Search

Background Limited research has reported the economic feasibility—from both a research and practice perspective—of efforts to recruit and enroll an intended audience in evidence-based approaches for disease prevention. This study aims to retrospectively assess and estimate the costs of a population health management (PHM) approach to identify, engage, and enroll patients in a Type 1 Hybrid Effectiveness-Implementation (HEI), diabetes-prevention trial. Methods We used descriptive analyses and activity-based costing to estimate the recruitment costs of a PHM approach integrated within a HEI trial. Measures included total costs and costs per participant screened and enrolled to ensure trial accrual rates were achieved. We took the perspective of a healthcare system which may adopt, and possibly sustain, the strategy in the typical practice. We also estimated replication costs based on how the strategy could be applied in healthcare systems interested in referring patients to a local diabetes prevention program from a payer perspective. In this case, we examined differences in cost based on requirements for and types of, glucose testing, and by labor activities and non-labor resources associated with recruitment using sensitivity analyses. Results The total recruitment and enrollment costs were $389,949 to accrue 599 participants over approximately 15 months. The average cost per screened and enrolled participant was $276 and $651, respectively. Primary costs included hemoglobin A1c testing ($83,106), recruitment screening calls ($48,791), and personnel time ($96,187). Translating to the typical settings, total recruitment costs for replication was estimated as $192,625 (range: $42,523-$208,876). Sensitivity analysis results indicated replication costs would be approximately $229 - $430 per patient enrolled if glucose testing was necessary, based on the Medicare covered services. For a private payer perspective, and without glucose testing, per-participant screening and enrollment costs were estimated at $30. Conclusions A PHM approach can be used to accrue a large number of participants in a short period of time for an HEI trial, at a comparable cost per participant. However, when trial requirements are removed and PHM approaches are used as a method for healthcare systems to identify and enroll patients in a local program—the costs are relatively low.

Introduction: Despite growing documentation of the efficacy of telemedicine in diabetes management, racial disparities in telemedicine-facilitated diabetes management remain underexplored. This study examined disparities in diabetes management outcomes between black and white patients with type 2 diabetes (T2D) in a remote monitoring program. Methods: The analysis sample included 914 white T2D patients and 365 black T2D patients in Nebraska who completed a 3-month remote patient monitoring and coaching after hospital discharge from 2014 to 2017. Ordinary least squares regression was estimated to examine racial differences in hemoglobin A1c (HbA1c), and logistic regression was used to determine the odds of HbA1c > 9% at the end of the program, controlling for demographics, baseline health conditions, and patient activation and engagement with the program. Results: The proportion of white patients with HbA1c > 9% was reduced from 16% at the baseline to 7% at program completion, and the corresponding reduction among black patients was from 30% to 18%. After adjusting for the effects of baseline HbA1c and other covariates, the average HbA1c among black patients at the end of the program was 0.23 points higher than that among white patients (p 9% was 1.68 times that of white patients (95% confidence interval [1.07-2.63]). Discussion: The remote patient monitoring and coaching program reduced the absolute gap between black and white T2D patients. However, substantial racial disparities in HbA1c still remained at the end of the program and warranted further research.

The primary function of the patient portal is to give patients greater access to their personal health information. Granting patients electronic access allows them to make well-informed health care decisions. This study aimed to identify sociodemographic differences in patient portal use and examine factors affecting patient portal utilization following the final stage of the Meaningful Use program which aimed to promote the use of certified electronic health record (EHR) technology. Survey data from Health Information National Trends Survey (HINTS) 5, cycles 1, 2, and 3 were analyzed. The sample included 8291 completed surveys. Multivariable logistic regression on a selected response for each surveyed question was used to assess the racial and ethnic difference after controlling for age, sex, income, and education. Subjects included English and Spanish speaking adults in the USA. Measures included assessment of patient portal use, patient portal access, understanding health information, usefulness of health records, and privacy and security. After adjusting for age, sex, income, and education, there was a significant association between race/ethnicity and patient portal non-users responding, “no need to use online medical record” as the reason for not using the patient portal (P = 0.005). Among the portal users, there were significant associations between race/ethnicity and health care provider maintaining an EHR (P = 0.006), being offered access to their portal (P

