Disparities in Diabetes Care: Differences Between Rural and Urban Patients Within a Large Health System.

PURPOSE: We sought to ascertain factors associated with the quality of diabetes care, comparing rural vs urban diabetic patients in a large health care system. METHODS: We conducted a retrospective cohort study assessing patients' attainment of the D5 metric, a diabetes care metric having 5 components (no tobacco use, glycated hemoglobin [A1c] level less than 8%, blood pressure less than 140/90 mm Hg, low-density lipoprotein cholesterol level at goal or statin prescribed, and aspirin use consistent with clinical recommendations). Covariates included age, sex, race, adjusted clinical group (ACG) score as a marker of complexity, insurance type, primary care clinician type, and health care use data. RESULTS: The study cohort consisted of 45,279 patients with diabetes, 54.4% of whom resided in rural locations. The D5 composite metric was met in 39.9% of rural patients and 43.2% of urban patients (P <.001). Rural patients were significantly less likely to have attained all metric goals than urban counterparts (adjusted odds ratio [AOR] = 0.93; 95% CI, 0.88-0.97). The rural group had fewer outpatient visits (mean number of visits = 3.2 vs 3.9, P <.001) and less often had an endocrinology visit (5.5% vs 9.3%, P <.001) during the 1-year study period. Patients with an endocrinology visit were less likely to have met the D5 metric (AOR = 0.80; 95% CI, 0.73-0.86), whereas the more outpatient visits patients had, the greater their likelihood of attainment (AOR per visit = 1.03; 95% CI, 1.03-1.04). CONCLUSIONS: Rural patients had worse diabetes quality outcomes than their urban counterparts, even after adjustment for other contributing factors and despite being part of the same integrated health system. Lower visit frequency and less specialty involvement in the rural setting are possible contributing factors.

Acute pain pathways: protocol for a prospective cohort study.

INTRODUCTION: Opioid analgesics are often used to treat moderate-to-severe acute non-cancer pain; however, there is little high-quality evidence to guide clinician prescribing. An essential element to developing evidence-based guidelines is a better understanding of pain management and pain control among individuals experiencing acute pain for various common diagnoses. METHODS AND ANALYSIS: This multicentre prospective observational study will recruit 1550 opioid-naïve participants with acute pain seen in diverse clinical settings including primary/urgent care, emergency departments and dental clinics. Participants will be followed for 6 months with the aid of a patient-centred health data aggregating platform that consolidates data from study questionnaires, electronic health record data on healthcare services received, prescription fill data from pharmacies, and activity and sleep data from a Fitbit activity tracker. Participants will be enrolled to represent diverse races and ethnicities and pain conditions, as well as geographical diversity. Data analysis will focus on assessing patients' patterns of pain and opioid analgesic use, along with other pain treatments; associations between patient and condition characteristics and patient-centred outcomes including resolution of pain, satisfaction with care and long-term use of opioid analgesics; and descriptive analyses of patient management of leftover opioids. ETHICS AND DISSEMINATION: This study has received approval from IRBs at each site. Results will be made available to participants, funders, the research community and the public. TRIAL REGISTRATION NUMBER: NCT04509115.

Interventions for Increasing Digital Equity and Access (IDEA) among rural patients who smoke: Study protocol for a pragmatic randomized pilot trial.

BACKGROUND: Cigarette smoking prevalence is higher among rural compared with urban adults, yet access to cessation programming is reduced. The Increasing Digital Equity and Access (IDEA) study aims to evaluate three digital access and literacy interventions for promoting engagement with an online evidence-based smoking cessation treatment (EBCT) program among rural adults. METHODS: The pilot trial will use a pragmatic, three-arm, randomized, parallel-group design with participants recruited from a Midwest community-based health system in Minnesota, Wisconsin, and Iowa. All participants will receive an online, 12-week, EBCT program, and written materials on digital access resources. Participants will be stratified based on state of residence and randomly assigned with 1:1:1 allocation to one of three study groups: (1) Control Condition-no additional study intervention (n = 30); (2) Loaner Digital Device-Bluetooth enabled iPad with data plan coverage loaned for the study duration (n = 30); (3) Loaner Digital Device + Coaching Support-loaner device plus up to six, 15-20 min motivational interviewing-based coaching calls to enhance participants' digital access and literacy (n = 30). All participants will complete study assessments at baseline and 4- and 12-weeks post-randomization. Outcomes are cessation program and trial engagement, biochemically confirmed smoking abstinence, and patient experience. RESULTS: A rural community advisory committee was formed that fostered co-design of the study protocol for relevance to rural populations, including the trial design and interventions. CONCLUSION: Study findings, processes, and resources may have relevance to other health systems aiming to foster digital inclusion in smoking cessation and chronic disease management programs and clinical trials in rural communities.

