Evaluating Quality of Care for Patients with Asthma in the Readmission Penalty Era.

RATIONALE: Asthma poses a significant burden for US patients and health systems, yet inpatient care quality is understudied. National chronic obstructive lung disease (COPD) readmission policies may affect inpatient asthma care through hospital responses to these polices due to imprecise diagnosis and identification of patients with COPD and asthma. OBJECTIVES: Evaluate inpatient care quality care for patients hospitalized with asthma and potential collateral effects of the Medicare COPD Hospital Readmissions Reduction Program (HRRP). METHODS: Retrospective cohort study of patients aged 18-54 years hospitalized for asthma across 924 US hospitals (Premier Healthcare Database). RESULTS: Care quality for patients with asthma was evaluated pre-HRRP implementation (n=20,820; January 2010-September 2014) and post-HRRP implementation (n=26,885; October 2014-December 2018) using adherence to inpatient care guidelines (recommended, non-recommended, and "ideal care" [all recommended with no non-recommended care]). Between 2010-2018, at least 80% of patients received recommended care annually. Recommended care decreased similarly (rate of 0.02%/month) post vs. pre-HRRP (p=0.8). Non-recommended care decreased more rapidly post-HRRP (rate of 0.29%/month) vs. pre-HRRP (rate of 0.17%/month; p<0.001) with changes driven largely by decreased antibiotic prescribing. Ideal care increased more rapidly post-HRRP (rate of 0.25%/month) vs. pre-HRRP (rate of 0.17%/month; p=0.02) with changes driven largely by non-recommended care improvements. CONCLUSIONS: Post-HRRP trends suggest asthma care improved with increased rates of guideline concordance in non-recommended and ideal care. While federal policies (e.g., HRRP) may have had positive collateral effects such as with asthma care, parallel care efforts including antibiotic stewardship likely contributed to these improvements.

Coconstruction of Supramolecular Lithium-Conducting Cross-Linked Networks Based on PVDF and Triblock Polymer Nanomicrosphere Solid-State Polymer Electrolytes for Lithium-Metal Batteries.

Uneven lithium plating and low ionic conductivity currently impede the realization of high-capacity rechargeable lithium metal batteries. And the conventional poly(ethylene oxide) (PEO) solid-state electrolytes are unsuitable for high-energy-density Li anode applications due to their low lithium-ion transference number and high reactivity with Li metal, leading to detrimental dendrite formation and potentially hazardous exothermic reactions with the electrolyte. In this study, we employ a supramolecular approach to develop a novel polymer solid-state electrolyte based on poly(vinylidene fluoride) (PVDF) and a novel triblock polymer nanomicrosphere, (poly(ε-caprolactone)-poly(ethylene glycol)-poly(ε-caprolactone), (PCL-PEG-PCL). The abundance of carbonyl and ether-oxygen functional groups in PCL-PEG-PCL enhances the lithium coordination environment within the polymer solid-state electrolyte. Additionally, the original C-F moieties of PVDF form hydrogen bonds with C-H and terminal hydroxyl groups in PCL-PEG-PCL, collectively creating a multichannel fast Li+-conducting supramolecular cross-linked network. The resulting electrolyte demonstrates a high ionic conductivity of 1.4 × 10-3 S cm-1 and an extended electrochemical window of 5.2 V. Moreover, the electrolyte exhibits a high lithium-ion transference number (tLi+ = 0.63) at room temperature and exhibits excellent interfacial compatibility with the lithium metal anode. For the resulting electrolyte utilized in LiFePO4 batteries, the capacity retention of the cells assembled with this electrolyte exceeds 91.3% after 1000 cycles at 25 °C and 2 C (0.281 mA cm-2).

The role of YAP/TAZ on joint and arthritis.