Background: Evidence-based guidelines for the management of type 2 diabetes (T2D) consist of blood glucose monitoring, medication adherence, and lifestyle modifications that may particularly benefit from reminders, consultation, education, and behavioral reinforcements through remote patient monitoring (RPM). Objectives: To identify predictors of weight loss and to examine the association between weight loss and hemoglobin A1C (HbA1C) outcomes for T2D patients who were enrolled in an RPM program for diabetes management. Materials and Methods: The study applied logistic and ordinary least-squares regression models to examine the relationship between baseline characteristics and the likelihood of weight loss during the RPM, and how the magnitude of weight loss was related to changes in HbA1C outcomes for 1,103 T2D patients who went through 3 months of RPM from 2014 to 2017. Results: Older patients were 3% more likely to have weight loss (odds ratio [OR], 1.03; 95% confidence interval [CI], 1.02-1.05), whereas patients with higher baseline HbA1C had 9% reduced odds (OR, 0.91; 95% CI, 0.85-0.97) of experiencing weight loss. For every pound of weight lost, there was a 0.02-point (95% CI, 0.01-0.03) reduction on the HbA1C measured at the end of the RPM. Moreover, compared with those who had weight loss of ≤3%, participants who had lost 5-7%, or >7% of their baseline weight had a 0.37- and 0.58-point reduction in HbA1C, respectively. Conclusions: This study revealed a notable relationship between weight loss and positive HbA1C outcomes for T2D patients in an RPM-facilitated diabetes management program, which pointed to the potential of integrating evidence-based lifestyle modification programs into future telemedicine programs to improve diabetes management outcomes.

Background: Several family-based efficacious pediatric weight management interventions (PWMIs) have been developed to reduce child weight status. These programs are typically based in larger cities...

Objectives: The objectives of our study were to (1) illustrate a public health workforce assessment process in a medium-sized city or county health department and (2) demonstrate the insights gained by moving from the use of aggregate department-level and competency domain-level training needs results to more granular division-level and skills-level results when creating a workforce development plan. Methods: We used a 130-question needs assessment to guide the creation of a workforce development plan for the Lincoln Lancaster County Health Department (LLCHD) in Nebraska and its 7 divisions. Using SurveyMonkey, we administered the survey to 128 (of the 129) LLCHD public health staff members in June 2015. Using a Likert scale, respondents indicated (1) the importance of the skill to their work and (2) their capacity to carry out 57 skills in 8 domains of the core competencies for public health professionals. We identified training needs as those for which the percentage of respondents who perceived moderate-to-high importance was at least 15 percentage points higher than the percentage of respondents who perceived moderate-to-high capacity. Results: LLCHD as a department had training needs in only 2 competency domains: financial planning and management (importance-capacity difference, 15 percentage points) and policy development and program planning (importance-capacity difference, 19 percentage points). The Health Promotion and Outreach division had training needs in all 8 domains (importance-capacity difference range, 15-45 percentage points). Of the 57 skills, 41 were identified by at least 1 of the LLCHD divisions as having training needs. In 24 instances, a division did not qualify as having training needs in the overall domain yet did have training needs for specific skills within a domain. Conclusions: When performing public health workforce assessments, medium-to-large public health departments can obtain detailed workforce training needs results that pertain to individual skills and that are tailored to each of their divisions. These results may help customize and improve workforce development plans, ensuring that the workforce has the necessary skills to do its job.

Background Association between high adiposity and the clinical progression of dementia remains puzzling. Objective To separately examine the association between body mass index (BMI) and cognitive, functional, and behavioral declines before, at, and after diagnosis of dementia, and further stratified by age groups, and sex. Methods A total of 1,141 individuals with incident dementia were identified from the Uniform Data Set of the National Alzheimer's Coordinating Center. Cognitive function was evaluated by Mini-Mental State Exam, functional abilities were assessed using Functional Activities Questionnaire, and behavioral symptoms were captured by Neuropsychiatric Inventory Questionnaire at each follow-up visit. We used separate linear-mixed effects models to examine the association. Results Compared to moderate baseline BMI, high baseline BMI was associated with 0.30-point slower annual progression rates in functional decline. For individuals aged 76 and over, high baseline BMI was associated with 0.42-point faster progression rates in cognitive decline annually. A U-shaped association between baseline BMI and cognitive decline was observed among men. Conclusion BMI levels before dementia diagnosis may facilitate the identification of different risk profiles for progression rates of cognitive and functional declines in individuals who developed dementia.

Population health management (PHM) strategies to address diabetes prevention have the potential to engage large numbers of at-risk individuals in a short duration. We examined a PHM approach to recruit participants to a diabetes prevention clinical trial in a metropolitan health system. We examined reach and representativeness and assessed differences from active and passive respondents to recruitment outreach, and participants enrolled through two clinical screening protocols. The PHM approach included an electronic health record (EHR) query, physician review of identified patients, letter invitation, and telephone follow-up. Data describe the reach and representativeness of potential participants at multiple stages during the recruitment process. Subgroup analyses examined proportional reach, participant differences based on passive versus active recruitment response, and clinical screening method used to determine diabetes risk status. The PHM approach identified 10,177 potential participants to receive a physician letter invitation, 60% were contacted by telephone, 2,796 (46%) completed telephone screening, 1,961 were eligible from telephone screen, and 599 were enrolled in 15 months. Accrual was unaffected by shifting clinical screening protocols despite the increase in participant burden. Relative to census data, study participants were more likely to be obese, female, older, and Caucasian. Relative to the patient population, enrolled participants were less likely to be Black and were older. Active respondents were more likely to have a higher income than passive responders. PHM strategies have the potential to reach a large number of participants in a relatively short period, though concerted efforts are needed to increase participant diversity.

