The cost-effectiveness of training US primary care physicians to conduct colorectal cancer screening in family medicine residency programs.

BACKGROUND: Demand for a wide array of colorectal cancer screening strategies continues to outpace supply. One strategy to reduce this deficit is to dramatically increase the number of primary care physicians who are trained and supportive of performing office-based colonoscopies or flexible sigmoidoscopies. This study evaluates the clinical and economic implications of training primary care physicians via family medicine residency programs to offer colorectal cancer screening services as an in-office procedure. METHODS: Using previously established clinical and economic assumptions from existing literature and budget data from a local grant (2013), incremental cost-effectiveness ratios are calculated that incorporate the costs of a proposed national training program and subsequent improvements in patient compliance. Sensitivity analyses are also conducted. RESULTS: Baseline assumptions suggest that the intervention would produce 2394 newly trained residents who could perform 71,820 additional colonoscopies or 119,700 additional flexible sigmoidoscopies after ten years. Despite high costs associated with the national training program, incremental cost-effectiveness ratios remain well below standard willingness-to-pay thresholds under base case assumptions. Interestingly, the status quo hierarchy of preferred screening strategies is disrupted by the proposed intervention. CONCLUSIONS: A national overhaul of family medicine residency programs offering training for colorectal cancer screening yields satisfactory incremental cost-effectiveness ratios. However, the model places high expectations on primary care physicians to improve current compliance levels in the US.

Behavioral and technological interventions targeting glycemic control in a racially/ethnically diverse population: a randomized controlled trial.

BACKGROUND: Diabetes self-care by patients has been shown to assist in the reduction of disease severity and associated medical costs. We compared the effectiveness of two different diabetes self-care interventions on glycemic control in a racially/ethnically diverse population. We also explored whether reductions in glycated hemoglobin (HbA1c) will be more marked in minority persons. METHODS: We conducted an open-label randomized controlled trial of 376 patients with type 2 diabetes aged ≥18 years and whose last measured HbA1c was ≥7.5% (≥58 mmol/mol). Participants were randomized to: 1) a Chronic Disease Self-Management Program (CDSMP; n = 101); 2) a diabetes self-care software on a personal digital assistant (PDA; n = 81); 3) a combination of interventions (CDSMP + PDA; n = 99); or 4) usual care (control; n = 95). Enrollment occurred January 2009-June 2011 at seven regional clinics of a university-affiliated multi-specialty group practice. The primary outcome was change in HbA1c from randomization to 12 months. Data were analyzed using a multilevel statistical model. RESULTS: Average baseline HbA1c in the CDSMP, PDA, CDSMP + PDA, and control arms were 9.4%, 9.3%, 9.2%, and 9.2%, respectively. HbA1c reductions at 12 months for the groups averaged 1.1%, 0.7%, 1.1%, and 0.7%, respectively and did not differ significantly from baseline based on the model (P = .771). Besides the participants in the PDA group reporting eating more high-fat foods compared to their counterparts (P < .004), no other significant differences were observed in participants' diabetes self-care activities. Exploratory sub-analysis did not reveal any marked reductions in HbA1c for minority persons but rather modest reductions for all racial/ethnic groups. CONCLUSIONS: Although behavioral and technological interventions can result in some modest improvements in glycemic control, these interventions did not fare significantly better than usual care in achieving glycemic control. More research is needed to understand how these interventions can be most effective in clinical practice. The reduction in HbA1c levels found in our control group that received usual care also suggests that good routine care in an integrated healthcare system can lead to better glycemic control. TRIAL REGISTRATION: Clinicaltrials.gov Identifier: NCT01221090.

Factors associated with successful completion of the chronic disease self-management program by adults with type 2 diabetes.

