Automated Text Message-Based Program and Use of Acute Health Care Resources After Hospital Discharge: A Randomized Clinical Trial

Importance

Postdischarge outreach from the primary care practice is an important component of transitional care support. The most common method of contact is via telephone call, but calls are labor intensive and therefore limited in scope.

Objective

To test whether a 30-day automated texting program to support primary care patients after hospital discharge reduces acute care revisits.

Design, Setting, and Participants

A 2-arm randomized clinical trial was conducted from March 29, 2022, through January 5, 2023, at 30 primary care practices within a single academic health system in Philadelphia, Pennsylvania. Patients were followed up for 60 days after discharge. Investigators were blinded to assignment, but patients and practice staff were not. Participants included established patients of the study practices who were aged 18 years or older, discharged from an acute care hospitalization, and considered medium to high risk for adverse health events by a health system risk score. All analyses were conducted using an intention-to-treat approach.

Intervention

Patients in the intervention group received automated check-in text messages from their primary care practice on a tapering schedule for 30 days following discharge. Any needs identified by the automated messaging platform were escalated to practice staff for follow-up via an electronic medical record inbox. Patients in the control group received a standard transitional care management telephone call from their practice within 2 business days of discharge.

Main Outcomes and Measures

The primary study outcome was any acute care revisit (readmission or emergency department visit) within 30 days of discharge.

Results

Of the 4736 participants, 2824 (59.6%) were female; the mean (SD) age was 65.4 (16.5) years. The mean (SD) length of index hospital stay was 5.5 (7.9) days. A total of 2352 patients were randomized to the intervention arm and 2384 were randomized to the control arm. There were 557 (23.4%) acute care revisits in the control group and 561 (23.9%) in the intervention group within 30 days of discharge (risk ratio, 1.02; 95% CI, 0.92-1.13). Among the patients in the intervention arm, 79.5% answered at least 1 message and 41.9% had at least 1 need identified.

Conclusions and Relevance

In this randomized clinical trial of a 30-day postdischarge automated texting program, there was no significant reduction in acute care revisits.

Trial Registration

ClinicalTrials.gov Identifier: NCT05245773.

Health Equity in the Veterans Health Administration From Veterans' Perspectives by Race and Sex

Importance

Advancing equitable patient-centered care in the Veterans Health Administration (VHA) requires understanding the differential experiences of unique patient groups.

Objective

To inform a comprehensive strategy for improving VHA health equity through the comparative qualitative analysis of care experiences at the VHA among veterans of Black and White race and male and female sex.

Design, Setting, and Participants

This qualitative study used a technique termed freelisting, an anthropologic technique eliciting responses in list form, at an urban academic VHA medical center from August 2, 2021, to February 9, 2022. Participants included veterans with chronic hypertension. The length of individual lists, item order in those lists, and item frequency across lists were used to calculate a salience score for each item, allowing comparison of salient words and topics within and across different groups. Participants were asked about current perceptions of VHA care, challenges in the past year, virtual care, suggestions for change, and experiences of racism. Data were analyzed from February 10 through September 30, 2022.

Main Outcomes and Measures

The Smith salience index, which measures the frequency and rank of each word or phrase, was calculated for each group.

Results

Responses from 49 veterans (12 Black men, 12 Black women, 12 White men, and 13 White women) were compared by race (24 Black and 25 White) and sex (24 men and 25 women). The mean (SD) age was 64.5 (9.2) years. Some positive items were salient across race and sex, including "good medical care" and telehealth as a "comfortable/great option," as were some negative items, including "long waits/delays in getting care," "transportation/traffic challenges," and "anxiety/stress/fear." Reporting "no impact" of racism on experiences of VHA health care was salient across race and sex; however, reports of race-related unprofessional treatment and active avoidance of race-related conflict differed by race (present among Black and not White participants). Experiences of interpersonal interactions also diverged. "Impersonal/cursory" telehealth experiences and the need for "more personal/attentive" care were salient among women and Black participants, but not men or White participants, who associated VHA care with courtesy and respect.

Conclusions and Relevance

In this qualitative freelist study of veteran experiences, divergent experiences of interpersonal care by race and sex provided insights for improving equitable, patient-centered VHA care. Future research and interventions could focus on identifying differences across broader categories both within and beyond race and sex and bolstering efforts to improve respect and personalized care to diverse veteran populations.

Assessment and prevention of hypoglycaemia in primary care among U.S. Veterans: a mixed methods study

Background

Hypoglycaemia from diabetes treatment causes morbidity and lower quality of life, and prevention should be routinely addressed in clinical visits.

Methods

This mixed methods study evaluated how primary care providers (PCPs) assess for and prevent hypoglycaemia by analyzing audio-recorded visits from five Veterans Affairs medical centres in the US. Two investigators independently coded visit dialogue to classify discussions of hypoglycaemia history, anticipatory guidance, and adjustments to hypoglycaemia-causing medications according to diabetes guidelines.

Findings

There were 242 patients (one PCP visit per patient) and 49 PCPs. Two thirds of patients were treated with insulin and 40% with sulfonylureas. Hypoglycaemia history was discussed in 78/242 visits (32%). PCPs provided hypoglycaemia anticipatory guidance in 50 visits (21%) that focused on holding diabetes medications while fasting and carrying glucose tabs; avoiding driving and glucagon were not discussed. Hypoglycaemia-causing medications were de-intensified or adjusted more often (p < 0.001) when the patient reported a history of hypoglycaemia (15/51 visits, 29%) than when the patient reported no hypoglycaemia or it was not discussed (6/191 visits, 3%). Haemoglobin A1c (HbA1c) was not associated with diabetes medication adjustment, and only 5/12 patients (42%) who reported hypoglycaemia with HbA1c <7.0% had medications de-intensified or adjusted.

Interpretation

PCPs discussed hypoglycaemia in one-third of visits for at-risk patients and provided limited hypoglycaemia anticipatory guidance. De-intensifying or adjusting hypoglycaemia-causing medications did not occur routinely after reported hypoglycaemia with HbA1c <7.0%. Routine hypoglycaemia assessment and provision of diabetes self-management education are needed to achieve guideline-concordant hypoglycaemia prevention.

Funding

U.S. Department of Veterans Affairs and National Institute of Diabetes and Digestive and Kidney Diseases (NIDDK).

Interventions to address global inequity in diabetes: international progress

Diabetes is a serious chronic disease with high associated burden and disproportionate costs to communities based on socioeconomic, gender, racial, and ethnic status. Addressing the complex challenges of global inequity in diabetes will require intentional efforts to focus on broader social contexts and systems that supersede individual-level interventions. We codify and highlight best practice approaches to achieve equity in diabetes care and outcomes on a global scale. We outline action plans to target diabetes equity on the basis of the recommendations established by The Lancet Commission on Diabetes, organising interventions by their effect on changing the ecosystem, building capacity, or improving the clinical practice environment. We present international examples of how to address diabetes inequity in the real world to show that approaches addressing the individual within a larger social context, in addition to addressing structural inequity, hold the greatest promise for creating sustainable and equitable change that curbs the global diabetes crisis.

Assessing an electronic self-report method for improving quality of ethnicity and race data in the Veterans Health Administration

Objective

Evaluate self-reported electronic screening (eScreening) in a VA Transition Care Management Program (TCM) to improve the accuracy and completeness of administrative ethnicity and race data.

Materials and Methods

We compared missing, declined, and complete (neither missing nor declined) rates between (1) TCM-eScreening (ethnicity and race entered into electronic tablet directly by patient using eScreening), (2) TCM-EHR (Veteran-completed paper form plus interview, data entered by staff), and (3) Standard-EHR (multiple processes, data entered by staff). The TCM-eScreening (n = 7113) and TCM-EHR groups (n = 7113) included post-9/11 Veterans. Standard-EHR Veterans included all non-TCM Gulf War and post-9/11 Veterans at VA San Diego (n = 92 921).

Results

Ethnicity: TCM-eScreening had lower rates of missingness than TCM-EHR and Standard-EHR (3.0% vs 5.3% and 8.6%, respectively, P < .05), but higher rates of "decline to answer" (7% vs 0.5% and 1.2%, P < .05). TCM-EHR had higher data completeness than TCM-eScreening and Standard-EHR (94.2% vs 90% and 90.2%, respectively, P < .05). Race: No differences between TCM-eScreening and TCM-EHR for missingness (3.5% vs 3.4%, P > .05) or data completeness (89.9% vs 91%, P > .05). Both had better data completeness than Standard-EHR (P < .05), which despite the lowest rate of "decline to answer" (3%) had the highest missingness (10.3%) and lowest overall completeness (86.6%). There was strong agreement between TCM-eScreening and TCM-EHR for ethnicity (Kappa = .92) and for Asian, Black, and White Veteran race (Kappas = .87 to .97), but lower agreement for American Indian/Alaska Native (Kappa = .59) and Native Hawaiian/Other Pacific Islander (Kappa = .50) Veterans.

Conculsions

eScreening is a promising method for improving ethnicity and race data accuracy and completeness in VA.

Racial, Ethnic, and Sex Differences in Methadone-Involved Overdose Deaths Before and After the US Federal Policy Change Expanding Take-home Methadone Doses

Importance

In March 2020, the Substance Abuse and Mental Health Services Administration (SAMHSA) permitted states to relax restrictions on take-home methadone doses for treatment-adherent patients to minimize COVID-19 exposures.

