United States

INTRODUCTION: Receiving over $250 million in state government support since 2022, crisis pregnancy centers (CPCs) have expanded following the Supreme Court’s overturn of Roe v. Wade, particularly in states with policies limiting abortion services. As a result, patients may have an increasingly difficult time distinguishing between CPCs and legitimate abortion providers, which may represent a significant barrier to care especially for patients looking for out-of-state abortion services. The National Abortion Federation (NAF) offers membership for providers whose abortion services meet their standardized requirements. However, it is unclear whether these providers sufficiently guarantee their services for patients unfamiliar with the NAF or if these providers clearly list their NAF membership on their website.The purpose of this study was to perform a website content analysis on NAF member facility websites to evaluate how each facility demonstrates the legitimacy of its services. 

METHODS: First, a list of 438 NAF member names and websites was compiled from the NAF’s “Find a Provider” page. Hospitals and Planned Parenthoods were excluded from this study, in addition to facilities that were closed, did not have a website, or did not offer abortion services. The 290 remaining NAF member websites were independently reviewed by two coders, with a third coder to resolve any discrepancies. All websites were evaluated for the following variables: mentions of the right to choose, inclusions of the NAF logo or certification, warnings about CPCs and misinformation, and where each member advertised their abortion services on their website (homepage or subpage). Websites were also assessed for explicit statements guaranteeing the clinic’s legitimacy. State abortion policies were categorized as being protective, neutral, restrictive, and most-restrictive (banned) based on classifications by the Guttmacher Institute. Protective and restrictive states that have a shared border with at least one most-restrictive state were labeled Protective-Bordering-Most-Restrictive (PBMR) and Restrictive-Bordering-Most-Restrictive (RBMR) respectively. Finally, a series of logistic regression analyses were performed to compare the aforementioned variables between different state classifications. 

RESULTS: Through our analysis, we found that 91% of providers mentioned the right to choose, although only 62% had it on their homepage. 96% of clinics that offer procedural abortions advertised it on their homepage, compared to 81% for medical abortions and 84% for abortion pills by mail. 63% of clinics in protective states advertised their NAF membership compared to 79% of clinics in restrictive states (OR = 0.5, p &lt; 0.01). Meanwhile, clinics in protective states were more likely than those in restrictive states to warn about CPCs (OR = 2.7, p &lt; 0.01). This same disparity in CPC warnings was also observed when comparing clinics in PBMR and RBMR states (OR = 3.1, p &lt; 0.01). While no significant differences were found nationally, clinics in PBMR states were considerably more likely to provide legitimacy statements than clinics in RBMR states (OR = 3.3, p &lt; 0.05). 

DISCUSSION: In conclusion, our study suggests that most NAF members clearly advertise their abortion services, especially for procedural abortions. Most NAF members also clearly mention the right-to-choose and their NAF membership. However, relatively few facilities provide guarantees of their legitimacy or warnings about CPCs, especially in RBMR states. Overall, our study suggests patients in restrictive states that are unfamiliar with the NAF may have a harder time identifying legitimate clinics than patients in protective states. Furthermore, patients in restrictive states may also be less informed about CPCs. Because of our results, moving forward we will be interested in assessing how abortion providers without NAF affiliations are able to demonstrate the legitimacy of their services.


AMA Research Challenge 2024 

Demonstrating Legitimacy: Assessing how Abortion Providers Guarantee Their Services

INTRODUCTION: Receiving over $250 million in state government support since 2022, crisis pregnancy centers (CPCs) have expanded following the Supreme Court’s overturn of Roe v. Wade, particularly in states with policies limiting abortion services. As a result, patients may have an increasingly difficult time distinguishing between CPCs and legitimate abortion providers, which may represent a significant barrier to care especially for patients looking for out-of-state abortion services. The National Abortion Federation (NAF) offers membership for providers whose abortion services meet their standardized requirements. However, it is unclear whether these providers sufficiently guarantee their services for patients unfamiliar with the NAF or if these providers clearly list their NAF membership on their website.The purpose of this study was to perform a website content analysis on NAF member facility websites to evaluate how each facility demonstrates the legitimacy of its services. 

