Development and Evaluation of a Clinician-Vetted Dementia Caregiver Resources Website: Mixed Methods Approach

BACKGROUND

About 11 million Americans are caregivers for the 6.7 million Americans currently living with dementia. They provide over 18 billion hours of unpaid care per year, yet most have no formal dementia education or support. It is extremely difficult for clinicians to keep up with the demand for caregiver education, especially as dementia is neurodegenerative in nature, requiring different information at different stages of the disease process. In this digital age, caregivers often seek dementia information on the internet, but clinicians lack a single, reliable compendium of expert-approved digital resources to provide to dementia caregivers.

OBJECTIVE

Our aim was to create a dementia caregiver resources website to serve as a hub for user-friendly, high-quality, and expert-reviewed dementia educational resources that clinicians can easily supply to family caregivers of people with dementia.

METHODS

An interdisciplinary website development team (representing dementia experts from occupational therapy, nursing, social work, geriatrics, and neurology) went through 6 iterative steps of website development to ensure resource selection quality and eligibility rigor. Steps included (1) resource collection, (2) creation of eligibility criteria, (3) resource organization by topic, (4) additional content identification, (5) finalize resource selection, and (6) website testing and launch. Website visits were tracked, and a 20-item survey about website usability and utility was sent to Veterans Affairs tele-geriatrics interdisciplinary specialty care groups.

RESULTS

Following website development, the dementia caregiver resource website was launched in February 2022. Over the first 9 months, the site averaged 1100 visits per month. The 3 subcategories with the highest number of visits were "general dementia information," "activities of daily living," and "self-care and support." Most (44/45, 98%) respondents agreed or strongly agreed that the website was easy to navigate, and all respondents agreed or strongly agreed that the resources were useful.

CONCLUSIONS

The iterative process of creating the dementia caregiver resources website included continuous identification, categorization, and prioritization of resources, followed by clinician feedback on website usability, accessibility, and suggestions for improvement. The website received thousands of visits and positive clinician reviews in its first 9 months. Results demonstrate that an expert-vetted, nationally, and remotely available resource website allows for easy access to dementia education for clinicians to provide for their patients and caregivers. This process of website development can serve as a model for other clinical subspecialty groups seeking to create a comprehensive educational resource for populations who lack easy access to specialty care.

The value of T2-weighted MRI contrast ratio combined with DWI in evaluating the pathological grade of solid lung adenocarcinoma

AIM

To assess the predictive value of T2-weighted (T2W) magnetic resonance imaging (MRI) in combination with diffusion-weighted imaging (DWI) for determining the pathological grading of solid lung adenocarcinoma.

MATERIALS AND METHODS

The clinical and imaging data from 153 cases of solid lung adenocarcinoma (82 men, 71 women, mean age 63.2 years) confirmed at histopathology in The First Affiliated Hospital of Xi'an Jiaotong University from January 2017 to May 2022 were analysed retrospectively. Adenocarcinomas were classified into low-grade (G1 and G2) and high-grade (G3) groups following the 2020 pathological grading system proposed by the International Association for the Study of Lung Cancer. The T2-weighted contrast ratio (T2CR), calculated as the T2 signal intensity of the lung mass/nodule divided by the T2 signal intensity of the right rhomboid muscle was utilised. Two experienced radiologists reviewed the MRI images independently, measured the T2CR, and obtained apparent diffusion coefficient (ADC) values. The Mann-Whitney U-test was used to compare general characteristics (sex, age, maximum diameter), T2CR, and ADC values between the low-grade and high-grade groups. The non-parametric Kruskal-Wallis test determined differences in T2CR and ADC values among the five adenocarcinoma subtypes. Receiver characteristic curve (ROC) analysis, along with area under the curve (AUC) calculation, assessed the effectiveness of each parameter in distinguishing the pathological grade of lung adenocarcinoma. A Z-test was used to compare the AUC values.

RESULTS

Among the 153 patients with adenocarcinoma, 103 had low-grade adenocarcinoma, and 50 had high-grade adenocarcinoma. The agreement between T2CR and ADC observers was good (0.948 and 0.929, respectively). None of the parameters followed a normal distribution (p<0.05). The ADC value was lower in the high-grade adenocarcinoma group compared to the low-grade adenocarcinoma group (p=0.004), while the T2CR value was higher in the high-grade group (p=0.011). Statistically significant differences were observed in maximum diameter and gender between the two groups (p<0.001 and p=0.005, respectively), while no significant differences were noted in age (p=0.980). Among the five adenocarcinoma subtypes, only the lepidic and micropapillary subtypes displayed statistical differences in ADC values (p=0.047), with the remaining subtypes showing no statistical differences (p>0.05). The AUC values for distinguishing high-grade adenocarcinoma from low-grade adenocarcinoma were 0.645 for ADC and 0.627 for T2CR. Combining T2CR, ADC, sex, and maximum diameter resulted in an AUC of 0.778, sensitivity of 70%, and specificity of 75%. This combination significantly improved diagnostic efficiency compared to T2CR and ADC alone (p=0.008, z = 2.624; p=0.007, z = 2.679).

CONCLUSION

The MRI quantitative parameters are useful for distinguishing the pathological grades of solid lung adenocarcinoma, offering valuable insights for precise lung cancer treatment.

Measuring the unmet needs of American military Veterans and their caregivers: Survey protocol of the HERO CARE survey

BACKGROUND

Empowering Veterans to age in place is a Department of Veterans Affairs priority. Family or unpaid caregivers play an important role in supporting Veterans to achieve this goal. Effectively meeting the needs of Veterans and caregivers requires identifying unmet needs and relevant gaps in resources to address those needs.

METHODS

Using a modified Socio-Ecological Model, we developed a prospective longitudinal panel design survey. We randomly selected 20,000 community-dwelling Veterans enrolled in the Veterans Health Administration (VHA), across five VHA sites. We oversampled Veterans with a higher predicted 2-year long-term institutional care (LTIC) risk. Veterans were mailed a packet containing a Veteran survey and a caregiver survey, to be answered by their caregiver if they had one. The Veteran survey assessed the following health-related domains: physical, mental, social determinants of health, and caregiver assistance. Caregivers completed questions regarding their demographic factors, caregiving activities, impact of caregiving, use of VA and non-VA services, and caregiver support resources. Follow-up surveys will be repeated twice at 12-month intervals for the same respondents. This article describes the HERO CARE survey protocol, content, and response rates.

RESULTS

We received responses from 8,056 Veterans and 3,579 caregivers between July 2021 and January 2022, with 95.6% being received via mail. Veteran respondents were mostly males (96.5%), over 65 years of age (94.9%), married (55.0%), Non-Hispanic White (75.2%), and residing in urban areas (80.7%).

CONCLUSIONS

This longitudinal survey is unique in its comprehensive assessment of domains relevant to older Veterans stratified by LTIC risk and their caregivers, focusing on social determinants, caregiver support, and the use of caregiver support resources. Survey data will be linked to Centers for Medicare & Medicaid Services and VA data. The results of this study will inform better planning of non-institutional care services and policy for Veterans and their caregivers.

Peer-to-Patient-Aligned Care Team (Peer-to-PACT; P2P), a Peer-Led Home Visit Intervention Program for Targeting and Improving Long-term Care Services and Support for Veterans With High Needs and High Risk: Protocol for a Mixed Methods Feasibility Study

BACKGROUND

Keeping older veterans with high needs and high risk (HNHR) who are at risk of long-term institutional care safely in their homes for as long as possible is a Department of Veterans Affairs priority. Older veterans with HNHR face disproportionate barriers and disparities to engaging in their care, including accessing care and services. Veterans with HNHR often have poor ability to maintain health owing to complicated unmet health and social needs. The use of peer support specialists (peers) is a promising approach to improving patient engagement and addressing unmet needs. The Peer-to-Patient-Aligned Care Team (Peer-to-PACT; P2P) intervention is a multicomponential home visit intervention designed to support older veterans with HNHR to age in place. Participants receive a peer-led home visit to identify unmet needs and home safety risks aligned with the age-friendly health system model; care coordination, health care system navigation, and linking to needed services and resources in collaboration with their PACT; and patient empowerment and coaching using Department of Veterans Affairs whole health principles.

OBJECTIVE

The primary aim of this study is to evaluate the preliminary effect of the P2P intervention on patient health care engagement. The second aim is to identify the number and types of needs and unmet needs as well as needs addressed using the P2P needs identification tool. The third aim is to evaluate the feasibility and acceptability of the P2P intervention delivered over 6 months.

METHODS

We will use a quantitative-qualitative convergent mixed methods approach to evaluate the P2P intervention outcomes. For our primary outcome, we will conduct an independent, 2-tailed, 2-sample t test to compare the means of the 6-month pre-post differences in the number of outpatient PACT encounters between the intervention and matched comparison groups. Qualitative data analysis will follow a structured rapid approach using deductive coding as well as the Consolidated Framework for Implementation Research.

RESULTS

Study enrollment began in July 2020 and was completed in March 2022. Our sample size consists of 114 veterans: 38 (33.3%) P2P intervention participants and 76 (66.7%) matched comparison group participants. Study findings are expected to be published in late 2023.

