Outcomes in an Interdisciplinary Diabetes Clinic in Rural Primary Care.

OBJECTIVE: The purpose of this study was to evaluate the effectiveness of an interdisciplinary diabetes team model of care in assisting patients to achieve improved glucose control in a primary care rural setting. METHODS: A family medicine clinic at a rural university medical center developed an interdisciplinary diabetes team clinic composed of a certified diabetes educator/dietitian, a case manager, a pharmacist, nursing staff, a family medicine resident, a psychologist, and a board-certified family medicine attending physician. Patients were referred if their hemoglobin A1c (HbA1c) was ≥9% (75 mmol/mol); patients were seen for an initial consultation and for additional visits as needed. RESULTS: A total of 94 patients attended an initial visit and at least 1 follow-up within 6 months. Mean age was 57 ± 13 years, and 54% were female. Median time from the initial intensive diabetes clinic visit to a follow-up visit was 2.8 months. There was a significant reduction in median HbA1c percentage from 10.25% (88.5 mmol/mol) ± 1.4% (range 73-104 mmol/mol) at the initial intensive diabetes clinic visit to 8.7% (72 mmol/mol) ± 1.8% (range 52-92 mmol/mol) at a 1- to 6-month follow-up (z = -7.161, P < 0.001) and a significant difference between baseline HbA1c (10.25% [88.5 mmol/mol] ± 1.4% [range 73-104 mmol/mol]) and latest HBA1c (1-18 months later) 8.4% (68 mmol/mol) ± 2.2% (range 44-92 mmol/mol; z = -7.022, P < 0.001). Overall, 86% of patients had a lower HbA1c at follow-up, and 33% had an HbA1c <8% (64 mmol/mol). There were no differences in patients' blood pressure, immunization rates, or lipid values between baseline and follow-up visits (P > 0.05). CONCLUSIONS: An interdisciplinary team approach to glycemic control can achieve significant reductions in HbA1c in the rural primary care setting.

Patient Attitudes and Participation in Hand Co-Washing in an Outpatient Clinic Before and After a Prompt.

Despite recent national emphasis, outpatient hand washing can be less than optimal. We tested a new approach involving both patient and physician hand washing. The study consisted of 384 questionnaires, 184 from phase 1 and 200 from phase 2. Patients stated doctors washed their hands 96.6% before examining them pre-intervention and 99.5% of the time post-intervention. Patients endorsed the importance of hand washing 98.7% of the time. "Co-washing" may offer a process to increase the practice of hand washing and decrease infection risk.

Dissemination Approaches to Participating Primary Care Providers in a Quality Improvement Program Addressing Opioid Use in Central Appalachia.

OBJECTIVES: Practice-based research networks (PBRNs) have been described as new clinical laboratories for primary care research and dissemination. PBRNs, however, have struggled to disseminate research results in a meaningful way to participating providers and clinics. METHODS: The Central Appalachia Inter-Professional Pain Education Collaborative was developed to work with PBRN clinics using quality improvement methods, deliver statewide continuing education activities to address the issue of opioid use in patients with chronic pain, and develop a multimodal mechanism to disseminate project results to clinics and participating providers. RESULTS: Successful change in the delivery of chronic pain care was dependent on the clinic's commitment to a team-based, patient-centered approach. Statistically significant improvements were shown in 10 of 16 process measures, and 80% of the participants agreed that the quality improvement process activity increased their knowledge and would improve their performance in managing patients with chronic pain, as well as patient outcomes in their practice. CONCLUSIONS: The Central Appalachia Inter-Professional Pain Education Collaborative project used an extensive and innovative dissemination plan under the rubric of "continual dissemination." Unlike traditional dissemination efforts that focus on summary presentations, this initiative used a continual dissemination approach that updated participants quarterly through multiple means throughout the project, which improved engagement in the project.

Cardiovascular Health Status in Baby Boomers with Diabetes Mellitus.

