OBJECTIVES: To examine time trends in disparities in low-income children's health insurance coverage and access to care by family immigration status.

METHODS: We used data from the National Survey of Children's Health in 2003 to 2011-2012, including 83,612 children aged 0 to 17 years with family incomes <200% of the federal poverty level. We examined 3 immigration status categories: citizen children with non-immigrant parents; citizen children with immigrant parents; and immigrant children. We used multi-variable regression analyses to obtain adjusted trends in health insurance coverage and access to care.

RESULTS: All low-income children experienced gains in health insurance coverage and access to care from 2003 to 2011-2012, regardless of family immigration status. Relative to citizen children with non-immigrant parents, citizen children with immigrant parents had a 5 percentage point greater increase in health insurance coverage (P = .06), a 9 percentage point greater increase in having a personal doctor or nurse (P < .01), and an 11 percentage point greater increase in having no unmet medical need (P < .01). Immigrant children had significantly lower health insurance coverage than other groups. However, the group had a 14 percentage point greater increase in having a personal doctor or nurse (P < .01) and a 26 percentage point greater increase in having no unmet medical need (P < .01) relative to citizen children with non-immigrant parents.

CONCLUSIONS: Some disparities in access to care related to family immigration status have lessened over time among children in low-income families, although large disparities still exist. Policy efforts are needed to ensure that children of immigrant parents and immigrant children are able to access health insurance and health care.

Jarlenski M, Baller J, Borrero S, Bennett W. Trends in disparities in low-income children’s health insurance coverage and access to care by family immigration status. Academic Pediatrics. 2016; 16(2): 208-215. PMID: 26329016


INTRODUCTION: Advancements in therapy have led to dramatic increases in the life expectancy of patients with cystic fibrosis (CF). As survival improves, young women with CF will have expectations for their sexual and reproductive health (SRH) futures similar to their counterparts without CF. As they face unique CF-specific SRH concerns, they may rely on CF care providers for disease-specific SRH care provision. The purpose of this study was to investigate the attitudes of CF providers toward female SRH and perceived barriers in the current CF care model.

MATERIALS AND METHODS: U.S. CF program directors (n = 16) participated in qualitative interviews investigating attitudes and barriers to female CF SRH care. Interviews were audio-recorded, transcribed, and coded using a thematic analysis approach.

RESULTS: Participants (nine pediatric, five adult, and two combined) all agreed CF providers have a fundamental role in CF female SRH care. Most respondents named lack of time and patient and provider discomfort as significant barriers to effective SRH communication. Other reported barriers included: lack of training in SRH, family members in the room, low priority of SRH in setting of other CF issues, and lack of adequate rapport with patients.

DISCUSSION: This is the first study to assess the attitudes and experiences of CF care providers toward SRH discussion and care among female CF patients. Despite their perceived fundamental role in CF female SRH care, CF providers face significant barriers. Investment in provider training is needed to better address the complex SRH needs of young female patients.

Kazmerski T, Tuchman LK, Borrero S, Weiner D, Pilewski J, Orenstein D, Miller E. Cystic fibrosis program directors’ attitudes toward sexual and reproductive health in young women with CF. Pediatric Pulmonology. 2016; 51(1): 22-7. PMID: 26551521


Rosenfeld E, Marx J, Terry MA, Stall R, Flatt J, Borrero S, Miller E. Perspectives on expedited partner therapy for chlamydia: A survey of health care providers. International Journal of STD & AIDS. 2016; 27(13): 1180-1186. PMID: 26446138.


OBJECTIVE: There is a dearth of research examining eating behaviors, such as binge eating, among male and female veterans. The present study evaluated the prevalence of self-reported eating problems as well as associations with body mass index and psychiatric disorders among male and female Iraq and Afghanistan veterans.

METHODS: Participants were 298 male and 364 female veterans (M = 33.3 ± 10.6 years old) from the Women Veterans Cohort Study, a study of male and female veterans enrolled for Veterans Affairs care in New England or Indiana. Veterans self-reported on emotion- and stress-related eatingeating disorder diagnoses, and disordered eating behaviors. Diagnoses of post-traumatic stress disorder, major depressive disorder, and alcohol abuse were obtained from administrative records.

RESULTS: Female veterans reported higher rates of eating problems than did their male counterparts. Women and men who engage in disordered eating had higher rates of post-traumatic stress disorder and major depressive disorder, and women who engage in disordered eating had greater rates of alcohol abuse than did female veterans without eating disordered behaviors.

CONCLUSIONS: Disordered eating may be a significant issue among Iraq and Afghanistan veterans, and veterans with eating problems are more likely to have comorbid mental health conditions that further increase their health risks.