CONCLUSIONS

Peers may help bridge the gap between PACT providers and veterans with HNHR by evaluating veterans' needs outside of the clinic, summarizing identified unmet needs, and developing team-based solutions in partnership with the PACT. The home visit component of the intervention provides eyes in the home and may be a promising and innovative tool to improve patient engagement.

INTERNATIONAL REGISTERED REPORT IDENTIFIER (IRRID)

DERR1-10.2196/46156.

Competencies for video telemedicine with older adult patients

BACKGROUND

Telemedicine has recently become a part of mainstream clinical practice. Many curricula have been developed to teach general and specialty-specific video telemedicine skills; however, a lack of defined best practices for translating comprehensive interprofessional geriatric care to the virtual setting presents a unique challenge to educators and clinicians. This manuscript introduces and describes the development of competencies for video telemedicine with older adults for all health professionals who treat them.

METHODS

A modified Delphi process was used in competency development. In 2019, interprofessional clinicians and educators who had expertise in telemedicine formed a competency development workgroup. The aim was to draft competencies for interprofessional video telemedicine with older adults while not duplicating existing competencies in geriatrics, interprofessional care, or general telemedicine. Draft competencies were circulated among experts in geriatric telemedicine and geriatric education for two rounds of comments. The competencies incorporated comments from 41 clinicians representing 7 professions.

RESULTS

Twenty-three competencies were created spanning six domains. A temporal organization by domain was used: (1) Overarching considerations, (2) Pre-visit preparation, (3) Beginning of the visit, (4) History taking and communication during the visit, (5) Exam during the visit (organized by the 5Ms: Mind, Mobility, Medication, Multicomplexity, and Matters Most), and (6) Post-visit coordination.

CONCLUSIONS

These newly developed competencies fill a gap left by those developed for specific disciplines or that do not address considerations for older adults. They lay the groundwork for curriculum development and the development of virtual Age-Friendly care.

Association between specific unmet functional needs and desire to institutionalize among caregivers of older veterans

OBJECTIVES

To evaluate the associations between specific functional needs of older Veterans and the desire to institutionalize (DTI) among their caregivers.

METHODS

Cross-sectional multivariable logistic regression analysis of 3579 Hero Care survey responses from caregivers of Veterans at five US sites from July to December 2021. Unmet needs were areas in which the caregiver reported the Veteran needed a little more or a lot more help. Caregiver DTI was defined as the caregiver reporting that they had discussed, considered, or taken steps toward a nursing home or assisted living placement for the Veteran or that they felt the Veteran would be better off in such a setting or they were likely to move the Veteran to another living arrangement.

RESULTS

Caregivers were largely white, retired, females with an average age of 71 and with some college education who spent an average of 8-9 h per day 6 days a week caring for a Veteran spouse. There was evidence of associations between the following needs and a DTI: managing incontinence, using the telephone, transportation, and arranging services in the home such as visiting nurses, home care aides, or meals on wheels. Unmet functional needs in other selected domains were not associated with the DTI.

CONCLUSION

Among caregivers of older Veterans, a need for more assistance managing incontinence, telephone use, transportation, and arranging in-home services were associated with the DTI. These may represent functional markers of important clinical determinants for institutionalization as well as potential targets for intervention to reduce caregiver DTI, such as programs that provide more caregiver or Veteran support in the home to meet these needs and reduce caregiver burden.

Recognizing the Needs of High-Need High-Risk Veterans

Introduction

Understanding the needs of higher-risk older adult patients can support the delivery of high quality and patient-centered healthcare. We sought to characterize the physical, functional, social and psychological needs of High-Need High-Risk (HNHR) Veterans. We hypothesized that the concept of frailty could be useful in identifying the highest-risk HNHR patients and characterizing their needs.

Methods

We conducted a cross-sectional study of Veterans in the Miami Veterans Affairs Healthcare System who were identified as High-Need High-Risk by the Department of Veterans Affairs (VA) using data analytic techniques. We analyzed data of 634 Veterans who completed questionnaires by mail, telephone or in person. We assessed the Veterans' frailty status and needs in the physical, functional, psychological and social domains. Beyond descriptive statistics, we used Chi-square (χ ²) test, one-way ANOVA and Kruskal-Wallis to analyze whether there were differences in Veterans' needs in relation to frailty status.

Results

The HNHR Veterans who participated in the questionnaire had complex needs that spanned the physical, functional, psychological, and social domains. We observed a potential mismatch between functional needs and social support; over two-thirds of respondents endorsed having dependence in at least one ADL but only about a third of respondents reported having a caregiver. Patients with frailty had higher levels of functional dependence and were more likely than the other HNHR respondents to report recent falls, recent hospitalizations, depression, and transportation issues.

Conclusion

High-Need High-Risk Veterans have complex needs related to the physical, functional, psychological and social domains. Within the HNHR population, HNHR Veterans with frailty appear to have particularly high levels of risk and multidomain needs. Increased attention to identifying members of these groups and aligning them with biopsychosocial interventions that are targeted to their specific needs may support development of appropriate strategies and care-models to support HNHR Veterans.

MEASURING UNMET NEEDS OF HIGH-NEED, HIGH-RISK AMERICAN VETERANS AND THEIR CAREGIVERS USING A PROSPECTIVE SURVEY

Success in delaying long term institutionalization (LTI) depends on creating means to adequately support each Veteran’s needs. To better understand the unmet needs of Veterans, we identified a random sample of 20,000 Veterans from five VA sites. Veterans were stratified into low-, moderate- or high-risk tiers using a measure of predicted 2-year probability of LTI. Veterans and their caregivers were asked to complete separate surveys to assess demographic, physical, psychological, and social domains, unmet needs, and experience with HCBS and caregiver support programs. Responses were received between July-Dec 2021 from 8056 Veterans (80.3+/-9.8y; 94.0% men; 82.6% White; 8.9% Hispanic) and 3579 caregivers (71.1+/-13.1y; 75.1% women; 80.5% White; 15.1% Hispanic; 57.1% spousal) responded by mail (96%) or online (4%). Both Veterans and caregivers endorse complex Veteran unmet needs spanning medical, psychological, and social domains. Survey results will be used to inform HCBS policy to support aging Veterans and their caregivers.

IMPROVING HOME-CARE SERVICES FOR HIGH-RISK OLDER ADULTS USING PEER-LED VIDEO VISITS TO HOME

Older Veterans at high-risk for institutionalization often require home- and community-based services (HCBS). Yet, current HCBS delivery often fails to meet the needs of high-risk Veterans due to decreased veteran engagement in outpatient programs and limited HCBS capacity. A promising approach to address these gaps is the use of Veteran-Peers to make home-visits. Peer-2-PACT is a peer-led needs-assessment intervention for high-risk older veterans. Two trained peers conducted a checklist-guided virtual and/or in-person home-assessment to identify unmet needs and home-safety concerns. Veterans with access, acceptance and ability for video-capable technology were offered video-visits. We report on the feasibility of video home-visits in this high-risk group, and the experience of the video-visits using the visit-data and interviews with peers.Eight of 27 Peer-2-PACT Veterans successfully completed initial video-visit to home. The video-visit participants (n=8) were age 74±9; Non-Hispanic Black (50%); males (100%), compared to initial in-person home-visit participants (n=19), age 75.3±10.8; Non-Hispanic Black (47%); males (89%). The commonest needs identified during video-home-visits were home-safety devices 5(62.5%), housing assistance 4(50%), and medication refills 2(25%). Peers report that identifying veterans suitable for video-visits was challenging. During video-visits, depth-perception by peers is limited and sometimes needed in-person follow-up. Main advantages of video-visits was ability to identify unmet needs, engage veterans, provide care during COVID, and tele-present to remote clinicians. Preliminary data suggest that peer-conducted video home-visits is a feasible way to identify unmet needs in some high-risk older adults. This is particularly important improve care of Veterans who live at a distance from the facility.

CHALLENGES AND SUPPORTS FOR VETERAN CAREGIVERS DURING THE COVID-19 PANDEMIC: A MIXED-METHODS STUDY

Informal caregivers face challenges in supporting older or medically-complex Veterans, which could be exacerbated by the COVID-19 pandemic. Our mixed methods observational study explored Veteran caregivers’ supports, challenges, and self-identified impacts during the pandemic. Caregivers whose veterans needed help with at least one activity of daily living for the last year and received care at one of five Veterans Health Administration (VA) study sites were eligible. Survey participants (n=46) were 96% female, 32-83 years old (median 59); most (83%) cared for a spouse. A majority (67%, n=31) reported increased stress since the start of the pandemic. Top sources of increased stress included worry about COVID-19 infection, increased caregiving responsibility, delayed access to care, concerns about vaccine safety, and employment or financial concerns. Caregiver interviews (n=26) qualitatively analyzed using a rapid, templated approach identified the following themes: (1) the benefits and challenges of VA COVID precautions to Veteran care access (e.g. telehealth, getting care for new problems), (2) supports afforded by and limits of the expansion of the VA Caregiver Support Program, (3) declines in Veteran physical and cognitive functioning, (4) increased caregiver role in Veterans’ support and care, (5) changes in work and living situations to address increased caregiving needs and/or reduce risk of exposure, and (6) loss of and then return to more usual routines and social outlets amid ongoing COVID-related uncertainties. Recommendations include targeted, personalized outreach to engage caregivers in existing supports, removing barriers and streamlining processes for obtaining services, and creating durable caregiver-to-caregiver, peer support opportunities.