OBJECTIVES: The objective of this study was to assess the cardiovascular health status of baby boomers with diabetes mellitus (DM) in comparison to the same-age population with DM 10 years previously. METHODS: The study was conducted in baby boomers with DM using data from the National Health and Nutrition Examination Survey (NHANES) 2009-2012 compared with NHANES 1999-2002. Cardiovascular health metrics were derived from the American Heart Association's Life's Simple 7. The primary outcome was the comparison of the proportion of individuals with each characteristic, including healthy diet, healthy weight, not smoking, exercising regularly, and maintaining an optimal level of glycated hemoglobin (HbA1C), cholesterol, and blood pressure. RESULTS: Current baby boomers with DM (NHANES 2009-2012) had more obesity (70.9% vs 58.8%; P = 0.009) and a lower proportion of ideal physical activity (20.9% vs 31.7%; P = 0.01) than people of the same age 10 years ago; fewer than 1% adhere to an ideal healthy diet. Current baby boomers more often had ideal cholesterol (59.4% vs 47.2; P = 0.01) and reached an ideal HbA1C (51.0% vs 43.4%; P = 0.047). Blood pressure control, adherence to ideal diet, and smoking rates were not significantly different from 10 years ago. In logistic regression analyses controlling for likely confounders, baby boomers persisted in having more obesity and exercising less often, and reaching an ideal cholesterol level more often (P < 0.01). CONCLUSIONS: Although improving in cholesterol and HbA1C, baby boomers demonstrated worsening in several key cardiovascular health indicators, particularly obesity and physical activity.

Patient Attitudes toward Weight Related Discussions in Rural Appalachian Primary Care Clinics.

PURPOSE: West Virginia (WV) consistently has one of the highest rates of obesity, nationally, yet previous studies suggest that conversations about weight with providers are infrequent. This study's aim was to determine frequency and type of weight-related discussions occurring in WV primary care clinics and whether discussions differed according to weight status. METHODS: A cross-sectional survey was completed by patients in rural primary care practices. Participants answered questions related to demographics, obesity related illnesses, experience receiving a physician mediated discussion, and attitude and beliefs related to weight. RESULTS: Among the total of 490 surveys collected, a little more than half of the participants (56.9%) have discussed weight with their physician; a majority of participants (89.5%) thought a physician should tell risks associated with an unhealthy weight; 78.3% participants felt weight loss is important to them; 86.1% participants believed weight affects their health. Participants with obesity were more likely than participants who are overweight to discuss weight with their physician (71.8 vs.44.0%, p<0.0001), and believed that their physicians helped them lose weight previously (29.4% vs 9.9%, p<0.0001) and can help them lose weight in the future (92.9% vs. 71.1, p<0.0001). CONCLUSION: Physicians are often having weight related discussions with patients with obesity however this discussion happens less with overweight patients. Practitioners may want to be more attentive to addressing weight related issues in overweight patients.

Impact of daily cooling treatment on skin inflammation in patients with chronic venous disease.

People with chronic venous disease are at high risk for developing venous leg ulcers. Inflammation is posited as a pathological factor for this chronic condition as evidenced by persistently elevated skin temperature. As part of a larger trial to test the effects of a cooling regimen on leg ulcer prevention, the objective of this preliminary study was to evaluate the first 30 days of intense daily cooling. Compared to a placebo control cuff, a gel cuff applied to the most severely affected lower leg skin for 30 min daily showed no statistically significant differences between temperatures taken in the home at baseline compared to those measured at the 1 month follow up visit. There were also no differences in temperatures noted between the two groups, although the temperatures in the treatment group were lower 30 min after treatment, an indication of adherence. There was no discernable decrease or increase in temperature at a given time point during the 30 day treatment period compared to the control group. It may be better to have patients monitor skin temperature on a daily basis and then apply the cuff as necessary, rather than requiring daily cooling based on baseline measurement. This "prn" approach may provide a sufficient cooling milieu to prevent escalation of inflammation and thwart ulcer occurrence or recurrence. Clinical trials registration #NCT01509599.

Intake of key chronic disease-related nutrients among baby boomers.