METHODS: First, a list of 438 NAF member names and websites was compiled from the NAF’s “Find a Provider” page. Hospitals and Planned Parenthoods were excluded from this study, in addition to facilities that were closed, did not have a website, or did not offer abortion services. The 290 remaining NAF member websites were independently reviewed by two coders, with a third coder to resolve any discrepancies. All websites were evaluated for the following variables: mentions of the right to choose, inclusions of the NAF logo or certification, warnings about CPCs and misinformation, and where each member advertised their abortion services on their website (homepage or subpage). Websites were also assessed for explicit statements guaranteeing the clinic’s legitimacy. State abortion policies were categorized as being protective, neutral, restrictive, and most-restrictive (banned) based on classifications by the Guttmacher Institute. Protective and restrictive states that have a shared border with at least one most-restrictive state were labeled Protective-Bordering-Most-Restrictive (PBMR) and Restrictive-Bordering-Most-Restrictive (RBMR) respectively. Finally, a series of logistic regression analyses were performed to compare the aforementioned variables between different state classifications. 

RESULTS: Through our analysis, we found that 91% of providers mentioned the right to choose, although only 62% had it on their homepage. 96% of clinics that offer procedural abortions advertised it on their homepage, compared to 81% for medical abortions and 84% for abortion pills by mail. 63% of clinics in protective states advertised their NAF membership compared to 79% of clinics in restrictive states (OR = 0.5, p < 0.01). Meanwhile, clinics in protective states were more likely than those in restrictive states to warn about CPCs (OR = 2.7, p < 0.01). This same disparity in CPC warnings was also observed when comparing clinics in PBMR and RBMR states (OR = 3.1, p < 0.01). While no significant differences were found nationally, clinics in PBMR states were considerably more likely to provide legitimacy statements than clinics in RBMR states (OR = 3.3, p < 0.05). 

DISCUSSION: In conclusion, our study suggests that most NAF members clearly advertise their abortion services, especially for procedural abortions. Most NAF members also clearly mention the right-to-choose and their NAF membership. However, relatively few facilities provide guarantees of their legitimacy or warnings about CPCs, especially in RBMR states. Overall, our study suggests patients in restrictive states that are unfamiliar with the NAF may have a harder time identifying legitimate clinics than patients in protective states. Furthermore, patients in restrictive states may also be less informed about CPCs. Because of our results, moving forward we will be interested in assessing how abortion providers without NAF affiliations are able to demonstrate the legitimacy of their services.

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Black maternal mortality rates in the United States continue to present a dire public health crisis, marked by stark disparities between Black and non-Black birthing outcomes. In this paper, we will investigate the persistent disparities in maternal health outcomes among Black women in the United States, with a specific focus on California, particularly within Los Angeles County. Drawing upon data obtained from the California Department of Public Health, we will highlight the challenges faced by Black mothers in accessing timely and adequate prenatal care, leading to a disproportionately high maternal mortality rate compared to their White counterparts. Through an analysis and critique of two key policies aimed at addressing maternal health disparities in California - the California Momnibus Act (SB 65) and the Perinatal Equity Initiative (PEI), we will identify the strengths and limitations inherent in these legislative efforts. Finally, the paper will propose policy recommendations aimed at enhancing access to quality prenatal care, addressing socioeconomic barriers, fostering provider cultural competency, and strengthening community outreach and diversity initiatives. By advocating for a holistic approach that tackles systemic racism and promotes patient-centered care, we seek to contribute to the ongoing conversations and efforts to address the Black maternal mortality crisis in California and the larger United States and improve prenatal health equity for Black families.

Ensuring Prenatal Health Equity: Policy Review and Recommendations for Black Families in California