The RESCUE problem solving intervention for stroke caregivers: A mixed-methods pilot study

PURPOSE/OBJECTIVE

Stroke caregivers face many challenges after a family member experiences stroke. Because caregivers play such a crucial role in health care, there is a need for more interventions in web-based formats that focus on caregiver psycho-education and skills building. A pilot study was devised to determine the feasibility, acceptability, and value of an active, 4-week telephone and web-based intervention for stroke caregivers.

METHOD/DESIGN

A one-group, pretest-posttest design with a mixed-methods approach was used. Qualitative data supplemented the quantitative findings. Community-dwelling caregivers of stroke patients were recruited from the Veterans Health Administration. Quantitative data were collected pre and postintervention. Semistructured interviews were completed with a subsample of caregivers to capture more detail about the acceptability and value of the intervention.

RESULTS

Ninety-three caregivers were recruited; 72 caregivers completed the intervention and 21 withdrew (77% completion rate). From pre- to posttest, caregiver depression (p = .008) and caregiver burden (p = .013) decreased. Problem-solving abilities and health-related quality of life showed no change. Seventy-eight percent of caregivers rated the intervention sessions with the nurses as very helpful or extremely helpful, and 76% reported using the problem-solving strategies a moderate amount to extremely often. Interviews suggest that the intervention was valuable and led to new strategies to relieve stress and prioritize health.

CONCLUSIONS/IMPLICATIONS

The intervention was feasible to implement and acceptable to caregivers. This intervention shows promise for fulfilling a need for more web-based interventions that focus on skills building and psycho-education, but more rigorous testing is needed to determine effectiveness. (PsycInfo Database Record (c) 2022 APA, all rights reserved).

MRI-based radiomics analysis in differentiating solid non-small-cell from small-cell lung carcinoma: a pilot study

AIM

To investigate the ability of a T2-weighted (W) magnetic resonance imaging (MRI)-based radiomics signature to differentiate solid non-small-cell lung carcinoma (NSCLC) from small-cell lung carcinoma (SCLC).

MATERIALS AND METHODS

The present retrospective study enrolled 152 eligible patients (NSCLC = 125, SCLC = 27). All patients underwent MRI using a 3 T scanner and radiomics features were extracted from T2W MRI. The least absolute shrinkage and selection operator (LASSO) logistic regression model was used to identify the optimal radiomics features for the construction of a radiomics model to differentiate solid NSCLC from SCLC. Threefold cross validation repeated 10 times was used for model training and evaluation. The conventional MRI morphology features of the lesions were also evaluated. The performance of the conventional MRI morphological features, and the radiomics signature model and nomogram model (combining radiomics signature with conventional MRI morphological features) was evaluated using receiver operating characteristic (ROC) curve analysis.

RESULTS

Five optimal features were chosen to build a radiomics signature. There was no significant difference in age, gender, and the largest diameter. The radiomics signature and conventional MRI morphological features (only pleural indentation and lymph node enlargement) were independent predictive factors for differentiating solid NSCLC from SCLC. The area under the ROC curves (AUCs) for MRI morphological features, and the radiomics model, and nomogram model was 0.69, 0.85, and 0.90 (ROC), respectively.

CONCLUSIONS

The T2W MRI-based radiomics signature is a potential non-invasive approach for distinguishing solid NSCLC from SCLC.

Gap in Willingness and Access to Video Visit Use Among Older High-risk Veterans: Cross-sectional Study

Background

The recent shift to video care has exacerbated disparities in health care access, especially among high-need, high-risk (HNHR) adults. Developing data-driven approaches to improve access to care necessitates a deeper understanding of HNHR adults’ attitudes toward telemedicine and technology access.

Objective

This study aims to identify the willingness, access, and ability of HNHR veterans to use telemedicine for health care.

Methods

WWe designed a questionnaire conducted via mail or telephone or in person. Among HNHR veterans who were identified using predictive modeling with national Veterans Affairs data, we assessed willingness to use video visits for health care, access to necessary equipment, and comfort with using technology. We evaluated physical health, including frailty, physical function, performance of activities of daily living (ADL) and instrumental ADL (IADL); mental health; and social needs, including Area Deprivation Index, transportation, social support, and social isolation.

Results

The average age of the 602 HNHR veteran respondents was 70.6 (SD 9.2; range 39-100) years; 99.7% (600/602) of the respondents were male, 61% (367/602) were White, 36% (217/602) were African American, 17.3% (104/602) were Hispanic, 31.2% (188/602) held at least an associate degree, and 48.2% (290/602) were confident filling medical forms. Of the 602 respondents, 327 (54.3%) reported willingness for video visits, whereas 275 (45.7%) were unwilling. Willing veterans were younger (P<.001) and more likely to have an associate degree (P=.002), be health literate (P<.001), live in socioeconomically advantaged neighborhoods (P=.048), be independent in IADLs (P=.02), and be in better physical health (P=.04). A higher number of those willing were able to use the internet and email (P<.001). Of the willing veterans, 75.8% (248/327) had a video-capable device. Those with video-capable technology were younger (P=.004), had higher health literacy (P=.01), were less likely to be African American (P=.007), were more independent in ADLs (P=.005) and IADLs (P=.04), and were more adept at using the internet and email than those without the needed technology (P<.001). Age, confidence in filling forms, general health, and internet use were significantly associated with willingness to use video visits.

Conclusions

Approximately half of the HNHR respondents were unwilling for video visits and a quarter of those willing lacked requisite technology. The gap between those willing and without requisite technology is greater among older, less health literate, African American veterans; those with worse physical health; and those living in more socioeconomically disadvantaged neighborhoods. Our study highlights that HNHR veterans have complex needs, which risk being exacerbated by the video care shift. Although technology holds vast potential to improve health care access, certain vulnerable populations are less likely to engage, or have access to, technology. Therefore, targeted interventions are needed to address this inequity, especially among HNHR older adults.

Factors Driving High-Need High-Risk Vulnerable Veterans Use of Outpatient Healthcare

Using predictive analytic modeling, the Veterans Affairs (VA) Geriatrics and Extended Care Data Analysis Center (GECDAC) identified vulnerable “High-Need High-Risk” (HNHR) Veterans, as requiring more support and services. We sought to identify variables linked with utilization of our outpatient HNHR C4 clinic offering Comprehensive Geriatric Assessment, Care Planning, Care Coordination, and Co-management". Of 724 HNHR Veterans contacted, 531 were reached and invited to participate; 193 were not reached, 326 were reached but declined the C4 clinic, 205 attended the clinic. We compared these groups. Independent variables were organized using Anderson’s behavioral model into predisposing (age, gender, race, ethnicity), enabling (drive time, service eligibility, Area Deprivation Index, marital status), and need factors (mental health cognitive condition, ambulatory care sensitive conditions, NOSOS, JFI, CAN, etc.). C4 enrollment acceptance was the outcome. Results showed that compared to patients who declined, HNHR veterans who attended C4 clinic had more chronic health conditions(p&lt;0.01), more service eligibility(p=0.01), more driving time to the closest VA clinic(p=0.01), and more were married (p=0.01). Patients who declined C4 clinic might have greater barriers to care access. Accessing needed healthcare among HNHR older adults maybe impacted more by enabling factors that allow the individual to seek care if needed and are the resources that may facilitate access to services, rather than need factors, which include individuals' perceptions of their health and functional state, and healthcare needs assessed by professionals. More social and intermediary determinants of health should be incorporated as enabling factors into models striving to understand drivers of healthcare use.

The Digital Divide Amongst High-Need High-Risk Veterans

High-need high-risk (HNHR) veterans are medically complex and at the highest risk of hospitalization and long-term institutionalization. Technology can mitigate challenges these veterans have in accessing healthcare. Willingness to use technology as well as access and ability to use technology were assessed in this study. At the time of the survey, 2543 Miami VAHS veterans were listed as HNHR. 634 veterans ultimately completed the questionnaire, and 602 answered the “willingness to use video-visits” question. Of the 602 respondents, 327 (54.3%) reported they were willing for video-visits with the VA, while 275 (45.6%) were not. Those who were willing were significantly younger (P<0.001), with higher educational qualifications (P=0.002), and more health literate than those not willing (P<0.001). They were more also capable of using the Internet, more likely to use email and be enrolled in the VA’s patient portal, My HealtheVet (P<0.001). However, of the veterans who were willing, 248 (75.8%) had a device with video-capable technology. Those with video-capable technology were younger (P=0.004), more health literate (P=0.01), and less likely to be Black or African American (P=0.007). They were more capable of using the Internet, more likely to use email, and be enrolled in My HealtheVet than those without (P<0.001). Half of the respondents were willing for video-visits but a quarter of those willing lacked requisite technology, thereby making only about 41.2% of the respondents willing and video-capable. To minimize the digital divide, especially during the ongoing COVID-19 pandemic, targeted measures need to address these disparities in this vulnerable population.