Rural Patient Experiences of Accessing Care for Chronic Conditions: A Systematic Review and Thematic Synthesis of Qualitative Studies.

PURPOSE: Access to health care is a long-standing concern for rural patients; however, administrative measures fail to capture the subjective patient experience of accessing health care. The purpose of this review was to synthesize the qualitative literature on patient and caregiver experiences of accessing health care services for chronic disease management among US residents of rural areas. METHODS: We searched Embase, MEDLINE, PsycInfo, CINAHL, and Scopus to identify qualitative studies published during 2010-2019. A thematic synthesis approach was used to analyze findings from included studies. RESULTS: A total of 62 studies involving 1,354 unique participants were included. The largest share of studies (24.2%) was focused on the experience of patients with cancer, followed by behavioral health (16.1%), HIV and AIDS (14.5%), and diabetes (12.9%). We identified 4 primary analytic themes of barriers and facilitators associated with the experience of accessing health care services for chronic disease management in rural areas: (1) navigating the rural environment, (2) navigating the health care system, (3) financing chronic disease management, and (4) rural life (ie, common elements of a distinct "rural" way of thinking and behaving). CONCLUSIONS: In this comprehensive review, we found that important cultural, structural, and individual factors influenced the rural patient's experience of health care access and use, including barriers and facilitators posed by geographic and built environments, and distinct rural mores. Our findings can inform policies and programs that both facilitate structural aspects of access and include culturally appropriate interventions.VISUAL ABSTRACT.

Pilot implementation to assess the feasibility and care team impact of an app-based interactive care plan to remotely monitor breast cancer survivors.

PURPOSE: To assess the feasibility of an app-based, electronic health record (EHR)-integrated, interactive care plan (ICP) for breast cancer (BC) survivors. METHODS: A single-arm pilot study was conducted with female BC survivors. ICP tasks included quarterly quality of life (QOL) questionnaire; monthly assessments of fatigue, insomnia, sexual dysfunction, hot flashes, and recurrence symptoms; and daily activity reminders. Embedded decision trees escalated recurrence symptoms to providers. On-demand education was available for self-management of treatment-related toxicities. The primary objective was to assess patients' engagement with ICP tasks against feasibility thresholds of 75% completion rate. Secondary objectives were evaluation of the system's functionality to track and escalate symptoms appropriately, and care team impact measured by volume of escalation messages generated. We report preliminary results 6 months after the last patient enrolled. RESULTS: Twenty-three patients enrolled August to November 2020. Mean age was 50.1 years. All patients engaged with at least one ICP task. The monthly average task completion rates were 62% for the QOL questionnaire, 59% for symptom assessments, and 37% for activity reminders. Task completion rate decreased over time. Eleven of 253 symptoms and QOL questionnaires (4.3%) generated messages for care escalation. CONCLUSION: Implementation of an app-based, EHR-integrated ICP in BC survivors was feasible and created minimal provider burden; however, patient engagement was below the feasibility threshold suggesting that changes may enhance broad implementation and adoption. IMPLICATIONS FOR CANCER SURVIVORS: An ICP may facilitate remote monitoring, symptom control, and recurrence surveillance for cancer survivors as strategies to enhance patient engagement are applied.

Association Between Area-Level Socioeconomic Deprivation and Diabetes Care Quality in US Primary Care Practices.

