Tag: nevin manimala

J Healthc Manag. 2026 Mar-Apr 01;71(2):122-139. doi: 10.1097/JHM-D-24-00185.

ABSTRACT

GOAL: This study examines the impact of supportive processes, work-life balance, and leadership on employees’ job satisfaction, intention to stay, and job engagement at US health centers.

METHODS: This study utilizes secondary data from the Health Center Workforce Well-Being Survey conducted by the Health Resources and Services Administration from late November 2022 to mid-February 2023. We conducted cross-sectional moderated mediation analyses using Model 60 from the Hayes PROCESS macro to examine the effects of supportive health center processes, work-life balance, and leadership on employee job satisfaction and, subsequently, employees’ intentions to stay and job engagement.

PRINCIPAL FINDINGS: The mediation analyses demonstrated that job satisfaction mediates the relationship between supportive processes and both intention to stay and job engagement. Moreover, work-life balance and leadership moderate the relationship between supportive processes and job satisfaction with different patterns. Leadership also plays a dual moderating role, reducing dependence on job satisfaction for employee intention to stay while amplifying its effect on job engagement.

PRACTICAL APPLICATIONS: Our findings highlight the need for targeted workforce strategies in health center settings. Healthcare leaders should first enhance employees’ job satisfaction by investing in workplace supportive processes, work-life balance initiatives, and leadership development tailored to their organizational context. After job satisfaction is strengthened, its influence on employees’ intention to stay and job engagement remains contingent on leadership. The decision about how much to invest in leadership initiatives should be guided by the organization’s current job satisfaction levels.

PMID:41817541 | DOI:10.1097/JHM-D-24-00185

J Healthc Manag. 2026 Mar-Apr 01;71(2):109-121. doi: 10.1097/JHM-D-24-00244.

ABSTRACT

GOAL: Burnout in healthcare remains a significant problem, with implications not only for physicians and advanced practice providers but also for the entire US healthcare system, including patients and payers. Significant work has been done to understand the antecedents of burnout and develop successful intervention strategies. Much of the attention has focused on either improving the work environment or enhancing individual resilience, with suboptimal results. Consequently, we examined individual fortitude-including resilience and other attributes-and its interaction with organizational support to extend the research into both individual- and workplace-level antecedent factors in burnout.

METHODS: Physicians and advanced practice providers from six healthcare systems were invited to participate in this study, with 753 completing the survey. The survey included valid and reliable instruments for burnout, fortitude, and perceived organizational support. Multiple methods of assessment were used to triangulate the interactive effects of fortitude (i.e., individual attributes or factors) and organizational support (i.e., workplace-related factors) on burnout. First, correlation analyses were performed to identify statistically significant relationships between individual- and workplace-related factors. Next, stepwise regression modeling was used to test the simultaneous impact of individual- and workplace-related factors by examining the interaction between fortitude and organizational support on burnout. Finally, a path model was developed to test for the mediating effect of fortitude on the relationship between organizational support and burnout.

PRINCIPAL FINDINGS: Significant negative correlations between both individual fortitude and perceived organizational support in the workplace on burnout were evident. Similarly, there was a positive association between fortitude and organizational support. Stepwise regression showed that the interaction of individual attributes and organizational support had the highest degree of significance (β = -.67, p < .01), with an adjusted R2 of .44. Fortitude was added in the second step (β = -.37, p < .01) and provided significant improvement over the previous model, consisting of the interaction variable. The adjusted R2 increased to .52 (X2 = 11.18, p < .01, Δ adj R2 = .08). While organizational support was significantly related to burnout, the addition of this variable to the model showed no significant improvement in explained variance (X2 = 0.18, ns, Δ adj R2 = .00). Subsequent path modeling showed that fortitude can partially mediate the relationship between organizational support and burnout. Empirically, this demonstrates that fortitude significantly affects the relationship between organizational support and reduced burnout.

PRACTICAL APPLICATIONS: The causes of burnout are multifaceted and unique to individuals. Organizational attempts to improve the work environment or increase individual resilience have been suboptimal, as burnout rates have remained stubbornly elevated. By considering the interaction of individual fortitude and organizational support, leaders can develop more effective intervention strategies to support healthcare providers.