Objective

To assess whether the methadone take-home policy change was associated with drug overdose deaths among different racial, ethnic, and sex groups.

Design, Setting, and Participants

Interrupted time series analysis from January 1, 2018, to June 30, 2022. Data analysis was conducted from February 18, 2023, to February 28, 2023. In this population-based cohort study of drug overdose mortality including 14 529 methadone-involved deaths, monthly counts of methadone-involved drug overdose deaths were obtained for 6 demographic groups: Hispanic men and women, non-Hispanic Black men and women, and non-Hispanic White men and women.

Exposure

On March 16, 2020, in response to the first wave of the COVID-19 pandemic, SAMHSA issued an exemption to the states that permitted up to 28 days of take-home methadone for stable patients and 14 days for less stable patients.

Main Outcome Measures

Monthly methadone-involved overdose deaths.

Results

From January 1, 2018, to June 30, 2022 (54 months), there were 14 529 methadone-involved deaths in the United States; 14 112 (97.1%) occurred in the study's 6 demographic groups (Black men, 1234; Black women, 754; Hispanic men, 1061; Hispanic women, 520; White men, 5991; and White women, 4552). Among Black men, there was a decrease in monthly methadone deaths associated with the March 2020 policy change (change of slope from the preintervention period, -0.55 [95% CI, -0.95 to -0.15]). Hispanic men also experienced a decrease in monthly methadone deaths associated with the policy change (-0.42 [95% CI, -0.68 to -0.17]). Among Black women, Hispanic women, White men, and White women, the policy change was not associated with a change in monthly methadone deaths (Black women, -0.27 [95% CI, -1.13 to 0.59]; Hispanic women, 0.29 [95% CI, -0.46 to 1.04]; White men, -0.08 [95% CI, -1.05 to 0.88]; and White women, -0.43 [95% CI, -1.26 to 0.40]).

Conclusions and Relevance

In this interrupted time series study of monthly methadone-involved overdose deaths, the take-home policy may have helped reduce deaths for Black and Hispanic men but had no association with deaths of Black or Hispanic women or White men or women.

Study protocol: Type III hybrid effectiveness-implementation study implementing Age-Friendly evidence-based practices in the VA to improve outcomes in older adults

BACKGROUND

Unmet care needs among older adults accelerate cognitive and functional decline and increase medical harms, leading to poorer quality of life, more frequent hospitalizations, and premature nursing home admission. The Department of Veterans Affairs (VA) is invested in becoming an "Age-Friendly Health System" to better address four tenets associated with reduced harm and improved outcomes among the 4 million Veterans aged 65 and over receiving VA care. These four tenets focus on "4Ms" that are fundamental to the care of older adults, including (1) what Matters (ensuring that care is consistent with each person's goals and preferences); (2) Medications (only using necessary medications and ensuring that they do not interfere with what matters, mobility, or mentation); (3) Mentation (preventing, identifying, treating, and managing dementia, depression, and delirium); and (4) Mobility (promoting safe movement to maintain function and independence). The Safer Aging through Geriatrics-Informed Evidence-Based Practices (SAGE) Quality Enhancement Research Initiative (QUERI) seeks to implement four evidence-based practices (EBPs) that have shown efficacy in addressing these core tenets of an "Age-Friendly Health System," leading to reduced harm and improved outcomes in older adults.

METHODS

We will implement four EBPs in 9 VA medical centers and associated outpatient clinics using a type III hybrid effectiveness-implementation stepped-wedge trial design. We selected four EBPs that align with Age-Friendly Health System principles: Surgical Pause, EMPOWER (Eliminating Medications Through Patient Ownership of End Results), TAP (Tailored Activities Program), and CAPABLE (Community Aging in Place - Advancing Better Living for Elders). Guided by the Pragmatic Robust Implementation and Sustainability Model (PRISM), we are comparing implementation as usual vs. active facilitation. Reach is our primary implementation outcome, while "facility-free days" is our primary effectiveness outcome across evidence-based practice interventions.

DISCUSSION

To our knowledge, this is the first large-scale randomized effort to implement "Age-Friendly" aligned evidence-based practices. Understanding the barriers and facilitators to implementing these evidence-based practices is essential to successfully help shift current healthcare systems to become Age-Friendly. Effective implementation of this project will improve the care and outcomes of older Veterans and help them age safely within their communities.

TRIAL REGISTRATION

Registered 05 May 2021, at ISRCTN #60,657,985.

REPORTING GUIDELINES

Standards for Reporting Implementation Studies (see attached).

Digital Health and Community Health Worker Support for Diabetes Management: a Randomized Controlled Trial

OBJECTIVE

The aim of this study was to evaluate the effectiveness of a digital health intervention plus community health worker (CHW) support on self-monitoring of blood glucose and glycosylated hemoglobin (HbA1c) among adult Medicaid beneficiaries with diabetes.

DESIGN

Randomized controlled trial.

SETTING

Urban outpatient clinic.

PARTICIPANTS

Adult Medicaid beneficiaries living with diabetes and treated with insulin and who had a HbA1c ≥ 9%.

INTERVENTION

Participants were randomly assigned to one of three arms. Participants in the usual-care arm received a wireless glucometer if needed. Those in the digital arm received a lottery incentive for daily glucose monitoring. Those in the hybrid arm received the lottery plus support from a CHW if they had low adherence or high blood glucose levels.

MAIN MEASURES

The primary outcome was the difference in adherence to daily glucose self-monitoring at 3 months between the hybrid and usual-care arms. The secondary outcome was difference in HbA1c from baseline at 6 months.

KEY RESULTS

A total of 150 participants were enrolled in the study. A total of 102 participants (68%) completed the study. At 3 months, glucose self-monitoring rates in the hybrid versus usual-care arms were 0.72 vs 0.65, p = 0.23. At 6 months, change in HbA1c in the hybrid versus usual-care arms was - 0.74% vs - 0.49%, p = 0.69.

CONCLUSION

There were no statistically significant differences between the hybrid and usual care in glucose self-monitoring adherence or improvements in HbA1C.

TRIAL REGISTRATION

This trial is registered with clinicaltrials.gov identifier: NCT03939793.

Evaluation of an Automated Text Message-Based Program to Reduce Use of Acute Health Care Resources After Hospital Discharge

IMPORTANCE

Posthospital contact with a primary care team is an established pillar of safe transitions. The prevailing model of telephone outreach is usually limited in scope and operationally burdensome.

OBJECTIVE

To determine whether a 30-day automated texting program to support primary care patients after hospital discharge is associated with reductions in the use of acute care resources.

DESIGN, SETTING, AND PARTICIPANTS

This cohort study used a difference-in-differences approach at 2 academic primary care practices in Philadelphia from January 27 through August 27, 2021. Established patients of the study practices who were 18 years or older, were discharged from an acute care hospitalization, and received the usual transitional care management telephone call were eligible for the study. At the intervention practice, 604 discharges were eligible and 430 (374 patients, of whom 46 had >1 discharge) were enrolled in the intervention. At the control practice, 953 patients met eligibility criteria. The study period, including before and after the intervention, ran from August 27, 2020, through August 27, 2021.

EXPOSURE

Patients received automated check-in text messages from their primary care practice on a tapering schedule during the 30 days after discharge. Any needs identified by the automated messaging platform were escalated to practice staff for follow-up via an electronic medical record inbox.

MAIN OUTCOMES AND MEASURES

The primary study outcome was any emergency department (ED) visit or readmission within 30 days of discharge. Secondary outcomes included any ED visit or any readmission within 30 days, analyzed separately, and 30- and 60-day mortality. Analyses were based on intention to treat.

RESULTS

A total of 1885 patients (mean [SD] age, 63.2 [17.3] years; 1101 women [58.4%]) representing 2617 discharges (447 before and 604 after the intervention at the intervention practice; 613 before and 953 after the intervention at the control practice) were included in the analysis. The adjusted odds ratio (aOR) for any use of acute care resources after implementation of the intervention was 0.59 (95% CI, 0.38-0.92). The aOR for an ED visit was 0.77 (95% CI, 0.45-1.30) and for a readmission was 0.45 (95% CI, 0.23-0.86). The aORs for death within 30 and 60 days of discharge at the intervention practice were 0.92 (95% CI, 0.23-3.61) and 0.63 (95% CI, 0.21-1.85), respectively.

CONCLUSIONS AND RELEVANCE

The findings of this cohort study suggest that an automated texting program to support primary care patients after hospital discharge was associated with significant reductions in use of acute care resources. This patient-centered approach may serve as a model for improving postdischarge care.

