Racial/Ethnic Health Disparities Among Rural Adults-United States, 2012-2015: <i>MMWR Surveillance Summaries</i> / November 17, 2017 / 66(23);1-9

The Role of Temperature, Wind Speed, and Precipitation on the Abundance of Culex Species and West Nile Virus Infection Rate in Rural West-Central Illinois

While most research on West Nile virus (WNV) and its main vector, the Culex mosquito, has been conducted in laboratory or urban settings, studies with field-caught mosquitoes in rural areas, such as west-central Illinois, are lacking. The objective of this research was to investigate key abiotic factors using macroclimate data, including temperature, precipitation, and wind speed, to determine their influence on field-caught mosquito abundance in 4 rural counties in Illinois from 2014 to 2016. Additionally, the relationship between minimum infection rate (MIR) and thermal time was examined. Using gravid traps at 15 sites, Culex mosquitoes were collected twice a week. A total of 5,255 adult female Culex mosquitoes (Cx. pipiens, Cx. quinquefasciatus, and Cx. restuans) were collected in 2014; 9,138 in 2015; and 5,702 in 2016. Regression models were developed based on outcomes of relationships between field-caught mosquitoes and abiotic factors. Precipitation and thermal time had the most significant relationship with mosquito abundance (r2 = 0.993 and r2 = 0.993, respectively), while wind speed was less (r2 = 0.714). The greatest number of Culex and the highest annual MIR were observed in 2015, which was also the driest of the 3 sampling seasons. Mosquito abundance was observed to increase with warmer degree days and MIR was found to increase with abundance in mosquitoes. These models can be used for other mosquito surveillance and monitoring studies in various climate types and environments.

Rural EMS STEMI Patients - Why the Delay to PCI?

BACKGROUND

The objective of this study is to identify patient and EMS agency factors associated with timely reperfusion of patients with ST-elevation myocardial infarction (STEMI).

METHODS

We conducted a cohort study of adult patients (≥18 years old) with STEMI activations from 2016 to 2020. Data was obtained from a regional STEMI registry, which included eight rural county EMS agencies and three North Carolina percutaneous coronary intervention (PCI) centers. On each patient, prehospital and in-hospital time intervals were abstracted. The primary outcome was the ability to achieve the 90-minute EMS FMC to PCI time goal (yes vs. no). We used generalized estimating equations accounting for within-agency clustering to evaluate the association between patient and agency factors and meeting first medical contact (FMC) to PCI time goal while accounting for clustering within the agency.

RESULTS

Among 365 rural STEMI patients 30.1% were female (110/365) with a mean age of 62.5 ± 12.7 years. PCI was performed within the time goal in 60.5% (221/365) of encounters. The FMC to PCI time goal was met in 45.5% (50/110) of women vs 69.8% (178/255) of men (p < 0.001). The median PCI center activation time was 12 min (IQR 7-19) in the group that received PCI within the time goal compared to 21 min (IQR 10-37) in the cohort that did not. After adjusting for loaded mileage and other clinical variables (e.g., pulse rate, hypertension etc.), the male sex was associated with an improved chance of meeting the goal of FMC to PCI (aOR: 2.94; 95% CI 2.11-4.10) compared to the female sex.

CONCLUSION

Nearly 40% of rural STEMI patients transported by EMS failed to receive FMC to PCI within 90 min. Women were less likely than men to receive reperfusion within the time goal, which represents an important health care disparity.

Native American Community Perspectives on Oral Health Access: Understanding the Impact of Rurality

PURPOSE

Oral health disparities related to access persist for American Indian/Alaska Native (AI/AN) communities compared to the general population, especially in rural areas of the United States. The objective of this study was to better understand community perspectives of oral health, how rurality impacts access to care, and attitudes towards the implementation of dental therapists in Oklahoma, particularly among the AI/AN population.

