The Diverse Implementation of Geriatrics-Orthopedics Comanagement Programs in the United States.

BACKGROUND: Many health systems are establishing geriatrics-orthopedics (Geri-Ortho) comanagement programs; however, there is paucity of published information on existing programs' variations in clinical operations, structure, and reported implementation challenges and perceived successes. OBJECTIVE: Our objective was to obtain detailed information about the variety of existing Geri-Ortho comanagement programs in the United States. DESIGN/PARTICPANTS: We conducted a cross-sectional survey of 44 existing Geri-Ortho comanagement programs, with 23 (52%) of programs responding. MEASUREMENT: Quantitative questions were used to assess operational, staffing, and financial structures; and qualitative questions were used to identify reported challenges and perceived successes of implementation. RESULTS: Programs self-identified as urban (n = 23), academic (n = 20), or nonprofit (n = 22) and as having a level I trauma center (n = 17). Most programs (n = 18) were funded fully by the institution. Fourteen programs used geriatricians, and nine used medicine/hospitalists as the supporting clinical service, whereas approximately half (n = 11) used these services in a true comanagement model. Six universal themes were identified as necessary for program implementation. The most commonly described successes perceived by all respondents were improvements in clinical outcomes and better interdisciplinary relationships. Reported challenges included difficulty in interdisciplinary geriatrics education, difficulty in adherence to protocols, and lack of funding for staffing. CONCLUSIONS: There are diverse types of Geri-Ortho comanagement programs in the United States, although universal elements exist. Many had similar challenges in implementation, and further studies are needed to determine which implementation elements are critical to clinical and financial outcomes. J Am Geriatr Soc 68:1714-1719, 2020.

Combined diabetes-renal multifactorial intervention in patients with advanced diabetic nephropathy: Proof-of-concept.

AIMS: To evaluate efficacy of a multifactorial-multidisciplinary approach in delaying CKD 3-4 progression to ESRD. METHODS: Two-year proof-of-concept stratified randomized control trial conducted in an outpatient clinic of a large public hospital system. This intervention, led by a team of endocrinologists, nephrologists, nurse practitioners, and registered dietitians, integrated intensive diabetes-renal care with behavioral/dietary and pharmacological interventions. 120 low-income adults with T2DM and CKD 3-4 enrolled; 58% male, 55% African American, 23% Hispanic. RESULTS: Primary outcome was progression rate from CKD 3-4 to ESRD. Fewer intervention (13%) than control (28%) developed ESRD, p<0.05. Intervention had greater albumin/creatinine ratio (ACR) decrease (62% vs. 42%, p<0.05) and A1C<7% attainment (50% vs. 30%, p<0.05) and trended toward better lipid/blood pressure control (p=NS). Significant differences between 25 ESRD and 95 ESRD-free patients were baseline eGFR (28 vs. 40ml/min/1.73m2), annual eGFR decline (15 vs. 3ml/min/year), baseline ACR (2362 vs. 1139mg/g), final ACR (2896 vs. 1201mg/g), and final A1C (6.9 vs. 7.8%). In multivariate Cox analysis, receiving the intervention reduced hazard ratio to develop ESRD (0.125, CI 0.029-0.54) as did higher baseline eGFR (0.69, CI 0.59-0.80). Greater annual eGFR decline increased hazard ratio (1.59, CI 1.34-1.87). CONCLUSIONS: The intervention delayed ESRD. Improved A1C and ACR plus not-yet-identified variables may have influenced better outcomes. Multifactorial-multidisciplinary care may serve as a CKD 3-4 treatment paradigm.

Applying the COM-B model to creation of an IT-enabled health coaching and resource linkage program for low-income Latina moms with recent gestational diabetes: the STAR MAMA program.

