Building Statewide Quality Improvement Capacity to Improve Cardiovascular Care and Health Equity: Lessons from the Tennessee Heart Health Network

DRIVING FORCES

Many states with high rates of cardiovascular disease (CVD) lack statewide quality improvement (QI) infrastructure (for example, resources, leadership, community) to address relevant health needs of the population. Academic health centers are well positioned to play a central role in addressing this deficiency. This article describes early experience and lessons learned in building statewide QI infrastructure through the Tennessee Heart Health Network (Network).

APPROACH

A statewide, multistakeholder network composed of primary care practices (PCPs), health systems, health plans, QI organizations, patients, and academic institutions was led by the University of Tennessee Health Science Center (UTHSC), an academic health center, to improve cardiovascular health by supporting dissemination and implementation of patient-centered outcomes research (PCOR) evidence-based interventions in primary care. PCPs were required to select and implement at least one of three interventions (health coaching, tailored health-related text messaging, and pharmacist-physician collaboration).

OUTCOMES AND KEY INSIGHTS

Thirty statewide organizational partners joined the Network in year one, including 18 health systems representing 77 PCPs (30.0% of 257 potentially eligible PCPs identified) with approximately 300,000 patients. The organizational partners share EHRs for the ongoing tracking and reporting of key health metrics, including hypertension control and delivery of tobacco cessation counseling. Of the 77 PCPs, 62 continue participation after year two (80.5% retention). Main barriers to participation and reasons for discontinuing participation included reluctance to share data and changes in leadership at the health system level. These 62 PCPs selected the following interventions to implement: health coaching (41.9%), tailored health-related text messages (48.4%), and pharmacist-physician collaboration (40.3%).

CONCLUSION AND WHAT'S NEXT

Academic health centers have broad reach and high acceptability by diverse stakeholders. Tennessee's experience illustrates how academic health centers can serve as platforms for building a statewide infrastructure for disseminating, implementing, and sustaining QI interventions at the practice level. Assessment of Network impact is ongoing.

Longitudinal Associations of Staff Shortages and Staff Levels with Health Outcomes in Nursing Homes

OBJECTIVES

To examine whether facility-reported staff shortages and total staff levels were independently associated with changes in nursing home (NH) outcomes in 2020.

DESIGN

Longitudinal cohort study.

SETTING AND PARTICIPANTS

A total of 8466 NHs with staffing and outcome data.

METHODS

This study used NH COVID-19 Public File (2020), Nursing Home Compare (2019-2020), and Payroll-Based Journal data (2019-2020). Outcome measures included the percentage of long-stay residents in a facility with declines in activities in daily living (ADLs), decreases in mobility, weight loss, and pressure ulcers in 2020 Q2, 2020 Q3, and 2020 Q4. Independent variables were whether NHs reported any shortage of aides or licensed nurses and total staff hours per resident day (HPRD). Separate 2-level (NH, state) Hierarchical Generalized Linear Mixed models examined the association of facility-reported shortages and staff hours with key NH resident outcomes, controlling for NH characteristics and COVID-19 infections.

RESULTS

The weekly percentage of NHs reporting any staff shortage averaged 20%. Total staff HPRD increased slightly from 3.7 in 2019 to 3.8 in 2020. Health outcomes were stable during 2019 and 2020 Q1 but worsened substantially starting in 2020 Q2. For example, the percentage of residents with mobility loss increased from 16.2% in 2020 Q1 to 27.9% in 2020 Q4. Facility-reported staff shortages were associated with an increase in the proportion of residents with an ADL decline (0.54 percentage points), mobility loss (0.80 percentage points), weight loss (0.22 percentage points), and pressure ulcers (0.22 percentage points) (all P < .01). Total staff HPRD was not associated with changes in any outcomes (all P > .05).

CONCLUSIONS AND IMPLICATIONS

NHs reported worsened health outcomes among long-stay residents in 2020, with worse outcomes found among facilities that reported staff shortages but not among those with lower total staff levels. Facility-reported shortages provide important quality information during the COVID-19 pandemic.

Racial differences in healthcare expenditures for prevalent multimorbidity combinations in the USA: a cross-sectional study

BACKGROUND

We aimed to model total charges for the most prevalent multimorbidity combinations in the USA and assess model accuracy across Asian/Pacific Islander, African American, Biracial, Caucasian, Hispanic, and Native American populations.

METHODS

We used Cerner HealthFacts data from 2016 to 2017 to model the cost of previously identified prevalent multimorbidity combinations among 38 major diagnostic categories for cohorts stratified by age (45-64 and 65 +). Examples of prevalent multimorbidity combinations include lipedema with hypertension or hypertension with diabetes. We applied generalized linear models (GLM) with gamma distribution and log link function to total charges for all cohorts and assessed model accuracy using residual analysis. In addition to 38 major diagnostic categories, our adjusted model incorporated demographic, BMI, hospital, and census division information.

RESULTS

The mean ages were 55 (45-64 cohort, N = 333,094) and 75 (65 + cohort, N = 327,260), respectively. We found actual total charges to be highest for African Americans (means $78,544 [45-64], $176,274 [65 +]) and lowest for Hispanics (means $29,597 [45-64], $66,911 [65 +]). African American race was strongly predictive of higher costs (p < 0.05 [45-64]; p < 0.05 [65 +]). Each total charge model had a good fit. With African American as the index race, only Asian/Pacific Islander and Biracial were non-significant in the 45-64 cohort and Biracial in the 65 + cohort. Mean residuals were lowest for Hispanics in both cohorts, highest in African Americans for the 45-64 cohort, and highest in Caucasians for the 65 + cohort. Model accuracy varied substantially by race when multimorbidity grouping was considered. For example, costs were markedly overestimated for 65 + Caucasians with multimorbidity combinations that included heart disease (e.g., hypertension + heart disease and lipidemia + hypertension + heart disease). Additionally, model residuals varied by age/obesity status. For instance, model estimates for Hispanic patients were highly underestimated for most multimorbidity combinations in the 65 + with obesity cohort compared with other age/obesity status groupings.

CONCLUSIONS

Our finding demonstrates the need for more robust models to ensure the healthcare system can better serve all populations. Future cost modeling efforts will likely benefit from factoring in multimorbidity type stratified by race/ethnicity and age/obesity status.

Age-related differences in risks and outcomes of 30-day readmission in adults with sickle cell disease

BACKGROUND

Literature on 30-day readmission in adults with sickle cell disease (SCD) is limited. This study examined the overall and age-stratified rates, risk factors, and healthcare resource utilization associated with 30-day readmission in this population.

METHODS

Using the Nationwide Readmissions Database, a retrospective cohort study was conducted to identify adult patients (aged ≥ 18) with SCD in 2016. Patients were stratified by age and followed for 30 days to assess readmission following an index discharge. The primary outcome was 30-day unplanned all-cause readmission. Secondary outcomes included index hospitalization costs and readmission outcomes (e.g., time to readmission, readmission costs, and readmission lengths of stay). Separate generalized linear mixed models estimated the adjusted odds ratios (aORs) for associations of readmission with patient and hospital characteristics, overall and by age.

RESULTS

Of 15,167 adults with SCD, 2,863 (18.9%) experienced readmission. Both the rates and odds of readmission decreased with increasing age. The SCD complications vaso-occlusive crisis and end-stage renal disease (ESRD) were significantly associated with increased likelihood of readmission (p < 0.05). Age-stratified analyses demonstrated that diagnosis of depression significantly increased risk of readmission among patients aged 18-to-29 years (aOR = 1.537, 95%CI: 1.215-1.945) but not among patients of other ages. All secondary outcomes significantly differed by age (p < 0.05).

CONCLUSION

This study demonstrates that patients with SCD are at very high risk of 30-day readmission and that younger adults and those with vaso-occlusive crisis and ESRD are among those at highest risk. Multifaceted, age-specific interventions targeting individuals with SCD on disease management are needed to prevent readmissions.