Solutions to Address Inequity in Diabetes Technology Use in Type 1 Diabetes: Results from Multidisciplinary Stakeholder Co-creation Workshops

Background: Racial-ethnic inequity in type 1 diabetes technology use is well documented and contributes to disparities in glycemic and long-term outcomes. However, solutions to address technology inequity remain sparse and lack stakeholder input. Methods: We employed user-centered design principles to conduct workshop sessions with multidisciplinary panels of stakeholders, building off of our prior study highlighting patient-identified barriers and proposed solutions. Stakeholders were convened to review our prior findings and co-create interventions to increase technology use among underserved populations with type 1 diabetes. Stakeholders included type 1 diabetes patients who had recently onboarded to technology; endocrinology and primary care physicians; nurses; diabetes educators; psychologists; and community health workers. Sessions were recorded and analyzed iteratively by multiple coders for common themes. Results: We convened 7 virtual 2-h workshops for 32 stakeholders from 11 states in the United States. Patients and providers confirmed prior published studies highlighting patient barriers and generated new ideas by co-creating solutions. Common themes of proposed interventions included (1) prioritizing more equitable systems of offering technology, (2) using visual and hands-on approaches to increase accessibility of technology and education, (3) including peer and family support systems more, and (4) assisting with insurance navigation and social needs. Discussion: Our study furthers the field by providing stakeholder-endorsed intervention ideas that propose feasible changes at the patient, provider, and system levels to reduce inequity in diabetes technology use in type 1 diabetes. Multidisciplinary stakeholder engagement in disparities research offers unique insight that is impactful and acceptable to the target population.

Perspectives on Racism in Health Care Among Black Veterans With Chronic Kidney Disease

IMPORTANCE

The burden of chronic kidney disease (CKD) and end-stage kidney disease falls disproportionately on Black individuals in the US, with Black veterans experiencing substantial consequences, and only a portion of the disparities in health conditions and health care can be explained by nonbiological factors. Among Black individuals, racism is likely one of those factors, suggesting the need to examine the consequences of racism and the resulting social structures that establish and perpetuate these racial disparities.

OBJECTIVE

To investigate the health care experiences of Black veterans with CKD and identify and explore the racial discrimination encountered by this vulnerable population.

DESIGN, SETTING, AND PARTICIPANTS

This qualitative study used semistructured interview guides to investigate the health care experiences of 36 Black veterans with CKD who received care at the Corporal Michael Crescenz Veterans Affairs Medical Center in Philadelphia, Pennsylvania, from October 2018 to September 2019. Interview transcripts were analyzed using applied thematic analysis.

RESULTS

Among 36 Black veterans with CKD who characterized racism in the context of their care at a Veterans Affairs medical center, the mean (SD) age was 66.0 (7.8) years; 35 participants (97.2%) were male, 1 participant (2.8%) was female, and 19 participants (52.8%) were married. The mean (SD) duration of military service was 8.0 (7.0) years. Overall, 15 participants (41.7%) were not dependent on dialysis, and hypertension was the most common comorbidity (9 participants [25.0%]). Veterans described the ways in which racism produced emotional and physical stress, including psychological symptoms (eg, anger and hurt) and physiological symptoms (eg, headaches). Veterans described a strong sense of distrust in the health care system coupled with a need to be hypervigilant during clinical encounters. When encountering racism, veterans described bottling up their feelings, which sometimes led to maladaptive behavior (eg, substance use). Veterans also described individual and collective positive strategies (eg, faith) for coping with the stress of racism.

CONCLUSIONS AND RELEVANCE

In this study, Black veterans with CKD experienced racism in the clinical setting that produced physical and emotional stress and a strong sense of distrust in the health care system. These findings highlight an important opportunity for education and training of health care professionals in the implementation of trauma-informed approaches to care as a means of addressing race-based stress and trauma.

Pediatric Hospitalizations from Immigration Detention in Texas, 2015-2018

Although there are concerns regarding children's health in immigration detention, there are little data regarding hospitalizations in this population. Using 2015-2018 Texas inpatient data, we identified 95 hospitalizations of children in detention and found that most (60%) were driven by infectious causes, and that 37% of these children were admitted to an intensive care unit (ICU) or intermediate ICU.

Transcriptome analysis of blastoderms exposed to prolonged egg storage and short periods of incubation during egg storage

BACKGROUND

Cool temperature egg storage prior to incubation is a common practice in the broiler industry; however, prolonged egg storage causes increased embryonic mortality and decreased hatchability and growth in surviving chicks. Exposing eggs to short periods of incubation during egg storage (SPIDES) reduces the adverse consequences of prolonged storage. SPIDES increases blastodermal cell viability by reducing apoptosis, though the counteracting mechanisms are unclear. To define the impact of prolonged storage and SPIDES, transcriptome analysis compared gene expression from blastoderms isolated from eggs exposed to the following treatments: control (CR, stored at 17 °C for 4 days), prolonged storage (NSR, stored at 17 °C for 21 days), SPIDES (SR, stored at 17 °C for 21 days with SPIDES), and incubated control (C2, stored at 17 °C for 4 days followed by incubation to HH (Hamburger-Hamilton) stage 2, used as the ideal standard development) (n = 3/group). Data analysis was performed using the CLC Genomics Workbench platform. Functional annotation was performed using DAVID and QIAGEN Ingenuity Pathway Analysis.

RESULTS

In total, 4726 DEGs (differentially expressed genes) were identified across all experimental group comparisons (q < 0.05, FPKM> 20, |fold change| > 1.5). DEGs common across experimental comparisons were involved in cellular homeostasis and cytoskeletal protein binding. The NSR group exhibited activation of ubiquitination, apoptotic, and cell senescence processes. The SR group showed activation of cell viability, division, and metabolic processes. Through comparison analysis, cellular respiration, tRNA charging, cell cycle control, and HMBG1 signaling pathways were significantly impacted by treatment and potential regulatory roles for ribosomal protein L23a (RPL23A) and MYC proto-oncogene, BHLH transcription factor (MYC) were identified.

CONCLUSIONS

Prolonged egg storage (NSR) resulted in enriched cell stress and death pathways; while SPIDES (SR) resulted in enriched basic cell and anti-apoptotic pathways. New insights into DNA repair mechanisms, RNA processing, shifts in metabolism, and chromatin dynamics in relation to egg storage treatment were obtained through this study. Although egg storage protocols have been examined through targeted gene expression approaches, this study provided a global view of the extensive molecular networks affected by prolonged storage and SPIDES and helped to identify potential upstream regulators for future experiments to optimize egg storage parameters.

Design of a randomized controlled trial of digital health and community health worker support for diabetes management among low-income patients

BACKGROUND

Insulin-dependent diabetes is a challenging disease to manage and involves complex behaviors, such as self-monitoring of blood glucose. This can be especially challenging in the face of socioeconomic barriers and in the wake of the COVID-19 pandemic. Digital health self-monitoring interventions and community health worker support are promising and complementary best practices for improving diabetes-related health behaviors and outcomes. Yet, these strategies have not been tested in combination. This protocol paper describes the rationale and design of a trial that measures the combined effect of digital health and community health worker support on glucose self-monitoring and glycosylated hemoglobin.

METHODS

The study population was uninsured or publicly insured; lived in high-poverty, urban neighborhoods; and had poorly controlled diabetes mellitus with insulin dependence. The study consisted of three arms: usual diabetes care; digital health self-monitoring; or combined digital health and community health worker support. The primary outcome was adherence to blood glucose self-monitoring. The exploratory outcome was change in glycosylated hemoglobin.

CONCLUSION

The design of this trial was grounded in social justice and community engagement. The study protocols were designed in collaboration with frontline community health workers, the study aim was explicit about furthering knowledge useful for advancing health equity, and the population was focused on low-income people. This trial will advance knowledge of whether combining digital health and community health worker interventions can improve glucose self-monitoring and diabetes-related outcomes in a high-risk population.

Adult hospitalizations from immigration detention in Louisiana and Texas, 2015-2018

Poor health conditions within immigration detention facilities have attracted significant concerns from policymakers and activists alike. There is no systematic data on the causes of hospitalizations from immigration detention facilities or their relative morbidity. The objective of this study, therefore, was to analyze the causes of hospitalizations from immigration detention facilities, as well as the percentage of hospitalizations necessitating ICU or intermediate-ICU (i.e, "step-down") admission and the types of surgical and interventional procedures conducted during these hospitalizations. We conducted a cross-sectional study of statewide adult (age 18 and greater) hospitalization data, with hospitalizations attributed to immigration facilities via payor designations (from Immigration and Customs Enforcement) and geospatial data in Texas and Louisiana from 2015-2018. Our analysis identified 5,215 hospitalizations of which 887 met inclusion criteria for analysis. Average age was 36 (standard deviation, 13.7), and 23.6% were female. The most common causes of hospitalization were related to infectious diseases (207, 23.3%) and psychiatric illness (147, 16.6%). 340 (38.3%) hospitalizations required a surgical or interventional procedure. Seventy-two (8.1%) hospitalizations required ICU admission and 175 (19.5%) required intermediate ICU. In this relatively young cohort, hospitalizations from immigration detention were accompanied with significant morbidity. Policymakers should mitigate the medical risks of immigration detention by improving access to medical and psychiatric care in facilities.

Incorporating African American Veterans' Success Stories for Hypertension Management: Developing a Behavioral Support Texting Protocol

Background

Peer narratives engage listeners through personally relevant content and have been shown to promote lifestyle change and effective self-management among patients with hypertension. Incorporating key quotations from these stories into follow-up text messages is a novel way to continue the conversation, providing reinforcement of health behaviors in the patients’ daily lives.

Objective

In our previous work, we developed and tested videos in which African American Veterans shared stories of challenges and success strategies related to hypertension self-management. This study aims to describe our process for developing a text-messaging protocol intended for use after viewing videos that incorporate the voices of these Veterans.