Importance: Diabetes management operates under a complex interrelationship between behavioral, social, and economic factors that affect a patient's ability to self-manage and access care. Objective: To examine the association between 2 complementary area-based metrics, area deprivation index (ADI) score and rurality, and optimal diabetes care. Design, Setting, and Participants: This cross-sectional study analyzed the electronic health records of patients who were receiving care at any of the 75 Mayo Clinic or Mayo Clinic Health System primary care practices in Minnesota, Iowa, and Wisconsin in 2019. Participants were adults with diabetes aged 18 to 75 years. All data were abstracted and analyzed between June 1 and November 30, 2020. Main Outcomes and Measures: The primary outcome was the attainment of all 5 components of the D5 metric of optimal diabetes care: glycemic control (hemoglobin A1c <8.0%), blood pressure (BP) control (systolic BP <140 mm Hg and diastolic BP <90 mm Hg), lipid control (use of statin therapy according to recommended guidelines), aspirin use (for patients with ischemic vascular disease), and no tobacco use. The proportion of patients receiving optimal diabetes care was calculated as a function of block group-level ADI score (a composite measure of 17 US Census indicators) and zip code-level rurality (calculated using Rural-Urban Commuting Area codes). Odds of achieving the D5 metric and its components were assessed using logistic regression that was adjusted for demographic characteristics, coronary artery disease history, and primary care team specialty. Results: Among the 31 934 patients included in the study (mean [SD] age, 59 [11.7] years; 17 645 men [55.3%]), 13 138 (41.1%) achieved the D5 metric of optimal diabetes care. Overall, 4090 patients (12.8%) resided in the least deprived quintile (quintile 1) of block groups and 1614 (5.1%) lived in the most deprived quintile (quintile 5), while 9193 patients (28.8%) lived in rural areas and 2299 (7.2%) in highly rural areas. The odds of meeting the D5 metric were lower for individuals residing in quintile 5 vs quintile 1 block groups (odds ratio [OR], 0.72; 95% CI, 0.67-0.78). Patients residing in rural (OR, 0.84; 95% CI, 0.73-0.97) and highly rural (OR, 0.81; 95% CI, 0.72-0.91) zip codes were also less likely to attain the D5 metric compared with those in urban areas. Conclusions and Relevance: This cross-sectional study found that patients living in more deprived and rural areas were significantly less likely to attain high-quality diabetes care compared with those living in less deprived and urban areas. The results call for geographically targeted population health management efforts by health systems, public health agencies, and payers.

New Apps Drive Health Care Innovation, Access to Care.

With the ubiquitous nature of smartphones, apps are a regular part of our day-to-day lives. They are also becoming a larger presence in health care, where they have the ability to expand access to care, help people monitor health changes, provide support for people living with chronic conditions, and coordinate communication between patients and their doctors. From detecting skin cancer to helping people with diabetes, new apps aim to change how people think about their health.

New Advances in Neurostimulation for Chronic Pain.

Around 50 million people in the United States live with-and suffer from-chronic pain. While some pain patients receive relief from physical therapy, medication, or surgery, others aren't helped by these treatments. "It's a debilitating situation," says Ryan Lakin, divisional vice president of R&D at Abbott. "Patients have trouble just living a normal life, doing a lot of things that we take for granted."

Follow-up Care for Breast Cancer Survivors.

Breast cancer survivorship guidelines recommend at least annual follow-up visits, yet the degree to which this occurs in clinical practice is uncertain. Claims data from a US commercial insurance database (OptumLabs) were used to identify women treated with curative intent surgery for newly diagnosed breast cancer between 2006 and 2014. In 25 035 women, median follow-up was 3 years. In the second year after surgery, 9.6% of the patients did not visit a primary care provider, an oncologist, or a surgeon (guideline-nonadherent). The guideline-nonadherent proportion increased from 7.8% in women diagnosed in 2006 to 12.2% in those diagnosed in 2014 (two-sided Wald P < .001). During years 2-6, guideline-nonadherence was also associated with older age, nonwhite race, no radiation, no chemotherapy, no endocrine therapy, and increasing time after surgery. There is a substantial and increasing rate of inadequate follow-up among breast cancer survivors. This has the potential to impair outcomes.

Novel approaches to support breast cancer survivorship care models.

The delivery of cancer survivorship care has been increasingly recognized as an area of healthcare in need of improvement. Several survivorship care models have previously been described in the literature. Yet, there is growing evidence that current models are both unsustainable for the future and fail to meet the diverse needs of cancer survivors. As a result, there has been an emphasis on developing innovative models of survivorship care that are accessible to patients and improve outcomes. Proposed solutions to address these concerns include enhanced collaboration and communication among care providers as well as incorporating the use of technology for survivorship care delivery. This article reviews existing models of survivorship care and describes future approaches to improve the care of breast cancer survivors.

