Patients In Rural Communities Research Articles

Feasibility characteristics of wrist-worn fitness trackers in health status monitoring for post-COVID patients in remote and rural areas.

Common, consumer-grade biosensors mounted on fitness trackers and smartwatches can measure an array of biometrics that have potential utility in post-discharge medical monitoring, especially in remote/rural communities. The feasibility characteristics for wrist-worn biosensors are poorly described for post-COVID conditions and rural populations. We prospectively recruited patients in rural communities who were enrolled in an at-home rehabilitation program for post-COVID conditions. They were asked to wear a FitBit Charge 2 device and biosensor parameters were analyzed [e.g. heart rate, sleep, and activity]. Electronic patient reported outcome measures [E-PROMS] for mental [bi-weekly] and physical [daily] symptoms were collected using SMS text or email [per patient preference]. Exit surveys and interviews evaluated the patient experience. Ten patients were observed for an average of 58 days and half [N = 5] were monitored for 8 weeks or more. Five patients [50%] had been hospitalized with COVID [mean stay = 41 days] and 4 [36%] had required mechanical ventilation. As baseline, patients had moderate to severe levels of anxiety, depression, and stress; fatigue and shortness of breath were the most prevalent physical symptoms. Four patients [40%] already owned a smartwatch. In total, 575 patient days of patient monitoring occurred across 10 patients. Biosensor data was usable for 91.3% of study hours and surveys were completed 82.1% and 78.7% of the time for physical and mental symptoms, respectively. Positive correlations were observed between stress and resting heart rate [r = 0.360, p<0.01], stress and daily steps [r = 0.335, p<0.01], and anxiety and daily steps [r = 0.289, p<0.01]. There was a trend toward negative correlation between sleep time and physical symptom burden [r = -0.211, p = 0.05]. Patients reported an overall positive experience and identified the potential for wearable devices to improve medical safety and access to care. Concerns around data privacy/security were infrequent. We report excellent feasibility characteristics for wrist-worn biosensors and e-PROMS as a possible substrate for multi-modal disease tracking in post-COVID conditions. Adapting consumer-grade wearables for medical use and scalable remote patient monitoring holds great potential.

Evolution of the roles of family physicians through collaboration with rehabilitation therapists in rural community hospitals: a grounded theory approach

BackgroundThe role of rural family physicians continues to evolve to accommodate the comprehensive care needs of aging societies. For older individuals in rural areas, rehabilitation is vital to ensure that they can continue to perform activities of daily living. In this population, a smooth discharge following periods of hospitalization is essential and requires management of multimorbidity, and rehabilitation therapists may require support from family physicians to achieve optimal outcomes. Therefore, this study aimed to investigate changes in the roles of rural family physicians in patient rehabilitation.MethodsAn ethnographic analysis was conducted with rural family physicians and rehabilitation therapists at a rural Japanese hospital. A constructivist grounded theory approach was applied as a qualitative research method. Data were collected from the participants via field notes and semi-structured interviews.ResultsUsing a grounded theory approach, the following three themes were developed regarding the establishment of effective interprofessional collaboration between family physicians and therapists in the rehabilitation of older patients in rural communities: 1) establishment of mutual understanding and the perception of psychological safety; 2) improvement of relationships between healthcare professionals and their patients; and 3) creation of new roles in rural family medicine to meet evolving needs.ConclusionEnsuring continual dialogue between family medicine and rehabilitation departments helped to establish understanding, enhance knowledge, and heighten mutual respect among healthcare workers, making the work more enjoyable. Continuous collaboration between departments also improved relationships between professionals and their patients, establishing trust in collaborative treatment paradigms and supporting patient-centered approaches to family medicine. Within this framework, understanding the capabilities of family physicians can lead to the establishment of new roles for them in rural hospitals. Family medicine plays a vital role in geriatric care in community hospitals, especially in rural primary care settings. The role of family medicine in hospitals should be investigated in other settings to improve geriatric care and promote mutual learning and improvement among healthcare professionals.