Comorbidities and neighborhood factors associated with prescription of sodium-glucose cotransporter protein-2 inhibitors and glucagon-like peptide-1 receptor agonists among medically underserved populations

BACKGROUND: Evidence from clinical trials shows that newer second-line diabetes medications-glucagon-like peptide 1 receptor agonists (GLP-1RAs) and sodium-glucose cotransporter 2 inhibitors (SGLT2is)-have cardio-renal protective effects in addition to their glucose-lowering properties. Despite strong evidence of benefits, there is limited evidence regarding prescribing patterns for these medications, especially among populations at high risk for disparities. OBJECTIVE: To examine the associations of cardio-renal and obesity comorbidities and neighborhood factors with the prescribing of GLP-1RAs or SGLT2is in comparison with dipeptidyl peptidase 4 inhibitors (DPP-4is) or sulfonylureas (SFUs) and for each of the newer second-line diabetes medications (GLP-1RA vs DPP-4i, SGLT2i vs DPP-4i, GLP-1RA vs SFU, and SGLT2i vs SFU) in medically underserved populations. METHODS: A retrospective cohort study was conducted using electronic medical records from a health care delivery system that serves medically underserved populations in the Mid-South region of the United States. Metformin-treated adult patients with type 2 diabetes, and at least 1 prescription for GLP-1RA, SGLT2i, DPP-4i, or SFU class medications, were identified between April 2016 and August 2021. Neighborhood factors were assessed at the census tract level by geocoding and linking patient addresses to neighborhood-level risk factors. Using multilevel logistic regression models, we examined the associations of comorbidities and neighborhood factors with the prescription of newer second-line diabetes medications. RESULTS: 7,723 patients received newer second-line diabetes medications, with 16% prescribed GLP-1RAs, 11% prescribed SGLT2is, 28% prescribed DPP-4is, and 45% prescribed SFUs. Patients with cerebrovascular disease were significantly less likely to receive newer second-line diabetes medications (odds ratio [OR] = 0.65, 95% CI = 0.52-0.80). Patients with obesity were more likely to receive newer second-line diabetes medications (OR = 1.68, 95% CI = 1.48-1.90). Living in neighborhoods with higher proportions of college graduates was associated with a higher likelihood of receiving newer second-line diabetes medications (quartile 3 vs 1: OR = 1.30, 95% CI = 1.06-1.59; and quartile 4 vs 1: OR = 1.46, 95% CI = 1.13-1.88). CONCLUSIONS: Our findings demonstrate substantial underprescribing and significant clinical and neighborhood variations in the use of newer second-line diabetes medications. We found lower use of newer second-line diabetes medications among patients with cerebrovascular disease and higher use in those with obesity. Our findings also suggest that newer second-line diabetes medications are first adopted by those in higher socioeconomic groups, thus increasing disparities in care. DISCLOSURES: Dr Surbhi reports grants or contracts from the Tennessee Department of Health, Agency for Healthcare Research and Quality, and PhRMA Foundation. Dr Bailey reports honoraria from the SouthEast Texas Chapter of the American College of Healthcare Executives, leadership or fiduciary role in the Coalition for Better Health and The Healthy City, Inc., and stock or stock options in Proctor and Gamble, Walmart, and Apple. Dr Kovesdy reports personal fees from Bayer, Abbott, AstraZeneca, Takeda, Tricida, Akebia, Cara Therapeutics, Vifor, Rockwell, CSL Behring, Boehringer Ingelheim, and GSK, outside the submitted work. The other authors report no conflicts of interest.

Effect of continuity of care on emergency department and hospital visits for obesity-associated chronic conditions: A federated cohort meta-analysis

BACKGROUND

Obesity-associated chronic conditions (OCC) are prevalent in medically underserved areas of the Southern US. Continuity of care with a primary care provider is associated with reduced preventable healthcare utilization, yet little is known regarding the impact of continuity of care among populations with OCC. This study aimed to examine whether continuity of care protects patients living with OCC and the subgroup with type 2 diabetes (OCC+T2D) from emergency department (ED) and hospitalizations, and whether these effects are modified by race and patient residence in health professional shortage areas (HPSA) METHODS: We conducted a retrospective federated cohort meta-analysis of 2015-2018 data from four large practice-based research networks in the Southern U.S. among adult patients with obesity and one more more additional diagnosed OCC. The outcomes included overall and preventable ED visits and hospitalizations. Continuity of care was assessed at the clinic-level using the Bice-Boxerman Continuity of Care Index RESULTS: A total of 111,437 patients with OCC and 47,071 patients with OCC+T2D from the four large practice-based research networks in the South were included in the meta-analysis. Continuity of Care index varied among sites from a mean (SD) of 0.6 (0.4) to 0.9 (0.2). Meta-analysis demonstrated that, regardless of race or residence in HPSA, continuity of care significantly protected OCC patients from preventable ED visits (IRR:0.95; CI:0.92-0.98) and protected OCC+T2D patients from overall ED visits (IRR:0.92; CI:0.85-0.99), preventable ED visits (IRR:0.95; CI:0.91-0.99), and overall hospitalizations (IRR:0.96; CI:0.93-0.98) CONCLUSION: Improving continuity of care may reduce ED and hospital use for patients with OCC and particularly those with OCC+T2D.

Integrating Lay Health Coaches Into Primary Care: Acceptability, Credibility, and Effectiveness From the Provider Perspective

The purpose of this mixed-methods, cross-sectional study was to assess the acceptability, effectiveness, and credibility of lay health coaches from the perspective of primary care personnel during coach integration into primary care teams through the Management of Diabetes in Everyday Life (MODEL) study. Surveys of 46 primary care clinic personnel were conducted in June 2017 and July 2017 to assess the acceptability, effectiveness, and credibility of lay health coaches in the clinics. Clinic personnel rated coach acceptability, impact, and credibility on a five-point Likert scale as 3.78, 3.76-4.04, and 3.71-3.95, respectively. Additionally, interviews revealed support for a team-based approach and recognition of the potential of coaches to enhance care. In the interviews clinic personnel also reported a lack of provider time to counsel patients as well as a need for improved provider-coach communication.

Development and integration of photonic Doppler velocimetry as a diagnostic for radiation driven experiments on the Z-machine

Plasma density measurements are key to a wide variety of high-energy-density (HED) and laboratory astrophysics experiments. We present a creative application of photonic Doppler velocimetry (PDV) from which time- and spatially resolved electron density measurements can be made. PDV has been implemented for the first time in close proximity, ∼6 cm, to the high-intensity radiation flux produced by a z-pinch dynamic hohlraum on the Z-machine. Multiple PDV probes were incorporated into the photoionized gas cell platform. Two probes, spaced 4 mm apart, were used to assess plasma density and uniformity in the central region of the gas cell during the formation of the plasma. Electron density time histories with subnanosecond resolution were extracted from PDV measurements taken from the gas cells fielded with neon at 15 Torr. As well, a null shot with no gas fill in the cell was fielded. A major achievement was the low noise high-quality measurements made in the harsh environment produced by the mega-joules of x-ray energy emitted at the collapse of the z-pinch implosion. To evaluate time dependent radiation induced effects in the fiber optic system, two PDV noise probes were included on either side of the gas cell. The success of this alternative use of PDV demonstrates that it is a reliable, precise, and affordable new electron density diagnostic for radiation driven experiments and more generally HED experiments.

Feasibility of a Brief Intervention to Increase Rapid Primary Care Follow-Up Among African American Patients With Uncontrolled Diabetes

The management of diabetes, like many other chronic conditions, depends on effective primary care engagement. Patients with diabetes without a usual source of care have a higher risk of uncontrolled disease, hospitalizations, and early death. Our objective was to study the effect of a brief intervention to help patients in medically underserved areas obtain rapid primary care follow-up appointments following hospitalization. We performed a pilot pragmatic randomized controlled trial of adult patients with uncontrolled diabetes who had been admitted to one of three hospitals in the Memphis, TN, area. The enhanced usual care arm received a list of primary care clinics, whereas the intervention group had an appointment made for them preceding their index discharge. Patients in both groups were evaluated for primary care appointment attendance within seven and fourteen days of index discharge. In addition, we examined barriers patients encounter to receiving rapid primary care follow-up using a secret shopper approach to assess wait times when calling primary care offices. Twelve patients were enrolled with six in each trial arm. Baseline demographics, access to medical care, and health literacy were similar across the groups. Primary care follow-up was also similar across the groups; no improvements in follow-up rates were seen in the group receiving assistance with making appointments. Identified barriers to making primary care follow-up appointments included inability to schedule an urgent appointment, long hold times when calling doctor’s offices and lack of transportation. Additionally, hold times when calling primary care offices were found to be excessively long in the medically underserved areas studied. The study demonstrates the feasibility of providing patient assistance with scheduling rapid primary care follow-up appointments at the time of discharge and the potential to improve care transitions and access to primary care among patients living in medically underserved areas. Larger pragmatic trials are needed to further test alternative approaches for insuring rapid primary care follow-up in vulnerable patients with ambulatory care-sensitive chronic conditions.

Democracy and case fatality rate of COVID-19 at early stage of pandemic: a multicountry study

Many studies have evaluated factors that influence the course of the COVID-19 pandemic in different countries. This multicountry study assessed the influence of democracy and other factors on the case fatality rate of COVID-19 during the early stage of the pandemic. We accessed the World Health Organization, World Bank, and the Democracy Index 2019 databases for data from the 148 countries. Multiple analyses were conducted to examine the association between the Democracy Index and case fatality rate of COVID-19. Within 148 countries, the percentage of the population aged 65 years and above (p = 0.0193), and health expenditure as a percentage of GDP (p = 0.0237) were positively associated with countries' case fatality rates. By contrast, hospital beds per capita helped to reduce the case fatality rates. In particular, the Democracy Index was positively associated with case fatality rates in a subgroup of 47 high-income countries. This study suggests that enhancing the health system with increased hospital beds and healthcare workforce per capita should reduce case fatality rate. The findings suggest that a higher Democracy Index is associated with more deaths from COVID-19 at the early stage of the pandemic, possibly due to the decreased ability of the government.