Background High attrition following initial enrollment in evidence-based weight loss programs is a common, challenging, and under-studied issue. A behavioral economics approach consisting of modest monetary incentives may help to engage participants beyond enrollment to close the initial attrition gap. Purpose To describe the methods and design of a pragmatic, online randomized controlled trial (RCT) of an incentivized, technology-facilitated weight loss program through an innovative research-practice partnership involving primary care, health promotion researchers, and a small business. Methods This study is a four-arm (1:1:1:1) RCT that compares the efficacy of outcome-based (weight loss), process-based (weighing in), a combination of outcome- and process-based, or choice-based incentives on sustaining program reach after initial enrollment for an evidence-based weight loss program. The multicomponent weight loss program includes a website, social cognitive theory-based daily health coaching, tailored messaging delivered via email and text messaging, access to online health coaches, and objective weight assessment through a community kiosk. The study will enroll 400 individuals aged 19 and older who have a body mass index ≥25 kg/m2, and have reliable access to the Internet or a smart phone. Participants will be followed for 3, 6, 9, and 12 months to assess program reach and representativeness, and continued participation after enrollment. The secondary outcomes include weight loss and program implementation costs. We will conduct participant focus groups to understand the barriers and facilitators of participation and key informant interviews focusing on clinic managers and care providers to explore the potential for future adoption and implementation of the evidence-based program. Discussion This study possesses the potential to close the attrition gap after initial enrollment in a web-based digital weight loss intervention in the primary care and community settings. Clinicaltrials.gov registration: NCT04225234 .

Introduction: Lifestyle modification to promote regular physical activity and healthy eating is a key element of diabetes management. We aimed at evaluating randomized controlled trials that assess...

The objective of this study was to evaluate changes in clinical outcomes for patients with type 2 diabetes (T2D) after a 3-month remote patient monitoring (RPM) program, and examine the relationship between hemoglobin A1c (HbA1c) outcomes and participant characteristics. The study sample included 955 patients with T2D who were admitted to an urban Midwestern medical center for any reason from 2014 to 2017, and used RPM for 3 months after discharge. Clinical outcomes included HbA1c, weight, body mass index (BMI), and patient activation scores. Logistic regression was used to estimate the likelihood of having a postintervention HbA1c9% by patient characteristics, among those who had baseline HbA1c9%. Most patients experienced decreases in HbA1c (67%) and BMI (58%), and increases in patient activation scores (67%) (P 0.001 in all 3 cases) at the end of RPM. Logistic regression analyses revealed that among patients who had HbA1c9% at baseline, men (odds ratio [OR] = 3.72; 95% confidence interval [CI], 1.43-9.64), those who had increased patient activation scores after intervention (OR = 1.05; 95% CI, 1.01-1.09), those who had higher baseline patient activation scores, and those who had a greater number of biometric data uploads during the intervention (OR = 1.02; 95% CI, 1.00-1.04) were more likely to have reduced their HbA1c to9% at the end of RPM. RPM for postdischarge patients with T2D might be a promising approach for HbA1c control with increased patient engagement. Future studies with study designs that include a control group should provide more robust evidence.

Cervical cancer is preventable; however, despite the existence of primary and secondary means of prevention, its incidence is still higher in certain socioeconomic groups and countries, suggesting gaps in cervical cancer prevention. The objective of this study was to evaluate the knowledge and awareness of health sciences university students in Cyprus regarding HPV and cervical cancer in order to better guide the future development of educational programs to improve cervical cancer prevention. This was a cross-sectional study of 178 university health sciences students in Cyprus using a validated questionnaire on HPV and cervical cancer prevention. Analysis of the completed questionnaires revealed moderate levels of knowledge and awareness with an overall mean score of 23.32 out of 33 on HPV and 8.12 out of 13 on cervical cancer, a score of 9.25 out of 14 on HPV vaccines, and a score of 5.93 out of 9 on cervical cancer screening. Older students achieved higher scores compared to younger students (mean score of 6.76 for 18–22 years old, 9.44 for 23–28 years old, and 10.25 for 29–38 years old; p

