Introduction: Massachusetts established 17 new Medicaid accountable care organizations (ACOs) and 24 affiliated Community Partners (CPs) in 2018 as part of a large-scale healthcare reform effort to improve care value. The new ACOs will receive $1.8 billion dollars in state and federal funding over 5 years through the Delivery System Reform Incentive Program (DSRIP). The multi-faceted study described in this protocol aims to address gaps in knowledge about Medicaid ACOs' impact on healthcare value by identifying barriers and facilitators to implementation and sustainment of the DSRIP-funded programs. Methods and analysis: The study's four components are: (1) Document Review to characterize the ACOs and CPs; (2) Semi-structured Key Informant Interviews (KII) with ACO and CP leadership, state-level Medicaid administrators, and patients; (3) Site visits with selected ACOs and CPs; and (4) Surveys of ACO clinical teams and CP staff. The Consolidated Framework for Implementation Research's (CFIR) serves as the study's conceptual framework; its versatile menu of constructs, arranged across five domains (Intervention Characteristics, Inner Setting, Outer Setting, Characteristics of Individuals, and Processes) guides identification of barriers and facilitators across multiple organizational contexts. For example, KII interview guides focus on understanding how Inner and Outer Setting factors may impact implementation. Document Review analysis includes extraction and synthesis of ACO-specific DSRIP-funded programs (i.e., Intervention Characteristics); KIIs and site visit data will be qualitatively analyzed using thematic analytic techniques; surveys will be analyzed using descriptive statistics (e.g., counts, frequencies, means, and standard deviations). Discussion: Understanding barriers and facilitators to implementing and sustaining Medicaid ACOs with varied organizational structures will provide critical context for understanding the overall impact of the Medicaid ACO experiment in Massachusetts. It will also provide important insights for other states considering the ACO model for their Medicaid programs. Ethics and dissemination: IRB determinations were that the overall study did not constitute human subjects research and that each phase of primary data collection should be submitted for IRB review and approval. Study results will be disseminated through traditional channels such as peer reviewed journals, through publicly available reports on the mass.gov website; and directly to key stakeholders in ACO and CP leadership.

BACKGROUND: Structurally marginalized groups experience disproportionately low rates of advance care planning (ACP). To improve equitable patient-centered end-of-life care, we examine barriers and facilitators to ACP among clinicians as they are central participants in these discussions. METHODS: In this national study, we conducted semi-structured interviews with purposively selected clinicians from six diverse health systems between August 2018 and June 2019. Thematic analysis yielded themes characterizing clinicians' perceptions of barriers and facilitators to ACP among patients, and patient-centered ways of overcoming them. RESULTS: Among 74 participants, 49 (66.2%) were physicians, 16.2% were nurses, and 13.5% were social workers. Most worked in primary care (35.1%), geriatrics (21.1%), and palliative care (19.3%) settings. Clinicians most frequently expressed difficulty discussing ACP with certain racial and ethnic groups (African American, Hispanic, Asian, and Native American) (31.1%), non-native English speakers (24.3%), and those with certain religious beliefs (Catholic, Orthodox Jewish, and Muslim) (13.5%). Clinicians were more likely to attribute barriers to ACP completion to patients (62.2%), than to clinicians (35.1%) or health systems (37.8%). Three themes characterized clinicians' difficulty approaching ACP (Preconceived views of patients' preferences; narrow definitions of successful ACP; lacking institutional resources), while the final theme illustrated facilitators to ACP (Acknowledging bias and rejecting stereotypes; mission-driven focus on ACP; acceptance of all preferences). CONCLUSIONS: Most clinicians avoided ACP with certain racial and ethnic groups, those with limited English fluency, and persons with certain religious beliefs. Our findings provide evidence to support development of clinician-level and institutional-level interventions and to reduce disparities in ACP.

Background: Pregnancy-related cardiovascular (CV) conditions are important predictors of future cardiovascular disease (CVD). Nontraditional factors, such as depression and chronic stress, have been associated with CVD, but their role in pregnancy-related CVD conditions (pCVD) remains unknown. To determine the association between nontraditional factors and CV conditions in pregnancy, and to explore if this risk varies by race. Methods: Using data from a prospective study of pregnant women within the veterans affairs health system (COMFORT study), we described the prevalence of nontraditional factors (e.g., depression, post-traumatic stress disorder [PTSD], chronic stress) and used logistic regression to determine the association between nontraditional factors and pregnancy-related CV conditions (pre-eclampsia/eclampsia, gestational hypertension, gestation diabetes, or preterm delivery). Analyses were then stratified by race. Results: Among 706 enrollees, 26% had pregnancy-related CV conditions. These women had significantly higher rates of depression (62% vs. 45%, p < 0.01), anxiety (50% vs. 37%, p = 0.01), PTSD (44% vs. 29%, p < 0.01), and high stress levels before pregnancy (22% vs. 16%, p = 0.05) compared with women with normal pregnancies. Overall, these factors were not associated with increased adjusted odds of pCVD. Overall, Black women had disproportionately higher rates of prepregnancy hypertension compared with White women (22% vs. 6%, p < 0.01). Conclusion: Women Veterans with pCVD are a high-risk group for future CVD, with disproportionately high rates of depression, anxiety, PTSD, and chronic stress. Racial disparities exist in pregnancy-related CV risk factors, which may further compound existing racial disparities in CVD among women Veterans.

BACKGROUND: The development of evidence-based care geared towards Black and Latina women living with uncontrolled type 2 diabetes is contingent upon their active recruitment into clinical interventions. Well-documented impediments to recruitment include a historical mistrust of the research community and socioeconomic factors that limit awareness and access to research studies. Although sociocultural and socioeconomic factors deter minorities from participating in clinical research, it is equally important to consider the role of stigma in chronic disease intervention studies. OBJECTIVE: We aim to share our discovery of diabetes-related stigma as an underrecognized impediment to recruitment for the Women in Control 2.0 virtual diabetes self-management education study. METHODS: Our initial recruitment plan used traditional strategies to recruit minority women with uncontrolled type 2 diabetes, which included letters and phone calls to targeted patients, referrals from clinicians, and posted flyers. After engaging a patient advisory group and consulting with experts in community advocacy, diabetes-related stigma emerged as a prominent barrier to recruitment. The study team reviewed and revised recruitment scripts and outreach material in order to better align with the lived experience and needs of potential enrollees. RESULTS: Using a more nuanced, community-centered recruitment approach, we achieved our target recruitment goal, enrolling 309 participants into the study, exceeding our target of 212. CONCLUSIONS: There is a need for updated recruitment methods that can increase research participation of patients who experience internalized diabetes stigma. To address disparities in minority health, further research is needed to better understand diabetes-related stigma and devise strategies to avert or address it. Jessica Martin-Howard, Paula Gardiner. Originally published in JMIR Diabetes (https://diabetes.jmir.org), 03.05.2021.