Methods

We used a multistep process, transforming video-recorded story excerpts from 5 Veterans into 160-character texts. We then integrated these into comprehensive 6-month texting protocols. We began with an iterative review of story transcripts to identify vernacular features and key self-management concepts emphasized by each storyteller. We worked with 2 Veteran consultants who guided our narrative text message development in substantive ways, as we sought to craft culturally sensitive content for texts. Informed by Veteran input on timing and integration, supplementary educational and 2-way interactive assessment text messages were also developed.

Results

Within the Veterans Affairs texting system Annie, we programmed five 6-month text-messaging protocols that included cycles of 3 text message types: narrative messages, nonnarrative educational messages, and 2-way interactive messages assessing self-efficacy and behavior related to hypertension self-management. Each protocol corresponds to a single Veteran storyteller, allowing Veterans to choose the story that most resonates with their own life experiences.

Conclusions

We crafted a culturally sensitive text-messaging protocol using narrative content referenced in Veteran stories to support effective hypertension self-management. Integrating narrative content into a mobile health texting intervention provides a low-cost way to support longitudinal behavior change. A randomized trial is underway to test its impact on the lifestyle changes and blood pressure of African American Veterans.

Trial Registration

ClinicalTrials.gov NCT03970590; https://clinicaltrials.gov/ct2/show/NCT03970590

International Registered Report Identifier (IRRID)

DERR1-10.2196/29423

[Non-infectious emergencies of the lower urinary tract and genitals]

INTRODUCTION

The objective of this narrative review was to report the most relevant data on the contemporary management of the main non-infectious emergencies of the lower urinary tract and genital organs.

METHODS

A narrative synthesis of the articles (French, English) available on the Pubmed database was carried out in June 2021. A request to the health surveillance network for emergencies and deaths (SurSaUD®, Santé Publique France) revealed original data on the epidemiology of non-infectious lower urinary tract and genital organs emergencies.

RESULTS

Non-infectious emergencies of the low urinary tract and genital organs represent a large panel of traumatic and non-traumatic situations, which constitute the 3rd reasons in urology for a consultation at the emergency department after, infectious disease (1st) and non-traumatic/non-infectious emergencies of the upper urinary tract (2nd). Hematuria is the 3rd urological reason for men for a consultation at the emergency department. Globally, pelvic trauma and genital traumatism mainly concern men. These emergencies rarely affect the prognosis but can be integrated into more complete situations which are likely to impact their treatment, particularly in multiple traumas.

CONCLUSIONS

In this article we report the epidemiology and the principles of management of non-infectious emergencies of the lower urinary tract and genital organs.

"I Didn't Really Have a Choice": Qualitative Analysis of Racial-Ethnic Disparities in Diabetes Technology Use Among Young Adults with Type 1 Diabetes

Background: Racial-ethnic disparities in diabetes technology use are well documented in young adults (YA) with type 1 diabetes (T1D), but modifiable targets for intervention still need to be identified. Our objective was to explore YA perspectives on technology access and support in routine clinical care. Materials and Methods: Participants were YA with T1D of Hispanic or non-Hispanic Black race-ethnicity from pediatric and adult endocrinology clinics in the Bronx, NY. We conducted semistructured individual interviews to explore how health care and personal experiences affected technology use. Interviews were audio-recorded and transcribed for analysis. We used a modified inductive coding approach with two independent coders and iterative coding processes to improve data reliability and validity. Results: We interviewed 40 YA with T1D: mean age 22 years; 62% female; 72% Medicaid insured; 72% Hispanic; 28% non-Hispanic Black; and mean hemoglobin A1C 10.3%. Themes were categorized into potentially exacerbating and alleviating factors of racial-ethnic disparities in technology use. Exacerbating factors included perceptions that providers were gatekeepers of information and prescription access to technology, providers did not employ shared decision making for use, and YA biases against technology were left unaddressed. Alleviating factors included provider optimism and tailoring of technology benefits to YA needs, and adequate Medicaid insurance coverage. Conclusions: Our results reveal potential intervention targets at the provider level to increase technology uptake among underrepresented YA with T1D. Diabetes health care providers need to be aware of inadvertent withholding of information and prescription access to technology. Provider approaches that address YA technology concerns and promote shared decision making help to mitigate racial/ethnic disparities in technology use.

[Infectious emergencies in urology]

OBJECTIVE

To report the nature, diagnosis and therapeutic strategy of infectious emergencies in urology.

MATERIAL AND METHODS

Bibliographic research from Pubmed, Embase, and Google scholar in July 2021. A synthesis of the guidelines of national infectious diseases societies.

RESULTS

Urosepsis and complicated urinary tract infection have a standardized definition. Diagnosis and therapeutic strategy are presented for upper tract urinary infection, male urinary infection, healthcare associated urinary infection, symptomatic canduria and urinary infections of the elderly. Appropriate antibiotherapy should be tailored to the degree of severity, bacterial ecosystem, patient characteristics et localization of the infection.

CONCLUSION

Urinary infections can be critical and require immediate care. Knowledge of the guidelines and of appropriate diagnosis and therapeutics strategy improve care which should be rapidly applied, and collegial.

Miniaturized percutaneous nephrolithotomy versus retrograde intrarenal surgery in the treatment of lower pole renal stones

OBJECTIVES

Miniaturization of percutaneous nephrolithotomy techniques have led to their increased consideration for lower pole renal stones that can prove more challenging to reach using retrograde intrarenal surgery. The objectives of the present study were to evaluate and compare the outcomes of miniaturized percutaneous nephrolithotomy (miniPCNL) and retrograde intrarenal surgery (RIRS) for the treatment of lower pole renal stones.

MATERIALS AND METHODS

A retrospective study was performed in two academic urology departments between January 2016 and June 2019. Patients presenting with one or multiple stones of the lower calyx and/or renal pelvis, between 10 and 40mm based on CT-scan treated by miniPCNL or RIRS were included.

RESULTS

In all, 115 miniPCNL and 118 RIRS procedures were included. The rate of patients with no significant residual fragment (stone free rate) after the first procedure was higher in the miniPCNL group (69% vs. 52% P=0.01), especially for stones>20mm (63% vs. 24% respectively, P<0.001) and stones with a density≥1000HU (69% vs. 42% respectively, P=0.009). The higher stone free rate of miniPCNL was confirmed in multivariate analysis, adjusting for stone size and number of stones, OR 4.02 (95% CI 2.08-8.11, P<0.0001). The overall postoperative complication rate was higher in the miniPCNL group than in the RIRS group (23% vs. 11%, P=0.01). A second intervention for the treatment of residual fragments was necessary for 9.6% of patients in the miniPCNL group versus 30.5% of patients in the RIRS group (P<0.001). Pre-stenting rate and duration of ureteral drainage (2 [1-8] vs. 25 days [7-37], P<0.001) were lower in the miniPCNL group.

CONCLUSIONS

The stone free rate was higher after miniPCNL, especially for stones>20mm and with a density>1000 HU, but was associated with a higher risk of postoperative complications and a longer hospital stay. RIRS resulted in fewer complications at the cost of a higher retreatment rate and longer ureteral stenting.

LEVEL OF EVIDENCE

3.

Evaluation of a collaborative VA network initiative to reduce racial disparities in blood pressure control among veterans with severe hypertension

BACKGROUND

Compared to White patients in the United States, Black patients have a higher prevalence of hypertension and more severe forms of this condition.

OBJECTIVE

To decrease racial disparities in blood pressure (BP) control among Black veterans with severe hypertension within a regional network of Veterans Affairs Medical Centers (VAMCs).

METHODS

Health system leaders, clinicians, and health services researchers collaborated on a 12-month quality improvement (QI) project to: (1) examine project implementation and the QI strategies used to improve BP control and (2) assess the effect of the initiative on Black-White differences in BP control among veterans with severe hypertension.

RESULTS

Within 9 participating VAMCs, the most frequently used QI strategies involved provider education (n=9), provider audit and feedback (n=8), and health care team change (n=7). Among 141,124 veterans with a diagnosis of hypertension, 9,913 had severe hypertension [2,533 (25.6%) Black and 7380 (74.4%) White]. Over the course of the project, the proportion of Black veterans with severe hypertension decreased from 7.5% to 6.6% (p=.002) and the racial difference in proportions for this condition decreased 0.9 percentage points, from 2.9% to 2.0% (p=.01).

CONCLUSIONS

A multicenter, equity-focused QI project in VA reduced the proportion of Black veterans with severe hypertension and ameliorated observed racial disparities for this condition. Embedding health services researchers within a QI team facilitated an evaluation of the processes and effectiveness of our initiative, providing a successful model for QI within a learning health care system.

Evidence-Based Community Health Worker Program Addresses Unmet Social Needs And Generates Positive Return On Investment

Interventions that address socioeconomic determinants of health are receiving considerable attention from policy makers and health care executives. The interest is fueled in part by expected returns on investment. However, many current estimates of returns on investment are likely overestimated, because they are based on pre-post study designs that are susceptible to regression to the mean. We present a return-on-investment analysis that is based on a randomized controlled trial of Individualized Management for Patient-Centered Targets (IMPaCT), a standardized community health worker intervention that addresses unmet social needs for disadvantaged people. We found that every dollar invested in the intervention would return $2.47 to an average Medicaid payer within the fiscal year.