PMID:41817540 | DOI:10.1097/JHM-D-24-00244

JAMA Netw Open. 2026 Mar 2;9(3):e260222. doi: 10.1001/jamanetworkopen.2026.0222.

ABSTRACT

IMPORTANCE: Adverse childhood experiences (ACEs) are key risk factors for major depressive disorder (MDD), but their associations with treatment-resistant depression (TRD) remain unclear, particularly after accounting for unmeasured confounding, such as shared genetic and familial environmental factors.

OBJECTIVE: To examine the association between ACEs and TRD while accounting for unmeasured confounding within families.

DESIGN, SETTING, AND PARTICIPANTS: This cohort study used a co-twin control design and was based on 2 Swedish Twin Registry cohorts: the Study of Twin Adults: Genes and Environment (STAGE) and the Young Adult Twins in Sweden Study (YATSS). The sample included twins born from 1959 to 1992 who completed surveys in 2005 to 2006 (for the STAGE cohort) or in 2013 to 2014 (for the YATSS cohort). Both cohorts were linked to Sweden’s National Patient Register and Prescribed Drug Register for follow-up until the end of 2016. Data analysis was conducted from September to November 2024.

EXPOSURE: ACEs, which were assessed using 7 yes or no items adapted from the Life Stressor Checklist-Revised: emotional neglect or abuse, physical neglect, physical abuse, sexual abuse, rape, hate crime, and witnessing family violence before age 19 years.

MAIN OUTCOMES AND MEASURES: TRD, which was defined as MDD diagnosed clinically or meeting the Diagnostic and Statistical Manual of Mental Disorders (Fourth Edition) criteria based on self-reported symptoms and having had at least 2 antidepressant switches of adequate duration (≥6 weeks) with no more than 14 weeks between consecutive prescriptions.

RESULTS: The full cohort included 21 192 twins, among whom 17 814 (10 205 females [57.3%]; mean [SD] age, 32.10 [7.82] years) were included in the main analysis. A total of 5558 individuals (31.2%) reported exposure to at least 1 ACE, and 996 (5.6%) reported 3 or more ACEs. The prevalence of TRD was 1.3% (n = 230) overall. Each additional ACE exposure was associated with increased odds of TRD (odds ratio [OR], 1.69; 95% CI, 1.56-1.84). In co-twin control analyses, the association remained within monozygotic and dizygotic twins (OR, 2.23; 95% CI, 1.30-3.83). Among ACE types, physical neglect (OR, 5.73; 95% CI, 3.75-8.75) and sexual abuse (OR, 5.01; 95% CI, 3.47-7.23) showed the greatest magnitude of associations with TRD.

CONCLUSIONS AND RELEVANCE: In this cohort study, ACE exposure was associated with an increased risk of TRD even after accounting for unmeasured familial confounding. The findings highlight the importance of preventing ACEs and incorporating ACE history into clinical assessment to identify individuals with MDD who may be at elevated risk for treatment resistance.

PMID:41817529 | DOI:10.1001/jamanetworkopen.2026.0222

JAMA Netw Open. 2026 Mar 2;9(3):e260237. doi: 10.1001/jamanetworkopen.2026.0237.

ABSTRACT

IMPORTANCE: Cost-related delayed or forgone care is an issue affecting Latino adults and may lead to increased emergency department (ED) visits.

OBJECTIVES: To examine the association between cost-related delayed or forgone physical and mental health care and ED visits among Latino adults aged 18 to 64 years in the US and to estimate within-group differences in ED visits by language, place of birth, heritage, citizenship status, and insurance status, after adjusting for delayed or forgone care.

DESIGN, SETTING, AND PARTICIPANTS: This cross-sectional study analyzed pooled data from January 1, 2019, to December 31, 2024 (2019-2024 waves) in the National Health Interview Survey, a nationally representative survey of noninstitutionalized US residents. The analytic sample included Latino adults aged 18 to 64 years.

EXPOSURE: Self-reported cost-related delayed or forgone physical and mental health care.

MAIN OUTCOME AND MEASURES: The primary outcome consisted of self-reported ED visits in the past 12 months (yes or no). Weighted multivariable logistic regression models estimated adjusted odds ratios (AORs) and 95% CIs, controlling for survey year and sociodemographic, health-related, and geographic factors.

