Publications

PURPOSE: Type 2 diabetes is a global pandemic, with 1 in 6 people expected to be diagnosed by 2050. The Diabetes Prevention Program (DPP) is an evidence-based program that has been shown to reduce A1c and bolster health outcomes in people with type 2 diabetes and prediabetes, but implementation has been varied, with lower uptake in rural and economically underserved communities. The study assessed whether there are geographic and socioeconomic disparities in the availability of hospital-supported DPPs in the US.

METHODS: We assessed DPPs in 3204 general medical hospitals. Data on hospital and county characteristics came from the American Hospital Association (AHA) Annual Survey, the Area Health Resource File, and County Health Rankings. We assessed geographic and socioeconomic differences between hospitals with and without DPPs using t-tests and chi-square tests. Rurality was determined based on the 2013 Rural-Urban Continuum Codes (RUCC). We then conducted a multivariable analysis to assess the relationship between geographic location, socioeconomic characteristics and the presence of a DPP, independent of hospital factors.

FINDINGS: Nearly half (49.3%, n = 1580) of hospitals in the U.S. reported having a DPP in 2021. DPPs were less commonly found in rural counties as well as micropolitan counties when compared to their urban counterparts. After controlling for hospital size and other community characteristics, these disparities disappeared. When including the interaction of hospital size and geographic location, the odds of offering DPPs was higher among large, rural hospitals. DPPs were also less commonly available in counties with more limited food access and in health professions shortage areas.

CONCLUSIONS: DPP implementation is less common in rural and underserved areas. The interaction between hospital size and location is helpful for understanding barriers to DPP availability.

BACKGROUND: To support adoption of Screening, Brief Intervention, and Referral to Treatment (SBIRT) for opioid use disorder (OUD), hospitals are likely to benefit from implementation strategies that are responsive to their unique environments. Yet there remains a gap in knowledge regarding which implementation strategies are needed to support SBIRT implementation and sustainment for OUD within safety-net hospitals.

OBJECTIVES: To obtain expert consensus on the most effective implementation strategies to enhance the adoption of SBIRT for OUD in safety-net hospitals.

DESIGN AND SETTING: A modified Delphi study, with two rounds of online surveys.

PARTICIPANTS: Eighteen US-based experts from within the fields of OUD-focused health services research, addiction medicine, and emergency medicine.

MAIN MEASURES: The primary outcome was consensus on 35 potential SBIRT implementation strategies, ranked on a 5-point Likert scale across three domains: Effectiveness, Feasibility, Impact on Equity. Consensus across respondents within both rounds was evaluated using the interquartile range. If the IQR was 1 or below on the 0 to 5 Likert scale, consensus was considered obtained. Items with a median value of 4 or higher were considered high priority.

RESULTS: Following two rounds of ranking, consensus was achieved for all survey items. In total, 62.85% strategies (n = 22) were rated as High in Effectiveness, 20.0% (n = 7) were rated as High in Feasibility, and 11.42% (n = 4) were rated High in Impact on Equity. Seven strategies ranked high in two areas, with three-Identify and Prepare Champions, Identify Early Adopters, and Conduct Educational Meetings-ranked as highly effective and feasible.

CONCLUSIONS: This consensus process provides strong support for implementation strategies that can be used to guide future practice and study. This work can encourage implementation of SBIRT for OUD within safety-net hospitals, and set the stage for future studies to evaluate the impact of different implementation strategies on patient outcomes following SBIRT.

CONTEXT: Environmental impacts on human health are an urgent concern, requiring greater focus and action from health care organizations. Nonprofit hospitals can address community needs through investing in environmental improvement (EI) projects aimed at reducing harm to the community from environmental hazards. These expenditures provide a useful model for understanding how hospitals can respond to environmental influences on health, but national patterns of EI expenditures are under-researched.

OBJECTIVE: To assess nationwide trends in nonprofit hospital EI spending from 2010 to 2021.

DESIGN: Observational study using Internal Revenue Service tax data.

SETTING: US nonprofit hospitals.

MAIN OUTCOMES AND MEASURES: We assessed associations between reported EI spending and hospital organization and community characteristics (hospital revenue (quintiles); bed size (<50, 50-199, 200-399, 400 +); participation in group reporting (yes/no); teaching affiliation (yes/no); rurality status; geographic region (Northeast, Midwest, West, and South), and county poverty (quartile).

RESULTS: There were 36 093 nonprofit hospital-years included in our analysis. 10.4% of hospitals reported EI spending. EI spending was positively associated with higher revenue and being in the Midwest region and negatively associated with area poverty. The years 2020 and 2021 were significantly associated with a lower likelihood of spending relative to 2010. 40% of hospitals included utilized group reporting. Only 6% of independently reporting hospitals reported EI spending. Among hospital organizations with any reported community-building expenses, the percentage of their total operating budget dedicated to EI averaged 0.002% each year (0%-1.52%).

CONCLUSIONS: Though EI investments are small relative to community-building spending, the characteristics of hospitals reporting these investments provide insight into EI trends over time and which hospitals are conducting these efforts. Future research should consider the specific gaps to stimulating EI, what environmental needs hospitals are equipped to fill, and their relevance to broader environmental health policies and initiatives.

BACKGROUND: Programs that aim to increase access to substance use disorder (SUD) treatment in hospital-based settings have proliferated in recent years. These efforts include transitional opioid programs (TOPs), which navigate patients to community-based SUD treatment programs post-discharge. Successful navigation from TOPs to outpatient treatment hinges on effective coordination between hospitals and post-discharge endpoints, yet it is unclear how hospitals can best develop effective partnerships with outpatient treatment organizations. The objective of this study is to synthesize the common themes underpinning the development of partnerships to facilitate care transitions between TOPs and ongoing SUD treatment.

METHODS: Qualitative study with staff and providers from hospitals affiliated with four safety-net health systems (n = 21) and leaders from community-based organizations (CBOs) and treatment facilities that had established referral partnerships with one of the four health systems in our study (n = 4).

RESULTS: Analysis of interview transcripts revealed seven common themes that underpinned the development of care transitions partnerships: (1) Active, intentional outreach; (2) Responding to a community need; (3) External Enabling Factors; (4) Leveraging reputations and community connections; (5) Focusing on operations; (6) Reciprocal relationships; and (7) Building Infrastructure and Processes to Ensure Collaboration. The seven identified themes were categorized into three groups corresponding to different partnership development stages. The first group revolves around the initial stage of meeting and developing a relationship (themes #1-4). The second set focuses on navigating and resolving challenges that arise in the partnership (themes #5-6). Lastly, the third group pertains to sustaining a partnership long-term (theme #7).

CONCLUSIONS: This study identifies seven core themes underlying the development of care transition partnerships for SUD patients within four safety net health systems and their CBO partners. These themes demonstrate how partner organizations can establish the trust, reciprocity, and commitment necessary to support patients through the critical transition period.