United States

The subject of maternal mortality and maternal health has been a topic of discussion for centuries but has recently gained traction in population health initiatives within the late 20th century. The United States has one of the highest rates of maternal mortality of all high-income countries, however, studies show that four in five maternal deaths in this country are preventable. Pregnant people of color and low-income mothers are overrepresented within these statistics, a detail that has been prevalent for decades. High maternal death rates are being perpetrated by the
growing nationwide shortage of the maternity workforce, following the rising number of restrictions to reproductive health care in many states. There have been many attempts to try and lower these numbers, but many of them have failed to gain much traction.
To alleviate these numbers and address the overall issue, I propose applying an add-on payment through Medicaid mandating that providers give comprehensive education to their pregnant patients. This would incentivize maternity workforce personnel to put aside time to properly inform families of potential complications and resources that are readily available to them. Another recommendation would be that states reinforce that all maternity care providers receive anti-bias and anti-racism training as part of a curriculum. Quality of care from providers
would increase drastically by enhanced patient trust in the medical workforce and any implicit biases potentially impeding on effective care from providers would be minimized. Innovative demonstration projects overseen by the Center for Medicare and Medicaid could also be implemented in select states to establish these recommendations. Pushing forth these initiatives would help many families and relieve the stress of maternal mortality within our healthcare system.

AMA Research Challenge 2024 

Addressing the Crisis of Maternal Mortality in the United States

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Purpose
Telehealth has become a mainstay of modern healthcare, post-COVID-19 pandemic era. Telehealth has increased access to healthcare providers across various regions, potentially reducing access disparities. Currently no studies exist evaluating the impact of telehealth on access equity in thoracic surgery. This paper aims to assess if telehealth increases access to thoracic oncologic surgery in disadvantaged communities.

Methods
A retrospective single institution review of thoracic surgery patients with an oncologic indication from March 2018 to November 2022 was conducted. Patients were stratified into office or telehealth groups based on the type of their first preoperative consultation visit. Patients being assessed for esophageal malignancy or mediastinal staging alone were excluded. Demographic data included age, sex, location by county, and state. Primary outcomes were median Area Deprivation Index (ADI) for state deciles and national percentiles for in-office and telehealth patients. The Area Deprivation Index (ADI) is a ranking of socioeconomic disadvantaged neighborhoods at the state or national level with consideration for factors such as income, education, employment status, and housing. Mann-Whitney U tests were used to analyze the ADI difference between groups. 

Results
759 patients met inclusion criteria, including 376 in office and 383 telemedicine. All telemedicine visits were audio only and conducted over the phone. There were no demographic differences between groups based on age (p=0.3) or sex (p=0.9). There was a total of 62 unique counties represented among all patients in this cohort. The majority of patients resided in Oregon (628/759, 82.74%) and Washington (108/759, 14.23%). Median ADI for national percentiles and state deciles can be seen in Table 1. The median ADI of telehealth patients was significantly higher than that of in office patients (34 v. 32, p<0.01). Similar results for telemedicine and in-office patients were found when evaluating Oregon specific ADIs (5 v 6, p<0.01). There was no difference in State ADIs for patients from Washington (p = 0.156).

Conclusions
Overall, patients in the telemedicine group had a higher disadvantaged rating than their in-office counterparts nationally and in Oregon. Telemedicine improves access to thoracic surgeons for patients from socioeconomically disadvantaged neighborhoods, addressing the unequal distribution of physicians and healthcare systems in these areas. Further studies should be conducted to evaluate the role of telehealth in increasing health equity in thoracic surgical cancer care.