Animal Models: New Biosensors and Technologies?Including Those for Bone Regrowth and Wound Healing?Advance Animal Health Care While Also Providing a Fertile Testing Ground for Human Health.

Dogs have bad breath. But when Montana sheep rancher Katy Harjes noticed her collie, Hoshi, had particularly bad breath and facial swelling, she was concerned that the symptoms might be a sign of something serious. She was right; ten-year-old Hoshi had squamous cell carcinoma, a common type of oral tumor found in dogs. The cancer had not metastasized, but the damage was extensive enough that part of Hoshi's lower jaw needed to be removed. Luckily, Hoshi was a suitable candidate for a stateof-the-art bone regrowth procedure developed by Frank Verstraete, B.V.Sc, Dr.Med.Vet., M.Med.Vet., and Boaz Arzi, D.V.M., oral surgeons at the University of California (UC), Davis, School of Veterinary Medicine. Consequently, Katy and Hoshi embarked on a 15-hour road trip to California.

Cancer Survivors: The Success Story That's Straining Health Care.

Since President Richard Nixon declared a "War on Cancer" in 1971, the number of cancer survivors in the United States has quadrupled [1] and is still rising. Thanks to advance in cancer detection and treatment, the almost 15 million cancer survivors in the United States today could grow to some 19 million by 2024 [2]. Increasing survival rates have resulted in a shift: cancer is often treated as a chronic illness rather than a death sentence. However, having so many cancer survivors to monitor, track, and treat has led to growing pains for healthcare providers-forcing them to develop new ways to treat this increasing yet still vulnerable population.

New Imaging Technology May Help Doctors Diagnose Amyloidosis: Due to stringent FDA rules, U.S. imaging of the disease has lagged behind Europe but a new synthetic molecule may change that.

One December day in 2013, Michael Rasmussen realized that just chewing his food made him tired. Short walks felt draining. At one point, he became so tired that he sat down and didn't get up for three days. Rasmussen had been a man in perfect health. For 30 years, he lived as an artist in the Aleutian Islands in Alaska and walked or biked everywhere. He even bicycled across the United States five times. But now he had slid into a horrible medical mystery.

Evaluation of the Aromatase Inhibition Potential of Freeze-Dried Grape Powder.

OBJECTIVE: To determine the role of freeze-dried grapes as a potential aromatase inhibitor by testing of plasma hormone levels. METHODS: A six-week study was conducted involving postmenopausal women during which 94 g of freeze-dried grape powder was consumed in addition to their usual diet. Plasma hormones were measured before and after the treatment. RESULTS: Of the 18 women involved in the study, average age and body mass index were 61.4 years and 24.4 respectively. For the hormone levels studied, the following median (interquartile range) percentage changes from baseline to six-week values were found: estradiol +11.8% (-34.4%, +44.2%), p = .42; estrone +3.4% (-15.7%, +12.9%), p = .64; estrone sulfate +5.3% (-19.9%, +56.3%), p = .35; testosterone -1.5% (-14.7%, +10.7%), p = .97; and androstenedione +12.6% (-17.1%, +49.1%), p = .15. The hormone levels did not significantly change between baseline and six weeks. Further, the changes that were observed did not tend to go in the hypothesized direction (estrogens and conjugates increased slightly, and testosterone decreased slightly). Only androstenedione showed a trend toward change in the hypothesized direction. CONCLUSIONS: In this study, there was no evidence that plasma hormone levels are altered by six weeks of daily consumption of 94 g of freeze-dried grape powder.

Chemoprevention of breast cancer.

The development of pharmacologic agents for the prevention of breast cancer is a significant milestone in medical and laboratory research. Despite these advances, the endorsement of preventive options has become challenging and complex, as physicians are expected to counsel and tailor their recommendations using a personalized approach taking into account medical comorbidities, degree of risk and patient preferences. This article provides a comprehensive overview of the major breast cancer prevention trials, review of the pharmacologic options available for breast cancer prevention, and strategies for integrating chemoprevention of breast cancer in high-risk women into clinical practice.

Patient understanding of the revised USPSTF screening mammogram guidelines: need for development of patient decision aids.