Group Yoga Sessions for Improving Breastfeeding: A Scoping Review 
Nyoko Brown, Denise Willoughby, Shahrzad Bazargan-Hejazi, PhD, Bita Amani, Ph.D., M.H.S, 
Miranda Lam
Charles R. Drew University of Medicine and Science – College of Medicine
Telephone: (661) 427-3679
Email: nyokobrown@cdrewu.edu
Abstract Title: Group Yoga Sessions for Improving Breastfeeding: A Scoping Review
Introduction: Breastmilk is crucial to the growth and development of healthy children. 
Investigating interventions that may improve lactation is important for the overall improvement 
of maternal and infant health outcomes. This scoping review aims to show how relaxation and 
physical health benefits from yoga can support breastfeeding efforts.
Background: Prenatal yoga may be used as an effective approach for increased lactation due to 
preliminary studies that have found beneficial effects on mental health such as depression and 
anxiety. 
Methods: An electronic search in PubMed was performed using the keywords: “breastfeeding 
AND stress factors”, “breastfeeding”, “yoga AND lactation”, “benefits of yoga”, “lactation”, 
“breastfeeding interventions.” Two investigators independently evaluated the titles and abstracts 
in the first stage and the full text in a second stage review. Articles not published between 2019 
and 2024, articles that did not examine relationships between yoga and breastfeeding and/or 
breastfeeding and mood disorders were excluded. 11 studies were selected and included. Data 
was independently extracted.
Results: Increased stress showed an association with a decrease in exclusive breastfeeding. 
Participants who exclusively breastfed, as opposed to supplementing with formula, showed 
lower risk of postpartum PTSD. Higher anxiety and depression scores were associated with 
lower maternal oxytocin levels during breastfeeding. Mindfulness, a large facet of yoga, was 
significantly and negatively associated with the discontinuation of breastfeeding. When looking 
at the effect of counseling with stress management on postpartum anxiety and distress, the 
intervention group showed significantly lower mean score of state anxiety. Participants who 
received the intervention also showed a significantly higher mean score of breastfeeding selfefficacy and milk output and volume. The most effective interventions were community-based 
interventions. 
Conclusions: Significant associations between breastfeeding practices and maternal distress 
suggest that a consistent mindfulness practice, such as yoga, may improve breastfeeding 
adequacy. Pre-natal yoga was found to lower stress, depression, and anxiety. Postpartum yoga 
was found to result in higher oxytocin and prolactin levels in primipara women. Group yoga
sessions also have a propensity towards creating community amongst participants, and 
community-based interventions were found to be the most successful in increasing early 
initiation breastfeeding.
References:
Asiodu, I. V., Waters, C. M., Dailey, D. E., & Lyndon, A. (2017). Infant Feeding DecisionMaking and the Influences of Social Support Persons Among First-Time African American 
Mothers. Matern Child Health J, 21(4), 863-872. https://doi.org/10.1007/s10995-016-2167-
x 
Astutik, R. Y., Pramono, N., Susanto, H., & Kartasurya, M. I. (2024). The effect of yoga training 
on postpartum prolactin and oxytocin levels in primipara women. J Med Life, 17(2), 210-216. 
https://doi.org/10.25122/jml-2023-0390 
“Breastfeeding.” World Health Organization, World Health Organization, www.who.int/healthtopics/breastfeeding#tab=tab_1. Accessed 14 July 2024. 
Chen, J., Lai, X., Zhou, L., Retnakaran, R., Wen, S. W., Krewski, D., Huang, L., Li, M., & Xie, 
R. H. (2022). Association between exclusive breastfeeding and postpartum post-traumatic 
stress disorder. Int Breastfeed J, 17(1), 78. https://doi.org/10.1186/s13006-022-00519-z 
Chinn, J. J., Martin, I. K., & Redmond, N. (2021). Health Equity Among Black Women in the 
United States. J Womens Health (Larchmt), 30(2), 212-219. 
https://doi.org/10.1089/jwh.2020.8868 
Corrigan, L., Moran, P., McGrath, N., Eustace-Cook, J., & Daly, D. (2022). The characteristics 
and effectiveness of pregnancy yoga interventions: a systematic review and metaanalysis. BMC Pregnancy Childbirth, 22(1), 250. https://doi.org/10.1186/s12884-022-
04474-9 
Dhaurali, S., Dugat, V., Whittler, T., Shrestha, S., Kiani, M., Ruiz, M. G., Ali, I., Enge, C., & 
Amutah-Onukagha, N. (2023). Investigating Maternal Stress, Depression, and 
Breastfeeding: A Pregnancy Risk Assessment Monitoring System (2016-2019) Analysis. 
Healthcare (Basel), 11(12). https://doi.org/10.3390/healthcare11121691 
Hulsbosch, L. P., Nyklicek, I., Boekhorst, M. G., Potharst, E. S., & Pop, V. J. (2023). 
