Background/Objectives: This study examines factors associated with child overweight/obesity (OW/OB), pre-COVID-19 and during the COVID-19 pandemic, among all U.S. children aged 10–17 years, with or without developmental disabilities (DD) and, separately, among the subgroup of children diagnosed with a DD. Methods: Using data from the National Survey of Children’s Health (NSCH, 2018–2021), we applied descriptive statistics and multivariate logistic regression analyses to estimate the odds ratios of associations between family resilience, screen time, and childhood overweight/obesity. Family resilience measures families’ communication and problem-solving behaviors. Screentime is time spent on TV, computer, cellphone or electronic devices. Results: In descriptive analyses, during COVID-19, 35.8% of all children were identified as OW/OB compared to 32.8% pre-COVID-19—a weighted increase of 3.0%. Among children with developmental disabilities, OW/OB increased from 37.4% to 39.3%. Children reporting ≥4 h of screentime use increased from pre-COVID-19 to during COVID-19 in both groups (All Children: pre-COVID: 33.5%, during COVID: 41.6%; Developmental Disabilities: pre-COVID: 39.9%, during COVID: 49.4%). Among all children, there was a positive and strong association between screentime use and OW/OB at both pre- and during COVID-19 years. Children belonging to households with low family resiliency had 1.31 times the odds of being overweight/obese (95% CI, 1.06–1.63, p < 0.05) before the pandemic. However, these results were not significant after the pandemic. Conclusions: Prevalence of overweight/obesity in all children and children with DD during the COVID-19 pandemic continued to rise. Screentime was found to be a key determinant in increased weight status. Contrary to our hypothesis, family resilience failed to emerge as a significant protective factor for OW/OB; additional research is needed to explore the protective role of family resiliency on childhood obesity. Study findings may provide insights into developing best practices and tailored interventions with early OW/OB screening and programs tailored towards the youngest group of children aged 10–12 years or below.

We investigate the causal effect of education on hospitalization. We apply novel techniques to estimate a sparse model that uses the least absolute selection and shrinkage operator (LASSO) regression with a data-driven penalty to construct optimal cross-validated instrumental variables and select a parsimonious set of controls. This method yields consistent and more efficient estimates relative to conventional instrumental variable procedures and overcomes the limitations of previous studies using compulsory schooling laws in the United States. We also use an approach for a valid inference that allows instruments to be only plausibly exogenous. Using the 1992-2016 Health and Retirement Study, our results suggest that an additional year of schooling in early life lowers the likelihood of two-year hospitalizations later in life by 2.6 percentage points (or about 9.5 percent). This estimate is robust to different model specifications and plausible amounts of imperfect exogeneity and is similar to the local treatment effect among potential compliers.