Osteoarthritis (OA) and rheumatoid arthritis (RA) are two common forms of arthritis with undefined etiology and pathogenesis. Yes-associated protein (YAP) and its homolog transcriptional coactivator with PDZ-binding motif (TAZ), which act as sensors for cellular mechanical and inflammatory cues, have been identified as crucial players in the regulation of joint homeostasis. Current studies also reveal a significant association between YAP/TAZ and the pathogenesis of OA and RA. The objective of this review is to elucidate the impact of YAP/TAZ on different joint tissues and to provide inspiration for further studying the potential therapeutic implications of YAP/TAZ on arthritis. Databases, such as PubMed, Cochran Library, and Embase, were searched for all available studies during the past two decades, with keywords "YAP," "TAZ," "OA," and "RA."

Neighborhood-level factors associated with COVID-19 vaccination rates: a case study in Chicago.

INTRODUCTION: Chicago's deeply-rooted racial and socioeconomic residential segregation is a pattern mirrored in other major cities, making it a prototype for studying the uptake of public health interventions across the US. Residential segregation is related to availability of primary care, sense of community, and trust in the healthcare system, components which are essential in the response to crises like Covid-19 in which vaccine rollout was primarily community-based. We aimed to evaluate the association between rates of access to primary care and community-belonging with Covid-19 vaccination within Chicago's neighborhoods. METHODS: Data from Chicago Department of Public Health (12/2020-6/2022) on Covid-19 vaccination rates, race/ethnicity (% Black and % Hispanic/Latinx residents), age (% >65), gender (% female), socioeconomic status (% below the federal poverty line), access to needed care rate, and rate of self-reported sense of community-belonging on the neighborhood level were analyzed. Linear mixed models (LMMs) were used to study the impact of variables on vaccination; each neighborhood was added as a random effect to account for with-community association. RESULTS: The average Covid-19 vaccination rates across Chicago's neighborhoods was 79%, ranging from 37 to 100%, with median 81%. We found that Covid-19 vaccination rates were positively correlated with access to needed care (p < 0.001) and community-belonging (p < 0.001). Community areas that had lower vaccination rates had greater percentage of Black residents (p < 0.0001) and greater poverty rates (p < 0.0001). After adjusting for poverty, race, gender and age in the models, the association between vaccination rates and access to care or community-belonging were no longer significant, but % Black residents and poverty remained significant. CONCLUSIONS: Though access to needed primary care and community-belonging are correlated with vaccination rates, this association was not significant when controlling for demographic factors. The association between poverty, race and vaccination status remained significant, indicating that socioeconomic and racial disparities across Chicago drive Covid-19 vaccine recommendation adherence regardless of care access. Understanding how poverty, and its intersectional relation to race and primary care access, affects vaccination should be a priority for public health efforts broadly.

BTLA contributes to acute-on-chronic liver failure infection and mortality through CD4+ T-cell exhaustion.

B- and T-lymphocyte attenuator (BTLA) levels are increased in patients with hepatitis B virus-related acute-on-chronic liver failure (HBV-ACLF). This condition is characterized by susceptibility to infection and T-cell immune exhaustion. However, whether BTLA can induce T-cell immune exhaustion and increase the risk of infection remains unclear. Here, we report that BTLA levels are significantly increased in the circulating and intrahepatic CD4+ T cells from patients with HBV-ACLF, and are positively correlated with disease severity, prognosis, and infection complications. BTLA levels were upregulated by the IL-6 and TNF signaling pathways. Antibody crosslinking of BTLA activated the PI3K-Akt pathway to inhibit the activation, proliferation, and cytokine production of CD4+ T cells while promoting their apoptosis. In contrast, BTLA knockdown promoted their activation and proliferation. BTLA-/- ACLF mice exhibited increased cytokine secretion, and reduced mortality and bacterial burden. The administration of a neutralizing anti-BTLA antibody reduced Klebsiella pneumoniae load and mortality in mice with ACLF. These data may help elucidate HBV-ACLF pathogenesis and aid in identifying novel drug targets.

Assembly of porous filaments by interfacial complexation of nanochitin-based Pickering emulsion and seaweed alginate.

