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
The cost of cancer treatment is higher for breast cancer than any other cancer diagnosis, leaving women with metastatic breast cancer (MBC) vulnerable to challenges given the extended length of cancer treatment, including financial, physical, and psychological burdens.
Objective
The purpose of this study was to examine the lived experiences of women diagnosed with MBC in the realm of financial concerns and unmet support needs specific to their cancer treatment.
Methods
This qualitative, phenomenological study included individual interviews that were audio-recorded and transcribed verbatim. Applied thematic analysis was completed using Atlas.ti. Interrater reliability using Cohen’s kappa was established at 0.80. Participants were recruited from a National Cancer Institute–designated cancer center in the United States.
Results
Sixteen participants were interviewed. A majority were White, non-Hispanic, married, unemployed, and had obtained at least a bachelor’s degree level of education. Nearly 19% of participants reported a gross household income of below $50,000. The mean age of participants was 55.6 years. Two major themes were identified, with each having three corresponding subthemes, including: 1) financial toxicities (cost of cancer treatments and medications, limitations of health insurance, and effect on employment); and 2) unmet support needs (managing usual responsibilities, emotional support, community and organizational support).
Discussion
The results highlight the financial and psychosocial needs of women with MBC. Treatment costs take a huge financial toll on patients and their families, including insured women with higher household incomes. Participants expressed a desire for specific MBC resources and support. Background
Chronic pain is a major cause of distress and disability, and biomarkers may aid in the assessment and treatment of it. Urine metabolites may be valuable bioindicators that can provide biological insight regarding chronic pain.
Objectives
To investigate the relationship between a multimarker composite measure of metabolites and patient-reported outcomes scores in adults with chronic pain, using data from a pragmatic clinical trial with a sequential, multiple-assignment randomized trial design.
Methods
Self-reported measures and urine samples from 169 active-duty service members with chronic pain were collected. Urine was analyzed using a preestablished panel of metabolites, including four previously identified biomarkers of pain: kynurenic acid, pyroglutamic acid, ethylmalonic acid, and methylmalonate. Multivariable linear regression models—adjusted for participant characteristics such as age and sex—were used to cross-sectionally examine the relationship between 11 patient-reported outcomes (fatigue, sleep-related impairment, anxiety, depression, anger, pain catastrophizing, physical function, pain interference, satisfaction with participation with social roles, pain intensity, and pain impact score) and the four urine metabolites both individually and as a composite (urine metabolite pain indicator, or UMPI). Given the study’s small sample size and exploratory nature, a significance threshold of p ≤ .10 was used for all analyses.
Results
The UMPI showed statistically significant associations with five self-reported measures (fatigue, anxiety, depression, physical functioning, and pain impact score); adjusted Pearson correlations ranged from .18 to .25. Individual metabolite analyses supported these findings, with all relationships between individual metabolites and self-reported measures showing positive associations. Kynurenic acid and ethylmalonic acid showed the strongest associations, each having statistically significant relationships with four individual self-reported measures, while pyroglutamic acid had statistically significant relationships with three self-reported measures and methylmalonate with none. The UMPI demonstrated feasible reliability.
Discussion
Our finding of associations between the UMPI and components of the self-reported measures supports the development of the UMPI and these four urine metabolites as biomarkers for chronic pain outcomes. Further research is planned and will be essential for establishing mechanistic insight and guiding biomarker development within the context of pain management. Background
The wear and tear from chronic stress exposure has been linked to premature aging through allostatic load; however, it is unclear how chronic stress exposure affects physical functioning and physical activity in older adults.
Objectives
The study aims were to examine the behavioral and functional adaptation to chronic stress in older adults and its mediational pathways.