Addressing the Inequities in Thoracic Surgery: How Telemedicine is Levelling the Playing Field

Background: The utilization of Nurse Practitioners (NPs) has emerged as a potential solution to address physician shortages, serve underserved areas, and manage high patient volumes in primary care settings. However, the scope of practice (SOP) laws for NPs varies significantly across states. Twenty-eight states and Washington D.C. allow full practice authority; twelve states have reduced practice regulations; and eleven states have restricted practice. This variation in regulatory frameworks, coupled with the cost-effectiveness of NPs compared to physicians, necessitates a comprehensive examination of the impact of NP SOP laws on health outcomes. As the United States faces an impending physician shortage, understanding the relationship between NP SOP and healthcare quality becomes crucial for informed policy decisions and effective workforce planning in primary care.

Methods: A legal epidemiology study was conducted to analyze the impact of Nurse Practitioner (NP) scope of practice (SOP) laws across five U.S. states: Oregon, Washington, California, Texas, and Illinois, representing a spectrum of regulatory frameworks. The study began by defining the research question on how NP SOP laws affect primary care outcomes. A comprehensive legal mapping process followed, involving the collection and coding of relevant laws from state legislatures to identify patterns and variations. Primary care health outcome data, including wait times, provider-to-population ratios, and mortality rates, were collected for each state. The analysis phase compared the coded legal data with health outcomes to assess the impact of different SOP laws.

Results: States with the highest number of NPs (approximately 20,000) tended to have the most restrictive SOP laws, while states with the lowest NP populations (around 2,000) had full SOP laws. States with full SOP demonstrated better primary care physician (PCP) to population ratios, ranging from 89.1 to 101.1 per 100,000 residents. No clear trends emerged regarding mortality rates and NP SOP laws. However, states with restricted SOP had the shortest PCP wait times, while full SOP states had the longest wait times. 

Conclusion: Full SOP for NPs can increase primary care access but does not necessarily improve mortality rates. Larger states face challenges in regulating full SOP NPs, possibly explaining why they have higher restrictions. Traditionally restrictive states like California and Texas are now considering bills to grant full SOP to NPs. This shift suggests a growing recognition of NPs' potential increase primary care access, highlighting the ongoing evolution of healthcare policy as states seek to balance professional regulation with the need for expanded primary care access to overcome the physician shortage.

Addressing the U.S. Physician Shortage: A Legal Epidemiology Analysis of Nurse Practitioner Scope of Practice Laws and Their Impact on Primary Care Access

Background: Timely initiation of antiretroviral therapy (ART) for non-occupational post-exposure prophylaxis (nPEP) is crucial in preventing HIV infection and advancing efforts to end the HIV epidemic (EHE). nPEP must be administered within 72 hours of high-risk exposure, ideally within 24 hours. Pharmacies may play a role in increasing access to nPEP and facilitating referrals for additional care, such as PrEP. Recent legislation permits pharmacist-prescribed nPEP (PDP), though provider attitudes toward this change have not been studied.
Methods: A survey querying physicians and medical trainees (students and residents) was conducted in 2024 during an annual state medical association conference. The survey included 24 questions on nPEP knowledge and attitudes towards pharmacist-prescribed nPEP (PDP). The survey was administered in person using electronic tablets, with voluntary participation incentivized by a monetary reward. Statistical analysis was conducted using SAS (9.4 version) software, with differences in responses between physicians and trainees evaluated. P values <0.05 were considered statistically significant.
Results: Of 89 respondents (56% of attendees), 61 were physicians and 28 were trainees. Notably, 28% of licensed providers indicated that pharmacist-directed prescribing (PDP) should not be allowed in the State of Ohio, while no trainees expressed this same opposition (p=0.001). Trainees were more likely to view pharmacist prescribing as safe and appropriate ((p =0.0135, p=0.013). Urban-based providers were more supportive of pharmacist prescribing than their rural counterparts (p=0.0195).
Conclusion: Trainees showed little opposition to PDP, whereas physicians expressed concerns about safety and appropriateness. Addressing these concerns is essential for integrating pharmacists into the EHE strategy.