Interfacial polyelectrolyte complexation spinning is an all-water, easy-to-operate method for production of composite filaments. Herein, this concept is extended to interfacial polyelectrolyte-emulsion complexation (IPEC) that better encodes structural and functional attributes of biomass substances into the filaments. This allows for formation of composite filaments by drawing contacting oppositely-charged chitin nanofiber-stabilized Pickering emulsion and seaweed alginate solution. The parameters affecting spinnability of the system including water-to-oil ratio, alginate concentration, and pH are comprehensively elucidated to support the design and application of IPEC. The composite filaments exhibit varied diameters and diverse porous structures that are adjustable by properties of Pickering droplets. The droplet diameter of precursor emulsion and pore size in the filaments are well correlated, revealing controllability of the IPEC spinning. The filaments are mechanically robust in dry condition and show stable performance even in wet condition. The release rate of filaments that is pre-loaded with hydrophilic drug is regulated by the internal pore size, showing capability on sustained release. This study offers a new perspective toward dry spinning via interfacial complexation of complicated nanochitin-based structural building blocks, aiming at developing high-performance fiber materials for advanced applications.

Diabetes Life Expectancy Prediction Model Inputs and Results From Patient Surveys Compared With Electronic Health Record Abstraction: Survey Study.

Background: Prediction models are being increasingly used in clinical practice, with some requiring patient-reported outcomes (PROs). The optimal approach to collecting the needed inputs is unknown. Objective: Our objective was to compare mortality prediction model inputs and scores based on electronic health record (EHR) abstraction versus patient survey. Methods: Older patients aged ≥65 years with type 2 diabetes at an urban primary care practice in Chicago were recruited to participate in a care management trial. All participants completed a survey via an electronic portal that included items on the presence of comorbid conditions and functional status, which are needed to complete a mortality prediction model. We compared the individual data inputs and the overall model performance based on the data gathered from the survey compared to the chart review. Results: For individual data inputs, we found the largest differences in questions regarding functional status such as pushing/pulling, where 41.4% (31/75) of participants reported difficulties that were not captured in the chart with smaller differences for comorbid conditions. For the overall mortality score, we saw nonsignificant differences (P=.82) when comparing survey and chart-abstracted data. When allocating participants to life expectancy subgroups (<5 years, 5-10 years, >10 years), differences in survey and chart review data resulted in 20% having different subgroup assignments and, therefore, discordant glucose control recommendations. Conclusions: In this small exploratory study, we found that, despite differences in data inputs regarding functional status, the overall performance of a mortality prediction model was similar when using survey and chart-abstracted data. Larger studies comparing patient survey and chart data are needed to assess whether these findings are reproduceable and clinically important.

Enhancing Chronic-Disease Education through Integrated Medical and Social Care: Exploring the Beneficial Role of a Community Teaching Kitchen in Oregon.

Teaching kitchens (TKs) are rapidly being utilized as models to integrate culinary education and chronic-disease education into healthcare settings. Our observational study details the structure and organizational processes (e.g., referral, services, medical and social care integration) of the Community TK at Providence Milwaukie Hospital in Portland, OR. We utilize electronic medical-record data from engaged TK participants (n = 3077) to evaluate between the association of engagement and clinical outcomes (e.g., HbA1c, blood pressure, weight and cholesterol). Mean baseline HbA1c of Highly Engaged TK patients with diabetes (n = 88) reduced from 9.8% to 8.6% at 6 months (p < 0.0001) and sustained significant reductions at 12, 18, 24, 30, and 36 months (p < 0.05). Highly Engaged patients with hypertension (n = 152) had significant, sustained reductions in blood pressure (p < 0.0001). Engaged patients in the same high-risk groups also had significant improvements in HbA1c and blood pressure. Both engagement subgroups had moderate improvements in weight change and cholesterol. This study shows promising associations of TK services that promote chronic-disease self-management with improved clinical outcomes among higher risk patients (e.g., high blood pressure, high HbA1c, high low-density lipoprotein) with different medical issues (e.g., diabetes, obesity) and social barriers (e.g., food insecurity).

Evaluating Effects of Virtual Diabetes Group Visits in Community Health Centers During the COVID-19 Pandemic.

