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English NC, Ivankova NV, Smith BP, Jones BA, Herbey II, Rosamond B, Kim DH, Oslock WM, Schoenberger-Godwin YMM, Pisu M, Chu DI. Providers' and survivors' perspectives on the availability and accessibility of surgery in gastrointestinal cancer care. J Gastrointest Surg 2024; 28:1330-1338. [PMID: 38824070 PMCID: PMC11298309 DOI: 10.1016/j.gassur.2024.05.019] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/11/2024] [Revised: 05/10/2024] [Accepted: 05/18/2024] [Indexed: 06/03/2024]
Abstract
BACKGROUND Surgery is essential for gastrointestinal (GI) cancer treatment. Many patients lack access to surgical care that optimizes outcomes. Scarce availability and/or low accessibility of appropriate resources may be the reason for this, especially in economically disadvantaged areas. This study aimed to investigate providers' and survivors' perspectives on barriers and facilitators to the availability and accessibility of surgical care. METHODS Semistructured interviews informed by surgical disparities and access-to-care conceptual frameworks with purposively selected GI cancer providers and survivors in Alabama and Mississippi were conducted. Survivors were within 3 years of diagnosis of stage I to III esophageal, pancreatic, or colorectal cancer. Transcripts were analyzed using inductive thematic and content analysis techniques. Intercoder agreement was reached at 90 %. RESULTS The 27 providers included surgeons (n = 11), medical oncologists (n = 2), radiation oncologists (n = 2), a primary care physician (n = 1), nurses (n = 8), and patient navigators (n = 3). This study included 36 survivors with ages ranging from 44 to 87 years. Of the 36 survivors, 21 (58.3 %) were male, and 11 (30.6 %) identified as Black. Responses were grouped into 3 broad categories: (i) transportation/geographic location, (ii) specialized care/testing, and (iii) patient-/provider-related factors. The barriers included lack and cost of transportation, reluctance to travel because of uneasiness with urban centers, low availability of specialized care, overburdened referral centers, provider-related referral biases, and low health literacy. Facilitators included availability of charitable aid, centralizing multidisciplinary care, and efficient appointment scheduling. CONCLUSION In the Deep South, barriers and facilitators to the availability and accessibility of GI surgical cancer care were identified at the health system, provider, and patient levels, especially for rural residents. Our data suggest targets for improving the use of surgery in GI cancer care.
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Affiliation(s)
- Nathan C English
- Division of Gastrointestinal Surgery, Department of Surgery, University of Alabama at Birmingham, Birmingham, AL, United States; Department of General Surgery, University of Cape Town, Cape Town, South Africa
| | - Nataliya V Ivankova
- Department of Health Services Administration, School of Health Professions, University of Alabama at Birmingham, Birmingham, AL, United States
| | - Burkely P Smith
- Division of Gastrointestinal Surgery, Department of Surgery, University of Alabama at Birmingham, Birmingham, AL, United States
| | - Bayley A Jones
- Division of Gastrointestinal Surgery, Department of Surgery, University of Alabama at Birmingham, Birmingham, AL, United States
| | - Ivan I Herbey
- Division of Gastrointestinal Surgery, Department of Surgery, University of Alabama at Birmingham, Birmingham, AL, United States
| | - Brendan Rosamond
- Department of General Surgery, Tilman J. Fertitta Family College of Medicine, University of Houston, Houston, TX, United States
| | - Dae Hyun Kim
- Department of Health Management and Policy, Georgetown University, DC, United States
| | - Wendelyn M Oslock
- Division of Gastrointestinal Surgery, Department of Surgery, University of Alabama at Birmingham, Birmingham, AL, United States; Department of Quality, Birmingham Veterans Affairs Medical Center, Birmingham, AL, United States
| | - Yu-Mei M Schoenberger-Godwin
- Division of Preventive Medicine, O'Neal Comprehensive Cancer Center, University of Alabama at Birmingham, Birmingham, AL, United States
| | - Maria Pisu
- Division of Preventive Medicine, O'Neal Comprehensive Cancer Center, University of Alabama at Birmingham, Birmingham, AL, United States
| | - Daniel I Chu
- Division of Gastrointestinal Surgery, Department of Surgery, University of Alabama at Birmingham, Birmingham, AL, United States.
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Kusnik A, Najim M, Renjith KM, Vyas C, Renjithlal SLM, Alweis R. The Influence of Urbanization on the Patterns of Hepatocellular Carcinoma Mortality From 1999 to 2020. Gastroenterology Res 2024; 17:116-125. [PMID: 38993549 PMCID: PMC11236338 DOI: 10.14740/gr1743] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/20/2024] [Accepted: 06/15/2024] [Indexed: 07/13/2024] Open
Abstract
Background Hepatocellular carcinoma (HCC) remains one of the leading causes of cancer-related fatalities despite early diagnosis and treatment progress, creating a significant public health issue in the United States. This investigation utilized death certificate data from the Centers for Disease Control and Prevention Wide-ranging Online Data for Epidemiologic Research (CDC WONDER) database to investigate HCC mortality patterns and death locations from 1999 to 2020. The objective was to analyze trends in HCC mortality across different population groups, considering the impact of urbanicity. Methods In this study, death certificate data obtained from the CDC WONDER database were utilized to investigate the trends in HCC mortality and location of death between 1999 and 2020. The annual percent change (APC) method was applied to estimate the average annual rate of change during the specified timeframe for the relevant health outcome. Furthermore, including data on the location of death and geographic areas allowed us to gain deeper insights into the patterns and characteristics of HCC and its impact on different regions. Results Between 1999 and 2020, there were 184,073 reported deaths attributed to HCC, and data on the location of death were available for all cases. Most deaths occurred during inpatient admissions (34.93%) or at home (41.19%). The study also found that the highest age-adjusted mortality rate (AAMR) for HCC was observed among male patients, particularly among those identified as Asian or Pacific Islander. Variations in AAMR were determined based on the level of urbanization or rurality of the area, with higher rates observed in more densely populated and urbanized regions. In contrast, less urbanized and populated areas experienced a profound increase in AAMR over the past two decades. Conclusion The HCC-related AAMRs have worsened over time for most ethnic groups, except for Asian or Pacific Islanders, which showed a reduction in APC despite having the worst AAMR. Although rural and less densely populated areas have substantially increased AAMR over the past two decades, more urbanized areas continued to have higher AAMR rates.
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Affiliation(s)
- Alexander Kusnik
- Department of Internal Medicine, Unity Hospital, Rochester, NY, USA
| | - Mostafa Najim
- Department of Internal Medicine, Unity Hospital, Rochester, NY, USA
| | | | - Charmee Vyas
- Division of Palliative Care, University of Kentucky, Lexington, KY, USA
| | | | - Richard Alweis
- Department of Internal Medicine, Unity Hospital, Rochester, NY, USA
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Bayrakdarian ND, Bonar EE, Duguid I, Hellman L, Salino S, Wilkins C, Jannausch M, McKay JR, Staton M, Dollard K, Nahum-Shani I, Walton MA, Blow FC, Coughlin LN. Acceptability and feasibility of a mobile behavioral economic health intervention to reduce alcohol use in adults in rural areas. DRUG AND ALCOHOL DEPENDENCE REPORTS 2024; 11:100225. [PMID: 38545408 PMCID: PMC10966148 DOI: 10.1016/j.dadr.2024.100225] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 12/22/2023] [Revised: 02/26/2024] [Accepted: 02/26/2024] [Indexed: 08/27/2024]
Abstract
Background At-risk alcohol use is associated with increased adverse health consequences, yet is undertreated in healthcare settings. People residing in rural areas need improved access to services; however, few interventions are designed to meet the needs of rural populations. Mobile interventions can provide feasible, low-cost, and scalable means for reaching this population and improving health, and behavioral economic approaches are promising. Methods We conducted a pilot randomized controlled trial focused on acceptability and feasibility of a mobile behavioral economic intervention for 75 rural-residing adults with at-risk alcohol use. We recruited participants from a large healthcare system and randomized them to one of four virtually-delivered conditions reflecting behavioral economic approaches: episodic future thinking (EFT), volitional choice (VC), both EFT and VC, or enhanced usual care control (EUC). The intervention included a telephone-delivered induction session followed by two weeks of condition-consistent ecological momentary interventions (EMIs; 2x/day) and ecological momentary assessments (EMAs; 1x/day). Participants completed assessments at baseline, post-intervention, and two-month follow-up, and provided intervention feedback. Results All participants completed the telephone-delivered session and elected to receive EMI messages. Average completion rate of EMAs across conditions was 92.9%. Among participants in active intervention conditions, 89.3% reported the induction session was helpful and 80.0% reported it influenced their future drinking. We also report initial alcohol use outcomes. Discussion The behavioral economic intervention components and trial procedures evaluated here appear to be feasible and acceptable. Next steps include determination of their efficacy to reduce alcohol use and public health harms.
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Affiliation(s)
- Natalie D. Bayrakdarian
- Addiction Center, Department of Psychiatry, University of Michigan, Ann Arbor, MI, United States
| | - Erin E. Bonar
- Addiction Center, Department of Psychiatry, University of Michigan, Ann Arbor, MI, United States
- Injury Prevention Center, University of Michigan, Ann Arbor, MI, United States
- Michigan Innovations in Addiction Care through Research & Education, University of Michigan, Ann Arbor, MI, United States
| | - Isabelle Duguid
- Addiction Center, Department of Psychiatry, University of Michigan, Ann Arbor, MI, United States
| | - Lauren Hellman
- Addiction Center, Department of Psychiatry, University of Michigan, Ann Arbor, MI, United States
| | - Sarah Salino
- Addiction Center, Department of Psychiatry, University of Michigan, Ann Arbor, MI, United States
| | - Chelsea Wilkins
- Addiction Center, Department of Psychiatry, University of Michigan, Ann Arbor, MI, United States
| | - Mary Jannausch
- Addiction Center, Department of Psychiatry, University of Michigan, Ann Arbor, MI, United States
| | - James R. McKay
- University of Pennsylvania, Philadelphia, PA, United States
- Crescenz Veterans Affairs Medical Center, Philadelphia, PA, United States
| | - Michele Staton
- Department of Behavioral Science, University of Kentucky, Lexington, KY, United States
| | | | - Inbal Nahum-Shani
- Institute for Social Research, University of Michigan, Ann Arbor, MI, United States
| | - Maureen A. Walton
- Addiction Center, Department of Psychiatry, University of Michigan, Ann Arbor, MI, United States
- Injury Prevention Center, University of Michigan, Ann Arbor, MI, United States
- Michigan Innovations in Addiction Care through Research & Education, University of Michigan, Ann Arbor, MI, United States
| | - Frederic C. Blow
- Addiction Center, Department of Psychiatry, University of Michigan, Ann Arbor, MI, United States
| | - Lara N. Coughlin
- Addiction Center, Department of Psychiatry, University of Michigan, Ann Arbor, MI, United States
- Injury Prevention Center, University of Michigan, Ann Arbor, MI, United States
- Michigan Innovations in Addiction Care through Research & Education, University of Michigan, Ann Arbor, MI, United States
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Peng W, Huang Q, Mao B. Evaluating variations in the barriers to colorectal cancer screening associated with telehealth use in rural U.S. Pacific Northwest. Cancer Causes Control 2024; 35:635-645. [PMID: 38001334 DOI: 10.1007/s10552-023-01819-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/23/2023] [Accepted: 10/22/2023] [Indexed: 11/26/2023]
Abstract
PURPOSE The incidence and mortality rates of colorectal cancer (CRC) remain consistently high in rural populations. Telehealth can improve screening uptake by overcoming individual and environmental disadvantages in rural communities. The present study aimed to characterize varying barriers to CRC screening between rural individuals with and without experience in using telehealth. METHOD The cross-sectional study surveyed 250 adults aged 45-75 residing in rural U.S. states of Alaska, Idaho, Oregon, and Washington from June to September 2022. The associations between CRC screening and four sets of individual and environmental factors specific to rural populations (i.e., demographic characteristics, accessibility, patient-provider factors, and psychological factors) were assessed among respondents with and without past telehealth adoption. RESULT Respondents with past telehealth use were more likely to screen if they were married, had a better health status, had experienced discrimination in health care, and had perceived susceptibility, screening efficacy, and cancer fear, but less likely to screen when they worried about privacy or had feelings of embarrassment, pain, and discomfort. Among respondents without past telehealth use, the odds of CRC screening decreased with busy schedules, travel burden, discrimination in health care, and lower perceived needs. CONCLUSION Rural individuals with and without previous telehealth experience face different barriers to CRC screening. The finding suggests the potential efficacy of telehealth in mitigating critical barriers to CRC screening associated with social, health care, and built environments of rural communities.