Analyzing the Attitudes of Ohio Physicians Regarding Pharmacist-Driven HIV Post-Exposure Prophylaxis​

Background/Objective:
Human papillomavirus (HPV) is the cause of cervical, vaginal, penile, throat, and anal cancer. Refugee, immigrant, and migrant communities experience several barriers to completing vaccinations. Refugee resettlement agencies and immigrant welcome centers are designed to play a pivotal role in ensuring families have the resources and support the transition to life in a new community. This study aims to assess the barriers experienced by these immigrant and refugee welcome centers or resettlement agencies in facilitating access to HPV vaccination for their families.

Methods:
To conduct this study, a survey with a set of survey questions evaluating legal, transportation, affordability, information gaps, and systemic barriers to accessing HPV vaccination was disseminated. After a thorough search, eight agencies were identified and recruited. 

Results:
Out of the eight agencies contacted, three agencies responded to the survey. As responses continue to come in, preliminary results indicate that the centers believe a low percentage of their families are receiving HPV vaccination. Cost of vaccination, scheduling difficulties, physical barriers, and perceptions about HPV were identified as the highly influential factors for the vaccination rates. 

Conclusion:
Responses from the survey indicated that the different efforts by the refugee resettlement agencies and immigrant welcome centers have addressed several barriers to accessing vaccinations. Despite these efforts, the cost of vaccination, scheduling difficulties, physical barriers, and perceptions of HPV continue to influence low vaccination rates. The identified barriers were highly influenced by the agency and the type of resources the agency had available to enable their clients to have access to vaccination. This presents an opportunity for continued collaboration between the Indiana Immunization Coalition, immigrant welcome centers, and refugee resettlement agencies. 


Assessing the Barriers to HPV Vaccination for Immigrant/Refugee Resettlement and Welcome Centers

Background
Texas is home to nearly 7 million people without broadband access, representing a large population unable to utilize telehealth services. Extending internet access thereby promotes health equity. Link Health is a Boston-based digital health program addressing this issue through a satellite program in Houston. Link Health helps disseminate information about federal programs such as the ACP and Lifeline, which connect eligible participants to low-cost broadband internet.

Methods
Link Health enrolls participants in-person and digitally. Ambassadors facilitate in-person enrollments through health centers and community events, discussing eligibility and applications for ACP and Lifeline. A Google Form collects participant’s demographic data. Participants are transferred to the FCC National Verifier site to complete enrollment. Digital sign-ups are completed via Link Health’s webpage or by responding to SMS messages with program information from remote ambassadors. Here, we compare enrollment across Houston and Boston to understand the populations served.

Results
Data collected in or after July 2023 were included. During this time, 800 participants were enrolled (402 in Boston; 398 in Houston). A greater proportion of participants enrolled in person in Boston (56%) than in Houston (47.2%). Proportionally more enrollees in Houston preferred to speak English (70.4%) than Spanish (28.9%) than in Boston, where the language split was more equal: 49.5% preferred English and 40.9% Spanish. A breakdown of language by sign-up method revealed a higher proportion of Spanish speakers enroll in-person rather than digitally: 78.3% of Spanish speakers in Houston and 74.4% in Boston versus 34% of English speakers in Houston and 50.2% in Boston. Racial composition of enrollees was similar across cities but not sign-up method: in Boston, 23.3% of enrollees were Black, 52.2% were Hispanic, and 14.4% were White. In Houston, 28.6% of enrollees were Black, 49.7% were Hispanic, and 13.8% were White. Across both cities in-person enrollees were 37% Black or African American, 68% Hispanic and 33% White. 

Conclusion
The Link Health Digital Equity Program has major implications in closing the digital divide beyond Boston. The disconnected population in Texas can benefit from the continuation of federal programs like the ACP and Lifeline which facilitate access to telehealth services. Maintaining in-person resources is essential to equitably serve these populations, many of whom speak Spanish and are Hispanic.