RESULTS: A total of 17 344 Latino adults were included, with a median age of 36.7 (IQR, 26,0-48.1) years. In weighted proportions, 50.7% were female, 58.5% had a high school education or less, and 16.9% reported delayed or forgone care. Respondents who reported cost-related delayed or forgone care had significantly higher odds of reporting at least 1 ED visit in the past 12 months (AOR, 1.78; 95% CI, 1.59-2.01) compared with those who did not report delaying or forgoing care. Females (AOR, 1.33; 95% CI, 1.21-1.47) and individuals with lower educational attainment (AOR for less than high school vs college graduate, 1.60; 95% CI, 1.34-1.92), public insurance (AOR, 1.69; 95% CI, 1.49-1.91), non-Mexican heritage (AOR, 1.18; 95% CI, 1.07-1.30), and poorer self-rated health (AOR, 4.09; 95% CI, 3.05-5.48) had higher odds of at least 1 ED visit. Compared with US-born individuals, those born outside the US had lower odds of having at least 1 ED visit (AOR, 0.75; 95% CI, 0.65-0.86). All estimates were adjusted for delayed or forgone care.

CONCLUSIONS AND RELEVANCE: In this cross-sectional study including Latino US adults, cost-related delays and forgone care were associated with increased ED use, underscoring the need for policies that reduce financial barriers to timely health care.

PMID:41817528 | DOI:10.1001/jamanetworkopen.2026.0237

JAMA Netw Open. 2026 Mar 2;9(3):e261385. doi: 10.1001/jamanetworkopen.2026.1385.

ABSTRACT

IMPORTANCE: Delivering integrated atrial fibrillation (AF) care to rural patients remains challenging. Patients aged 75 years and older in rural areas represent a particularly at-risk subgroup, and effective and scalable strategies to optimize AF care in this population are urgently needed.

OBJECTIVE: To evaluate the effectiveness of a village doctor-led, telemedicine-supported integrated care model in rural patients aged 75 years and older with AF.

DESIGN, SETTING, AND PARTICIPANTS: This was a prespecified subgroup analysis of the Novel Model of Integrated Care of Older Patients With Atrial Fibrillation in Rural China (MIRACLE-AF) cluster randomized clinical trial, which was conducted across 30 village clinics in Jiangdu County, Jiangsu Province, China, from December 2020 to May 2024. Patients with AF aged 65 years and older and residing in rural villages under study were eligible for the MIRACLE-AF trial. In this prespecified subgroup study, patients aged 75 years and older were analyzed. Additional age cutoffs (≥70, ≥75, and ≥80 years) were applied to assess the consistency of intervention benefits across age groups.

INTERVENTIONS: Village doctor-led, telemedicine-supported integrated AF care or usual care.

MAIN OUTCOMES AND MEASURES: A composite of cardiovascular death, ischemic or hemorrhagic stroke, hospitalization for worsening heart failure or acute coronary syndrome, and emergency visits for AF.

RESULTS: Among 1039 patients included in the primary analysis of the MIRACLE-AF trial (mean [SD] age, 75.8 [5.7] years; 460 women [44.3%]), 589 patients with AF aged 75 years or older (median [IQR] age, 79 [77-82] years; 273 women [46.3%]) were included in this analysis. Among them, 297 patients received the MIRACLE-AF intervention and 292 patients received usual care. Over 36 months of follow-up, the MIRACLE-AF intervention resulted in a significantly lower risk of the primary composite outcome compared with usual care (7.4%; 95% CI, 5.6%-9.2% vs 11.3%; 95% CI, 8.5%-14.1% per year; rate difference, -3.93 percentage points; 95% CI, -7.41 to -0.44 percentage points; P = .02; adjusted hazard ratio, 0.70; 95% CI, 0.49 to 0.98; P = .04).

CONCLUSIONS AND RELEVANCE: In this prespecified subgroup analysis of the MIRACLE-AF trial, a novel care model significantly improved outcomes in patients with AF aged 75 years or older in rural settings.

TRIAL REGISTRATION: ClinicalTrials.gov Identifier: NCT04622514.

PMID:41817526 | DOI:10.1001/jamanetworkopen.2026.1385

JAMA Netw Open. 2026 Mar 2;9(3):e261543. doi: 10.1001/jamanetworkopen.2026.1543.