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Affiliation(s)
- Wei Peng
- Edward R. Murrow College of Communication, Washington State University, Murrow Hall 211, Pullman, WA, 99164, USA.
| | - Qian Huang
- Department of Communication, University of North Dakota, Grand Forks, ND, USA
| | - Bingjing Mao
- TSET Health Promotion Research Center, Stephenson Cancer Center, University of Oklahoma Health Sciences Center, Oklahoma City, OK, USA
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5
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Mills CA, Yeager VA, Unroe KT, Holmes A, Blackburn J. The impact of rural general hospital closures on communities-A systematic review of the literature. J Rural Health 2024; 40:238-248. [PMID: 37985431 DOI: 10.1111/jrh.12810] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/18/2023] [Revised: 09/30/2023] [Accepted: 11/03/2023] [Indexed: 11/22/2023]
Abstract
PURPOSE To compile the literature on the effects of rural hospital closures on the community and summarize the evidence, specifically the health and economic impacts, and identify gaps for future research. METHODS A systematic review of the relevant peer-reviewed literature, published from January 2005 through December 2021, included in the EMBASE, CINAHL, PubMed, EconLit, and Business Source Complete databases, as well as "gray" literature published during the same time period. A total of 21 articles were identified for inclusion. FINDINGS Over 90% of the included studies were published in the last 8 years, with nearly three-fourths published in the last 4 years. The most common outcomes studied were economic outcomes and employment (76%), emergent, and non-emergent transportation, which includes transport miles and travel time (42.8%), access to and supply of health care providers (38%), and quality of patient outcomes (19%). Eighty-nine percent of the studies that examined economic impacts found unfavorable results, including decreased income, population, and community economic growth, and increased poverty. Between 11 and 15.7 additional minutes were required to transport patients to the nearest emergency facility after closures. A lack of consistency in measures and definition of rurality challenges comparability across studies. CONCLUSIONS The comprehensive impact of rural hospital closures on communities has not been well studied. Research shows predominantly negative economic outcomes as well as increased time and distance required to access health care services. Additional research and consistency in the outcome measures and definition of rurality is needed to characterize the downstream impact of rural hospital closures.
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Affiliation(s)
- Carol A Mills
- Department of Health Policy and Administration, College of Health and Human Development, The Pennsylvania State University, University Park, Pennsylvania, USA
| | - Valerie A Yeager
- Indiana University Richard M. Fairbanks School of Public Health at IUPUI, Indianapolis, Indiana, USA
| | - Kathleen T Unroe
- Division of General Internal Medicine and Geriatrics, Indiana University School of Medicine, Indianapolis, Indiana, USA
- Indiana University Center for Aging Research, Regenstrief Institute, Inc, Indianapolis, Indiana, USA
| | - Ann Holmes
- Indiana University Richard M. Fairbanks School of Public Health at IUPUI, Indianapolis, Indiana, USA
| | - Justin Blackburn
- Indiana University Richard M. Fairbanks School of Public Health at IUPUI, Indianapolis, Indiana, USA
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6
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Winiker AK, Schneider KE, Hamilton White R, O'Rourke A, Grieb SM, Allen ST. A qualitative exploration of barriers and facilitators to drug treatment services among people who inject drugs in west Virginia. Harm Reduct J 2023; 20:69. [PMID: 37264367 PMCID: PMC10233537 DOI: 10.1186/s12954-023-00795-w] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/15/2022] [Accepted: 05/11/2023] [Indexed: 06/03/2023] Open
Abstract
BACKGROUND The opioid overdose crisis in the USA has called for expanding access to evidence-based substance use treatment programs, yet many barriers limit the ability of people who inject drugs (PWID) to engage in these programs. Predominantly rural states have been disproportionately affected by the opioid overdose crisis while simultaneously facing diminished access to drug treatment services. The purpose of this study is to explore barriers and facilitators to engagement in drug treatment among PWID residing in a rural county in West Virginia. METHODS From June to July 2018, in-depth interviews (n = 21) that explored drug treatment experiences among PWID were conducted in Cabell County, West Virginia. Participants were recruited from locations frequented by PWID such as local service providers and public parks. An iterative, modified constant comparison approach was used to code and synthesize interview data. RESULTS Participants reported experiencing a variety of barriers to engaging in drug treatment, including low thresholds for dismissal, a lack of comprehensive support services, financial barriers, and inadequate management of withdrawal symptoms. However, participants also described several facilitators of treatment engagement and sustained recovery. These included the use of medications for opioid use disorder and supportive health care workers/program staff. CONCLUSIONS Our findings suggest that a range of barriers exist that may limit the abilities of rural PWID to successfully access and remain engaged in drug treatment in West Virginia. Improving the public health of rural PWID populations will require expanding access to evidence-based drug treatment programs that are tailored to participants' individual needs.
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Affiliation(s)
- Abigail K Winiker
- Department of Health, Behavior and Society, Johns Hopkins Bloomberg School of Public Health, 624 N. Broadway St., Baltimore, MD, 21205, USA.
| | - Kristin E Schneider
- Department of Mental Health, Johns Hopkins Bloomberg School of Public Health, 624 N. Broadway St., Baltimore, MD, 21205, USA
| | - Rebecca Hamilton White
- Department of Health, Behavior and Society, Johns Hopkins Bloomberg School of Public Health, 624 N. Broadway St., Baltimore, MD, 21205, USA
| | - Allison O'Rourke
- DC Center for AIDS Research, Department of Psychological and Brain Sciences, George Washington University, 2125 G St. NW, Washington, DC, 20052, USA
| | - Suzanne M Grieb
- Center for Child and Community Health Research, Department of Pediatrics, Johns Hopkins School of Medicine, Baltimore, MD, 21224, USA
| | - Sean T Allen
- Department of Health, Behavior and Society, Johns Hopkins Bloomberg School of Public Health, 624 N. Broadway St., Baltimore, MD, 21205, USA
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Alwadei A, Alnaami I, Alenazy K, Marei A, BaHammam LO, Nasser S, Alswilem AM, Maklad A, Shehata SF, Alqahtani MS, Al-Shahrani A, Balbaid A. Impact of Rural vs. Urban Residence on Survival Rates of Patients with Glioblastoma: A Tertiary Care Center Experience. Brain Sci 2022; 12:brainsci12091186. [PMID: 36138922 PMCID: PMC9496950 DOI: 10.3390/brainsci12091186] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/06/2022] [Revised: 08/19/2022] [Accepted: 08/22/2022] [Indexed: 11/16/2022] Open
Abstract
Purpose: Although the association between residential location and survival in patients with different cancer types has been established, the conclusions are contentious, and the underlying mechanisms remain unknown. Here, we reviewed the impact of residence on the survival of patients with glioblastoma (GBM). Methods: We conducted a retrospective study to compare the impact of rural and urban residence on the survival rates of patients with GBM diagnosed in Riyadh City and outside Riyadh. All patients in this study were treated in a tertiary care hospital, and their survival rates were analyzed in relation to their residence and other related factors, namely radiotherapy timing. Results: Overall, 125 patients were included: 61 from Riyadh City and 64 from outside. The majority of patients in both groups were aged >50 years (p = 0.814). There was no statistically significant difference between the groups in the Eastern Cooperative Oncology Group Performance Status (p = 0.430), seizure (p = 0.858), or initiation timing of radiotherapy (p = 0.781). Furthermore, the median survival rate in the Riyadh group versus the other group was 14.4 months and 12.2 months, respectively, with no statistical significance (p = 0.187). Conclusions: Our study showed that residential location had no significant effect on GBM prognosis. However, further studies with a larger sample size are required to delineate the other factors of referral within the healthcare system to facilitate the management of these patients within a specific timeframe.
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Affiliation(s)
- Ali Alwadei
- Department of Neurosurgery, College of Medicine, Imam Abdulrahman Bin Faisal University, Dammam 34212, Saudi Arabia
- Correspondence:
| | - Ibrahim Alnaami
- Division of Neurosurgery, Department of Surgery, College of Medicine, King Khalid University, Abha 62523, Saudi Arabia
| | - Kawthar Alenazy
- Department of Radiation Oncology, King Fahad Medical City, Riyadh 11525, Saudi Arabia
| | - Amal Marei
- Department of Radiation Oncology, King Fahad Medical City, Riyadh 11525, Saudi Arabia
- Department of Clinical Oncology, Ain Shams University, Cairo 11566, Egypt
| | - Leenh O. BaHammam
- College of Medicine, Alfaisal University, Riyadh 11533, Saudi Arabia
- King Saud Medical City, Riyadh 12746, Saudi Arabia
| | - Sameh Nasser
- Department of Radiation Oncology, King Fahad Medical City, Riyadh 11525, Saudi Arabia
| | | | - Ahmed Maklad
- Department of Radiation Oncology, King Fahad Medical City, Riyadh 11525, Saudi Arabia
- Department of Clinical Oncology, Sohag University, Sohag 82524, Egypt
| | - Shehata F. Shehata
- Department of Family and Community Medicine, College of Medicine, King Khalid University, Abha 62523, Saudi Arabia
| | - Mohammad Salem Alqahtani
- Department of Neurosurgery, College of Medicine, Imam Abdulrahman Bin Faisal University, Dammam 34212, Saudi Arabia
| | - Abdulelah Al-Shahrani
- Department of Neurosurgery, College of Medicine, Imam Abdulrahman Bin Faisal University, Dammam 34212, Saudi Arabia
| | - Ali Balbaid
- Department of Radiation Oncology, King Fahad Medical City, Riyadh 11525, Saudi Arabia
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Hong N, Herrera A, Furr JM, Georgiadis C, Cristello J, Heymann P, Dale CF, Heflin B, Silva K, Conroy K, Cornacchio D, Comer JS. Remote Intensive Group Behavioral Treatment for Families of Children with Selective Mutism. EVIDENCE-BASED PRACTICE IN CHILD AND ADOLESCENT MENTAL HEALTH 2022; 8:439-458. [PMID: 38155719 PMCID: PMC10752620 DOI: 10.1080/23794925.2022.2062688] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/30/2023]
Abstract
Selective mutism (SM) is a relatively rare, but highly interfering, child anxiety disorder characterized by a consistent failure to speak in certain situations, despite demonstrating fluent speech in other contexts. Exposure-based cognitive behavioral therapy and Parent-Child Interaction Therapy adapted for SM can be effective, but the broad availability and accessibility of such specialty care options remains limited. Stay-at-home guidelines to mitigate the spread of COVID-19 further limited the accessibility of office-based specialty care for SM. Building on separate lines of research supporting intensive treatments and telehealth service delivery models, this paper is the first to describe the development, preliminary feasibility, acceptability, and efficacy of a Remote Intensive Group Behavioral Treatment (IGBT) for families of young children with SM (N=9). Treatment leveraged videoconferencing technology to deliver caregiver training sessions, lead-in sessions, 5 consecutive daily IGBT sessions, and an individualized caregiver coaching session. Remote IGBT was found to be both feasible and acceptable. All families (100%) completed diagnostic assessments and caregiver-report questionnaires at four major study timepoints (i.e., intake, pre-treatment, post-treatment, 4-month follow-up) and participated in all treatment components. Caregivers reported high treatment satisfaction at post-treatment and 4-month follow-up and low levels of burden associated with treatment participation at post-treatment. Approximately half of participating children were classified as treatment responders by independent evaluators at post-treatment and 4-month follow-up. Although these pilot results should be interpreted with caution, the present work underscores the potential utility of using videoconferencing to remotely deliver IGBT to families in their natural environments.
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9
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Bao C, Bardhan IR. Performance of Accountable Care Organizations: Health Information Technology and Quality–Efficiency Trade-Offs. INFORMATION SYSTEMS RESEARCH 2021. [DOI: 10.1287/isre.2021.1080] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
Abstract
Under a traditional fee-for-service payment model, healthcare providers typically compromise the quality of care in order to reduce costs. Drawing on data from a national sample of accountable care organizations (ACOs), we study whether financial incentives offered under the Affordable Care Act led to fundamental changes in care delivery. Our research suggests that effective use of health information technology (IT) by ACO providers is critical in balancing competing goals of quality and efficiency. Unlike hospitals that did not participate in value-based care initiatives, ACOs were able to generate better quality outcomes while also improving overall efficiency. Furthermore, ACO providers that used health IT effectively demonstrated better patient health outcomes due to greater information integration with other providers. In other words, ACOs created value by not only reducing the cost of care but also improving patient outcomes simultaneously. Our research provides a roadmap for practitioners to succeed in a value-based healthcare environment and for policy makers to design better incentives to promote interorganizational information sharing across providers. Our findings suggest that healthcare policy needs to incorporate appropriate incentives to foster effective IT use for care coordination between healthcare providers.