Diabetes is the seventh leading cause of death in the US. Diabetes group visits (GVs), which include group education and individual medical visits have been shown to improve clinical outcomes. However, few studies have evaluated virtual GVs. We conducted a single-arm pilot study to test the impact of virtual diabetes GVs in Midwestern community health centers (CHCs). Adult patients with diabetes participated in monthly virtual GVs for 6 months. Surveys and chart abstraction were used to assess patient-reported and clinical outcomes. Five CHCs implemented virtual GVs with 34 patients attending at least one session. Virtual GVs show promise as evidenced by these findings: (1) Patients had a nonsignificant decrease in A1C. (2) In the subgroup of patients with baseline A1C ≥ 9%, there was a significant decrease in A1C. (3) Patients had significant increases in diabetes knowledge and support as well as a decrease in diabetes distress. Future studies with a larger sample size and a control comparison group are needed to assess the impact of virtual GVs on patient outcomes.

Optimized CRISPR/Cas9 system for gene knockout in chicken DF1 cells.

The editing efficiency primarily hinders the utility of Clustered Regularly Interspaced Short Palindromic Repeats (CRISPR) technology in poultry. For a better understanding of the factors that influence the efficiency of gene knockout mediated by CRISPR/Cas9 in chicken DF1 cells, the single or dual single guide RNA (sgRNA) targeted exon regions of genes (taking anti-Müllerian hormone, TGF-beta receptor type-2 and Peroxisome proliferator-activated receptor gamma as examples) were designed. The sgRNA-CRISPR/Cas9 vectors with corresponding reporter vectors were transfected into DF1 cells. T7 endonuclease 1 (T7E1) and amplicon sequencing assay were compared for evaluating genome editing efficiency and the indel profiles were analyzed based on the data of amplicon sequencing. Meanwhile, to evaluate the precision of Cas9 cleavage, we also analyzed the homology of small insertion with the nucleotides of upstream and downstream of cleave sties. The surrogate reporter systems showed strong enrichment function, and the indel percentages were increased after puromycin selection. The indel ratios of T7E1 assay were lower than amplicon sequencing assay, which indicated T7E1 isn't fit to be used as the sole evaluation criterion for the targeting efficiency of CRISPR/Cas9. Based on the amplicon sequencing analysis, the editing efficiency showed noticeable differences among cells treated with different sgRNAs. However, the variety of indel efficiencies was not related to the GC content of sgRNA or chromosome types of targeted genes. The results showed that the dual sgRNA might not raise the indel ratios compared with individual sgRNA, but they could increase the ratios of the fragment deletions. The present study suggested that the surrogate reporter was an effective method to promote the editing efficiencies of CRISPR/Cas9 in chicken cells. The dual sgRNA could increase the fragment deletions, and the sensitivity of amplicon sequencing to detect cleavage was higher than the T7 endonuclease 1 assay. These results are essential to improve the application of CRISPR/Cas9 technology in chicken cells.

Role of m6A modification in immune microenvironment of digestive system tumors.

Digestive system tumors are huge health problem worldwide, largely attributable to poor dietary choices. The role of RNA modifications in cancer development is an emerging field of research. RNA modifications are associated with the growth and development of various immune cells, which, in turn, regulate the immune response. The majority of RNA modifications are methylation modifications, and the most common type is the N6-methyladenosine (m6A) modification. Here, we reviewed the molecular mechanism of m6A in the immune cells and the role of m6A in the digestive system tumors. However, further studies are required to better understand the role of RNA methylation in human cancers for designing diagnostic and treatment strategies and predicting the prognosis of patients.

Population Health Management Approach to Depression Symptom Monitoring in Primary Care via Patient Portal: A Randomized Controlled Trial.