Geographic Differences in Pediatric Surgical Mortality in Canada: A Retrospective Cohort Study

ObjectiveThis study describes differences in postoperative mortality for pediatric patients in rural communities compared to urban communities. BackgroundCanada has the second largest land mass in the world, with a population density of 4 people per km2. There are 18 children’s hospitals in Canada offering pediatric surgical services, all in urban centres, yet nearly one-fifth of the population lives in rural or remote communities. Children who live in rural settings may have worse surgical outcomes, including mortality rates, compared with urban populations. MethodsPediatric patients, from birth to 18 years old, who had surgery from January 1, 2011, to December 31, 2021, at a single Children's Hospital were included in the study. Data was obtained from the provincial Operating Room Information System (ORIS) database. Postal code, rural and urban status, distance to children's hospital (0-50 km, 51-100 km, 101-150 km, 151-200 km, and >200 km), and procedure urgency were collected. 30-day mortality for all procedures was collected. Results85,998 surgical procedures were performed at ACH between 2011 and 2021. 17,773 (20.7%) of patients lived >50 km or more from the hospital – 5,329 (6.2%) 51- 100 km, 4,053 (4.7%) 101-150 km, n=2,323 (2.7%) 151-200 km, and 6,070 (7.1%) >200 km. Rural patients had higher 30-day mortality rates than urban patients, with an odds ratio of mortality (rural vs urban) of 2.30 (95% CI, 0.95 to 5.60). When stratified by distance, patients living closer to the hospital (0-50 km) had lower odds of mortality. ConclusionsCanadian Rural patients have higher operative mortality risks than urban patients. This study identifies a vulnerable group of patients who do not have equal access to care and may experience worse outcomes.

#1381 Economic evaluation of an integrated care program versus conventional care for chronic kidney disease patients in rural communities of Thailand

Abstract Background and Aims This study evaluates an integrated care program for chronic kidney disease (CKD), which has demonstrated effectiveness in delaying kidney function decline in the rural population of Thailand. Efficacy of the program was initially established through the ESCORT-1 study, a cluster-randomized controlled trial (doi: 10.1186/s12882-016-0414-4), and further demonstrated the effectiveness by the larger-scale prospective cohort study, ESCORT-2 (doi: 10.1111/nep.13849). The aim of this study is to assess the cost-effectiveness of incorporating this program into Thailand's public health benefit package, with the goal of establishing it as a model for similar rural areas in resource-limited settings. Method Following the Thailand's guideline for health technology assessment, a cost-utility analysis utilizing data from the ESCORT studies, local databases, and literatures. The integrated care program was tailored to primary healthcare system by using preexisting workforces. It involved a collaboration between Multi-Disciplinary Care Teams (MDCT) at district hospitals and Community Care Network (CCN) teams at Sub-District Health Centers (SDHC). The MDCT, comprising general practitioners, CKD nurse managers, pharmacists, a nutritionist, and a physical therapist, provided key patient education on diet, medication adherence, exercise, and avoiding certain medications and herbal remedies. The CCN teams, including community nurses and village health volunteers, conducted home visits for health monitoring and lifestyle guidance. Both MDCT and CCN personnel received training in CKD care based on the NKF-K/DOQI and KDIGO Clinical Practice Guidelines. A decision-analytic Markov model and Monte-Carlo simulation were applied to quantify and compare the lifetime costs and quality-adjusted life years (QALY) outcomes of the intervention and conventional-care from a societal perspective considering both direct and indirect costs. The analysis included extensive sensitivity analyses, incorporating a probabilistic model and scenario-analyses based on patient ages, CKD stages, and varying program efficacy. Additionally, a budget impact analysis from the payer's perspective assessed the financial impact and affordability over a five-year period. Results The integrated care program was found to dominate conventional care. The results indicated an incremental cost-effectiveness of (-)278,000 Thai Baht (∼7,267 EUR) per QALY for the base case analysis. Probabilistic analysis demonstrated consistent outcomes, with the integrated care program being cost-effective at almost 100% of the time during analysis at the 160,000 Thai Baht (∼4,182 EUR) willingness-to-pay threshold (Fig. 1). These results are driven by significant cost savings due to reduced time and overall costs in dialysis before death. The program is most cost-effective when provided early to patients, in terms of both age and CKD stages (Fig. 2). The budget impact analysis showed that introducing the intervention could save the payer 184 billion Thai Baht (4.76 billion EUR) over five years. (The exchange rate; 1 Thai Baht = 38.26 EUR) Conclusion The integrated care program for patients with stage 3-4 CKD is cost-effective and suitable for inclusion in Thailand's health benefit package, mainly due to its significant cost savings and enhanced health outcomes. The program's design, focusing on sustainability and feasibility by utilizing existing workforces, positions it as a viable model for similar economic and healthcare contexts, especially in resource-limited countries.

Geographic variation in breast reconstruction surgery after mastectomy for females with breast cancer in Alberta, Canada.

