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.

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.

Meaningful conversations in living with and treating chronic conditions: development of the ICAN discussion aid.

BACKGROUND: The needs of the growing population of complex patients with multiple chronic conditions calls for a different approach to care. Clinical teams need to acknowledge, respect, and support the work that patients do and the capacity they mobilize to enact this work, and to adapt and self-manage. Tools that enable this approach to care are needed. METHODS: Using user-centered design principles, we set out to create a discussion aid for use by patients, clinicians, and other health professionals during clinical encounters. We observed clinical encounters, visited patient homes, and dialogued with patient support groups. We then developed and tested prototypes in routine clinical practice. Then we refined a final prototype with extensive stakeholder feedback. RESULTS: From this process resulted the ICAN Discussion Aid, a tool completed by the patient and reviewed during the consultation in which patients classified domains that contribute to capacity as sources of burden or satisfaction; clinical demands were also classified as sources of help or burden. The clinical review facilitated by ICAN generates hypotheses regarding why some treatment plans may be problematic and may not be enacted in the patient's situation. CONCLUSION: We successfully created a discussion aid to elucidate and share insights about the capacity patients have to enact the treatment plan and hypotheses as to why this plan may or may not be enacted. Next steps involve the evaluation of the impact of the ICAN Discussion Aid on clinical encounters with a variety of health professionals and the impact of ICAN-informed treatment plans on patient-important outcomes.

Alternative splicing: functional diversity among voltage-gated calcium channels and behavioral consequences.

Neuronal voltage-gated calcium channels generate rapid, transient intracellular calcium signals in response to membrane depolarization. Neuronal Ca(V) channels regulate a range of cellular functions and are implicated in a variety of neurological and psychiatric diseases including epilepsy, Parkinson's disease, chronic pain, schizophrenia, and bipolar disorder. Each mammalian Cacna1 gene has the potential to generate tens to thousands of Ca(V) channels by alternative pre-mRNA splicing, a process that adds fine granulation to the pool of Ca(V) channel structures and functions. The precise composition of Ca(V) channel splice isoform mRNAs expressed in each cell are controlled by cell-specific splicing factors. The activity of splicing factors are in turn regulated by molecules that encode various cellular features, including cell-type, activity, metabolic states, developmental state, and other factors. The cellular and behavioral consequences of individual sites of Ca(V) splice isoforms are being elucidated, as are the cell-specific splicing factors that control splice isoform selection. Altered patterns of alternative splicing of Ca(V) pre-mRNAs can alter behavior in subtle but measurable ways, with the potential to influence drug efficacy and disease severity. This article is part of a Special Issue entitled: Calcium channels.

Assessing the influence of landscape conservation and protected areas on social wellbeing using random forest machine learning.

The urgency of interconnected social-ecological dilemmas such as rapid biodiversity loss, habitat loss and fragmentation, and the escalating climate crisis have led to increased calls for the protection of ecologically important areas of the planet. Protected areas (PA) are considered critical to address these dilemmas although growing divides in wellbeing can exacerbate conflict around PAs and undermine effectiveness. We investigate the influence of proximity to PAs on wellbeing outcomes. We develop a novel multi-dimensional index of wellbeing for households and across Africa and use Random Forest Machine Learning techniques to assess the importance score of households' proximity to protected areas on their wellbeing outcomes compared with the importance scores of an array of other social, environmental, and local and national governance factors. This study makes important contributions to the conservation literature, first by expanding the ways in which wellbeing is measured and operationalized, and second, by providing additional empirical support for recent evidence that proximity to PAs is an influential factor affecting observed wellbeing outcomes, albeit likely through different pathways than the current literature suggests.

Development and acceptability of PETS-Now, an electronic point-of-care tool to monitor treatment burden in patients with multiple chronic conditions: a multi-method study.

