Health affairs scholar最新文献

The substantial carbon footprint imparted by medical services warrants increased attention to their environmental impact. National guideline organizations such as the US Preventive Services Task Force (USPSTF) recommend multiple modalities for average-risk colorectal cancer (CRC) screening with varying resource intensity. The aim of this study was to quantify the environmental burden for 2 of the most used CRC screening modalities, colonoscopy and the multi-target stool DNA (mt-sDNA) test. A validated CRC microsimulation model was used to estimate the number of screening and follow-up tests for a cohort of 1 million average-risk individuals who underwent screening between ages 45 and 75. Component resources used for mt-sDNA, including waste products, energy, and transportation for colonoscopy and mt-sDNA, were collected from January 1, 2023, to January 1, 2024, and converted to carbon-equivalent emissions. Resources used for colonoscopy were captured from the literature. Resources devoted to screening colonoscopy were substantially (59%) higher than those to mt-sDNA, even when including follow-up colonoscopy. Of note, follow-up colonoscopy accounted for the majority (64%) of total emissions for the mt-sDNA screening strategy. Compared with colonoscopy screening, mt-sDNA substantially reduces the carbon emissions attributable to population-level CRC screening. Environmental impact should be included as a factor when choosing among guideline-recommended CRC screening strategies.

Due to an FDA "black box" warning for heightened risk of death, Choosing Wisely (CW) recommends avoiding antipsychotic prescription drugs as first-line treatment for dementia-related agitation. Yet, post-CW trends among community-dwelling patients with dementia remain unknown. In this retrospective cohort study, we used nationally representative Health and Retirement Study survey data linked to Medicare fee-for-service claims (January 1, 2010-December 31, 2018) to analyze prescribing trends during the pre-publication (2010-2012), publication (2013-2015), and post-publication (2016-2018) periods of CW recommendations. We included community-dwelling adults aged ≥65 years with dementia. We utilized multivariable mixed regression models to determine the percentage of patients prescribed any, potentially low-value, and potentially indicated antipsychotics. Among an estimated 2.4-2.7 million patients with dementia, any antipsychotic prescribing increased from 9.4% (95% CI, 6.4%-12.3%) during the pre-publication period (2010-2012) to 15.8% (95% CI, 12.8%-18.8%) (P < 0.001) during the publication period (2013-2015). Potentially low-value and potentially indicated prescriptions also increased. Post-publication period (2016-2018) prescribing of 16.0% (95% CI, 13.0%-19.1%) (P < 0.001) remained higher than pre-publication. Among older Americans with dementia, antipsychotic prescriptions increased after the publication of CW recommendations and held steady in the subsequent post-publication period. Stronger interventions, such as electronic clinical decision support tools and financial incentives, are needed to curb low-value antipsychotic prescribing for this vulnerable population.

The International Classification of Diseases, 11th Revision (ICD-11), developed by the World Health Organization, represents a transformative update to global health data classification systems. Building on the foundation of ICD-10, it introduces innovative features such as multilingual coding, advanced interoperability, postcoordination, and improved specificity, enabling better alignment with modern healthcare and digital information systems. This commentary explores the adoption pathways for ICD-11 in France and the United States, 2 countries with complex healthcare infrastructures and distinct implementation strategies. France's phased roadmap, led by the National Health Information Agency, prioritizes system readiness, workforce training, and pilot testing to ensure smooth integration with hospital information systems. In contrast, the United States, guided by the National Committee on Vital and Health Statistics, focuses on regulatory alignment, funding models, and system modifications to support a seamless transition. The manuscript underscores the critical role of academic research in refining ICD-11's applications, assessing its impact on healthcare quality, and optimizing tools for implementation. Drawing lessons from early adopters globally, we advocate for a coordinated, resource-driven approach to achieve full ICD-11 adoption within 5 years. This transition is poised to enhance health data accuracy, support clinical research, and improve population health outcomes worldwide.

This study examines healthcare disparities affecting children from Spanish-speaking households in the United States, focusing on the relationship between primary language spoken at home and access to care, utilization of health services, and quality of care. Using data from the 2021 National Survey of Children's Health, we analyzed responses from English- and Spanish-speaking families to understand potential language-driven gaps in healthcare. The findings reveal that children in Spanish-speaking households are more likely to lack insurance, lack a usual source of care, and to forgo needed medical attention compared with their English-speaking peers. These children also use fewer health services, particularly specialty and school-based care. Parents in Spanish-speaking households report lower-quality interactions with healthcare providers, citing insufficient time spent with their child, inadequate listening, limited shared decision-making, and a lack of cultural sensitivity. Furthermore, these findings could not be explained by group-level differences in demographics, geographic distribution, or financial condition. Our results underscore the urgent need for targeted interventions and policies to bridge language barriers, improve provider communication, and enhance health equity for families with limited English proficiency. By addressing these challenges, the healthcare system can work toward providing more equitable care for Hispanic and Spanish-speaking children and their families.