Racial-Ethnic Disparities in Diabetes Technology use Among Young Adults with Type 1 Diabetes

Background: Recent studies highlight racial-ethnic disparities in insulin pump and continuous glucose monitor (CGM) use in people with type 1 diabetes (T1D), but drivers of disparities remain poorly understood beyond socioeconomic status (SES). Methods: We recruited a diverse sample of young adults (YA) with T1D from six diabetes centers across the United States, enrolling equal numbers of non-Hispanic (NH) White, NH Black, and Hispanic YA. We used multivariate logistic regression to examine to what extent SES, demographics, health care factors (care setting, clinic attendance), and diabetes self-management (diabetes numeracy, self-monitoring of blood glucose, and Self-Care Inventory score) explained insulin pump and CGM use in each racial-ethnic group. Results: We recruited 300 YA with T1D, aged 18-28 years. Fifty-two percent were publicly insured, and the mean hemoglobin A1c was 9.5%. Large racial-ethnic disparities in insulin pump and CGM use existed: 72% and 71% for NH White, 40% and 37% for Hispanic, and 18% and 28% for NH Black, respectively. After multiple adjustment, insulin pump and CGM use remained disparate: 61% and 53% for NH White, 49% and 58% for Hispanic, and 20 and 31% for NH Black, respectively. Conclusions: Insulin pump and CGM use was the lowest in NH Black, intermediate in Hispanic, and highest in NH White YA with T1D. SES was not the sole driver of disparities nor did additional demographic, health care, or diabetes-specific factors fully explain disparities, especially between NH Black and White YA. Future work should examine how minority YA preferences, provider implicit bias, systemic racism, and mistrust of medical systems help to explain disparities in diabetes technology use.

The Gears of Knowledge Translation: Process Evaluation of the Dissemination and Implementation of a Patient Engagement Toolkit

BACKGROUND

Patient engagement is a key tenet of patient-centered care and is associated with many positive health outcomes. To improve resources for patient engagement, we created a web-based, interactive patient engagement toolkit to improve patient engagement in primary care across the Veterans Health Administration (VHA).

OBJECTIVE

To use the knowledge translation (KT) framework to evaluate the dissemination and implementation of a patient engagement toolkit at facilities across one region in the VHA.

DESIGN

Using a mixed-methods approach, this process evaluation involved phone monitoring via semi-structured interviews and group meetings, during which we explored barriers and facilitators to KT. Outcomes were assessed using a structured rubric and existing patient satisfaction measures.

PARTICIPANTS

We enlisted implementers at 40 VHA facilities primarily serving Pennsylvania, New Jersey, and Delaware to implement patient engagement practices at their sites. Sites were randomly assigned into a high or low coaching group to assess whether external support influenced implementation.

KEY RESULTS

Sites with high rubric scores employed and possessed several elements across the KT trajectory from identification of the problem to sustainment of knowledge use. Key factors for successful implementation and dissemination included implementer engagement, organizational support, and strong collaborators. The most frequently cited barriers included short staffing, time availability, lack of buy-in, and issues with leadership. Successful implementers experienced just as many barriers, but leveraged facilitators to overcome obstacles. While sites that received more coaching did not have different outcomes, they were more likely to revisit the toolkit and indicated that they felt more accountable to local personnel.

CONCLUSIONS

Because leveraging available resources is a key component of successful implementation, future toolkits should highlight the type of facilitators necessary for successful implementation of toolkit content in healthcare settings. The ability to tailor interventions to local context is critical for overcoming barriers faced in most healthcare settings.

In ovo culturing of turkey (Meleagris gallopavo) ovarian tissue to assess graft viability and maturation of prefollicular germ cells and follicles

Biobanking of turkey ovarian tissue appears to be the most cost-effective method for the long-term preservation of female genetics. However, to ensure the successful transplantation of biobanked ovarian tissue for breed or line revival, the transplantation and development of fresh ovarian tissue must be evaluated. To assess transplantability, ovaries from poults 1 to 15 days posthatch (dph) were cultured in ovo in chicken eggs for 6 d and compared with the equivalent fresh tissue. The viability of cultured ovarian tissue was evaluated visually, whereas the level of late-stage apoptosis was measured via the TUNEL assay. In addition, the diameter and density of prefollicular germ cells and follicles (primordial and primary) were measured to assess maturation. Results showed that all cultured grafts (74/74), on surviving chicken chorioallantoic membrane, were viable with low levels (0.8 ± 0.1%) of late-stage apoptosis. The diameter of prefollicular germ cells in cultured ovaries from poults at 5 and 7 dph were larger (P < 0.002) than that of their preculture counterparts but were not able to reach their in vivo size. No significant follicular growth was observed in ovaries cultured in ovo; however, prefollicular germ cell density was over 4-fold greater in ovaries cultured from 7 dph poults (81,030 ± 17,611/mm³) than in their in vivo counterpart (16,463 ± 6,805/mm³). Interestingly, cultured ovaries from all other ages displayed equal or lower (P ≤ 0.05) prefollicular germ cell densities than their in vivo counterparts. Cultured ovaries from poults at 5 and 7 dph also exhibited an increase (P ≤ 0.05) in follicle density compared with their preculture counterparts; whereas, cultured ovaries from 15 dph poults had decreased densities (P < 0.001) compared with their preculture counterparts. This study demonstrated that, although age of ovarian tissue cultured in ovo did not affect the overall viability, 7 dph ovaries appeared to have a better cellular morphology after culturing in ovo than other ages. In addition, we also demonstrated for the first time that avian follicles can form during tissue culturing in ovo.

Effect of Peer Mentors in Diabetes Self-management vs Usual Care on Outcomes in US Veterans With Type 2 Diabetes: A Randomized Clinical Trial

IMPORTANCE

Diabetes is a substantial public health issue. Peer mentoring is a low-cost intervention for improving glycemic control in patients with diabetes. However, long-term effects of peer mentoring and creation of sustainable models are not well studied.

OBJECTIVE

Assess the effects of a peer support intervention for improving glycemic control in patients with diabetes and evaluate a model in which former mentees serve as mentors.

DESIGN, SETTING, AND PARTICIPANTS

A randomized clinical trial was conducted from September 27, 2012, to March 21, 2018, at the Corporal Michael J. Crescenz Medical Center. US veterans with type 2 diabetes aged 30 to 75 years with hemoglobin A1C (HbA1c) greater than 8% received support over 6 months from peers with prior poor glycemic control but who had achieved HbA1c less than or equal to 7.5% (phase 1). Phase 1 mentees were then randomized to become a mentor or not to new randomly assigned participants in phase 2. Outcomes were assessed at 6 and 12 months. Data were analyzed from October 5, 2016, to September 4, 2018.

INTERVENTIONS

Mentors who received an initial training session and monthly reinforcement training were assigned 1 mentee and given $20 for each month they contacted their mentee at least weekly.

MAIN OUTCOMES AND MEASURES

Primary outcome was HbA1c change at 6 months. Secondary outcomes included HbA1c change at 12 months and change in low-density lipoprotein, blood pressure, diabetes quality of life, and depression symptoms at 6 and 12 months.

RESULTS

The study enrolled 365 participants into phase 1 and 122 participants into phase 2. Most participants were Black (341 [66%]) and male (454 [96%]), with a mean (SD) age of 60 (7.5) years. Mean phase 1 HbA1c change at 6 months for usual care was -0.20% (95% CI, -0.46% to 0.06%) vs -0.52% (95% CI, -0.76% to -0.29%) for mentees (P = .06). Mean phase 2 HbA1c change at 6 months for usual care was -0.46% (95% CI, -1.02% to 0.10%) vs 0.08% (95% CI, -0.42% to 0.57%) for mentees (P = .16). There were no differences in secondary outcomes or HbA1c levels at 12 months. There was no benefit to past mentees who became mentors.

CONCLUSIONS AND RELEVANCE

In this randomized clinical trial, a peer mentor intervention did not improve 6-month HbA1c levels and did not have sustained benefits.

TRIAL REGISTRATION

ClinicalTrials.gov Identifier: NCT01651117.

Racial-Ethnic Inequity in Young Adults With Type 1 Diabetes

CONTEXT

Minority young adults (YA) currently represent the largest growing population with type 1 diabetes (T1D) and experience very poor outcomes. Modifiable drivers of disparities need to be identified, but are not well-studied.

OBJECTIVE

To describe racial-ethnic disparities among YA with T1D and identify drivers of glycemic disparity other than socioeconomic status (SES).

DESIGN

Cross-sectional multicenter collection of patient and chart-reported variables, including SES, social determinants of health, and diabetes-specific factors, with comparison between non-Hispanic White, non-Hispanic Black, and Hispanic YA and multilevel modeling to identify variables that account for glycemic disparity apart from SES.

SETTING

Six diabetes centers across the United States.

PARTICIPANTS

A total of 300 YA with T1D (18-28 years: 33% non-Hispanic White, 32% non-Hispanic Black, and 34% Hispanic).

MAIN OUTCOME

Racial-ethnic disparity in HbA1c levels.

RESULTS

Non-Hispanic Black and Hispanic YA had lower SES, higher HbA1c levels, and much lower diabetes technology use than non-Hispanic White YA (P < 0.001). Non-Hispanic Black YA differed from Hispanic, reporting higher diabetes distress and lower self-management (P < 0.001). After accounting for SES, differences in HbA1c levels disappeared between non-Hispanic White and Hispanic YA, whereas they remained for non-Hispanic Black YA (+ 2.26% [24 mmol/mol], P < 0.001). Diabetes technology use, diabetes distress, and disease self-management accounted for a significant portion of the remaining non-Hispanic Black-White glycemic disparity.