Adamts18 Deficiency Causes Spontaneous SMG Fibrogenesis in Adult Mice

Chronic sclerosing sialadenitis of the submandibular gland (also known as Küttner tumor) is characterized by concomitant swelling of the submandibular glands secondary to strong lymphocytic infiltration and fibrosis. The pathogenesis of this disease has been unclear, but it is associated with immune disorders. ADAMTS18 is a member of the ADAMTS superfamily of extracellular proteinases. In this study, we showed that Adamts18 is highly expressed in submandibular salivary gland (SMG) during embryonic development and decreases but is retained in adult SMG tissue in mice. Adamts18 deficiency led to reduced cleft formation and epithelial branching in embryonic SMG before embryonic day 15.5 in mice. No significant histologic changes in the later stages of branching or the morphology of SMG were detected in Adamts18^-/- mice. However, Adamts18 deficiency causes spontaneous SMG fibrogenesis and fibrosis in adult mice. At 8 wk of age, Adamts18^-/- mice began to manifest the first signs of pathologic changes of mild fibrosis and CD11b⁺ cell infiltration in SMG tissues. At ≥8 mo, all male and female Adamts18^-/- mice developed unilateral or bilateral SMG scleroma that is similar to patients with chronic sclerosing sialadenitis of the submandibular gland. Adamts18^-/- mice also showed secretory dysfunction and severe dental caries. Histologically, SMG scleroma is characterized by progressive periductal fibrosis, acinar atrophy, irregular duct ectasis, and dense infiltration of IgG-positive plasma cells. A significant infiltration of CD4⁺ T lymphocytes and CD11b⁺ monocytes and macrophages was also detected in the SMG scleroma of Adamts18^-/- mice. The levels of TGF-β1, IL-6, and IL-33 were significantly increased in Adamts18^-/- SMGs, which induces chronic inflammation and myofibroblast activation, ultimately leading to fibrosis. This study indicates that Adamts18 regulates the early branching morphogenesis of embryonic SMG and plays a role in protecting from spontaneous SMG fibrogenesis via modulating local inflammation, autoimmune reaction, and myofibroblast activation in adult mice.

Effect of radiomics from different virtual monochromatic images in dual-energy spectral CT on the WHO/ISUP classification of clear cell renal cell carcinoma

AIM

To investigate the effect of radiomics obtained from different virtual monochromatic images (VMIs) in dual-energy spectral computed tomography (CT) on the World Health Organization/International Association for Urological Pathology (WHO/ISUP) classification of clear cell renal cell carcinoma (ccRCC).

MATERIALS AND METHODS

A retrospective study of 99 ccRCC patients who underwent contrast-enhanced dual-energy CT was undertaken. ccRCC was confirmed at surgery or biopsy and graded according to the WHO/ISUP pathological grading criteria as low grade (n=68, grade I and II) or high grade (n=31, grade III and IV). Radiomics risk scores (RRSs) for differentiating high and low grades of ccRCC were constructed from 11 sets of VMI in (40-140 keV, 10 keV interval) the cortical phase. Receiver operating characteristic (ROC) curves were drawn and the area under the curves (AUCs) was calculated to evaluate the discriminatory power of RRS for each VMI. The Hosmer-Lemeshow test was used to evaluate the goodness-of-fit of each model and the decision curve was used to analyse its net benefit to patients.

RESULTS

The AUC values for distinguishing low-from high-grade ccRCC with RRS of 40-140 keV VMIs were all >0.920. The Hosmer-Lemeshow test showed that the p-values of RRS of VMIs were >0.05, suggesting good fits. In the decision curve analysis, RRS from the 40-140 keV VMIs had similar decision curves and provided better net benefits than considering all patients either as high-grade or low-grade.

CONCLUSIONS

The RRS obtained from multiple VMIs in dual-energy spectral CT have high diagnostic efficiencies for distinguishing between low- and high-grade ccRCC with no significant differences between different VMIs.

Synthesis of silver nanoparticles using Lactobacillus bulgaricus and assessment of their antibacterial potential

Many pathogenic strains have acquired multidrug-resistant patterns in recent a year, which poses a major public health concern. The growing need for effective antimicrobial agents as novel therapies against multidrug-resistant pathogens has drawn scientist attention toward nanotechnology. Silver nanoparticles are considered capable of killing multidrug-resistant isolates due to their oligo-dynamic effect on microorganisms. In this research study NPs were synthesized using the gram-positive bacteria Lactobacillus bulgaricus and its activity against selected pathogenic strains. Lactobacillus bulgaricus pure cultures were isolated from raw milk and grown in "De Man, Rogasa, and Sharp" broth for synthesis of nanoparticles. Lactobacillus bulgaricus culture was centrifuged and Cell- free supernatant of it was employed with aqueous silvery ions and evaluated their antibacterial activities against bacterial strains i.e. Staphylococcus aureus, Staphylococcus epidermidis and Salmonella typhi using agar well diffusion assay. Antibiotic profiling against selected pathogenic strains were also conducted using disc diffusion method. The synthesis and characterization of silver nanoparticles were monitored primarily by the conversion of the pale-yellow color of the mixture into a dark-brown color and via ultraviolet-visible absorption spectroscopy and Scanning electron microscopy respectively. The result showed that that AgNPs with size (30.65-100 nm) obtained from Lactobacillus bulgaricus were found to exhibit antibacterial activities against selected bacterial strains. Taken together, these findings suggest that Lactobacillus bulgaricus has great potential for the production of AgNPs with antibacterial activities and highly effective in comparison to tested antibiotics.

Factors Associated With Hospitalization by Veterans in Home-Based Primary Care

OBJECTIVES

This study examined the extent to which program site-based and Veteran characteristics were associated with potentially avoidable hospitalizations or other hospitalization of Veterans enrolled in the Veterans Affairs (VA) Home-Based Primary Care (HBPC).

DESIGN

Retrospective claims-based study.

SETTING AND PARTICIPANTS

HBPC programs that responded to a national survey of HBPC programs (n = 189) in fiscal year (FY) 2016 were studied. Veterans in the analysis cohort were identified as having been enrolled in VA-HBPC in FY2016 who had not received care by VA-HBPC within 1 year prior to their first HBPC enrollment in FY2016 (N = 8497).

METHODS

Multinomial logistic regression analysis with 5 outcome categories within the 6 months following the first HBPC enrollment date: (1) any potentially avoidable hospitalizations for ambulatory care-sensitive conditions (ACSC) as identified by AHRQ Prevention Quality Indicator (PQI), (2) any other hospitalizations for non-ACSC conditions, (3) died during study period, (4) discharged from HBPC, or (5) remained at home with HBPC. Average marginal effects (AME) of veteran-level and VA-HBPC-level covariates are reported for each of the outcome categories.

RESULTS

More frail Veterans and Veterans 85 years old or older were more likely to have potentially preventable ACSC hospitalizations (AME = 5.4%, 1.8%, respectively). Veterans who were younger than 75 years, functionally impaired, bed-bound, or frail were more likely to have non-ACSC hospitalization (AME = 3.0%, 2.2%, 3.5%, and 9.0%, respectively). Veterans with low frailty index scores were less likely to have non-ACSC hospitalizations (AME = -17.1%). Six-month hospitalization patterns were not associated with reported HBPC site characteristics.

CONCLUSIONS AND IMPLICATIONS

Within the framework of the national VA HBPC program, variations in the structural model used at HBPC sites are not significantly associated with hospitalizations. Tailoring of HBPC care, based on individual patient factors and clinical judgment rather than standard protocols, may be central to the success of HBPC in reducing ACSC hospitalizations.

GRECC Connect Increases Access to Geriatric Specialty Care for Rural, Older Veterans With Complex Care Needs

A higher percentage of Veterans in rural areas are older, have multiple chronic conditions and select the VA for healthcare. To address the needs of rural older Veterans with complex needs, GRECC Connect hubs use case finding approaches combined with regular outreach and education to VA community-based outpatient clinic (CBOC) providers serving rural Veterans and caregivers. Alignment of GRECC Connect services with needs of providers and patients promotes establishment of therapeutic alliances in caring for medically complex older Veterans. After identifying high risk, high need patients, hubs use the following strategies to increase access to geriatric specialty care through telehealth modalities: 1) Co-management of patients through e-consultation and telehuddles (GRECC Connect interprofessional geriatric specialty care teams extend support to CBOC providers); 2) Clinical video telehealth to CBOCs and Video on Demand to Veteran homes (to reduce travel burden); and, 3) Tele-group visits (especially for behavioral health and caregiver support).