Nursing-sensitive quality indicators (NSIs) measure improvements in patient care quality and safety that nurses directly or indirectly influence. Existing standardized NSIs are often general, developed in high-resource countries, and may not reflect aspects of care most relevant to pediatric cancer in resource-diverse settings and countries. Our previous multiphase research established a preliminary core set of pediatric cancer NSIs based on Delphi expert consensus and peer-reviewed literature. This study aims to finalize a core set of NSIs to measure improvements in the quality of nursing care delivered to children and adolescents with cancer in resource-diverse settings and countries. A sequential mixed methods research design, intersected with a modified-Delphi method was utilized. A purposive sample of 43 multidisciplinary pediatric cancer experts from 24 countries participated. Round 1 (web-based survey): Panelists rated 12 potential NSIs by importance, use/usability, perceived feasibility, and face validity (1=lowest, 9=highest). Median and interquartile range scores were calculated. Next, panelists selected their top 10 NSIs and ranked them by importance (1=most important, 10=least important) for inclusion in a final core set of NSIs. Mean importance scores were calculated through reverse scoring. Round 2 (virtual panel meetings): Meeting 1: A subgroup of 11 panelists discussed Round 1 survey results and refined the list of NSIs and their specifications. Meeting 2: A separate subgroup of 10 panelists reviewed Meeting 1 findings and finalized NSI specifications. Expert panelists prioritized 9 NSIs for inclusion in the final core set. These include NSIs that are novel to pediatric cancer (n=3): chemotherapy/biotherapy administration, patient/family discharge education, and Pediatric Early Warning Score assessment; NSIs that have been modified from existing NSIs (n=4): hand hygiene, intravenous infiltration and extravasation, pain assessment/management, and vascular access device maintenance; and existing NSIs (n=2): central line-associated bloodstream infections and nurse staffing. Expert panelists excluded 3 NSIs: oral care, psychosocial screening, and nausea assessment/management. Findings underscore the need for tailoring NSIs to measure improvements in pediatric cancer care delivery globally. The next steps include pilot testing NSIs in 3 resource-diverse countries. Courtney E. Sullivan, Wendy Landier, Julie Buser, Lauri Linder, Jack Needleman, Paola Friedrich, Patricia A. Patrician. Finalizing a Core Set of Pediatric Cancer Nursing-Sensitive Quality Indicators for Use in Resource- Diverse Settings and Countries: A Mixed Methods Modified-Delphi Study [abstract]. In: Proceedings of the 13th Annual Symposium on Global Cancer Research; 2025 Sep 16. Philadelphia (PA): AACR; Cancer Epidemiol Biomarkers Prev 2025;34(12_Suppl):Abstract nr 70.

The nursing service in hospitals is a large, complex service. It delivers ordered drugs and other services; assesses and monitors patient status, including progress as expected or problems or developing complications, risks of falls, pressure ulcers, delirium and disorientation, pain, and mental status (especially depression and agitation); and initiates interventions when necessary. The nursing service provides psycho- social support to patients and their families, patient education, care coordination with other services, physical care and assistance in activities of daily living, and patient and family preparation for discharge. The work of staff on these units, especially work of registered nurses (RNs), is physically, emotionally, cognitively, and managerially demanding. Research has repeatedly shown that when RN staffing is low, length of stay, adverse events, and deaths increase. Research also shows that efforts to substitute RNs with other lesser-skilled staff, such as nursing assistants, ultimately cost more in longer lengths of stay than is saved in staffing costs. This is not the case for increasing the hours of RNs. The savings in length of stay and adverse events in terms of hospital costs offset approximately onehalf to two-thirds the costs of increased RN hours (Dall et al., 2009; Griffiths et al., 2021; Martsolf et al., 2014; Needleman et al., 2006). When the benefits to patients of reduced risk of death are taken into account, the value of safer RN staffing levels merits staffing at these levels (Griffiths et al., 2023). However, this value is not realized or monetized by a hospital; thus, it does not necessarily enter into hospital staffing decisions. In cost-effectiveness terms, higher RN hours is a "more for more" decision - spending more to realize more value, which from a patient perspective, is worth it. The failure of many hospitals to staff at safe and efficient levels has created pressure for mandating minimum staffing through regulation or legislation. This article reviews national and global efforts for regulation or legislation to ensure appropriate nurse staffing levels are in place to keep patients safe.