Objectives:The aim of this study was to systematically investigate existing literature on the costs of home-based telemedicine programs, and to further summarize how the costs of these telemedicine programs vary by equipment and services provided.Methods:We undertook a systematic review of related literature by searching electronic bibliographic databases and identifying studies published from January 1, 2000, to November 30, 2017. The search was restricted to studies published in English, results from adult patients, and evaluation of home telemedicine programs implemented in the United States. Summarized telemedicine costs per unit of outcome measures were reported.Results:Twelve studies were eligible for our review. The overall annual cost of providing home-based telemedicine varied substantially depending on specific chronic conditions, ranging from USD1,352 for heart failure to USD206,718 for congestive heart failure (CHF), chronic obstructive pulmonary disease (COPD), and diabetes as a whole. The estimated cost per-patient-visit ranged from USD24 for cancer to USD39 for CHF, COPD, or chronic wound care.Conclusions:The costs of home-based telemedicine programs varied substantially by program components, disease type, equipment used, and services provided. All the selected studies indicated that home telemedicine programs reduced care costs, although detailed cost data were either incomplete or not presented in detail. A comprehensive analysis of the cost of home-based telemedicine programs and their determinants is still required before the cost efficiency of these programs can be better understood, which becomes crucial for these programs to be more widely adopted and reimbursed.

This study assessed the lifetime health and economic consequences of an efficacious scalable community weight loss program for overweight and obese adults. We applied a state-transition Markov model to project lifetime economic outcome (US dollar) and the degree of disease averted as a result of a weight loss intervention, compared with no intervention, from a payer perspective. Effect sizes of the intervention on weight loss, by sex, race and ethnicity, and body mass index (BMI) of participants, were derived from a 12-month community program. Relative risk of diseases across BMI levels and other parameters were informed by the literature. A return on investment (ROI) analysis was conducted to present the overall cost-benefit of the program. Simulation results showed that among 33,656 participants and at a cost of $2.88 million, the program was predicted to avert (with a corresponding estimated medical costs saved of) 78 cases of coronary heart disease ($28 million), 9 cases of strokes ($971,832), 92 cases of type 2 diabetes ($24 million), 1 case of colorectal cancer ($357,022), and 3 cases of breast cancer ($483,259) over the participant lifetime. The estimated medical costs saved per participant was $1,403 ($1,077 of African American men and $1,532 of Hispanic men), and the ROI was $16.7 ($12.8 for African American men and $18.3 for Hispanic men) for every $1 invested. We concluded that a scalable efficacious community weight loss program provides a cost-effective approach with significant ROI, which will assist informed decisions for future adoption and dissemination.

Background Rural residents are at high risk for obesity; however, little resources exist to address this disproportional burden of disease. Primary care may provide an opportunity to connect primary care patients with overweight and obesity to effective weight management programming. Objective The purpose of this study is to examine the utility of different physician referral and engagement processes for improving the reach of an evidence-based and technology-delivered weight management program with counseling support for rural primary care patients. Methods A total of 5 rural primary care physicians were randomly assigned a sequence of four referral strategies: point-of-care (POC) referral with active telephone follow-up (ATF); POC referral, no ATF; a population health registry–derived letter referral with ATF; and letter referral, no ATF. For registry-derived referrals, physicians screened a list of patients with BMI ≥25 and approved patients for participation to receive a personalized referral letter via mail. Results Out of a potential 991 referrals, 573 (57.8%) referrals were made over 16 weeks, and 98 (9.9%) patients were enrolled in the program (58/98, 59.2% female). Differences based on letter (485/991, 48.9%) versus POC (506/991, 51.1%) referrals were identified for completion (100% vs 7%; P Conclusions Letter referral with ATF appears to be the best option for enrolling a large number of patients in a digitally delivered weight management program; however, POC with ATF and letters without ATF yielded similar numbers at a lower cost. The best referral option is likely dependent on the best fit with clinical resources. Trial Registration ClinicalTrials.gov NCT03690557; http://clinicaltrials.gov/ct2/show/NCT03690557

The level of assistance patients with Alzheimer’s disease (AD) require in their care may be an important predictor of resource use, costs of care and quality of life. The Dependence Scale (DS), a measure of care-assistance required, was used to estimate costs of care and quality of life of patients with AD categorized into six dependence stages based upon the summated item scores of the DS. Data was derived from a three-year, non-interventional study of 132 patients with probable AD (ages 50 to 85) and caregiver dyads. We investigated the association between DS scores and healthcare costs, health-related quality of life (HRQoL), caregiver burden and estimated annual costs and HRQoL for six dependence stages in adjusted models. DS scores were significant predictors of healthcare costs, HRQoL, and caregiver burden. The estimated annual healthcare costs and a measure of HRQoL (EuroQoL-5D) ranged from $11,418 and 1.00 for those at very mild dependence stage to $101,715 and 0.26 for those at very severe dependence stage. DS scores classified into six dependence stages provides a useful method to estimate unique levels of care-associated costs and health utilities for pharmacoeconomic evaluations of new treatments for AD.

