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Background Differential access to healthcare is associated with disparities in maternal outcomes. Telehealth is one approach for improving access to maternal services. However, little is known regarding how health systems leverage telehealth to close the access gap. Objective This study examines how health systems have approached decisions about using telehealth for maternal services before and during the COVID-19 public health emergency and what factors were considered. Methods We conducted semi-structured interviews with 15 health system leaders between July and October 2021 and June and August 2022. We used a rapid analysis followed by a content analysis approach. Results Five health systems did not provide maternal telehealth services before the PHE due to a lack of reimbursement. Two health systems provided limited services as research endeavors, and one had integrated telehealth into routine maternity care. During the PHE, all transitioned to telehealth, with the primary consideration being patient and staff safety. At the time of the interview, key considerations shifted to patient access, patient preferences, patient complexity, return on investment, and staff burnout. However, several barriers impacted telehealth use, including coverage of portable devices and connectivity. These issues were reported to be common among underinsured, low-income, and rural patients. Health systems with particularly advanced capabilities worked on approaches to fill access gaps for these patients. Conclusion Some health systems prioritized telehealth to improve access to high-quality maternal services for patients at the highest risk of adverse outcomes. However, policy and patient-level barriers to equitable implementation of these services persist.

Background Physician migration is a problem of international concern, and studies have attempted to determine whether macroeconomic and developmental factors predict nationwide decreases in physician migration. Like the nutritional and epidemiologic transitions, there is an understood “migration transition” as well, with migration levels for highly educated individuals decreasing as national income increases. This approach can provide insights into the macroeconomic determinants and predictors of medical emigration. Methods We drew annual data from 2000 to 2021 on new physician migration (i.e., flows) to the Organization for Economic Co-operation and Development (OECD), converted into logged flows, and charted against logged origin country real GDP per capita (2017 international dollars, purchasing power parity). We fit an ordinary least squares (OLS) model and gravity model, testing the relationship between the year-lagged natural log of real GDP per capita and the natural log of total annual emigration flows separately in ordinary least squares and gravity model analyses. Results Descriptive results show overall a U-shaped relationship between origin GDP and emigration rates; however, descriptive trends disaggregated by region of the world show that as origin GDP rises, migration outflows generally decline in Central Asia and East Asia & the Pacific; generally increase in Europe; are bimodal in the Middle East and North Africa and Latin America; and remain the same in sub-Saharan Africa. Gravity models demonstrate, across all regions, no quadratic relationship and a negative linear relationship. However, within-region models showed a negative relationship with origin GDP per capita in East Asia and the Pacific, Central and South Asia, and North America and no statistical effect elsewhere, although with increasing lags, there was a positive relationship in sub-Saharan Africa and the European Union (EU) and a positive relationship nearing statistical significance in non-EU European countries. Conclusion The relationship between national income and physician emigration is complex and heavily dependent on geography, indicating that different mechanisms might be driving physician migration trends in different regions.

Policy Points Policymakers should invest in programs to support rural health systems, with a more targeted focus on spatial accessibility and racial and ethnic equity, not only total supply or nearest facility measures. Health plan network adequacy standards should address spatial access to nearest and second nearest hospital care and incorporate equity standards for Black and Latinx rural communities. Black and Latinx rural residents contend with inequities in spatial access to hospital care, which arise from fundamental structural inequities in spatial allocation of economic opportunity in rural communities of color. Long‐term policy solutions including reparations are needed to address these underlying processes. Context The growing rate of rural hospital closures elicits concerns about declining access to hospital‐based care. Our research objectives were as follows: 1) characterize the change in rural hospital supply in the US South between 2007 and 2018, accounting for health system closures, mergers, and conversions; 2) quantify spatial accessibility (in 2018) for populations most at risk for adverse outcomes following hospital closure—Black and Latinx rural communities; and 3) use multilevel modeling to examine relationships between structural factors and disparities in spatial access to care. Methods To calculate spatial access, we estimated the network travel distance and time between the census tract–level population‐weighted centroids to the nearest and second nearest operating hospital in the years 2007 and 2018. Thereafter, to describe the demographic and health system characteristics of places in relation to spatial accessibility to hospital‐based care in 2018, we estimated three‐level (tract, county, state‐level) generalized linear models. Findings We found that 72 (10%) rural counties in the South had ≥1 hospital closure between 2007 and 2018, and nearly half of closure counties (33) lost their last remaining hospital to closure. Net of closures, mergers, and conversions meant hospital supply declined from 783 to 653. Overall, 49.1% of rural tracts experienced worsened spatial access to their nearest hospital, whereas smaller proportions experienced improved (32.4%) or unchanged (18.5%) access between 2007 and 2018. Tracts located within closure counties had longer travel times to the nearest acute care hospital compared with tracts in nonclosure counties. Moreover, rural tracts within Southern states with more concentrated commercial health insurance markets had shorter travel times to access the second nearest hospital. Conclusions Rural places affected by rural hospital closures have greater travel burdens for acute care. Across the rural South, racial/ethnic inequities in spatial access to acute care are most pronounced when travel times to the second nearest open acute care hospital are accounted for.

