Oral Health and Older Adults: A Narrative Review

Oral health's association with general health, morbidity, and mortality in older adults highlights its importance for healthy aging. Poor oral health is not an inevitable consequence of aging, and a proactive, multidisciplinary approach to early recognition and treatment of common pathologies increases the likelihood of maintaining good oral health. Some individuals may not have regular access to a dentist, and opportunities to improve oral health may be lost if health professionals fail to appreciate the importance of oral health on overall well-being and quality of life. The authors of this narrative review examined government websites, the American Dental Association Aging and Dental Health website, and the Healthy People 2030 oral objectives and identified xerostomia, edentulism, caries, periodontitis, and oral cancer as five key topics for the non-dental provider. These conditions are associated with nutritional deficiencies, poorer quality of life, increased risk of disease development and poorer outcomes for cardiovascular disease, diabetes, and other systemic conditions prevalent among older adults. It is important to note that there is a bi-directional dimension to oral health and chronic diseases, underscoring the value of a multidisciplinary approach to maintaining oral health in older adults.

Electronic Nicotine Delivery Systems Use and Periodontal Health-Findings from the Population Assessment of Tobacco and Health Study

(1) Background: Electronic nicotine delivery systems (ENDSs) are rapidly increasing in the U.S., however, information about their long-term risks and benefits remains limited. This study examined the relationship between ENDS use and periodontal health among U.S. adults. (2) Methods: Data came from 33,822 adults who participated in the 2016-2018 wave of the Population Assessment of Tobacco and Health (PATH) study. Inclusion criteria were adults without a history of cigarette smoking or diabetes. Logistic regression analysis was performed to estimate the associations between ENDS use and a history of periodontal disease, with multivariable logistic regression adjusting for factors associated with poor oral health. (3) Results: Of the study participants, 2321 were never ENDS users, 38 were regular ENDS users, and 512 were non-regular ENDS users. Compared to never ENDS users, regular ENDS users had higher odds of poor periodontal health including bone loss around teeth. Regular ENDS use was also independently associated with higher odds of poor oral health compared to non-regular ENDS users. (4) Conclusions: This study suggests an association between ENDS use and increased risk of periodontal health issues in the United States. These findings align with previous research linking ENDS use to poor oral health.

Community Water Fluoridation in Focus: A Comprehensive Look at Fluoridation Levels across America

Objective: This study reports on the number and percentage of community water systems (CWSs) meeting fluoride concentration standards set by the U.S. Department of Health and Human Services (DHHS). The study also explored changes in the population exposed to optimally fluoridated water in these systems between 2006 and 2020. Methods: This study analyzed U.S. Centers for Disease Control and Prevention data from 2006 to 2020, tabulating state-specific CWS fluoridation rates, ranking them, and calculating the percent change. Results: In 2020, 72.7% of the US population received CWS water, with 62.9% of those individuals served by a CWS system meeting DHHS fluoridation standards. This compares to 69.2% receiving CWS water in 2006 and 74.6% in 2012. The overall change in those receiving fluoridated water was 1.4%, from 61.5% in 2006 to 62.9% in 2020. State-specific percentages ranged from 8.5% in Hawaii to 100% in Washington DC in 2020 (median: 76.4%). Conclusions: Although endorsed by the American Dental Association, the percentage of individuals receiving fluoridated water did not increase substantially from 2006 to 2020, indicating that there has not been much progress toward meeting the Healthy People 2030 goal that 77.1% of Americans receive water with enough fluoride to prevent tooth decay.

Factors Associated with Periodontitis in Younger Individuals: A Scoping Review

Periodontitis is a disease that affects many young adults, and if left untreated, it can have lasting and permanent effects on an individual's oral health. The purpose of this scoping review was to review the recent literature to identify factors that place young individuals at risk of stage II or III periodontitis. Using the PRISMA guidelines for scoping reviews, three databases were systematically searched for peer-reviewed human studies published in English that investigated risk factors associated with stage II and/or III periodontitis in individuals less than 40 years of age. This review excluded abstracts, literature reviews, including narrative, scoping, and systematic reviews and meta-analyses, conference proceedings, letters to the editor, and editorials. The authors then extracted data from the relevant studies using a predefined form to summarize the aims, design, results, risk factors examined, and the type and severity of periodontitis. Among a total of 2676 articles screened, only three articles met the review's inclusion criteria. Of these articles, one was a longitudinal case-control study and two were cross-sectional studies. Identified risk factors associated with stage II or III periodontitis included self-reported bleeding when brushing, low bone mineral density, being overweight, and smoking in young adults. Of note, only three studies met the inclusion criteria, suggesting a gap in the research literature.

Association between fluoride exposure and blood pressure

Objectives

This study investigated whether fluoride was associated with an increased prevalence of high blood pressure (BP) among adolescents in the United States.

Methods

The study sample consisted of 2015-2016 National Health and Nutrition Examination Survey participants aged 13-17 years. Independent-samples t-tests, Chi-square tests, and regression models were used to analyze the data.

Results

A total of 814 participants met the study criteria. The findings showed that the proportion of patients with high levels of water or plasma fluoride in the high BP group was higher than that in the normal BP group. However, after adjusting for sociodemographic covariates, neither water nor plasma fluoride levels were significantly associated with a high BP.

Conclusions

This study did not find an association between either water or plasma fluoride levels and high BP. Further study is needed to exclude a dose dependent effect at higher levels of fluoride.

A National Study Exploring the Association Between Fluoride Levels and Dental Fluorosis

Importance

While the effects of fluoride on health have been widely researched, fewer high-quality studies examine the association of fluoride levels in water and dental fluorosis.

Objective

To investigate the association between fluoride exposure from drinking water and dental fluorosis.

Design, Setting, and Participants

This cross-sectional study used the 2013-2014 and 2015-2016 National Health and Nutrition Examination Survey (NHANES) data (January 1, 2013, through December 31, 2016). NHANES uses a complex sampling technique to develop nationally representative sample estimates of the US population that consists of interviews and physical assessments. Children and adolescents aged 6 to 15 years were included because NHANES contains their data for all 3 forms of fluoride measures: plasma fluoride levels, water levels of fluoride, and dietary fluoride supplementation. Data were analyzed from January 1 to April 30, 2023.

Exposures

Water and plasma fluoride levels were measured by laboratory personnel. Dietary fluoride supplement data were self-reported.

Main Outcomes and Measures

The Dean's Fluorosis Index was used to evaluate fluorosis status for each tooth. The dental fluorosis severity value was based on the second most affected tooth. Independent variables included plasma and water fluoride concentrations and dietary fluoride supplementation. An independent samples t test was used to compare fluoride exposures between groups, and Pearson correlation assessed the association between plasma and water fluoride levels. To assess whether fluoride exposures were associated with dental fluorosis, logistic regression analyses were conducted.

Results

There were 1543 participants in the 2013-2014 NHANES cycle (weighted proportion male, 51.9%; mean [SD] age, 11.0 [2.7] years) and 1452 in the 2015-2016 cycle (weighted proportion male, 52.6%; mean [SD] age, 11.1 [2.8] years). A weighted 87.3% exhibited some degree of fluorosis in the 2013-2014 cycle and 68.2% in the 2015-2016 cycle. Higher fluoride levels in water and plasma were significantly associated with higher odds of dental fluorosis (adjusted odds ratios, 2.378 [95% CI, 2.372-2.383] in the 2013-2014 cycle and 1.568 [95% CI, 1.564-1.571] in the 2015-2016 cycle).

Conclusions and Relevance

The findings of this cross-sectional study suggest that exposure to higher concentrations of fluoride in water and having higher plasma levels of fluoride were associated with a greater risk of dental fluorosis. Further research can help policy makers develop policies that balance substantial caries prevention with the risk of dental fluorosis.