ABSTRACT

IMPORTANCE: Evidence of cost-effectiveness is needed to demonstrate the value of smoking cessation behavioral interventions.

OBJECTIVE: To evaluate the cost-effectiveness of motivation and problem-solving (MAPS) against standard treatment (ST) for smoking cessation among patients with a history of cervical intraepithelial neoplasia or cervical cancer.

DESIGN, SETTING, AND PARTICIPANTS: In this economic evaluation, a cost-effectiveness analysis was conducted from the perspective of cancer centers using data collected in a randomized clinical trial conducted between February 2017 and January 2020 with follow-up until August 2021 that compared MAPS with ST. MAPS is a behavioral intervention that emphasizes smoking cessation and relapse prevention while addressing life events, stressors, and other individual concerns. The trial included up to 6 counseling sessions of MAPS delivered over 12 months. Data were analyzed from January 2024 to December 2025.

EXPOSURE: Inclusion in a smoking cessation randomized clinical trial that compared MAPS with ST.

MAIN OUTCOMES AND MEASURES: Deterministic and probabilistic cost-effectiveness analyses were conducted and findings were reported as incremental cost-effectiveness ratio and cost-effectiveness acceptability curve, respectively, for 7-day point prevalence abstinence at months 12 and 18.

RESULTS: The analysis included 194 participants. Study participants had a mean (SD) age of 47.8 (10.8) years, had a mean (SD) smoking history of 29.1 (12.1) years, and smoked a mean (SD) of 15.5 (8.7) cigarettes per day. Mean costs were $522.74 (95% CI, $500.19 to $545.29) and $389.26 (95% CI, $362.67 to $415.84) per participant for MAPS (98 participants) and ST (96 participants), respectively. At month 12, abstinence rates were 26.5% and 12.5% for MAPS and ST, respectively. The deterministic analysis found that the incremental cost for MAPS vs ST was $921 per quit at month 12 and $7458 per quit at month 18. The probabilistic analysis found that at the societal willingness to pay of $10 000 per quit, the probability that MAPS is cost-effective at month 12 was nearly 100% but reduced to 52% at month 18. Subgroup analysis found a lower incremental cost-effectiveness ratio when comparing the high MAPS engagement subgroup with the ST group. The cost-effectiveness of MAPS (vs ST) was sustained at month 18 among the high MAPS engagement subgroup despite a decline in 7-day abstinence.

CONCLUSIONS AND RELEVANCE: In this cost-effectiveness analysis, there was robust evidence supporting the cost-effectiveness of MAPS (vs ST) at month 12 and moderate evidence at month 18 in terms of incremental cost per quit. The attenuation of intervention outcome over time was more pronounced among participants with less than 4 sessions of MAPS.

PMID:41817524 | DOI:10.1001/jamanetworkopen.2026.1543

JAMA Netw Open. 2026 Mar 2;9(3):e261585. doi: 10.1001/jamanetworkopen.2026.1585.

ABSTRACT

IMPORTANCE: Colorectal cancer is the third most commonly diagnosed cancer and the third leading cause of cancer-associated deaths in the US. Hispanic and non-Hispanic Black patients experience higher colorectal cancer mortality rates compared with non-Hispanic White patients. More data are needed to understand the role of cancer biology in colorectal cancer survival disparities among racial and ethnic minority groups.

OBJECTIVE: To evaluate racial and ethnic differences in KRAS variant frequency and the association of presence of a KRAS variant with colorectal cancer-specific survival.

DESIGN, SETTING, AND PARTICIPANTS: This population-based cross-sectional study used data from the Surveillance, Epidemiology, and End Results Program and included patients diagnosed with colorectal cancer from 2010 through 2015, with follow-up through December 31, 2018. Data were analyzed between December 2023 and August 2024.

EXPOSURE: Racial and ethnic differences in KRAS variant frequency.

MAIN OUTCOMES AND MEASURES: Outcomes of interest were cumulative incidence of colorectal cancer-specific death, assessed using cumulative incidence functions, and subdistribution hazard ratio (sHR) for colorectal cancer-specific death, assessed using Fine-Gray regression models.