The current economic burden of cardiovascular (CV)-related hospitalizations grouped by diagnoses and procedures in the United States has not been well characterized. The objective was to identify current trends in CV-related hospitalizations, procedural utilization, and health care costs using the most recent 6 years of hospitalization data. A retrospective analysis of discharge data from the National Inpatient Sample database was conducted to determine trends in CV-related hospitalizations, costs, and procedures for each year from 2016 to the most recent available dataset, 2021. Total CV-related costs were adjusted to and reported in 2023 dollars. In 2021, there were 4,687,370 CV-related hospitalizations at a cost of $108 billion. Heart failure hospitalizations accounted for the highest costs at $18.5 billion, followed by non-ST-elevation myocardial infarction at $11.2 billion and stroke at $10.9 billion. Significant upward trends in costs from 2016 to 2021 were observed for heart failure, stroke, atrial fibrillation, ST-elevation myocardial infarction, chest pain, hypertensive emergency, ventricular tachycardia, aortic dissection, sudden cardiac death, pericarditis, supraventricular tachycardia, and pulmonary heart disease. Over the 6 observational years, total costs increased by over $10 billion, representing a 10% increase. However, the increases were not linear, as there was a significant increase of 6.5% from 2018 to 2019, then a decrease of over 7% from 2019 to 2020, followed by an increase of approximately 6% from 2020 to 2021. By 2030, total CV-related costs are projected to reach $131.3 billion. For all years, coronary procedures were the most performed, followed by extracorporeal membrane oxygenation, non-bypass peripheral vascular surgery, pacemaker placement, and coronary artery bypass graft surgery. Both transcatheter aortic valve replacement and MitraClip procedures demonstrated significant upward trends from 2016 to 2021. Overall, from the years 2016 to 2021, CV-related hospitalizations, costs, and procedures demonstrated upward trends. In conclusion, CV disease remains a high burden in the hospital setting with tremendous health care costs.

IntroductionAbout one in six children in the US, about 17% of the population, have one or more intellectual or developmental disabilities. Increases in disability due to neurodevelopmental or mental health conditions have increased by 21% in the last decade. Early intervention based on developmental screening and provider-initiated monitoring can significantly improve long-term health and cognitive outcomes. This paper assesses whether differences in receipt of developmental screening or monitoring are associated with access to a high-quality primary care medical home and having a provider who shows sensitivity to a family’s customs and values among neurotypical children and children with intellectual and developmental disabilities (IDD).MethodsWe used cross-sectional data from the National Survey of Children’s Health (NSCH) from 2017 to 2019. The NSCH is a nationally representative, parent-completed annual survey of children under 18. Children between 9 months and 5 years with IDD (n = 2,385) and neurotypical children (n = 20,200) were included in the analysis.ResultsUptake of developmental screening/monitoring in neurotypical children and children with IDD conditions was associated with belonging to minority race/ethnic backgrounds, specifically Black, Asian, and AIAN/NHPI, and single-parent households with lower incomes, being publicly insured or uninsured and not having access to a high-quality medical home. Weighted regression models showed that the odds of neurotypical children receiving developmental monitoring/screening were 53% higher when their healthcare provider always or usually demonstrated cultural sensitivity to the family’s values and customs (OR 1.53, 95% CI, 1.08–2.18, p < 0.05). For children with IDD, the odds of receipt of monitoring/screening increased by 2.1 times when the provider always/usually demonstrated an understanding of the family’s cultural norms (95% CI, 0.99–4.43, p = 0.053). Being female was significantly associated with a lack of screening/surveillance (OR 0.73, 95% CI, 0.58–0.91, p < 0.05).DiscussionWith the rising prevalence of children with IDD conditions, early identification of developmental delays and subsequent access to interventions are crucial steps in supporting children and children with IDD to receive preventive care, services, and reduce disparities in accessing quality care. Implementing culturally sensitive approaches can be a low-cost and effective intervention in improving rates of provider-initiated monitoring and parent-completed screening.

Many healthcare systems have implemented intensive outpatient primary care programs with the hopes of reducing healthcare costs. The Veterans Health Administration (VHA) piloted primary care intensive management (PIM) for patients at high risk for hospitalization or death, or “high-risk.” We evaluated whether a referral model would decrease high-risk patient costs. Retrospective cohort study using a quasi-experimental design comparing 456 high-risk patients referred to PIM from October 2017 to September 2018 to 415 high-risk patients matched on propensity score. Veterans in the top 10th percentile of risk for 90-day hospitalization or death and recent hospitalization or emergency department (ED) visit. PIM consisted of interdisciplinary teams that performed comprehensive assessments, intensive case management, and care coordination services. Change in VHA and non-VHA outpatient utilization, inpatient admissions, and costs 12 months pre- and post-index date. Of the 456 patients referred to PIM, 301 (66 https://clinicaltrials.gov/study/NCT04521816