Slane JD, Levine MD, Borrero S, Mattocks KM, Ozier AD, Silliker N, Bathulapalli H, Brandt C, Haskell SG. Eating behaviors: Prevalence, psychiatric comorbidity, and associations with body mass index among male and female Iraq and Afghanistan veterans. Military Medicine. 2016; 181(11):e1650-e1656. PMID: 27849502.


OBJECTIVE: To explore the attitudes, preferences, and experiences of patients with cystic fibrosis (CF) and CF providers toward sexual and reproductive health (SRH) care for young women with CF.

METHODS: Young women with CF aged 18 to 30 years from a US CF care center and pediatric and adult CF program directors from a national sample participated in qualitative interviews investigating their experiences regarding SRH care and their attitudes and preferences toward SRH care provision in the CF setting. Interviews were audio-recorded, transcribed, and coded by using a thematic analysis approach.

RESULTS: Twenty-two patient participants and 16 CF program directors were interviewed. Themes shared by both groups included the importance of SRH discussion in the CF care setting, patient and provider discomfort as a barrier to SRH care, and the need for SRH educational resources and provider training to improve SRH care. Providers highlighted the lack of standardization around SRH care in the current CF care model. Patients desired SRH educational resources coupled with early SRH discussions initiated by their CF provider.

CONCLUSIONS: Both CF providers and patients agree that the CF provider has a fundamental role in providing CF-specific SRH care. Educational resources coupled with individualized SRH discussions may facilitate improved SRH care for young women with CF. Investigation into the implementation of SRH education and services into pediatric-onset chronic disease care models is needed.

Kazmerski T, Borrero S, Tuchman L, Weiner D, Pilewski J, Orenstein D, Miller E. Provider and patient attitudes regarding sexual health in females with cystic fibrosis. Pediatrics. 2016; 137(6): e20154452. PMID: 27244858.

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ABSTRACT: Medicaid is an important source of health insurance coverage for low-income pregnant women and covers nearly half of all deliveries in the United States. In the face of budgetary pressures, several state Medicaid programs have implemented or are considering implementing episode-based payments for perinatal care. Under the episode-based payment model, Medicaid programs make a single payment for all pregnancy-related medical services provided to women with low- and medium-risk pregnancies from 40 weeks before delivery through 60 days postpartum. The health care provider who delivers a live birth is assigned responsibility for all care and must meet certain quality metrics and stay within delineated cost-per-episode parameters. Implementation of cost- and quality-dependent episode-based payments for perinatal care is notable because there is no published evidence about the effects of such initiatives on pregnancy or birth outcomes. In this article, we highlight challenges and potential adverse consequences related to defining the perinatal episode and assigning a responsible health care provider. We also describe concerns that perinatal care quality metrics may not address the most pressing health care issues that are likely to improve health outcomes and reduce costs. In their current incarnations, Medicaid programs' episode-based payments for perinatal care may not improve perinatal care delivery and subsequent health outcomes. Rigorous evaluation of the new episode-basedpayment initiatives is critically needed to inform policymakers about the intended and unintended consequences of implementing episode-based payments for perinatal care.

Jarlenski M, Borrero S, La Charité T, Zite N. Episode-based payment for perinatal care in Medicaid: Implications for practice and policy. Obstetrics and Gynecology. 2016; 127(6): 1080-1084. PMID: 2715962


BACKGROUND: Internal medicine residents are expected to be able to provide gender-specific care. The objective of this study was to develop a consensus list of core topics and procedural skills in women's health to allow residency program directors to prioritize and standardize educational efforts in women's health.

METHODS: We conducted a two-round Delphi of women's health experts. Participants were given a list of topics and asked to: (1) rank each topic based on how important they felt each topic was for internal medicine residents to be proficient in upon graduation, and (2) identify which topics were critical for a women's health curriculum. Mean importance ratings for all topics and mean agreement ratings for the critical topics were calculated. The list of critical topics mirrored the list of important topics; therefore, our consensus list included any topic that received a mean importance rating of ≥4.

RESULTS: Of the 41 experts invited to participate, 46% (19) completed the first round with 100% (19/19) completing the second round. The majority (62.5%, n = 35) of topics received an importance rating of ≥4. The highest-ranking topics included cervical cancer screening, screening for osteoporosis, and diagnosis of sexually transmitted infections (mean rating of 4.95/each). Other highly rated topics included those related to contraception/reproductive planning, breast disease, menopause, and performing the breast and pelvic examinations. The diagnosis of gender-specific conditions was generally rated as more important than the management of the conditions. In addition, pregnancy-related topics were overall deemed as less important for internal medicine training.

