Availability of cancer care services and the organization of care delivery at critical access hospitals.

INTRODUCTION: Critical access hospitals (CAHs) provide an opportunity to meet the needs of individuals with cancer in rural areas. Two common innovative care delivery methods include the use of traveling oncologists and teleoncology. It is important to understand the availability and organization of cancer care services in CAHs due to the growing population with cancer and expected declines in oncology workforce in rural areas. METHODS: Stratified random sampling was used to generate a sample of 50 CAHs from each of the four U.S. Census Bureau-designated regions resulting in a total sample of 200 facilities. Analyses were conducted from 135 CAH respondents to understand the availability of cancer care services and organization of cancer care across CAHs. RESULTS: Almost all CAHs (95%) provided at least one cancer screening or diagnostic service. Forty-six percent of CAHs reported providing at least one component of cancer treatment (chemotherapy, radiation, or surgery) at their facility. CAHs that offered cancer treatment reported a wide range of health care staff involvement, including 34% of respondents reporting involvement of a local oncologist, 38% reporting involvement of a visiting oncologist, and 28% reporting involvement of a non-local oncologist using telemedicine. CONCLUSION: Growing disparities within rural areas emphasize the importance of ensuring access to timely screening and guideline-recommended treatment for cancer in rural communities. These data demonstrated that CAHs are addressing the growing need through a variety of approaches including the use of innovative models that utilize non-local providers and telemedicine to expand access to crucial services for rural residents with cancer.

Cultivating across "pockets of excellence": challenges to sustaining efforts to improve osteoporosis care.

We conducted in-depth, semi-structured interviews with clinicians involved in bone health care to understand the challenges of implementing and sustaining bone health care interventions. Participants identified individual- and system-level challenges to care delivery, implementation, and sustainment. We discuss opportunities to address challenges through a commitment to relationship- and infrastructure-building support. PURPOSE: Osteoporosis and fracture-related sequalae exact significant individual and societal costs; however, identification and treatment of at-risk patients are troublingly low, especially among men. The purpose of this study was to identify challenges to implementing and sustaining bone health care delivery interventions in the Veterans Health Administration. METHODS: We conducted interviews with endocrinologists, pharmacists, primary care physicians, rheumatologists, and orthopedic surgeons involved in bone health care (n = 20). Interviews were audio-recorded and transcribed verbatim. To determine thematic domains, we engaged in an iterative, qualitative content analysis of the transcripts. RESULTS: Participants reported multiple barriers to delivering bone health care and to sustaining the initiatives designed to address delivery challenges. Challenges of bone health care delivery existed at both the individual level-a lack of patient and clinician awareness and competing clinical demands-and the system level-multiple points of entry to bone health care, a dispersion of patient management, and guideline variability. To address the challenges, participants developed initiatives targeting the identification of at-risk patients, clinician education, increasing communication, and care coordination. Sustaining initiatives, however, was challenged by staff turnover and the inability to achieve and maintain priority status for bone health care. CONCLUSION: The multiple, multi-level barriers to bone health care affect both care delivery processes and sustainment of initiatives to improve those processes. Barriers to care delivery, while tempered by intervention, are entangled and persist alongside sustainment challenges. These challenges require relationship- and infrastructure-building support.

Relationship of the neutrophil/lymphocyte ratio with cardiovascular risk markers in premenopausal and postmenopausal women.

INTRODUCTION: Cardiovascular disease is more frequent in postmenopausal women. Atherosclerosis is associated with inflammation and the neutrophil/lymphocyte ratio (NLR) is a marker of inflammation whose behavior in postmenopause is unknown. AIM OF THE STUDY: To know the relationship of the NLR with cardiovascular risk markers in premenopausal and postmenopausal women. MATERIAL AND METHODS: Premenopausal and postmenopausal women were studied, in all of them a complete hemogram and the NLR, platelet/lymphocyte ratio (PLR) were calculated, also glucose and lipids levels were measured. In all of them subcutaneous and visceral fat, carotid intima-media thickness (IMT), epicardial fat were measured by ultrasound Also baseline and and after flow-mediated stimulus the arterial diameter, the pulsatility index and the resistive index of the brachial artery were measured by ultrasound. The results are reported with medians and intervals, Mann-Whitney U and Spearman correlation analysis were performed. RESULTS: Eighty two patients were recruited, 41 premenopausal and 41 postmenopausal. When comparing both groups there was no difference in glucose, lipids, NLR, PLR, carotid IMT, epicardial fat, subcutaneous fat, visceral fat or Doppler parameters of the brachial artery. CONCLUSION: NLR was not different between premenopausal and postmenopausal women but abnormal PLR was greater in those postmenopausal with vasomotor symptoms.