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Affiliation(s)
- Chenzhang Bao
- Spears School of Business, Oklahoma State University, Tulsa, Oklahoma 74106
| | - Indranil R. Bardhan
- McCombs School of Business, The University of Texas at Austin, Austin, Texas 78705
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10
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Layton W, Lemmon K, Coustasse A. Charge masters and the effects on hospitals. INTERNATIONAL JOURNAL OF HEALTHCARE MANAGEMENT 2021. [DOI: 10.1080/20479700.2020.1721748] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/25/2022]
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11
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Dayoub EJ, Eberly LA, Nathan AS, Khatana SAM, Adusumalli S, Navar AM, Giri J, Groeneveld PW. Adoption of PCSK9 Inhibitors Among Patients With Atherosclerotic Disease. J Am Heart Assoc 2021; 10:e019331. [PMID: 33904340 PMCID: PMC8200752 DOI: 10.1161/jaha.120.019331] [Citation(s) in RCA: 16] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
Background PCSK9 (proprotein convertase subtilisin/kexin type 9) inhibitors represent a promising class of lipid‐lowering therapy, although their use has been limited by cost concerns. Methods and Results A retrospective cohort study was conducted using a nationwide commercial claims database comprising patients with atherosclerotic cardiovascular disease (ASCVD), aged 18 to 64 years. We identified the number of patients with ASCVD started on a PCSK9 inhibitor from the dates of US Food and Drug Administration approval in quarter 3 2015 through quarter 2 2019. Secondary objectives identified the proportions of patients started on a PCSK9 inhibitor in various ASCVD risk groups based on statin use and baseline low‐density lipoprotein cholesterol. We identified 126 419 patients with ASCVD on either PCSK9 inhibitor or statin therapy. Among these patients, 1168 (0.9%) filled a prescription for a PCSK9 inhibitor. The number of patients initiating a PCSK9 inhibitor increased from 2 patients in quarter 3 2015 to 119 patients in quarter 2 2019, corresponding to an increase from 0.05% to 2.5% of patients with ASCVD already on statins who started PCSK9 inhibitor therapy. Of patients with ASCVD with high adherence to a high‐intensity statin, 13 643 had low‐density lipoprotein cholesterol ≥70 mg/dL, and in this subgroup, 119 (0.9%) patients initiated a PCSK9 inhibitor. Conclusions Few patients started PCSK9 inhibitors from 2015 through mid‐2019, despite increasing trial evidence of efficacy, guidelines recommending PCSK9 inhibitors in high‐risk patients with ASCVD, and price reductions during this period. The magnitude of price reductions may not yet be sufficient to influence use management strategies aimed to limit PCSK9 inhibitor use.
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Affiliation(s)
- Elias J Dayoub
- Division of Cardiovascular Medicine Hospital of the University of Pennsylvania Philadelphia PA.,Department of Medicine Hospital of the University of Pennsylvania Philadelphia PA.,Center for Cardiovascular Outcomes, Quality, and Evaluative Research University of Pennsylvania Philadelphia PA.,Leonard Davis Institute of Health Economics at the University of Pennsylvania Philadelphia PA
| | - Lauren A Eberly
- Division of Cardiovascular Medicine Hospital of the University of Pennsylvania Philadelphia PA.,Department of Medicine Hospital of the University of Pennsylvania Philadelphia PA.,Center for Cardiovascular Outcomes, Quality, and Evaluative Research University of Pennsylvania Philadelphia PA.,Leonard Davis Institute of Health Economics at the University of Pennsylvania Philadelphia PA
| | - Ashwin S Nathan
- Division of Cardiovascular Medicine Hospital of the University of Pennsylvania Philadelphia PA.,Department of Medicine Hospital of the University of Pennsylvania Philadelphia PA.,Center for Cardiovascular Outcomes, Quality, and Evaluative Research University of Pennsylvania Philadelphia PA.,Leonard Davis Institute of Health Economics at the University of Pennsylvania Philadelphia PA
| | - Sameed Ahmed M Khatana
- Division of Cardiovascular Medicine Hospital of the University of Pennsylvania Philadelphia PA.,Department of Medicine Hospital of the University of Pennsylvania Philadelphia PA.,Center for Cardiovascular Outcomes, Quality, and Evaluative Research University of Pennsylvania Philadelphia PA.,Leonard Davis Institute of Health Economics at the University of Pennsylvania Philadelphia PA.,Michael J. Crescenz Veterans Affairs Medical Center Philadelphia PA
| | - Srinath Adusumalli
- Division of Cardiovascular Medicine Hospital of the University of Pennsylvania Philadelphia PA.,Department of Medicine Hospital of the University of Pennsylvania Philadelphia PA.,Center for Cardiovascular Outcomes, Quality, and Evaluative Research University of Pennsylvania Philadelphia PA.,Leonard Davis Institute of Health Economics at the University of Pennsylvania Philadelphia PA
| | - Ann Marie Navar
- Duke Clinical Research InstituteDuke University School of Medicine Durham NC
| | - Jay Giri
- Division of Cardiovascular Medicine Hospital of the University of Pennsylvania Philadelphia PA.,Department of Medicine Hospital of the University of Pennsylvania Philadelphia PA.,Center for Cardiovascular Outcomes, Quality, and Evaluative Research University of Pennsylvania Philadelphia PA.,Leonard Davis Institute of Health Economics at the University of Pennsylvania Philadelphia PA.,Michael J. Crescenz Veterans Affairs Medical Center Philadelphia PA
| | - Peter W Groeneveld
- Department of Medicine Hospital of the University of Pennsylvania Philadelphia PA.,Center for Cardiovascular Outcomes, Quality, and Evaluative Research University of Pennsylvania Philadelphia PA.,Leonard Davis Institute of Health Economics at the University of Pennsylvania Philadelphia PA.,Michael J. Crescenz Veterans Affairs Medical Center Philadelphia PA
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Assessing clinical quality performance and staffing capacity differences between urban and rural Health Resources and Services Administration-funded health centers in the United States: A cross sectional study. PLoS One 2020; 15:e0242844. [PMID: 33290435 PMCID: PMC7723285 DOI: 10.1371/journal.pone.0242844] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/30/2019] [Accepted: 11/10/2020] [Indexed: 11/19/2022] Open
Abstract
BACKGROUND In the United States, there are nearly 1,400 Health Resources and Services Administration-funded health centers (HCs) serving low-income and underserved populations and more than 600 of these HCs are located in rural areas. Disparities in quality of medical care in urban vs. rural areas exist but data on such differences between urban and rural HCs is limited in the literature. We examined whether urban and rural HCs differed in their performance on clinical quality measures before and after controlling for patient, organizational, and contextual characteristics. METHODS AND FINDINGS We used the 2017 Uniform Data System to examine performance on clinical quality measures between urban and rural HCs (n = 1,373). We used generalized linear regression models with the logit link function and binomial distribution, controlling for confounding factors. After adjusting for potential confounders, we found on par performance between urban and rural HCs in all but one clinical quality measure. Rural HCs had lower rates of linking patients newly diagnosed with HIV to care (74% [95% CI: 69%, 80%] vs. 83% [95% CI: 80%, 86%]). We identified control variables that systematically accounted for eliminating urban vs. rural differences in performance on clinical quality measures. We also found that both urban and rural HCs had some clinical quality performance measures that were lower than available national benchmarks. Main limitations included potential discrepancy of urban or rural designation across all HC sites within a HC organization. CONCLUSIONS Findings highlight HCs' contributions in addressing rural disparities in quality of care and identify opportunities for improvement. Performance in both rural and urban HCs may be improved by supporting programs that increase the availability of providers, training, and provision of technical resources.
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O'Hanlon CE, Kranz AM, DeYoreo M, Mahmud A, Damberg CL, Timbie J. Access, Quality, And Financial Performance Of Rural Hospitals Following Health System Affiliation. Health Aff (Millwood) 2020; 38:2095-2104. [PMID: 31794306 DOI: 10.1377/hlthaff.2019.00918] [Citation(s) in RCA: 34] [Impact Index Per Article: 8.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
More than 100 rural hospitals have closed since 2010. Some rural hospitals have affiliated with health systems to improve their financial performance and potentially avoid closure, but the effects of affiliation on rural hospitals and their patients are unclear. To examine the relationship between affiliation and performance, we compared rural hospitals that affiliated with a health system in the period 2008-17 and a propensity score-weighted set of nonaffiliating rural hospitals on twelve measures of structure, utilization, financial performance, and quality. Following health system affiliation, rural hospitals experienced a significant reduction in on-site diagnostic imaging technologies, the availability of obstetric and primary care services, and outpatient nonemergency visits, as well as a significant increase in operating margins (by 1.6-3.6 percentage points from a baseline of -1.6 percent). Changes in patient experience scores, readmissions, and emergency department visits were similar for affiliating and nonaffiliating hospitals. While joining health systems may improve rural hospitals' financial performance, affiliation may reduce access to services for patients in rural areas.
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Affiliation(s)
- Claire E O'Hanlon
- Claire E. O'Hanlon ( cohanlon@rand. org ) is an advanced fellow in health services research in the Center for the Study of Healthcare Innovation, Implementation, and Policy, Veterans Affairs Greater Los Angeles Healthcare System, in California, and an adjunct policy researcher at the RAND Corporation in Santa Monica, California
| | - Ashley M Kranz
- Ashley M. Kranz is a policy researcher at the RAND Corporation in Arlington, Virginia
| | - Maria DeYoreo
- Maria DeYoreo is a statistician at the RAND Corporation in Santa Monica
| | - Ammarah Mahmud
- Ammarah Mahmud is a policy analyst at the RAND Corporation in Arlington
| | - Cheryl L Damberg
- Cheryl L. Damberg is the RAND Distinguished Chair in Healthcare Payment Policy and a principal senior researcher at the RAND Corporation in Santa Monica
| | - Justin Timbie
- Justin Timbie is a senior policy researcher at the RAND Corporation in Arlington
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Birtley NM, Phillips L. The business and practice of psychiatric advanced practice nursing in long term care. Arch Psychiatr Nurs 2020; 34:288-296. [PMID: 33032748 DOI: 10.1016/j.apnu.2020.07.007] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/03/2019] [Revised: 03/03/2020] [Accepted: 07/02/2020] [Indexed: 10/23/2022]
Affiliation(s)
- Nancy M Birtley
- Sinclair School of Nursing, University of Missouri-Columbia, Columbia, MO, United States of America; Nancy M. Birtley, LLC, Psychiatric Consultation Services, St. Louis, MO, United States of America.
| | - Lorraine Phillips
- School of Nursing, College of Health Sciences, University of Delaware, Newark, DE, Unites States of America
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Musgrove KA, Abdelsattar JM, LeMaster SJ, Ballou MC, Kappel DA, Borgstrom DC. Optimal Resources for Rural Surgery. Am Surg 2020; 86:1057-1061. [PMID: 33049163 DOI: 10.1177/0003134820942142] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
BACKGROUND Timely access to emergency general surgery services, including trauma, is a critical aspect of patient care. This study looks to identify resource availability at small rural hospitals in order to improve the quality of surgical care. METHODS Forty-five nonteaching hospitals in West Virginia were divided into large community hospitals with multiple specialties (LCHs), small community hospitals with fewer specialties (SCHs), and critical access hospitals (CAHs). A 58-question survey on optimal resources for surgery was completed by 1 representative surgeon at each hospital. There were 8 LCHs, 18 SCHs, and 19 CAHs with survey response rates of 100%, 83%, and 89%, respectively. RESULTS One hundred percent of hospitals surveyed had respiratory therapy and ventilator support, computerized tomography (CT) scanner and ultrasound, certified operating rooms, lab support, packed red blood cells (PRBC), and FFP accessible 24/7. Availability of cryoprecipitate, platelets, tranexamic acid (TXA), and prothrombin complex concentrate (PCC) decreased from LCHs to CAHs. The majority had board-certified general surgeons; however, only 86% LCHs, 53% SCHs, and 50% CAHs had advanced trauma life support (ATLS) certification. One hundred percent of LCHs had operating room (OR) crew on call within 30 minutes, emergency cardiovascular equipment, critical care nursing, on-site pathologist, and biologic/synthetic mesh, whereas fewer SCHs and CAHs had these resources. One hundred percent of LCHs and SCHs had anesthesia availability 24/7 compared to 78% of CAHs. DISCUSSION Improving access to the aforementioned resources is of utmost importance to patient outcomes. This will enhance rural surgical care and decrease emergency surgical transfers. Further education and research are necessary to support and improve rural trauma systems.