Early Patient-Centered Outcomes Research Experience With the Use of Telehealth to Address Disparities: Scoping Review

BACKGROUND

Health systems and providers across America are increasingly employing telehealth technologies to better serve medically underserved low-income, minority, and rural populations at the highest risk for health disparities. The Patient-Centered Outcomes Research Institute (PCORI) has invested US $386 million in comparative effectiveness research in telehealth, yet little is known about the key early lessons garnered from this research regarding the best practices in using telehealth to address disparities.

OBJECTIVE

This paper describes preliminary lessons from the body of research using study findings and case studies drawn from PCORI seminal patient-centered outcomes research (PCOR) initiatives. The primary purpose was to identify common barriers and facilitators to implementing telehealth technologies in populations at risk for disparities.

METHODS

A systematic scoping review of telehealth studies addressing disparities was performed. It was guided by the Arksey and O'Malley Scoping Review Framework and focused on PCORI's active portfolio of telehealth studies and key PCOR identified by study investigators. We drew on this broad literature using illustrative examples from early PCOR experience and published literature to assess barriers and facilitators to implementing telehealth in populations at risk for disparities, using the active implementation framework to extract data. Major themes regarding how telehealth interventions can overcome barriers to telehealth adoption and implementation were identified through this review using an iterative Delphi process to achieve consensus among the PCORI investigators participating in the study.

RESULTS

PCORI has funded 89 comparative effectiveness studies in telehealth, of which 41 assessed the use of telehealth to improve outcomes for populations at risk for health disparities. These 41 studies employed various overlapping modalities including mobile devices (29/41, 71%), web-based interventions (30/41, 73%), real-time videoconferencing (15/41, 37%), remote patient monitoring (8/41, 20%), and store-and-forward (ie, asynchronous electronic transmission) interventions (4/41, 10%). The studies targeted one or more of PCORI's priority populations, including racial and ethnic minorities (31/41, 41%), people living in rural areas, and those with low income/low socioeconomic status, low health literacy, or disabilities. Major themes identified across these studies included the importance of patient-centered design, cultural tailoring of telehealth solutions, delivering telehealth through trusted intermediaries, partnering with payers to expand telehealth reimbursement, and ensuring confidential sharing of private information.

CONCLUSIONS

Early PCOR evidence suggests that the most effective health system- and provider-level telehealth implementation solutions to address disparities employ patient-centered and culturally tailored telehealth solutions whose development is actively guided by the patients themselves to meet the needs of specific communities and populations. Further, this evidence shows that the best practices in telehealth implementation include delivery of telehealth through trusted intermediaries, close partnership with payers to facilitate reimbursement and sustainability, and safeguards to ensure patient-guided confidential sharing of personal health information.

Observation of ionization trends in a laboratory photoionized plasma experiment at Z

We report experimental and modeling results for the charge state distribution of laboratory photoionized neon plasmas in the first systematic study over nearly an order of magnitude range of ionization parameter ξ∝F/N_{e}. The range of ξ is achieved by flexibility in the experimental platform to adjust either the x-ray drive flux F at the sample or the electron number density N_{e} or both. Experimental measurements of photoionized plasma conditions over such a range of parameters enable a stringent test of atomic kinetics models used within codes that are applied to photoionized plasmas in the laboratory and astrophysics. From experimental transmission data, ion areal densities are extracted by spectroscopic analysis that is independent of atomic kinetics modeling. The measurements reveal the net result of the competition between photon-driven ionization and electron-driven recombination atomic processes as a function of ξ as it affects the charge state distribution. Results from radiation-hydrodynamics modeling calculations with detailed inline atomic kinetics modeling are compared with the experimental results. There is good agreement in the mean charge and overall qualitative similarities in the trends observed with ξ but significant quantitative differences in the fractional populations of individual ions.

Refining a traditional urban-rural classification approach to better assess heterogeneity of treatment effects in patient-centered outcomes research

This article describes a rationale and approach for modifying the traditional rural-urban commuting area (RUCA) coding scheme used to classify U.S. ZIP codes to enable suburban/rural vs. urban core comparisons in health outcomes research that better reflect current geographic differences in access to care in U.S. populations at risk for health disparities. The proposed method customization is being employed in the Patient-Centered Outcomes Research Institute-funded Management Of Diabetes in Everyday Life (MODEL) study to assess heterogeneity of treatment effect for patient-centered diabetes self-care interventions across the rural-urban spectrum. The proposed suburban/rural vs. urban core classification scheme modification is based on research showing that increasing suburban poverty and rapid conversion of many rural areas into suburban areas in the U.S. has resulted in similar health care access problems in areas designated as rural or suburban.•

The RUCA coding scheme was developed when a much higher percentage of U.S. individuals resided in areas with very low population density.

•

Using the MODEL study example, this study demonstrates that the RUCA classification scheme using ZIP codes does not reflect real differences in health care access experienced by medically underserved study participants.

•

Both internal and external validation data suggest that the proposed suburban/rural vs. urban core customization of the RUCA geographic coding scheme better reflects real differences in healthcare access and is better able to assess the differential impact of clinical interventions designed to address geographic differences in access among vulnerable populations.

Background measurement methods for opacity experiments conducted at the Z facility

Laboratory experiments typically test opacity models by measuring spectrally resolved transmission of a sample using bright backlight radiation. A potential problem is that any unaccounted background signal contaminating the spectrum will artificially reduce the inferred opacity. Methods developed to measure background signals in opacity experiments at the Sandia Z facility are discussed. Preliminary measurements indicate that backgrounds are 9%-11% of the backlight signal at wavelengths less than 10 Å. Background is thus a relatively modest correction for all Z opacity data published to date. Future work will determine how important background is at longer wavelengths.

Association of Weight Loss With Type 2 Diabetes Remission Among Adults in Medically Underserved Areas: A Retrospective Cohort Study

PURPOSE

To examine the association between weight loss and type 2 diabetes remission among vulnerable populations living in medically underserved areas of the Mid-Southern United States.

DESIGN

Quantitative, retrospective cohort study.

SETTING

114 ambulatory sites and 5 adults' hospitals in the Mid-South participating in a regional diabetes registry.

PARTICIPANTS

9,900 adult patients with type 2 diabetes, stratified by remission status, with 1 year of baseline electronic medical record data, and 1 year of follow-up data for the 2015-2018 study period.

MEASURES

The outcomes were diabetes remissions, categorized as any remission, partial remission, and complete remission based on the guidelines of the American Diabetes Association. The exposure was weight loss, calculated by the change in the Body Mass Index (BMI) as a proxy measure.

ANALYSIS

χ² tests, Fisher's exact tests, and the Mann-Whitney U-test were used to examine the differences in patient characteristics by remission status across the 3 remission categories, as appropriate. Multiple multivariable logistic regressions adjusting for confounders were performed to estimate the adjusted odds ratios (aORs) for the associations between weight loss and diabetes remission.

RESULTS

Among 9,900 patients identified, a reduction of 0.3 kg/m² (standard deviation: 2.5) in the average BMI from the baseline to the follow-up was observed. 10.8% achieved any type of remission, with 9.8% for partial and 1.0% for complete remissions. Greater weight loss was significantly associated with an increased likelihood of any (aOR = 1.07, 95% confidence interval (CI), 1.06-1.08), partial (aOR 1.06, 95% CI, 1.04-1.07), and complete diabetes remission (aOR 1.10, 95% CI, 1.07-1.13).

CONCLUSIONS

Weight loss is significantly associated with diabetes remission among patients living in medically underserved areas, but complete remission is rare.

Increases in multimorbidity with weight class in the United States

Little is known regarding how multimorbidity combinations associated with obesity change with increase in body weight. This study employed data from the national Cerner HealthFacts Data Warehouse to identify changes in multimorbidity patterns by weight class using network analysis. Networks were generated for 154 528 middle-aged patients in the following categories: normal weight, overweight, and classes 1, 2, and 3 obesity. The results show significant differences (P-value<0.05) in prevalence by weight class for all but three of 82 diseases considered. The percentage of patients with multimorbidity (excluding obesity) increases from in 55.1% in patients with normal weight, to 57.88% with overweight, 70.39% with Class 1 obesity, 73.99% with Class 2 obesity, and 71.68% in Class 3 obesity, increasing most substantially with the progression from overweight to class 1 obesity. Most prevalent disease clusters expand from only hypertension and dorsalgia in normal weight, to add joint disorders in overweight, lipidemias in class 1 obesity, diabetes in class 2 obesity, and sleep disorders and chronic kidney disease in class 3 obesity. Recognition of multimorbidity patterns associated with weight increase is essential for true precision care of obesity-associated chronic conditions and can help clinicians identify and address preclinical disease before additional complications arise.