OBJECTIVES: The dietary habits of baby boomers (people born between 1946 and 1964) undoubtedly will have a substantial impact on their future health; however, dietary information regarding the intake of key chronic disease-related nutrients is lacking for this generation. The objective of this study was to compare the dietary intake of key chronic disease-related nutrients of the baby boomer generation with the previous generation of middle-aged adults. METHODS: National cross-sectional study comparison analyzing data from the National Health and Nutrition Examination Survey (NHANES) including NHANES III (1988-1994) and the NHANES for 2007-2010, focused on adult respondents ages 46 to 64 years who were not institutionalized at the time of each survey. The two cohorts were compared with regard to dietary intake of key nutritional components. The main outcome measures were intake of total calories, sodium, cholesterol, fat, fruits, vegetables, vitamin C, water, and fiber. RESULTS: The baby boomers' average daily intake of nutrients exceeded that of the previous generation of middle-aged adults for total calories (2118/1999), total fat (82/76 g), sodium (3513/3291 mg), and cholesterol (294/262 g; all P < 0.001). The intake of vitamin C (105/89 g), water (1208/1001 g), and vegetables (199/229 g) was less than that of the previous generation (P < 0.001), and the dietary intake of fruit and fiber was unchanged. In regression analyses, dietary changes remained significant after controlling for age, race, sex, and socioeconomic status (all P < 0.01). CONCLUSIONS: The study findings document higher dietary intake of key chronic disease-related nutrients along with reduced vegetable intake among baby boomers compared with the previous generation of middle-aged adults. These findings are indicative of a diet that may contribute to increased rates of chronic disease among individuals in this age group.

Publication of research presented at STFM and NAPCRG conferences.

PURPOSE: Presentations of research are important in the dissemination of new knowledge, but they do not reach the same audience as research published in journals. The purpose of this study was to evaluate the proportion of presentations at recent major primary care research conferences that have become published. METHODS: Oral and poster presentations for completed and work-in-progress projects from the 2007 and 2008 North American Primary Care Research Group (NAPCRG) and Society of Teachers of Family Medicine (STFM) annual conferences were included in the analysis. The first presenter for each presentation was searched on PubMed, and titles and abstracts for presentations were compared for content to titles and abstracts of potential matches found on PubMed. We analyzed the proportion of presentations that were published in peer-reviewed journals, mean time to publication, and the proportions of the type of journal in which the article appeared (family medicine vs other) were analyzed. RESULTS: There were 1,329 presentations included in the study. Overall, 34.4% of projects presented were also published. More oral presentations (42.9%) were published than were poster presentations (25.3%) (P <.001). Mean time to publication was 15.4 months. Oral presentations were published more quickly (13.7 months) than poster presentations (18.6 months) (P <.001). Published reports appeared in 192 different journals. Family medicine journals accounted for 36.5% of published. CONCLUSIONS: More than one-third of all presentations at STFM and NAPCRG conferences were published in journals indexed in PubMed. Time to publication was comparable to that of other specialties. Fewer than 2 of every 5 reports were published are in a family medicine journal, suggesting vast breadth in family medicine research. Family medicine academicians need to refocus efforts on transforming presentations into published articles in peer-reviewed journals for broader dissemination of research findings.

Expanding models for rural primary care in West Virginia.

This review paper outlines current and newer rural healthcare organizational models to improve availability and access to healthcare services for our state's large rural population. Included in the review are several suggested models for addressing rural healthcare needs: (a) the rural interdisciplinary medical home model; (b) the spoke and wheel model; (c) medical center/community linkages; (d) technology-based outreach modalities, such as tele-health; (e) part-time physician care and (f) expanding the role of health education centers to improve rural primary care. The overall goal is to stimulate exploration, funding and adoption of some of these models and advocate novel methods of addressing and reducing healthcare disparities in rural West Virginia.

Patient opinion regarding patient-centered medical home fundamentals.

OBJECTIVES: Although conceptually there is agreement on how the Patient-Centered Medical Home (PCMH) should be organized, there is little information regarding which PCMH components are the most important to patients. METHODS: An anonymous, voluntary survey was administered to patients at three US academic medical centers. Questions sought opinions regarding the National Committee for Quality Assurance's key components and essential elements of the PCMH. Analysis of the survey responses was conducted using SAS version 9.1. RESULTS: A total of 780 surveys were returned. Patients expressed believing strongly that the ability to coordinate care, help patients to manage their own disease, and track laboratory results were the most important aspects of a PCMH office. There were no differences in response to the survey according to age, sex, race, or site. Patients listed care coordination, patient self-management, and improved access to care as the top priority attributes of a PCMH. CONCLUSIONS: Patients were consistent in their opinions that care coordination, access, and patient self-management were the most important elements of a PCMH.