Methods
Data from the Health and Retirement Study 2016 and 2020 (N = 3075, mean age 66 years) were analyzed. Chronic and perceived stress exposure was quantified using Troxel’s Chronic Stressors Scale and Cohen’s Perceived Stress Scale. Physical activity was quantified using self-reported questionnaires, including light, moderate, and vigorous physical activity. Physical functioning was operated as a latent construct with four perceived physical limitations (i.e., difficulty in movement, hand strength, shortness of breath, and balance). The cross-sectional data were analyzed using latent regression analysis. The longitudinal data were analyzed using serial mediation based on MacKinnon’s bias-corrected bootstrap confidence intervals.
Results
Cross-sectionally, psychological stress, as a latent construct indicated by stress exposure and stress perception, explained more variances in perceived physical limitation than physical activity. Longitudinally, perceived stress and physical activity mediated the relationship between chronic stress exposure and perceived physical limitation with significant indirect effects. Furthermore, perceived physical limitation suppressed the effect of chronic stress exposure on physical activity levels. The effects of mediation and suppression remained significant after the adjustment for age, gender, years of education, race, number of comorbidities, working status, and marital status.
Discussion
The promotion of physical activity and physical functioning in older adults might not achieve the optimal outcome if the program design overlooks the target population’s chronic stress process and functional limitations. 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
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
Despite known links between oral health and dementia and the growing understanding of the role of the human microbiome in health, few studies have explored the relationship between the oral microbiome and cognition. Additionally, there is a notable absence of research on how the oral microbiome is associated with cognitive function in Black adult caregivers of cancer patients despite their elevated risk for both oral disease and cognitive impairment.
Objectives
This study aimed to characterize the oral microbiome of Black caregivers of people living with cancer and explore the association of the oral microbiome with cognitive performance.
Methods
Thirty-one self-identified Black or African American caregivers of cancer patients in the greater metropolitan Atlanta area participated in the study. They provided oral microbiome samples. Cognitive performance was assessed using the Montreal Cognitive Assessment (MoCA), depressive symptoms with the Center for Epidemiological Studies-Depression Scale, and individual race-related stress with the Index of Race-Related Stress–Brief. Salivary microbiome diversity was analyzed using alpha and beta diversity metrics, and taxa associated with cognition were identified through differential abundance testing, adjusting for potential confounders.
Results
The mean age of participants was 54.8 years. MoCA scores ranged from 18 to 30, with a mean of 25. Participants were categorized into normal cognition (MoCA ≥ 26, n = 12) and low cognition (MoCA Background
There is a dearth of research inclusive of African American adults living with obstructive sleep apnea (OSA) despite differences in symptom presentations compared to non-Hispanic White patient populations. Less is known regarding the potential effect of comorbidities, including hypertension, on commonly reported symptoms, such as fatigue, and their association with inflammatory biomarkers.
Objective
This longitudinal pilot study aimed to characterize fatigue symptom presentations among African American adults newly diagnosed with OSA and discern peripheral blood analytes linked to symptoms while accounting for co-occurring hypertension.
Methods
African American adults newly diagnosed with OSA with and without co-occurring hypertension were approached by study staff and recruited following their diagnostic visit with sleep medicine clinicians at two health systems and followed over 6 months after commencing continuous positive airway pressure treatment. Patient-Reported Outcomes Measurement Information System Fatigue surveys and plasma were collected every 3 months from 29 participants. Mixed-effects models examined changes in fatigue symptom presentations over time while accounting for plasma-based analytes and hypertension status.
Results
Despite higher fatigue symptom severity upon diagnosis, participants with co-occurring hypertension reported greater improvements in fatigue scores after commencing continuous positive airway pressure treatment for up to 6 months than those without hypertension. Inverse correlations were observed between fatigue scores, C-reactive protein, matrix metalloproteinase-8, and osteoprotegerin analyte levels among participants with/without hypertension. Across all participants, changes in interleukin-6 were associated with changes in fatigue scores in the first 3 months after diagnosis.