Vitamin D in the Prevention and Treatment of Oral Cancer: A Scoping Review

Introduction: Oral cancer is a serious health problem with an increasing incidence worldwide. Researchers have studied the potential anti-cancerous action of vitamin D and its association with several cancers including oral cancer. The purpose of this scoping review is to synthesize the existing literature on the role of vitamin D on oral cancer. Methods: A scoping review of the literature was conducted using the framework developed by Arkey and O'Malley and the PRISMA-ScR guidelines. Nine databases were searched for peer-reviewed human studies published in English that either investigated the association of vitamin D with, or its impact on either the prevention or treatment of oral cancer. The authors then extracted data using a predefined form to summarize information about article type, study design, participant characteristics, interventions, and outcomes. Results: Fifteen articles met the review criteria. Among the 15 studies, 11 were case-control, 3 were cohort studies, and 1 was a clinical trial. In four studies, the evidence supported a preventive action of vitamin D against oral cancer and a reduction in the negative side effects associated with chemo- and radiotherapy. Several studies that focused on genetic polymorphisms and the expression of the 1,25 dihydroxyvitamin D3 receptor (VDR) suggested significant associations with vitamin D and increased oral cancer risk and worse survival rates. In contrast, two studies did not reveal a strong association between vitamin D and oral cancer. Conclusions: The current evidence suggests an association between vitamin D deficiency and an increased risk of oral cancer. VDR gene polymorphisms might also be a part of future preventive and therapeutic strategies against oral cancer. Carefully designed studies are required to explore and define what role, if any, vitamin D might play in the prevention and treatment of oral cancer.

Telemedicine among Adults Living in America during the COVID-19 Pandemic

Background and Objectives Telemedicine can expand healthcare access to populations, but relying on technology risks a digital divide. Therefore, it is important to understand who utilizes telemedicine. This study explores telemedicine usage across socio-demographic groups in the United States during COVID-19. Methods Data came from the Household Pulse Survey (HPS) between 14 April 2021, to 11 April 2022. HPS is a rapid online response survey that assesses household experiences during COVID-19. We calculated descriptive statistics and used cross-correlation to test each pair of the time series curves. Results High school graduates used the least telemedicine (20.58%), while those with some college (23.29%) or college graduates (22.61%) had similar levels, and those with less than a high school education fluctuated over time. Black people had higher levels of use (26.31%) than Asians (22.01%). Individuals with disabilities (35.40%) used telemedicine more than individuals without disabilities (20.21%). Individuals 80 years or over (27.63%) used telemedicine more than individuals 18 to 29 years old (18.44%). Cross-correlations for the time series pairs across demographics revealed significant differences in telemedicine use for all demographic groups over time. Conclusions Overall, elderly, Black people, individuals with some college, and persons with disabilities report higher levels of telemedicine use. Telemedicine may improve healthcare access post-pandemic, but more research is needed to understand factors that drive differences among groups.

E-cigarette addiction and harm perception: Does initiation flavor choice matter?

Introduction

The 21^st century was marked by a dramatic increase in adolescent e-cigarette use in the United States (US). The popularity of non-traditional flavor types, including fruit and pastry, is thought to contribute toward growing product use nationally, leading to a variety of federal and state regulations limiting the use of non-traditional flavors in the US. The relationship between flavor type and increased adolescent use suggests a possible link between flavor use and addiction and harm perception. This study assessed if the flavor type used when initiating e-cigarette use predicted addiction and harm perceptions.

Methods

The study utilized data from the multi-wave youth Population Assessment of Tobacco Health Study. It explored the impact initiating e-cigarette use with traditional versus non-traditional flavor types among cigarette users on the outcome variables: e-cigarette addiction and harm perception. Both e-cigarette addiction and harm perception were measured using self-report, Likert scale questionnaires. Descriptive statistics characterized the study variables and linear regression analyses performed to test whether flavor initiation type is associated with addiction and harm perception.

Results

The study sample consisted of 1,043 youth (weighted N = 1,873,617) aged 12 to 17 years who reported at least one instance of e-cigarette use. After adjusting for age, age of onset, sex, race and annual household income there was no statistically significant difference in addiction levels between those initiating with traditional versus non-traditional flavors (p = 0.294). Similarly, traditional versus non-traditional flavor initiation did not show a statistically significant difference in adolescent e-cigarette harm perceptions (p = 0.601).

Conclusions

Traditionally flavored e-cigarette initiation produces similar risk for addiction and harm perceptions as non-traditionally flavored initiation. These findings suggest that banning non-traditional flavors alone may be ineffective in curbing e-cigarette addiction and harm perception. Additional research is needed to better understand which e-cigarette product characteristics and behaviors may be associated with greater addiction and reduced harm perceptions.

Teledentistry Implementation During the COVID-19 Pandemic: Scoping Review

Background

COVID-19 spreads via aerosol droplets. The dental profession is at high risk of contracting the virus since their work includes treatment procedures that produce aerosols. Teledentistry offers an opportunity to mitigate the risk to dental personnel by allowing dentists to provide care without direct patient contact.

Objective

The purpose of this scoping review was to examine the implementation, challenges, strategies, and innovations related to teledentistry during the COVID-19 pandemic lockdown.

Methods

This scoping review evaluated teledentistry use during the pandemic by searching for articles in PubMed and Google Scholar using the search terms teledentistry, tele-dentistry, covid-19, coronavirus, telehealth, telemedicine, and dentistry. Inclusion criteria consisted of articles published in English from March 1, 2020, to April 1, 2022, that were relevant to dentistry and its specialties, and that included some discussion of teledentistry and COVID-19. Specifically, the review sought to explore teledentistry implementation, challenges, strategies to overcome challenges, and innovative ideas that emerged during the pandemic. It followed the 2020 Preferred Reporting Items for Systematic reviews and Meta-Analyses for Scoping Reviews (PRISMA-ScR). This approach is organized into 5 distinct steps: formulating a defined question, using the question to develop inclusion criteria to identify relevant studies, an approach to appraise the studies, summarizing the evidence using an explicit methodology, and interpreting the findings of the review.

Results

A total of 32 articles was included in this scoping review and summarized by article type, methodology and population, and key points about the aims; 9 articles were narrative review articles, 10 were opinion pieces, 4 were descriptive studies, 3 were surveys, 2 were integrative literature reviews, and there was 1 each of the following: observational study, systematic review, case report, and practice brief. Teledentistry was used both synchronously and asynchronously for virtual consultations, often employing commercial applications such as WhatsApp, Skype, and Zoom. Dental professionals most commonly used teledentistry for triage, to reduce in-person visits, and for scheduling and providing consultations remotely. Identified challenges included patient and clinician acceptance of teledentistry, having adequate infrastructure, reimbursement, and security concerns. Strategies to address these concerns included clinician and patient training and utilizing Health Insurance Portability and Accountability Act-compliant applications. Benefits from teledentistry included providing care for patients during the pandemic and extending care to areas lacking access to dental care.

Conclusions

Pandemic lockdowns led to new teledentistry implementations, most commonly for triage but also for follow-up and nonprocedural care. Teledentistry reduced in-person visits and improved access to remote areas. Challenges such as technology infrastructure, provider skill level, billing issues, and privacy concerns remain.

An Exploration of the Use and Impact of Preventive Measures on Skin Cancer

Background: Skin cancer is the most common form of cancer, and both clinical and epidemiological data link cumulative solar dosages and the number of sunburns to skin cancer. Each year, more than 5.4 million new cases of skin cancer are diagnosed, incurring a significant health and financial burden. Recommended preventive measures for skin cancer include the use of sunscreen, sun avoidance, and protective clothing. This study used a national database to examine the association of preventive measures with the prevalence of skin cancer, specifically analyzing the preventive measures of sunscreen use, staying in the shade, and wearing long-sleeved shirts. The second aim was to determine which characteristics, if any, correlated with using prevention measures. Methods: This study analyzed data from the National Health and Nutritional Examination Survey 2015−2016 cycle to examine the association of three preventive measures (using sunscreen, staying in the shade, and wearing long-sleeved shirts) with skin cancer. Logistic regression and chi-square tests were utilized to examine the relationship between skin cancer and these prevention methods. Results: Sunscreen use (OR = 3.752; p < 0.05) was statistically associated with a lower prevalence of skin cancer, while wearing long-sleeved shirts (OR = 6.911; p = 0.064) and staying in the shade (OR = 0.646; p = 0.481) did not emerge as factors significantly associated with a lower prevalence after controlling for gender, race/ethnicity, marital status, income, health insurance, and general health. Additionally, men and individuals of color were less likely to use sunscreen. Conclusion: Sunscreen use was associated with a lower prevalence of skin cancer, while wearing long-sleeved shirts and staying in the shade was not significantly linked to lower rates of skin cancer, suggesting that these measures may not be as effective as sunscreen for preventing skin cancer. Men and individuals of color were significantly less likely to use sunscreen. These findings can help guide future education efforts and research regarding skin cancer prevention and suggest the need to develop male-oriented programs to mitigate the gender disparity in employing sun-protection measures.