METHODS

A descriptive, observational study design was utilized. An exploratory survey was conducted online and comprised of qualitative and quantitative data. The total frequencies and percentages were evaluated for the quantitative questions. The qualitative data was analyzed using thematic analysis. Utilizing descriptive and qualitative research methods, the focus was to describe the experiences of the respondents and their characteristics related to oral health in Oklahoma.

RESULTS

A total of 201 responses were obtained, where 65% (n = 131) identified as an enrolled member or employee of a tribe represented in Oklahoma. Key qualitative themes included community access to care, community concerns, and community motivated solutions.

CONCLUSIONS

AI/AN communities are an underserved group in healthcare. Although communities in rural areas face major barriers to oral health services, evidence-based solutions can be implemented.

Exploring Barriers to the Inclusion of Underrepresented Minorities in Urology: The Temporal and Financial Costs of Residency Interviews

OBJECTIVE

To investigate whether interview travel cost and time differed for urology residency applicants from medical schools with higher versus lower proportions of students from groups underrepresented in medicine (URiMs).

METHODS

We identified 22 medical schools, 11 with <15% and 11 with >20% URiM students, and 17 "highly ranked" urology residency programs. We contacted the residency programs and requested interview dates, preferred lodging options, and institution-based cost-savings. We constructed interview itineraries for 22 hypothetical students (one from each school), and compared the total cost and time for travel to all 17 interviews. Total travel time and interview costs for the students at schools with <15% and >20% URiM were compared, with findings considered statistically significant at p<0.05.

RESULTS

Each student was able to attend all 17 interviews. The median total cost was similar for applicants from schools >20% URiM ($8074.80; range: $7027.60-$13,702.59) and <15% URiM ($8764.60; range: $6698.48-$11966.83; p=0.89). The median aggregate travel time for applicants from schools >20% URiM was 176.4 (range: 93.7-246.2) hours and for applicants from schools <15% URiM was 160.5 (range: 128.2-203.9) hours (p=0.62).

CONCLUSIONS

Financial and temporal costs were similar for applicants from medical schools with <15% or >20% URiM students. Thus, absolute cost considerations are unlikely to account for differences in URiM representation in urology. However, the relative impact of interview costs may be different for URiM students. Effective and durable engagement of URiM students in urology requires an introspective assessment of objective versus anecdotal barriers to recruiting and retaining URiM medical students.

COVID-19 and opioid use disorder: Expanding treatment access in rural settings

ABSTRACT

Substance use treatment inequities among rural populations are well documented and the COVID-19 pandemic has exacerbated these inequalities, forcing healthcare providers to be creative in the delivery of treatment. Systematic reviews on the use of telehealth to treat patients with substance use disorder indicate that it is a promising alternative to in-person services. This article examines the evidence supporting the use of telehealth in treating patients with opioid use disorder and explores other promising options that can help overcome pandemic-related barriers to treatment.

Creating a pronation therapy team: One hospital's journey

ABSTRACT

Prone positioning is a recommended therapy for patients with COVID-19 who develop acute respiratory distress syndrome. This article describes the creation, operation, and evolution of the pronation therapy team at the author's Veterans Affairs facility.

Near Vision but not Hearing Loss is Associated with Lacking a Usual Source of Health Care

Objectives: Sensory loss may be a barrier to accessing healthcare services, and this study seeks to examine the association of sensory loss with whether older adults report having a usual source of health care. Methods: Our study included 7548 older adults who participated in the National Health and Aging Trends Study in 2015. Having a self-reported usual source of health care was our outcome, and hearing and vision loss were our primary independent variables. Results: In multivariate analysis accounting for demographics, socioeconomic, health status, and environmental covariates, near vision loss but not distance vision or hearing loss was associated with decreased odds of having a usual source of health care. Discussion: That older adults with near vision loss were less likely to report having a usual source of health care is concerning. Examining barriers to care is needed to identify sensory loss-relevant processes to optimize and intervene upon.