Social Determinants and Frailty in High-Need, High-Risk Veterans

The VA Geriatrics and Extended Care Data Analysis Center uses national predictive modelling to identify High-Need High-Risk (HNHR) Veterans, to provide targeted services and reduce hospitalization and institutionalization risk. To learn the needs of Miami VA HNHR Veterans, we mailed a needs-assessment survey to 2124 Veterans, of whom 634 responded (29.8% response rate). The average respondent age was 70.5±9.2. Among them, 127(20%) were &lt;65 years old, 326(51.4%) were 65-74, and 179(28.2%) were ≥75; 389(61.4%) White, 225(35.5%) Black/African Americans; 515(81.2%) were Non-Hispanic, 111(17.5%) Hispanic/Latino; 173(27.3%) were high school graduates, 350(55.2%) had at least some college credit, 39(6.2%) had a master’s degree or more and 536(84.5%) were health literate. As per Morley’s FRAIL scale, 266(42%) were frail, 242(38.2%) were pre-frail and 87(13.7%) were robust. Social risk factors possibly associated with frailty were analyzed using ordinal logistic regression. Univariate analysis showed significant association with poor health literacy, having a caregiver, social isolation, transportation trouble, delayed or missed doctors’ appointments due to transportation, a negative perception of aging, likelihood of depression, being homebound, inability to use the internet, lack of technology for video conferencing and lack of email use (p≤0.01). Through multivariate ordinal logistic regression analysis, adjusting for patients’ age and Jen Frailty Index, we found that the same social risk factors other than internet use showed significant association with frailty (p≤0.01). HNHR Veterans have complex social needs with a limited ability to manage their chronic conditions, necessitating interventions that address not only their medical issues but also their access barriers and social support.

Postdischarge Intervention for Stroke Caregivers: Protocol for a Randomized Controlled Trial

BACKGROUND

The majority of stroke survivors return to their homes and need assistance from family caregivers to perform activities of daily living. These increased demands coupled with the lack of preparedness for their new roles lead to a high risk for caregivers developing depressive symptoms and other negative outcomes. Follow-up home support and problem-solving interventions with caregivers are crucial for maintaining stroke survivors in their homes. Problem-solving interventions are effective but are underused in practice because they require large amounts of staff time to implement and are difficult for caregivers logistically.

OBJECTIVE

The aim of this study is to test a problem-solving intervention for stroke caregivers that can be delivered over the telephone during the patient's transitional care period (time when the stroke survivor is discharged to home) followed by 8 asynchronous online sessions.

METHODS

The design is a two-arm parallel randomized clinical trial with repeated measures. We will enroll 240 caregivers from eight Veterans Affairs (VA) medical centers. Participants randomized into the intervention arm receive a modified problem-solving intervention that uses telephone and web-based support and training with interactive modules, fact sheets, and tools on the previously developed and nationally available Resources and Education for Stroke Caregivers' Understanding and Empowerment Caregiver website. In the usual care group, no changes are made in the information, discharge planning, or care the patients who have had a stroke normally receive, and caregivers have access to existing VA resources (eg, caregiver support line, self-help materials). The primary outcome is a change in caregiver depressive symptoms at 11 and 19 weeks after baseline data collection. Secondary outcomes include changes in stroke caregivers' burden, knowledge, positive aspects of caregiving, self-efficacy, perceived stress, health-related quality of life, and satisfaction with care and changes in stroke survivors' functional abilities and health care use. The team will also determine the budgetary impact, facilitators, barriers, and best practices for implementing the intervention. Throughout all phases of the study, we will collaborate with members of an advisory panel.

RESULTS

Study enrollment began in June 2015 and is ongoing. The first results are expected to be submitted for publication in 2021.

CONCLUSIONS

This is the first known study to test a transitional care and messaging center intervention combined with technology to decrease caregiver depressive symptoms and to improve the recovery of stroke survivors. If successful, findings will support an evidence-based model that can be transported into clinical practice to improve the quality of caregiving post stroke.

TRIAL REGISTRATION

ClinicalTrials.gov NCT01600131; https://www.clinicaltrials.gov/ct2/show/NCT01600131.

INTERNATIONAL REGISTERED REPORT IDENTIFIER (IRRID)

DERR1-10.2196/21799.

Characteristics of Women Enrolled in a Patient Portal Intervention for Menopause

Background: We developed a 6-month educational intervention addressing menopause and management of menopausal symptoms called "My HealtheVet to Enable And Negotiate for Shared decision-making" or MEANS. MEANS is offered through secure messaging via the My HealtheVet patient portal system. Materials and Methods: Women veterans aged 45-60 years registered at the Miami, West Palm Beach, and Orlando Veterans Affairs Healthcare Systems (VAHS). Intervention group: women in the Miami VAHS enrolled in My HealtheVet who were sent an invitation, agreed to participate, and completed the baseline survey. Comparison group: women from the Miami, West Palm Beach, and Orlando VAHS who responded to the baseline survey. Results: The intervention group enrolled 269 women at Miami VAHS: average age 53.2 years; 42.4% white, 43.1% black, and 24.2% Hispanic; 95.9% already used My Healthe Vet. The Comparison group had 590 women: average age 53.8 years; 70.8% white, 20.7% black, and 10.2% Hispanic; 57.6% already used My Healthe Vet. Conclusions: The differences between the intervention and comparison groups likely represent the regional demographic variations and the disparate recruitment techniques adopted for the two groups. Using within- and between-group comparisons at the end of the 6-month intervention, this novel project will evaluate the feasibility of a patient portal intervention on knowledge and shared decision-making regarding menopause among racially and ethnically diverse women. The study highlights the scalable and enormous potential for patient portals in nonurgent chronic disease management and shared decision-making, important in the existing health care climate, wherein "meaningful use" of electronic health records is mandated. Because of the COVID-19 pandemic, medical care has abruptly changed to telehealth and this approach to patient education is more relevant now than ever before. This quality improvement project's registration number is ClinicalTrials.gov ID: NCT03109145.

Replacing true unenhanced imaging in renal carcinoma with virtual unenhanced images in dual-energy spectral CT: a feasibility study

AIM

To investigate the clinical value of virtual unenhanced (VNC) spectral computed tomography (CT) images to replace the conventional true unenhanced spectral CT images (TNC) in diagnosing renal carcinoma.

MATERIALS AND METHODS

Fifty-six cases of renal carcinoma confirmed by histopathology underwent conventional plain CT and contrast-enhanced spectral CT at arterial phase (AP) and venous phase (VP). VNC images were generated on an AW4.6 workstation. The CT attenuation, image noise, contrast-to-noise ratio (CNR), and signal-noise-ratio (SNR) of the renal lesions and normal kidneys, long and short axis diameters of the lesion were measured from the three image sets and analysed using one-way analysis of variance (ANOVA). Two radiologists evaluated image quality subjectively using a five-point score, and lesion signature using a three-point score. Image quality scores were compared statistically and tested for consistency.

RESULTS

The two reviewers had good agreement for subjective evaluation (Kappa>0.70) and there was no difference in the quality of the scores among the three image groups. The lesion signature scores were all above the acceptable level. The CNR and SNR values in VNC were significantly higher than in TNC (p<0.05). VNC images had lower renal noise than in TNC (p<0.05). There was no difference in the long and short axis diameters of the lesion among the three image groups. VNC had higher CT attenuation values for the lesion and kidney than TNC (p<0.05), but the differences were <5 HU.

CONCLUSION

VNC images in spectral CT may be used to replace the conventional plain CT to reduce imaging duration and radiation dose in diagnosing renal carcinoma.

National Geriatric Network Rapidly Addresses Trainee Telehealth Needs in Response to COVID-19

BACKGROUND/OBJECTIVES

Coronavirus disease 2019 (COVID‐19) has pushed many geriatric healthcare providers to attempt video visits for the first time. Although the Veterans Health Administration (VA) is a pioneer in telemedicine, rapid shifts to nearly exclusive use of telehealth for healthcare delivery and changes regarding trainee engagement in telehealth served as the impetus for rapidly assessing telehealth training needs.

DESIGN

National needs assessment (online survey) of associated health trainees and medical fellows affiliated with Geriatric Research Education and Clinical Centers (GRECCs).

SETTING

National GRECC network ‐‐ 20 VA centers of excellence focused on supporting Veterans as they age. Each GRECC is affiliated with a school of medicine at a major university.

PARTICIPANTS

Trainees (n = 89) representing 12 disciplines.

RESULTS

Two‐thirds of participants had received some telehealth training. However, most had never done a video‐to‐home visit, and, regardless of telehealth experience, they reported low confidence. Based on open‐ended questions exploring training needs, educational resources were rapidly developed and disseminated.

INTERVENTION

Within 1 week of the assessment, a nuts‐and‐bolts guide regarding remote access, technology requirements, video‐conferencing platforms, and managing emergencies was sent to the national network of GRECC associate directors for education for dissemination among discipline‐specific training directors at their sites. This resource was subsequently submitted to the national VA COVID Strong Practices SharePoint site. An interdisciplinary team of geriatric specialists with extensive video‐to‐home experience also organized a national webinar that peaked at just over 700 participants. GRECC Connect, a network of geriatric specialty teams funded to improve care access for rural older veterans using telehealth and associated health training programs at each GRECC facilitated rapid development and dissemination of both resources.