This study examines factors associated with completion (attendance ≥4 of 6 sessions) of the Chronic Disease Self-Management Program (CDSMP) by adults with type 2 diabetes. Patients with glycated hemoglobin ≥ 7.5 within 6 months were enrolled and completed self-report measures on demographics, health status, and self-care (n = 146). Significant differences in completion status were found for several self-care factors including healthful eating plan, spacing carbohydrates, frequent exercise, and general health. Completion was not influenced by race/ethnicity or socioeconomics. Results suggest better attention to exercise and nutrition at the start of CDSMP may be associated with completion, regardless of demographic subgroup.

Determinants of HPV vaccine awareness and healthcare providers' discussion of HPV vaccine among females.

Two human papillomavirus (HPV) vaccines are available and can prevent 98% of HPV 16 and 18 infections. This study aimed to explore determinants of 1) HPV vaccine awareness among a cohort of low-income women participating in a cancer prevention program in Central Texas and compare them to United States residents; 2) determinants of healthcare providers' discussion of HPV vaccine among female residents of the United States. Bivariate and multivariable analysis of HPV vaccine awareness using survey data (n = 359) collected between 2014 and 2016 in Central Texas, and the Health Information and Nutrition Survey (HINTS) data which is a nationally representative dataset (unweighted n = 1214) collected in 2013 were conducted. Bivariate and multivariable regression analyses of healthcare providers' discussion of the HPV vaccine using the HINTS survey data were also conducted. Compared to non-Hispanic Whites, there was a decreased likelihood of HPV vaccine awareness among non-Hispanic Blacks (OR = 0.50; 95% CI = 0.28-0.90) and Hispanics (OR = 0.55; 95% CI = 0.30-0.99) in the grant funded program, as well as non-Hispanic Blacks (OR = 0.28; 95% CI = 0.14-0.58) and Hispanics (OR = 0.22; 95% CI = 0.12-0.41) in the HINTS data. There was also a decreased likelihood of healthcare providers discussing the HPV vaccine with respondents who were 35-49 years (OR = 0.50; 95% CI = 0.30-0.84), 50-64 years (OR = 0.26; 95% CI = 0.14-0.49) or ≥ 65 years compared to those who were 18-34 years among the HINTS data respondents. Interventions to increase HPV awareness among non-Hispanic Blacks and Hispanics, as well as encourage healthcare providers' discussion of the HPV vaccination during patient encounters regardless of the patient's age are needed.

Expanding Access to Colorectal Cancer Screening: Benchmarking Quality Indicators in a Primary Care Colonoscopy Program.

BACKGROUND: An inadequate supply of physicians who perform colonoscopies contributes to suboptimal screening rates, especially among the underserved. This shortage could be reduced if primary care physicians perform colonoscopies. This purpose of this article is to report quality indicators from colonoscopy procedures performed by family medicine physicians as part of a colorectal cancer prevention program targeting uninsured, low-income individuals. METHODS: A grant-funded colorectal cancer screening program was implemented to increase access to affordable colonoscopies for underinsured or uninsured residents of target counties while providing colonoscopy training to family medicine resident physicians. Colonoscopies were performed or supervised by 4 board-certified family physicians. Data were collected between 2011 and 2014. RESULTS: A total of 1155 colonoscopies were performed on 1101 individuals over a 3-year period. Cecal intubation rate was 96.25%. Adenoma detection rates among men and women >50 years old were 38.15% and 25.96%, respectively. There was 1 perforation, which was referred to a hospital, and 1 instance of postprocedural bleeding, which spontaneously resolved. CONCLUSIONS: Primary care physicians performing colonoscopies met the recommended quality indicators set forth by the American Society for Gastrointestinal Endoscopy.

The role of health literacy and communication habits on previous colorectal cancer screening among low-income and uninsured patients.