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Affiliation(s)
- Kelsey A Musgrove
- 24041 Department of General Surgery, West Virginia University, Morgantown, WV, USA
| | - Jad M Abdelsattar
- 24041 Department of General Surgery, West Virginia University, Morgantown, WV, USA
| | - Stephanie J LeMaster
- 24041 Department of General Surgery, West Virginia University, Morgantown, WV, USA
| | - Marguerite C Ballou
- 24041 Department of General Surgery, West Virginia University, Morgantown, WV, USA
| | | | - David C Borgstrom
- 24041 Department of General Surgery, West Virginia University, Morgantown, WV, USA
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Suh J, Williams S, Fann JR, Fogarty J, Bauer AM, Hsieh G. Parallel Journeys of Patients with Cancer and Depression: Challenges and Opportunities for Technology-Enabled Collaborative Care. ACTA ACUST UNITED AC 2020; 4. [PMID: 32656502 DOI: 10.1145/3392843] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/03/2023]
Abstract
Depression is common but under-treated in patients with cancer, despite being a major modifiable contributor to morbidity and early mortality. Integrating psychosocial care into cancer services through the team-based Collaborative Care Management (CoCM) model has been proven to be effective in improving patient outcomes in cancer centers. However, there is currently a gap in understanding the challenges that patients and their care team encounter in managing co-morbid cancer and depression in integrated psycho-oncology care settings. Our formative study examines the challenges and needs of CoCM in cancer settings with perspectives from patients, care managers, oncologists, psychiatrists, and administrators, with a focus on technology opportunities to support CoCM. We find that: (1) patients with co-morbid cancer and depression struggle to navigate between their cancer and psychosocial care journeys, and (2) conceptualizing co-morbidities as separate and independent care journeys is insufficient for characterizing this complex care context. We then propose the parallel journeys framework as a conceptual design framework for characterizing challenges that patients and their care team encounter when cancer and psychosocial care journeys interact. We use the challenges discovered through the lens of this framework to highlight and prioritize technology design opportunities for supporting whole-person care for patients with co-morbid cancer and depression.
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Affiliation(s)
- Jina Suh
- University of Washington, USA and Microsoft Research, USA
| | | | - Jesse R Fann
- University of Washington, USA and Seattle Cancer Care Alliance, USA
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Rural Population Aging and the Hospital Utilization in Cities: The Rise of Medical Tourism in China. INTERNATIONAL JOURNAL OF ENVIRONMENTAL RESEARCH AND PUBLIC HEALTH 2020; 17:ijerph17134790. [PMID: 32635241 PMCID: PMC7369718 DOI: 10.3390/ijerph17134790] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 05/27/2020] [Revised: 06/28/2020] [Accepted: 06/30/2020] [Indexed: 11/17/2022]
Abstract
The disparity of rural and urban hospital utilization has aroused much concern. With the improvement of their living standards, patients in rural areas have an emerging need for traveling across borders for better medical treatment in China. This paper reveals the medical tourism of rural residents towards urban hospitals driven by hospital needs and points out that such disparities may be caused by medical tourism. The ratio of people aged 65 and above in total rural populations was used to identify the potential target customers for medical tourism. Based on rural and urban datasets ranging from 2007-2017 on the provincial level, this paper presents a mobile treatment model and market concentration model with an ecological foundation. The feasible generalized least squared approach was used in the estimation of the fixed-effect regressions. The study found that there was a positive and significant relationship between rural old-age ratios and urban inpatient visits from different income groups. On average, a one percent rise in rural old-age ratio would increase the inpatient visits of urban hospitals by 138 thousand persons. There was also a positive and significant relationship between the rural old-age ratio and the market concentration of urban inpatient visits. It was found that the rural old-age ratio significantly influenced the market concentration of urban inpatient visits in the middle-high income regions. The research showed that each income group from the rural aged population had participated in medical tourism, traveled to urbanized regions and made inpatient visits to urbanized medical facilities. It was also indicated that the rural aged population, especially from the middle-high income groups had a positive and significant influence on the market concentration of urban inpatient visits in the province.
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Odoi EW, Nagle N, Zaretzki R, Jordan M, DuClos C, Kintziger KW. Sociodemographic Determinants of Acute Myocardial Infarction Hospitalization Risks in Florida. J Am Heart Assoc 2020; 9:e012712. [PMID: 32427043 PMCID: PMC7428988 DOI: 10.1161/jaha.119.012712] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/05/2023]
Abstract
Background Identifying social determinants of myocardial infarction (MI) hospitalizations is crucial for reducing/eliminating health disparities. Therefore, our objectives were to identify sociodemographic determinants of MI hospitalization risks and to assess if the impacts of these determinants vary by geographic location in Florida. Methods and Results This is a retrospective ecologic study at the county level. We obtained data for principal and secondary MI hospitalizations for Florida residents for the 2005-2014 period and calculated age- and sex-adjusted MI hospitalization risks. We used a multivariable negative binomial model to identify sociodemographic determinants of MI hospitalization risks and a geographically weighted negative binomial model to assess if the strength of associations vary by location. There were 645 935 MI hospitalizations (median age, 72 years; 58.1%, men; 73.9%, white). Age- and sex-adjusted risks ranged from 18.49 to 69.48 cases/10 000 persons, and they were significantly higher in counties with low education levels (risk ratio [RR]=1.033, P<0.0001) and high divorce rate (RR, 0.995; P=0.018). However, they were significantly lower in counties with high proportions of rural (RR, 0.996; P<0.0001), black (RR, 1.026; P=0.032), and uninsured populations (RR, 0.983; P=0.040). Associations of MI hospitalization risks with education level and uninsured rate varied geographically (P for non-stationarity test=0.001 and 0.043, respectively), with strongest associations in southern Florida (RR for <high school education, 1.036-1.041; RR for uninsured rate, 0.971-0.976). Conclusions Black race, divorce, rural residence, low education level, and lack of health insurance were significant determinants of MI hospitalization risks, but associations with the latter 2 were stronger in southern Florida. Thus, interventions for addressing MI hospitalization risks need to prioritize these populations and allocate resources based on empirical evidence from global and local models for maximum efficiency and effectiveness.
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Affiliation(s)
- Evah Wangui Odoi
- Comparative and Experimental Medicine College of Veterinary Medicine The University of Tennessee Knoxville TN
| | - Nicholas Nagle
- Department of Geography The University of Tennessee Knoxville TN
| | - Russell Zaretzki
- Department of Business Analytics and Statistics The University of Tennessee Knoxville TN
| | - Melissa Jordan
- Public Health Research Division of Community Health Promotion Florida Department of Health Tallahassee FL
| | - Chris DuClos
- Environmental Public Health Tracking Division of Community Health Promotion Florida Department of Health Tallahassee FL
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Wolfe MK, McDonald NC, Holmes GM. Transportation Barriers to Health Care in the United States: Findings From the National Health Interview Survey, 1997-2017. Am J Public Health 2020; 110:815-822. [PMID: 32298170 DOI: 10.2105/ajph.2020.305579] [Citation(s) in RCA: 122] [Impact Index Per Article: 30.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022]
Abstract
Objectives. To quantify the number of people in the US who delay medical care annually because of lack of available transportation and to examine the differential prevalence of this barrier for adults across sociodemographic characteristics and patient populations.Methods. We used data from the National Health Interview Survey (1997-2017) to examine this barrier over time and across groups. We used joinpoint regression analysis to identify significant changes in trends and multivariate analysis to examine correlates of this barrier for the year 2017.Results. In 2017, 5.8 million persons in the United States (1.8%) delayed medical care because they did not have transportation. The proportion reporting transportation barriers increased between 2003 and 2009 with no significant trends before or after this window within our study period. We found that Hispanic people, those living below the poverty threshold, Medicaid recipients, and people with a functional limitation had greater odds of reporting a transportation barrier after we controlled for other sociodemographic and health characteristics.Conclusions. Transportation barriers to health care have a disproportionate impact on individuals who are poor and who have chronic conditions. Our study documents a significant problem in access to health care during a time of rapidly changing transportation technology.
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Affiliation(s)
- Mary K Wolfe
- Mary K. Wolfe and Noreen C. McDonald are with the Department of City and Regional Planning, University of North Carolina at Chapel Hill. G. Mark Holmes is with the Department of Health Policy and Management and North Carolina Rural Health Research and Policy Analysis Center at the Cecil G. Sheps Center for Health Services Research, University of North Carolina at Chapel Hill
| | - Noreen C McDonald
- Mary K. Wolfe and Noreen C. McDonald are with the Department of City and Regional Planning, University of North Carolina at Chapel Hill. G. Mark Holmes is with the Department of Health Policy and Management and North Carolina Rural Health Research and Policy Analysis Center at the Cecil G. Sheps Center for Health Services Research, University of North Carolina at Chapel Hill
| | - G Mark Holmes
- Mary K. Wolfe and Noreen C. McDonald are with the Department of City and Regional Planning, University of North Carolina at Chapel Hill. G. Mark Holmes is with the Department of Health Policy and Management and North Carolina Rural Health Research and Policy Analysis Center at the Cecil G. Sheps Center for Health Services Research, University of North Carolina at Chapel Hill
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Bowen DJ, Powers DM, Russo J, Arao R, LePoire E, Sutherland E, Ratzliff ADH. Implementing collaborative care to reduce depression for rural native American/Alaska native people. BMC Health Serv Res 2020; 20:34. [PMID: 31931791 PMCID: PMC6958691 DOI: 10.1186/s12913-019-4875-6] [Citation(s) in RCA: 12] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/09/2019] [Accepted: 12/25/2019] [Indexed: 12/25/2022] Open
Abstract
BACKGROUND The purpose of this study was to identify the effects of Collaborative Care on rural Native American and Alaska Native (AI/AN) patients. METHODS Collaborative Care was implemented in three AI/AN serving clinics. Clinic staff participated in training and coaching designed to facilitate practice change. We followed clinics for 2 years to observe improvements in depression treatment and to examine treatment outcomes for enrolled patients. Collaborative Care elements included universal screening for depression, evidence-based treatment to target, use of behavioral health care managers to deliver the intervention, use of psychiatric consultants to provide caseload consultation, and quality improvement tracking to improve and maintain outcomes. We used t-tests to evaluate the main effects of Collaborative Care and used multiple linear regression to better understand the predictors of success. We also collected qualitative data from members of the Collaborative Care clinical team about their experience. RESULTS The clinics participated in training and practice coaching to implement Collaborative Care for depressed patients. Depression response (50% or greater reduction in depression symptoms as measured by the PHQ-9) and remission (PHQ-9 score less than 5) rates were equivalent in AI/AN patients as compared with White patients in the same clinics. Significant predictors of positive treatment outcome include only one depression treatment episodes during the study and more follow-up visits per patient. Clinicians were overall positive about their experience and the effect on patient care in their clinic. CONCLUSIONS This project showed that it is possible to deliver Collaborative Care to AI/AN patients via primary care settings in rural areas.
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Affiliation(s)
- Deborah J. Bowen
- University of Washington, A204, 1959 NE Pacific Street, Seattle, WA 98195 USA
| | - Diane M. Powers
- University of Washington, A204, 1959 NE Pacific Street, Seattle, WA 98195 USA
| | - Joan Russo
- University of Washington, A204, 1959 NE Pacific Street, Seattle, WA 98195 USA
| | - Robert Arao
- University of Washington, A204, 1959 NE Pacific Street, Seattle, WA 98195 USA
| | - Erin LePoire
- University of Washington, A204, 1959 NE Pacific Street, Seattle, WA 98195 USA
| | - Earl Sutherland
- Bighorn Valley Health Center, 10 4th Street W, Hardin, MT USA
| | - Anna D. H. Ratzliff
- University of Washington, A204, 1959 NE Pacific Street, Seattle, WA 98195 USA
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Rural-Urban Differences in Access to Primary Care: Beyond the Usual Source of Care Provider. Am J Prev Med 2020; 58:89-96. [PMID: 31862103 DOI: 10.1016/j.amepre.2019.08.026] [Citation(s) in RCA: 23] [Impact Index Per Article: 5.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/30/2019] [Revised: 08/21/2019] [Accepted: 08/22/2019] [Indexed: 11/22/2022]
Abstract
INTRODUCTION In the U.S., rural residents have poorer health than urban residents and this disadvantage is growing. Therefore, it is important to understand rural-urban differences in access to medical care. This study compared the percentage of individuals with a usual source of care and characteristics of usual source of care providers across 3 urban-rural categories. METHODS This study identified 51,920 adults from the 2014-2016 Medical Expenditure Panel Survey and estimated the percentage with a usual source of care across the rural-urban categories. Then, differences in a variety of provider characteristics were examined. Estimates were weighted to be representative of the U.S. non-institutionalized population and adjusted for age, race/ethnicity, self-rated health, and presence of chronic conditions. Analysis was conducted in 2018 and 2019. RESULTS Compared with metropolitan county residents, residents of the most rural counties were 7 percentage points more likely to have a usual source of care (81% vs 74%), but their providers were 13 percentage points less likely to be physicians (22% vs 35%). Despite having to travel longer to reach their usual source of care providers, residents of the most rural counties were 18 percentage points less likely than metropolitan residents to have usual source of care providers with office hours on nights and weekends (27% vs 39%). CONCLUSIONS Rural-urban differences in access to care are complex; there is a rural disadvantage on some dimensions of access but not others. To understand rural-urban disparities in healthcare access, research should move beyond the usual source of care provider as an overall indicator and instead investigate disparities using multiple indicators of access based on theoretically distinct domains.