Background: Appropriate staffing is essential to acute care delivery. Staffing ratio policy generates controversy. Purpose: This study examines perspectives on unit -level nurse -to -patient ratio policy in adult medical-surgical units. Method: Delphi methodology uses an invited diverse panel to analyze a policy's effects. Panelists completed iterative surveys about the impact they expect from unit -level ratio policy. Findings: Panelists demonstrated moderate agreement that the proposed policy could increase staffing levels, decrease patient length of stay, and reduce nurse attrition. Other potential outcomes included reducing staffing in units above the minimum and increasing short-term costs. Panelists agreed that the policy could increase patient safety and nurse satisfaction and did not agree about the effect on long-term cost and innovation. Panelists also anticipated a mostly positive effect on patients and nurses. Discussion: Policies that set unit -level nurse -to -patient ratios offer a potential strategy to improve medical-surgical staffing. Policy design should consider the range of expected outcomes. (c) 2024 Elsevier Inc. All rights reserved.

Previous articleNext article No AccessIncreased Schooling Reduces Hospitalization Later in Life: New Evidence with Optimal Instruments from the United StatesDahai Yue, Ninez A. Ponce, Jack Needleman, Susan L. Ettner, and Adriana Lleras-MuneyDahai Yue Search for more articles by this author , Ninez A. Ponce Search for more articles by this author , Jack Needleman Search for more articles by this author , Susan L. Ettner Search for more articles by this author , and Adriana Lleras-Muney Search for more articles by this author PDFPDF PLUS Add to favoritesDownload CitationTrack CitationsPermissionsReprints Share onFacebookTwitterLinkedInRedditEmailPrint SectionsMoreDetailsFiguresReferencesCited by American Journal of Health Economics Just Accepted Published for the American Society of Health Economists (ASHEcon) Article DOIhttps://doi.org/10.1086/728403 Views: 25Total views on this site HistoryAccepted October 20, 2023 © 2023 American Society of Health Economics. All Rights reserved.PDF download Crossref reports no articles citing this article.

Background: Provision of team-based primary care (PC) is associated with improved care quality, but limited empirical evidence guides practices on how to optimize team functioning. We examined how evidence-based quality improvement (EBQI) was used to change PC team processes. EBQI activities were supported by research-clinical partnerships and included multilevel stakeholder engagement, external facilitation, technical support, formative feedback, QI training, local QI development and across-site collaboration to share proven practices.Methods: We used a comparative case study in two VA medical centers (Sites A and B) that engaged in EBQI between 2014 and 2016. We analyzed multiple qualitative data sources: baseline and follow-up interviews with key stakeholders and provider team ("teamlet") members (n = 64), and EBQI meeting notes, reports, and sup-porting materials.Results: Site A's QI project entailed engaging in structured daily huddles using a huddle checklist and developing a protocol clarifying team member roles and responsibilities; Site B initiated weekly virtual team meetings that spanned two practice locations. Respondents from both sites perceived these projects as improving team structure and staffing, team communications, role clarity, staff voice and personhood, accountability, and ulti-mately, overall team functioning over time.Conclusion: EBQI enabled local QI teams and other stakeholders to develop and implement innovations to improve PC team processes and characteristics in ways that improved teamlet members' perceptions of team functioning.Implications: EBQI's multi-level approach may empower staff and facilitate innovation by and within teams, making it an effective implementation strategy for addressing unique practice-based challenges and supporting improvements in team functioning across varied clinical settings.Level of evidence: VI.