Assessing the Impact of Pilot Community-based Digital Equity Program in Houston

Abstract Title
Prenatal Exposure to Tetrachloroethylene and Adverse Birth Outcomes: Systematic Review & Meta- Analysis
Background
Tetrachloroethylene (PCE) is a chemical widely used in dry cleaning, metal degreasing, and textile processing. Occupational activities and improper waste management may lead to PCE contamination in indoor air and/or drinking water. Several studies have assessed associations between prenatal exposure to PCE and adverse birth outcomes, but a comprehensive review is needed to establish the strength and quality of these results. The aim of this study was to synthesize evidence and meta-analyze the associations between prenatal exposure to PCE and specific adverse birth outcomes: spontaneous abortions, stillbirths, CNS defects, oral cleft defects, neural tube defects, birthweight, preterm birth, and small-for-gestational-age.
Methods
Search Methods
Six electronic databases were searched to identify relevant studies with no restrictions on date, publication type or geographic location. Reference lists of included studies were also hand searched.
Selection Criteria
Studies were included if they were observational studies that statistically quantified the association between PCE and the adverse birth outcomes of interest. Participants included pregnant women with infants exposed to PCE in the antenatal period. Comparator groups were unexposed. Studies in which effects of PCE were not disaggregated were excluded.
Data Collection and Analysis
Main results and study characteristics were extracted from each relevant study. Critical appraisal was performed using the Newcastle–Ottawa Scale (NOS) for case-control and cohort studies and the Agency for Healthcare Research and Quality (AHRQ) for cross-sectional studies. Risk ratios were calculated for each outcome using David Wilson’s Online Effect Size Calculator. Effect sizes were then pooled using random effects meta-analyses. Subgroup analyses by exposure pathway, country, and study design were also conducted when possible. Sensitivity to risk of bias was also conducted where possible.
Results
Eighteen studies were included. Risk of bias was high in one, moderate in seven, and low in ten studies. Meta-analyses found that prenatal PCE exposure correlated significantly with any adverse birth outcome (RR=1.16, p=0.049, I2=60%) and spontaneous abortions (RR=1.38, p < 0.01, I2=1.7%). While elevated risk ratios were found for PCE exposure and other outcomes (any congenital anomaly, stillbirths, CNS defects, oral cleft defects, neural tube defects, low birthweight, preterm birth, and small-for-gestational- age), they were not significant.
Conclusion

Overall, prenatal exposure to PCE is significantly associated with higher risk of any adverse birth outcome and spontaneous abortions. This highlights the importance of minimizing PCE through policy measures and monitoring of water and air samples. Future research should address limitations in the evidence base and potential biological mechanisms.

Association between Prenatal Exposure to Tetrachloroethylene and Adverse Birth Outcomes: Systematic Review and Meta-Analysis

Background
Previous studies reported a reduction in cardiac catheterization laboratory activations for ST-Elevation Myocardial Infarctions in the US1 and Spain2 during the early COVID-19 pandemic. We analyzed the long-term relationship between regional COVID burden and acute myocardial infarction (AMI) incidence across the US.

Methods
Monthly ACS data was drawn from the de-identified Vizient database of clinical data. Patients diagnosed with AMI (defined by ICD-10 code I.21) were drawn from 20 US hospital systems from January 2019 to June 2023. COVID-19 data were drawn from the de-identified New York Times github database of COVID-19 data. Monthly positive COVID-19 cases were drawn at the state level and then grouped within the West, Midwestern, Northeastern, Mid-Atlantic, and Southern regions. March 1, 2020 was identified as the beginning of the “after COVID” (AC) period and any prior data were identified as the “before COVID” (BC) period (January 2019 to February 2020). Spearman’s ρ assessed the association between statewide COVID-19 cases and AMI diagnoses, and was repeated with a one-month delay applied to AMI diagnoses to account for the potential lag time between COVID-19 burden and corresponding behavioral modifications. A mixed linear model with random intercepts corrected for time as a continuous variable estimated the percent change in STEMI activations in the BC versus adjusted AC (aAC) period (March 2020 to April 2021).

