used to measure fatigue. The V3/V4 region of the bacterial 16S rRNA gene was sequenced to investigate gut microbial composition. Relative abundance and diversity values were calculated.
Results
We found that Black women with PCOS experience mild to moderate levels of fatigue. An inverse relationship between fatigue scores and alpha diversity values was found for the gut microbiome. We also found distinct beta diversity profiles based on fatigue. Lastly, when controlling for hypertension and body mass index, Ruminococcus bromii, Blautia obeum, Roseburia, and HT002 were associated with three subscales of the MFI-20.
Discussion
Black women with PCOS experience mild to moderate fatigue. Clinicians should be cognizant of this population’s increased risk for fatigue to adequately address their healthcare needs. We also found that gut microbial composition was associated with fatigue in Black women with PCOS. Specifically, a higher relative abundance of certain gut bacteria involved in short-chain fatty acid production and anti-inflammatory pathways was correlated with lower fatigue levels. Future studies should further investigate the link between the gut microbiome and fatigue to determine whether this relationship is causal as better insight could inform tailored diet and exercise interventions to alter the gut microbiome and reduce fatigue.
Background
Older adults from specific racial and ethnic minoritized groups experience disproportionately higher asthma prevalence, morbidity, and mortality. They also often use emergency departments (EDs) to manage their asthma. High-quality primary care can improve asthma control and prevent ED use. Nurse practitioners (NPs) provide an increasing proportion of primary care to minoritized patients, yet often, they work in poor work environments that strain NP care.
Objectives
We examined whether racial and ethnic health disparities in ED visits among older adults with asthma are moderated by the NP work environment in primary care practices.
Methods
In 2018–2019, we used a cross-sectional design to collect survey data on NP work environments from 1,244 NPs in six geographically diverse states (i.e., Arizona, California, New Jersey, Pennsylvania, Texas, and Washington). We merged the survey data with 2018 Medicare claims data from 46,658 patients with asthma to assess the associations of all-cause and ambulatory care-sensitive conditions, ED visits with NPs’ work environment, and race and ethnicity using logistic regression.
Results
More than one third of patients with asthma visited the ED in 1 year, and a quarter of them had an ambulatory care-sensitive condition ED visit. Black and Hispanic patients were more likely than White patients to have all-cause and ambulatory care-sensitive condition ED visits. NP work environment moderated the association of race with all-cause and ambulatory care-sensitive condition ED visits among patients with asthma. Greater standardized NP work environment scores were associated with lower odds of all-cause and ambulatory care-sensitive condition ED visits between Black and White patients.
Discussion
Disparities in ED visits between Black and White patients with asthma decrease when these patients receive care in care clinics with more favorable NP work environments. Preventing unnecessary ED visits among older adults with asthma is a likely benefit of favorable NP work environments. As the NP workforce grows, creating favorable work environments for NPs in primary care is vital for narrowing the health disparity gap.
Background
Safe and reliable implementation of complex study protocols in multisite clinical trials requires that all study personnel have 24/7 access to up-to-date study materials. Study websites can serve as an electronic manual of operations (eMOO) to support trial conduct.
Objective
We describe the development, organization, and maintenance of a study website and eMOO to facilitate quick and efficient communication during conduct of a complex, multisite, international clinical trial.
Methods
We worked closely with our information technology department to develop and maintain our study website, which includes a public home page, a section for parents and families, and three password-protected portals that serve as an eMOO for (a) study sites, (b) study site investigators, and (c) the operations team (e.g., clinical coordination center, data coordination center).
Results
The public home page is helpful for families contemplating study participation and for nonparticipating sites considering joining our trial. The patient and family education section supports family participation in the study. The study site portal contains all information needed for local study teams to safely manage a study patient. The investigator portal provides access to research-specific materials needed to lead the study at each site. The operations team portal supports overall study management. For other scientists considering use of a study website for their multisite research, we recommend close collaboration with information technology for development and maintenance, limited and clearly defined roles for version control, and use of unmodifiable file formats to prevent unapproved alterations of study materials.
