Designing a Framework for Remote Cancer Care Through Community Co-design: Participatory Development Study.

BACKGROUND: Recent shifts to telemedicine and remote patient monitoring demonstrate the potential for new technology to transform health systems; yet, methods to design for inclusion and resilience are lacking. OBJECTIVE: The aim of this study is to design and implement a participatory framework to produce effective health care solutions through co-design with diverse stakeholders. METHODS: We developed a design framework to cocreate solutions to locally prioritized health and communication problems focused on cancer care. The framework is premised on the framing and discovery of problems through community engagement and lead-user innovation with the hypothesis that diversity and inclusion in the co-design process generate more innovative and resilient solutions. Discovery, design, and development were implemented through structured phases with design studios at various locations in urban and rural Kentucky, including Appalachia, each building from prior work. In the final design studio, working prototypes were developed and tested. Outputs were assessed using the System Usability Scale as well as semistructured user feedback. RESULTS: We co-designed, developed, and tested a mobile app (myPath) and service model for distress surveillance and cancer care coordination following the LAUNCH (Linking and Amplifying User-Centered Networks through Connected Health) framework. The problem of awareness, navigation, and communication through cancer care was selected by the community after framing areas for opportunity based on significant geographic disparities in cancer and health burden resource and broadband access. The codeveloped digital myPath app showed the highest perceived combined usability (mean 81.9, SD 15.2) compared with the current gold standard of distress management for patients with cancer, the paper-based National Comprehensive Cancer Network Distress Thermometer (mean 74.2, SD 15.8). Testing of the System Usability Scale subscales showed that the myPath app had significantly better usability than the paper Distress Thermometer (t63=2.611; P=.01), whereas learnability did not differ between the instruments (t63=-0.311; P=.76). Notable differences by patient and provider scoring and feedback were found. CONCLUSIONS: Participatory problem definition and community-based co-design, design-with methods, may produce more acceptable and effective solutions than traditional design-for approaches.

Longitudinal analysis of cost and dental utilization patterns for older adults in outpatient and long-term care settings in Minnesota.

BACKGROUND: Dental utilization patterns and costs of providing comprehensive oral healthcare for older adults in different settings have not been examined. METHODS: Retrospective longitudinal cohort data from Apple Tree Dental (ATD) were analyzed (N = 1,159 total; 503 outpatients, 656 long-term care residents) to describe oral health status at presentation, service utilization patterns, and care costs. Generalized estimating equation (GEE) repeated measures analysis identified significant contributors to service cost over the three-year study period. RESULTS: Cohort mean age was 74 years (range = 55-104); the outpatient (OP) group was younger compared to the long-term care (LTC) group. Half (56%) had Medicaid, 22% had other insurance, and 22% self-paid. Most (72%) had functional dentitions (20+ teeth), 15% had impaired dentitions (9-19 teeth), 6% had severe tooth loss (1-8 teeth), and 7% were edentulous (OP = 2%, LTC = 11%). More in the OP group had functional dentition (83% vs. 63% LTC). The number of appointments declined from 5.0 in Year 1 (OP = 5.7, LTC = 4.4) to 3.3 in Year 3 (OP = 3.6, LTC = 3.0). The average cost to provide dental services was $1,375/year for three years (OP = $1,427, LTC = $1,336), and costs declined each year, from an average of $1,959 (OP = $2,068, LTC = $1,876) in Year 1 to $1,016 (OP = $989, LTC = $1,037) by Year 3. Those with functional dentition at presentation were significantly less costly than those with 1-19 teeth, while edentulous patients demonstrated the lowest cost and utilization. Year in treatment, insurance type, dentition type, and problem-focused first exam were significantly associated with year-over-year cost change in both OP and LTC patients. CONCLUSION: Costs for providing comprehensive dental care in OP and LTC settings were similar, modest, and declined over time. Dentate patients with functional dentition and edentulous patients were less costly to treat. LTC patients had lower utilization than OP patients. Care patterns shifted over time to increased preventive care and decreased restorative care visits.

Molecular features of the copper binding sites in the octarepeat domain of the prion protein.

Recent evidence suggests that the prion protein (PrP) is a copper binding protein. The N-terminal region of human PrP contains four sequential copies of the highly conserved octarepeat sequence PHGGGWGQ spanning residues 60-91. This region selectively binds Cu2+ in vivo. In a previous study using peptide design, EPR, and CD spectroscopy, we showed that the HGGGW segment within each octarepeat comprises the fundamental Cu2+ binding unit [Aronoff-Spencer et al. (2000) Biochemistry 40, 13760-13771]. Here we present the first atomic resolution view of the copper binding site within an octarepeat. The crystal structure of HGGGW in a complex with Cu2+ reveals equatorial coordination by the histidine imidazole, two deprotonated glycine amides, and a glycine carbonyl, along with an axial water bridging to the Trp indole. Companion S-band EPR, X-band ESEEM, and HYSCORE experiments performed on a library of 15N-labeled peptides indicate that the structure of the copper binding site in HGGGW and PHGGGWGQ in solution is consistent with that of the crystal structure. Moreover, EPR performed on PrP(23-28, 57-91) and an 15N-labeled analogue demonstrates that the identified structure is maintained in the full PrP octarepeat domain. It has been shown that copper stimulates PrP endocytosis. The identified Gly-Cu linkage is unstable below pH approximately 6.5 and thus suggests a pH-dependent molecular mechanism by which PrP detects Cu2+ in the extracellular matrix or releases PrP-bound Cu2+ within the endosome. The structure also reveals an unusual complementary interaction between copper-structured HGGGW units that may facilitate molecular recognition between prion proteins, thereby suggesting a mechanism for transmembrane signaling and perhaps conversion to the pathogenic form.