BACKGROUND: The aim of this study was to develop a web-based tool for patients with multiple chronic conditions (MCC) to communicate concerns about treatment burden to their healthcare providers. METHODS: Patients and providers from primary-care clinics participated. We conducted focus groups to identify content for a prototype clinical tool to screen for treatment burden by reviewing domains and items from a previously validated measure, the Patient Experience with Treatment and Self-management (PETS). Following review of the prototype, a quasi-experimental pilot study determined acceptability of using the tool in clinical practice. The study protocol was modified to accommodate limitations due to the Covid-19 pandemic. RESULTS: Fifteen patients with MCC and 18 providers participated in focus groups to review existing PETS content. The pilot tool (named PETS-Now) consisted of eight domains (Living Healthy, Health Costs, Monitoring Health, Medicine, Personal Relationships, Getting Healthcare, Health Information, and Medical Equipment) with each domain represented by a checklist of potential concerns. Administrative burden was minimized by limiting patients to selection of one domain. To test acceptability, 17 primary-care providers first saw 92 patients under standard care (control) conditions followed by another 90 patients using the PETS-Now tool (intervention). Each treatment burden domain was selected at least once by patients in the intervention. No significant differences were observed in overall care quality between patients in the control and intervention conditions with mean care quality rated high in both groups (9.3 and 9.2, respectively, out of 10). There were no differences in provider impressions of patient encounters under the two conditions with providers reporting that patient concerns were addressed in 95% of the visits in both conditions. Most intervention group patients (94%) found that the PETS-Now was easy to use and helped focus the conversation with the provider on their biggest concern (98%). Most providers (81%) felt they had learned something new about the patient from the PETS-Now. CONCLUSION: The PETS-Now holds promise for quickly screening and monitoring treatment burden in people with MCC and may provide information for care planning. While acceptable to patients and clinicians, integration of information into the electronic medical record should be prioritized.

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.

Seeking Pain Relief With Fewer Side Effects.

For the one in five adults who suffer from chronic pain, treatment largely relies on pharmaceuticals, which can come with serious downsides [1]. "They mitigate pain, but in the long term lead to such significant side effects and consequences that the burden from the treatment many times starts to exceed the burden from disease, and it attacks the person's quality of life," says Padma Gulur, M.D., professor of anesthesiology and head of the Pain Relief and Opioid Mitigation Innovation Science (PROMIS) Laboratory, Duke University (Figure 1).

The Search for Pain Biomarkers.

For many medical conditions, clinicians can collect quantitative indicators of disease, such as heart rate, body temperature, or levels of a specific protein in a blood sample. For chronic pain, however, such biological markers have not yet been identified. This information gap occurs even though chronic pain is one of the most common reasons why adults seek medical care [1]. If they could be identified, biological markers (or "biomarkers") for chronic pain could improve patient care by giving doctors a more complete picture of a particular patient's condition.

The effect of primary care clinician type and care team characteristics on health care costs.

OBJECTIVE: To evaluate health care costs as a function of assigned primary care clinician type and care team characteristics. METHODS: Administrative data were collected for 68 family medicine clinicians (40 physicians and 28 nurse practitioners [NPs]/physician assistant [PAs]), on 11 care teams (variable MD, NP and PA on teams), caring for 77,141 patients. We performed a generalized linear mixed multivariable regression model of standardized per member per month (PMPM) median cost as the outcome, with four practice sites included as random effects. RESULTS: In bivariate analysis, cost was higher in physicians than NP/PAs, in more complex patients, and associated with emergency department (ED) visit rate. On multivariate analysis, patient complexity, ED visit rate and higher patient experience ratings were independently associated with greater PMPM cost. More time in practice was associated with lower PMPM cost. In the adjusted multivariate model, physicians had 8.3% lower median PMPM costs than NP/PAs (p = 0.046). CONCLUSIONS: The primary drivers of greater PMPM cost were patient complexity, ED visits and patient satisfaction.

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.

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.

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.

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.

Probing the Future of Psychedelics for Mental Health.