Stimulant use is an important driver of HIV/STI transmission among men who have sex with men (MSM). Evaluating factors associated with increased stimulant use is critical to inform HIV prevention programming efforts. This study seeks to use machine learning variable selection techniques to determine characteristics associated with increased stimulant use and whether these factors differ by HIV status. Data from a longitudinal cohort of predominantly Black/Latinx MSM in Los Angeles, CA was used. Every 6 months from 8/2014–12/2020, participants underwent STI testing and completed surveys evaluating the following: demographics, substance use, sexual risk behaviors, and last partnership characteristics. Least absolute shrinkage and selection operator (lasso) was used to select variables and create predictive models for an interval increase in self-reported stimulant use across study visits. Mixed-effects logistic regression was then used to describe associations between selected variables and the same outcome. Models were also stratified based on HIV status to evaluate differences in predictors associated with increased stimulant use. Among 2095 study visits from 467 MSM, increased stimulant use was reported at 20.9

Background: Comorbidities are common among patients with schizophrenia yet the prevalence of comorbidity combinations and their associations with inpatient service utilization and readmission have been scarcely explored. Methods: Data were extracted from discharge summaries of patients whose primary diagnosis was schizophrenia spectrum disorders (ICD-10: F20-F29). We identified 30 most frequent comorbidities in patients' secondary diagnoses and then used the association rule mining (ARM) method to derive comorbidity combinations associated with length of stay (LOS), daily expense and one-year readmission. Results: The study included data from 8252 patients. The top five most common comorbidities were extrapyramidal syndrome (EPS, 44.58%), constipation (31.63%), common cold (21.80%), hyperlipidemia (20.99%) and tachycardia (19.13%). Most comorbidity combinations identified by ARM were significantly associated with longer LOS (>= 70 days), few were associated with higher daily expenses, and fewer with readmission. The 3-way combination of common cold, hyperlipidemia and fatty liver had the strongest association with longer LOS (adjusted OR (aOR): 3.38, 95% CI: 2.12-5.38). The combination of EPS and mild cognitive disorder was associated with higher daily expense (>= 700 RMB) (aOR: 1.67, 95% CI: 1.20-2.31). The combination of constipation, tachycardia and fatty liver were associated with higher 1-year readmission (aOR: 2.05, 95% CI: 1.03-4.09). Conclusion: EPS, constipation, and tachycardia were among the most commonly reported comorbidities in schizophrenia patients in Beijing, China. Specific groups of comorbidities may contribute to higher inpatient psychiatric service utilization and readmission. The mechanism behind the associations and potential interventions to optimize service use warrant further investigation.

Substance use during sexual encounters (sexualized substance use) is an important driver of HIV and sexually transmitted infection (STI) disparities that are experienced by men who have sex with men (MSM). This analysis aimed to identify patterns of sexualized substance use and their associations with HIV risk behaviors. We utilized visit-level data from a longitudinal cohort of predominantly Black/Latinx MSM, half with HIV and half with substance use in Los Angeles, California. Every 6 months from 8/2014 to 3/2020, participants underwent STI testing and completed surveys on demographics, sexualized substance use (stimulant and/or alcohol intoxication during oral sex, receptive anal intercourse [RAI] and/or insertive anal intercourse [IAI]), transactional sex, biomedical HIV prevention (pre-/post-exposure prophylaxis use or undetectable viral load), and depressive symptoms. Latent class analysis was used to identify patterns of sexualized substance use. Multinomial logit models evaluated risk behaviors associated with latent classes. Among 2386 study visits from 540 participants, 5 classes were identified: no substance use, sexualized stimulant use, sexualized alcohol use, sexualized stimulant and alcohol use, and stimulant/alcohol use during oral sex and RAI. Compared to the no sexualized substance use class, sexualized stimulant use was associated with transactional sex, current diagnosis of STIs, not using HIV biomedical prevention, and depressive symptoms. Sexualized alcohol use had fewer associations with HIV risk behaviors. Patterns of sexual activities, and the substances that are used during those activities, confer different risk behavior profiles for HIV/STI transmission and demonstrate the potential utility of interventions that combine substance use treatment with HIV prevention.