CONCLUSION

This study demonstrated large racial-ethnic inequity in YA with T1D, especially among non-Hispanic Black participants. Our findings reveal key opportunities for clinicians to potentially mitigate glycemic disparity in minority YA by promoting diabetes technology use, connecting with social programs, and tailoring support for disease self-management and diabetes distress to account for social contextual factors.

Effects of a standardized community health worker intervention on hospitalization among disadvantaged patients with multiple chronic conditions: A pooled analysis of three clinical trials

OBJECTIVE

To analyze the effects of a standardized community health worker (CHW) intervention on hospitalization.

DATA SOURCES/STUDY SETTING

Pooled data from three randomized clinical trials (n = 1340) conducted between 2011 and 2016.

STUDY DESIGN

The trials in this pooled analysis were conducted across diseases and settings, with a common study design, intervention, and outcome measures. Participants were patients living in high-poverty regions of Philadelphia and were predominantly Medicaid insured. They were randomly assigned to receive usual care versus IMPaCT, an intervention in which CHWs provide tailored social support, health behavior coaching, connection with resources, and health system navigation. Trial one (n = 446) tested two weeks of IMPaCT among hospitalized general medical patients. Trial two (n = 302) tested six months of IMPaCT among outpatients at two academic primary care clinics. Trial three (n = 592) tested six months of IMPaCT among outpatients at academic, Veterans Affairs (VA), and Federally Qualified Health Center primary care practices.

DATA COLLECTION/EXTRACTION METHODS

The primary outcome for this study was all-cause hospitalization, as measured by total number of hospital days per patient. Hospitalization data were collected from statewide or VA databases at 30 days postenrollment in Trial 1, twelve months postenrollment in Trial 2, and nine months postenrollment in Trial 3.

PRINCIPAL FINDINGS

Over 9398 observed patient months, the total number of hospital days per patient in the intervention group was 66 percent of the total in the control group (849 days for 674 intervention patients vs 1258 days for 660 control patients, incidence rate ratio (IRR) 0.66, P < .0001). This reduction was driven by fewer hospitalizations per patient (0.27 vs 0.34, P < .0001) and shorter mean length of stay (4.72 vs 5.57 days, P = .03). The intervention also decreased rates of hospitalization outside patients' primary health system (18.8 percent vs 34.8 percent, P = .0023).

CONCLUSIONS

Data from three randomized clinical trials across multiple settings show that a standardized CHW intervention reduced total hospital days and hospitalizations outside the primary health system. This is the largest analysis of randomized trials to demonstrate reductions in hospitalization with a health system-based social intervention.

Germ cell dynamics during nest breakdown and formation of the primordial follicle pool in the domestic turkey (Meleagris gallopavo)

This study determined, for the first time, the different subpopulations of germ cells and stereological changes within the cortex of the functional left ovary during germ cell nest breakdown, and formation of the primordial follicle pool in the domestic turkey. This was accomplished by measuring the size, density, and count of prefollicular germ cells and primordial follicles in turkey poults between 1 and 35 days posthatch (dph). The percent volume (PV) of germ cells and follicles within the cortex was also calculated as a means of validating the counting technique. The total percent volume of germ cells and primordial follicles within the cortex ranged between 42 and 84%, suggesting that the counting technique was valid. Our findings show that before germ cell nest breakdown (5 dph), there were roughly 1,000,000 prefollicular germ cells within the cortex of the left ovary and that germ cell nest breakdown initiated between 5 and 7 dph, characterized by a decrease (P ≤ 0.001) in prefollicular germ cell density and the subsequent appearance of primordial follicles. Nest breakdown is followed on day 9 by the first increase (P ≤ 0.05) in size of prefollicular germ cells. These cells continue to grow throughout nest breakdown. The majority (>90%) of germ cell nest breakdowns concluded by 15 dph; although, the primordial follicle pool was not fully established until 35 dph, as determined by a total lack of prefollicular germ cells. At this point, the pool was comprised of an estimated 60,000 primordial follicles and shows that during nest breakdown and follicle pool formation, ∼94% of germ cells were lost. This 94% decrease in the number of germ cells during nest breakdown in the turkey is comparable to the domestic chicken but is greater than the average two-thirds which are lost in mammalian species.

Impact of a Multidisciplinary, Endocrinologist-Led Shared Medical Appointment Model on Diabetes-Related Outcomes in an Underserved Population

A multidisciplinary endocrinologist-led shared medical appointment (SMA) model showed statistically significant reductions in A1C from baseline over 3 years that were not significantly different from appointments with endocrinologists or primary care providers alone within a resource-poor population. Similarly, the SMA model achieved clinical outcomes on par with endocrinologist-only visits with the added benefit of improving endocrine provider productivity and specialty access for patients. Greater patient engagement with the SMA model was associated with significantly lower A1C.

Peripheral histamine and neonatal growth performance in swine

Identification of plasma and/or serum markers at birth that will predict animal performance may be useful for identifying animals susceptible to poor growth. Metabolomic analysis of plasma from newborn swine was used to identified potential metabolite differences between 8 pairs of littermates with similar birth weights but whose ADG differed by >50 g/d so that, at weaning (21 d), littermates differed in BW by 1.62 kg (P < 0.01). Plasma analysis failed to identify metabolic pathways impacted by growth, most likely because of the small sample population. Interestingly, despite comparative analysis of 576 metabolites between these slow-growing and normal-growing littermates, the relative abundance of only 36 metabolites differed between the pairs. Most of these metabolites could be eliminated as potential markers because of the difficulty with the extraction and rapid measurement of their plasma/serum concentrations. Histamine differed from most of these potential metabolite markers in that commercial sandwich ELISAs are readily available. Using an ELISA, we verified the metabolomic data, demonstrating that plasma histamine concentrations were 150% higher in slow-growing than normal growing littermates of similar birth weight (P < 0.05). Subsequently, a separate data set was obtained using swine from a different geographical location and genetic background and also showed that elevated histamine (ng/mL) at birth is associated with increased preweaning growth rate (P = 0.009, r = 0.306, n = 9 litters). Together, the data indicate that perinatal histamine concentrations may serve as a tool to identify potentially slower growing pigs and as a serum biomarker for predicting litter growth rate.

Feasibility of Diabetes Self-Management Telehealth Education for Older Adults During Transitions in Care

The current study investigated the feasibility of telehealth-delivered diabetes self-management education and support (DSMES) for older adults with type 2 diabetes mellitus following hospital discharge. The intervention included one in-person home visit and follow-up weekly virtual DSMES for 4 additional weeks. Diabetes knowledge was measured at baseline and completion of the program. The Telehealth Usability Questionnaire was completed following the final session. Hemoglobin A1C (A1C) level was abstracted from the electronic health record at baseline and 3 months post hospital discharge. Hospital re-admissions were measured at 30 days post index hospital stay. Of the 20 patients enrolled, 12 completed the intervention. The most common reason for attrition was discharge to a skilled nursing facility (3/20). Participants who completed the intervention increased their diabetes knowledge scores. A1C values decreased by 1.1%, and there were no hospital readmissions for any patient who completed the program. Participants described the program as useful and were satisfied with the program. These results suggest that it is feasible to identify and enroll patients in a telehealth education program for diabetes during hospital admission. [Research in Gerontological Nursing, 13(3), 138-145.].

Insights Into Veterans' Perspectives on a Peer Support Program for Glycemic Management

PURPOSE

The purpose of this study was to explore the mentor-mentee relationship in veterans with type 2 diabetes and gain insight into successful pairings.

METHODS

Qualitative semistructured interviews were conducted as part of a peer mentoring randomized controlled trial to understand participants' experiences, their relationship with their partner, and how the intervention affected self-care behaviors. Purposive sampling was done to ensure adequate representation of mentees who made large strides in reaching their glycemic targets, those who made marginal improvements toward their glycemic goals, and those who got worse. All interviews were audio-recorded, transcribed, and analyzed for salient themes.

RESULTS

The intervention was well received, with most participants describing it as valuable. Participants perceived the intervention to have a number of benefits, including accessible support, enhanced self-confidence, increased accountability, better self-efficacy, improved glycemic management, and a fulfilled sense of altruism. Participants did encounter barriers, including logistical, interpersonal, and individual obstacles. The more successful mentees tended to be more effusive in their description of their mentors, endorsed a stronger sense of connection to their mentor, described a more structured interaction with their mentor, and tended to be more complimentary of the intervention.

CONCLUSIONS

Large peer support programs are appealing and well received. These programs can be optimized by selecting naturally inclined mentors, providing additional training to introduce more structure into mentorship interactions, and targeting mentees who are not struggling with overwhelming comorbidities.

Effectiveness of Technologically Enhanced Peer Support in Improving Glycemic Management Among Predominantly African American, Low-Income Adults With Diabetes

PURPOSE

The purpose of the study was to examine whether a peer coaching intervention is more effective in improving clinical outcomes in diabetes when enhanced with e-health educational tools than peer coaching alone.

METHODS

The effectiveness of peer coaches who used an individually tailored, interactive, web-based tool (iDecide) was compared with peer coaches with no access to the tool. Two hundred and ninety Veterans Affairs patients with A1C ≥8.0% received a 6-month intervention with an initial session with a fellow patient trained to be a peer coach, followed by weekly phone calls to discuss behavioral goals. Participants were randomized to coaches who used iDecide or coaches who used nontailored educational materials at the initial session. Outcomes were A1C (primary), blood pressure, and diabetes social support (secondary) at 6 and 12 months.