Mounting evidence suggests that psychedelics may be useful for treating a range of different neuropsychiatric conditions that currently have limited treatment options. On May 4-6, 2021, leaders from academia and industry discussed a variety of issues related to the development and adoption of psychedelic drugs for different conditions during the virtual Psychedelic Therapeutics and Drug Development Conference. Selected topics from the conference are presented below.

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."

Patient Voice and Mission: Why Do Patients Choose Family Medicine and What Do They Value?

Known gaps exist between what patients value and institutions prioritize. We sought to incorporate patients' reasons for valuing family medicine into a new Mission and Vision statement by deploying brief surveys to a convenience sample of patients. We conducted descriptive quantitative analyses of demographics and inductive content analysis of written responses. Patients returned 92 (20%) of 450 questionnaires. Responders were 63% female, mean age of 47 years. Patients noted distinguishing features of family medicine were (1) continuity of care, (2) all-encompassing care, and (3) trusted referrals. Some patients reported not knowing there was a distinction between family medicine and other primary care.

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.

Clinician Care Team Composition and Health Care Utilization.

OBJECTIVE: To test the hypothesis that a greater proportion of physician time on primary care teams are associated with decreased emergency department (ED) visits, hospital admissions, and readmissions, and to determine clinician and care team characteristics associated with greater utilization. PATIENTS AND METHODS: We retrospectively analyzed administrative data collected from January 1 to December 31, 2017, of 420 family medicine clinicians (253 physicians, 167 nurse practitioners/physician assistants [NP/PAs]) with patient panels in an integrated health system in 59 Midwestern communities serving rural and urban areas in Minnesota, Wisconsin, and Iowa. These clinicians cared for 419,581 patients through 110 care teams, with varying numbers of physicians and NP/PAs. Primary outcome measures were rates of ED visits, hospitalizations, and readmissions. RESULTS: The proportion of physician full-time equivalents on the team was unrelated to rates of ED visits (rate ratio [RR] = 0.826; 95% confidence interval [CI], 0.624 to 1.063), hospitalizations (RR = 0.894; 95% CI, 0.746 to 1.072), or readmissions (RR = -0.026; 95% CI, 0.364 to 0.312). In separate multivariable models adjusted for clinician and practice-level characteristics, the rate of ED visits was positively associated with mean panel hierarchical condition category (HCC) score, urban vs rural setting, NP/PA vs physician, and lower years in practice. The rate of inpatient admissions was associated with HCC score, and 30-day hospital readmissions were positively associated with HCC score, lower years in practice, and male clinicians. CONCLUSION: Care team physician and NP/PA composition was not independently related to utilization. More complex panels had higher rates of ED visits, hospitalization, and readmissions. Statistically significant differences between physician and NP/PA panels were only evident for ED visits.

Perinatal Mood and Anxiety Disorder Management in Multicenter Community Practices: Clinicians' Training, Current Practices and Perceived Strategies to Improve Future Implementation.

BACKGROUND: This study aimed to explore clinicians' perspectives on the current practice of perinatal mood and anxiety disorder (PMAD) management and strategies to improve future implementation. METHODS: This study had a cross-sectional, descriptive design. A 35-item electronic survey was sent to clinicians (N = 118) who treated perinatal women and practiced at several community clinics at an academic medical center in the United States. RESULTS: Among clinicians who provided care for perinatal women, 34.7% reported never receiving PMAD management training and 66.3% had less than 10 years of experience. Out of 10 patients who reported psychiatric symptoms, 47.8% of clinicians on average reported providing PMAD management to 1 to 3 patients and 40.7% noted that they conducted screening only when patient expresses PMAD symptoms. Suggested future improvements were providing training, developing a referral list, and establishing integrated behavioral health services. CONCLUSIONS: Results from this study indicated that while PMAD screening and management was implemented, improvements are warranted to meet established guidelines. Additionally, clinicians endorsed providing PMAD management to a small percentage of perinatal patients. Suggested strategies to increase adoption and implementation of PMAD management should be explored to improve access to behavioral health services for perinatal women.