Background: It remains unclear how demographic and clinical characteristics are related to the risk of incident mild cognitive impairment (MCI) by its subtypes. Moreover, the contribution of the subtypes of incident MCI to the progression to dementia remains puzzling. Methods: We used data collected by the National Alzheimer Coordinating Center. Our analysis sample included cognitively normal subjects at baseline. The associations were examined using competing-risks survival regression models and Cox proportional hazards models. Results: About 16.3% of subjects developed incident MCI of whom 15.8% progressed to Alz­heimer disease (overall mean follow-up of 4.3 years). The risk of incident amnestic MCI (aMCI) was greater in subjects with 1 copy (subhazard ratio [SHR]: 1.23; 95% CI: 1.00–1.50) or 2 copies (SHR: 2.14; 95% CI: 1.49–3.05) of the APOE ε4 allele than in those who had no ε4 allele. Multiple-domain aMCI patients were more likely to progress to dementia than single-domain aMCI patients (hazard ratio: 2.14; 95% CI: 1.28–3.58). Conclusions: Cognitively normal subjects with an APOE ε4 allele had a higher likelihood of developing aMCI and the MCI subtype was associated with the dementia subtype. Our findings provide important information about practical indicators for the prediction of cognitive decline.

Background Diabetes prevention remains a top public health priority; digital approaches are potential solutions to existing scalability and accessibility challenges. There remains a gap in our understanding of the relationship between effectiveness, costs, and potential for sustained implementation of digital diabetes prevention strategies within typical healthcare settings. Purpose To describe the methods and design of a type 1 hybrid effectiveness-implementation trial of a digital diabetes prevention program (DPP) using the iPARIHS and RE-AIM frameworks. Methods The trial will contrast the effects of two DPP interventions: (1) small group, in-person class, and (2) a digital DPP consisting of small group support, personalized health coaching, digital tracking tools, and weekly behavior change curriculum. Each intervention includes personal action planning with a focus on key elements of the lifestyle intervention from the CDC National DPP. Adults at risk for diabetes (BMI ≥25 and 5.7% ≤ HbA1c ≤ 6.4) will be randomly assigned to either the intervention group (n = 241) or the small group (n = 241). Assessment of primary (HbA1c) and secondary (weight loss, costs, cardiovascular risk factors) outcomes will occur at baseline, 4, and 12 months. Additionally, the trial will explore the potential for future adoption, implementation, and sustainability of the digitally-based intervention within a regional healthcare system based on key informant interviews and assessments of organizational administrators and primary care physicians. Conclusion This trial of a digital DPP will allow the research team to determine the relationships between reach, effectiveness, implementation, and costs.

Rural adults have a higher risk of developing obesity than urban adults. Several evidence-based interventions have targeted rural regions, but their impact, defined as reach (number and representativeness of participants) by effectiveness, has not been examined. The purpose of this review was to determine the impact of rural weight loss interventions and the availability of data across dimensions of the reach, effectiveness, adoption, implementation, and maintenance (RE-AIM) framework. A systematic review was conducted to identify rural weight loss interventions that targeted adults. RE-AIM-related data were abstracted from each article. We performed a meta-analysis to examine effectiveness. Sixty-four articles reported on rural weight loss interventions, describing 50 unique interventions. The median number of participants was 107. Median participation rate differed between values reported by the authors (62%) and values computed using a standard method (32%). Two studies reported on sample representativeness; none reported comparisons made between target and actual delivery settings. Median weight loss per participant was 3.64 kg. Meta-analyses revealed the interventions achieved a significant weight reduction, and longer-duration interventions resulted in greater weight loss. Rural weight loss interventions appear to be effective in supporting clinically meaningful weight loss but reach and cost outcomes are still difficult to determine.