The association of adolescent e-cigarette harm perception to advertising exposure and marketing type

BACKGROUND

Despite controversy over their possible health consequences, manufacturers of e-cigarettes employ a variety of marketing media to increase their popularity among adolescents. This study analyzed the relationship between adolescent e-cigarette harm perception and five types of e-cigarette advertising exposures: social media, radio, billboard, newspaper, and television.

METHODS

This study used data from Wave 4.5 of the Population Assessment of Tobacco and Health Study (PATH). PATH collects demographic data and interview individuals about issues pertaining to tobacco use, health outcomes, attitudes, and behaviors. This study applied factor analysis to three individual PATH harm perception items to develop a composite harm perception score. Using linear regression, the study explored the relationship of harm perception and participant responses to their recalled viewing of five different types (i.e., newspaper, radio, billboard, television and social media) of advertisements within the past 30 days. A second analysis explored if adjusting for exposure to anti-tobacco messaging and environmental factors such as family approval mitigated the association of harm perception and advertisement types.

RESULTS

The study sample consisted of 12,570 (weighted N = 23,993,149) individuals aged 12 to 17 years old. Unadjusted past 30-day exposure to newspaper, radio, billboard, and social media advertising all correlated with a reduced harm perception, but only the associations for newspaper and social media were statistically significant (p<0.05). After adjusting for environmental support factors, exposure to warning labels, and anti-tobacco advertisements, the analysis yielded statistically significant associations between increased e-cigarette harm perception and exposure to radio, billboard, and television advertisements (p<0.05). Adjusting for covariates also reduced the association of marketing and harm perception for all forms of media.

CONCLUSION

E-cigarette advertising influences adolescent perceptions of harm in e-cigarette use, particularly for social media and newspaper advertisements. This association weakens when adjusted for covariates such as environmental support and exposure to anti-tobacco marketing. These findings provide evidence for policy makers to continue anti-tobacco marketing and incorporate environmentally supportive strategies such as holistic, family-centered educational approaches to reduce e-cigarette use among adolescents.

Evaluating Fidelity to Comprehensive Medication Management in Pharmacy Education Courses Teaching the Patient Care Process

Objective. To evaluate fidelity to the comprehensive medication management (CMM) framework in a patient care skills course by using CMM essential functions to analyze the domains of content and competency.Methods. A mixed methods approach was used to compare the curriculum of the Pharmacist's Patient Care Process II skills course to the nationally developed CMM framework. The content of the course curriculum was mapped to the CMM framework and the percentage of omissions and deficiencies were calculated. Student competency was analyzed using pharmacy students' assessment scores.Results. Of the 102 class hours in the PPCP II course, 41.5 hours (40.7%) were spent teaching CMM content. Deficiencies in and omissions of content from the CMM framework were calculated at 14.3%, indicating an overall alignment with the CMM framework of 71.4%. For the competency domain, the percentage of students initially achieving competence ranged from 76.6% to 98.7% on formative assessments in 2018-2019 and 2019-2020, combined academic years. For the summative assessment, 87.5% in 2018-2019 and 69.2% in 2019-2020 achieved competency on their first attempt, with levels rising significantly to 98.8% and 98.7%, respectively, after remediation. Overall, 98.7% of students achieved competency in CMM-related course curriculum.Conclusion. About 70% of the CMM framework for the core domain of content can be covered in approximately 40 hours of direct curricular time, and the majority of students can achieve competency. The omissions of and deficiencies in CMM content identified in this study highlight opportunities for course improvement. Remediation of students with deficient skills resulted in a significant improvement in the percentage of students achieving competence in CMM.

Using machine learning to identify factors associated with practice location of the healthcare workforce

INTRODUCTION

Past studies examined factors associated with rural practice, but none employed newer machine learning (ML) methods to explore potential predictors. The primary aim of this study was to identify factors related to practice in a rural area. Secondary aims were to capture a more precise understanding of the demographic characteristics of the healthcare professions workforce in Utah (USA) and to assess the viability of ML as a predictive tool.

METHODS

This study incorporated four datasets - the 2017 dental workforce, the 2016 physician workforce, the 2014 nursing workforce and the 2017 pharmacy workforce - collected by the Utah Medical Education Council. Supervised ML techniques were used to identify factors associated with practice location, the outcome variable of interest.

RESULTS

The study sample consisted of 11 259 healthcare professionals with an average age of 46.6 years, of which 36.6% were males and 94.5% Caucasian. Four ML methods were applied to assess model performance by comparing accuracy, sensitivity, specificity and area under the receiver operating characteristic (ROC) curve. Of the methods used, support vector machine performed the best (accuracy 99.7%, precision 100%, sensitivity 100%, specificity 99.4% and ROC 0.997). The models identified income and rural upbringing as the top factors associated with rural practice.

CONCLUSION

By far, income emerged as the most important factor associated with rural practice, suggesting that attractive income offers might help rural communities address health professional shortages. Rural upbringing was the next most important predictive factor, validating and updating earlier research. The performance of the ML algorithms suggests their usefulness as a tool to model other databases for individualized prediction.

Health Disparities Associated with Females Reporting Human Papillomavirus Infection in the United States

Few studies provide detailed findings about the health disparities of women being told by a physician whether they have ever had a human papillomavirus (HPV) infection. This study sought to characterize the prevalence and characteristics associated with women age 18 to 59 years in the United States who report being told they were infected with HPV. This study used data from the National Health and Nutritional Examination Survey. Descriptive statistics were computed on study variables and multiple logistic regression analyses were conducted to explore the association of the study variables with the outcome variable. Sampling weights were applied to produce national estimates of prevalence. The sample consisted of 1,669 females, representative of 75,107,170 females in the United States population. Around 11.5% reported being told that they had an HPV infection, of which 60.9% were White, and 82.9% were born in the United States. White women are 2.0 times more likely to be told they have HPV than Asian women and 2.8 times more likely than Black women. United States-born women were 2.1 times more likely told they had an HPV infection than those foreign born. This study found that among U.S. women, less than 12% reported ever having been told they have had an HPV infection. Epidemiologic findings suggest gaps between ever being told of a previous infection and being diagnosed with a clinically relevant HPV infection. Despite epidemiologic data indicating higher HPV prevalence among those less educated and women of color, these groups were less likely to report ever being told they have an HPV infection than White women, and those with a college degree suggesting communication gaps among these subgroups about HPV infection that might exist. Strategies to address potential gaps in communication among these subgroups can potentially reduce the economic burden and health disparities related to HPV infection.

Examination of orthodontic expenditures and trends in the United States from 1996 to 2016: disparities across demographics and insurance payers

Background

Orthodontics prevent and treat facial, dental, and occlusal anomalies. Untreated orthodontic problems can lead to significant dental public health issues, making it important to understand expenditures for orthodontic treatment. This study examined orthodontic expenditures and trends in the United States over 2 decades.

Methods

This study used data collected by the Medical Expenditure Panel Survey to examine orthodontic expenditures in the United States from 1996 to 2016. Descriptive statistics for orthodontic expenditures were computed and graphed across various groups. Trends in orthodontic expenditures were adjusted to the 2016 United States dollar to account for inflation and deflation over time. Sampling weights were applied in estimating per capita and total expenditures to account for non-responses in population groups.

Results

Total orthodontic expenditures in the United States almost doubled from $11.5 billion in 1996 to $19.9 billion in 2016 with the average orthodontic expenditure per person increasing from $42.69 in 1996 to $61.52 in 2016. Black individuals had the lowest per capita orthodontic visit expenditure at $30.35. Out-of-pocket expenses represented the highest total expenditure and although the amount of out-of-pocket expenses increased over the years, they decreased as a percentage of total expenditures. Public insurance increased the most over the study period but still accounted for the smallest percentage of expenditures. Over the course of the study, several annual decreases were interspersed with years of increased spending

Conclusion

While government insurance expenditure increased over the study period, out of pocket expenditures remained the largest contributor. Annual decreases in expenditure associated with economic downturns and result from the reliance on out-of-pocket payments for orthodontic care. Differences in spending among groups suggest disparities in orthodontic care among the US population.