CONCLUSION

We quickly identified and responded to telehealth training needs of geriatrics trainees to optimize care for rural older adults as part of a rapid response to COVID‐19. Although the webinar and nuts‐and‐bolts resources were developed within the VA context, they have demonstrated high demand and broader applicability. Results should continue to inform curriculum development efforts to address telehealth training gaps within and outside the VA.

Piezoelectric modulation of broadband photoresponse of flexible tellurium nanomesh photodetectors

Flexible photodetector shows great potential applications in intelligent wearable devices, health monitoring, and biological sensing. In this work, single crystal β-tellurium nanowires were grown on flexible muscovite by molecular beam epitaxy, constructing high-density ordered nanomesh structure. The prepared photodetectors based on tellurium nanomesh exhibit excellent mechanical flexibility, fast response in a broad range from ultraviolet to near-infrared, and good photosensitivity. We found that the flexible photodetectors with Shottky contact drastically suppressed dark current, while the response speed was lowered in comparison to the devices with ohmic contact, as holes would take a long time to tunnel through the Shottky barrier between metal and p-type Te. Moreover, the photoresponse of flexible Shottky photodetectors can be modulated by piezoelectricity of tellurium, and pronounced photocurrent increase after bending many times. Under external stress, polarization charges could tune Shottky barrier height of the metal/tellurium, resulting in variation of photocurrent. This research not only explores the broadband photoresponse and piezoelectric effect of tellurium nanomesh, but also promotes the integration and development of broadband flexible optoelectronic devices.

A MULTI-SITE PROGRAM TO PROVIDE GERIATRICS TELECONSULTATION TO OLDER RURAL VETERANS (GRECC CONNECT)

Older Veterans living in rural areas often do not have access to geriatrics team care; rural frontline providers and teams may need support to address the needs of older adults with complex chronic conditions. GRECC Connect aims to link up geriatric teams at Geriatric Research, Education and Clinical Centers (GRECCs) and rural clinics to provide geriatric consultation remotely through clinical video telehealth (CVT) and other means. GRECC Connect is established in twelve GRECCs across the country with links to rural clinics in their catchment area; consultations led to identification and meeting of care needs of older adults with complex conditions, improving medication use and reducing older adults’ need for travel to long distances for consultation. In this presentation, we review the experience of establishing connections with rural clinics, impact on older adult care and adaptations needed to address local needs and contexts.

EVALUATION OF THE RESCUE PROGRAM FOR REDUCING STROKE CAREGIVER STRESS AND IMPROVING PROBLEM-SOLVING ABILITIES

Research shows that caregiver interventions that combine problem-solving with psycho-education are the most effective for addressing stroke caregiver concerns. The Resources and Education for Stroke Caregivers’ Understanding and Empowerment (RESCUE) program, designed to reduce caregiver stress, depression, and burden, developed as a result of this evidence. A 4-week telephone and web-based clinical demonstration project led by registered nurses was established as part of the VHA Office of Geriatrics and Extended Care’s Non-Institutional Long Term Care Initiative. The goals of this clinical demonstration were to improve problem-solving skills and provide individualized support for stroke caregivers. A single-group pre and post-test design was used and 72 caregivers of veterans with stroke completed the intervention; qualitative and quantitative methods were used for evaluation. The outcome variables were caregiver depressive symptoms, problem-solving abilities, burden, health-related quality of life and care recipient functional abilities. Post-tests were conducted 2-6 weeks after the intervention. The evaluation found that there were statistically-significant decreases in caregiver depressive symptoms and burden from pre- to post-test assessments. Caregivers’ negative problem orientation significantly decreased. The other components of problem-solving abilities did not change. Qualitative data revealed how the program increased caregivers’ confidence in problem-solving which led to new strategies to relieve stress. Interviews also revealed how the intervention affected caregivers in unexpected ways, such as improved intimate relationships and new perspectives on caregiving. The preliminary effectiveness and barriers and facilitators of implementing a stroke caregiver program will be discussed.

FEASIBILITY OF MOBILE HEALTH FOR LOW-INCOME MINORITY HISPANIC PATIENTS WITH A STROKE

Stroke is a leading cause of death and functional impairment that disproportionately impacts Hispanics. Several studies have supported the feasibility of mobile health interventions (mHealth) to provide health monitoring and patient education for improving chronic disease management, but none have focused on Latino stroke patients. The Hispanic Secondary Stroke Prevention Initiative is a randomized study of 200 stroke patients designed to evaluate the impact of a 12-month multi-modal Community Health Worker (CHW) and mHealth intervention on blood pressure control. Eligible participants were Latinos who experienced a mild-moderate stroke within the last five years. The CHW component included home visits, telephone calls, and daily text messages to obtain home blood pressure readings and provide patient navigation and health education. Feasibility was defined as the proportion of patients that responded to at least half the messages. Pre-post paired t-tests assessed improvements in question accuracy while correlation coefficients highlighted improvements in response rates. Among the 65 participants randomized to the intervention, the response rate was as follows: 37% - >50% response, 21% - 25-50%, 19% - 10-25%, and 23% - <10%, This finding suggests that mHealth interventions may be challenging in this population. However, the proportion of questions answered correctly increased from 63% to 84% in the intervention period’s last two months (p<0.05). There was a positive correlation between increased response rates and response accuracy to patient education assessments (r=0.82, p<0.05). These improvements in health knowledge suggest that a subset of patients may benefit from mHealth interventions, and the benefit correlates with use.

SELF-GLUCOSE MONITORING AND HYPOGLYCEMIA RISK IN OLDER RURAL VETERANS WITH TYPE 2 DIABETES

Hypoglycemia evaluation is expected in every encounter with diabetic patients. However, self-monitoring and self-management may not be complete at home, and limited by geriatric syndromes. Furthermore, hypoglycemia risk increases with age, and rurality may limit access to frequent monitoring. We identified 112 rural veterans with high hypoglycemia risk, using the local medication database (sulfonylureas and insulin), combined with age and glycated hemoglobin (HbA1c). Statistical analyses were conduct using SAS 9.4 (Cary, NC). We used Chi-square, Fisher’s, One-way ANOVA for baseline variables, and a multivariate logistic regression model to assess the association of hypoglycemia and risk factors, including age, HbA1c%, self-monitoring, and knowledge. Hypoglycemia was reported in 30.4% of cases, of whom the majority were younger than those not reporting hypoglycemia (72.0±4.3 vs 75.0±6.5 years, p=.015). Baseline HbA1c% was higher in cases with hypoglycemia compared to those without (7.7±1.6% versus 7.3±1.2%, not statistically significant). There were no significant differences between pharmacologic regimens, self-monitoring, and general knowledge. Veterans who knew hypoglycemia symptoms were 6 times more likely to reported hypoglycemia, compared with veterans who did not know any symptoms. We contacted primary care teams (PCT) for whom medications were adjusted. Hypoglycemia risk is high in the older population, and telemedicine programs can support primary care teams to improve management of their patients. Poor symptom knowledge needs to be addressed, while considering special attention for hypoglycemia unawareness in the oldest age group. We are implementing a project using continuous glucose monitoring in this high-risk population.

SOCIAL ISOLATION AND MENTAL HEALTH CHALLENGES AMONG HIGH-NEEDS VETERANS

Using predictive analytic modeling, the Veterans Affairs has identified vulnerable Veterans, labeled as High Need High Risk (HNHR), as those who need greater services and support. To better understand their need gaps, we assessed function, mobility, mood, and caregiver status using a mailed needs assessment questionnaire to 1112 HNHR Veterans. Among the 341(30.7%) respondents, they were primarily 274(80.4%) Non-Hispanics; 210(61.6%) Whites, and 119(34.9%) Black or African Americans; average age was 69.5±9.6 years old; 310(90.4%) had ≥high school education. The average Barthel ADL score was 81.5±22.8 and average Lawton IADL score was 5.8±2.2. Walking or balance issues were present among 260(75.8%), 227(66.2%) said they use an assistive device, and 167(48.7%) had suffered ≥1 fall, 43(12.5%). Regarding depression, 117(34.3%) screened positive (PHQ2 score≥3). These were significantly younger (66.7±9.1) than those who did not (70.8±9.3, p≤0.01). They were also significantly lower functioning (5.37±2.1 vs.6.38±2 Lawton IADL score, p≤0.01), more dependent (77.8±23.1 vs 86±19.2 Barthel ADL score, p≤0.01). We also observed significant differences in their telephone contact with family (never to once/week) [35(29.9%) vs. 27(13.4%), (p≤0.01)]; in meeting with friends or relatives ≥3times a week [12(10.3%) vs. 69(34.3%), (p≤0.01)]; and in likelihood of attending meetings with clubs or other organizations [94(80.3%) vs. 138(68.7%), p=0.040]. Detecting depression is a priority among HNHR Veterans. There is an urgent need to devise viable strategies to offer interventions that incorporate mental health needs and reduce social isolation, potentially addressing mobility, function, and transportation.