Selective mortality and nonresponse in longitudinal analyses would lead to biased estimates. In this study, we draw data from the 1992–2016 Health and Retirement Study and used a multinomial logit model to examine the impacts of participants' demographics, health conditions, and socioeconomic status on both follow-up status in 2016 (Always-in; Died; Other Attritors, non-death sample attrition; Ever-out, skipped some intermediate surveys) and between-wave dropout. We then applied an inverse probability weighting approach to compensate for attrition in the analysis of education and hospitalizations. We found that many demographics (e.g., sex, age, race, ethnicity, marital status), socioeconomic factors (e.g., education, house ownership, labor force participation) and health conditions (e.g., self-reported health, and chronic conditions) had large and statistically significant associations with loss of follow-up. Our results show that loss of follow-up leads to substantial underestimation of the education-hospitalization association. After correcting attrition bias in a pooled cross-sectional analysis, the association of having a high school degree, some college, and college or above with any two-year hospitalizations increased by 59.7

BACKGROUND: Asthma disproportionately affects individuals with lower income. High uninsured rates are a potential driver for this disparity. Previous studies have not examined the effect of the Affordable Care Act (ACA) on asthma- related outcomes for individuals with low income. RESEARCH QUESTION: What is the impact of insurance status and the ACA on asthma outcomes for adults 18 to 64 years of age in households with low-income status? STUDY DESIGN AND METHODS: This study was a pooled cross-sectional observational study using National Health Interview Survey data from 2011 through 2013 and 2016 through 2018. Individuals 18 to 64 years of age with a history of asthma and low income were included. Survey-weighted regression modeling and mediation analysis was used to explore the relationship of insurance status and asthma control. Univariate and multivariate surveyweighted regression modeling then was used to evaluate the correlation of the ACA and asthma outcomes. RESULTS: We identified 4,043 individual observations. Having health insurance was correlated with improved asthma outcomes (OR, 1.25). This relationship was completely mediated by cost barriers to medications and physician visits. Although the ACA resulted in significant changes in insurance status (OR, 2.4), no statistically significant change was found in asthma outcomes. Furthermore, cost barriers to both medications and physician visits persisted in the insured population, 20.7% and 30.0%, respectively. INTERPRETATION: Insurance coverage is associated with improved asthma control for adults 18 to 64 years from households with low socioeconomic status. The ACA reduced the rates of uninsured, but did not have the same magnitude of effect on reducing cost barriers. The persistence of cost barriers may explain in part the lack of population-level improvement in asthma control.

Background: Prior research has found that 25% of women veterans who are new to the Department of Veterans Affairs (VA) health care system discontinue services within 3 years of initial use. Although it has been suggested that providing more gender-sensitive care might improve women veterans' health care experiences, no study has yet documented an empirical relationship between clinic and provider factors associated with the provision of gender-sensitive care and women veterans' care discontinuity.Methods: Surveys of primary care providers (n = 82) and staff members (n = 108) from 12 VA medical centers were linked to administrative data for women veteran patients with at least one primary care visit in 2014 and 2015 (n = 9,958). Patient care discontinuity was operationalized as having no additional primary care visit within 3 years after the patient's baseline visit. Key indicators of gender-sensitive comprehensive primary care included type of medical home (women's health-focused vs. general primary care), workforce gender sensitivity, team functioning, perceived quality of provider/staff communication, leadership support for medical home implementation, and other structural components of care delivery (e.g., chaperone availability). We used logistic regression to assess the association between these indicators and women's care discontinuity, measuring discontinuity for both new and continuing VA users and controlling for patient characteristics.Results: Eleven percent of women patients discontinued primary care within 3 years. Poor workforce gender sensitivity (lowest quartile vs. top three quartiles) was significantly associated with higher odds of discontinuity (odds ratio, 1.26; 95% confidence interval, 1.01-1.57); other indicators were not associated with discontinuity.Conclusions: This study is the first to document a relationship between workforce gender sensitivity and women vet-erans' care continuity. This finding underscores the need for additional attention to enhancing workforce gender sensitivity in VA.Published by Elsevier Inc. on behalf of Jacobs Institute of Women's Health, George Washington University.