OBJECTIVE: To determine the association between health literacy, communication habits and colorectal cancer (CRC) screening among low-income patients. METHODS: Survey responses of patients who received financial assistance for colonoscopy between 2011 and 2014 at a family medicine residency clinic were analyzed using multivariate logistic regression (n = 456). There were two dependent variables: (1) previous CRC screening and (2) CRC screening adherence. Our independent variables of interest were health literacy and communication habits. RESULTS: Over two-thirds (67.13%) of respondents had not been previously screened for CRC. Multivariate analysis showed a decreased likelihood of previous CRC screening among those who had marginal (OR = 0.52; 95% CI = 0.29-0.92) or inadequate health literacy (OR = 0.49; 95% CI = 0.27-0.87) compared to those with adequate health literacy. Controlling for health literacy, the significant association between educational attainment and previous CRC screening was eliminated. Thus, health literacy mediated the relationship between educational attainment and previous CRC screening. There was no significant association between communication habits and previous CRC screening. There was no significant association between screening guideline adherence, and health literacy or communication. CONCLUSION: Limited health literacy is a potential barrier to CRC screening. Suboptimal CRC screening rates reported among those with lower educational attainment may be mediated by limited health literacy.

Rural Healthy People 2020: New Decade, Same Challenges.

PURPOSE: The health of rural America is more important than ever to the health of the United States and the world. Rural Healthy People 2020's goal is to serve as a counterpart to Healthy People 2020, providing evidence of rural stakeholders' assessment of rural health priorities and allowing national and state rural stakeholders to reflect on and measure progress in meeting those goals. The specific aim of the Rural Healthy People 2020 national survey was to identify rural health priorities from among the Healthy People 2020's (HP2020) national priorities. METHODS: Rural health stakeholders (n = 1,214) responded to a nationally disseminated web survey soliciting identification of the top 10 rural health priorities from among the HP2020 priorities. Stakeholders were also asked to identify objectives within each national HP2020 priority and express concerns or additional responses. FINDINGS AND CONCLUSIONS: Rural health priorities have changed little in the last decade. Access to health care continues to be the most frequently identified rural health priority. Within this priority, emergency services, primary care, and insurance generate the most concern. A total of 926 respondents identified access as the no. 1 rural health priority, followed by, no. 2 nutrition and weight status (n = 661), no. 3 diabetes (n = 660), no. 4 mental health and mental disorders (n = 651), no. 5 substance abuse (n = 551), no. 6 heart disease and stroke (n = 550), no. 7 physical activity and health (n = 542), no. 8 older adults (n = 482), no. 9 maternal infant and child health (n = 449), and no. 10 tobacco use (n = 429).

Effects of diabetes self-management programs on time-to-hospitalization among patients with type 2 diabetes: a survival analysis model.

OBJECTIVE: This study compared time-to-hospitalization among subjects enrolled in different diabetes self-management programs (DSMP). We sought to determine whether the interventions delayed the occurrence of any acute event necessitating hospitalization. METHODS: Electronic medical records (EMR) were obtained for 376 adults enrolled in a randomized controlled trial (RCT) of Type 2 diabetes (T2DM) self-management programs. All study participants had uncontrolled diabetes and were randomized into either: personal digital assistant (PDA), Chronic Disease Self-Management Program (CDSMP), combined PDA and CDSMP (COM), or usual care (UC) groups. Subjects were followed for a maximum of two years. Time-to-hospitalization was measured as the interval between study enrollment and the occurrence of a diabetes-related hospitalization. RESULTS: Subjects enrolled in the CDSMP-only arm had significantly prolonged time-to-hospitalization (Hazard ratio: 0.10; p=0.002) when compared to subjects in the control arm. Subjects in the PDA-only and combined PDA and CDSMP arms showed no improvements in comparison to the control arm. CONCLUSION: CDSMP can be effective in delaying time-to-hospitalization among patients with T2DM. PRACTICE IMPLICATIONS: Reducing unnecessary healthcare utilization, particularly inpatient hospitalization is a key strategy to improving the quality of health care and lowering associated health care costs. The CDSMP offers the potential to reduce time-to-hospitalization among T2DM patients.

Primary care physicians' perceptions of diabetes treatment protocols.