Men and Oral Health: A Review of Sex and Gender Differences

Sex and gender related health disparities in oral health remain an underappreciated and often over looked aspect of well-being. The goal of this narrative review is to identify sex and gender related oral health disparities by summarizing the current literature related to differences in oral health between men and women. The review identified that men are more likely to: ignore their oral health, have poorer oral hygiene habits, and experience higher rates of periodontal disease, oral cancer, and dental trauma. Men also visit dentists less frequently and compared to women seek oral treatment more often for an acute problem and less often for disease prevention. Women exhibit more positive attitudes about dental visits, greater oral health literacy, and demonstrate better oral health behaviors than men. Men disproportionately develop periodontal diseases due to a combination of biological and gender related reasons including immune system factors, hormone differences, poorer oral hygiene behaviors, and greater tobacco use. There is a male to female ratio of 2:1 for oral cancer, largely attributable to more tobacco use, heavier use of alcohol, and longer sun exposure. Minority men experience a disproportionate burden of oral health disparities because of both their gender and race/ethnic identities. In conclusion, this review identifies several differences between men and women related to oral health and highlights the need for further research to better understand these disparities and how to incorporate them into developing prevention, education and treatment strategies to improve oral health in men.

Development and implementation of a patient assistance fund: a descriptive study

BACKGROUND

The purpose of this descriptive study is to outline the Roseman University of Health Sciences (RUHS) College of Dental Medicines' Patient Assistance Fund development, organization and outcomes. The description and reported results provide insight to others considering similar health professions programs.

METHODS

The Patient Assistance Fund (PAF) affords dental students an opportunity to petition for and obtain financial assistance for their most disadvantaged patients. In this study, two sources of data were collected and used with a quantitative analysis for data collected as part of the PAFs operation and a qualitative analysis to evaluate the patient experiences.

RESULTS

A total of 16 student advocates, consisting of 6 males and 10 females from the D3 and D4 classes made 26 presentations to the PAF board committee. The combined amount requested from the PAF was $47,428.00 ("Cost of Treatment Plan") representing an average request per patient of $1824.15 (range $324.00 to $4070.00). The approved procedures and treatment plans totaled $21,278.36 ("Cost of Approved Procedures") with an average of $818.40 (range $204.00 to $2434.00) per patient. Patients and students expressed a high degree of satisfaction with the program.

CONCLUSIONS

This study provides an overview of the structure, funding sources, expenditures and patient services supported by a dental student managed patient assistance fund. The experiences at RUHS College of Dental Medicine (CODM) suggest that other healthcare professions schools can develop similar type programs that yield benefit both to students and to patients in need.

Prediction of 30-Day Hospital Readmissions for All-Cause Dental Conditions using Machine Learning

Introduction

It is unknown whether patients admitted for all-cause dental conditions (ACDC) are at high risk for hospital readmission, or what are the risk factors for dental hospital readmission.

Objective

We examined the prevalence of, and risk factors associated with, 30-day hospital readmission for patients with an all-cause dental admission. We applied artificial intelligence to develop machine learning (ML) algorithms to predict patients at risk of 30-day hospital readmission.

Methods

This study used data extracted from the 2013 Nationwide Readmissions Database (NRD). There were a total of 11,341 cases for all-cause index admission for dental patients admitted to the hospitals. Descriptive statistics were used to analyze patient characteristics. This study applied five techniques to build risk prediction models and to identify risk factors. Model performance was evaluated using area under the receiver operating characteristic curve (AUC), and accuracy, sensitivity, specificity and precision.

Results

There were 11% of patients admitted for ACDC readmitted within 30 days of hospital discharge. On average, the total charge per patient was $131,004 for those with 30-day readmission (n=1254) and $69,750 for those without readmission (n=10,087). Factors significantly associated with 30-day hospital readmission included total charges, number of diagnoses, age, number of chronic conditions, length of hospital stays, number of procedures, Medicare insurance and Medicaid insurance, and severity of illness. Model performance from all methods was similar with the artificial neural network showing the highest AUC of 0.739.

Conclusion

Our results demonstrate that readmission after hospitalization with ACDC is fairly common. If one-third of the 30-day readmission cases can be avoided, there is a potential annual saving of over $25 million among the twenty-one states represented in the NRD. The ML algorithms can predict hospital readmission in dental patients and should be further tested to aid the reduction of hospital readmission and enhancement of patient-centered care.

In an era of uncertainty: Impact of COVID-19 on dental education

PURPOSE/OBJECTIVES

The coronavirus disease 2019 (COVID-19) pandemic arguably represents the worst public health crisis of the 21^st century. However, no empirical study currently exists in the literature that examines the impact of the COVID-19 pandemic on dental education. This study evaluated the impact of COVID-19 on dental education and dental students' experience.

METHODS

An anonymous online survey was administrated to professional dental students that focused on their experiences related to COVID-19. The survey included questions about student demographics, protocols for school reopening and student perceptions of institutional responses, student concerns, and psychological impacts.

RESULTS

Among the 145 respondents, 92.4% were pre-doctoral dental students and 7.6% were orthodontic residents; 48.2% were female and 12.6% students lived alone during the school closure due to the pandemic. Students' age ranged from 23 to 39 years. Younger students expressed more concerns about their emotional health (P = 0.01). In terms of the school's overall response to COVID-19, 73.1% students thought it was effective. The majority (83%) of students believed that social distancing in school can minimize the development of COVID-19. In general, students felt that clinical education suffered after transitioning to online but responded more positively about adjustments to other online curricular components.

CONCLUSIONS

The COVID-19 pandemic significantly impacted dental education. Our findings indicate that students are experiencing increased levels of stress and feel their clinical education has suffered. Most students appear comfortable with technology adaptations for didactic curriculum and favor masks, social distancing, and liberal use of sanitizers.

Men and COVID-19: A Pathophysiologic Review

Coronaviruses are single-stranded ribonucleic acid viruses that can cause illnesses in humans ranging from the common cold to severe respiratory disease and even death.In March 2020, the World Health Organization declared the 2019 novel coronavirus disease (COVID-19) caused by the severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) as the first pandemic. Compared to women, most countries with available data report that men with COVID-19 have greater disease severity and higher mortality. Lab and animal data indicate that men respond differently to the SARS-CoV-2 infection, offering possible explanations for the epidemiologic observations. The plausible theories underlying these observations include sex-related differences in angiotensin-converting enzyme 2 receptors, immune function, hormones, habits, and coinfection rates.In this review we examine these factors and explore the rationale as to how each may impact COVID-19. Understanding why men are more likely to experience severe disease can help in developing effective treatments, public health policies, and targeted strategies such as early recognition and aggressive testing in subgroups.

Social Network Analysis of COVID-19 Sentiments: Application of Artificial Intelligence

Background

The coronavirus disease (COVID-19) pandemic led to substantial public discussion. Understanding these discussions can help institutions, governments, and individuals navigate the pandemic.

Objective

The aim of this study is to analyze discussions on Twitter related to COVID-19 and to investigate the sentiments toward COVID-19.

Methods

This study applied machine learning methods in the field of artificial intelligence to analyze data collected from Twitter. Using tweets originating exclusively in the United States and written in English during the 1-month period from March 20 to April 19, 2020, the study examined COVID-19–related discussions. Social network and sentiment analyses were also conducted to determine the social network of dominant topics and whether the tweets expressed positive, neutral, or negative sentiments. Geographic analysis of the tweets was also conducted.

Results

There were a total of 14,180,603 likes, 863,411 replies, 3,087,812 retweets, and 641,381 mentions in tweets during the study timeframe. Out of 902,138 tweets analyzed, sentiment analysis classified 434,254 (48.2%) tweets as having a positive sentiment, 187,042 (20.7%) as neutral, and 280,842 (31.1%) as negative. The study identified 5 dominant themes among COVID-19–related tweets: health care environment, emotional support, business economy, social change, and psychological stress. Alaska, Wyoming, New Mexico, Pennsylvania, and Florida were the states expressing the most negative sentiment while Vermont, North Dakota, Utah, Colorado, Tennessee, and North Carolina conveyed the most positive sentiment.

Conclusions

This study identified 5 prevalent themes of COVID-19 discussion with sentiments ranging from positive to negative. These themes and sentiments can clarify the public’s response to COVID-19 and help officials navigate the pandemic.

Health and dental care expenditures in the United States from 1996 to 2016

Introduction

As total health and dental care expenditures in the United States continue to rise, healthcare disparities for low to middle-income Americans creates an imperative to analyze existing expenditures. This study examined health and dental care expenditures in the United States from 1996 to 2016 and explored trends in spending across various population subgroups.