RESULTS: A total of 21 354 patients (mean [SD] age at diagnosis, 62.54 [13.78] years; 9653 females [45.2%]; median [IQR] follow-up, 2.67 [1.25-4.17] years) were included in the analysis, including 1680 Asian or Pacific Islander patients (7.8%), 2459 Hispanic patients (11.5%), 2761 non-Hispanic Black patients (12.9%), and 14 454 non-Hispanic White patients (67.7%). Hispanic patients and non-Hispanic Black patients had higher KRAS variant frequencies than non-Hispanic Asian or Pacific Islander patients and non-Hispanic White patients (44.2% and 48.3% vs 37.5% and 39.3%, respectively). Among patients with KRAS wild-type tumors, the unadjusted cumulative incidence of colorectal cancer-specific death was highest for Hispanic patients (59.5%; 95% CI, 55.4%-63.3%; P < .001); among patients with KRAS variant tumors, colorectal cancer-specific death was highest for non-Hispanic Black patients (67.3%; 95% CI, 63.3%-70.9%; P < .001). Among patients with KRAS wild-type tumors, Hispanic patients showed a significantly increased risk of colorectal cancer-specific death (sHR, 1.11; 95% CI, 1.01-1.22; P = .03). Among patients with KRAS variant tumors, non-Hispanic Black patients had a significantly increased risk of colorectal cancer-specific death (sHR, 1.18; 95% CI, 1.07-1.29; P < .001).

CONCLUSIONS AND RELEVANCE: In this cross-sectional study of patients with colorectal cancer, Hispanic patients and non-Hispanic Black patients had higher KRAS variant prevalence than non-Hispanic White patients. Among patients with a KRAS variant, non-Hispanic Black patients had worse cause-specific survival than non-Hispanic White patients. Among patients with wild-type KRAS, Hispanic patients had worse survival compared with non-Hispanic White patients. These findings highlight the need for further research on racial and ethnic differences in KRAS-related outcomes.

PMID:41817523 | DOI:10.1001/jamanetworkopen.2026.1585

JAMA Otolaryngol Head Neck Surg. 2026 Mar 12. doi: 10.1001/jamaoto.2026.0044. Online ahead of print.

ABSTRACT

IMPORTANCE: Otitis media with effusion (OME) is a common condition in children that can lead to hearing loss and developmental delays. Although tympanostomy tube (TT) placement is the standard treatment for persistent OME, recurrence after tube extrusion and the need for reoperation remain significant concerns.

OBJECTIVE: To evaluate the clinical effectiveness of autoinflation in reducing OME recurrence and reoperation rates after TT extrusion in pediatric patients.

DESIGN, SETTING, AND PARTICIPANTS: This prospective randomized clinical trial, conducted from September 2019 to August 2022 at a tertiary hospital, enrolled children with chronic OME who underwent TT placement with 2 years of follow-up after TT extrusion. The statistical analysis took place between March 2024 and February 2025.

INTERVENTIONS: After TT extrusion, patients were randomized to receive autoinflation with the autoinflation device for 5 weeks or to undergo observation alone.

MAIN OUTCOMES AND MEASURES: The main outcomes were OME recurrence and reoperation rates using otoscopic and tympanometric evaluations.

RESULTS: Sixty-six children enrolled in the study; 54 were included in the final analysis (26 in the autoinflation group and 28 in the observation group). Among 54 children (mean [SD] age, 55.5 [18.5] months; 30 [55.6%] male), the recurrence rate was 5 of 26 patients (19.2%) in the autoinflation group and much higher at 10 of 28 patients (35.7%) in the observation group (difference, 16.5 percentage points [pp]; 95% CI, -7.4 pp to 37.8 pp), while the reoperation rate was much lower in the autoinflation group at 2 of 26 patients (7.7%) compared to the observation group at 8 of 28 patients (28.6%; difference, 20.9 pp; 95% CI,-0.29 pp to 40.2 pp). In the autoinflation group, tympanometry showed minimal change from the first follow-up after TT extrusion to after 5 weeks of autoinflation therapy (type A tympanogram: 19 of 26 patients [73.1%] to 20 of 26 patients [76.9%]; type C tympanogram: 7 of 26 patients [26.9%] to 6 of 26 patients [23.1%]). In contrast, the observation group exhibited a decline in type A tympanograms (21 of 28 patients [75.0%] to 16 of 28 patients [57.1%]) and an increase in type C tympanograms (7 of 28 patients [25.0%] to 12 of 28 patients [42.9%]).