Depression is undertreated in primary care. Using patient portals to administer regular symptom assessments could facilitate more timely care. At an urban academic medical center outpatient clinic, patients with active portal accounts and depression on their problem list or a positive screen in the past year were randomized to assessment during triage at visits (usual care) versus usual care plus assessment via portal (population health care). Portal invitations were sent regardless of whether patients had scheduled appointments. More patients completed assessments in the population health care arm than usual care: 59% versus 18%, P < 0.001. Depression symptoms were more common among patients who completed their initial assessment via the portal versus in the clinic. In the population health care arm, 57% (N = 80/140) of patients with moderate-to-severe symptoms completed at least 1 follow-up assessment versus 37% (N = 13/35) in usual care. A portal-based population health approach could improve depression monitoring in primary care.

Visible-Light-Induced Stoichiometric Coupling of Alkylarenes and Trifluoromethyl Ketones.

A visible-light induced direct C(sp3)-H functionalization of alkylarenes with trifluoromethyl ketones has been reported to access valuable benzyl-substituted trifluoromethyl alcohols in a stoichiometric manner. Readily available petroleum-derived alkylarenes are employed as latent benzylation reagents. With a bromine radical as the hydrogen atom transfer reagent, primary, secondary, and tertiary benzyl C-H bonds are suitable coupling partners. Additionally, the late-stage modification of bioactive molecules highlights the potential application of this approach.

Structural Maintenance of Chromosome Protein 4 Promotes the Progression of Cardia Adenocarcinoma via Regulation of the Wnt/ß-catenin Signaling Pathway.

BACKGROUND: Structural maintenance of chromosome protein 4 (SMC4) is crucial for chromosome assembly and separation, but its role and mechanism in cardia adenocarcinoma (CA) are unknown. METHODS: SMC4 expression levels were initially detected by protein profiling in 20 pairs of CA tumor tissues and adjacent normal tissues. The level of SMC4 expression in CA cells was then evaluated using a western blot analysis. Cell proliferation was evaluated by CCK-8 and clone formation tests. Scratch and transwell tests were used to investigate cell migration as well as invasion, while through the flow cytometry, we examined the cell apoptosis and progression of the cell cycle. The regulatory effects of the epithelial-mesenchymal transition (EMT) and the Wnt/ß-catenin pathway were investigated using western blot. A tumorigenesis experiment was used to investigate the influence of SMC4 on tumor development in nude mice. RESULTS: This study showed overexpression of SMC4 in CA tissues and cells. Knockdown of SMC4 can significantly inhibit the proliferation, migration and invasion, stimulate cell apoptosis, induce cell cycle arrest in the G0/G1 phase of CA cells, and inhibit tumor growth in vivo. In addition, down-regulation of SMC4 resulted in decreased expression of Bcl-2, Cyclin D1, CDK4, CDK6, ß-catenin, phosphorylated GSK-3ß, N-cadherin, and Vimentin, with an increased level of proteins, i.e., Bax, cleaved-caspase3, and E-cadherin. When SMC4 was overexpressed, these effects were reversed. CONCLUSION: SMC4 can facilitate the biological progression of CA, suggesting that SMC4 could be a potential therapeutic target for the disease.

Inhibition of HBV replication by EVA1A via enhancing cellular degradation of HBV components and its potential therapeutic application.

Hepatitis B virus (HBV) DNA is much higher during HBeAg-positive chronic HBV infection (EP-CBI) than during HBeAg-negative chronic HBV infection (EN-CBI), although the necroinflammation in liver is minimal and the adaptive immune response is similar in both phases. We previously reported that mRNA levels of EVA1A were higher in EN-CBI patients. In this study, we aimed to investigate whether EVA1A inhibits HBV gene expression and examine the underlying mechanisms. The available cell models for HBV replication and model HBV mice were used to investigate how EVA1A regulates HBV replication and the antiviral activity based on gene therapy. The signaling pathway was determined through RNA sequencing analysis. The results demonstrated that EVA1A can inhibit HBV gene expression in vitro and in vivo. In particular, EVA1A overexpression resulted in accelerated HBV RNA degradation and activation of the PI3K-Akt-mTOR pathway, two processes that directly and indirectly inhibiting HBV gene expression. EVA1A is a promising candidate for treating chronic hepatitis B (CHB). In conclusion, EVA1A is a new host restriction factor that regulates the HBV life cycle via a nonimmune process.