Gender, racial, ethnic and socioeconomic disparities in palliative care encounters in ischemic strokes admissions

BACKGROUND

There is a scarcity of data on disparities in palliative care encounters in ischemic stroke patients. We have sought to answer these questions using the national inpatient database (NIS) data between 2002 and 2017. We aim to study gender, racial, regional, and socioeconomic disparities in palliative care encounters in ischemic stroke patients.

METHODS

We have analyzed the NIS data from January 2002 to December 2017 using the International Classification of Diseases, 9th Revision, Clinical Modification (ICD-9-CM), and ICD-10-CM codes. Linear regression was used for trend analysis and multiple logistic regression was used for adjusted analysis.

RESULTS

A total of 9,542,169 discharge encounters with a diagnosis of ischemic stroke were recorded from 2002 to 2017. Out of these 412,394 (4.3%) had a palliative care (PC) encounter. The median age for patients with a PC encounter was 81 (Interquartile range [IQR 79-88]). PC encounters have shown a rapid increase over the years (from 0.5% in 2002 to 8.3% in 2017, p < 0.01). Adjusted multivariate analysis showed that African Americans (OR, 0.726 [95%CI, 0.716-0.736], p < 0.01), and Hispanics (OR, 0.738 [95%CI, 0.725-0.751]) were less likely to have a PC encounters. Females (OR, 1.18 7 [95% CI, 1.177-1.197], p < 0.01) were more likely to have PC encounters. Patients with better socio-economic status (OR, 1.034 [95%CI, 1.011-1.034], p < 0.01), having private insurance (OR, 1.562 [95%CI, 1.542-1.583], p < 0.01) and being in urban centers (OR, 1.815 [95%CI, 1.788-1.843], p < 0.01) were more likely to receive a PC encounter.

CONCLUSIONS

Significant racial, ethnic and socioeconomic disparities exist in PC encounters in ischemic stroke patients. The underlying reasons for this need to be explored further.

Receipt of Timely Primary Care Services Following Post-Acute Skilled Nursing Facility Care

OBJECTIVES

Our study examined the proportion of skilled nursing facility (SNF) post-acute care residents who did not receive timely primary care provider (PCP) services following discharge, factors associated with lack of timely PCP services, and factors associated with perfect 30-day home time among those who did not receive timely PCP services.

DESIGN

Longitudinal cohort study; data sources included Medicare claims and other administrative databases.

SETTING AND PARTICIPANTS

25,357 fee-for-service New York State Medicare beneficiaries aged 65 years and older admitted to SNFs for post-acute care in 2014 and then discharged to the community.

METHODS

Our outcomes were a timely PCP visit (within 7 days of SNF discharge) and perfect 30-day home time, and we examined their association with patient, SNF, and county factors.

RESULTS

Among SNF discharges, 60.6% had a timely PCP visit. In multivariate regression analyses, female sex, nonwhite race, Medicare only status, less functional impairment and medical comorbidity, a surgical hospitalization, fewer hospital days, more SNF days, absence of home health services, for-profit SNF status, higher SNF star rating, lower ratio of registered nurse/total nursing hours, and rural counties were associated with lower odds of a timely PCP visit following SNF discharge. Among those without a timely PCP visit, female sex, less cognitive and functional impairment, less medical comorbidity, a surgical hospitalization, fewer hospital days, receipt of home health services, and higher SNF star rating were associated with increased odds of perfect 30-day home time following SNF discharge.

CONCLUSIONS AND IMPLICATIONS

That 4 in 10 post-acute care SNF patients did not have a timely PCP visit post-SNF discharge, with racial minority and rural county status associated with decreased odds of a timely PCP visit, is concerning. Examination of whether the timing and type of outpatient visit may have varying effects on different post-acute care subpopulations would build on this work.