Breastfeeding continuation is associated with trait mindfulness but not with trajectories of 
postpartum depressive symptoms. Midwifery, 124, 103770. 
https://doi.org/10.1016/j.midw.2023.103770 
Hulsbosch, L. P., Potharst, E. S., Boekhorst, M. G., Nyklicek, I., & Pop, V. J. (2021). 
Breastfeeding intention and trait mindfulness during pregnancy. Midwifery, 101, 103064. 
https://doi.org/10.1016/j.midw.2021.103064 
Isiguzo, C., Mendez, D. D., Demirci, J. R., Youk, A., Mendez, G., Davis, E. M., & Documet, P. 
(2023). Stress, social support, and racial differences: Dominant drivers of exclusive 
breastfeeding. Matern Child Nutr, 19(2), e13459. https://doi.org/10.1111/mcn.13459 
Krol, K. M., & Grossmann, T. (2018). Psychological effects of breastfeeding on children and 
mothers. Bundesgesundheitsblatt Gesundheitsforschung Gesundheitsschutz, 61(8), 977-
985. https://doi.org/10.1007/s00103-018-2769-0 (Psychologische Effekte des Stillens auf 
Kinder und Mutter.) 
Lin, I. H., Huang, C. Y., Chou, S. H., & Shih, C. L. (2022). Efficacy of Prenatal Yoga in the 
Treatment of Depression and Anxiety during Pregnancy: A Systematic Review and MetaAnalysis. Int J Environ Res Public Health, 19(9). https://doi.org/10.3390/ijerph19095368 
Nagel, E. M., Howland, M. A., Pando, C., Stang, J., Mason, S. M., Fields, D. A., & Demerath, E. 
W. (2022). Maternal Psychological Distress and Lactation and Breastfeeding Outcomes: 
a Narrative Review. Clin Ther, 44(2), 215-227. 
https://doi.org/10.1016/j.clinthera.2021.11.007 
Noushad, S., Ahmed, S., Ansari, B., Mustafa, U. H., Saleem, Y., & Hazrat, H. (2021). 
Physiological biomarkers of chronic stress: A systematic review. Int J Health Sci 
(Qassim), 15(5), 46-59. https://www.ncbi.nlm.nih.gov/pubmed/34548863 
https://www.ncbi.nlm.nih.gov/pmc/articles/PMC8434839/pdf/IJHS-15-46.pdf 
Oddy, W. H. (2017). Breastfeeding, Childhood Asthma, and Allergic Disease. Ann Nutr Metab,
70 Suppl 2, 26-36. https://doi.org/10.1159/000457920 
Onyewuenyi, T. L., Peterman, K., Zaritsky, E., Ritterman Weintraub, M. L., Pettway, B. L., 
Quesenberry, C. P., Nance, N., Surmava, A. M., & Avalos, L. A. (2023). Neighborhood 
Disadvantage, Race and Ethnicity, and Postpartum Depression. JAMA Netw Open, 
6(11), e2342398. https://doi.org/10.1001/jamanetworkopen.2023.42398 
Oztora, S., Arslan, A., Caylan, A., & Dagdeviren, H. N. (2019). Postpartum depression and 
affecting factors in primary care. Niger J Clin Pract, 22(1), 85-91. 
https://doi.org/10.4103/njcp.njcp_193_17 
Pezley, L., Cares, K., Duffecy, J., Koenig, M. D., Maki, P., Odoms-Young, A., Clark 
Withington, M. H., Lima Oliveira, M., Loiacono, B., Prough, J., Tussing-Humphreys, L., 
& Buscemi, J. (2022). Efficacy of behavioral interventions to improve maternal mental 
health and breastfeeding outcomes: a systematic review. Int Breastfeed J, 17(1), 67. 
https://doi.org/10.1186/s13006-022-00501-9 
Rasaei, L., Tehrani, T. D., & Heidari, Z. (2023). Relationships between spiritual health and 
perceived stress with breastfeeding adequacy in mothers with infants aged 1-6 months. J 
Educ Health Promot, 12, 69. https://doi.org/10.4103/jehp.jehp_234_22 
Shamsdanesh, S., Nourizadeh, R., Hakimi, S., Ranjbar, F., & Mehrabi, E. (2023). The effect of 
counseling with stress management approach on postpartum anxiety and distress and 
breastfeeding self-efficacy during COVID-19 pandemic: a ramdomized controlled trial. 
BMC Pregnancy Childbirth, 23(1), 26. https://doi.org/10.1186/s12884-023-05356-4 
Simsek Sahin, E., & Can Gurkan, O. (2023). The Effect of Prenatal Yoga on Pregnancy-Related 
Symptoms: A Pilot Quasi-Experimental Study. Complement Med Res, 30(3), 195-203. 
https://doi.org/10.1159/000528801 (Die Wirkung von Schwangerschaftsyoga auf 
schwangerschaftsbedingte Symptome: eine quasi-experimentelle Pilotstudie.) 
Tavallali, F., Vahedparast, H., Hajinezhad, F., & Bagherzadeh, R. (2023). Effect of Foot 
Reflexology and Benson Relaxation on Pain, Breastfeeding and Weight of Neonates of 
Women Undergoing a Cesarean Section. Arch Iran Med, 26(7), 381-388. 
https://doi.org/10.34172/aim.2023.58 
Thul, T. A., Corwin, E. J., Carlson, N. S., Brennan, P. A., & Young, L. J. (2020). Oxytocin and 
postpartum depression: A systematic review. Psychoneuroendocrinology, 120, 104793. 
https://doi.org/10.1016/j.psyneuen.2020.104793 
Truchet, S., & Honvo-Houeto, E. (2017). Physiology of milk secretion. Best Pract Res Clin 
Endocrinol Metab, 31(4), 367-384. https://doi.org/10.1016/j.beem.2017.10.008 
Villar-Alises, O., Martinez-Miranda, P., & Martinez-Calderon, J. (2023). Prenatal Yoga-Based 
Interventions May Improve Mental Health during Pregnancy: An Overview of Systematic 
Reviews with Meta-Analysis. Int J Environ Res Public Health, 20(2). 
https://doi.org/10.3390/ijerph20021556