RESULTS

Two hundred and fifty-five participants (88%) completed 6-month and 237 (82%) 12-month follow-up. Ninety-eight percent were men, and 63% were African American. Participants in both groups improved A1C values (>-0.6%, P < .001) at 6 months and maintained these gains at 12-month follow-up ( >-0.5%, P < .005). Diabetes social support was improved at both 6 and 12 months ( P < .01). There were no changes in blood pressure.

CONCLUSIONS

Clinical gains achieved through a volunteer peer coach program were not increased by the addition of a tailored e-health educational tool.

Long-term oncological outcomes of cystic renal cell carcinoma according to the Bosniak classification

OBJECTIVES

To evaluate the prognostic role of the Bosniak classification on the long-term oncological outcomes of cystic renal cell carcinomas.

MATERIAL AND METHOD

In a national multicentric retrospective study, we included patients treated surgically for localized cystic RCC from 2000 to 2010. Patients with a follow-up of less than 4 years, benign tumors, and ablative treatments were excluded. The primary outcome was disease-free survival.

RESULTS

152 patients met the inclusion criteria: Bosniak II (6%), III (53%), IV (41%), with a median follow-up of 61 (12-179) months. Characteristics of the population and the tumors were [median, (min-max)] age 57 (25-84) years old, tumor size 43 mm (20-280), RENAL score 7 (4-12), PADUA score 8 (5-14). Treatments were 55% partial nephrectomy, 45% radical nephrectomy, 74% open surgery, and 26% laparoscopy. In pathological report, cystic RCC were mainly of low grade (1-2, 77%) and low stage (pT1, 81%). The two main histological subtypes were conventional (56%) and papillary (23%) RCC. Staging at presentation and histological characteristics were similar between Bosniak III and IV, except for high grade which was more common in Bosniak IV (12 vs 36%, p < 0.01). The Bosniak classification was not predictive of the recurrence, as 5- and 10-year disease-free survival were similar in Bosniak III and IV (92% vs 92% and 84% vs 83%, p = 0.60).

CONCLUSION

The Bosniak classification is predictive of the risk of malignancy but not of the oncological prognosis. Regardless of the initial Bosniak categories, almost all cystic RCCs were of low stage/grade and had low long-term recurrence rate.

Pathways to Abortion at a Tertiary Care Hospital: Examining Obesity and Delays

CONTEXT

Advancing gestational age can increase the cost of an abortion and is a significant risk factor for complications. While obesity is not associated with increased risks, anecdotal evidence suggests that obese women seeking services at freestanding abortion clinics are often referred for hospital-based care, which can lead to delays.

METHODS

In 2016, a cross-sectional survey collected data on the experiences of 201 women who had obtained abortions at a hospital-based clinic in Philadelphia; rates of medical complications were determined from hospital records. Multivariable logistic regression analysis was used to assess if obesity was associated with whether patients had been referred from freestanding abortion clinics or reported other paths to care. Differences in wait time and up-front out-of-pocket costs were examined by women's referral status.

RESULTS

No difference in rates of abortion complications was found between patient groups. Women who were severely obese (body mass index of at least 40 kg/m² ) were more likely than normal-weight individuals to have been referred from a freestanding abortion clinic (odds ratio, 7.5). The median wait time to get an abortion was 28 days for referred patients and 12 days for others. Multivariable analysis confirmed that referred patients waited twice as long as other patients (rate ratio, 2.0) and paid 66% more in up-front costs.

CONCLUSIONS

Future research is needed to determine whether obese women seeking abortions are being referred despite evidence that they do not require hospital-based care. If obese women are suffering delays because of referral, strategies to help overcome delay should also be explored.

Effect of Community Health Worker Support on Clinical Outcomes of Low-Income Patients Across Primary Care Facilities: A Randomized Clinical Trial

IMPORTANCE

Addressing the social determinants of health has been difficult for health systems to operationalize.

OBJECTIVE

To assess a standardized intervention, Individualized Management for Patient-Centered Targets (IMPaCT), delivered by community health workers (CHWs) across 3 health systems.

DESIGN, SETTING, AND PARTICIPANTS

This 2-armed, single-blind, multicenter randomized clinical trial recruited patients from 3 primary care facilities in Philadelphia, Pennsylvania, between January 28, 2015, and March 28, 2016. Patients who resided in a high-poverty zip code, were uninsured or publicly insured, and who had a diagnosis for 2 or more chronic diseases were recruited, and patients were randomized to either the CHW intervention or the control arm (goal setting only). Follow-up assessments were conducted at 6 and 9 months after enrollment. Data were analyzed using an intention-to-treat approach from June 2017 to March 2018.

INTERVENTION

Participants set a chronic disease management goal with their primary care physician; those randomized to the CHW intervention received 6 months of tailored support.

MAIN OUTCOMES AND MEASURES

The primary outcome was change in self-rated physical health. The secondary outcomes were self-rated mental health, chronic disease control, patient activation, patient-reported quality of primary care, and all-cause hospitalization.

RESULTS

Of the 592 participants, 370 (62.5%) were female, with a mean (SD) age of 52.6 (11.1) years. Participants in both arms had similar improvements in self-rated physical health (mean [SD], 1.8 [11.2] vs 1.6 [9.9]; P = .89). Patients in the intervention group were more likely to report the highest quality of care (odds ratio [OR], 1.8; 95% CI, 1.4-2.4; risk difference [RD], 0.12; P < .001) and spent fewer total days in the hospital at 6 months (155 days vs 345 days; absolute event rate reduction, 69%) and 9 months (300 days vs 471 days; absolute event rate reduction, 65%). This reduction was driven by a shorter average length of stay (difference, -3.1 days; 95% CI, -6.33 to 0.22; P = .06) and a lower mean number of hospitalizations (difference, -0.3; 95% CI, -0.6 to 0.0; P = .07) among patients who were hospitalized. Patients in the intervention group had a lower odds of repeat hospitalizations (OR, 0.4; 95% CI, 0.2-0.9; RD, -0.24; P = .02), including 30-day readmissions (OR, 0.3; 95% CI, 0.1-0.9; RD, -0.17; P = .04).

CONCLUSIONS AND RELEVANCE

A standardized intervention did not improve self-rated health but did improve the patient-perceived quality of care while reducing hospitalizations, suggesting that health systems may use a standardized intervention to address the social determinants of health.

TRIAL REGISTRATION

ClinicalTrials.gov identifier: NCT02347787.

Why Effective Interventions Do Not Work for All Patients: Exploring Variation in Response to a Chronic Disease Management Intervention

BACKGROUND

Half of all Americans have a chronic disease. Promoting healthy behaviors to decrease this burden is a national priority. A number of behavioral interventions have proven efficacy; yet even the most effective of these has high levels of nonresponse.

OBJECTIVES

In this study, we explore variation in response to an evidence-based community health worker (CHW) intervention for chronic disease management.

RESEARCH DESIGN

We used a convergent parallel design that combined a randomized controlled trial with a qualitative process evaluation that triangulated chart abstraction, in-depth interviews and participant observation.

SUBJECTS

Eligible patients lived in a high-poverty region and were diagnosed with 2 or more of the following chronic diseases: diabetes, obesity, hypertension or tobacco dependence. There were 302 patients in the trial, 150 of whom were randomly assigned to the CHW intervention. Twenty patients and their CHWs were included in the qualitative evaluation.

RESULTS

We found minimal differences between responders and nonresponders by sociodemographic or clinical characteristics. A qualitative process evaluation revealed that health behavior change was challenging for all patients and most experienced failure (ie, gaining weight or relapsing with cigarettes) along the way. Responders seemed to increase their resolve after failed attempts at health behavior change, while nonresponders became discouraged and "shut down."

CONCLUSIONS

Failure is a common and consequential aspect of health behavior change; a deeper understanding of failure should inform chronic disease interventions.

Physician Experiences With High Value Care in Internal Medicine Residency: Mixed-Methods Study of 2003-2013 Residency Graduates

Phenomenon: High healthcare costs and relatively poor health outcomes in the United States have led to calls to improve the teaching of high value care (defined as care that balances potential benefits of interventions with their harms including costs) to physicians-in-training. Numerous interventions to increase high value care in graduate medical education were implemented at the national and local levels over the past decade. However, there has been little evaluation of their impact on physician experiences during training and perceived preparedness for practice. We aimed to assess trends in U.S. physician experiences with high value care during residency over the past decade.

APPROACH

This mixed-methods study used a cross-sectional survey mailed July 2014 to January 2015 to 902 internists who completed residency in 2003-2013, randomly selected from the American Medical Association Masterfile. Quantitative analyses of survey responses and content analysis of free-text comments submitted by respondents were performed.