Using a Personal Health Library-Enabled mHealth Recommender System for Self-Management of Diabetes Among Underserved Populations: Use Case for Knowledge Graphs and Linked Data

Background

Traditionally, digital health data management has been based on electronic health record (EHR) systems and has been handled primarily by centralized health providers. New mechanisms are needed to give patients more control over their digital health data. Personal health libraries (PHLs) provide a single point of secure access to patients' digital health data and enable the integration of knowledge stored in their digital health profiles with other sources of global knowledge. PHLs can help empower caregivers and health care providers to make informed decisions about patients’ health by understanding medical events in the context of their lives.

Objective

This paper reports the implementation of a mobile health digital intervention that incorporates both digital health data stored in patients’ PHLs and other sources of contextual knowledge to deliver tailored recommendations for improving self-care behaviors in diabetic adults.

Methods

We conducted a thematic assessment of patient functional and nonfunctional requirements that are missing from current EHRs based on evidence from the literature. We used the results to identify the technologies needed to address those requirements. We describe the technological infrastructures used to construct, manage, and integrate the types of knowledge stored in the PHL. We leverage the Social Linked Data (Solid) platform to design a fully decentralized and privacy-aware platform that supports interoperability and care integration. We provided an initial prototype design of a PHL and drafted a use case scenario that involves four actors to demonstrate how the proposed prototype can be used to address user requirements, including the construction and management of the PHL and its utilization for developing a mobile app that queries the knowledge stored and integrated into the PHL in a private and fully decentralized manner to provide better recommendations.

Results

To showcase the main features of the mobile health app and the PHL, we mapped those features onto a framework comprising the user requirements identified in a use case scenario that features a preventive intervention from the diabetes self-management domain. Ongoing development of the app requires a formative evaluation study and a clinical trial to assess the impact of the digital intervention on patient-users. We provide synopses of both study protocols.

Conclusions

The proposed PHL helps patients and their caregivers take a central role in making decisions regarding their health and equips their health care providers with informatics tools that support the collection and interpretation of the collected knowledge. By exposing the PHL functionality as an open service, we foster the development of third-party applications or services and provide motivational technological support in several projects crossing different domains of interest.

Using preliminary data and prospective power analyses for mid-stream revision of projected group and subgroup sizes in pragmatic patient-centered outcomes research

Pragmatic clinical trials are commonly used in patient-centered outcomes research to assess heterogeneity of treatment effects. Patient-Centered Outcomes Research Institute (PCORI) methodology standards for assessing heterogeneity of treatment effects are extremely rigorous, but their implementation in real-world settings can be difficult. Predicting recruitment effectiveness and subgroup characteristics is often challenging and may require mid-stream revision of projected group and subgroup sizes. Yet, little real-world data are available to demonstrate methodologically valid approaches to address situations where such revisions are necessary. These data were used for mid-stream revision of group and subgroup sizes in the Management of Diabetes in Everyday Life (MODEL) clinical trial. The planned number of randomized participants retained over the one-year study period was reduced from 800 to 581 due to recruitment difficulties among potential participants residing in rural areas. Prospective power analyses are based on the revised target of 581 participants retained and the proportions of 167 participants with various key baseline characteristics, who had been randomized in MODEL by January 2018, as reported to the Patient Center Outcomes Research Institute (PCORI) and the MODEL Data Safety and Monitoring Committee. Power calculations are based on two-sided t-tests with type-I error rates of 0.05 and the assumption that effect sizes will range from small (standardized difference = 0.36) to medium (= 0.50). The primary outcome variables are how many days in the previous week participants 1) ate healthy meals, 2) participated in at least 30 minutes of physical activity, and 3) took medications as prescribed. The POWER procedure of SAS 9.4 was used for all analyses. These data, along with the approach, can assist statisticians as they plan future pragmatic clinical trials evaluating heterogeneity of treatment effects. These data can help inform investigators, conducting patient-centered outcomes research, as they define subgroups for either confirmatory analyses for testing heterogeneity of treatment effects or for exploratory analyses where estimation of confidence bounds may be useful for generating future hypotheses. (This work was supported through a Patient-Centered Outcomes Research Institute (PCORI) Project Program Award (SC15-1503-28336), www.ClinicalTrials.gov and Identifier: NCT02957513 [1].)

Can primary care access reduce health care utilization for patients with obesity-associated chronic conditions in medically underserved areas?

OBJECTIVES

The prevalence and burdens of obesity-associated chronic conditions (OCC) are rising nationwide, particularly in health professional shortage areas (HPSA). This study examined the impact of access to primary care on health care utilization for vulnerable populations with OCC in the South.

METHODS

Adult patients with obesity (BMI ≥ 30 kg/m² ), greater than or equal to one additional OCC, and self-reported primary care access data were retrospectively identified from hospital and emergency department (ED) electronic medical records of a major health care system in the South. Multivariable logistic regression assessed factors associated with self-reported access to primary care. Multivariable zero-inflated negative binomial models assessed effect of HPSA residence on relationships between self-reported access to primary care and health care utilization.

RESULTS

A total of 29 674 patients were identified. Hypertension (76.1%), type 2 diabetes mellitus (34.1%), and hyperlipidemia (32.9%) were the most prevalent OCC. Males (odds ratio [OR]: 0.43; 95% confidence interval [CI], 0.40-0.47), unmarried (OR: 0.69; 95% CI, 0.63-0.76), and uninsured (OR: 0.29; 95% CI, 0.27-0.32) had lower odds of access to primary care. For patients living in HPSA (vs non-HPSA), access to primary care was associated with higher incidence of overall ED use (relative risk [RR]: 1.38; 95% CI, 1.19-1.61) and lower incidence of potentially preventable hospital use (RR: 0.59; 95% CI, 0.38-0.92).

CONCLUSION

Paradoxically, access to primary care may increase ED use while reducing potentially preventable hospital utilization for patients with OCC in HPSA. Increasing access to primary care alone, without strengthening its capacity to serve the needs of vulnerable patients, may be insufficient to reduce hospital utilization.

Continuity of Care for Patients with Obesity-Associated Chronic Conditions: Protocol for a Multisite Retrospective Cohort Study

BACKGROUND

Obesity affects nearly half of adults in the United States and is contributing substantially to a pandemic of obesity-associated chronic conditions such as type 2 diabetes, hypertension, and arthritis. The obesity-associated chronic condition pandemic is particularly severe in low-income, medically underserved, predominantly African-American areas in the southern United States. Little is known regarding the impact of geographic, income, and racial disparities in continuity of care on major health outcomes for patients with obesity-associated chronic conditions.

OBJECTIVE

The aim of this study is to assess, among patients with obesity-associated chronic conditions, and within this group, patients with type 2 diabetes, (1) whether continuity of care is associated with lower overall and potentially preventable emergency department and hospital utilization, (2) the effect of geographic, income, and racial disparities on continuity of care and on health care utilization, (3) whether continuity of care particularly protects individuals at risk for disparities from adverse health outcomes, and (4) whether characteristics of health systems are associated with higher continuity of care and better outcomes.

METHODS

Using 2015-2018 data from 4 practice-based research networks participating in the Southern Obesity and Diabetes Coalition, we will conduct a retrospective cohort analysis and distributed meta-analysis. Patients with obesity-associated chronic conditions and with type 2 diabetes will be assessed within each health system, following a standardized study protocol. The primary study outcomes are overall and preventable emergency department visits and hospitalizations. Continuity of care will be calculated at the facility level using a modified version of the Bice-Boxerman continuity of care index. Race will be assessed using electronic medical record data. Residence in a low-income area or a health professional shortage area respectively will be assessed by linking patient residence ZIP codes to the Centers for Medicare & Medicaid Services database.

RESULTS

In 4 regional health systems across Tennessee, Mississippi, Louisiana, and Arkansas, a total of 53 adult hospitals were included in the study. A total of 147,889 patients with obesity-associated chronic conditions who met study criteria were identified in these health systems, of which 45,453 patients met the type 2 diabetes criteria for inclusion. Results are expected by the end of 2020.

CONCLUSIONS

This study should reveal whether health system efforts to increase continuity of care for patients with obesity and diabetes have potential to improve outcomes and reduce costs. Analyzing disparities in continuity of care and their effect on major health outcomes can help demonstrate how to improve care and use of health care resources for vulnerable patients with obesity-associated chronic conditions, and within this group, patients with type 2 diabetes. Better understanding of the association between continuity and health care utilization for these vulnerable populations will contribute to the development of higher-value health systems in the southern United States.

INTERNATIONAL REGISTERED REPORT IDENTIFIER (IRRID)

DERR1-10.2196/20788.