GREATER HYPOGLYCEMIA UNAWARENESS IN OLDER COMPARED TO YOUNGER RURAL VETERANS WITH TYPE 2 DIABETES

Hypoglycemia is of great concern in older patients, especially when complicated with multimorbidity and geriatric syndromes. We implemented a telemedicine model to address hypoglycemia knowledge, risk factors, incidence and comanagement with their primary care teams (PCT). We identified 166 consecutive rural veterans with high hypoglycemia risk, based on a local medication database (sulfonylureas and insulin), age, and recent glycated hemoglobin A1c (HbA1c). We conducted a telephone medication reconciliation and survey assessing glucose self-monitoring (GSM), hypoglycemia knowledge and symptoms. Variables were tested using chi-square, Fisher’s, and one-way ANOVA. Multivariable logistic regression model was built to assess the association of hypoglycemia and age group, adjusted with treatment, HbA1c%, self-monitoring, and knowledge. There were 54 veterans aged <65 (younger), and 112 veterans aged ≥65 years (older). Average HbA1c was higher in younger than older (8.20±1.96 vs 7.43±1.34%, p=.003). There was no difference in treatment regimens, but the older had greater GSM (p=.028) and lower hypoglycemia symptom knowledge (p=.026). Symptomatic hypoglycemia was greater in younger versus older (50.0% vs 30.4%, p=0.014). Recent (past-2-weeks) hypoglycemic events were more frequent in younger than older (24.1 vs 1.79%, p<.001). Regression analyses showed that younger veterans were more likely to have hypoglycemia (OD=2.37, 95% CI 1.11-5.04). Our results indicate a great need to evaluate older adults with high hypoglycemia risk, in whom we observed less reports of hypoglycemia albeit with similar regimens and lower HbA1c. We suspect greater hypoglycemia unawareness, thus we are implementing a project using continuous glucose monitoring in this high-risk population.

AGE- AND ETHNICITY-RELATED DISPARITIES IN TECHNOLOGY USE AMONG HIGH-RISK VETERANS

Using predictive analytic modelling, the Veterans Affairs has identified Veterans considered to be High Need High Risk (HNHR) requiring increased support. This pilot study sent needs assessment questionnaires to 1112 HNHR Veterans to better understand gaps regarding technology use, access, physical function, and mobility. There were 341(30.7%) respondents: 270(80.4%) Non-Hispanic, 64(18.8%) Hispanic/Latino; 210(61.6%) White, 119(34.9%) Black/African Americans; and 310(90.4%) had ≥high school education. Average Barthel(ADL) score was 81.5±22.8 and Lawton(IADL) score was 5.8±2.2. Younger Veterans (age<70) were more likely able to use Internet ((117(65%) vs 74(46%)),(p≤0.01) and email (106(58.9%) vs 67(41.6%),( p≤0.01). They were also more likely enrolled in MyHealtheVet (87(48.3%) vs 58(36%),(p=0.043). Secure messaging was used by 62(34.3%) younger and 37(23%) older Veterans,(p=0.026). More higher functioning Veterans (140(55.1%)) used email than lower functioning (33(37.9%)),(p=0.018). Among higher functioning Veterans, 148(58.3%) were willing to use videoconference for care coordination and 116(45.7%) owned a smartphone or computer with camera for this; more than lower functioning Veterans (33(37.9%) and 28(32.2%)), (p≤0.01 for both). Less dependent Veterans preferred to be contacted via cellphone (88(62.4%)) or Internet (10(7.1%)) compared to the more dependent (96(48%) and 6(3%)) respectively (p=0.01). Only 71(44.1%) of older Veterans were willing to use videoconference (p≤0.01) and 54(33.5%) owned a smartphone or computer with camera,(p≤0.01). There are significant variations in technology use by age and ethnicity. However, although there are differences by functional ability, a significant number of disabled veterans are willing and able to use technology, and this may provide a way to address access barriers in this population.

A DECADE OF STROKE CAREGIVER RESEARCH: THE RESCUE CREST STUDY

Stroke caregivers need education and support to care for suddenly disabled family members. To address this need, we are conducting a nurse-led intervention, called RESCUE CREST, to teach caregivers problem-solving skills using an educational website and an online messaging center. In our first, preliminary study, we pre-tested an investigator-created, senior-friendly website called RESCUE (Resources and Education for Stroke Caregivers’ Understanding and Empowerment) using focus groups and interviews with clinicians and caregivers. We refined the website based on additional surveys, a cognitive usability study, and Webtrends analysis. In the second study, we used a single-group pre- and post-test design to evaluate the content and outcomes of the problem-solving intervention. Third, we conducted a four-arm RCT (4-week intervention, 8-week intervention, attention control, standard care) to refine our methods. We will describe the lessons learned and results of our 10 years of stroke caregiver research that provide background for the RESCUE CREST study.

GRECC Connect: Geriatrics Telehealth to Empower Health Care Providers and Improve Management of Older Veterans in Rural Communities

A telehealth program supports meaningful partnerships between urban geriatric specialists and rural health care providers to facilitate increased access to specialty care.

A Patient Portal Intervention for Menopause Knowledge and Shared Decision-Making

Background: Menopause is a time often fraught with changes and symptoms, which may require difficult choices and decision-making. During this period, women would benefit from a better understanding and in-depth discussions with providers regarding menopause, associated conditions, and appropriate therapy. Patient portals offer a potential means to improve knowledge and shared decision-making (SDM) about menopause. Materials and Methods: This protocol article explores the feasibility of using the secure messaging (SM) function of the Veterans Affairs (VA) Patient Portal, "My HealtheVet" to implement an educational intervention and measure its impact on knowledge and SDM in the management of menopause. Results: This is a quality improvement pilot study in which women veterans of menopausal age in the Miami VA are offered an educational intervention via a patient portal, while women veterans in two neighboring VA facilities are not. Intervention participants receive weekly SMs with information on menopause symptoms, and treatment. After 6-months, all participants are surveyed on menopause knowledge, SDM, and satisfaction with the program. Conclusion: This study is among the first to assess the impact of an innovative patient portal intervention to improve knowledge and SDM between patients and providers regarding menopause. If successful, our program will add to the "meaningful use" of patient portals and offer a scalable and timely resource for SDM about menopause.

A commentary on methodological issues in stroke caregiver research: lessons learned from three RESCUE intervention studies

Stroke caregivers represent a distinct population and require unique considerations when conducting intervention research. Unfortunately, there are few published recommendations for conducting intervention trials with stroke caregivers. Thus, the goal of this paper is to provide foundational guidance for stroke caregiving researchers. We describe lessons learned from three trials of the RESCUE intervention to illustrate methodological issues in stroke caregiver research. We identify challenges encountered while conducting a clinical demonstration project, pilot study, and multi-site randomized controlled trial of a problem-solving and skills-building stroke caregiver intervention. We use our research experiences to exemplify or enhance understanding of each issue and describe the strategies we employed to overcome these obstacles. We present issues related to and recommendations for study design, theoretical frameworks, eligibility criteria, recruitment and retention, human subjects protection, intervention design, treatment fidelity, outcome measures, and qualitative methods. Identifying approaches to circumvent methodological challenges can help advance research on and implementation of stroke caregiver programs.

Hispanic Secondary Stroke Prevention Initiative Design: Study Protocol and Rationale for a Randomized Controlled Trial

Background

Hispanic-Latino populations face a disproportionate stroke burden and are less likely to have sufficient control over stroke risk factors in comparison with other ethnic populations. A promising approach to improving chronic health outcomes has been the use of community health workers (CHWs).

Objective

The objective of this randomized controlled trial is to evaluate the effectiveness of a CHW intervention among Latino patients at risk of recurrent stroke.

Methods

The Hispanic Secondary Stroke Prevention Initiative (HiSSPI) is a randomized clinical trial of 300 Latino participants from South Florida who have experienced a stroke within the last 5 years. Participants randomized into the CHW intervention arm receive health education and assistance with health care navigation and social services through home visits and phone calls. The intervention also includes a mHealth component in which participants also receive daily text messages (short message service). The primary outcome is change in systolic blood pressure at 12 months. Other secondary outcomes include changes in low-density lipoprotein, glycated hemoglobin, and medication adherence.

Results

Study enrollment began in 2015 and will be completed by the end of 2018. The first results are expected to be submitted for publication in 2020.

Conclusions

HiSSPI is one of the first randomized controlled trials to examine CHW-facilitated stroke prevention and will provide rigorous evidence on the impact of CHWs on secondary stroke risk factors among Latino individuals who have had a stroke.

Trial Registration

ClinicalTrials.gov NCT02251834; https://clinicaltrials.gov/ct2/show/NCT02251834 (Archived by WebCite at http://www.webcitation.org/72DgMqftq)

International Registered Report Identifier (IRRID)

RR1-10.2196/11083

Association of the CAN score with the FRAIL scale in community dwelling older adults

BACKGROUND

Frailty is a state of vulnerability to stressors which results in higher morbidity, mortality and healthcare utilization. The FRAIL scale is used as a validated screening for frailty. The Care Assessment Need (CAN) score is automatically generated from electronic health record data using a statistical model that includes data elements similar to the deficit accumulation model for frailty and predicts risk for hospitalization and/or mortality.

AIM

To determine the correlation of the CAN score with the FRAIL scale.