Evaluating inhaler education interventions for hospitalized children with asthma: A randomized controlled trial.

BACKGROUND: Most children with asthma have poor inhaler technique, with detrimental morbidity effects. Guidelines recommend clinicians provide inhaler education at every opportunity, yet resources are limited. A low-cost, technology-based intervention-Virtual Teach-to-Goal (V-TTG)-was developed to deliver tailored inhaler technique education with high fidelity. OBJECTIVE: To evaluate whether V-TTG leads to less inhaler misuse among children with asthma who are hospitalized vs brief intervention (BI, reading steps aloud). METHODS: A single-center randomized controlled trial of V-TTG vs BI was conducted with 5-to-10-year-old children with asthma hospitalized between January 2019 and February 2020. Inhaler technique was assessed pre- and post-education using 12-step validated checklists (misuse: < 10 steps correct). RESULTS: Among 70 children enrolled, mean age was 7.8 years (SD = 1.6). Most (86%) were Black. Most had an emergency department visit (94%) or hospitalization (90%) in the previous year. At baseline, nearly all children misused inhalers (96%). The proportion of children with inhaler misuse decreased significantly in V-TTG (100%→74%, P = .002) and BI (92%→69%, P = .04) groups, with no difference between groups at both time points (P = .2 and .9). On average, children performed 1.5 more steps correctly (SD = 2.0), with greater improvement with V-TTG (mean [SD] = 1.7 [1.6]) vs BI (mean [SD] = 1.4 [2.3]), though not significant (P = .6). Concerning pre and post technique, older children were significantly more likely than younger children to show more correct steps (mean change = 1.9 vs 1.1, P = .002). CONCLUSION: A technology-based intervention for tailored inhaler education led to improved technique among children, similarly to reading steps aloud. Older children saw greater benefits. Future studies should evaluate the V-TTG intervention across diverse populations and disease severities to identify the greatest impact. CLINICAL TRIAL REGISTRATION: NCT04373499.

New Frontiers in Diabetes Care: Quality Improvement Study of a Population Health Team in Rural Critical Access Hospitals.

BACKGROUND: Rural populations are older, have higher diabetes prevalence, and have less improvement in diabetes-related mortality rates compared to urban counterparts. Rural communities have limited access to diabetes education and social support services. OBJECTIVE: Determine if an innovative population health program that integrates medical and social care models improves clinical outcomes for patients with type 2 diabetes in a resource-constrained, frontier area. DESIGN/PARTICIPANTS: Quality improvement cohort study of 1764 patients with diabetes (September 2017-December 2021) at St. Mary's Health and Clearwater Valley Health (SMHCVH), an integrated health care delivery system in frontier Idaho. The United States Department of Agriculture's Office of Rural Health defines frontier as sparsely populated areas that are geographically isolated from population centers and services. INTERVENTION: SMHCVH integrated medical and social care through a population health team (PHT), where staff assess medical, behavioral, and social needs with annual health risk assessments and provide core interventions including diabetes self-management education, chronic care management, integrated behavioral health, medical nutritional therapy, and community health worker navigation. We categorized patients with diabetes into three groups: patients with two or more PHT encounters during the study (PHT intervention), one PHT encounter (minimal PHT), and no PHT encounters (no PHT). MAIN MEASURES: HbA1c, blood pressure, and LDL over time for each study group. KEY RESULTS: Of the 1764 patients with diabetes, mean age was 68.3 years, 57% were male, 98% were white, 33% had three or more chronic conditions, and 9% had at least one unmet social need. PHT intervention patients had more chronic conditions and higher medical complexity. Mean HbA1c of PHT intervention patients significantly decreased from baseline to 12 months (7.9 to 7.6%, p < 0.01) and sustained reductions at 18 months, 24 months, 30 months, and 36 months. Minimal PHT patients decreased HbA1c from baseline to 12 months (7.7 to 7.3%, p < 0.05). CONCLUSION: The SMHCVH PHT model was associated with improved hemoglobin A1c among less well-controlled patients with diabetes.