Group Yoga Sessions for Improving Breastfeeding: A Scoping Review

Introduction: 
The Dobbs decision (June 24, 2022), which overturned Roe v. Wade, introduced significant changes to abortion laws across the United States. It remains unclear how this policy shift has impacted reproductive health care among different racial groups. This study aims to evaluate these effects, hypothesizing that the Dobbs decision would lead to increased preventive measures and decreased abortion procedures due to heightened awareness and potential legal restrictions.
Methods: 
Utilizing data from the TriNetX global health research network, which aggregates electronic health records (EHR) from over 120 clinical sites, patient cohorts were categorized based on ICD, CPT, or medication codes, focusing on periods before and after the Dobbs decision (June 30, 2020, to January 1, 2022, and December 31, 2022, to June 30, 2024, with a 6-month washout period). The groupings included prevention (contraceptive medication, emergency contraceptives, encounters for general counseling and advice on contraception, and insertion of IUD), screening (PAP tests), complications (preterm labor, spontaneous abortion, pregnancy with abortive outcome), and overall abortion procedures. Statistical analyses, including propensity matching for demographic features and access to healthcare services, were performed to identify significant trends and disparities within TriNetX.
Results: 
TriNetX identified 9,124,941 patients after propensity matching 35 ± 13.1 age of which 60.1% white, 16.8% black, 13.1% Hispanic, and 4.3% Asian. Adverse pregnancy outcomes slightly increased post-Dobbs (OR: 1.05, 95% CI: 1.04-1.06, p-value < 0.01). There was an increase in abortion procedures post-Dobbs (OR: 1.05, 95% CI: 1.03-1.08, p-value < 0.01), but disaggregated data into individual racial groups found unique reproductive health behavioral patterns. Abortions were non-significant for the white and Asian populations (p = .24, and .80, respectively). The only racial group to have increased preventive measures post-Dobbs were Asians (OR: 1.1, 95% CI: 1.07-1.12, p-value < 0.01). Screenings statistically significantly decreased for all racial groups (OR: 0.78, 95% CI: 1.77-1.78, p-value < 0.01) post-Dobbs.
Conclusion:
Adverse pregnancy outcomes rose for all racial groups except African Americans, and Asians were the only group with a significant increase in preventive measures. Odds ratio for these findings are slightly above 1.0, which indicates that the observed changes may not be clinically significant. This analysis underscores the importance of continuing research and dialogue on the potential impacts of the Dobbs decision on women's health and racial disparities.

Impact of the Dobbs Decision on Abortion Rates, Preventive Measures, and Pregnancy Outcomes Across Racial Groups: A Large Public Health Database Analysis

Background:
The use of soft tissue filler injections in aesthetic and medical procedures has seen a significant growth in popularity in recent years, with a reported 317% increase from 2000 to 2017 globally. With this increase also is a rise in associated periorbital complications, ranging from temporary skin discoloration to permanent vision loss. While many complications have been reported to date, there is a lack of comprehensive data on the geographic locations where these complications are being reported from. Our objective was to perform a review of filler complications reported globally to identify trends.