Primary care physicians' perceptions of diabetes treatment protocols (DTPs) in the management of type 2 diabetes mellitus (T2DM) were examined at the individual and organizational levels. A 27-item electronic survey was administered to primary care physicians from an integrated multispecialty health care system in Texas. Information was collected on various aspects of DTPs, including attitudes toward these protocols, perceived barriers, and knowledge, as well as utilization of diabetes self-management programs. Besides quality of care, the primary care physicians surveyed generally had mixed feelings regarding DTPs' ability to contribute positively to other aspects of health care; in addition, only a small percentage were familiar with some currently available self-management programs. Given that implementation of DTPs depends on primary care physicians, we should address physicians' attitudes and perceptions toward DTPs so as to increase utilization of these helpful protocols.

Challenges and opportunities for implementing diabetes self-management guidelines.

PURPOSE: The purpose of this article was to examine primary care providers' perceived challenges when implementing evidence-based diabetes self-management guidelines and opportunities for promoting the use of such guidelines in practice. METHODS: We engaged 3 group discussions with 43 key stakeholders representing family physicians, medical directors, and quality assurance leaders in a large, university-affiliated, integrated health care organization in Central Texas. Transcripts from group discussions were summarized using thematic content analysis. RESULTS: Key themes that emerged as challenges of implementing evidence-based diabetes self-management guidelines included lack of easily retrievable electronic patient health information, inadequate coordination with other health care providers when implementing guidelines, conflict between information in the guidelines and physicians' knowledge, and physician compensation by patient load rather than by quality of care. Two main opportunities identified were the use of health coaches or nurses trained in diabetes self-management and active collaboration between practicing providers and key stakeholders in the development and dissemination of guidelines. CONCLUSION: Our study shows a need for involving front-line family physicians and other primary care providers as well as patients in the design and development of best practice guidelines to enhance implementation of diabetes self-management guidelines in primary care settings.

Provision of counseling on diabetes self-management: are there any age disparities?

OBJECTIVE: To determine whether there are any age-related disparities in the frequency of provision of counseling and education for diabetes care in a large HMO in Central Texas. METHODS: EMR search from 13 primary care clinics on patients aged ≥18 years (n=1300) who had been diagnosed with type 2 diabetes. RESULTS: There were no significant age differences in the frequency of provision of counseling about HBGM, diet, smoking or diabetes education. However, there were significant age differences in the provision of exercise counseling. Patients aged ≥75 were significantly less likely to have been provided exercise counseling than those aged <65 (adjusted OR=0.60; 95% CI=0.37-0.98). The mean HbA1c for patients aged ≥75 and 65-74 were significantly lower than that of patients aged <65 (8.9 vs. 9.0 vs. 9.7; P<0.001). CONCLUSION: While age-related variations in self-management protocols were not found, the provision of formal diabetes education was low (29.4%). The persistence of key risk factors in later life (e.g., obesity) underscores the need for better self-management protocols for older adults. PRACTICE IMPLICATIONS: Additional efforts on strategies to increase counseling about lifestyle habits and diabetes self-management care by appropriate health care providers is needed. Diabetes counseling should be individually tailored in older population.

Disparities in diabetes management by race or ethnicity in a primary care clinic in central Texas.

We determined the nature and magnitude of extant health disparities in patients with type 2 diabetes (T2DM) by race and ethnicity. Data were abstracted from the electronic medical records and charts of all patients 18 years or older who had been diagnosed with T2DM and seen over a 1-year period in one primary care clinic. Data abstracted included patient demographics; provision of counseling on smoking cessation, diet, exercise, and home blood glucose monitoring (HBGM); health care utilization; laboratory measures; and clinical outcomes. No significant racial or ethnic differences were found in the rate of provision of counseling on smoking cessation, diet, exercise, and HBGM, which were all suboptimal according to American Diabetes Association recommendations. In addition, no significant differences were found in the mean number of hospital admissions, emergency room visits, and referrals for specialty care. However, the mean HbA1c levels for African Americans (9.9%) and Hispanics (9.0%) were significantly higher than that of whites (8.7%; P<.0001), even after controlling for body mass index and age. Explanation of the significant racial and ethnic differences found in HbA1c levels, despite similar diabetes self-management treatment protocols or health care utilization, calls for further research.