BACKGROUND: The purpose of the study was to examine patients' understanding of the revised screening mammogram guidelines released by the United States Preventive Services Task Force (USPSTF) in 2009 addressing age at initiation and frequency of screening mammography. METHODS: Patients from the Departments of Family Medicine, Internal Medicine, and Obstetrics and Gynecology (n = 150) at a tertiary care medical center in the United States completed a survey regarding their understanding of the revised USPSTF guidelines following their release, within four to six months of their scheduled mammogram (March 2010 to May 2010). RESULTS: Of the patients surveyed, 97/147 (67%) indicated increased confusion regarding the age and frequency of screening mammography, 61/148 (41%) reported increased anxiety about mammograms, and 58/146 (40%) reported anxiety about their own health status following the release of the revised screening guidelines. Most of the patients surveyed, 111/148 (75%), did not expect to change their timing or frequency of screening mammograms in the future. CONCLUSION: Results from this survey suggested increased confusion and possibly an increase in patients' anxiety related to screening mammography and their own health status following the release of the revised USPSTF screening mammogram guidelines to the public and subsequent media portrayal of the revised guidelines. Although the study did not specifically address causality for these findings, the results highlight the need for improvements in the communication of guidelines to patients and the public. Development of shared decision-making tools and outcomes should be considered to address the communication challenge.

The mammography controversy: when should you screen?

ACOG's new guidelines call for more frequent breast cancer screening. The USPSTF recommends less. What's best for your patients?

The neuronal splicing factor Nova controls alternative splicing in N-type and P-type CaV2 calcium channels.

Many cellular processes are involved in optimizing protein function for specific neuronal tasks; here we focus on alternative pre-mRNA splicing. Alternative pre-mRNA splicing gives cells the capacity to modify and selectively re-balance their existing pool of transcripts in a coordinated way across multiple mRNAs, thereby effecting relatively rapid and relatively stable changes in protein activity. Here we report on and discuss the coordinated regulation of two sites of alternative splicing, e24a and e31a, in P-type CaV2.1 and N-type CaV2.2 channels. These two exons encode 4 and 2 amino acids, respectively, in the extracellular linker regions between transmembrane spanning segments S3 and S4 in domains III and IV of each CaV2 subunit. Recent genome-wide screens of splicing factor-RNA binding events by Darnell and colleagues show that Nova-2 promotes inclusion of e24a in CaV2.2 mRNAs in brain. We review these studies and show that a homologous e24a is present in theCaV2 .1 gene, Cacna1a, and that it is expressed in different regions of the nervous system. Nova-2 enhances inclusion of e24a but represses e31a inclusion in CaV2.1 and CaV2.2 mRNAs in brain. It is likely that coordinated alternative pre-mRNA splicing across related CaV2 genes by common splicing factors, allows neurons to orchestrate changes in synaptic protein function while maintaining a balanced and functioning system.

Orexin neurons express a functional pancreatic polypeptide Y4 receptor.

The receptor subtypes that mediate the effects of neuropeptide Y (NPY) on food intake have not been clearly defined. The NPY Y4 receptor has been identified recently as a potential mediator of the regulation of food intake. The purpose of the present study was to characterize the central site of action of the Y4 receptor using a combination of neuroanatomical and physiological approaches. Using immunocytochemistry, Y4-like immunoreactivity was found to be colocalized with orexin cell bodies in the lateral hypothalamic area (LHA) and orexin fibers throughout the brain. In situ hybridization confirmed the expression of Y4 mRNA in orexin neurons. To determine the functional interaction between Y4 receptors and orexin neurons, we examined the effects of rat pancreatic polypeptide (rPP), a Y4-selective ligand, or NPY, a nonselective ligand, administered directly into the LHA on the stimulation of food and water intake and c-Fos expression. Both rPP and NPY significantly increased food and water intake when they were administered into the LHA, although NPY was a more potent stimulator of food intake. Furthermore, both NPY and rPP significantly stimulated c-Fos expression in the LHA. However, whereas rPP stimulated c-Fos expression in orexin neurons, NPY did not. Neither rPP nor NPY stimulated c-Fos in melanin-concentrating hormone neurons, but both activated neurons of an unknown phenotype in the LHA. These results suggest that a functional Y4 receptor is expressed on orexin neurons and that these neurons are activated in response to a ligand with high affinity for the Y4 receptor (rPP). Although these data suggest a role for central Y4 receptors, the endogenous ligand for this receptor has yet to be clearly established.