Tea and coffee consumption and MRSA nasal carriage.

PURPOSE: Hot tea and coffee have been found to have antimicrobial properties. The purpose of this study was to determine whether the consumption of tea, coffee, or both is associated with less frequent nasal carriage of methicillin-resistant Staphylococcus aureus (MRSA). METHODS: We performed a secondary analysis of data from the 2003-2004 National Health and Nutrition Examination Survey to investigate the relationship between the consumption of coffee, hot tea, cold tea, and soft drinks, and MRSA nasal carriage among the noninstitutionalized population of the United States. RESULTS: An estimated 2.5 million persons (1.4% of the population) were MRSA nasal carriers. In an adjusted logistic regression analysis controlling for age, race, sex, poverty-income ratio, current health status, hospitalization in the past 12 months, and use of antibiotics in the past month, individuals who reported consuming hot tea were one-half as likely to have MRSA nasal carriage relative to individuals who drank no hot tea (odds ratio = 0.47; 95% confidence interval, 0.31-0.71). Similarly, individuals who reported consuming coffee had about a one-half reduction in the risk of MRSA nasal carriage relative to individuals who drank no coffee (odds ratio = 0.47; 95% confidence interval, 0.24-0.93). CONCLUSIONS: Consumption of hot tea or coffee is associated with a lower likelihood of MRSA nasal carriage. Our findings raise the possibility of a promising new method to decrease MRSA nasal carriage that is safe, inexpensive, and easily accessible.

The effect of a cryotherapy gel wrap on the microcirculation of skin affected by chronic venous disorders.

AIM: The aim of this randomized clinical trial was to investigate a cryotherapy (cooling) gel wrap applied to lower leg skin affected by chronic venous disorders to determine whether therapeutic cooling improves skin microcirculation. BACKGROUND: Chronic venous disorders are under-recognized vascular health problems that result in severe skin damage and ulcerations of the lower legs. Impaired skin microcirculation contributes to venous leg ulcer development, thus new prevention therapies should address the microcirculation to prevent venous leg ulcers. METHODS: Sixty participants (n = 30 per group) were randomized to receive one of two daily 30-minute interventions for four weeks. The treatment group applied the cryotherapy gel wrap around the affected lower leg skin, or compression and elevated the legs on a special pillow each evening at bedtime. The standard care group wore compression and elevated the legs only. Laboratory pre- and post-measures included microcirculation measures of skin temperature with a thermistor, blood flow with a laser Doppler flowmeter, and venous refill time with a photoplethysmograph. Data were collected between 2008 2009 and analysed using descriptive statistics, paired t-tests or Wilcoxon signed ranks tests, logistic regression analyses, and mixed model analyses. RESULTS: Fifty-seven participants (treatment = 28; standard care = 29) completed the study. The mean age was 62 years, 70% female, 50% African American. In the final adjusted model, there was a statistically significant decrease in blood flow between the two groups (-6.2[-11.8; -0.6], P = 0.03). No statistically significant differences were noted in temperature or venous refill time. CONCLUSION: Study findings suggest that cryotherapy improves blood flow by slowing movement within the microcirculation and thus might potentially provide a therapeutic benefit to prevent leg ulcers.

A Relationship Between Mortality and Eating Breakfast and Fiber.