Methods:
Several databases were used to identify articles globally published on periorbital complications from filler injections. The following terms were used to search across PubMed and Scopus: “blindness filler complications”, “ocular filler complications”, “filler complications vision loss”, and “filler complications”. Articles were identified from 2000 to 2024. Screening was performed to determine relevance of articles for this study via the title and abstract of each study. Articles were then analyzed for authors, country of study, injection site, filler material, and type of filler complication. Non-English studies were translated using Google Translate to extract pertinent information for our research.

Results:
A total of 2463 cases were identified of filler complications, with hyaluronic acid fillers being 79.7% of cases, calcium hydroxylapatite being 3.3% of cases, and polymethylmethacrylate being 1% of cases. A total of 526 cases reported on complications associated with vision loss or other ocular conditions, with most cases reported from China. Overall, the three countries with the highest number of filler complications reported were China (144 cases), the United States (130 cases), and Malaysia (91 cases).

Conclusion:
The findings of this study illuminate global trends in filler complications and underscores the prevalence of serious complications associated with vision loss. Our data suggests that there may be significant underreporting in the literature of complications associated with filler injections and emphasizes a need to further investigate whether lower reports of complications in certain countries are a result of lower incidence of complications or from underreporting. As we delve deeper into global trends concerning periorbital complications, we advocate for increased reporting of cases through publication or other complication-focused databases. This will enhance our understanding and inform better and safer practices in the field.


Mapping Reports of Periorbital Filler Complications Globally

Background 
Street Medicine Phoenix, a medical outreach program advocating for unhoused individuals, is the first United States based program utilizing the USee global vision refraction kit (USee) to enhance vision care. Costing $5 per use, the USee can refract patients and provide eyewear within 15 minutes, avoiding delays associated with shipment times and patients lost to follow-up. Other more widely used forms of refraction, such as the portable PlenOptika autorefractor (PlenOptika), are more expensive and can only provide a prescription, which is usually paired with another modality of creating and distributing glasses. This two-step process leads to the delivery of glasses weeks after initial refraction, which is not optimal for a population in constant flux. We report on the USee’s effectiveness in improving visual acuity compared to the PlenOptika.

Methods
This participation-based study first assessed patients' uncorrected refraction. Patients were then refracted using PlenOptika and USee devices. Applying the manual refraction prescription, USee corrective lenses were inserted into frames, and corrected visual acuity was rerecorded. 2x2 Factorial ANOVA, spilt plot design was used to compare before and after refraction visual acuity. Bland Altman assessed the difference in spheres obtained from both devices. In addition, patients whose visual acuity improved to at least 20/40 monocularly were recorded (the legal minimum for driving in Arizona).

Results
180 eyes in 90 patients with mean age of 51.50 ± 12.66 years underwent refraction utilizing each device. Primary outcome was change in visual acuity with use of the USee device. Visual acuity in LogMar before refraction was 0.713 (0.624 - 0.801) and visual acuity in LogMar after refraction was 0.322 (0.269 - 0.374), p< 0.001. Bland Altman showed minimal outliers. 76% of patients were refracted to within 20/40. Median VA improved from 20/80 to 20/30, a 4 Snellen line improvement. Before and after percentage of patients with the ability to drive was 35.9% and 79.2%, respectively.

Conclusion
The USee provides refractive measurements similar to that from the PlenOptika and provides measurable improvement in visual acuity among patients, making it a viable, more expedient option for use in under-resourced populations. By increasing this population's ability to drive, the intervention enables more individual freedom and job opportunities. Refraction with instantaneous eyewear distribution significantly improves outcomes for transient populations in need of refractive improvement.

Novel Refractive Technology to Improve Vision in an Urban Homeless Population

The growing popularity of social media platforms like TikTok has facilitated increased discourse on refractive eye surgeries (RESs), such as Laser-Assisted In-Situ Keratomileusis (LASIK), among healthcare providers and patients. This study aims to evaluate the quality, reliability, and user engagement of RES-related content on TikTok, with a focus on comparing content created by ophthalmology-related providers (ORPs) and non-ORPs (patients). A total of 124 videos were analyzed based on understandability, reliability, and accountability, using the PEMAT-A/V, CRAAP, and JAMA Benchmark criteria, respectively. Videos were selected through predefined search terms and hashtags, and statistical analysis was performed using independent two-tailed t-tests. Results showed that ORP videos garnered significantly more views than non-ORP videos (p = 0.027), although user engagement metrics did not differ substantially between the two groups. ORP videos scored higher in both actionability (PEMAT, p = 0.024) and overall quality (CRAAP and JAMA, p = 0.001). Despite these strengths, ORP content frequently omitted explanations of technical jargon and potential negative outcomes such as chronic dry eye or financial conflicts of interest. In contrast, non-ORP content was more transparent about costs and negative experiences but scored lower in reliability and accuracy. This study underscores the need for enhanced regulation and standardized criteria to ensure the dissemination of accurate and transparent RES-related information on social media. Future research should focus on addressing existing gaps in accountability, reliability, and educational quality in TikTok's medical content.