Methods

Using data collected by the Medical Expenditure Panel Survey, this study examined health and dental care expenditures in the United States from 1996 to 2016. Trends in spending were displayed graphically and spending across subgroups examined. All expenditures were adjusted for inflation or deflation to the 2016 dollar.

Results

Both total health and dental expenditures increased between 1996 and 2016 with total healthcare expenditures increasing from $838.33 billion in 1996 to $1.62 trillion in 2016, a 1.9-fold increase. Despite an overall increase, total expenditures slowed between 2004 and 2012 with the exception of the older adult population. Over the study period, expenditures increased across all groups with the greatest increases seen in older adult health and dental care. The per capita geriatric dental care expenditure increased 59% while the per capita geriatric healthcare expenditure increased 50% across the two decades. For the overall US population, the per capita dental care expenditure increased 27% while the per capita healthcare expenditure increased 60% over the two decades. All groups except the uninsured experienced increased dental care expenditure over the study period.

Conclusions

Healthcare spending is not inherently bad since it brings benefits while exacting costs. Our findings indicate that while there were increases in both health and dental care expenditures from 1996 to 2016, these increases were non-uniform both across population subgroups and time. Further research to understand these trends in detail will be helpful to develop strategies to address health and dental care disparities and to maximize resource utilization.

Mastery learning in a bachelor's of nursing program: the Roseman University of Health Sciences experience

BACKGROUND

Roseman University of Health Sciences (RUHS) developed and delivers a mastery learning curriculum designed for students to acquire the knowledge and skills to become competent nurses. Despite a trend in nursing education to adopt competency-based education (CBE) models, there is little in the nursing literature about programs based on a mastery model. The aim of this study is to describe an undergraduate nursing program built on a mastery learning model and to report on program outcome measures.

METHODS

The 18-month BSN nursing program is divided into blocks, varying in length and focusing on a single subject. Students must demonstrate mastery, defined as ≥90% on an assessment, to pass a block. Recognizing the critical nature of health care, educators seek methods to assure that practitioners become competent to perform the services they provide.Program outcomes reported include comparisons to national standards and RUHS student exit survey data.

RESULTS

From 2013 to 2017 the RUHS College of Nursing students' pass rates ranged from 82 to 97% for the National Council Licensure Examination exam compared to national pass rates between 81.8-84.5% during the same time frame. The program completion rate ranged from 86 to 100% and employment rates exceeded accreditation standards. Students reported overall satisfaction with their education as 4.38 and with the block system as 4.74 (5 point Likert scale).

CONCLUSIONS

Roseman University's mastery learning model appears successful as measured by high levels of student satisfaction, outcomes on exams, and degree completion when compared to national averages. The results suggest that other nursing and health profession's programs can develop a successful mastery based learning model.

The state of the science of interprofessional collaborative practice: A scoping review of the patient health-related outcomes based literature published between 2010 and 2018

Introduction

If interprofessional collaborative practice is to be an important component of healthcare reform, then an evidentiary base connecting interprofessional education to interprofessional practice with significantly improved health and healthcare outcomes is an unconditional necessity. This study is a scoping review of the current peer reviewed literature linking interprofessional collaborative care and interprofessional collaborative practice to clearly identified healthcare and/or patient health-related outcomes. The research question for this review was: What does the evidence from the past decade reveal about the impact of Interprofessional collaborative practice on patient-related outcomes in the US healthcare system?

Materials and methods

A modified preferred reporting items for systematic reviews and meta-analyses (PRISMA) approach was followed.

Results

Of an initial 375 articles retrieved 20 met review criteria. The most common professions represented in the studies reviewed were physicians, pharmacists and nurses. Primary care was the most common care delivery setting and measures related to chronic disease the most commonly measured outcomes. No study identified negative impacts of interprofessional collaborative practice. Eight outcome categories emerged from a content analysis of the findings of the reviewed studies.

Conclusions

The results suggest a need for more research on the measurable impact of interprofessional collaborative practice and/or care on patient health-related outcomes to further document its benefits and to explore the models, systems and nature of collaborations that best improve population health, increase patient satisfaction, and reduce cost of care.

Dental care utilization: examining the associations between health services deficits and not having a dental visit in past 12 months

Background

A growing literature supports the contention that closing the divide between dental and medical care can improve access to and coordination of patient care. Health service deficits (HSDs) entail: no routine medical exam, no personal healthcare provider (HCP), no health insurance, and/or delaying medical care because of cost all within the last 12 months. Examining the associations between HSDs and dental care utilization could inform strategies and interventions aimed at narrowing the gap between the medical and dental professions. This study explored whether HSDs are associated with not having a dental care visit within the last 12 months. In addition, the study sought to provide an updated analysis of the characteristics and factors associated with dental care utilization.

Methods

Two thousand sixteen Behavioral Risk Factor Surveillance System survey data were analyzed using bivariate and multivariable techniques. The outcome variable for this study was: last dental visit was longer than 12 months ago.

Results

US adults without healthcare insurance, without a personal HCP, who had delayed medical care because of cost, and who had their last routine medical visit longer than 12 months ago had greater odds of not having a dental visit within the last 12 months. Further, this study identified disparities in dental care utilization among males, rural residents, those earning less than $50,000 per year, Non-Hispanic Blacks and Non-Hispanic other races. Individuals with six or more and/or all of their permanent teeth removed and current smokers also had greater odds of not having had a dental care visit in the past 12 months.

Conclusions

Findings suggest that a stronger integration of medical and dental care might increase dental care utilization. In addition, persistent disparities in dental care utilization remain for several demographic groups. Targeted interventions offer the promise of helping achieve HP 2020 goals for improved oral health.

A scoping review exploring the opioid prescribing practices of US dental professionals

BACKGROUND

The prescribing practices of dental professionals may play an important role in the opioid epidemic. The authors performed a scoping review of the current original research literature on dental professionals' prescribing practices for opioid analgesics published from 2000 through 2017.

TYPES OF STUDIES REVIEWED

With the use of a modified Preferred Reporting Items for Systematic Reviews and Meta-Analyses approach, the inclusion criteria entailed published articles written in English that had an opioid focus, had a dental health care professional prescriber, entailed a US setting, were peer reviewed, had an identified data source, were not review articles, and were not opinion articles. Five databases were searched to identify relevant literature.

RESULTS

Of 221 articles, 18 met the inclusion criteria. Eight distinct and mutually exclusive themes emerged from these studies: impact of patient demographic characteristics on opioid prescribing, comparison of opioid prescribing by different provider type, quantity of opioids prescribed and consumed, types of opioids prescribed by dental professionals, assessment of self-reported opioid prescribing, opioid prescriptions by procedure, impact of pharmacy integration into dental practice, and implementation of risk mitigation strategies.

CONCLUSIONS AND PRACTICAL IMPLICATIONS

There is a surprising paucity of research that investigated the prescribing patterns of dentists. Available research suggests that dental practice does not always align with proposed guidelines for opioid prescribing. Some studies that explored interventions found changes in prescribing, suggesting the potential benefit of developing practical strategies targeted to dental providers who prescribed opioids.

A scoping review of opioid misuse in the rural United States

INTRODUCTION

This study is a scoping review of the original research literature onthe misuse of opioids in the rural United States (US) and maps theliterature of interest to address the question: What does theoriginal research evidence reveal about the misuse of opioids inrural US communities?

METHODS

This study used a modified preferred reporting items for systematicreviews and meta-analyses (PRISMA) approach which is organized byfive distinct elements or steps: beginning with a clearly formulatedquestion, using the question to develop clear inclusion criteria toidentify relevant studies, using an approach to appraise the studiesor a subset of the studies, summarizing the evidence using anexplicit methodology, and interpreting the findings of the review.

RESULTS

The initial search yielded 119 peer reviewed articles and aftercoding, 41 papers met the inclusion criteria. Researcher generatedsurveys constituted the most frequent source of data. Most studieshad a significant quantitative dimension to them. All the studieswere observational or cross-sectional by design.

CONCLUSIONS

This analysis found an emerging research literature that hasgenerated evidence supporting the claim that rural US residents andcommunities suffer a disproportionate burden from the misuseof opioidscompared to their urban or metropolitan counterparts.