Results
The mean monthly AMI diagnoses was 6581.86 (SD=362.43) in the BC period and 6654.79 (SD=725.76) in the AC period. No states demonstrated a negative association between monthly COVID-19 and AMI diagnoses with all sites (ρ=0.33; 95%CI=0.016-0.59), Colorado (ρ=0.48; 95%CI=0.18-0.7), Massachusetts (ρ=0.4; 95%CI=0.09-0.64), New Hampshire (ρ=0.11; 95%CI=0.1-0.65), and Pennsylvania (ρ=0.46; 95%CI=0.15-0.68) revealing positive associations. With a one-month delay applied to ACS diagnoses, Colorado (ρ=0.53; 95%CI=0.24-0.74), Massachusetts (ρ=0.34; 95%CI=0.02-0.60), and Pennsylvania (ρ=0.37; 95%CI=0.05-0.63) demonstrated positive associations. In the mixed linear model, the percent change of regional and statewide AMI diagnoses in the aAC period was negative in the first three months compared to the BC period, albeit not reaching statistical significance.

Conclusions
No negative association was found between monthly statewide or aggregate COVID-19 burden and AMI diagnoses among, even with a one-month delay applied to AMI diagnoses. Contradicting previous studies, there was no observed reduction in AMI diagnoses across hospital systems after the start of the COVID-19 pandemic. This may reflect psychosocial factors such sedentarism, social distancing, or increased ED visits for chest pain; however, studies with more precise regional data are required to validate these results.

Association between Regional COVID-19 Burden and Acute Myocardial Infarctions in the United States

Background
Nepal has the highest mortality rate from chronic lung diseases globally. The World Bank reports that over 30 percent of Nepalese patients currently use tobacco products. Yet, the smoking epidemic is still under-researched in Nepal. This research seeks to understand the Nepalese peoples’ attitudes towards smoking, in order to develop sustainable, culturally appropriate smoking cessation programs in Nepal.

Methods
Participants were recruited from outpatient multispecialty clinics at the Tribhuvan University Teaching Hospital in July 2023. Participants (n= 250) met eligibility requirements if they were 18+ years of age and had used a tobacco product in the last 15 years. Participation was voluntary and both verbal and written consent was obtained. The 46-question survey was administered verbally using interpreters and answers were entered into data management application Qualtrics. Data analysis was conducted using R statistical analysis software, and results are reported as numbers and proportions. 

Results
Participants included 231 (92.4%) males, 18 (7.2%) females, and one participant who identified with neither (0.4%). Of the participants, 36 were 18-24 years old (14.4%), 82 were 25-39 (32.8%), 64 were 40-54 (25.6%), and 68 were 55-89 (27.2%). Approximately 69% of participants were married, and 17% did not attend any formal schooling. Peer pressure by friends or family (friends smoking by 78%, and family smoking by 21%) was given as a reason for smoking initiation, and curiosity was selected by 48% of participants. The most prevalent reason for delaying smoking initiation was lack of peer pressure (friends do not smoke (66.8%). Continued smoking was attributed to killing time (22.4%), energy and euphoria (21.2%), and dealing with anger and anxiety (18.8%) as the most popular reasons. The large number of male participants supports previous results that men are three times as likely to smoke as women. Social pressures were the most dominant factors that accounted for smoking initiation. Similarly, lack of social pressures resulted in delayed smoking initiation. Friends smoking was not offered as an option for continued smoking. Participants continuation reasoning points to stress and boredom as contributing factors.

Conclusion
The results of our cross-sectional study suggest a potential for public health interventions to reduce social pressure to smoke or introduce measures to replace the habit and decrease stress.