Discussion
Findings indicate that hypertension is linked to increased fatigue upon diagnosis of OSA in this sample of African American adults. Fatigue in persons with hypertension improved after treatment in this sample. These hypothesis-generating findings can inform future interventional studies aimed at improving fatigue among persons with OSA while leveraging markers linked to fatigue symptom severity as potential objective markers of improvements. Further research on the role of inflammatory markers, such as IL-6, on fatigue symptom presentations is warranted in persons with OSA. Background
The complex work of public health nurses (PHNs) specifically related to mental health assessment, intervention, and outcomes makes it difficult to quantify and evaluate the improvement in client outcomes attributable to their interventions.
Objectives
We examined heterogeneity across parents of infants served by PHNs receiving different interventions, compared the ability of traditional propensity scoring methods versus energy-balancing weight (EBW) techniques to adjust for the complex and stark differences in baseline characteristics among those receiving different interventions, and evaluated the causal effects of the quantity and variety of PHN interventions on client health and social outcomes.
Methods
This retrospective study of 4,109 clients used existing Omaha System data generated during the routine documentation of PHN home visit data. We estimated the effects of intervention by computing and comparing weighted averages of the outcomes within the different treatment groups using two weighting methods: (a) inverse probability of treatment (propensity score) weighting and (b) EBWs.
Results
Clients served by PHNs differed in baseline characteristics with clients with more signs/symptoms. Both weighting methods reduced heterogeneity in the sample. EBWs were more effective than inverse probability of treatment weighting in adjusting for multifaceted confounding and resulted in close balance of 105 baseline characteristics. Weighting the sample changed outcome patterns, especially when using EBWs. Clients who received more PHN interventions and a wider variety of them had improved knowledge, behavior, and status outcomes with no plateau over time, whereas the unweighted sample showed plateaus in outcomes over the course of home-visiting services.
Discussion
Causal analysis of PHN-generated data demonstrated PHN intervention effectiveness for clients with mental health signs/symptoms. EBWs are a promising tool for evaluating the true causal effect of PHN home-visiting interventions. Background
Preterm birth affects 10% of all births annually in the United States. Outcomes of people born preterm are challenging to predict because of multiple influences, including gestational age, birth weight, and social and environmental contexts, that contribute to an individual’s growth and developmental trajectory. The influence of toxic stress is underrepresented in the literature assessing preterm birth outcomes.
Objectives
The current analyses use the eco-bio-developmental model of poverty and preterm birth as a framework to model the pathways among toxic stress, preterm birth, and neurodevelopmental outcomes. Poverty and toxic stress were hypothesized to increase the risk for impaired neurodevelopmental and academic outcomes—both directly and indirectly.
Methods
The analytic sample of 55,873 children aged 6–17 years was derived from the National Survey of Children’s Health 2020–2021. Structural equation models with combined measurement and path models for each dependent variable were constructed using latent toxic stress variables. The structural path equations included direct paths from the latent measure of prenatal toxic stress, preterm birth status, and the latent measure of childhood toxic stress to the neurodevelopmental outcome, as well as an indirect, mediated path from prenatal toxic stress through preterm birth status to the outcome.
Results
Across models, higher levels of prenatal toxic stress were significantly associated with preterm birth and lower birth weight ranges. Preterm low birth weight status was associated with a greater likelihood of neurodevelopmental impairment, repeating a grade, and special education plans. The predicted probabilities of neurodevelopmental impairment, repeating grades, and special education plans are significantly higher with above-average levels of exposure to prenatal and childhood toxic stress.
Discussion
There is a need for prospective studies that assess predictors and outcomes of preterm birth that are stratified by gestational age and consider the timing, chronicity, and influence of toxic stress and environmental exposures. There is an imperative for public health programs and policies designed to support families, caregivers, and children to address the individual and structural social determinants of health that contribute to toxic stress, thereby increasing preterm birth rates and negatively affecting the outcomes of children born preterm. Background
Women veterans have a high prevalence of traditional and nontraditional risks for cardiovascular disease (CVD) including obesity and posttraumatic stress disorder. Experts from the U.S. Department of Veterans Affairs have called for actions to improve the cardiovascular health of this population. One approach is to assess women veterans’ barriers to care-seeking for CVD prevention, to inform future intervention research.