A review of mastery learning: The roseman model as an illustrative case

BACKGROUND

An educational method gaining acceptance in health profession's training is mastery learning. Mastery learning requires learners to demonstrate essential knowledge and skills measured against rigorously set standards without regard to time. The key elements of mastery learning include focus on a single subject, short curricular blocks, setting specific objectives, using frequent feedback, deliberative practice, and demonstrating mastery before moving onto the next subject. Roseman University of the Health Sciences College of Pharmacy (COP) developed and delivered an accelerated mastery learning curriculum designed to develop knowledge and skills through active learning.

METHODS

The COP uses a mastery model for its PharmD program. The didactic curriculum is divided into 2-week assessment blocks focusing on a single subject. Students must demonstrate mastery, defined as ≥90% on an assessment, to pass a block. Students failing a block assessment receive feedback and a second opportunity to pass. Students failing their repeat assessment continue onto the next block, but require summer remediation before moving onto the next year.

RESULTS

National pass rates for the US pharmacy board examination ranged between 92.6% and 96.9% during the 2010-2015 period, while the COP scores ranged from 93.0% to 99.0% and fell below national pass rates on only one occasion. The attrition rate was 6.5%, below the national rate of 10.8%. Students reported an overall satisfaction with their education of 3.82 (Likert scale 1-5) and 4.04 for the block system.

DISCUSSION

Overall, the Roseman University mastery model is successful. Students report high levels of satisfaction and outcomes on examinations and attrition compares favorably to national averages.

A Population-Based, Cross-Sectional Study Examining Health Services Deficits of US Veterans Using 2014 Behavioral Risk Factor Surveillance System Data: Is Rural Residency an Independent Risk Factor after Controlling for Multiple Covariates?

Introduction: In 2014, it was reported that there was a backlog of an estimated 1.2 million claims nationwide at the United States Veterans Administration (VA). This ecological occurrence opened up a space for asking and answering some important questions about health service deficits (HSD) of US veterans, which is the focus of the research reported on in this paper. The purpose of this study was to ascertain if rural veterans were more likely to experience HSDs than urban military veterans after controlling for a number of covariates. Methods: Bivariate and multivariate data analysis strategies were used to examine 2014 Behavioral Risk Factor Surveillance System (BRFSS) survey data. HSD was the dependent variable. Results: Two multivariate models were tested. The first logistic regression analysis yielded that rural veterans had higher odds of having at least one HSD. The second yielded that rural US veterans in 2014 who had higher odds of having at least one HSD were: 18-64 years of age, unemployed seeking employment, living in households with annual incomes lower than $75,000, without a university degree, not part of a married or unmarried couple, a current smoker, and/or a binge drinker within the last 30 days. Conclusions: The study described here fills identified epidemiological gaps in our knowledge regarding rural US military veterans and HSDs. The findings are not only interesting but important, and should be used to inform interventions to reduce HSDs for rural veterans.

Periodontitis: a global disease and the primary care provider's role

Individuals who regularly visit a primary care provider (PCP) may not see a dentist, creating opportunities for PCPs to improve oral health. However, a lack of expertise among PCPs may limit their impact to improve public oral health. Using a non-systematic literature review, this article summarises the relevant literature about periodontitis. Periodontitis affects 10% to -15% of the world's population. Caused by bacterial inflammation in gingival pockets, periodontal disease can destroy tissues surrounding the teeth. Factors linked to periodontal disease include diabetes, atherosclerosis and smoking. Good oral hygiene is important for both prevention and treatment. Mechanical removal of gingival irritants by scaling and root planing combined with adjunctive antimicrobial therapy are first-line treatment options. Surgery is indicated when healthy levels of gingival tissue are not attained from first-line treatments. By understanding the fundamentals of periodontitis the primary care provider can educate patients, promote healthy oral health behaviours and appropriately refer patients with signs and symptoms of periodontal disease.

Clinical implications of aging

Figure summarizes the major changes of aging and some key ways these changes affect pages. Though many changes occur with aging, under normal or resting conditions, there is usually very little functionally that is diminished solely on the basis of aging. The net effects are reductions in reserve capacity and placing geriatric patients at higher risk for adverse consequences related to medications and diseases. Interactions between lifestyle factors, such as exercise, diet, and environmental exposures, have a large impact on aging and lead to great individual variability. The interplay between these environmental factors, aging, and development of chronic diseases multiply the amount of variation seen as individual's age.

A cross-sectional study on health differences between rural and non-rural U.S. counties using the County Health Rankings

Background

By examining 2013 County Health Rankings and Roadmaps data from the University of Wisconsin and the Robert Wood Johnson Foundation, this paper seeks to add to the available literature on health variances between United States residents living in rural and non-rural areas. We believe this is the first study to use the Rankings data to measure rural and urban health differences across the United States and therefore highlights the national need to address shortfalls in rural healthcare and overall health. The data indicates that U.S. residents living in rural counties are generally in poorer health than their urban counterparts.

Methods

We used 2013 County Health Rankings data to evaluate differences across the six domains of interest (mortality, morbidity, health behaviors, clinical care, social and economic factors, and physical environment) for rural and non-rural U.S. counties. This is a cross-sectional study employing chi-square analysis and logit regression.

Results

We found that residents living in rural U.S. counties are more likely to have poorer health outcomes along a variety of measurements that comprise the County Health Rankings’ indexed domains of health quality. These populations have statistically significantly (p ≤ 0.05) lower scores in such areas as health behavior, morbidity factors, clinical care, and the physical environment. We attribute the differences to a variety of factors including limitations in infrastructure, socioeconomic differences, insurance coverage deficiencies, and higher rates of traffic fatalities and accidents.

Discussions

The largest differences between rural and non-rural counties were in the indexed domains of mortality and clinical care.

Conclusions

Our analysis revealed differences in health outcomes in the County Health Rankings’ indexed domains between rural and non-rural U.S. counties. We also describe limitations and offer commentary on the need for more uniform measurements in the classification of the terms rural and non-rural. These results can influence practitioners and policy makers in guiding future research and when deciding on funding allocation.

Nursing home quality: a comparative analysis using CMS Nursing Home Compare data to examine differences between rural and nonrural facilities

BACKGROUND

Advances in medicine and an aging US population suggest that there will be an increasing demand for nursing home services. Although nursing homes are highly regulated and scrutinized, their quality remains a concern and may be a greater issue to those living in rural communities. Despite this, few studies have investigated differences in the quality of nursing home care across the rural-urban continuum. The purpose of this study was to compare the quality of rural and nonrural nursing homes by using aggregated rankings on multiple quality measures calculated by the Centers for Medicare and Medicaid Services and reported on their Nursing Home Compare Web site.

METHODS

Independent-sample t tests were performed to compare the mean ratings on the reported quality measures of rural and nonrural nursing homes. A linear mixed binary logistic regression model controlling for state was performed to determine if the covariates of ownership, number of beds, and geographic locale were associated with a higher overall quality rating.

RESULTS

Of the 15,177 nursing homes included in the study sample, 69.2% were located in nonrural areas and 30.8% in rural areas. The t test analysis comparing the overall, health inspection, staffing, and quality measure ratings of rural and nonrural nursing homes yielded statistically significant results for 3 measures, 2 of which (overall ratings and health inspections) favored rural nursing homes. Although a higher percentage of nursing homes (44.8%-42.2%) received a 4-star or higher rating, regression analysis using an overall rating of 4 stars or higher as the dependent variable revealed that when controlling for state and adjusting for size and ownership, rural nursing homes were less likely to have a 4-star or higher rating when compared with nonrural nursing homes (OR = .901, 95% CI 0.824-0.986).

CONCLUSIONS

Mixed model logistic regression analysis suggested that rural nursing home quality was not comparable to that of nonrural nursing homes. When controlling for state and adjusting for nursing home size and ownership, rural nursing homes were not as likely to earn a 4-or higher star quality rating as nonrural nursing homes.

Health service deficits and school-aged children with asthma: a population-based study using data from the 2007-2008 National Survey of Child Health

BACKGROUND

Asthma is one of the most common and costly illnesses of childhood. This study addresses health services deficits experienced by school-aged children with asthma.

METHODS

Analyzing data from the 2007-2008 National Survey of Child Health, this cross-sectional study used household income, race/ethnicity, and geographic residency as the primary independent variables and health service deficits as the dependent variable.