Attitudes Around Smoking Initiation and Cessation in Kathmandu, Nepal

Background: Refugee families (both adults and children) face numerous health inequalities, barriers, and disparities to accessing healthcare services and oftentimes present with complex medical and social needs unfamiliar to healthcare providers. It is therefore critical to analyze these health issues and healthcare requirements amongst this minoritized population. This study examines barriers to care and acculturation among refugee and underserved families with children in Roanoke, Virginia. This study aims to add to needs-assessments to enhance pediatric refugee healthcare models in Roanoke and similar resettlement areas.
Methods: A 10-item questionnaire in 2023 and an 18-item questionnaire in 2024 were administered to attendees at community events for refugee and immigrant children in Roanoke City. The survey included questions about healthcare barriers including language interpretation needs and difficulty scheduling medical appointments as well as acculturation topics, including perceived familial safety and usage of resettlement resource aid. The questionnaires were adapted from screening tools, including the Accountable Health Communities Screening Tool and the Hispanic Community Health Study Acculturation Questionnaire.
Results: 149 respondents completed the questionnaires across both years. 62.9% (2023) and 79.5% (2024) identified Spanish as their preferred language. 13.9% (2023) and 54.1% (2024) found obtaining personal transportation to medical appointments challenging. 65.8% (2024) of families did not use any local resettlement resources and 41.0% (2024) reported significant familial support during these periods. 97.2% (2024) were provided with a language interpreter during clinic and hospital visits, and 91.2% (2024) preferred a human interpreter for translation in these settings.
Conclusion: Personal transportation may not be feasible for families with financial constraints, preventing access to medical care. Familial support systems were shown to positively impact the acculturation process for these families, and there is an opportunity for community outreach to increase awareness of unused local resources to aid in resettlement. Language interpreter use may improve patient ease and understanding during medical visits. Further analysis of healthcare needs within this community emphasizes the importance of advocating for resources that assist in equitable healthcare delivery and acculturation in similar-sized resettlement communities.

Barriers in Access to Medical Care amongst Underserved Minoritized Families in Southwest Virginia

Abstract Title
Black and White Menthol Smokers’ Perceptions of the FDA’s Proposed Ban on Menthol Cigarettes 

Background
Menthol as a characterizing flavor in cigarettes is a critical public health issue due, in large part, to targeted tobacco industry marketing that has led to Black adults disproportionately using a product that is more addictive and harder to quit. Recent estimates indicate that 81% of Black adults who smoke and 34%-51% of adults who smoke in other racial/ethnic minority groups use menthol cigarettes. In April 2022, FDA announced its commitment to advance a product standard banning menthol in cigarettes and prohibiting characterizing flavors other than tobacco in cigars. To-date, no federal menthol cigarette or flavored cigar (MC/FC) product standards (commonly called ‘bans’) have been enacted, despite evidence that these actions could potentially improve public health and promote smoking cessation.

Methods
Study participants were registered workers on Amazon’s Mechanical Turk (MTurk) who opted into the study between July 2023 and January 2024. Eligible participants (n=3,200) completed a survey assessing perceptions and perceived impacts of the FDA’s proposed product standard limiting characterizing flavors in MC/FC. Eligible participants were African American/Black or White adults (> 21 years of age) who had been menthol cigarette smokers for at least one year and were using a computer with a United States IP address.

Results
There was no difference in favor/opposition to the proposed MC/FC ban with 37.2% of Black and 34.5% of White adults who smoke menthol cigarettes stating that they were in favor of the ban (p=0.13). Notably, while overall endorsement of beliefs that menthol cigarettes are more addictive, harmful, and harder to quit than non-menthol cigarettes was low overall, Black participants in this study were more likely than White participants to endorse these beliefs. A greater proportion of Black adults also demonstrated support for the FDA's proposed rationale for the product standard. Both groups were concerned that a MC/FC ban would lead to increased policing and victimization in their community (95.3% overall) and other vulnerable communities (90.9% overall).

Conclusion
Our research has produced several key findings, including identification of factors associated with support of or opposition to the ban, racial differences in perceptions of the proposed ban, determination of specific concerns related to the impact of the ban, and participant intentions for future tobacco use or cessation following the ban. This data will serve to inform the FDA’s policies on menthol flavoring and assist public health researchers in planning for best smoking cessation practices in anticipation of the proposed policy shift.



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