BACKGROUND: Recent studies suggest that intermittent fasting or skipping breakfast may be good strategies for weight loss and better health. The objective of this study was to determine whether regular breakfast is associated with overall or cardiovascular mortality. METHODS: Cohort study with follow-up mortality data from the NHANES 1999-2002. National weighted sample. Outcomes were overall and cardiovascular mortality; secondary was fiber intake. RESULTS: Out of 5761 participants, there were 4778 (82.9%) identified as breakfast eaters and 2027 deaths (35.2%); 469 (23.1%) deaths were due to cardiovascular diseases. The average daily intake of calories was 2015, and fiber was 16.3 g/day. A total of 17.7%, 66.0%, and 11.4% of participants had diabetes, hypertension, and cardiovascular diseases, respectively. Analysis showed breakfast eaters were older, had lower body mass index, and ate more calories and fiber daily than non-breakfast eaters. Cox proportional hazard regression analyses showed that compared to non-breakfast eaters, the breakfast eaters were less likely to experience mortality after multivariable adjustments (overall mortality: hazard ratio [HR], 0.69; 95% confidence interval [CI], 0.57-0.84 and cardiovascular mortality: HR, 0.45; 95% CI, 0.32-0.63). For the breakfast eaters, fiber intake >25 g/day was associated with 21% (HR, 0.79; 95% CI, 0.66-0.96) reduction in all-cause mortality after multivariable adjustments. CONCLUSIONS: Regular daily intake of breakfast appears to be associated with lower overall and cardiovascular mortality, particularly when consuming fiber >25 g/day. Further studies examining specific breakfast foods and the timing of foods would be helpful.

Association of urinary polycyclic aromatic hydrocarbons and serum C-reactive protein.

The association of 9 urinary monohydroxy polycyclic aromatic hydrocarbons (OH-PAHs) with serum C-reactive protein (CRP) was investigated using the National Health and Nutrition Examination Survey (NHANES) 2003-2004. The unweighted number of participants included was 999, which represented 139,362,776 persons in the non-institutionalized US population. In adjusted logistic regressions, two OH-PAHs, 2-hydroxyphenanthrene and 9-hydroxyfluorene, were associated with elevated CRP (>3mg/l). Logistic regressions were adjusted for age, gender, race, exercise, body mass index, smoking status, diabetes, and hypertension. 2-Hydroxyphenanthrene >148ng/g creatinine had an odds ratio of 3.17 (95% CI 1.73-5.81) compared to 2-hydroxyphenanthrene < or =48ng/g creatinine, and 9-hydroxyfluorene >749ng/g creatinine had an odds ratio of 2.28 (95% CI 1.08-4.83) compared to 9-hydroxyfluorene < or =160ng/g creatinine. Intermediate levels of 2-hydroxyphenanthrene (49-148ng/g creatinine), and 9-hydroxyfluorene (161-749ng/g creatinine) were also significantly associated with elevated CRP compared to the respective reference categories. In a combined analysis, OH-PAHs were classified as low, medium, and high. Low OH-PAH was 2-hydroxyphenanthrene < or =48ng/g creatinine and 9-hydroxyfluorene < or =160ng/g creatinine. High OH-PAH was 2-hydroxyphenanthrene >148ng/g creatinine or 9-hydroxyfluorene >749ng/g creatinine. Participants not assigned to the low or high categories were classified as having medium OH-PAH concentrations. Compared to the low OH-PAH group, high OH-PAH had an odds ratio of 3.60 (95% CI 2.01-6.46) in an adjusted logistic regression. Given that inflammation (characterized here by CRP) is an important factor in the development of atherosclerosis and cardiovascular disease, these results suggest a role for OH-PAHs in the progression of atherosclerosis.

Impact of a policy allowing for over-the-counter statins.

BACKGROUND: allowing statins to be sold without a prescription has been widely debated in Great Britain, Canada and the USA. AIMS: To examine the impact of the recent policy in Great Britain allowing patients to purchase over-the-counter (OTC) 10 mg dose of a cholesterol-lowering drug (simvastatin) on meeting the needs of individuals at moderate risk of coronary heart disease (CHD). METHODS: we undertook an analysis of adults (aged >20 years) in the nationally representative 2006 Health Survey for England (HSE, n =10 007). We evaluated the proportion of individuals using OTC statins among all adults aged 20 years and over and among individuals eligible for them according to current guidelines. RESULTS: among adults in the HSE, 44.1% met the criteria for referral to a general practitioner for CHD risk, 9.7% were eligible for OTC statins and 46.1% did not meet the eligibility for prescribed or OTC statin therapy. Less than 1% (0.7%) were taking OTC statins. The proportion of individuals using OTC statins among those eligible for them was low and comparable to that in the overall population (0.2%). Among those taking OTC statins, 71.5% were also taking prescribed lipid lowering agents. CONCLUSION: these results suggest that the aim of addressing the treatment gap among individuals at moderate risk by offering access to OTC statins has not been achieved two years after the implementation of the policy.