Introduction Assessing costs of an evidence-based health promotion programme is crucial to understand the economic feasibility of adopting or sustaining the programme. This study conducted a cost analysis of a remote patient monitoring (RPM) programme to enhance the post-discharge management of type 2 diabetes. Methods Using retrospective data collected during RPM implementation from September 2014 to February 2018, we estimated the costs of implementing an RPM in the primary care setting. Measures included total and average annual costs, costs per participant who was enrolled or completed the programme, and costs per person-day. We further conducted sensitivity and scenario analyses to examine variations in estimated programme costs associated with varying programme efficiencies and alternative personnel compositions of the RPM team. Results The total RPM implementation costs were estimated at US$4,374,544 with an average annual programme costs of US$1,249,870, which translated to US$3207 per participant ( n = 1364) completing the three-month programme. The per person-day cost was averaged at US$24 (182,932 person-days). Sensitivity and scenario analyses results indicate that the sustainment costs were approximately US$1.6 million annually and the per-person-day costs were between US$21 and US$29 with each nurse coach on average serving a panel of 62–93 patients. Conclusion The implementation and sustainment costs of an RPM programme, estimated under various assumptions of programme efficiency and care team compositions, as exemplified in this study, will help healthcare organizations make informed decisions in budgeting for and sustaining telehealth programmes to enhance diabetes management.

We examined the effectiveness of the weight management program used by the University of Minnesota in reducing health care expenditures and improving quality of life of its employees, and also in reducing their absenteeism during a 3-year intervention.A differences-in-differences regression approach was used to estimate the effect of weight management participation. We further applied ordinary least squares regression models with fixed effects to estimate the effect in an alternative analysis.Participation in the weight management program significantly reduced health care expenditures by $69 per month for employees, spouses, and dependents, and by $73 for employees only. Quality-of-life weights were 0.0045 points higher for participating employees than for nonparticipating ones. No significant effect was found for absenteeism.The workplace weight management used by the University of Minnesota reduced health care expenditures and improved quality of life.

To assess the overall effect of telemedicine on diabetes management and to identify features of telemedicine interventions that are associated with better diabetes management outcomes.Hedges's g was estimated as the summary measure of mean difference in HbA1c between patients with diabetes who went through telemedicine care and those who went through conventional, non-telemedicine care using a random-effects model. Q statistics were calculated to assess if the effect of telemedicine on diabetes management differs by types of diabetes, age groups of patients, duration of intervention, and primary telemedicine approaches used.The analysis included 55 randomized controlled trials with a total of 9258 patients with diabetes, out of which 4607 were randomized to telemedicine groups and 4651 to conventional, non-telemedicine care groups. The results favored telemedicine over conventional care (Hedges's g=-0.48, p0.001) in diabetes management. The beneficial effect of telemedicine were more pronounced among patients with type 2 diabetes (Hedges's g=-0.63, p0.001) than among those with type 1 diabetes (Hedges's g=-0.27, p=0.027) (Q=4.25, p=0.04).Compared to conventional care, telemedicine is more effective in improving treatment outcomes for diabetes patients, especially for those with type 2 diabetes.

Aims To examine gender differences in program completion and glycemic outcomes for patients with type 2 diabetes (T2D) in a remote patient monitoring (RPM) program for diabetes management. Methods Based on data from an RPM program that enrolled post-discharge T2D patients (n = 1645) in 2014–2017, logistic regression models were estimated to assess gender difference in the likelihood of completing the three-month RPM program; whereas ordinary least squares (OLS) regression models were used to examine gender difference in post-RPM hemoglobin A1c (HbA1c), controlling for demographics, baseline health status, including HbA1c, patient activation scores, and physiological data upload frequency for patients who had completed the program. Results Among enrolled participants, men had lower odds of completing the three-month RPM program than women (adjusted odds ratio, 0.61; 95% confidence interval [CI], 0.39–0.95). However, among those who completed the program, men had lower post-RPM HbA1c than women (−0.18; 95% CI, −0.33, −0.03) after controlling for baseline HbA1c and other covariates. Conclusions While female patients with T2D were more likely to complete the RPM program, they showed a higher glycemic level at the end of the program compared to male patients. To close gender disparities in health, interventions through telemedicine tailored towards women’s diabetes outcomes and men’s engagement level are warranted.

Background: The documented efficacy and promise of telemedicine in diabetes management does not necessarily mean that it can be easily translated into clinical practice. An important barri...