FINDINGS

A total of 456 physicians (50.6%) responded. Fewer than one fourth reported being exposed to teaching about high value care at least frequently (23.6%, 106/450). Only 43.8% of respondents (193/446) felt prepared to use overtreatment guidelines in conversations with patients, whereas 85.8% (379/447) felt prepared to participate in shared decision making with patients at the conclusion of their training, and 84.4% (380/450) reported practicing generic prescribing. Physicians who completed residency more recently were more likely to report practicing generic prescribing and feeling well prepared to use overtreatment guidelines in conversations with patients (p < .01 for both). Insights: In a national survey, recent U.S. internal medicine residency graduates were more likely to experience high value care during training, which may reflect increased national and local efforts in this area. However, being exposed to high value care as a trainee may not translate into specific tools for practice. In fact, many U.S. internists reported inadequate exposure to prepare them for patient discussions about costs and the use of overtreatment guidelines in practice.

Community Health Worker Support for Disadvantaged Patients With Multiple Chronic Diseases: A Randomized Clinical Trial

OBJECTIVES

To determine whether a community health worker (CHW) intervention improved outcomes in a low-income population with multiple chronic conditions.

METHODS

We conducted a single-blind, randomized clinical trial in Philadelphia, Pennsylvania (2013-2014). Participants (n = 302) were high-poverty neighborhood residents, uninsured or publicly insured, and diagnosed with 2 or more chronic diseases (diabetes, obesity, tobacco dependence, hypertension). All patients set a disease-management goal. Patients randomly assigned to CHWs also received 6 months of support tailored to their goals and preferences.

RESULTS

Support from CHWs (vs goal-setting alone) led to improvements in several chronic diseases (changes in glycosylated hemoglobin: -0.4 vs 0.0; body mass index: -0.3 vs -0.1; cigarettes per day: -5.5 vs -1.3; systolic blood pressure: -1.8 vs -11.2; overall P = .08), self-rated mental health (12-item Short Form survey; 2.3 vs -0.2; P = .008), and quality of care (Consumer Assessment of Healthcare Providers and Systems; 62.9% vs 38%; P < .001), while reducing hospitalization at 1 year by 28% (P = .11). There were no differences in patient activation or self-rated physical health.

CONCLUSIONS

A standardized CHW intervention improved chronic disease control, mental health, quality of care, and hospitalizations and could be a useful population health management tool for health care systems.

TRIAL REGISTRATION

clinicaltrials.gov identifier: NCT01900470.

US internists' awareness and use of overtreatment guidelines: a national survey

OBJECTIVES

To assess physician views and perceived adoption of overtreatment guidelines and measure whether adoption of these guidelines influenced the recommendation of a targeted service.

STUDY DESIGN

A cross-sectional survey mailed from July 2014 to January 2015 to 902 internists who completed residency between 2003 and 2013, randomly selected from the American Medical Association Masterfile.

METHODS

Poisson regression was used to model the rate of recommending a targeted service included in the guidelines, based on the level of guideline adoption.

RESULTS

A total of 456 physicians responded (51% response rate). Most expressed familiarity with overtreatment guidelines (88.5%), a comfort level with discussing these guidelines with patients (79.9%), and described overtreatment guidelines as a useful tool in their practice (81.6%). Physicians in the highest tertile of guideline adoption reported double-digit rates of recommending antibiotics for sinusitis (29.7%), mammogram at end of life (16.5%), and electrocardiogram testing for asymptomatic patients (11.0%). Physicians in the bottom tertile of guideline adoption reported lower rates of recommending x rays (-12.0%; 95% confidence interval [CI], -19.4% to -4.5%; P = .002), magnetic resonance imaging for lower back pain (-4.8%; 95% CI, -8.1% to -1.5%; P = .004), and cardiac testing for asymptomatic patients (-10.2%; 95% CI, -18.9% to -1.5%; P = .02).

CONCLUSIONS

US internal medicine physicians who completed residency between 2003 and 2013 reported high levels of adoption of overtreatment guidelines. Physicians who reported the highest levels of guideline adoption reported recommending services targeted by these guidelines in their practice.

Patient and Partner Feedback Reports to Improve Statin Medication Adherence: A Randomized Control Trial

BACKGROUND

Simple nudges such as reminders and feedback reports to either a patient or a partner may facilitate improved medication adherence.

OBJECTIVE

To test the impact of a pill bottle used to monitor adherence, deliver a daily alarm, and generate weekly medication adherence feedback reports on statin adherence.

DESIGN

Three-month, three-arm randomized clinical trial (ClinicalTrials.gov identifier: NCT02480530).

PARTICIPANTS

One hundred and twenty-six veterans with known coronary artery disease and poor adherence (medication possession ratio <80 %).

INTERVENTION

Patients were randomized to one of three groups: (1) a control group (n = 36) that received a pill-monitoring device with no alarms or feedback; (2) an individual feedback group (n = 36) that received a daily alarm and a weekly medication adherence feedback report; and (3) a partner feedback group (n = 54) that received an alarm and a weekly feedback report that was shared with a friend, family member, or a peer. The intervention continued for 3 months, and participants were followed for an additional 3 months after the intervention period.

MAIN MEASURES

Adherence as measured by pill bottle. Secondary outcomes included change in LDL (mg/dl), patient activation, and social support.

KEY RESULTS

During the 3-month intervention period, medication adherence was higher in both feedback arms than in the control arm (individual feedback group 89 %, partner feedback group 86 %, control group 67 %; p < 0.001 and = 0.001). At 6 months, there was no difference in medication adherence between either of the feedback groups and the control (individual feedback 60 %, partner feedback 52 %, control group 54 %; p = 0.75 and 0.97).

CONCLUSIONS

Daily alarms combined with individual or partner feedback reports improved statin medication adherence. While neither an individual feedback nor partner feedback strategy created a sustainable medication adherence habit, the intervention itself is relatively easy to implement and low cost.

Decision-making and goal-setting in chronic disease management: Baseline findings of a randomized controlled trial

OBJECTIVE

Growing interest in collaborative goal-setting has raised questions. First, are patients making the 'right choices' from a biomedical perspective? Second, are patients and providers setting goals of appropriate difficulty? Finally, what types of support will patients need to accomplish their goals? We analyzed goals and action plans from a trial of collaborative goal-setting among 302 residents of a high-poverty urban region who had multiple chronic conditions.

METHODS

Patients used a low-literacy aid to prioritize one of their chronic conditions and then set a goal for that condition with their primary care provider. Patients created patient-driven action plans for reaching these goals.

RESULTS

Patients chose to focus on conditions that were in poor control and set ambitious chronic disease management goals. The mean goal weight loss -16.8lbs (SD 19.5), goal HbA1C reduction was -1.3% (SD 1.7%) and goal blood pressure reduction was -9.8mmHg (SD 19.2mmHg). Patient-driven action plans spanned domains including health behavior (58.9%) and psychosocial (23.5%).

CONCLUSIONS

High-risk, low-SES patients identified high priority conditions, set ambitious goals and generate individualized action plans for chronic disease management.

PRACTICE IMPLICATIONS

Practices may require flexible personnel who can support patients using a blend of coaching, social support and navigation.

A randomized controlled trial of a community health worker intervention in a population of patients with multiple chronic diseases: Study design and protocol

Upstream interventions - e.g. housing programs and community health worker interventions- address socioeconomic and behavioral factors that influence health outcomes across diseases. Studying these types of interventions in clinical trials raises a methodological challenge: how should researchers measure the effect of an upstream intervention in a sample of patients with different diseases? This paper addresses this question using an illustrative protocol of a randomized controlled trial of collaborative-goal setting versus goal-setting plus community health worker support among patients multiple chronic diseases: diabetes, obesity, hypertension and tobacco dependence. At study enrollment, patients met with their primary care providers to select one of their chronic diseases to focus on during the study, and to collaboratively set a goal for that disease. Patients randomly assigned to a community health worker also received six months of support to address socioeconomic and behavioral barriers to chronic disease control. The primary hypothesis was that there would be differences in patients' selected chronic disease control as measured by HbA1c, body mass index, systolic blood pressure and cigarettes per day, between the goal-setting alone and community health worker support arms. To test this hypothesis, we will conduct a stratum specific multivariate analysis of variance which allows all patients (regardless of their selected chronic disease) to be included in a single model for the primary outcome. Population health researchers can use this approach to measure clinical outcomes across diseases.

CLINICAL TRIALS REGISTRATION

ClinicalTrials.gov Identifier: NCT01900470.

An Adult Health Care–Based Pediatric to Adult Transition Program for Emerging Adults With Type 1 Diabetes

Purpose

The purpose of the study was to evaluate an adult health care program model for emerging adults with type 1 diabetes transitioning from pediatric to adult care.

Methods

Evaluation of the Pediatric to Adult Diabetes Transition Clinic at the University of Pennsylvania included a cohort of 72 emerging adults with type 1 diabetes, ages 18 to 25 years. Data were extracted from transfer summaries and the electronic medical record, including sociodemographic, clinical, and follow-up characteristics. Pre- and postprogram assessment at 6 months included mean daily blood glucose monitoring frequency (BGMF) and glycemic control (A1C). Paired t tests were used to examine change in outcomes from baseline to 6 months, and multiple linear regression was utilized to adjust outcomes for baseline A1C or BGMF, sex, diabetes duration, race, and insulin regimen. Open-ended survey responses were used to assess acceptability amongst participants.

Results

From baseline to 6 months, mean A1C decreased by 0.7% (8 mmol/mol), and BGMF increased by 1 check per day. Eighty-eight percent of participants attended ≥2 visits in 6 months, and the program was rated highly by participants and providers (pediatric and adult).

Conclusions

This study highlights the promise of an adult health care program model for pediatric to adult diabetes transition.