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Sineshaw HM, Sahar L, Osarogiagbon RU, Flanders WD, Yabroff KR, Jemal A. County-Level Variations in Receipt of Surgery for Early-Stage Non-small Cell Lung Cancer in the United States. Chest 2020; 157:212-222. [PMID: 31813533 PMCID: PMC6965692 DOI: 10.1016/j.chest.2019.09.016] [Citation(s) in RCA: 23] [Impact Index Per Article: 5.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/30/2019] [Revised: 09/09/2019] [Accepted: 09/12/2019] [Indexed: 12/18/2022] Open
Abstract
BACKGROUND Although counties are the smallest geographic level for comprehensive health-care delivery analysis, little is known about county-level variations in receipt of curative-intent surgery for early-stage non-small cell lung cancer (NSCLC) and factors contributing to such variations in the United States. METHODS A total of 179,189 patients aged ≥ 35 years who were diagnosed with stage I to II NSCLC between 2007 and 2014 in 2,263 counties were identified from 39 states, the District of Columbia, and Detroit population-based cancer registries; the data were compiled by the North American Association of Central Cancer Registries. The percentage of patients who underwent surgery was calculated for each county with ≥ 20 cases. Adjusted risk ratios were generated by using generalized estimating equation models with modified Poisson regression. RESULTS Receipt of surgery for early-stage NSCLC during 2007 to 2014 according to county ranged from 12.8% to 48.6% in the lowest decile of counties, to 74.3% to 91.7% in the highest decile of counties. There were pockets of low surgery receipt rate counties within each state. For example, there was a 25% absolute difference between the lowest and highest surgery receipt rate counties in Massachusetts. Counties in the lowest quartile for receipt of surgery were those with a high proportion of non-Hispanic black subjects, high poverty and uninsured rates, low surgeon-to-population ratio, and nonmetropolitan status. CONCLUSIONS Receipt of curative-intent surgery for early-stage NSCLC varied substantially across counties in the United States, with pockets of low receipt counties in each state. Low surgery receipt counties were characterized by unfavorable area-level socioeconomic and health-care delivery factors.
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Affiliation(s)
| | | | | | - W Dana Flanders
- American Cancer Society, Atlanta, GA; Rollins School of Public Health, Emory University, Atlanta, GA
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Odoi EW, Nagle N, DuClos C, Kintziger KW. Disparities in Temporal and Geographic Patterns of Myocardial Infarction Hospitalization Risks in Florida. INTERNATIONAL JOURNAL OF ENVIRONMENTAL RESEARCH AND PUBLIC HEALTH 2019; 16:E4734. [PMID: 31783516 PMCID: PMC6926732 DOI: 10.3390/ijerph16234734] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 11/07/2019] [Revised: 11/23/2019] [Accepted: 11/24/2019] [Indexed: 12/12/2022]
Abstract
Knowledge of geographical disparities in myocardial infarction (MI) is critical for guiding health planning and resource allocation. The objectives of this study were to identify geographic disparities in MI hospitalization risks in Florida and assess temporal changes in these disparities between 2005 and 2014. This study used retrospective data on MI hospitalizations that occurred among Florida residents between 2005 and 2014. We identified spatial clusters of hospitalization risks using Kulldorff's circular and Tango's flexible spatial scan statistics. Counties with persistently high or low MI hospitalization risks were identified. There was a 20% decline in hospitalization risks during the study period. However, we found persistent clustering of high risks in the Big Bend region, South Central and southeast Florida, and persistent clustering of low risks primarily in the South. Risks decreased by 7%-21% in high-risk clusters and by 9%-28% in low-risk clusters. The risk decreased in the high-risk cluster in the southeast but increased in the Big Bend area during the last four years of the study. Overall, risks in low-risk clusters were ahead those for high-risk clusters by at least 10 years. Despite MI risk declining over the study period, disparities in MI risks persist. Eliminating/reducing those disparities will require prioritizing high-risk clusters for interventions.
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Affiliation(s)
- Evah W. Odoi
- Comparative and Experimental Medicine, College of Veterinary Medicine, The University of Tennessee, Knoxville, TN 37996, USA;
| | - Nicholas Nagle
- Department of Geography, The University of Tennessee, Knoxville, TN 37996, USA;
| | - Chris DuClos
- Environmental Public Health Tracking, Division of Community Health Promotion, Florida Department of Health, Tallahassee, FL 32399, USA;
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Elo IT, Hendi AS, Ho JY, Vierboom YC, Preston SH. Trends in Non-Hispanic White Mortality in the United States by Metropolitan-Nonmetropolitan Status and Region, 1990-2016. POPULATION AND DEVELOPMENT REVIEW 2019; 45:549-583. [PMID: 31588154 PMCID: PMC6771562 DOI: 10.1111/padr.12249] [Citation(s) in RCA: 45] [Impact Index Per Article: 9.0] [Reference Citation Analysis] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 05/23/2023]
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Tailor TD, Choudhury KR, Tong BC, Christensen JD, Sosa JA, Rubin GD. Geographic Access to CT for Lung Cancer Screening: A Census Tract-Level Analysis of Cigarette Smoking in the United States and Driving Distance to a CT Facility. J Am Coll Radiol 2019; 16:15-23. [DOI: 10.1016/j.jacr.2018.07.007] [Citation(s) in RCA: 23] [Impact Index Per Article: 4.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/24/2018] [Revised: 06/15/2018] [Accepted: 07/05/2018] [Indexed: 02/08/2023]
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Chen A, Lo Sasso AT, Richards MR. Supply-side effects from public insurance expansions: Evidence from physician labor markets. HEALTH ECONOMICS 2018; 27:690-708. [PMID: 29194846 DOI: 10.1002/hec.3625] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 11/15/2016] [Revised: 08/29/2017] [Accepted: 10/24/2017] [Indexed: 06/07/2023]
Abstract
Medicaid and the Child Health Insurance Programs (CHIP) are key sources of coverage for U.S. children. Established in 1997, CHIP allocated $40 billion of federal funds across the first 10 years but continued support required reauthorization. After 2 failed attempts in Congress, CHIP was finally reauthorized and significantly expanded in 2009. Although much is known about the demand-side policy effects, much less is understood about the policy's impact on providers. In this paper, we leverage a unique physician dataset to examine if and how pediatricians responded to the expansion of the public insurance program. We find that newly trained pediatricians are 8 percentage points more likely to subspecialize and as much as 17 percentage points more likely to enter private practice after the law passed. There is also suggestive evidence of greater private practice growth in more rural locations. The sharp supply-side changes that we observe indicate that expanding public insurance can have important spillover effects on provider training and practice choices.
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Affiliation(s)
- Alice Chen
- Sol Price School of Public Policy, University of Southern California, Los Angeles, CA, USA
| | - Anthony T Lo Sasso
- School of Public Health, Health Policy and Administration, Institute of Government and Public Affairs, University of Illinois-Chicago, Chicago, IL, USA
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Doshi JA, Puckett JT, Parmacek MS, Rader DJ. Prior Authorization Requirements for Proprotein Convertase Subtilisin/Kexin Type 9 Inhibitors Across US Private and Public Payers. Circ Cardiovasc Qual Outcomes 2018; 11:e003939. [DOI: 10.1161/circoutcomes.117.003939] [Citation(s) in RCA: 27] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/15/2017] [Accepted: 11/27/2017] [Indexed: 12/31/2022]
Affiliation(s)
- Jalpa A. Doshi
- From the Department of Medicine, Perelman School of Medicine, University of Pennsylvania, Philadelphia (Dr Doshi, J.T. Puckett, Dr Parmacek, and Dr Rader) and the Leonard Davis Institute of Health Economics, Philadelphia (Dr Doshi)
| | - Justin T. Puckett
- From the Department of Medicine, Perelman School of Medicine, University of Pennsylvania, Philadelphia (Dr Doshi, J.T. Puckett, Dr Parmacek, and Dr Rader) and the Leonard Davis Institute of Health Economics, Philadelphia (Dr Doshi)
| | - Michael S. Parmacek
- From the Department of Medicine, Perelman School of Medicine, University of Pennsylvania, Philadelphia (Dr Doshi, J.T. Puckett, Dr Parmacek, and Dr Rader) and the Leonard Davis Institute of Health Economics, Philadelphia (Dr Doshi)
| | - Daniel J. Rader
- From the Department of Medicine, Perelman School of Medicine, University of Pennsylvania, Philadelphia (Dr Doshi, J.T. Puckett, Dr Parmacek, and Dr Rader) and the Leonard Davis Institute of Health Economics, Philadelphia (Dr Doshi)
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Dasgupta S, Hall HI, Hernandez AL, Ocfemia MCB, Saduvala N, Oster AM. Receipt and timing of HIV drug resistance testing in six U.S. jurisdictions. AIDS Care 2017; 29:1567-1575. [PMID: 28464705 PMCID: PMC5685490 DOI: 10.1080/09540121.2017.1316356] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/19/2022]
Abstract
The Department of Health and Human Services recommends drug resistance testing at linkage to HIV care. Because receipt and timing of testing are not well characterized, we examined testing patterns among persons with diagnosed HIV who are linked to care. Using surveillance data in six jurisdictions for persons aged ≥13 years with HIV infection diagnosed in 2013, we assessed the proportion receiving testing, and among these, the proportion receiving testing at linkage. Multivariable log-binomial regression modeling estimated associations between selected characteristics and receipt of testing (1) overall, and (2) at linkage among those tested. Of 9,408 persons linked to care, 66% received resistance testing, among whom 68% received testing at linkage. Less testing was observed among male persons who inject drugs (PWID), compared with men who have sex with men (adjusted prevalence ratio [aPR]: 0.88; 95% confidence interval [CI]: 0.81-0.97) and persons living in areas with population <500,000 compared with those in areas with population ≥2,500,000 (aPR: 0.88; CI: 0.84-0.93). In certain jurisdictions, testing was lower for persons with initial CD4 counts ≥500 cells/mm3, compared with those with CD4 counts <200 cells/mm3 (aPR range: 0.80-0.85). Of those tested, testing at linkage was lower among male PWID (aPR: 0.85; CI: 0.75-0.95) and, in some jurisdictions, persons with CD4 counts ≥500 cells/mm3 (aPR range: 0.63-0.73). Two-thirds of persons with diagnosed HIV who were linked to care received resistance testing, and most received testing at linkage as recommended. Improving receipt and timing of testing among male PWID, persons in less populous settings, and in all jurisdictions, regardless of CD4 count, may improve care outcomes.
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Affiliation(s)
- Sharoda Dasgupta
- Division of HIV/AIDS Prevention, Centers for Disease Control and Prevention, Atlanta, USA
| | - H. Irene Hall
- Division of HIV/AIDS Prevention, Centers for Disease Control and Prevention, Atlanta, USA
| | - Angela L. Hernandez
- Division of HIV/AIDS Prevention, Centers for Disease Control and Prevention, Atlanta, USA
| | | | | | - Alexandra M. Oster
- Division of HIV/AIDS Prevention, Centers for Disease Control and Prevention, Atlanta, USA
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An investigation of survivorship clinic attendance among childhood cancer survivors living in a five-state rural region. J Cancer Surviv 2017; 12:196-205. [PMID: 29185177 DOI: 10.1007/s11764-017-0658-4] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/24/2017] [Accepted: 10/21/2017] [Indexed: 10/18/2022]
Abstract
PURPOSE Cancer survivorship clinics manage cancer-related health complications and are available primarily in urban areas. We examine how demographic, clinical, and geographic-based characteristics are associated with attendance at the only pediatric survivorship clinic in a largely rural, multistate region. METHODS One thousand eight hundred sixteen cancer survivors were diagnosed at age ≤ 25 from 1986 to 2005 while living in the region. Cox models incorporating death as a competing risk and generalized estimating equations calculated hazards ratios (HR) for characteristics measured at the clinic's opening. Subjects were followed from the clinic opening their first visit, death, emigration from the catchment area, or December 31, 2014. RESULTS Five percent of survivors visited the clinic. Attendance is positively associated with a leukemia or lymphoma diagnosis (HR = 3.32, 95% confidence interval [CI] = 1.72-6.78 vs CNS tumors), previous relapse (HR = 1.78, 95% CI = 1.00-3.19), and residing >100 mi from the clinic (HR = 2.05, 95% CI 1.03-4.10). Survivors aged ≥ 31 years at clinic opening (HR = 0.19, 95% CI = 0.07-0.54) are less likely to attend than younger survivors. Residence between 16 and 100 mi had an inverse association with attendance, although not significant. CONCLUSION Survivorship clinics are not widely attended by survivors in this catchment region. Efforts should be made to recruit survivors aged ≥ 31 and diagnosed with CNS tumors. Distance has a complex association with attendance, which could be attributed to the limited availability of preventative services in regions > 100 mi from the clinic. IMPLICATIONS FOR CANCER SURVIVORS Survivors living in this catchment region may not be receiving care necessary to prevent severe late effects.