RESULTS

Multivariate analysis yielded that other/multiracial (odds ratio [OR], 1.234; 95% confidence interval [CI], 1.226-1.242) and Hispanic (OR, 2.207; 95% CI, 1.226-1.242) school-aged children with asthma had greater odds of having health services deficits as did both urban (OR, 1.106; 95% CI, 1.099-1.113) and rural (OR, 1.133; 95% CI, 1.124-1.142) school-aged children with asthma. Children with either moderate (OR, 1.195; 95% CI, 1.184-1.207) or mild (OR, 1.445; 95% CI, 1.431-1.459) asthma had greater odds of having a health services deficit than those with severe asthma. Low-income school-aged children with asthma had greater odds of having a health services deficit than high-income children (OR, 1.031; 95% CI, 1.026-1.036). At lesser odds of having a health service deficit were those who were African American, of middle-range income, male, or who were school-aged children with asthma in good to excellent health.

CONCLUSION

Both African American and other/multiracial school-aged children were at greater risk of having asthma than either Caucasian or Hispanic children. Three vulnerable subgroups of school-aged children with asthma-rural, Hispanic, and those of low income were the most likely to have health service deficits.

A cross-sectional study of US rural adults' consumption of fruits and vegetables: do they consume at least five servings daily?

Background

Rural residents are increasingly identified as being at greater risk for health disparities. These inequities may be related to health behaviors such as adequate fruits and vegetable consumption. There is little national-level population-based research about the prevalence of fruit and vegetable consumption by US rural population adults. The objective of this study was to examine the prevalence differences between US rural and non-rural adults in consuming at least five daily servings of combined fruits and vegetables.

Methods

Cross-sectional analysis of weighted 2009 Behavioral Risk Factor Surveillance Survey (BRFSS) data using bivariate and multivariate techniques. 52,259,789 US adults were identified as consuming at least five daily servings of fruits and vegetables of which 8,983,840 were identified as living in rural locales.

Results

Bivariate analysis revealed that in comparison to non-rural US adults, rural adults were less likely to consume five or more daily servings of fruits and vegetables (OR = 1.161, 95% CI 1.160-1.162). Logistic regression analysis revealed that US rural adults consuming at least five daily servings of fruits and vegetables were more likely to be female, non-Caucasian, married or living with a partner, living in a household without children, living in a household whose annual income was > $35,000, and getting at least moderate physical activity. They were also more likely to have a BMI of <30, have a personal physician, have had a routine medical exam in the past 12 months, self-defined their health as good to excellent and to have deferred medical care because of cost. When comparing the prevalence differences between rural and non-rural US adults within a state, 37 States had a lower prevalence of rural adults consuming at least five daily servings of fruits and vegetables and 11 States a higher prevalence of the same.

Conclusions

This enhanced understanding of fruit and vegetable consumption should prove useful to those seeking to lessen the disparity or inequity between rural and non-rural adults. Additionally, those responsible for health-related planning could benefit from the knowledge of how their state ranks in comparison to others vis-à-vis the consumption of fruits and vegetables by rural adults---a population increasingly being identified as one at risk for health disparities.

Adequacy of diabetes care for older U.S. rural adults: a cross-sectional population based study using 2009 BRFSS data

Background

In the U.S. diabetes prevalence estimates for adults ≥ 65 years exceed 20%. Rural communities have higher proportions of older individuals and health disparities associated with rural residency place rural communities at risk for a higher burden from diabetes. This study examined the adequacy of care received by older rural adults for their diabetes to determine if older rural adults differed in the receipt of adequate diabetes care when compared to their non-rural counterparts.

Methods

Cross-sectional data from the 2009 Behavioral Risk Factor Surveillance Survey were examined using bivariate and multivariate analytical techniques.

Results

Logistic regression analysis revealed that older rural adults with diabetes were more likely to receive less than adequate care when compared to their non-rural counterparts (OR = 1.465, 95% CI: 1.454-1.475). Older rural adults receiving less than adequate care for their diabetes were more likely to be: male, non-Caucasian, less educated, unmarried, economically poorer, inactive, a smoker. They were also more likely to: have deferred medical care because of cost, not have a personal health care provider, and not have had a routine medical check-up within the last 12 months.

Conclusion

There are gaps between what is recommended for diabetes management and the management that older individuals receive. Older adults with diabetes living in rural communities are at greater risk for less than adequate care when compared to their non-rural counterparts. These results suggest the need to develop strategies to improve diabetes care for older adults with diabetes and to target those at highest risk.

Morinda citrifolia L. (noni) improves the Quality of Life in adults with Osteoarthritis

Background: Morinda citrifolia Linn (noni), as a “pain killer”, has been used as a traditional medicine by Polynesians for over 2000 years. It was reported to have a broad range of therapeutic effects including analgesic and anti-inflammation. The in-vitro and in vivoanti-inflammatory and analgesic properties of noni juice (NJ) suggest that NJ may be a useful adjunctive treatment for osteoarthritis (OA). In this pilot study we explored whether NJ improves the symptoms and Quality of Life (QoL) for adults with OA. We also sought to evaluate the tolerability and safety of NJ for patients with OA in a primary care setting. Methods: This was an open label three-month intervention pilot study. Data were collected by pre/post intervention survey and laboratory testing. Inclusion criteria were: adults of both sexes aged 40 to 75, with a diagnosis of OA on the hip or knee by x-ray examination provided by their primary care physician, not on prescription medicine for OA, and who were willing to drink 3 oz of NJ a day for 90 days. Results: Of the 64 questions measuring different aspects of QoL asked on the pre/post survey, 49 (77%) had significant pre/post mean scale differences as measured by independent t-test. The OA patients reported being significantly more satisfied with their current health conditions including mobility, walking and bending, hand, finger, and arm functions, household tasks, social activity, arthritis pain, work ability, level of tension, and mood. The study participants were also more positive about their future health and reported taking less over-the-counter (OTC) pain relievers. Pre/post laboratory testing including: lipid panel, liver and kidney functions were in the normal ranges. High Sensitive C Reactive Protein (hsCRP), an inflammatory biomarker, was reduced by 10% after the intervention. Conclusion: As a nutritional supplement, NJ demonstrated a potential therapeutic effect and improved the symptoms and the QoL for adults with OA. A larger, double blinded, and placebo controlled clinical trial study is needed to confirm these benefits. NJ has the potential to become an adjunctive therapy for OA patients. Clinical trial registration number: NCT01070264.Key words: Morinda citrifolia (noni), Noni juice (NJ), Osteoarthritis, Quality of life (QoL), pain scales

The impact of rural training experiences on medical students: a critical review

PURPOSE

To address the growing shortage of rural physicians, several medical schools have developed rural training experiences for their students. However, little is known about the educational impact of these experiences. Thus, the authors conducted a critical review of North American studies examining medical student outcomes associated with rural training experiences.

METHOD

A comprehensive search strategy was used to identify studies about undergraduate medical education in a rural setting, searching PubMed from 1966 to June 2009. The researchers evaluated titles and abstracts to identify publications that appeared to report measures associated with undergraduate medical school rural training experience. Only those studies with a measurable outcome such as career choice, practice location, clinical competency, and student satisfaction were analyzed.

RESULTS

The review identified a total of 72 studies. Most were single-cohort studies or cohort studies with control groups, with career choice and practice location the most commonly reported measure. The majority reported that rural experiences influenced students toward primary care specialties and to consider rural practice. Studies using self-report found that students generally valued the experience and had a high degree of satisfaction.

CONCLUSIONS

This review shows that placement in rural settings is a positive learning experience that students and preceptors value. Although the evidence supports that these rotations influence practice site and career choice, it is not clear whether they reinforce preexisting interest or have the ability to motivate previously uninterested students to consider careers in primary care or rural medicine.

Determining an association between having a medical home and uncontrolled asthma in US school-aged children: a population-based study using data from the National Survey of Children's Health

INTRODUCTION

The American Academy of Pediatrics and the American Academy of Family Physicians believe that infants, children, and adolescents benefit from having a medical home, characterized by accessible, continuous, comprehensive, family-centered, coordinated, compassionate, and culturally effective care. Several studies suggest that patients with asthma benefit from having a medical home. However, no national study has been conducted examining the relationships between having a medical home and asthma control in school-aged children with asthma. The purpose of this study was to examine the hypothesis that having an adequate medical home is protective against uncontrolled asthma in children.