This secret shopper study compares the wait times for scheduling a first-time primary-care appointment among adults enrolled in Medicaid Managed Care who speak English, Spanish, or Mandarin in the Los Angeles, Houston, and New York Metropolitan Statistical Areas. Primary-care practices in Medicaid Managed Care Organization directories were randomized by language. The objective of the secret shoppers was to schedule first-time primary-care appointments, either in person or via telehealth. We found that the average wait times for Spanish and Mandarin speakers were greater than for English speakers by 3.73 and 14 days in Los Angeles and 7.29 and 2.55 days in Houston, respectively. The average wait time among Spanish and Mandarin speakers was 2.22 and 1.76 days less compared with English speakers in New York. We discuss the importance of policies and provide recommendations to address disparities in health access and use among adults with limited English proficiency.

Pregnant and lactating women (PLW) have historically been excluded from vaccine research, creating inequities in vaccine access and uptake for PLW. US federal research policies create the framework for inclusion of diverse populations, including PLW, in research. We conducted a policy analysis and interviews (n = 29) with experts in vaccine research for PLW to characterize the existing policy landscape and to identify policy strategies to promote inclusion of PLW in vaccine trials. We integrated policy analysis and interview results to inform 5 policy recommendations. Current federal policy does not require or incentivize the inclusion of PLW in vaccine trials. The Food and Drug Administration (FDA) guidance on inclusion of PLW in vaccine and other clinical research is nonbinding and lacks clarity. Extant policies do not adequately allay liability concerns among vaccine developers. To address these concerns, we recommend that US Congress pass legislation authorizing the FDA to require inclusion of PLW in vaccine research; incentivize sponsors to complete timely vaccine studies in PLW; create a national no-fault compensation program for clinical research participants, including PLW; remove pregnancy from the "vulnerable population" designation in FDA human subjects regulations; and clarify existing federal regulations pertaining to clinical research with PLW.

Rates of opioid use disorder (OUD) have increased in older adults (age ≥ 50). Medications for OUD (MOUD) treat OUD effectively; however, limited data exist on whether older adults with OUD are provided MOUD. Using 2016-2020 claims data from Medicare beneficiaries with a new episode of OUD, we calculated rates of MOUD initiation (first dispensing within 14 days of index event), engagement (dispensing of a second MOUD within 34 days of initiation), and retention (receiving MOUD consistently over 180 days). Among beneficiaries with qualifying index events (N = 40 336), 17%, 38%, and 45% were ages 20-49, 50-64, and ≥ 65, respectively. Five hundred and three beneficiaries with a qualifying index event (1.3%) initiated MOUD, 461 (1.1%) reached engagement, and 309 (0.8%) were retained. Multivariable logistic regressions showed older age was associated with reduced MOUD initiation (compared with those aged 20-49, adjusted odds ratios [aORs] were 0.79 [95% CI, 0.64-0.98] and 0.36 [95% CI, 0.25-0.51] for ages 50-64 and ≥65, respectively). Reduced MOUD initiation was associated with female sex (aOR = 0.74; 95% CI, 0.61-0.89) and increasing comorbidity score (aOR = 0.76 per 1-point increase; 95% CI, 0.72-0.80). These results suggest that in addition to general efforts to increase uptake of MOUD, age-specific strategies are needed.

Although apps are widely available and have several advantages as a tool to support alcohol reduction and recovery, little is known about how individuals are using them. In 2024, we conducted an exploratory sequential mixed-methods study that coupled in-depth interviews with 22 app users and a nationally representative survey of 2002 adults. We explored experiences with and perceptions of alcohol reduction apps. Approximately 6% of US adults in the sample reported using alcohol reduction apps, and for most, it was the only support to address problematic drinking. In interviews, some users viewed apps as an alternative to traditional services and a way to independently address alcohol use; however, apps were seen as disconnected from care even by those who also used other supports. App users accessed a variety of features, with the most common being motivational content, tracking alcohol consumption, and educational content. Findings suggest that there are opportunities to not only introduce apps to individuals receiving healthcare services or participating in mutual support groups, but to reference and embed them in those settings. New approaches to regulation and reimbursement may support adoption as well as integration into healthcare services.