Ophthalmology and TikTok: A Study on the Portrayal of Refractive Eye Surgery Procedures on Social Media

Abstract
Aims: To examine if healthcare access modifies the association between age at diagnosis of diabetes and the prevalence of retinopathy. 
Methods: BRFSS 2020 survey data was obtained from 12,198 adults. Participants with missing information in the variables “retinopathy” (N = 569) and "insurance-cost barrier” (N = 75) were excluded. The final sample included 11,556 participants. Age at diagnosis of diabetes was the main exposure and retinopathy was the main outcome. We tested if the main association was different among the insurance-cost barrier variable. Binary logistic regression models were used to calculate odds ratios (OR) and 95% confidence intervals (CI). 
Results: The odds of retinopathy decreased by 26% in patients 46-64 years-of-age (OR 0.74; 95 CI 0.58-0.95) and 57% in those 65+ (OR 0.43; 95 CI 0.28-0.64). The odds decreased by 39% if female (OR 0.61; 95 CI 0.49- 0.76). An increase in odds by 83% (OR 1.83; 95 CI 1.07-3.14) occurred in other non-Hispanics, 50% (OR 1.50; 95 CI 1.14-1.98) in black non-Hispanics and 60% (OR 1.60; 95 CI 1.10-2.31) in Hispanics. There was no evidence that age at diagnosis of diabetes and presence of retinopathy varied by insurance cost (p>0.05).
Conclusion: Health professionals may utilize these results to advocate for early disease intervention.



The Association Between Age at Diagnosis of Diabetes and Development of Diabetic Retinopathy and Assessment of Healthcare Access as an Effect Modifier

Introduction: Socioeconomic status (SES) has been associated with differences in patient-reported outcome scores and complication rates across orthopedics. Area Deprivation Index (ADI) is a validated measure of an area’s socioeconomic status based on 17 different census variables. ADI has been associated with complications following total knee arthroplasty and may be associated with clinical outcomes and complications following rotator cuff repair.  The purpose of this study is to investigate the impact socioeconomic factors have on outcomes following primary arthroscopic rotator cuff repair.   
  
Methods: Patients who underwent primary rotator cuff repair at a single institution from 3/11/2014-9/29/2022 were identified. Patient demographics, pre- and post-operative Visual Analog Scale (VAS) scores, Patient-Reported Outcomes Measurement Information System (PROMIS) scores—specifically PROMIS Upper Extremity (UE) function, PROMIS Pain Interference (PI), and PROMIS Depression (D)—range of motion, complications, and subsequent ipsilateral shoulder surgeries were collected. ADI was collected from an online mapping database using each patient’s home address. Patients were split into ADI terciles, with ADI 1 representing the least disadvantaged group and ADI 3 representing the most disadvantaged group. ANOVA, T-test and chi-square analyses were conducted for continuous variables and categorical variables, respectively.   
  
Results: In total 467 patients underwent rotator cuff repair and had complete demographic data and postoperative follow-up through one year. There was a significant difference in race, with 78.2% of patients identifying as black in ADI 3 versus 18.1% in ADI 1 (P<0.001). Pre-operative PROMIS-PI, VAS, forward flexion (FF), and abduction (ABD) were significantly worse in ADI 3 compared to ADI 1 (P=0.001, P<0.001, P=0.012, P=0.023). Patients in ADI 3 had significantly worse PROMIS-UE score, PROMIS-PI, VAS, FF and ABD at 1-year postoperatively compared to ADI 1 (P=0.016, P<0.001, P<0.001, P<0.001, P=0.034). 9.8% of patients in ADI 1, 32.6% in ADI 2 and 57.6% in ADI 3 experienced a postoperative complication (P=0.54). Retears were more common in ADI 3 (62%) compared to ADI 2 (28%) and ADI 1 (10%) (P=0.47). There was a greater but not significant number of reoperations performed for patients in ADI 3 (63.4%) compared to ADI 2 (31.7%) and ADI 1 (4.9%) (P=0.22).   
  