METHODS

To test this hypothesis, cross-sectional data from the 2003-2004 National Survey of Children's Health were analyzed. Analyses entailed creating the variables "medical home" as well as "uncontrolled asthma" from multiple variables. Multivariate analysis was performed using children with uncontrolled asthma as the dependent variable.

RESULTS

The logistic regression model performed yielded that school-aged children with uncontrolled asthma were more likely to: speak a primary language other than English (OR, 1.069; 95% CI, 1.045-1.093); live in households with incomes<100% of the federal poverty level (FPL) (OR, 1.826; 95% CI, 1.810-1.842); not have health insurance (OR, 2.296; 95% CI, 2.263-2.330); live in rural rather than metropolitan areas (OR, 1.275; 95% CI, 1.262-1.287); and be non-Caucasian (OR, 2.067; 95% CI, 2.050-2.085). Multivariate analysis also yielded that children with uncontrolled asthma were more likely to have a medical home (OR, 1.138; 95% CI, 1.128-1.148).

CONCLUSIONS

After controlling for possible confounding variables, this study did not detect an association between having a medical home and asthma control for children with asthma aged 5 to 17 years. Additional research should examine the relationship between variables, such as poverty, place of residence, health insurance status, and the medical home, not only in the instance of uncontrolled asthma, but for other childhood health conditions.

Disparities in stroke symptomology knowledge among US midlife women: an analysis of population survey data

OBJECTIVE

A higher prevalence of stroke appears to exist among women aged 45 to 54 years compared with same-aged men. In addition, compared with their male counterparts, women have a threefold risk of delay in hospital arrival time. Inadequate knowledge of stroke symptomology may account for this disparity in hospital arrival time. We assessed current knowledge of stroke symptoms among US women in midlife and examined the relationship between symptom knowledge and race, income, education, deferring medical care, having a primary care provider, and health insurance status.

METHODS

This was a cross-sectional study analyzing 2003-2005 Behavioral Risk Factor Surveillance Survey data. From the 7 stroke symptom knowledge questions asked on the survey, a Stroke Knowledge Score was computed for each respondent. Multivariate data analysis techniques were used.

RESULTS

Multivariate analysis revealed that US women aged 45 to 54 years with low stroke knowledge scores were: more likely to be Hispanic (OR = 4.44, CI = 4.37-4.51) or African-American (OR = 2.55, CI = 2.52-2.58); have less than a high school education (OR = 2.67, CI = 2.63-2.71); have an annual household income <$35,000 (OR = 2.00, CI = 1.98-2.02); have a primary care provider (OR = 1.78, CI = 1.75-1.81); have deferred medical care because of cost (OR = 1.35, CI = 1.33,1.36); and are less likely to have health insurance (OR = 0.70, CI = 0.67- 0.71).

CONCLUSIONS

Disparities in stroke symptom knowledge exist along racial/ethnic and socioeconomic lines. Nevertheless, mid-life women have high levels of knowledge about the symptoms of stroke, hence strategies aimed at encouraging women to act promptly when experiencing symptoms could yield more benefit in reducing delays in stroke treatment than educational programs.

Comparison of US accredited and non-accredited rural critical access hospitals

BACKGROUND

US critical access hospitals play an integral role in rural healthcare. Accreditation may be helpful in assuring that these hospitals provide high-quality care.

OBJECTIVE

To determine whether quality measures used in the US Centers for Medicare and Medicaid Services Hospital Compare database differed for critical access hospitals based on Joint Commission on Accreditation of Healthcare Organizations accreditation status.

RESEARCH DESIGN

Cross-sectional with t-test statistics computed on weighted data to ascertain statistically significant differences (P < or = 0.01).

MAIN OUTCOME MEASURE

Differences between accredited and non-accredited rural critical access hospitals on quality care indicators related to acute myocardial infarction, heart failure, pneumonia and surgical infection.

SUBJECTS

US critical access hospitals.

RESULTS

The differences between accredited and non-accredited rural critical access hospitals for 4 out of 16 hospital quality indicators were statistically significant (P < or = 0.01) and favored accredited hospitals. Also, accredited hospitals were more likely to rank in the top half of hospitals for 6 of the 16 quality measures.

CONCLUSIONS

The results indicate that in the setting of critical access hospitals, external accreditation appears to result in modestly better performance.

Who is providing and who is getting asthma patient education: an analysis of 2001 National Ambulatory Medical Care Survey data

Patient education in asthma management is important; however, there is little known about the characteristics of patients receiving asthma education or how often primary care physicians provide it. The objective of the study was to identify the characteristics of patients receiving asthma education. It was a cross-sectional study using 2001 National Ambulatory Medical Care Survey data. The study included 1230 physicians providing office-based ambulatory medical care in the United States. Patients in the study (weighted n=11,279,952) were those diagnosed with asthma based on International Classification of Diseases, 9th Revision code receiving care from a pediatrician, internist or a family physician. Main and secondary outcome measures were asthma education ordered or provided. Multivariate analysis indicated that asthma patients receiving education were more likely to have office visits >20 min [odds ratio (OR) = 3.934], be seen for an acute reason (OR = 2.268), be seen in follow-up rather than an initial visit (OR = 1.780), live in rural rather than metropolitan areas (OR = 1.507), have public rather than private insurance (OR = 1.276) and be seen in privately owned practices (OR = 1.248). Bivariate analyses indicated that patients seeing family physicians were more likely than those seeing internists or pediatricians to receive education. Patient education was not uniformly provided. Family physicians provided more asthma education than either pediatricians or internists. Future research should investigate the quality of education provided.

Disparities in adult African American women's knowledge of heart attack and stroke symptomatology: an analysis of 2003-2005 Behavioral Risk Factor Surveillance Survey data

BACKGROUND

Heart disease and stroke are the first and third leading causes of death of American women, respectively. African American women experience a disproportionate burden of these diseases compared with Caucasian women and are also more likely to delay seeking treatment for acute symptoms. As knowledge is a first step in seeking care, this study examined the knowledge of heart attack and stroke symptoms among African American women.

METHODS

This was a cross-sectional study analyzing 2003-2005 Behavioral Risk Factor Surveillance Survey (BRFSS) data. A composite heart attack and stroke knowledge score was computed for each respondent from the 13 heart attack and stroke symptom knowledge questions. Multivariate logistic regression was performed using low scores on the heart attack and stroke knowledge questions as the dependent variable.

RESULTS

Twenty percent of the respondents were low scorers, and 23.8% were high scorers. Logistic regression analysis showed that adult African American women who earned low scores on the composite heart attack and stroke knowledge questions (range 0-8 points) were more likely to be aged 18-34 (OR = 1.36, CI 1.35, 1.37), be uninsured (OR = 1.32, CI 1.31, 1.33), have an annual household income <$35,000 (OR = 1.46, CI 1.45, 1.47), and have a primary healthcare provider (OR = 1.22, CI 1.20, 1.23).

CONCLUSIONS

The findings indicated that knowledge of heart attack and stroke symptoms varied significantly among African American women, depending on socioeconomic variables. Targeting interventions to African American women, particularly those in lower socioeconomic groups, may increase knowledge of heart attack and stroke symptoms, subsequently improving preventive action taken in response to these conditions.

Primary prevention of overweight and obesity: an analysis of national survey data

BACKGROUND

Obesity is rapidly approaching tobacco as the leading cause of preventable morbidity and mortality. Health care providers have the opportunity to address this through primary prevention strategies.

OBJECTIVE

To assess whether health care professionals provide primary prevention for overweight and obesity by examining the percentage of healthy-weight (body mass index [BMI] = 18.5-24.9 kg/m(2)) individuals who report being advised to maintain a healthy weight.

DESIGN

Cross-sectional analysis of the 2003 Behavioral Risk Factor Surveillance Survey data.

PARTICIPANTS

Noninstitutionalized U.S. adults >18 years of age.

RESULTS

Among healthy BMI respondents, only 2.6% reported receiving primary prevention. Logistic regression analyses yielded that healthy-weight adults receiving primary prevention were more likely to report: being 18-49 years of age, annual household incomes <$35,000, having at least 1 comorbidity, having a health care provider, changed eating habits to include less fat or fewer calories, and using physical activity to maintain or lose weight. Men were also more likely to receive primary prevention.

CONCLUSIONS

Only a very small proportion of healthy-weight adults received primary prevention, which suggests that physicians are missing opportunities to help address the epidemic of adult obesity in the US.