CONCLUSION: Our study generated a consensus list of 35 core topics in women's heath that should serve as a guide to residency programs for the development of women's health curricula.

Farkas A, Tilstra S, Borrero S, McNeil M. Establishing consensus on residency education in women’s health. Journal of Women’s Health. 2017; 26(1):13-17. PMID: 27732128

INTRODUCTION: The number of female patients with CF able to consider pregnancy has increased with improved therapies. This study explored attitudes and decision making regarding pregnancy among young women with CF.
METHODS: Twenty-two women with CF ages 18-30 years completed semi-structured, in-person interviews exploring experiences with preconception counseling and reproductive care in the CF setting. Interviews were audio-recorded, transcribed, and coded using a thematic analysis approach. Results Participants indicated CF is a major factor in pregnancy decision making. Although women acknowledged that CF influences attitudes toward pregnancy, many expressed confusion about how CF can affect fertility/pregnancy. Many perceived disapproval from CF providers regarding pregnancy and were dissatisfied with reproductive care in the CF setting. Discussion Young female patients with CF reported poor understanding of the effect of CF on fertility and pregnancy and limited preconception counseling in CF care. Improvements in female sexual and reproductive health care in CF are warranted.

Kazmerski T, Gmelin T, Slocum B, Borrero S, Miller E. Attitudes and decision making related to pregnancy among young women with cystic fibrosis. Maternal and Child Health Journal. 2017; 21(4):818-824. PMID: 27531009.


BACKGROUND: Some types of sexually transmitted infection (STI) have higher prevalence in females than males, and among black, relative to whitefemales. Identifying mechanisms of STI risk is critical to effective intervention. The authors tested a model in which alcohol and marijuana use serve as mediating factors in the associations between depression and conduct problems with sexual risk behavior (SRB) and STI in adolescent females.

METHODS: The Pittsburgh Girls Study is a longitudinal observational study of females who have been followed annually to track the course of mental and physical health conditions. The 3 oldest cohorts (N = 1750; 56.8% black, 43.2% white) provided self-reports of substance use, depression and conduct problems, SRB, and STI at ages 16-18. A path model tested alcohol and marijuana use at age 17 as mechanisms that mediate the associations of depression and conduct problems at age 16 with SRB and STI at age 18.

RESULTS: Race was involved in 2 risk pathways. In one pathway, white females reported greater alcohol use, which was associated with greater SRB. In another pathway, black females reported earlier sexual onset, which was associated with subsequent SRB. Public assistance use was independently associated with early sexual onset and STI. SRB, but not substance use, mediated the association of depression and conduct problems with STI.

CONCLUSIONS: Differences by race in pathways of risk for SRB and STI, involving, for example, alcohol use and early sexual onset, were identified for young white and black females, respectively. Depression and conduct problems may signal risk for SRB and STI in young females, and warrant attention to improve health outcomes.

Chung T, Feifei Y, Hipwell AE, Stepp SD, Miller E, Borrero S, Hawk M. Alcohol and marijuana use in pathways of risk for sexually transmitted infection in white and black adolescent females. Substance Abuse. 2017; 38 (1):77-81. PMID: 27897467


ABSTRACT: Health care providers in the Veterans Affairs system are caring for a growing number of women of childbearing age. Prior research shows that a significant number of women veterans are prescribed category D or X teratogenic medications. However, the majority do not receive teratogenic risk or contraceptive counseling. In order to improve teratogenic medication prescribing practices at the Veterans Affairs Pittsburgh Healthcare System, we developed a framework called TARCC to guide primary care providers through appropriate teratogenic risk counseling. The components of TARCC are teratogen (Are you prescribing a potential teratogen?), alternative (Did you consider a nonteratogenic alternative?), risks (Did you discuss the risks of the medication?), contraception (Did you discuss contraception?), and chart (Did you chart your discussion?). We incorporated TARCC into an electronic health record reminder. Additional probes, educational tools, and options to place consults and orders are included within the reminder. The Teratogen Pharmacy E-consult prompts a pharmacist to electronically review a patient's medications and provide recommendations regarding potential alternatives and discussions of risks and benefits. This article describes the development and implementation of the TARCC framework in a clinical reminder.

Shroff S, McNeil M, Borrero S. An innovative framework to improve teratogenic medication prescribing practices. Journal of Midwifery and Women’s Health. 2017: 62(3):353-357. PMID: 28485536


BACKGROUND: Sexual dysfunction is common in midlife women and can have a significant negative impact on quality of life. Although treatments exist, there is little research on which sexual function outcomes and treatments midlife women prefer.