Improving Diabetes Care Through Population Health Innovations and Payments: Lessons from Western Maryland.

BACKGROUND: Global budgets might incentivize healthcare systems to develop population health programs to prevent costly hospitalizations. In response to Maryland's all-payer global budget financing system, University of Pittsburgh Medical Center (UPMC) Western Maryland developed an outpatient care management center called the Center for Clinical Resources (CCR) to support high-risk patients with chronic disease. OBJECTIVE: Evaluate the impact of the CCR on patient-reported, clinical, and resource utilization outcomes for high-risk rural patients with diabetes. DESIGN: Observational cohort study. PARTICIPANTS: One hundred forty-one adult patients with uncontrolled diabetes (HbA1c > 7%) and one or more social needs who were enrolled between 2018 and 2021. INTERVENTIONS: Team-based interventions that provided interdisciplinary care coordination (e.g., diabetes care coordinators), social needs support (e.g., food delivery, benefits assistance), and patient education (e.g., nutritional counseling, peer support). MAIN MEASURES: Patient-reported (e.g., quality of life, self-efficacy), clinical (e.g., HbA1c), and utilization outcomes (e.g., emergency department visits, hospitalizations). KEY RESULTS: Patient-reported outcomes improved significantly at 12 months, including confidence in self-management, quality of life, and patient experience (56% response rate). No significant demographic differences were detected between patients with or without the 12-month survey response. Baseline mean HbA1c was 10.0% and decreased on average by 1.2 percentage points at 6 months, 1.4 points at 12 months, 1.5 points at 18 months, and 0.9 points at 24 and 30 months (P<0.001 at all timepoints). No significant changes were observed in blood pressure, low-density lipoprotein cholesterol, or weight. The annual all-cause hospitalization rate decreased by 11 percentage points (34 to 23%, P=0.01) and diabetes-related emergency department visits also decreased by 11 percentage points (14 to 3%, P=0.002) at 12 months. CONCLUSIONS: CCR participation was associated with improved patient-reported outcomes, glycemic control, and hospital utilization for high-risk patients with diabetes. Payment arrangements like global budgets can support the development and sustainability of innovative diabetes care models.

Exploring the Value of Improvisational Theater in Medical Education for Advancing the Doctor-Patient Relationship and Health Equity.

PURPOSE: Health care inequities persist, and it is difficult to teach health professions students effectively about implicit bias, structural inequities, and caring for patients from underrepresented or minoritized backgrounds. Improvisational theater (improv), where performers create everything in a spontaneous and unplanned manner, may help teach health professions trainees about advancing health equity. Core improv skills, discussion, and self-reflection can help improve communication; build trustworthy relationships with patients; and address bias, racism, oppressive systems, and structural inequities. METHOD: Authors integrated a 90-minute virtual improv workshop using basic exercises into a required course for first-year medical students at University of Chicago in 2020. Sixty randomly chosen students took the workshop and 37 (62%) responded to Likert-scale and open-ended questions about strengths, impact, and areas for improvement. Eleven students participated in structured interviews about their experience. RESULTS: Twenty-eight (76%) of 37 students rated the workshop as very good or excellent, and 31 (84%) would recommend it to others. Over 80% of students perceived their listening and observation skills improved, and that the workshop would help them take better care of patients with experiences different than their own. Six (16%) students experienced stress during the workshop but 36 (97%) felt safe. Eleven (30%) students agreed there were meaningful discussions about systemic inequities. Qualitative interview analysis showed that students thought the workshop helped develop interpersonal skills (communication, relationship building, empathy); helped personal growth (insights into perception of self and others, ability to adapt to unexpected situations); and felt safe. Students noted the workshop helped them to be in the moment with patients and respond to the unexpected in ways more traditional communication curricula have not. The authors developed a conceptual model relating improv skills and equity teaching methods to advancing health equity. CONCLUSIONS: Improv theater exercises can complement traditional communication curricula to advance health equity.