OBJECTIVE To identify patient, provider, and delivery system-level factors associated with colorectal cancer (CRC) screening and validate findings across multiple data sets. DESIGN A concurrent mixed-methods design using electronic health records, provider survey, and provider interview. SETTING Eight primary care accountable care organization clinics in Nebraska. MEASURES Patients' demographic/social characteristics, health utilization behaviors, and perceptions toward CRC screening; provider demographics and practice patterns; and clinics' delivery systems (eg, reminder system). ANALYSIS Quantitative (frequencies, logistic regression, and t tests) and qualitative analyses (thematic coding). RESULTS At the patient level, being 65 years of age and older (odds ratio [OR] = 1.34, P < .001), being non-Hispanic white (OR = 1.93, P < .001), having insurance (OR = 1.90, P = .01), having an annual physical examination (OR = 2.36, P < .001), and having chronic conditions (OR = 1.65 for 1-2 conditions, P < .001) were associated positively with screening, compared with their counterparts. The top 5 patient-level barriers included discomfort/pain of the procedure (60.3%), finance/cost (57.4%), other priority health issues (39.7%), lack of awareness (36.8%), and health literacy (26.5%). At the provider level, being female (OR = 1.88, P < .001), having medical doctor credentials (OR = 3.05, P < .001), and having a daily patient load less than 15 (OR = 1.50, P = .01) were positively related to CRC screening. None of the delivery system factors were significant except the reminder system. Interview data provided in-depth information on how these factors help or hinder CRC screening. Discrepancies in findings were observed in chronic condition, colonoscopy performed by primary doctors, and the clinic-level system factors. CONCLUSIONS This study informs practitioners and policy makers on the effective multilevel strategies to promote CRC screening in primary care accountable care organization or equivalent settings. Some inconsistent findings between data sources require additional prospective cohort studies to validate those identified factors in question. The strategies may include (1) developing programs targeting relatively younger age groups or racial/ethnic minorities, (2) adapting multilevel/multicomponent interventions to address low demands and access of local population, (3) promoting annual physical examination as a cost-effective strategy, and (4) supporting organizational capacity and infrastructure (eg, IT system) to facilitate implementation of evidence-based interventions.

Background Agriculture workers are exposed to microbial component- and particulate matter-enriched organic dust aerosols. Whereas it is clear that exposure to these aerosols can lead to lung inflammation, it is not known how inflammatory responses are resolved in some individuals while others develop chronic lung disease. Interleukin (IL)-10 is an immunomodulatory cytokine that is recognized as a potent anti-inflammatory and pro-resolving factor. The objective of this study was to determine whether there is a relationship of systemic IL-10 and proinflammatory responses and/or respiratory health effects in humans with prior agriculture exposure. Methods This is a cross sectional study of 625 veterans with > 2 years of farming experience. Whole blood was stimulated with or without organic dust and measured for IL-6, TNFα and IL-10. Participants underwent spirometry and respiratory symptoms were assessed by questionnaire. Results We found that baseline IL-10 concentration from the whole blood assay was inversely associated with ΔTNF-α (r = − 0.63) and ΔIL-6 (r = − 0.37) levels. Results remained highly significant in the linear regression model after adjusting for age, sex, BMI, race, education, smoking status, and white blood cell count (ΔTNF-α, p

Background: The mortality benefits of meeting the US federal guidelines for physical activity, which includes recommendations for both aerobic and muscle-strengthening activities, have never been examined among smokers. Our aim was to investigate the association between reporting to meet the guidelines and all-cause, cancer, cardiovascular disease, and respiratory disease mortality among smokers. Methods: We pooled data from the 1998–2009 National Health Interview Survey, which were linked to records in the National Death Index (n = 68,706). Hazard ratios (HR) were computed to estimate the effect of meeting the physical activity guidelines on mortality. Results: Smokers who reported meeting the guidelines for physical activity had 29% lower risk of all-cause mortality (HR: 0.71; 95% confidence interval [CI], 0.62–0.81), 46% lower risk of mortality from cardiovascular disease (HR: 0.54; 95% CI, 0.39–0.76), and 26% lower risk of mortality from cancer (HR: 0.74; 95% CI, 0.59–0.93), compared with those who reported meeting neither the aerobic nor the muscle-strengthening recommendations of the guidelines. Meeting the aerobic recommendation of the guidelines was associated with a 42% decline in that risk (HR: 0.58; 95% CI, 0.44–0.77). Conclusion: Smokers who adhere to physical activity guidelines show a significant reduction in mortality.

Objective We examined the impact of a disease management (DM) program offered at the University of Minnesota for those with various chronic diseases. Methods Differences-in-differences regression equations were estimated to determine the effect of DM participation by chronic condition on expenditures, absenteeism, hospitalizations, and avoidable hospitalizations. Results Disease management reduced health care expenditures for individuals with asthma, cardiovascular disease, congestive heart failure, depression, musculoskeletal problems, low back pain, and migraines. Disease management reduced hospitalizations for those same conditions except for congestive heart failure and reduced avoidable hospitalizations for individuals with asthma, depression, and low back pain. Disease management did not have any effect for individuals with diabetes, arthritis, or osteoporosis, nor did DM have any effect on absenteeism. Conclusions Employers should focus on those conditions that generate savings when purchasing DM programs. Clinical significance This study suggests that the University of Minnesota's DM program reduces hospitalizations for individuals with asthma, cardiovascular disease, depression, musculoskeletal problems, low back pain, and migraines. The program also reduced avoidable hospitalizations for individuals with asthma, depression, and low back pain.