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Xu H, Chen J, Xu H, Qin Z. Geographic Variations in the Incidence of Glioblastoma and Prognostic Factors Predictive of Overall Survival in US Adults from 2004-2013. Front Aging Neurosci 2017; 9:352. [PMID: 29163134 PMCID: PMC5681990 DOI: 10.3389/fnagi.2017.00352] [Citation(s) in RCA: 35] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/03/2017] [Accepted: 10/17/2017] [Indexed: 12/22/2022] Open
Abstract
Objective: The purpose of this study was to evaluate variations in the regional incidence of glioblastoma in US adults in 2004-2013. Study Design and Setting: We evaluated 24,262 patients with primary glioblastoma. Data were categorized based on geographic regions that included different SEER registry sites as follows: (1) Northeast: Connecticut, New Jersey (3,977 patients); (2) South: Kentucky, Louisiana, Metropolitan Atlanta, Rural Georgia, Greater Georgia (excluding AT and RG) (5,212 patients); (3) North Central: Metropolitan Detroit, Iowa (2,320 patients); (4) West: Hawaii, New Mexico, Seattle (Puget Sound), Utah, San Francisco-Oakland SMSA, San Jose-Monterey, Los Angeles, Greater California (excluding SF, LA, and SJ), Alaska (12,753 patients). Results: Statistically significant differences in the rates of overall patient survival (P < 0.001) and the incidence of glioblastoma (24.31, 22.6, 20.35, 15.03 per 100,000/year in the South, Northeast, West, North Central regions, respectively) were identified between geographic regions. Multivariate Cox regression analysis demonstrated that overall survival was better in patients of Asian or Pacific Islander race. In addition, age, registry site, marital status, tumor laterality, histological classification, the extent of disease, tumor size, tumor extension, and treatment methods were identified as significant prognostic factors. Conclusion: Glioblastoma incidence is geographic region and race/ethnicity-dependent.
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Affiliation(s)
| | | | | | - Zhiyong Qin
- Department of Neurosurgery, Huashan Hospital Shanghai Medical College, Fudan University, Shanghai, China
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Chavez LJ, Kelleher KJ, Matson SC, Wickizer TM, Chisolm DJ. Mental Health and Substance Use Care Among Young Adults Before and After Affordable Care Act (ACA) Implementation: A Rural and Urban Comparison. J Rural Health 2017; 34:42-47. [DOI: 10.1111/jrh.12258] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/20/2017] [Revised: 04/21/2017] [Accepted: 05/24/2017] [Indexed: 12/22/2022]
Affiliation(s)
- Laura J. Chavez
- Center for Innovation in Pediatric Practice; The Research Institute at Nationwide Children's Hospital; Columbus Ohio
- Division of Health Services Management and Policy, College of Public Health; Ohio State University; Columbus Ohio
| | - Kelly J. Kelleher
- Center for Innovation in Pediatric Practice; The Research Institute at Nationwide Children's Hospital; Columbus Ohio
- Division of Health Services Management and Policy, College of Public Health; Ohio State University; Columbus Ohio
| | - Steven C. Matson
- Division of Adolescent Medicine; Nationwide Children's Hospital; Columbus Ohio
| | - Thomas M. Wickizer
- Division of Health Services Management and Policy, College of Public Health; Ohio State University; Columbus Ohio
| | - Deena J. Chisolm
- Center for Innovation in Pediatric Practice; The Research Institute at Nationwide Children's Hospital; Columbus Ohio
- Division of Health Services Management and Policy, College of Public Health; Ohio State University; Columbus Ohio
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Moody L, Satterwhite E, Bickel WK. Substance Use in Rural Central Appalachia: Current Status and Treatment Considerations. RURAL MENTAL HEALTH 2017; 41:123-135. [PMID: 29057030 PMCID: PMC5648074 DOI: 10.1037/rmh0000064] [Citation(s) in RCA: 89] [Impact Index Per Article: 12.7] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
Abstract
The burden of substance use and especially the unmatched rates of overdoses in rural Central Appalachia highlight the need for innovative approaches to curb the initiation to drug misuse and to address current substance use disorders. Effective substance use interventions involve a thorough understanding of the region. In Central Appalachia, many of the barriers to treatment are shared with other rural and impoverished areas, including a lack of access to health care and lack of health care providers with specialized training. Parts of Appalachia also present their own considerations, including the challenges of fostering trust and encouraging treatment-seeking in communities with dense, long-term, place-based social and family networks. Current policies and interventions for substance use have been largely inadequate in the region, as evidenced by continued increases in substance use and substance-related deaths, especially related to nonmedical prescription drug use and increasing heroin use. The authors discuss ways in which rural life, poverty, identity, and values in Appalachia have influenced substance use and treatment and propose strategies and interventions to improve outcomes.
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Affiliation(s)
- Lara Moody
- Virginia Tech Carilion Research Center, Roanoke, VA, USA
- Virginia Tech, Department of Psychology, Blacksburg, VA, USA
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Fontanella CA, Hiance-Steelesmith DL, Gilchrist R, Bridge JA, Weston D, Campo JV. Quality of care for Medicaid-enrolled youth with bipolar disorders. ADMINISTRATION AND POLICY IN MENTAL HEALTH AND MENTAL HEALTH SERVICES RESEARCH 2016; 42:126-38. [PMID: 24729042 DOI: 10.1007/s10488-014-0553-5] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Abstract
This study examined conformance to clinical practice guidelines for children and adolescents with bipolar disorders and identified patient and provider factors associated with guideline concordant care. Administrative records were examined for 4,047 Medicaid covered youth aged 5-18 years with new episodes of bipolar disorder during 2006-2010. Main outcome measures included 5 claims-based quality of care measures reflecting national treatment guidelines. Measures addressed appropriate pharmacotherapy, therapeutic drug monitoring, and psychosocial treatment. The results indicated that current treatment practices for youth diagnosed with bipolar disorder typically fall short of recommended practice guidelines. Although the majority of affected youth are treated with recommended first-line pharmacotherapy, only a minority receive therapeutic drug monitoring and/or psychotherapy of recommended duration, underscoring the need for quality improvement initiatives.
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Affiliation(s)
- Cynthia A Fontanella
- Department of Psychiatry, College of Medicine, The Ohio State University, 1670 Upham Road, Columbus, OH, 43210, USA,
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Fontanella CA, Guada J, Phillips G, Ranbom L, Fortney JC. Individual and contextual-level factors associated with continuity of care for adults with schizophrenia. ADMINISTRATION AND POLICY IN MENTAL HEALTH AND MENTAL HEALTH SERVICES RESEARCH 2016; 41:572-87. [PMID: 23689992 DOI: 10.1007/s10488-013-0500-x] [Citation(s) in RCA: 26] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
This retrospective cohort study examined rates of conformance to continuity of care treatment guidelines and factors associated with conformance for persons with schizophrenia. Subjects were 8,621 adult Ohio Medicaid recipients, aged 18-64, treated for schizophrenia in 2004. Information on individual-level (demographic and clinical characteristics) and contextual-level variables (county socio-demographic, economic, and health care resources) were abstracted from Medicaid claim files and the Area Resource File. Outcome measures captured four dimensions of continuity of care: (1) regularity of care; (2) transitions; (3) care coordination, and (4) treatment engagement. Multilevel modeling was used to assess the association between individual and contextual-level variables and the four continuity of care measures. The results indicated that conformance rates for continuity of care for adults with schizophrenia are below recommended guidelines and that variations in continuity of care are associated with both individual and contextual-level factors. Efforts to improve continuity of care should target high risk patient groups (racial/ethnic minorities, the dually diagnosed, and younger adults with early onset psychosis), as well as community-level risk factors (provider supply and geographic barriers of rural counties) that impede access to care.
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Affiliation(s)
- Cynthia A Fontanella
- Department of Psychiatry, The Ohio State University, 1670 Upham Drive, Columbus, OH, 43210, USA,
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Davidsson N, Södergård B. Access to Healthcare among People with Physical Disabilities in Rural Louisiana. SOCIAL WORK IN PUBLIC HEALTH 2016; 31:188-195. [PMID: 26983377 DOI: 10.1080/19371918.2015.1099496] [Citation(s) in RCA: 18] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/05/2023]
Abstract
The aim was to explore the perceptions about factors that impede and facilitate access to healthcare among rural residents in Louisiana with physical disabilities. The participants were recruited through local churches and word of mouth. Nine in-depth interviews were conducted. The interviews were analyzed using content analysis. Seven categories containing barriers and facilitators were found. The interviewees described lack of transportation, lack of specialized care locally, limits in insurance coverage, lack of financial resources, and lack of knowledge about health care to be the main barriers. The main facilitators were social support, mainly from family and friends, transportation assistance, continuity of care, trust in doctors, and insurance coverage. People with disabilities in rural areas face several barriers when accessing health care but also multiple facilitators. A group that was identified as particularly vulnerable were low-income households that were not eligible for Medicare/Medicaid but still had high expenditures on health care due to disabilities.
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Affiliation(s)
- Nina Davidsson
- a Department of Public Health Sciences , Karolinska Institutet , Stockholm , Sweden
| | - Björn Södergård
- a Department of Public Health Sciences , Karolinska Institutet , Stockholm , Sweden
- b Dental and Pharmaceutical Benefits Agency , TLV, Stockholm , Sweden
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Chen HF, Carlson E, Popoola T, Suzuki S. The Impact of Rurality on 30-Day Preventable Readmission, Illness Severity, and Risk of Mortality for Heart Failure Medicare Home Health Beneficiaries. J Rural Health 2015; 32:176-87. [PMID: 26348123 DOI: 10.1111/jrh.12142] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 07/22/2015] [Indexed: 11/28/2022]
Abstract
PURPOSE To examine the impact of rurality on 30-day preventable readmission, and the illness severity and risk of mortality for 30-day preventable readmissions. METHODS We analyzed heart failure Medicare beneficiaries who received home health services for postacute care after hospital discharge in 2009. The study was a cross-sectional design with the unit of analysis as the home health episode for postacute care. Data sources included the following: Medicare Beneficiary Summary File, Medicare Provider Analysis Review, Outcome Assessment Information Set, Home Health Agency Research Identifiable File, and Area Health Resources File. The dependent variables were 30-day preventable readmission, and the extreme/major level of illness severity and of risk of mortality for a 30-day preventable readmission. The key independent variable was rurality defined as remote rural, adjacent rural, and micropolitan areas, with urban areas in the reference group. FINDINGS Home health beneficiaries in remote rural areas had 27% lower 30-day preventable readmission than those in urban areas. Home health beneficiaries in adjacent rural areas were 33% less likely to have high illness severity at readmission due to a preventable condition than those in urban areas. CONCLUSIONS Geographical location affects preventable readmission and illness severity of preventable readmission. Patients' geographic location along with patients' risk factors should be taken into consideration in the risk adjustment model for the financial incentive program that penalizes home health agencies with high preventable readmissions.
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Affiliation(s)
- Hsueh-Fen Chen
- Department of Health Management and Policy, School of Public Health, University of North Texas Health Science Center, Fort Worth, Texas
| | - Erin Carlson
- Department of Health Management and Policy, School of Public Health, University of North Texas Health Science Center, Fort Worth, Texas
| | - Taiye Popoola
- Department of Health Policy and Management, School of Medicine, University of Kansas Medical Center, Kansas City, Kansas
| | - Sumihiro Suzuki
- Department of Biostatistics and Epidemiology, School of Public Health, University of North Texas Health Science Center, Fort Worth, Texas
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A Multicenter Cardiovascular MR Network for Tele-Training and Beyond: Setup and Initial Experiences. J Am Coll Radiol 2015; 12:876-83. [DOI: 10.1016/j.jacr.2015.03.006] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/15/2015] [Accepted: 03/04/2015] [Indexed: 12/21/2022]
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Richards MR, Saloner B, Kenney GM, Rhodes KV, Polsky D. Availability of New Medicaid Patient Appointments and the Role of Rural Health Clinics. Health Serv Res 2015; 51:570-91. [PMID: 26119695 DOI: 10.1111/1475-6773.12334] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022] Open
Abstract
OBJECTIVE To examine the willingness to accept new Medicaid patients among certified rural health clinics (RHCs) and other nonsafety net rural providers. DATA SOURCES Experimental (audit) data from a 10-state study of primary care practices, county-level information from the Area Health Resource File, and RHC information from the Center for Medicare and Medicaid Services. STUDY DESIGN We generate appointment rates for rural and nonrural areas by patient-payer type (private, Medicaid, self-pay) to then motivate our focus on within-rural variation by clinic type (RHC vs. non-RHC). Multivariate linear models test for statistical differences and assess the estimates' sensitivity to the inclusion of control variables. DATA COLLECTION The primary data are from a large field study. PRINCIPAL FINDINGS Approximately 80 percent of Medicaid callers receive an appointment in rural areas-a rate more than 20 percentage points greater than nonrural areas. Importantly, within rural areas, RHCs offer appointments to prospective Medicaid patients nearly 95 percent of the time, while the rural (nonsafety net) non-RHC Medicaid rate is less than 75 percent. Measured differences are robust to covariate adjustment. CONCLUSIONS Our study suggests that RHC status, with its alternative payment model, is strongly associated with new Medicaid patient acceptance. Altering RHC financial incentives may have consequences for rural Medicaid enrollees.