The Personal Health Library: A Single Point of Secure Access to Patient Digital Health Information

Traditionally, health data management has been EMR-based and mostly handled by health care providers. Mechanisms are needed to give patients more control over their health conditions. Personal Health Libraries (PHLs) provide a single point of secure access to patients' digital health information that can help empower patients to make better-informed decisions about their health care. This paper reports a work-in-progress on leveraging tools and methods from artificial intelligence and knowledge representation to build a private, decentralized PHL that supports interoperability and, ultimately, true care integration. We demonstrate how a social application querying such a decentralized PHL can deliver a tailored push notification intervention focused on improving self-care behaviors in diabetic adults from medically underserved communities.

The management of diabetes in everyday life study: Design and methods for a pragmatic randomized controlled trial comparing the effectiveness of text messaging versus health coaching

Background African American patients with uncontrolled diabetes living in medically underserved areas need effective clinic-based interventions to improve self-care behaviors. Text messaging (TM) and health coaching (HC) are among the most promising low-cost population-based approaches, but little is known about their comparative effectiveness in real-world clinical settings. Objective Use a pragmatic randomized controlled trial design to determine the comparative effectiveness of TM and HC with enhanced usual care (EC) in African American adults with uncontrolled diabetes and multiple chronic health conditions. Methods/design The Management of Diabetes in Everyday Life (MODEL) study is randomizing 646 patients (n = 581with anticipated 90% retention) to 3 intervention arms: TM, HC, and EC. Participants are African American adults living in medically underserved areas of the Mid-South, age ≥ 18, with uncontrolled diabetes (A1c ≥ 8), one or more additional chronic conditions, and who have a phone with texting and voicemail capability. Primary outcome measures: the general diet, exercise, and medication adherence subscales of the revised Summary of Diabetes Self-Care Activities questionnaire assessed at one year. Secondary outcomes: diabetes-specific quality of life, primary care engagement, and average blood sugar (A1c). The study will also assess heterogeneity of treatment effects by six key baseline participant characteristics. Conclusions We describe the design and methods of the MODEL study along with design revisions required during implementation in a pragmatic setting. This trial, upon its conclusion, will allow us to compare the effectiveness of two promising low-cost primary care-based strategies for supporting self-care behaviors among African Americans individuals with uncontrolled diabetes. ClinicalTrials.gov registration number: NCT02957513.

X-ray heating and electron temperature of laboratory photoionized plasmas

We discuss the experimental and modeling results for the x-ray heating and temperature of laboratory photoionized plasmas. A method is used to extract the electron temperature based on the analysis of transmission spectroscopy data that is independent of atomic kinetics modeling. The results emphasized the critical role of x-ray heating and radiation cooling in determining the energy balance of the plasma. They also demonstrated the dramatic impact of photoexcitation on excited-state populations, line emissivity, and radiation cooling. Modeling calculations performed with astrophysical codes significantly overestimated the measured temperature.

Medication nonadherence, mental health, opioid use, and inpatient and emergency department use in super-utilizers

OBJECTIVES

To examine whether mental health conditions, opioid use, and medication nonadherence are associated with inpatient and emergency department (ED) use among Medicare super-utilizers from medically underserved areas.

STUDY DESIGN

Retrospective panel study.

METHODS

The study included Medicare super-utilizers (≥3 hospitalizations or ≥2 hospitalizations with ≥2 ED visits in 6 months) served by a health system in a medically underserved area in the South from February 2013 to December 2014 with at least 1 filled prescription for hypertension, type 2 diabetes, cardiovascular, and/or chronic obstructive pulmonary disease/asthma medications. We used random effects negative binomial models to assess whether mental health diagnosis, opioid use, and medication nonadherence were associated with preventable and overall hospitalizations and ED visits stratified by age (18-64 vs ≥65 years).

RESULTS

Overall chronic disease medication nonadherence was associated with more frequent hospitalizations and ED visits for both younger (hospitalizations: incidence rate ratio [IRR], 1.31; 95% CI, 1.16-1.47; ED visits: IRR, 1.33; 95% CI, 1.14-1.55) and older (hospitalizations: IRR, 1.34; 95% CI, 1.20-1.49; ED visits: IRR, 1.18; 95% CI, 1.02-1.38) beneficiaries. Mental health diagnosis was significantly associated with higher hospitalizations and ED visits among both age groups. Although associations between opioid medication use and inpatient and ED use were inconsistent and not significant in most cases, we found that 7 or more days' supply of opioids was associated with lower preventable hospitalizations in Medicare beneficiaries 65 years or older.

CONCLUSIONS

The study findings highlight the importance of improving medication adherence and addressing behavioral health needs in Medicare super-utilizers.

Characteristics of Health-related Text Messages Preferred by Medically Underserved African-American Patients with Diabetes

Introduction

Text messaging (TM) is increasingly used by the U.S. medical practices and healthcare delivery systems, but little is known about preferences of medically underserved minority patients for TM supporting improved self-care decisions. We sought to determine the characteristics of text messages and TM programs preferred by African-American patients with diabetes in medically underserved areas.

Methods

This convergent mixed methods study employed a self-administered survey and focus group interviews. Quantitative and qualitative data were collected simultaneously, analyzed separately, and merged to provide a holistic view of the TM characteristics patients preferred. Participants (N = 36) were recruited from a medically underserved area in Memphis, Tennessee. Focus group data were uploaded into the NVivo qualitative data analysis software program, and main themes were identified. Standard frequencies were calculated for survey responses.

Results

Participants ranged in the age of 22-74 years (M = 54.1; SD = 14.6) were predominantly female (77.8%), African-Americans (88.9%), and had at least a high school education (91.7%). A majority used mobile phones for sending (69.4%) and receiving (72.2%) text messages. Participants wanted to receive daily (44.4%) or weekly (47.2%) text messages from their healthcare provider (61.1%), or a motivational message program (33.3%). They preferred actionable messages with a positive tone and wanted options to customize message type, content, and frequency according to their preferences, goals, and needs.

Discussion

Medically underserved African-American diabetes patients want customized text messages that are practical, actionable, encouraging, and from their doctor. Healthcare providers seeking to develop patient-centered TM programs for medically underserved minority patients should personalize and tailor messages according to patient preferences, health goals, and self-care needs.

Effect of Intensive Interdisciplinary Transitional Care for High-Need, High-Cost Patients on Quality, Outcomes, and Costs: a Quasi-Experimental Study

BACKGROUND

Many health systems have implemented team-based programs to improve transitions from hospital to home for high-need, high-cost patients. While preliminary outcomes are promising, there is limited evidence regarding the most effective strategies.

OBJECTIVE

To determine the effect of an intensive interdisciplinary transitional care program emphasizing medication adherence and rapid primary care follow-up for high-need, high-cost Medicaid and Medicare patients on quality, outcomes, and costs.

DESIGN

Quasi-experimental study.

PATIENTS

Among 2235 high-need, high-cost Medicare and Medicaid patients identified during an index inpatient hospitalization in a non-profit health care system in a medically underserved area with complete administrative claims data, 285 participants were enrolled in the SafeMed care transition intervention, and 1950 served as concurrent controls.

INTERVENTIONS

The SafeMed team conducted hospital-based real-time screening, patient engagement, enrollment, enhanced discharge care coordination, and intensive home visits and telephone follow-up for at least 45 days.

MAIN MEASURES

Primary difference-in-differences analyses examined changes in quality (primary care visits, and medication adherence), outcomes (preventable emergency visits and hospitalizations, overall emergency visits, hospitalizations, 30-day readmissions, and hospital days), and medical expenditures.

KEY RESULTS

Adjusted difference-in-differences analyses demonstrated that SafeMed participation was associated with 7% fewer hospitalizations (- 0.40; 95% confidence interval (CI), - 0.73 to - 0.06), 31% fewer 30-day readmissions (- 0.34; 95% CI, - 0.61 to - 0.07), and reduced medical expenditures ($- 8690; 95% CI, $- 14,441 to $- 2939) over 6 months. Improvements were limited to Medicaid patients, who experienced large, statistically significant decreases of 39% in emergency department visits, 25% in hospitalizations, and 79% in 30-day readmissions. Medication adherence was unchanged (+ 2.6%; 95% CI, - 39.1% to 72.9%).

CONCLUSIONS

Care transition models emphasizing strong interdisciplinary patient engagement and rapid primary care follow-up can enable health systems to improve quality and outcomes while reducing costs among high-need, high-cost Medicaid patients.

Systematic Study of L-Shell Opacity at Stellar Interior Temperatures

The first systematic study of opacity dependence on atomic number at stellar interior temperatures is used to evaluate discrepancies between measured and modeled iron opacity [J. E. Bailey et al., Nature (London) 517, 56 (2015)NATUAS0028-083610.1038/nature14048]. High-temperature (>180  eV) chromium and nickel opacities are measured with ±6%-10% uncertainty, using the same methods employed in the previous iron experiments. The 10%-20% experiment reproducibility demonstrates experiment reliability. The overall model-data disagreements are smaller than for iron. However, the systematic study reveals shortcomings in models for density effects, excited states, and open L-shell configurations. The 30%-45% underestimate in the modeled quasicontinuum opacity at short wavelengths was observed only from iron and only at temperature above 180 eV. Thus, either opacity theories are missing physics that has nonmonotonic dependence on the number of bound electrons or there is an experimental flaw unique to the iron measurement at temperatures above 180 eV.