Not all women 50–74 years received biennial mammography and the situation is worse in rural areas. Accountable care organizations (ACO) emphasize coordinated care, use of electronic health system, and preventive quality measures and these practices may improve their patients’ breast cancer screening rate. Using medical record data of 8,347 women patients aged 50–74 years from eight rural ACO clinics in Nebraska, this study examined patient-, provider-, and county-level barriers and facilitators for breast cancer screening. A generalized estimating equations model was used to account for the correlation among patients from the same provider and county. The multi-level logistic regression results suggest that uninsured non-Hispanic Black patients were less likely to meet the biennial mammography screening guideline. Patients whose preferred language being English, having a preventive visit in the past 12 months, having one or more chronic conditions were more likely to meet the biennial mammography screening guideline. Patients with a primary care provider (PCP) that was male, without a medical doctor degree were less likely to screen biennially. Patients with a PCP that reviewed performance report quarterly, or manually checked patients’ mammography screening status during visits were more likely to screen biennially. Interestingly, patients whose PCP reported being reminded by a care coordination team were less likely to screen biennially. Patients living in counties with more PCPs were also more likely to screen biennially. The study findings suggest that efforts targeting individual and practice-level barriers could be most effective in improving mammography screening for these rural ACO patients.

Background The U.S. Preventive Services Task Force in 2009 recommended increased aspirin use for primary prevention of cardiovascular disease ( CVD ) in men ages 45 to 79 years and women ages 55 to 79 years for whom benefit outweighs risk. This study estimated the clinical efficacy and cost‐effectiveness of a statewide public and health professional awareness campaign to increase regular aspirin use among the target population in Minnesota to reduce first CVD events. Methods and Results A state‐transition Markov model was developed, adopting a payer perspective and lifetime time horizon. The main outcomes of interest were quality‐adjusted life years, costs, and the number of CVD events averted among those without a prior CVD history. The model was based on real‐world data about campaign effectiveness from representative state‐specific aspirin use and event rates, and estimates from the scholarly literature. Implementation of a campaign was predicted to avert 9874 primary myocardial infarctions in men and 1223 primary ischemic strokes in women in the target population. Increased aspirin use was associated with as many as 7222 more major gastrointestinal bleeding episodes. The cost‐effectiveness analysis indicated cost‐saving results for both the male and female target populations. Conclusions Using current U.S. Preventive Services Task Force recommendations, a state public and health professional awareness campaign would likely provide clinical benefit and be economically attractive. With clinician adjudication of individual benefit and risk, mechanisms can be made available that would facilitate achievement of aspirin's beneficial impact on lowering risk of primary CVD events, with minimization of adverse outcomes.

OBJECTIVE: The study objective was to evaluate and update the safety data from randomized controlled trials of tumor necrosis factor inhibitors in patients treated for rheumatoid arthritis. METHODS: A systematic literature search was conducted from 1990 to May 2013. All studies included were randomized, double-blind, controlled trials of patients with rheumatoid arthritis that evaluated adalimumab, certolizumab pegol, etanercept, golimumab, or infliximab treatment. The serious adverse events and discontinuation rates were abstracted, and risk estimates were calculated by Peto odds ratios (ORs). RESULTS: Forty-four randomized controlled trials involving 11,700 subjects receiving tumor necrosis factor inhibitors and 5901 subjects receiving placebo or traditional disease-modifying antirheumatic drugs were included. Tumor necrosis factor inhibitor treatment as a group was associated with a higher risk of serious infection (OR, 1.42; 95% confidence interval [CI], 1.13-1.78) and treatment discontinuation due to adverse events (OR, 1.23; 95% CI, 1.06-1.43) compared with placebo and traditional disease-modifying antirheumatic drug treatments. Specifically, patients taking adalimumab, certolizumab pegol, and infliximab had an increased risk of serious infection (OR, 1.69, 1.98, and 1.63, respectively) and showed an increased risk of discontinuation due to adverse events (OR, 1.38, 1.67, and 2.04, respectively). In contrast, patients taking etanercept had a decreased risk of discontinuation due to adverse events (OR, 0.72; 95% CI, 0.550.93). Although ORs for malignancy varied across the different tumor necrosis factor inhibitors, none reached statistical significance. CONCLUSIONS: These meta-analysis updates of the comparative safety of tumor necrosis factor inhibitors suggest a higher risk of serious infection associated with adalimumab, certolizumab pegol, and infliximab, which seems to contribute to higher rates of discontinuation. In contrast, etanercept use showed a lower rate of discontinuation. These data may help guide clinical comparative decision making in the management of rheumatoid arthritis.