Glucosamine/Chondroitin and Mortality in a US NHANES Cohort.

BACKGROUND: Limited previous studies in the United Kingdom or a single US state have demonstrated an association between intake of glucosamine/chondroitin and mortality. This study sought to investigate the association between regular consumption of glucosamine/chondroitin and overall and cardiovascular (CVD) mortality in a national sample of US adults. METHODS: Combined data from 16,686 participants in National Health and Nutrition Examination Survey 1999 to 2010, merged with the 2015 Public-use Linked Mortality File. Cox proportional hazards models were conducted for both CVD and all-cause mortality. RESULTS: In the study sample, there were 658 (3.94%) participants who had been taking glucosamine/chondroitin for a year or longer. During followup (median, 107 months), there were 3366 total deaths (20.17%); 674 (20.02%) were due to CVD. Respondents taking glucosamine/chondroitin were less likely to have CVD mortality (hazard ratio [HR] = 0.51; 95% CI, 0.28-0.92). After controlling for age, use was associated with a 39% reduction in all-cause (HR = 0.61; 95% CI, 0.49-0.77) and 65% reduction (HR = 0.35; 95% CI, 0.20-0.61) in CVD mortality. Multivariable-adjusted HR showed that the association was maintained after adjustment for age, sex, race, education, smoking status, and physical activity (all-cause mortality, HR = 0.73; 95% CI, 0.57-0.93; CVD mortality, HR = 0.42; 95% CI, 0.23-0.75). CONCLUSIONS: Regular intake of glucosamine/chondroitin is associated with lower all-cause and CVD mortality in a national US cohort and the findings are consistent with previous studies in other populations. Prospective studies to confirm the link may be warranted.

Improving Chronic Obstructive Pulmonary Disease (COPD) Symptoms Using a Team-Based Approach.

BACKGROUND: Chronic obstructive pulmonary disease (COPD) is the third leading cause of death in the United States (US), with West Virginia bearing a disproportionate disease burden. Complex COPD cases can be difficult to manage during a standard primary care provider (PCP) visit, and pharmacological treatment regimens should be individually tailored to each patient. METHODS: To address these needs, the West Virginia University Department of Family Medicine created an interdisciplinary COPD specialty clinic that uses a team-based approach to treat patients with COPD. In order to evaluate the effectiveness of the specialty clinic, we conducted a retrospective chart review to examine the impact of the clinic on patient hospitalizations, emergency department visits, and urgent care visits six months and one year before and after initiating care at the clinic. We also examined the impact of the clinic on patients' self-reported nicotine dependency, COPD symptoms, and tobacco use behavior. Patients referred to the clinic and having at least one visit from February 2015 to February 2019 were included in this study (n = 149). RESULTS: Patients treated at the COPD specialty clinic had significantly fewer hospital admissions and ED visits six months after and one year after initiating care at the clinic as compared to six months before and one year before, respectively. Patients at this clinic also reported smoking significantly fewer cigarettes per day with significantly fewer self-identifying as smokers and experiencing significantly reduced COPD symptoms. CONCLUSION: An interdisciplinary, team-based approach was effective for improving the health of COPD patients in an Appalachian academic primary care practice.

The impact of fiber supplementation on ADMA levels.

BACKGROUND: Asymmetric dimethylarginine (ADMA) is an emerging biomarker that has been associated with oxidative metabolism and increased cardiovascular risk. Little information is available regarding the effect of diet on ADMA. METHODS: The authors studied 86 overweight/obese adults as part of a clinical trial of psyllium supplementation to determine whether 3 months of such supplementation would affect ADMA levels. Forty-one people in the intervention group received 14 g/day of psyllium in addition to their usual diet compared with 45 controls who followed their usual diet alone. The 2 groups were comparable at baseline in demographic characteristics and body mass index. RESULTS: Baseline ADMA levels were elevated in this overweight/obese population compared with published reference values in healthy individuals (0.75 vs 0.50 micromol/L). The change in ADMA levels over 3 months was not different in the psyllium group compared with the control group (-.03 vs -.01 micromol/L, P=.73). CONCLUSIONS: These findings do not support a significant effect of psyllium fiber supplementation on ADMA.