METHODS

A cross-sectional study of 503 community-dwelling older adults. We compared the FRAIL scale with the CAN score.

RESULTS

The CAN score was significantly different between robust, prefrail and frail. Post hoc analysis revealed significant increases in scores from robust to prefrail and frail groups, in that order. The CAN score and FRAIL scale showed a correlation.

CONCLUSIONS

The CAN score show a moderate positive association with the FRAIL scale.

The Promise of Electronic Health Records to Promote Shared Decision Making: A Narrative Review and a Look Ahead

BACKGROUND

Shared decision making (SDM) involves the sharing of best available evidence between patients and providers in the face of difficult decisions. We examine outcomes that occur when electronic health records (EHRs) are purposefully used with the goal of improving SDM and detail which EHR functions can benefit SDM.

METHODS

A systematic search of PubMed yielded 1369 articles. Studies were included only if they used EHR interventions to support SDM and included results that showed impact on SDM. Articles were excluded if they did not measure the impact of the intervention on SDM or did not discuss how SDM had been supported by the EHR.

RESULTS

Five studies demonstrated improved clinical outcomes, positive lifestyle behavior changes, more deliberation from patients regarding use of imaging, and less decisional conflict about medication use among patients with use of EHRs aiding SDM.

DISCUSSION

Few EHRs have integrated SDM, and even fewer evaluations of these exist. EHRs have potential in supporting providers during all steps of SDM. The promise of EHRs to support SDM has yet to be fully exploited.

Diabetes Treatment in the Elderly: Incorporating Geriatrics, Technology, and Functional Medicine

PURPOSE OF REVIEW

The current approach to diabetes in the elderly incorporates components from the comprehensive geriatric approach. The most updated guidelines from the American Diabetes Association reflect influence from the consensus made in 2012 with the American Geriatrics Society. Notably, the framework included the evaluation for geriatric syndromes (falls and urinary incontinence), functional and cognitive abilities. The goal for this review is to provide an updated summary of treatment strategies for community-dwelling older adults. We identified the need to expand our approach by addressing innovative approaches and scientific concepts from telemedicine, functional medicine, and geriatrics.

RECENT FINDINGS

Findings on cardiovascular protection with sodium-glucose co-transporter 2 inhibitors (SGLT-2i) and some glucagon-like peptide 1 receptor agonists (GLP-1RA) support their use for older patients with diabetes. However, careful consideration for agent selection must incorporate the presence of geriatric issues, such as geriatric syndromes, or functional and cognitive decline, as they could increase the risk and impact adverse reactions. Telemedicine interventions can improve communication and connection between older patients and their providers, and improve glycemic control. Functional medicine concepts can offer additional adjuvant strategies to support the therapeutic interventions and management of diabetes in the elderly. A systematic review confirmed the efficacy and safety of metformin as first-line therapy of type 2 diabetes in the older adult, but multiple reports highlighted the risk for vitamin B12 deficiency. Randomized controlled trials showed the efficacy and safety of antihyperglycemic agents in the elderly, including some with longer duration and lesser risk for hypoglycemia. Randomized clinical trials showed cardiovascular protection with SGLT-2i (empagliflozin, canagliflozin) and GLP-1RA (liraglutide, semaglutide). The most current guidelines recommend addressing for geriatric syndromes, physical and cognitive function in the elderly, in order to individualize targets and therapeutic strategies. Clinicians managing diabetes in the elderly can play a major role for the early detection and evaluation of geriatric issues in their patients. Telemedicine interventions improve glycemic control, and certain functional medicine strategies could be adjuvant interventions to reduce inflammation and stress, but more studies focused on the elderly population are needed.

Validation of an automatically generated screening score for frailty: the care assessment need (CAN) score

BACKGROUND

Frailty is a state of vulnerability to stressors that is prevalent in older adults and is associated with higher morbidity, mortality and healthcare utilization. Multiple instruments are used to measure frailty; most are time-consuming. The Care Assessment Need (CAN) score is automatically generated from electronic health record data using a statistical model. The methodology for calculation of the CAN score is consistent with the deficit accumulation model of frailty. At a 95 percentile, the CAN score is a predictor of hospitalization and mortality in Veteran populations. The purpose of this study was to validate the CAN score as a screening tool for frailty in primary care.

METHODS

This is a cross-sectional, validation study compared the CAN score with a 40-item Frailty Index reference standard based on a comprehensive geriatric assessment. We included community-dwelling male patients over age 65 from an outpatient geriatric medicine clinic. We calculated the sensitivity, specificity, positive predictive value, negative predictive value and diagnostic accuracy of the CAN score.

RESULTS

184 patients over age 65 were included in the study: 97.3% male, 64.2% White, 80.9% non-Hispanic. The CGA-based Frailty Index defined 14.1% as robust, 53.3% as prefrail and 32.6% as frail. For the frail, statistical analysis demonstrated that a CAN score of 55 provides sensitivity, specificity, PPV and NPV of 91.67, 40.32, 42.64 and 90.91% respectively whereas at a score of 95 the sensitivity, specificity, PPV and NPV were 43.33, 88.81, 63.41, 77.78% respectively. Area under the receiver operating characteristics curve was 0.736 (95% CI = .661-.811).

CONCLUSION

CAN score is a potential screening tool for frailty among older adults; it is generated automatically and provides acceptable diagnostic accuracy. Hence, the CAN score may be a useful tool to primary care providers for detection of frailty in their patient panels.

Mobile Technologies for Managing Heart Failure: A Systematic Review and Meta-analysis

BACKGROUND

Randomized clinical trials (RCTs) conducted among heart failure (HF) patients have reported that mobile technologies can improve HF-related outcomes. Our aim was to conduct a meta-analysis to evaluate m-Health's impact on healthcare services utilization, mortality, and cost.

METHODS

We searched MEDLINE, Cochrane, CINAHL, and EMBASE for studies published between 1966 and May-2017. We included studies that compared the use of m-Health in HF patients to usual care. m-Health is defined as the use of mobile computing and communication technologies to record and transmit data. The outcomes were HF-related and all-cause hospital days, cost, admissions, and mortality.

RESULTS

Our search strategy resulted in 1,494 articles. We included 10 RCTs and 1 quasi-experimental study, which represented 3,109 patients in North America and Europe. Patient average age range was 53-80 years, New York Heart Association (NYHA) class III, and Left Ventricular Ejection Fraction <50%. Patients were mostly monitored daily and followed for an average of 6 months. A reduction was seen in HF-related hospital days. Nonsignificant reductions were seen in HF-related cost, admissions, and mortality and total mortality. We found no significant differences for all-cause hospital days and admissions, and an increase in total cost.

CONCLUSIONS

m-Health reduced HF-related hospital days, showed reduction trends in total mortality and HF-related admissions, mortality and cost, and increased total costs related to more clinic visits and implementation of new technologies. More studies reporting consistent quality outcomes are warranted to give conclusive information about the effectiveness and cost-effectiveness of m-Health interventions for HF.

Systematic review with meta-analysis: effectiveness and tolerability of interferon-free direct-acting antiviral regimens for chronic hepatitis C genotype 1 in routine clinical practice in Asia

BACKGROUND

Direct-acting antiviral (DAA) regimens have shown high efficacy and tolerability for patients with HCV genotype 1/1b (GT1/1b) in clinical trials. However, robust real-world evidence of interferon (IFN)-free DAA treatment for HCV GT1-infected patients in Asia is still lacking.

AIM

To systematically review and meta-analyse the effectiveness and tolerability of IFN-free DAA therapy for HCV GT1 infection in Asia.

METHODS

We included studies that enrolled adult patients with HCV GT1 infection in routine clinical practice in Asia, using IFN-free DAA regimens, and reported sustained virological response (SVR) after 12/24 weeks end-of-treatment by 31 May 2017. The pooled SVR rates were computed with a random-effects model. Subgroup analysis and meta-regression as previously registered in PROSPERO were performed to determine how pre-planned variables might have affected the pooled estimates.

RESULTS

We included 41 studies from eight countries and regions, comprising of 8574 individuals. The pooled SVR rates for GT1 were 89.9% (95% CI 88.6-91.1, I²  = 55.1%) with daclatasvir/asunaprevir (DCV/ASV) and 98.1% (95% CI 97.0-99.0, I²  = 41.0%) with ledipasvir/sofosbuvir ± ribavirin (LDV/SOF ± RBV). Baseline cirrhosis but not prior treatment history and age, attenuated the effectiveness of both regimens. Baseline resistance associated substitutions (RASs) severely attenuated SVR of DCV/ASV (65.4% vs 94.3%, P < 0.001) and only minimally with LDV/SOF ± RBV (94.5% vs 99.2%, P = 0.003). Patients with renal dysfunction treated with DCV/ASV showed a higher SVR rate (93.9% vs 89.8%, P = 0.046). Patients with hepatocellular carcinoma (HCC) LDV/SOF ± RBV achieved a lower SVR than those without HCC (94.1% vs 98.7%, P = 0.001).

CONCLUSION

All oral DAA treatment of HCV GT1 resulted in high cure rates in Asian patients in routine clinical practice setting including elderly patients and those with end-stage renal disease.