BACKGROUND: One of the fastest growing risk groups for early onset of diabetes is women with a recent pregnancy complicated by gestational diabetes, and for this group, Latinas are the largest at-risk group in the USA. Although evidence-based interventions, such as the Diabetes Prevention Program (DPP), which focuses on low-cost changes in eating, physical activity and weight management can lower diabetes risk and delay onset, these programs have yet to be tailored to postpartum Latina women. This study aims to tailor a IT-enabled health communication program to promote DPP-concordant behavior change among postpartum Latina women with recent gestational diabetes. The COM-B model (incorporating Capability, Opportunity, and Motivational behavioral barriers and enablers) and the Behavior Change Wheel (BCW) framework, convey a theoretically based approach for intervention development. We combined a health literacy-tailored health IT tool for reaching ethnic minority patients with diabetes with a BCW-based approach to develop a health coaching intervention targeted to postpartum Latina women with recent gestational diabetes. Current evidence, four focus groups (n = 22 participants), and input from a Regional Consortium of health care providers, diabetes experts, and health literacy practitioners informed the intervention development. Thematic analysis of focus group data used the COM-B model to determine content. Relevant cultural, theoretical, and technological components that underpin the design and development of the intervention were selected using the BCW framework. RESULTS: STAR MAMA delivers DPP content in Spanish and English using health communication strategies to: (1) validate the emotions and experiences postpartum women struggle with; (2) encourage integration of prevention strategies into family life through mothers becoming intergenerational custodians of health; and (3) increase social and material supports through referral to social networks, health coaches, and community resources. Feasibility, acceptability, and health-related outcomes (weight loss, physical activity, consumption of healthy foods, breastfeeding, and glucose screening) will be evaluated at 9 months postpartum using a randomized controlled trial design. CONCLUSIONS: STAR MAMA provides a DPP-based intervention that integrates theory-based design steps. Through systematic use of behavioral theory to inform intervention development, STAR MAMA may represent a strategy to develop health IT intervention tools to meet the needs of diverse populations. TRIAL REGISTRATION: ClinicalTrials.gov NCT02240420.

Chemotherapeutic and targeted biological agents for metastatic bladder cancer: a comprehensive review.

The American Cancer Society estimates that 73 510 new cases of bladder cancer will be diagnosed and 15 000 deaths will result this year. The paper summarizes the clinical evidence for the use of platinum-based, non-platinum-based and new targeted biological agents, while reporting the future directions in the treatment of metastatic bladder cancer. For cisplatin-base regimens, the combination of methotrexate, vinblastine, doxorubicin and cisplatin (M-VAC) has been the mainstream treatment for both advanced and metastatic bladder cancers. It showed significant improvement in the complete response rate and overall survival time in comparison with single-agent cisplatin. For cisplatin-ineligible patients, namely patients with renal impairment, symptomatic cardiac disease and poor performance status, alternative therapies consisting of paclitaxel, gemcitabine and carboplatin were shown to be of benefit. Pemetrexed and vinflunine have also shown effectiveness, with small but demonstrable overall survival benefits. Gemcitabine-based doublet therapies (combined with paclitaxel, docetaxel, irinotecan, oxaliplatin or epirubicin) have all been shown to be effective and well-tolerated. Several new targeted therapies, such as gefetinib, sorafenib and lapatinib, have received attention in recent years; however, their effectiveness as single agents in a relapse setting have not been optimal and more studies are warranted.

Characteristics of patients with type 2 diabetes mellitus in two rural, medically underserved communities.

In the state of Hawai'i, Native Hawaiians and Filipinos suffer from increased disparities, compared to other groups, in diabetes prevalence and adverse health outcomes that are exacerbated by challenges to health care access among rural communities. To address the limited literature describing rural, underserved patients with diabetes in Hawai'i, this paper aims to characterize two rural communities that are located on Moloka'i and Lana'i in federally-designated medically underserved areas and that are served by a single Native Hawaiian health care system entitled Na Pu'uwai. Descriptive analyses examining associations between variables were performed using the baseline demographic information, clinical measures, and questionnaire responses collected from 40 adult study participants with diabetes. The data revealed that the study participants had a high prevalence of insulin use (60%); a HbA1c level greater than or equal to 9% (55%); a high-fat diet (73%); and comorbidities, including hyperlipidemia (85%), hypertension (83%), and obesity (70%). Furthermore, among the participants, the mean SF-12v2™ General Health Perceptions Score was significantly lower for participants with uncontrolled diabetes compared to those with controlled diabetes (P = .02); however, this association was not statistically significant in the multivariable regression model that adjusted for age and number of diabetes medications. Based on these results, the participants appear to belong to a high-risk group with a complicated manifestation of diabetes. This study adds to the growing body of literature demonstrating disparities in diabetes among rural, minority, and underserved communities, highlighting the need for further investigation, development, and implementation of strategies for reaching these vulnerable populations.