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Affiliation(s)
- Michael R Richards
- Leonard Davis Institute of Health Economics, Colonial Penn Center, University of Pennsylvania, 3641 Locust Walk, Philadelphia, PA
| | - Brendan Saloner
- Department of Health Policy and Management, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD
| | | | - Karin V Rhodes
- Perelman School of Medicine, Center for Emergency Care Policy & Research, University of Pennsylvania, Philadelphia, PA
| | - Daniel Polsky
- Wharton School and Perelman School of Medicine, Leonard Davis Institute of Health Economics, Colonial Penn Center, University of Pennsylvania, Philadelphia, PA
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Elam CL, Weaver AD, Whittler ET, Stratton TD, Asher LM, Scott KL, Wilson EA. Discerning applicants' interests in rural medicine: a textual analysis of admission essays. MEDICAL EDUCATION ONLINE 2015; 20:27081. [PMID: 25795383 PMCID: PMC4368712 DOI: 10.3402/meo.v20.27081] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 12/24/2014] [Accepted: 02/10/2015] [Indexed: 06/04/2023]
Abstract
BACKGROUND Despite efforts to construct targeted medical school admission processes using applicant-level correlates of future practice location, accurately gauging applicants' interests in rural medicine remains an imperfect science. This study explores the usefulness of textual analysis to identify rural-oriented themes and values underlying applicants' open-ended responses to admission essays. METHODS The study population consisted of 75 applicants to the Rural Physician Leadership Program (RPLP) at the University of Kentucky College of Medicine. Using WordStat, a proprietary text analysis program, applicants' American Medical College Application Service personal statement and an admission essay written at the time of interview were searched for predefined keywords and phrases reflecting rural medical values. From these text searches, derived scores were then examined relative to interviewers' subjective ratings of applicants' overall acceptability for admission to the RPLP program and likelihood of practicing in a rural area. RESULTS The two interviewer-assigned ratings of likelihood of rural practice and overall acceptability were significantly related. A statistically significant relationship was also found between the rural medical values scores and estimated likelihood of rural practice. However, there was no association between rural medical values scores and subjective ratings of applicant acceptability. CONCLUSIONS That applicants' rural values in admission essays were not related to interviewers' overall acceptability ratings indicates that other factors played a role in the interviewers' assessments of applicants' acceptability for admission.
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Affiliation(s)
- Carol L Elam
- Office of Medical Education, University of Kentucky College of Medicine, Lexington, KY, USA;
| | - Anthony D Weaver
- Department of Internal Medicine, University of Kentucky College of Medicine, Lexington, KY, USA
| | - Elmer T Whittler
- Center of Excellence in Rural Health, Hazard, KY, USA
- University of Kentucky College of Medicine, Lexington, KY, USA
| | - Terry D Stratton
- Office of Medical Education, University of Kentucky College of Medicine, Lexington, KY, USA
| | - Linda M Asher
- Office of Rural and Community Health, University of Kentucky College of Medicine, Lexington, KY, USA
| | - Kimberly L Scott
- Office of Medical Education, University of Kentucky College of Medicine, Lexington, KY, USA
| | - Emery A Wilson
- Office of Medical Education, University of Kentucky College of Medicine, Lexington, KY, USA
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Johnson CE, Bush RL, Harman J, Bolin J, Evans Hudnall G, Nguyen AM. Variation in Utilization of Health Care Services for Rural VA Enrollees With Mental Health-Related Diagnoses. J Rural Health 2015; 31:244-53. [PMID: 25599892 DOI: 10.1111/jrh.12105] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
Abstract
PURPOSE Rural-dwelling Department of Veterans Affairs (VA) enrollees are at high risk for a wide variety of mental health-related disorders. The objective of this study is to examine the variation in the types of mental and nonmental health services received by rural VA enrollees who have a mental health-related diagnosis. METHODS The Andersen and Aday behavioral model of health services use and the Agency for Healthcare Research and Quality Medical Expenditure Panel Survey (MEPS) data were used to examine how VA enrollees with mental health-related diagnoses accessed places of care from 1999 to 2009. Population survey weights were applied to the MEPS data, and logit regression was conducted to model how predisposing, enabling, and need factors influence rural veteran health services use (measured by visits to different places of care). Analyses were performed on the subpopulations: rural VA, rural non-VA, urban VA, and urban non-VA enrollees. FINDINGS For all types of care, both rural and urban VA enrollees received care from inpatient, outpatient, office-based, and emergency room settings at higher odds than urban non-VA enrollees. Rural VA enrollees also received all types of care from inpatient, office-based, and emergency room settings at higher odds than urban VA enrollees. Rural VA enrollees had higher odds of a mental health visit of any kind compared to urban VA and non-VA enrollees. CONCLUSIONS Based on these variations, the VA may want to develop strategies to increase screening efforts in inpatient settings and emergency rooms to further capture rural VA enrollees who have undiagnosed mental health conditions.
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Affiliation(s)
- Christopher E Johnson
- Department of Health Services, School of Public Health, University of Washington, Seattle, Washington
| | - Ruth L Bush
- College of Medicine, Texas A&M Health Science Center, Round Rock, Texas
| | - Jeffrey Harman
- Department of Health Services Research, Management, and Policy, College of Public Health and Health Professions, University of Florida, Gainesville, Florida
| | - Jane Bolin
- Southwest Rural Health Research Center, Texas A&M Health Science Center, College Station, Texas
| | - Gina Evans Hudnall
- South Central Mental Illness, Research, Education and Clinical Center and Houston Center for Quality of Care and Utilization Studies, Michael E. Debakey VA Medical Center, Houston, Texas.,Health Services Research and Development Section, Department of Medicine, Baylor College of Medicine, Houston, Texas
| | - Ann M Nguyen
- Department of Health Services, School of Public Health, University of Washington, Seattle, Washington
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Epstein JN, Kelleher KJ, Baum R, Brinkman WB, Peugh J, Gardner W, Lichtenstein P, Langberg J. Variability in ADHD care in community-based pediatrics. Pediatrics 2014; 134:1136-43. [PMID: 25367532 PMCID: PMC4243070 DOI: 10.1542/peds.2014-1500] [Citation(s) in RCA: 80] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/06/2023] Open
Abstract
BACKGROUND Although many efforts have been made to improve the quality of care delivered to children with attention-deficit/hyperactivity disorder (ADHD) in community-based pediatric settings, little is known about typical ADHD care in these settings other than rates garnered through pediatrician self-report. METHODS Rates of evidence-based ADHD care and sources of variability (practice-level, pediatrician-level, patient-level) were determined by chart reviews of a random sample of 1594 patient charts across 188 pediatricians at 50 different practices. In addition, the associations of Medicaid-status and practice setting (ie, urban, suburban, and rural) with the quality of ADHD care were examined. RESULTS Parent- and teacher-rating scales were used during ADHD assessment with approximately half of patients. The use of Diagnostic and Statistical Manual of Mental Disorders criteria was documented in 70.4% of patients. The vast majority (93.4%) of patients with ADHD were receiving medication and only 13.0% were receiving psychosocial treatment. Parent- and teacher-ratings were rarely collected to monitor treatment response or side effects. Further, fewer than half (47.4%) of children prescribed medication had contact with their pediatrician within the first month of prescribing. Most variability in pediatrician-delivered ADHD care was accounted for at the patient level; however, pediatricians and practices also accounted for significant variability on specific ADHD care behaviors. CONCLUSIONS There is great need to improve the quality of ADHD care received by children in community-based pediatric settings. Improvements will likely require systematic interventions at the practice and policy levels to promote change.
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Affiliation(s)
- Jeffery N. Epstein
- Department of Pediatrics, Cincinnati Children’s Hospital Medical Center, Cincinnati, Ohio
| | - Kelly J. Kelleher
- Department of Pediatrics, Nationwide Children’s Hospital, Columbus, Ohio
| | - Rebecca Baum
- Department of Pediatrics, Nationwide Children’s Hospital, Columbus, Ohio
| | - William B. Brinkman
- Department of Pediatrics, Cincinnati Children’s Hospital Medical Center, Cincinnati, Ohio
| | - James Peugh
- Department of Pediatrics, Cincinnati Children’s Hospital Medical Center, Cincinnati, Ohio
| | - William Gardner
- Department of Pediatrics, Nationwide Children’s Hospital, Columbus, Ohio;,Department of Psychiatry, Dalhousie University, Halifax, Nova Scotia, Canada
| | | | - Joshua Langberg
- Department of Psychology, Virginia Commonwealth University, Richmond, Virginia
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Michimi A, Ellis-Griffith G, Lartey G, Ellis-Griffith C, Hunt M. Variability between self-reported diabetes and measured glucose among health screening participants in South Central Kentucky. Prim Care Diabetes 2014; 8:31-38. [PMID: 24149055 DOI: 10.1016/j.pcd.2013.09.001] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/02/2013] [Revised: 08/31/2013] [Accepted: 09/05/2013] [Indexed: 01/22/2023]
Abstract
AIMS To assess self-reported diabetes and random glucose among health screening participants and examine factors associated with these two diabetes outcomes. METHODS Study subjects were adults aged ≥18 years who participated in diabetes screenings via a mobile health clinic operated by the Institute for Rural Health at Western Kentucky University from 2006 to 2011. Data on self-reported diabetes were based on physicians' past diagnosis. Random plasma glucose was obtained during the screenings. Non-fasting plasma glucose levels of ≥180mg/dl and ≥140mg/dl were used as cutoffs to determine diabetes and diabetes or pre-diabetes, respectively. Logistic regression was used to examine factors associated with self-reported diabetes and elevated non-fasting glucose levels controlling for comorbidities and sociodemographic factors. RESULTS The proportion of self-reported diabetes was 9.6%. The proportion of participants with ≥180mg/dl was 3.2% and that with ≥140mg/dl was 7.4%. Odds ratios indicated that self-reported diabetes was higher in older and obese groups and those who had hypertension and hypercholesterolemia and family history of diabetes, while elevated non-fasting glucose levels were higher among participants without health insurance and those who reported they had diabetes. CONCLUSIONS Variability in risks between self-reported diabetes and measured glucose should be incorporated in diabetes self-care.
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Affiliation(s)
- Akihiko Michimi
- Department of Public Health, College of Health and Human Services, Western Kentucky University, USA.
| | - Gregory Ellis-Griffith
- Department of Public Health, College of Health and Human Services, Western Kentucky University, USA.
| | - Grace Lartey
- Department of Public Health, College of Health and Human Services, Western Kentucky University, USA.
| | - Chandra Ellis-Griffith
- School of Nursing, College of Health and Human Services, Western Kentucky University, USA.
| | - Matthew Hunt
- The Institute for Rural Health, College of Health and Human Services, Western Kentucky University, USA.
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Kirchhoff AC, Hart G, Campbell EG. Rural and urban primary care physician professional beliefs and quality improvement behaviors. J Rural Health 2014; 30:235-43. [PMID: 24528129 DOI: 10.1111/jrh.12067] [Citation(s) in RCA: 25] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
Abstract
PURPOSE We evaluated whether primary care physicians (PCPs) from urban and rural practices differ on attitudes and behaviors related to quality improvement (QI) activities, patient relationships, and professionalism/self-regulation. METHODS Data from a national survey that assessed physician attitudes and behaviors based on the Physician Charter on Medical Professionalism were used. Of the 1,891 survey respondents, N = 840 were PCPs (n = 274 family medicine (response rate = 67.5%); n = 257 general internal medicine (60.8%); and n = 309 pediatricians (72.7%)). Using Rural-Urban Commuting Area (RUCA) codes, PCPs were classified as urban and rural according to their practice ZIP code. FINDINGS A total of n = 691 physicians were urban and n = 127 rural. Attitudes regarding participating in QI did not differ by practice location; however, rural PCPs were more likely to have reviewed an other physician's records for QI than urban PCPs (65.6% vs 48.0%, P < .001). Rural physicians were more likely to agree that physicians should talk with their patients about the cost of care than urban PCPs (40.5% vs 29.2%, P = .02). While all PCPs endorsed attitudes regarding the importance of professional behaviors (eg, reporting impaired/incompetent colleagues, disclosing medical errors) at generally similar levels, their behaviors differed. More rural physicians had a personal knowledge of an impaired/incompetent physician than urban physicians (20.7% vs 12.7%, P = .02). CONCLUSIONS PCPs from rural and urban areas share similar attitudes regarding the importance of participating in QI and fulfilling professional responsibilities. However, certain behaviors (eg, knowledge of impaired colleagues) do differ. These results should be confirmed in larger studies of rural PCPs.