AIM: To better understand the sexual function outcomes that were most important to sexually active women 45 to 60 years old and the types of treatments they would prefer from individual interviews and focus groups.

METHODS: Twenty individual interviews and three focus groups (N = 39) were led by a trained facilitator, audio recorded, and transcribed. Two investigators developed a codebook, and the primary investigator coded all data. A second investigator coded five randomly selected interviews to ensure intercoder reliability. Codes relating to outcomes and treatment preferences were examined to identify central themes.

RESULTS: The mean age was 52.8 years (range = 45-59). When asked what they would want a sexual dysfunction treatment to do, womensought solutions to specific sexual problems: low desire, vaginal pain and dryness, and decreased arousal or ability to achieve orgasm. However, when asked about the most important aspect of their sex life, most women indicated emotional outcomes, such as enhanced intimacy with their partner, were most important to them. Most women preferred behavioral over pharmaceutical treatments, citing concerns about side effects. These women felt that behavioral treatments might be better equipped to address physical and psychological aspects of sexual problems.

CLINICAL IMPLICATIONS: This study highlights the importance of considering not only physical but also emotional outcomes when evaluating and treating sexual dysfunction in midlife women. It also emphasizes the importance of developing behavioral treatments in addition to pharmaceutical treatments.

STRENGTHS AND LIMITATIONS: By using a qualitative approach, this study allowed women the time and space to speak their own words about their experiences with sexuality at midlife. In addition, different racial and ethnic groups and menopausal statuses were represented. Limitations include limited generalizability, as is true for most qualitative research. In addition, although most women did endorse sexualproblems, we did not exclude women with no sexual complaints.

CONCLUSIONS: Midlife women value physical and emotional outcomes with regard to sexual function. Many midlife women in this sample expressed a preference for behavioral approaches over pharmaceutical approaches for the treatment of sexual dysfunction.

Thomas HN, Hamm M, Hess R, Borrero S, Thurston R. Patient-centered outcomes and treatment preferences regarding sexual problems: A qualitative study among midlife women. Journal of Sexual Medicine. 2017; 14(8):1011-1017. PMID: 28647404. PMCID: PMC5538956.

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OBJECTIVES: Spontaneous abortion (SAB) affects over 1 million US women each year, yet little is known about the intendedness of these pregnancies. We examined prevalence and correlates of unintended and unwanted pregnancies ending in SAB.

STUDY DESIGN: We used nationally-representative cross-sectional data of US women aged 15-44 from the 2011-2013 National Survey of Family Growth to examine pregnancies ending in SAB. We used modified Poisson regression models to evaluate associations between demographic and pregnancy characteristics with unintended and unwanted pregnancy.

RESULTS: Among 1351 pregnancies ending in SAB, 44.5% were unintended (i.e. unwanted or occurring sooner than desired). Younger women with SAB were more likely to report unintended pregnancies than women 30-44 years, and women 15-19 years reported unintended pregnancy most often [adjusted relative risk (aRR)=3.0; 95% confidence interval (CI): 2.2-4.1]. Unintended pregnancy was two times more likely among unmarried than married women [never married: aRR=2.2; 95% CI: 1.7-2.7; previously married: aRR=2.2; 95% CI: 1.7-3.0]. Other factors associated with unintended pregnancy were multiparity compared to nulliparity [aRR=2.6; 95% CI: 1.7-4.1 for ≥3 children; aRR=1.8; 95% CI: 1.3-2.5 for 2 children] and inter-pregnancy interval ≤12 months compared to >12 months [aRR=1.4; 95% CI: 1.2-1.7]. We found similar associations with unwanted pregnancies ending in SAB (15.3% of pregnancies). Neither race/ethnicity nor socioeconomic indicators were independently associated with unintended or unwanted pregnancy ending in SAB.

CONCLUSIONS: Many pregnancies ending in spontaneous abortion are unintended and/or unwanted. Women with pregnancy loss, like all reproductive-aged women, should receive comprehensive counseling about reproductive planning and contraception.

IMPLICATIONS: Similar to all pregnancies, nearly half of pregnancies ending in spontaneous abortion are unintended and/or unwanted, suggesting that many women experiencing spontaneous abortion may benefit from a review of family planning desires and the provision of reproductive planning counseling and effective contraception to prevent future undesired pregnancy.

Flink-Bochacki R, Meyn LA, Chen BA, Achilles SL, Chang JC, Borrero S. Examining intendedness among pregnancies ending in spontaneous abortion. Contraception. 2017; 96(2):111-117. PMID:28578152.