Bivariate Spatial Pattern between Smoking Prevalence and Lung Cancer Screening in US Counties

Objectives: Lung cancer screening (LCS) with low-dose computed tomography (LDCT) has been a reimbursable preventive service covered by Medicare since 2015. Geographic disparities in the access to LDCT providers may contribute to the low uptake of LCS. We evaluated LDCT service availability for older adults in the United States (US) based on Medicare claims data and explored its ecological correlation with smoking prevalence. Materials and Methods: We identified providers who provided at least 11 LDCT services in 2016 using the Medicare Provider Utilization and Payment Data: Physician and Other Supplier Public Use File. We constructed a 30-mile Euclidian distance buffer around each provider’s location to estimate individual LDCT coverage areas. We then mapped the county-level density of LDCT providers and the county-level prevalence of current daily cigarette smoking in a bivariate choropleth map. Results: Approximately 1/5 of census tracts had no LDCT providers within 30 miles and 46% of counties had no LDCT services. At the county level, the median LDCT density was 0.5 (interquartile range (IQR): 0–5.3) providers per 1000 Medicare fee-for-service beneficiaries, and cigarette smoking prevalence was 17.5% (IQR: 15.2–19.8%). High LDCT service availability was most concentrated in the northeast US, revealing a misalignment with areas of high current smoking prevalence, which tended to be in the central and southern US. Conclusions: Our maps highlight areas in need for enhanced workforce and capacity building aimed at reducing disparities in the access and utilization of LDCT services among older adults in the US.

Challenges in Managing Acute Cardiovascular Diseases and Follow Up Care in Rural Areas: A Narrative Review

This narrative review explores relevant literature that is related to the challenges in implementing evidence-based management for clinicians in rural and remote areas, while primarily focussing on management of acute coronary syndrome (ACS) and follow up care. A targeted literature search around rural/urban differences in the management of ACS, cardiovascular disease, and cardiac rehabilitation identified multiple issues that are related to access, including the ability to pay, transport and geographic distances, delays in patients seeking care, access to diagnostic testing, and timely treatment in an appropriate facility. Workforce shortages or lack of ready access to relevant expertise, cultural differences, and complexity that arises from comorbidities and from geographical isolation amplified diagnostic challenges. Given the urgency in management of ACS, rural clinicians must act quickly to achieve optimal patient outcomes. New technologies and quality improvement approaches enable better access to rapid diagnosis, as well as specialist input and care. Achieving an uptake of cardiac rehabilitation in rural and remote settings poses challenges that may reduce with the use of alternative models to centre-based rehabilitation and use of modern technologies. Expediting improvement in cardiovascular outcomes and reducing rural disparities requires system changes and that clinicians embrace attention to prevention, emergency management, and follow up care in rural contexts.

Advancing Racial/Ethnic and Cultural Sensitivity Among PMHNP Students Through Education, Practice, and Experience

BACKGROUND: There is an increased need for mental health providers to be more attuned to behavioral health needs of racial/ethnic/cultural minorities and the role of social milieus. AIMS: We prioritized training and assessing racial/ethnic and cultural sensitivity among psychiatric mental health nurse practitioner students throughout coursework, clinical practice, and experiences in underserved settings. METHOD: Prior to beginning clinical coursework, students completed a course on culturally competent care where we measured their (n = 26) perception of their ability to be racially/ethnically sensitive providers at the beginning and end of the semester, demonstrating significant improvement. During clinical coursework, preceptors measured students' racially/ethnically and culturally sensitive clinical behaviors with patients. RESULTS: Sensitivity of students in clinical training significantly improved over a semester of clinical supervision. Our results indicated that placements in underserved settings improved students' racial/ethnic/cultural sensitivity but only among advanced students. At final evaluation, advanced students in underserved settings self-reported significantly higher racial/ethnic and cultural sensitivity than students not in an underserved setting. CONCLUSIONS: Our data suggest that we can produce more racially/ethnically and culturally sensitivity providers through coursework, supervised clinical practice, and experiences in underserved settings. These data are preliminary, and we plan to follow up these results and replicate this work with other cohorts in future semesters.