Objective
The objective of this study was to describe women veterans’ barriers to care-seeking for CVD prevention, guided by the theory of care-seeking behavior and concept awareness.
Methods
Using a cross-sectional, descriptive design, a national sample of 245 women veterans participated in an online survey about barriers to care-seeking. Participants provided narrative responses to open-ended items, endorsements to closed-ended items, and rankings of their top five barriers. Researchers conducted poststratification weighting of numerical data to reflect the women veteran population.
Results
Narrative responses described unaffordable and inaccessible services, feeling harassed or not respected in healthcare settings, and lack of awareness of risks for CVD. Frequently endorsed barriers were unaffordable and inaccessible services. Frequently ranked barriers were feeling not respected in healthcare settings and clinicians not recommending CVD prevention.
Discussion
Findings support concepts in theory of care-seeking behavior and concept awareness. Understanding women veterans’ barriers to care-seeking for CVD prevention can inform clinicians and researchers as they address these barriers. Background
People with chronic obstructive pulmonary disease (COPD) occasionally develop acute exacerbation of COPD—a potentially fatal condition. Psychological distress was associated with acute exacerbation of COPD. However, the evidence on the effect of psychological distress on acute exacerbation of COPD remains unclear.
Objective
The aim of this study was to explore the influence of psychological distress on acute exacerbation of COPD and its consequences.
Methods
The current review was conducted in accordance with Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines using three databases (PubMed, CINAHL, and PsyINFO) that were searched to identify relevant articles. Pooled risk ratios and 95% confidential interval were calculated from the included studies’ data with random-effect methods to estimate the effect of psychological distress on acute exacerbation of COPD and its consequences.
Results
Nineteen articles were included in the review. Most revealed that psychological distress was significantly associated with increased risk of acute exacerbation of COPD and its consequences. The meta-analyses showed that psychological distress increased risk of acute exacerbation of COPD, COPD-related hospitalization, and death.
Conclusion
Psychological distress had negative effects on acute exacerbation of COPD and its consequences. The results of the meta-analyses show that persons with COPD and psychological distress had a greater risk of acute exacerbation of COPD, hospitalization, and death. Background
Readmissions following hospitalization for common surgical procedures are prevalent among older adults and are disproportionally experienced by Hispanic patients. One potential explanation for these disparities is that Hispanic patients may receive care in hospitals with lower-quality nursing care.
Objectives
The objective of this study was to evaluate the relationship between the hospital-level work environment of nurses and hospital readmissions among older Hispanic patients.
Methods
Using linked data sources from 2014 to 2016, we conducted a cross-sectional analysis of 522 hospitals and 732,035 general, orthopedic, and vascular surgical patients (80,978 Hispanic patients and 651,057 non-Hispanic White patients) in four states. Multivariable logistic regression models were employed to determine the relationship between the work environment and older Hispanic patient readmissions at multiple time periods (7, 30, and 90 days).
Results
In final adjusted models that included an interaction between work environment and ethnicity, an increase in the quality of the work environment resulted in a decrease in the odds of readmission that was greater for older Hispanic surgical patients at all time periods. Specifically, an increase in three of the five work environment subscales (Nurse Participation in Hospital Affairs, Nursing Foundations for Quality of Care, and Staffing and Resource Adequacy) was associated with a reduction in the odds of readmission that was greater for Hispanic patients than their non-Hispanic White counterparts.
Discussion
System-level investments in the work environment may reduce Hispanic patient readmission disparities. This study’s findings may be used to inform the development of targeted interventions to prevent hospital readmissions for Hispanic patients. 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. 
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