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Affiliation(s)
- Anne C Kirchhoff
- Department of Pediatrics, University of Utah School of Medicine, Salt Lake City, Utah; Cancer Control and Population Sciences, Huntsman Cancer Institute, Salt Lake City, Utah
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Rongey C, Shen H, Hamilton N, Backus LI, Asch SM, Knight S. Impact of rural residence and health system structure on quality of liver care. PLoS One 2013; 8:e84826. [PMID: 24386420 PMCID: PMC3873451 DOI: 10.1371/journal.pone.0084826] [Citation(s) in RCA: 21] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/23/2013] [Accepted: 11/21/2013] [Indexed: 02/07/2023] Open
Abstract
Background Specialist physician concentration in urban areas can affect access and quality of care for rural patients. As effective drug treatment for hepatitis C (HCV) becomes increasingly available, the extent to which rural patients needing HCV specialists face access or quality deficits is unknown. We sought to determine the influence of rural residency on access to HCV specialists and quality of liver care. Methods The study used a national cohort of 151,965 Veterans Health Administration (VHA) patients with HCV starting in 2005 and followed to 2009. The VHA’s constant national benefit structure reduces the impact of insurance as an explanation for observed disparities. Multivariate cox proportion regression models for each quality indicator were performed. Results Thirty percent of VHA patients with HCV reside in rural and highly rural areas. Compared to urban residents, highly rural (HR 0.70, CI 0.65-0.75) and rural (HR 0.96, CI 0.94-0.97) residents were significantly less likely to access HCV specialty care. The quality indicators were more mixed. While rural residents were less likely to receive HIV screening, there were no significant differences in hepatitis vaccinations, endoscopic variceal and hepatocellular carcinoma screening between the geographic subgroups. Of note, highly rural (HR 1.31, CI 1.14-1.50) and rural residents (HR 1.06, CI 1.02-1.10) were more likely to receive HCV therapy. Of those treated for HCV, a third received therapy from a non-specialist provider. Conclusion Rural patients have less access to HCV specialists, but this does not necessarily translate to quality deficits. The VHA's efforts to improve specialty care access, rural patient behavior and decentralization of HCV therapy beyond specialty providers may explain this contradiction. Lessons learned within the VHA are critical for US healthcare systems restructuring into accountable care organizations that acquire features of integrated systems.
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Affiliation(s)
- Catherine Rongey
- Department of Medicine, Veterans Affairs Medical Center and University of California San Francisco, San Francisco, California, United States of America
- * E-mail:
| | - Hui Shen
- Department of Biostatics and Epidemiology, University of California San Francisco, San Francisco, California, United States of America
| | - Nathan Hamilton
- Department of Biostatics and Epidemiology, University of California San Francisco, San Francisco, California, United States of America
| | - Lisa I. Backus
- Department of Medicine, Veterans Affairs Medical Center, Palo Alto, California, United States of America
- Office of Public Health and Population Health, Department of Veterans Affairs, Washington, District of Columbia, United States of America
| | - Steve M. Asch
- Department of Medicine, Veterans Affairs Medical Center, Palo Alto, California, United States of America
- Department of Medicine, Stanford University, Stanford, California, United States of America
| | - Sara Knight
- Departments of Psychiatry and Urology, Veterans Affairs Medical Center, San Francisco, California, United States of America
- Office of Research and Development, Department of Veterans Affairs, Washington, District of Columbia, United States of America
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Stensland J, Akamigbo A, Glass D, Zabinski D. Rural and urban Medicare beneficiaries use remarkably similar amounts of health care services. Health Aff (Millwood) 2013; 32:2040-6. [PMID: 24173368 DOI: 10.1377/hlthaff.2013.0693] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
Medicare payment policies for rural health care providers are influenced by the assumption that the limited supply of physicians in rural areas causes rural Medicare beneficiaries to receive fewer health care services than their urban counterparts do. This assumption has contributed to the growth in special payments to rural providers. As a result, Medicare pays rural providers $3 billion more each year in special payments than they would receive under traditional payment rates. To test the validity of the assumption that rural beneficiaries systematically receive less care, we analyzed claims data for all Medicare fee-for-service beneficiaries in 2008, stratified by rural/urban status and region. After adjusting for health status, we found no significant differences between rural and urban beneficiaries in either the amount of health care received or satisfaction with access to care. Although there were systematic differences in the amount of care used across regions of the country, there was very little difference within a region between rural and urban areas. To the extent that Medicare payment policies are designed to ensure access, they should be assessed on the basis of achieving similar service use rather than similar local physician supply. They should also be targeted to isolated rural providers needed to preserve access to care.
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Palmer NRA, Geiger AM, Lu L, Case LD, Weaver KE. Impact of rural residence on forgoing healthcare after cancer because of cost. Cancer Epidemiol Biomarkers Prev 2013; 22:1668-76. [PMID: 24097196 PMCID: PMC3833446 DOI: 10.1158/1055-9965.epi-13-0421] [Citation(s) in RCA: 44] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
Abstract
BACKGROUND Routine follow-up care is recommended to promote the well-being of cancer survivors, but financial difficulties may interfere. Rural-urban disparities in forgoing healthcare due to cost have been observed in the general population; however, it is unknown whether this disparity persists among survivors. The purpose of this study was to examine rural-urban disparities in forgoing healthcare after cancer due to cost. METHODS We analyzed data from 7,804 cancer survivors in the 2006 to 2010 National Health Interview Survey. Logistic regression models, adjusting for sociodemographic and clinical characteristics, were used to assess rural-urban disparities in forgoing medical care, prescription medications, and dental care due to cost, stratified by age (younger: 18-64, older: 65+). RESULTS Compared with urban survivors, younger rural survivors were more likely to forgo medical care (P < 0.001) and prescription medications (P < 0.001) due to cost; older rural survivors were more likely to forgo medical (P < 0.001) and dental care (P = 0.05). Rural-urban disparities did not persist among younger survivors in adjusted analyses; however, older rural survivors remained more likely to forgo medical [OR = 1.66, 95% confidence interval (CI) = 1.11-2.48] and dental care (OR = 1.54, 95%CI = 1.08-2.20). CONCLUSIONS Adjustment for health insurance and other sociodemographic characteristics attenuates rural-urban disparities in forgoing healthcare among younger survivors, but not older survivors. Financial factors relating to healthcare use among rural survivors should be a topic of continued investigation. IMPACT Addressing out-of-pocket costs may be an important step in reducing rural-urban disparities in healthcare, especially for older survivors. It will be important to monitor how healthcare reform efforts impact disparities observed in this vulnerable population.
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Affiliation(s)
- Nynikka R A Palmer
- Authors' Affiliations: Social Science and Health Policy, Epidemiology and Prevention, Biostatistical Sciences, Division of Public Health Sciences, Wake Forest School of Medicine, Winston-Salem, North Carolina; Health Services and Economics Branch, Applied Research Program, Division of Cancer Control and Population Science, National Cancer Institute, Rockville, Maryland
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Erickson LD, Hedges DW, Call VRA, Bair B. Prevalence of and factors associated with subclinical posttraumatic stress symptoms and PTSD in urban and rural areas of Montana: a cross-sectional study. J Rural Health 2013; 29:403-12. [PMID: 24088214 DOI: 10.1111/jrh.12017] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
Abstract
PURPOSE Posttraumatic stress disorder (PTSD) is an important clinical problem, but little is known about PTSD in rural, nonclinical populations. To better understand PTSD in rural areas, we examined the prevalence and risk and protective factors in urban, rural, and highly rural communities in Montana for both subclinical posttraumatic stress symptoms (PTSS) and PTSD. METHODS We compared the prevalence of PTSS and PTSD in urban, rural, and highly rural communities in bivariate and multivariable regression analyses using self-reported cross-sectional survey data from the Montana Health Matters study (N = 3,512), a state-representative household-based survey done in 2010-2011. We also explore potential risk and protective factors for PTSS and PTSD and whether risk and protective factors for each differ by rurality. FINDINGS There were no differences in the level of PTSS by rurality in bivariate or multivariate models, and the bivariate relationship between rurality and PTSD became nonsignificant in a multivariate model. Only locus of control was predictive for PTSS; however, gender, age, marital status, income, employment status, community fit, locus of control, and religiosity were associated with PTSD. Some risk and protective factors operate differently by rurality. CONCLUSIONS Although our findings are subject to weaknesses common to cross-sectional data and are based on questionnaire reports, it appears that there are different risk and protective factors for PTSS and PTSD, suggesting that PTSD may be qualitatively different from PTSS. Furthermore, differences in risk and protective factors across urban and rural communities suggest more attention is needed to understand PTSD in rural communities.
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Hunt JB, Curran G, Kramer T, Mouden S, Ward-Jones S, Owen R, Fortney J. Partnership for implementation of evidence-based mental health practices in rural federally qualified health centers: theory and methods. Prog Community Health Partnersh 2012; 6:389-98. [PMID: 22982852 DOI: 10.1353/cpr.2012.0039] [Citation(s) in RCA: 20] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
Abstract
BACKGROUND Mental health and substance abuse are among the most commonly reported reasons for visits to Federally Qualified Health Centers (CHCs), yet only 6.5% of encounters are with on-site behavioral health specialists. Rural CHCs are significantly less likely to have on-site behavioral specialists than urban CHCs. Because of this lack of mental health specialists in rural areas, the most promising approach to improving mental health outcomes is to help rural primary care (PC) providers deliver evidence-based practices (EBPs). Despite the scope of these problems, no research has developed an effective implementation strategy for facilitating the adoption of mental health EBPs for rural CHCs. We sought to describe the conceptual components of an implementation partnership that focuses on the adaption and adoption of mental health EBPs by rural CHCs in Arkansas. METHODS We present a conceptual model that integrates seven separate frameworks: (1) Jones and Wells' Evidence-Based Community Partnership Model, (2) Kitson's Promoting Action on Research Implementation in Health Services (PARiHS) implementation framework, (3) Sackett's definition of evidence-based medicine, (4) Glisson's organizational social context model, (5) Rubenstein's Evidence-Based Quality Improvement (EBQI) facilitation process, (6) Glasgow's RE-AIM evaluation approach, and (7) Naylor's concept of shared decision making. CONCLUSIONS By integrating these frameworks into a meaningful conceptual model, we hope to develop a successful implementation partnership between an academic health center and small rural CHCs to improve mental health outcomes. Findings from this implementation partnership should have relevance to hundreds of clinics and millions of patients, and could help promote the sustained adoption of EBPs across rural America.
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Affiliation(s)
- Justin B Hunt
- Division of Health Services Research, Psychiatric Research Institute, University of Arkansas for Medical Sciences, USA
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Girio-Herrera E, Owens JS, Langberg JM. Perceived barriers to help-seeking among parents of at-risk kindergarteners in rural communities. JOURNAL OF CLINICAL CHILD AND ADOLESCENT PSYCHOLOGY 2012; 42:68-77. [PMID: 22963042 DOI: 10.1080/15374416.2012.715365] [Citation(s) in RCA: 32] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 10/26/2022]
Abstract
This study examined help-seeking and perceived barriers to children's mental health service utilization in a large sample of parents living in rural communities who are at various stages in the help-seeking process. The goals were to (a) obtain a demographic profile of at-risk kindergarteners and their parents, (b) examine parent-reported help-seeking behaviors, and (c) assess barriers to mental health service use. Parent and teacher report of the Behavior Assessment System for Children, Second Edition, were used to screen children (N = 597) at kindergarten entry and to identify their risk status. Parents also completed the Barriers to Participation Scale and reported the frequency of help-seeking behaviors related to their child's problems. Using a cutoff score of 1.5 standard deviations above the mean, nearly half (51%) of children were identified as at-risk (76% low risk, 24% high risk) for emotional, behavioral, social, and adaptive problems. Barriers and help-seeking did not differ across parents of low and high risk children. Among parents of at-risk children, only 33% believed their child had a problem. Parents sought informal help more often than professional help; however, medical doctors and school staff were sought most among professionals. The majority of parents (61%) endorsed at least one barrier that would interfere with mental health service use. Results highlight the importance of early school mental health screening and the need for interventions to increase parent problem recognition and engagement in mental health service utilization.
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