Socrates's Last Words to the Physician God Asklepios: An Ancient Call for a Healing Ethos in Civic Life

Socrates’s last words have remained enigmatic despite over two millennia of philosophical, literary, and historical interpretations. This paper suggests that Socrates was executed for questioning the imperialistic actions of Athens in the Peloponnesian War by elevating the emerging cult of Asklepios and advocating for Asklepian ideals. Plato’s dialogues show that Socrates saw Asklepios as more worthy of emulation than the warlike gods of the state-supported Greek pantheon. While dying from the executioner’s hemlock, Socrates asks his friend Crito to pay the traditional thank offering given to the physician-god: a cock symbolizing rebirth. He looks to the only god then known to revive the dead to help his ideas and spirit live on. Socrates’s last words thwart Athenian authorities’ attempts to silence him, issue a call for Asklepian ideals to prevail in the city of Athens, and identify the selfless caring for others exemplified by Asklepios as the highest duty for all humans. Socrates calls us from the past to remember timeless Asklepian physician duties to self, patients, and community. Socrates reminds modern physicians of their personal duty to make their own spiritual health their first priority, their professional duty to comfort the sick and alleviate suffering, and their societal duty to advocate for the vulnerable, sick, and suffering and the health of the public.

A compact multi-plane broadband (0.5-17 keV) spectrometer using a single acid phthalate crystal

Acid phthalate crystals such as KAP crystals are a method of choice to record x-ray spectra in the soft x-ray regime (E ∼ 1 keV) using the large (001) 2d = 26.63 Å spacing. Reflection from many other planes is possible, and knowledge of the 2d spacing, reflectivity, and resolution for these reflections is necessary to evaluate whether they hinder or help the measurements. Burkhalter et al. [J. Appl. Phys., 52, 4379 (1981)] showed that the (013) reflection has efficiency comparable to the 2nd order reflection (002), and it can overlap the main first order reflection when the crystal bending axis ( b -axis) is contained in the dispersion plane, thus contaminating the main (001) measurement in a convex crystal geometry. We present a novel spectrograph concept that makes these asymmetric reflections helpful by setting the crystal b -axis perpendicular to the dispersion plane. In such a case, asymmetric reflections do not overlap with the main (001) reflection and each reflection can be used as an independent spectrograph. Here we demonstrate an achieved spectral range of 0.8-13 keV with a prototype setup. The detector measurements were reproduced with a 3D ray-tracing code.

The Effect of Opioid Use and Mental Illness on Chronic Disease Medication Adherence in Superutilizers

BACKGROUND

Nonadherence to essential chronic medications has been identified as a potential driver of high health care costs in superutilizers of inpatient services. Few studies, however, have documented the levels of nonadherence and factors associated with nonadherence in this high-cost, vulnerable population.

OBJECTIVE

To examine the factors associated with nonadherence to essential chronic medications, with special emphasis on mental illness and use of opioid medications.

METHODS

This study was a retrospective panel analysis of 2-year baseline data for Medicare Part D beneficiaries eligible for the SafeMed care transitions program in Memphis, Tennessee, from February 2013 to December 2014. The 2-year baseline data for each patient were divided into four, 6-month patient periods. The study included Medicare superutilizers (defined as patients with ≥ 3 hospitalizations or ≥ 2 hospitalizations with ≥ 2 emergency visits in 6 months) with continuous Part D coverage who had filled at least 1 drug class used to treat hypertension, diabetes mellitus, congestive heart failure, coronary artery disease, or chronic lung disease. The outcome included medication nonadherence assessed using proportion of days covered (PDC), with PDC < 80% defined as nonadherent, and the main exposure variables included mental illness (defined as a diagnosis of depression or anxiety or ≥ 1 anxiolytic or antidepressant fill) and opioid medication fills assessed in each 6-month period. Pooled observations from the four 6-month periods were used for multivariable analyses using the patient periods as the unit of analysis. A random effects model with robust standard errors and a binary distribution were used to examine associations between independent variables (time invariant and time variant factors) and medication nonadherence. The model included lagged effects of time variant factors measured in each period.

RESULTS

Overall nonadherence to essential chronic medications ranged from 39.3% to 58.4%, with the highest for chronic lung disease medications (49.1%-64.4%). Factors associated with nonadherence included ≥ 4 opioid medication fills in the previous 6-month period (adjusted odds ratio [OR] = 1.90, 95% CI = 1.32-2.73); age 22-44 and 45-64 years vs. ≥ 65 years (OR = 3.57, 95% CI = 2.07-6.16, and OR = 2.07, 95% CI = 1.49-2.88); and a higher number of unique prescribers (OR = 1.10, 95% CI = 1.04-1.17). Factors protecting against nonadherence included higher number of unique medications filled (OR = 0.95, 95% CI = 0.92-0.98) and ≥ 1 physician office visit in the previous 6-month period (OR = 0.66, 95% CI = 0.46-0.94).

CONCLUSIONS

This study demonstrated that high levels of opioid medication use are significantly associated with essential chronic disease medication nonadherence among superutilizers. Other risk factors for nonadherence were aged < 65 years, low-income status, and a higher number of unique prescribers. Factors protecting against nonadherence were physician office visits and filling higher number of medications. Medication management interventions targeting superutilizers should focus on supporting chronic disease medication adherence.

DISCLOSURES

This project was supported by Funding Opportunity Number 1C1CMS331067-01-00 from the Centers for Medicare & Medicaid Services, Center for Medicare and Medicaid Innovation. Support was also provided by the Pharmaceutical Research and Manufacturers of America Foundation. The content of this study is solely the responsibility of the authors. The authors declare no relevant conflicts of interest or financial relationships. Study concept and design were contributed by Surbhi, Bailey, and Graetz. Surbhi and Wan collected the data, and data interpretation was performed primarily by Surbhi, along with Graetz, Bailey, and Gatwood. The manuscript was primarily written by Surbhi, with assistance from Bailey and Graetz, and revised by Bailey, Graetz, Gatwood, and Surbhi. This study was presented as a poster at the Academy Health Annual Research Meeting in Boston, Massachusetts, on June 26-28, 2016.

Benchmark Experiment for Photoionized Plasma Emission from Accretion-Powered X-Ray Sources

The interpretation of x-ray spectra emerging from x-ray binaries and active galactic nuclei accreted plasmas relies on complex physical models for radiation generation and transport in photoionized plasmas. These models have not been sufficiently experimentally validated. We have developed a highly reproducible benchmark experiment to study spectrum formation from a photoionized silicon plasma in a regime comparable to astrophysical plasmas. Ionization predictions are higher than inferred from measured absorption spectra. Self-emission measured at adjustable column densities tests radiation transport effects, demonstrating that the resonant Auger destruction assumption used to interpret black hole accretion spectra is inaccurate.

Numerical investigations of potential systematic uncertainties in iron opacity measurements at solar interior temperatures

Iron opacity calculations presently disagree with measurements at an electron temperature of ∼180-195 eV and an electron density of (2-4)×10^{22}cm^{-3}, conditions similar to those at the base of the solar convection zone. The measurements use x rays to volumetrically heat a thin iron sample that is tamped with low-Z materials. The opacity is inferred from spectrally resolved x-ray transmission measurements. Plasma self-emission, tamper attenuation, and temporal and spatial gradients can all potentially cause systematic errors in the measured opacity spectra. In this article we quantitatively evaluate these potential errors with numerical investigations. The analysis exploits computer simulations that were previously found to reproduce the experimentally measured plasma conditions. The simulations, combined with a spectral synthesis model, enable evaluations of individual and combined potential errors in order to estimate their potential effects on the opacity measurement. The results show that the errors considered here do not account for the previously observed model-data discrepancies.

SafeMed: Using pharmacy technicians in a novel role as community health workers to improve transitions of care

OBJECTIVES

To describe the design, implementation, and early experience of the SafeMed program, which uses certified pharmacy technicians in a novel expanded role as community health workers (CPhT-CHWs) to improve transitions of care.

SETTING

A large nonprofit health care system serving the major medically underserved areas and geographic hotspots for readmissions in Memphis, TN.

PRACTICE INNOVATION

The SafeMed program is a care transitions program with an emphasis on medication management designed to use low-cost health workers to improve transitions of care from hospital to home for superutilizing patients with multiple chronic conditions and polypharmacy.

EVALUATION

CPhT-CHWs were given primary responsibility for patient outreach after hospital discharge with the use of home visits and telephone follow-up. SafeMed program CPhT-CHWs served as pharmacist extenders, obtaining medication histories, assisting in medication reconciliation and identification of potential drug therapy problems (DTPs), and reinforcing medication education previously provided by the pharmacist per protocol.