Discussion
Although investment in development and maintenance has been significant, we have appreciated marked value to our operations team and study sites. Our study website development process is relevant to other scientists conducting multisite clinical research.
Background
Patients with multiple chronic conditions often have many care plans, polypharmacy, and unrelieved symptoms that contribute to high emergency department and hospital use. High-quality primary care delivered in practices that employ nurse practitioners can help prevent the need for such acute care services. However, such practices located in primary care health professional shortage areas face challenges caring for these patients because of higher workloads and fewer resources.
Objective
We examined differences in hospitalization and emergency department use among patients with multiple chronic conditions who receive care from practices that employ nurse practitioners in health professional shortage areas compared to practices that employ nurse practitioners in non-health professional shortage areas.
Methods
We performed an analysis of Medicare claims, merged with Health Resources and Services Administration data on health professional shortage area status in five states. Our sample included 394,424 community-dwelling Medicare beneficiaries aged ≥65 years, with at least two of 15 common chronic conditions who received care in 779 practices that employ nurse practitioners. We used logistic regression to assess the relationship between health professional shortage area status and emergency department visits or hospitalizations.
Results
We found a higher likelihood of emergency department visits among patients in health professional shortage areas compared to those in non-health professional shortage areas and no difference in the likelihood of hospitalization.
Discussion
Emergency department use differences exist among older adults with multiple chronic conditions receiving care in practices that employ nurse practitioners in health professional shortage areas, compared to those in non-health professional shortage areas. To address this disparity, the health professional shortage area program should invest in recruiting and retaining nurse practitioners to health professional shortage areas to ease workforce shortages.
Background
Substantial effort has been invested to combat childhood obesity, but overall effects are disappointing, especially in low-income racial minority children. One possible reason is a lack of focus on the important stress–eating connection. Stress can negatively influence eating behaviors, leading to an increased appetite for high-fat and energy-dense foods.
Objective
This study aimed to evaluate the preliminary effects of a healthy eating and stress management program targeting multiple theoretical variables on improving eating behavior (dyads’ fruit/vegetable intake, emotional eating), food insecurity, anthropometric characteristics (dyads’ body mass index, % body fat), cardiovascular health (dyads’ blood pressure), and mental well-being (parental stress).
Methods
A one-group, quasi-experimental pilot study was conducted among 107 low-income parent–preschooler dyads. The 14-week program included a parent component, a parent–preschooler learning component, and a day care-based preschooler component.
Results
The program had positive effects on improving dyads’ fruit/vegetable intake, food insecurity, body mass index, and blood pressure and parents’ nutrition knowledge, self-efficacy, support, food resource management behavior, problem-focused coping, and home eating environment. The overall satisfaction rate was 95.2%, and 88.1% stated that the program assisted their families with having a healthy lifestyle.
Discussion
Results support the preliminary effects of the program on improving health outcomes in rural and urban low-income families. Although warranting further investigation with a more rigorous randomized controlled trial, the healthy eating and stress management program provides a potential solution to the current coexistence of an obesity epidemic and mental health crisis.
Background
Nurses’ primary role in clinical settings for persons living with dementia is to lessen the strain of dementia on daily life, monitor comorbidities, and manage medications. However, no comprehensive literature review has investigated the effectiveness of nurse-led interventions for persons living with dementia.
Objective
The purpose of this study was to evaluate randomized controlled trials on the efficacy of nurse-led dementia interventions and provide an extended range of outcomes related to cognitive function, depression, and quality of life.
Methods
A comprehensive literature search of six databases was conducted from database inception to August 10, 2022. Methodologies were evaluated, followed by a pooled analysis using random effects models to explain the effects of nurse-led dementia interventions on patients.
Results
Nurse-led interventions were more effective than standard care in alleviating depression and improving quality of life. However, they did not enhance cognitive performance.
Discussion
Nurse-led interventions for dementia alleviate depression and improve quality of life. However, because of lack of randomized controlled trials, the analysis found less effectiveness in improving cognitive function. Therefore, further trials are needed to corroborate these findings. 
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