Rapid opioid reduction or discontinuation among high-dose long-term opioid therapy patients (HD-LTOT) is associated with increased risk of heroin use, overdose, opioid use disorder, and mental health crises. We examined the association of residential segregation and healthcare access with rapid opioid reduction or discontinuation among HD-LTOT patients, and examined effect measure modification of individual-level characteristics.OBJECTIVERapid opioid reduction or discontinuation among high-dose long-term opioid therapy patients (HD-LTOT) is associated with increased risk of heroin use, overdose, opioid use disorder, and mental health crises. We examined the association of residential segregation and healthcare access with rapid opioid reduction or discontinuation among HD-LTOT patients, and examined effect measure modification of individual-level characteristics.Using 2006-2018 North Carolina private insurance claims data, we conducted a retrospective cohort study of 18-64 years old HD-LTOT patients (≥ 90 morphine milligram equivalents for 81/90 consecutive days), with one-year follow-up. The outcome was rapid opioid reduction or discontinuation (versus maintenance, increase, or gradual reduction/discontinuation). Individual-level characteristics included age, sex, and clinical diagnoses (post-traumatic stress disorder (PTSD), depression, anxiety, and substance use disorder). Neighborhood-level characteristics included healthcare access (measured as geographic distance to healthcare facilities) and residential segregation (operationalized using the Index of Concentration at the Extremes). We conducted bivariate linear regression to estimate one-year risk differences (RDs) and 95% confidence intervals (CIs).METHODSUsing 2006-2018 North Carolina private insurance claims data, we conducted a retrospective cohort study of 18-64 years old HD-LTOT patients (≥ 90 morphine milligram equivalents for 81/90 consecutive days), with one-year follow-up. The outcome was rapid opioid reduction or discontinuation (versus maintenance, increase, or gradual reduction/discontinuation). Individual-level characteristics included age, sex, and clinical diagnoses (post-traumatic stress disorder (PTSD), depression, anxiety, and substance use disorder). Neighborhood-level characteristics included healthcare access (measured as geographic distance to healthcare facilities) and residential segregation (operationalized using the Index of Concentration at the Extremes). We conducted bivariate linear regression to estimate one-year risk differences (RDs) and 95% confidence intervals (CIs).Of 13,375 HD-LTOT patients, 48.6% experienced rapid opioid reduction or discontinuation during one-year follow-up. Female patients and those diagnosed with PTSD who live in areas of least racial and economic privilege have higher risks of rapid opioid reduction or discontinuation compared to those living in areas with the most racial and economic privilege.RESULTSOf 13,375 HD-LTOT patients, 48.6% experienced rapid opioid reduction or discontinuation during one-year follow-up. Female patients and those diagnosed with PTSD who live in areas of least racial and economic privilege have higher risks of rapid opioid reduction or discontinuation compared to those living in areas with the most racial and economic privilege.Healthcare providers need to address potential biases towards patients living in underserved and marginalized communities and intersectionality with mental health stigma by prioritizing training and education in delivering unbiased care during opioid tapering.CONCLUSIONHealthcare providers need to address potential biases towards patients living in underserved and marginalized communities and intersectionality with mental health stigma by prioritizing training and education in delivering unbiased care during opioid tapering.

Black immigrants are a growing proportion of the Black population in the USA, and despite the fact that they now comprise nearly a quarter of Black urban residents, few studies address the relationships between racial segregation and maternal and birth outcomes among Black immigrants. In this study of birth outcomes among US-born and immigrant Black mothers in New York City between 2010 and 2014, we applied multilevel models, assessing the association between segregation (measured through a novel kernel-based measure of local segregation) and adverse birth outcomes (preterm birth (PTB) and low birth weight (LBW; < 2500 g)) among African-born, Caribbean-born, and US-born Black mothers. We found that African-born and Caribbean/Latin American–born Black mothers had a significantly lower incidence of PTB compared with US-born Black mothers (7.0 and 10.1, respectively, compared with 11.2 for US-born mothers). We also found disparities in the incidence of infant LBW by nativity, with the highest incidence among infants born to US-born mothers (10.9), compared with African-born (6.9) and Caribbean-born mothers (9.0). After adjusting for maternal (maternal age; higher rates of reported drug use and smoking) and contextual characteristics (neighborhood SES; green space access), we found that maternal residence in an area with high Black segregation increases the likelihood of PTB and LBW among US-born and Caribbean-born Black mothers. In contrast, the association between segregation and birth outcomes was insignificant for African-born mothers. Associations between tract-level socioeconomic disadvantage and birth outcomes also varied across groups, with only US-born Black mothers showing the expected positive association with risk of PTB and LBW.