RESULTS

CPhT-CHW training included patient communication skills, motivational interviewing, medication history taking, teach-back techniques, drug disposal practices, and basic disease management. Some CPhT-CHWs experienced difficulties adjusting to an expanded scope of practice. Nonetheless, once the Tennessee Board of Pharmacy affirmed that envisioned SafeMed CPhT-CHW roles were consistent with Board rules, additional responsibilities were added for CPhT-CHWs to enhance their effectiveness. Patient outreach teams including CPhT-CHWs achieved increases in home visit and telephone follow-up rates and were successful in helping identify potential DTPs.

CONCLUSION

The early experience of the SafeMed program demonstrates that CPhT-CHWs are well suited for novel expanded roles to improve care transitions for superutilizing populations. CPhT-CHWs can identify and report potential DTPs to the pharmacist to help target medication therapy management. Critical success factors include strong CPhT-CHW patient-centered communication skills and strong pharmacist champions. In collaboration with state pharmacy boards and pharmacist associations, the SafeMed CPhT-CHW model can be successfully scaled to serve superutilizing patients throughout the country.

Unmet Primary Care Needs in Diabetic Patients with Multimorbidity in a Medically Underserved Area

Background:

Diabetic patients with multimorbidity in medically underserved minority communities are less engaged in primary care and experience high emergency department (ED) utilization. This study assesses unmet primary care needs among diabetic patients in a medically underserved area (MUA).

Community Context:

A suburb of Memphis—Whitehaven, Tennessee (Shelby County, ZIP codes 38109 and 38116)—majority African American (96.6%) with 30.5% below the poverty level.

Methods:

Community case study using multiple data sources including diabetes registry, individual interviews, focus groups, and a survey of 30 ED patients with diabetes and multimorbidity.

Results:

Diabetes registry data indicated that 95.5% of 5723 diabetic patients had multimorbidity. Over 91.5% were uncontrolled at some point in 2014 to 2015. Only 83% of patients with diabetes and multimorbidity reported having a primary care provider (PCP) and those without a PCP were more likely to report delays in needed care. Patients expressed strong interest in health coaching (88%) and receiving text messages from the doctor’s office (73%). Individual patient interviews (n = 9) and focus groups (n = 11) revealed common primary care and self-care experiences and needs including diabetes education, improved patient–provider communication, health-care access and coverage, and strengthened primary care and community.

Conclusion:

This study demonstrates that almost 1 in 5 ED complex diabetic patients in an MUA do not have a PCP, and that difficulty accessing primary care often results in patients forgoing needed care. Qualitative findings support these conclusions. These results suggest that primary care capacity and infrastructure to support diabetes self-care need strengthening in MUAs.

Measurement and models of bent KAP(001) crystal integrated reflectivity and resolution (invited)

The Advanced Light Source beamline-9.3.1 x-rays are used to calibrate the rocking curve of bent potassium acid phthalate (KAP) crystals in the 2.3-4.5 keV photon-energy range. Crystals are bent on a cylindrically convex substrate with a radius of curvature ranging from 2 to 9 in. and also including the flat case to observe the effect of bending on the KAP spectrometric properties. As the bending radius increases, the crystal reflectivity converges to the mosaic crystal response. The X-ray Oriented Programs (xop) multi-lamellar model of bent crystals is used to model the rocking curve of these crystals and the calibration data confirm that a single model is adequate to reproduce simultaneously all measured integrated reflectivities and rocking-curve FWHM for multiple radii of curvature in both 1st and 2nd order of diffraction.

Calibrated simulations of Z opacity experiments that reproduce the experimentally measured plasma conditions

Recently, frequency-resolved iron opacity measurements at electron temperatures of 170-200 eV and electron densities of (0.7-4.0)×10(22)cm(-3) revealed a 30-400% disagreement with the calculated opacities [J. E. Bailey et al., Nature (London) 517, 56 (2015)]. The discrepancies have a high impact on astrophysics, atomic physics, and high-energy density physics, and it is important to verify our understanding of the experimental platform with simulations. Reliable simulations are challenging because the temporal and spatial evolution of the source radiation and of the sample plasma are both complex and incompletely diagnosed. In this article, we describe simulations that reproduce the measured temperature and density in recent iron opacity experiments performed at the Sandia National Laboratories Z facility. The time-dependent spectral irradiance at the sample is estimated using the measured time- and space-dependent source radiation distribution, in situ source-to-sample distance measurements, and a three-dimensional (3D) view-factor code. The inferred spectral irradiance is used to drive 1D sample radiation hydrodynamics simulations. The images recorded by slit-imaged space-resolved spectrometers are modeled by solving radiation transport of the source radiation through the sample. We find that the same drive radiation time history successfully reproduces the measured plasma conditions for eight different opacity experiments. These results provide a quantitative physical explanation for the observed dependence of both temperature and density on the sample configuration. Simulated spectral images for the experiments without the FeMg sample show quantitative agreement with the measured spectral images. The agreement in spectral profile, spatial profile, and brightness provides further confidence in our understanding of the backlight-radiation time history and image formation. These simulations bridge the static-uniform picture of the data interpretation and the dynamic-gradient reality of the experiments, and they will allow us to quantitatively assess the impact of effects neglected in the data interpretation.

Impact of Medicare Part D on Racial Disparities in Adherence to Cardiovascular Medications Among the Elderly

Medicare Part D improved medication adherence among the elderly, but to date, its effect on disparities in adherence remains unknown. We estimated Part D impact on racial/ethnic disparities in adherence to cardiovascular medications among seniors, using pooled data from the Medical Expenditure Panel Survey (2002-2010) on 14,221 Medicare recipients (65+ years) and 3,456 near-elderly controls (60-64 years). Study sample included White, Black, or Hispanic respondents who used at least one cardiovascular medication. Twelve-month adherence was measured as having an overall proportion of days covered ≥80%. Adherence disparities were defined according to the Institute of Medicine framework. Using difference-in-differences logistic regression, we found Part D to be associated with a 16-percentage-point decrease in the White-Hispanic disparity in overall adherence among seniors, net of the change among controls. Black-White disparities worsened only among men, by 21 percentage points. Increasing access and improving quality of medication use among disadvantaged seniors should remain a policy priority.

Use of and interest in mobile health for diabetes self-care in vulnerable populations

Objective

We aimed to assess use of and interest in mobile health (mHealth) technology and in-person services for diabetes self-care in vulnerable populations.

Methods

We delivered a self-administered cross-sectional survey. Participants were recruited at two primary care practices (P1 and P2) with P1 located in a medically underserved area and P2 in an affluent suburb. Two-sample t-tests and chi-square tests were used with p < 0.05 significant. In addition, a secondary analysis was performed to analyse differences in use and interest in mHealth by age.

Results

Of 75 eligible patients, 60 completed the survey (80% response rate). P1 patients had significantly higher interest in three of five categories of in-person diabetes support services, one of four categories of health-related text messages (TM), and three of eight categories of mHealth applications ( p < 0.05). Smartphone users reported higher interest in TM ( p = 0.004) and mHealth applications for diabetes self-care ( p = 0.004). Younger patients were more likely to have a smartphone ( p < 0.006), use the Internet ( p < 0.0012), use smartphone applications ( p < 0.0004), and to be interested in using applications to manage their diabetes ( p < 0.004).

Discussion

This study shows substantial patient interest in TM and mHealth applications for diabetes self-care and suggests that patients in underserved areas may have particularly high interest in using mHealth solutions in primary care. Younger patients and smartphone users were more likely to be interested in using applications to manage their diabetes. As more patients use smartphones, interest in using mHealth to support patient self-care and strengthen primary care infrastructure will continue to grow.

Analysis and implementation of a space resolving spherical crystal spectrometer for x-ray Thomson scattering experiments

The application of a space-resolving spectrometer to X-ray Thomson Scattering (XRTS) experiments has the potential to advance the study of warm dense matter. This has motivated the design of a spherical crystal spectrometer, which is a doubly focusing geometry with an overall high sensitivity and the capability of providing high-resolution, space-resolved spectra. A detailed analysis of the image fluence and crystal throughput in this geometry is carried out and analytical estimates of these quantities are presented. This analysis informed the design of a new spectrometer intended for future XRTS experiments on the Z-machine. The new spectrometer collects 6 keV x-rays with a spherically bent Ge (422) crystal and focuses the collected x-rays onto the Rowland circle. The spectrometer was built and then tested with a foam target. The resulting high-quality spectra prove that a spherical spectrometer is a viable diagnostic for XRTS experiments.