Conclusion: Lower socioeconomic status measured by ADI is associated with worse preoperative and 1-year postoperative pain, shoulder function and range of motion following rotator cuff repair, but no difference in reoperation or complications.

Lower Socioeconomic Status is Correlated with Worse Outcomes After Arthroscopic Rotator Cuff Repair

Background: Downward trends in inflation-adjusted Medicare reimbursement to hand surgeons have been reported, likely to offset increasing costs associated with the aging population. Less is known regarding Medicaid reimbursement to physicians, but generally Medicaid reimbursement rates are thought to be lower than Medicare. Given the ability for each state to set rates for a given procedure, discrepancies exist in Medicaid reimbursements between states. This study compared Medicaid and Medicare rates for common hand surgery procedures to determine national and state differences in reimbursement.

Methods: Medicare rates for 26 commonly billed hand procedures, based on prior reimbursement studies, were obtained from the Center for Medicare & Medicaid fee schedule database. Corresponding work RVUs for each procedure were also collected here. Medicaid rates were found at states’ Medicaid online fee schedule website. State rates were compared to corresponding Medicare rates using mean values and dollar differences. These dollar differences were also divided by work RVUs. Each states’ reimbursement values were also adjusted using the Medicare Wage Index to account for regional wage differences. Variability between states and between procedures was analyzed using percentages as a function of Medicare reimbursement and by coefficient of variation values. Coefficient of variation values were calculated by dividing the standard deviation by the mean for each procedure, and values further from zero indicate higher variability within a dataset.

Results: Medicaid reimbursement was lower than Medicare for 22 of the 26 procedures included in the analysis. On average, Medicaid rates were 18% lower than Medicare, a difference that increased to 29% when accounting for wage differences. Average dollar differences by procedure ranged from $205 less to $110 more for Medicaid. Dollar differences per RVU ranged from $38 less to $48 more for Medicaid. State Medicaid rates ranged from 30% to 158% of Medicare. Variability was low among Medicare procedures, with a coefficient of variation of 0.06. Medicaid variability between states ranged from 0.26-0.57 for unadjusted data and 0.36-0.67 for wage-adjusted data.

Conclusion: On average, Medicaid reimbursement is substantially lower than Medicare for common hand surgery procedures. There was wide variability in Medicaid rates, both between states and procedures. Adjustment for wage differences increased the percent difference and variability, suggesting a lack of objective metrics used to set Medicaid prices. Hand surgeons should be aware of variable prices between states and advocate for policy that fairly reimburses them while promoting better access to care for this vulnerable population.

Medicaid Reimbursement to Hand Surgeons is 18% Less than Medicare and Highly Variable, Ranging from 30-158% of Average Medicare Rates by State

Objective: This study aims to compare HPV vaccination rates, knowledge, and treatment decision-making between a predominantly white and Asian population. 

Study Design: Cross-sectional survey-based study

Setting: Otolaryngology clinics at a tertiary academic center. 

Methods: Descriptive statistics were utilized to assess rates of vaccination, HPV knowledge, and HPV vaccine treatment decision-making, with significance testing utilized to compare between the Asian American and non-Asians of the sample. Multivariable logistic regression was utilized to understand factors associated with vaccination. 

Results: In this cohort (n=237), vaccination among adults (n=69, 29.4%) and their children (n=62, 51.2%) was low. Knowledge that the HPV vaccine is not recommended only for women was lower among the Asian cohort (66.7% vs. 79.9%; p=0.023), while knowledge that full protection requires more than one dose was higher among Asians (76.3% vs. 54.2%; p=0.001). Asians were more likely to report that when they did not receive HPV vaccination it was due to not being knowledgeable about the vaccine (52.6% vs. 17.4%; p<0.001). Among those with non-vaccinated children, Asians were more likely to report that their children were not vaccinated because they were not knowledgeable about the vaccine (40.0% vs. 32.4%; p=0.045), friends and family discouraged vaccination (12.0% vs. 0.0% p=0.038). In a multivariable regression of factors associated with HPV vaccination, only increased age showed significant association with likelihood (OR: 0.92 [95%CI: 0.89-0.94]).

Conclusion: This study generates hypotheses regarding reasons why Asian-Americans may be less likely to receive HPV vaccination, and it demonstrates a potential opportunity to improve HPV vaccination in this cohort.

Next from AMA Research Challenge 2024

Ensuring Prenatal Health Equity: Policy Review and Recommendations for Black Families in California

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