CONCLUSION AND RELEVANCE: In this randomized clinical trial, autoinflation after TT extrusion was safe, feasible, and associated with a reduced need for repeat surgical intervention. The observed difference in recurrence was compatible with a clinically meaningful reduction. These findings support the use of autoinflation as a noninvasive rehabilitative strategy to enhance eustachian tube function and maintain middle ear ventilation following TT extrusion.

TRIAL REGISTRATION: ClinicalTrials.gov Identifier: NCT07122999.

PMID:41817520 | DOI:10.1001/jamaoto.2026.0044

Value Health Reg Issues. 2026 Mar 12:101602. doi: 10.1016/j.vhri.2026.101602. Online ahead of print.

ABSTRACT

OBJECTIVES: Malaysia bears a considerable burden of cardiovascular diseases, reporting one of the highest prevalence rates in Southeast Asia. This underscores the need for equitable access to and efficient use of statins, the primary agents in cardiovascular disease prevention in Malaysia’s 2-tiered health system. This study compared trends in the utilization, expenditures, and cost per defined daily dose (DDD) of statins in Malaysia’s public and private healthcare sectors from 2004 to 2022.

METHODS: National aggregate data on simvastatin, atorvastatin, and rosuvastatin were extracted from the Malaysian Statistics on Medicines. Expenditures were adjusted for inflation. Cost per DDD was calculated by dividing inflation-adjusted expenditure by total DDDs consumed. Joinpoint regression was used to describe temporal changes in utilization and expenditure trends.

RESULTS: Statin utilization increased in both sectors over the study period, with substantially stronger growth in the public sector. Atorvastatin had the highest growth rate in the public sector with an average annual percent change of 25.27%, whereas rosuvastatin increased most rapidly in the private sector (average annual percent change 13.09%). There were substantial differences in the cost per DDD for the statins between the 2 sectors over the study period. The public sector demonstrated improved cost efficiency over time, whereas the private sector exhibited persistently high expenditures, especially for rosuvastatin.

CONCLUSIONS: There were distinct differences in statin utilization and cost burden between the public and private sectors. Targeted measures to promote generic uptake and address pricing disparities are essential to ensure equitable access to statins across Malaysia’s 2-tiered healthcare system.

PMID:41817501 | DOI:10.1016/j.vhri.2026.101602

J Nutr Educ Behav. 2026 Mar 12:S1499-4046(26)00031-X. doi: 10.1016/j.jneb.2026.01.016. Online ahead of print.

ABSTRACT

OBJECTIVE: An evaluation of a team-based pilot program with food vouchers.

DESIGN: Single-arm prepost mixed-method study.

SETTING: Two safety-net primary care clinics in San Francisco.

PARTICIPANTS: Black/African American and/or Hispanic/Latinx patients with uncontrolled diabetes (hemoglobin A1c >8%).

INTERVENTION(S): Six-month program including pharmacist and nutritionist visits, transportation assistance, and smoking cessation resources, plus $160 per month of grocery and produce vouchers.

MAIN OUTCOME MEASURE(S): Glycemic control and blood pressure. Secondary outcomes included qualitative insights into program benefits.

ANALYSIS: Descriptive statistics were used for patient characteristics, voucher use, and program satisfaction. Clinical outcomes used McNemar’s tests for paired categorical variables and paired t tests for continuous variables. Interviews were transcribed and analyzed with deductive coding.

RESULTS: A total of 45 participants redeemed 68.7% of vouchers. Uncontrolled hypertension (≥ 140/90 mmHg) decreased significantly from 45.9% to 21.6% (P = 0.007, n = 41). There was no statistically significant change in mean hemoglobin A1c from baseline to program end (10.1% vs 9.7%; P = 0.17). Mean low-density and body mass index were not significantly different. Major themes from interviews include changes in health behaviors, improved relationships with food, and strengthened engagement with team-based care.

CONCLUSIONS AND IMPLICATIONS: Combining vouchers and team-based care may be an avenue to improve care for patients with diabetes. Further investigation of this program model through a larger and rigorously designed study is needed for conclusive findings on this approach.

PMID:41817481 | DOI:10.1016/j.jneb.2026.01.016