Improving medication adherence in hypercholesterolemia: challenges and solutions

Medication nonadherence is a prevalent public health issue that contributes to significant medical costs and detrimental health outcomes. This is especially true in patients with hypercholesterolemia, a condition affecting millions of American adults and one that is associated with increased risk for coronary and cerebrovascular events. Considering the magnitude of outcomes related to this disease, the medical community has placed significant emphasis on addressing the treatment for high cholesterol, and progress has been made in recent years. However, poor adherence to therapy continues to plague health outcomes and more must be understood and done to address suboptimal medication taking. Here we provide an overview of the reasons for poor medication adherence in patients with hypercholesterolemia and describe recent efforts to curb nonadherence. Suggested approaches for improving medication taking in patients with high cholesterol are also provided to guide practitioners, patients, and payers.

Parallax diagnostics of radiation source geometric dilution for iron opacity experiments

Experimental tests are in progress to evaluate the accuracy of the modeled iron opacity at solar interior conditions [J. E. Bailey et al., Phys. Plasmas 16, 058101 (2009)]. The iron sample is placed on top of the Sandia National Laboratories z-pinch dynamic hohlraum (ZPDH) radiation source. The samples are heated to 150-200 eV electron temperatures and 7× 10(21)-4× 10(22) cm(-3) electron densities by the ZPDH radiation and backlit at its stagnation [T. Nagayama et al., Phys. Plasmas 21, 056502 (2014)]. The backlighter attenuated by the heated sample plasma is measured by four spectrometers along ±9° with respect to the z-pinch axis to infer the sample iron opacity. Here, we describe measurements of the source-to-sample distance that exploit the parallax of spectrometers that view the half-moon-shaped sample from ±9°. The measured sample temperature decreases with increased source-to-sample distance. This distance must be taken into account for understanding the sample heating.

The U.S. health insurance marketplace: are premiums truly affordable?

The Patient Protection and Affordable Care Act requires that individuals have health insurance or pay a penalty. Individuals are exempt from paying this penalty if the after-subsidy cost of the least-expensive plan available to them is greater than 8% of their income. For this study, premium data for all health plans offered on the state and federal health insurance marketplaces were collected; the after-subsidy cost of premiums for the least-expensive bronze plan for every county in the United States was calculated; and variations in premium affordability by age, income, and geographic area were assessed. Results indicated that-although marketplace subsidies ensure affordable health insurance for most persons in the United States-many individuals with incomes just above the subsidy threshold will lack affordable coverage and will be exempt from the mandate. Furthermore, young individuals with low incomes often pay as much as or more than older individuals for bronze plans. If substantial numbers of younger, healthier adults choose to remain uninsured because of cost, health insurance premiums across all ages may increase over time.

Hypertension Awareness and Associated Factors among Older Chinese Adults

Hypertension is one of the most preventable chronic conditions. Improving hypertension awareness is a critical first step to reducing morbidity and mortality from hypertension in the elderly, yet the factors associated with hypertension awareness in China are poorly understood. The objective of this paper is to examine the extent to which older Chinese adults are aware of their hypertension, and factors associated with this awareness. We included 2404 adults aged 60 years or older clinically identified as hypertensive from panel data surveyed in 1997, 2000, 2004, and 2006 as part of the China Health and Nutrition Survey. Comparing this data with respondents' self-reported diagnosis of hypertension enabled us to characterize hypertension awareness. Covariates included socio-demographic, health status, functional disability, and behavioral factors. Generalized estimating equations were used to identify factors for hypertension awareness. We found 22.9% in 1997 and 42.7% in 2006 of study participants were aware of their hypertensive status. Lower awareness was found among those who lived in rural areas [odds ratio (OR) = 0.64, 95% Confidence Interval (CI), 0.47-0.88]. Higher awareness was noted for persons who were aware of their hypertensive status in a previous survey wave (OR = 7.43, 95% CI, 5.45-10.13), had high income (OR = 1.55, 95% CI, 1.05-2.28), had stage two hypertension (OR = 2.28, 95% CI, 1.69-3.06), had acute condition (OR = 2.54, 95% CI, 1.89-3.42), and had greater activities of daily living limitations (OR = 1.24, 95% CI, 1.08-1.43). Studying dynamics of hypertension awareness can help inform both clinical and public health approaches to improve healthcare.

Comparative studies of Escherichia coli strains using different glucose uptake systems: Metabolism and energetics

Modifying substrate uptake systems is a potentially powerful tool in metabolic engineering. This research investigates energetic and metabolic changes brought about by the genetic modification of the glucose uptake and phosphorylation system of Escherichia coli. The engineered strain PPA316, which lacks the E. coli phosphotransferase system (PTS) and uses instead the galactose-proton symport system for glucose uptake, exhibited significantly altered metabolic patterns relative to the parent strain PPA305 which retains PTS activity. Replacement of a PTS uptake system by the galactose-proton symport system is expected to lower the carbon flux to pyruvate in both aerobic and anaerobic cultivations. The extra energy cost in substrate uptake for the non-PTS strain PPA 316 had a greater effect on anaerobic specific growth rate, which was reduced by a factor of five relative to PPA 305, while PPA 316 reached a specific growth rate of 60% of that of the PTS strain under aerobic conditions. The maximal cell densities obtained with PPA 316 were approximately 8% higher than those of the PTS strain under aerobic conditions and 14% lower under anaerobic conditions. In vivo NMR results showed that the non-PTS strain possesses a dramatically different intracellular environment, as evidenced by lower levels of total sugar phosphate, NAD(H), nucleoside triphosphates and phosphoenolpyruvate, and higher levels of nucleoside diphosphates. The sugar phosphate compositions, as measured by extract NMR, were considerably different between these two strains. Data suggest that limitations in the rates of steps catalyzed by glucokinase, glyceraldehyde-3-phosphate dehydrogenase, phosphofructokinase, and pyruvate kinase may be responsible for the low overall rate of glucose metabolism in PPA316. (c) 1997 John Wiley & Sons, Inc. Biotechnol Bioeng 56: 583-590, 1997.

Inverse metabolic engineering: A strategy for directed genetic engineering of useful phenotypes

The classical method of metabolic engineering, identifying a rate-determining step in a pathway and alleviating the bottleneck by enzyme overexpression, has motivated much research but has enjoyed only limited practical success. Intervention of other limiting steps, of counterbalancing regulation, and of unknown coupled pathways often confounds this direct approach. Here the concept of inverse metabolic engineering is codified and its application is illustrated with several examples. Inverse metabolic engineering means the elucidation of a metabolic engineering strategy by: first, identifying, constructing, or calculating a desired phenotype; second, determining the genetic or the particular environmental factors conferring that phenotype; and third, endowing that phenotype on another strain or organism by directed genetic or environmental manipulation. This paradigm has been successfully applied in several contexts, including elimination of growth factor requirements in mammalian cell culture and increasing the energetic efficiency of microaerobic bacterial respiration. (c) 1996 John Wiley & Sons, Inc.

MPS: An artificially intelligent software system for the analysis and synthesis of metabolic pathways

The concepts of artificial intelligence have been applied for the development of a software system for metabolic pathway synthesis (MPS). An easily expandable data base system for storing enzyme and substance descriptions is used by a search algorithm for the identification of possible ways to interconvert carbon-carrying metabolites. A versatile screening capability permits the user to identify all pathways which contain or exclude any combination of enzymes, substrates, and/or products. Information provided by MPS can be used to predict on a qualitative basis the effects of adding or deleting enzymatic activities to or from the cellular environment, to classify pathways with respect to cellular objectives, and to extract information about metabolic regulation. MPS can be used subsequently to aid the identification of appropriate genotypes or genetic modifications that will redirect metabolism towards amplified production of desirable bioproducts. Two examples illustrating the capabilities of MPS are presented. In the first example, which considers the conversion of glucose 6-phosphate to pyruvate, MPS synthesized the classical catabolic pathways (EMP, pentose phosphate and ED) along with possible variations. A route for the biosynthesis of L-alanine that does not incorporate the enzyme alanine aminotransferase was revealed by MPS during synthesis of alternative pathways which produce L-alanine from pyruvate.

Communication to the editor. Application of the cross-regulation system as a metabolic switch

The ability to switch metabolic flow from one pathway to another at a desired point in a bioprocess expands the horizons of metabolic engineering. Such an externally inducible switch can be realized by embedding synthetic operons behind tow corss-regulated promoters. This results in coordinated cessation of transcription of one operon while transcription of a second operon is simultaneously activated. The ability to effect such coordinated and inverse control of transcription of two operons has been illustrated experimentally using a model construct containing two different reporter genes, Vitreoscilla hemoglobin (VHb) and chloramphenicol acetyltransferase (CAT), fused to lambdaP(L) and tac promoters, respectively, along with corresponding repressor genes in a cross-regulation configuration. Only VHb production was observed preinduction, and postinduction only CAT was produced. The framework presented here and its obvious extensions can be used with different combinations of promoter systems and synthetic operon constructs to achieve complicated metabolic flux regulation in diverse host. (c) 1994 John Wiley & Sons, Inc.