Between 1990 and 2020, 334 rural hospitals closed in the United States, and since 2011 hospital closures have outnumbered new hospital openings. This scoping review evaluates peer-reviewed studies published since 1990 with a focus on rural hospital closures, synthesizing studies across six themes: 1) health care policy environment, 2) precursors to rural hospital closures, 3) economic impacts, 4) effects of rural hospital closures on access to care, 5) health and community impacts, and 6) definitions of rural hospitals and communities. In the 1990s, rural hospitals that closed were smaller, while rural hospitals that closed in the 2010s tended to have more beds. Many studies of the health impacts of rural hospital closures yielded null findings. However, these studies differed in their definitions of \"rural hospital closure.\" Given the accelerated rate of hospital closures, more attention should be paid to hospitals that serve rural communities of color and low-income communities.

PurposeMetastatic breast cancer (MBC) patients often face substantial financial burden due to prolonged and expensive therapy. However, in-depth experiences of financial burden among MBC patients are not well understood.MethodsQualitative interviews were conducted to describe the experiences of financial burden for MBC patients, focusing on the drivers of financial burden, their experience using their health insurance, accessing financial assistance, and any resulting cost-coping behaviors. Interviews were transcribed and qualitatively analyzed using a descriptive phenomenological approach to thematic analysis.ResultsA total of n = 11 MBC patients or caregiver representatives participated in the study. MBC patients were on average 50.2 years of age (range: 28–65) and 72.7% non-Hispanic White. MBC patients were diagnosed as metastatic an average of 3.1 years (range: 1–9) before participating in the study. Qualitative analysis resulted in four themes including (1) causes of financial burden, (2) financial assistance mechanisms, (3) health insurance and financial burden, and (4) cost-coping behaviors. Both medical and non-medical costs drove financial burden among participants. All participants reported challenges navigating their health insurance and applying for financial assistance. Regardless of gaining access to assistance, financial burden persisted for nearly all patients and resulted in cost-coping behaviors.ConclusionOur findings suggest that current systems for health insurance and financial assistance are complex and difficult to meet patient needs. Even when MBC patients accessed assistance, excess financial burden persisted necessitating use of financial coping-behaviors such as altering medication use, maintaining employment, and taking on debt.

Abstract Background In addition to greater delays in cancer screening and greater financial hardship, rural-dwelling cancer patients experience greater costs associated with accessing cancer care, including higher cumulative travel costs. This study aimed to identify and synthesize peer-reviewed research on the cumulative and overlapping costs associated with care access and utilization. Methods A scoping review was conducted to identify relevant studies published after 1995 by searching 5 electronic databases: PubMed, Scopus, Cumulative Index of Nursing and Allied Health Literature (CINAHL), PsycInfo, and Healthcare Administration. Eligibility was determined using the PEO (Population, Exposure, and Outcomes) method, with clearly defined populations (cancer patients), exposures (financial hardship, toxicity, or distress; travel-related burdens), and outcomes (treatment access, treatment outcomes, health-related quality of life, and survival/mortality). Study characteristics, methods, and findings were extracted and summarized. Results Database searches yielded 6439 results, of which 3366 were unique citations. Of those, 141 were eligible for full-text review, and 98 studies at the intersection of cancer-related travel burdens and financial hardship were included. Five themes emerged as we extracted from the full texts of the included articles: 1) Cancer treatment choices, 2) Receipt of guideline-concordant care, 3) Cancer treatment outcomes, 4) Health-related quality of life, and 5) Propensity to participate in clinical trials. Conclusions This scoping review identifies and summarizes available research at the intersection of cancer care-related travel burdens and financial hardship. This review will inform the development of future interventions aimed at reducing the negative effects of cancer-care related costs on patient outcomes and quality of life.

Climate-related extreme weather events disrupt health-care systems and exacerbate health disparities, particularly affecting individuals diagnosed with cancer. This study explores the intersection of climate vulnerability and cancer burden in North Carolina (NC). Using county-level data from the US Climate Vulnerability Index (CVI) and the NC Department of Health and Human Services, we analyzed cancer incidence and mortality rates from 2017 to 2021. Our findings reveal a robust correlation between CVI percentiles and cancer mortality (r = 0.72). Counties with high area deprivation like Scotland, Robeson, and Halifax had the highest CVI percentiles of 0.68, 0.67, and 0.66, with respective cancer mortality rates of 193, 195, and 196 per 100 000 person-years. Correlations between CVI and cancer incidence were modest (r = 0.22). These results underscore the need for targeted public health interventions to mitigate climate-related health disparities. Future work could focus on exploring specific climate hazards and cancer outcomes to enhance preparedness and resilience in cancer care.