Breast cancer is the most common cancer affecting females in Canada, and about half of females with breast cancer are treated with mastectomy. We sought to evaluate geographic variation in breast reconstruction surgery in Alberta, Canada. Using linked population-based administrative databases, we extracted data on all Alberta females aged 18 years and older who were diagnosed with breast cancer and treated with mastectomy during 2004-2017. Analyses included regression modelling of odds of reconstruction at 1 year and a spatial scan to identify geographic clusters of lower numbers of reconstruction. A total of 16 198 females diagnosed with breast cancer were treated with a mastectomy, and 1932 (11.9%) had reconstruction within 1 year postmastectomy. Those with reconstruction were more likely to be younger (adjusted odds ratio [OR] 16.7, 95% confidence interval [CI] 13.7-20.3; aged 21-44 yr v. ≥ 65 yr) and were less likely to be from lower-income neighbourhoods. They were more likely to have at least 1 comorbidity and were more likely to have advanced stages of cancer and to require chemotherapy (adjusted OR 0.55, 95% CI 0.47-0.65) or radiotherapy after mastectomy (adjusted OR 0.59, 95% CI 0.39-0.87) than females without reconstruction. We identified rural northern and southeastern clusters with frequencies of reconstruction that were 69.6% and 41.6% of what was expected, respectively. We found an overall postmastectomy rate of breast reconstruction of 11.9%, and we identified geographic variation. Predictors of reconstruction in Alberta were similar to those previously described in the literature, specifically with patients in rural communities having lower rates of reconstruction than their urban counterparts. These results suggest that further interventions are required to identify the specific barriers to reconstruction within rural communities and to create strategies to ensure equitable access to all residents.

Prevalence and associated factors of abortion among women with severe mental disorders

BackgroundAbortion behaviors among individuals with mental disorders presented major obstacles to women's health. However, few studies reported the prevalence and associated factors of abortion among women with severe mental disorders in China. Consequently, this study aims to investigate the prevalence of abortion among female patients in rural communities and identify potential health risks. MethodThis was a cross-sectional study of 276 women aged 18 years and older with severe mental disorders in rural areas of Shandong Province, China. The pregnancy history, abortion history and socio-demographic characteristics of women were investigated by questionnaire. Logistic regression analysis was employed to examine the associated factors for different abortion behaviors. ResultThe study showed that 82.61 % (228/276) of patients had a pregnancy history. Among the patients with a pregnancy history, 43.42 % (99/228) reported having had at least one abortion, and 15.79 % (36/228) had more than one. In the other side, 31.58 % (72/228) of them experienced spontaneous abortion, while 12.72 % (29/228) experienced induced abortion. Age at first gestation (aOR 0.80, 95 % CI 0.70–0.90) and age at last gestation (aOR 1.17, 95 % CI 1.07–1.27) were both associated with abortion. Anxiety was related to spontaneous (aOR 1.08, 95 % CI 1.02–1.15) and repeat abortions (aOR 1.10, 95 % CI 1.01–1.19). In addition, religion (aOR 10.47, 95 % CI 2.81–39.01), number of children≥2 (aOR 0.18, 95 % CI 0.04–0.77), and family functioning (aOR 1.31, 95 % CI 1.06–1.63) were associated with induced abortion. ConclusionWomen with severe mental disorders in rural regions have notably higher rates of abortion compared to the general female population, particularly for spontaneous abortions. Gestational age and anxiety of pregnant patients deserve attention and preventive measures to avoid the outcomes of abortion.

Remote assessment and monitoring with advanced wound therapy to optimise clinical outcomes, access and resources.

Patients in rural communities may have limited access to wound care; however, this may be mitigated by using a shared care approach. This study assessed the impact of a remote assessment and monitoring tool in combination with adjunctive continuous topical oxygen therapy (cTOT) in patients with diabetes and hard-to-heal wounds. Patients with hard-to-heal wounds (defined as no visible improvement in the previous four weeks) were enrolled to this 12-week pilot study to validate a shared care approach using an Advanced Digital Wound Care Platform-telehealth (ADWCPt) system (eKare Inc., US) coupled with cTOT. Patient and wound assessments were reviewed by the clinician either remotely, via telehealth calls, or at the clinic, and the number of face-to-face clinic visits was recorded. Patient health status scores were captured before and after the study, along with feedback on usability of the remote platform and cTOT device. The wounds in all eight patients studied reduced in size over 12 weeks (mean percentage area reduction 92.0%), and two wounds were completely re-epithelialised. Another wound almost healed (99.2% wound area reduction). Clinical interactions consisted of self-assessments (n=80, 50.0%), video assessments with the clinician (n=27, 16.9%), and face-to-face interactions in clinic (n=53, 33.1%). Operational efficiencies encompassed a 54.0% increase in the number of clinical interactions, whereas clinical time was reduced by 25.8%. Health status scores improved across all eight patients and feedback on the shared approach and cTOT device was favourable. A shared care model with ADWCPt coupled with an innovative cTOT device saved time and resources, improving patient access and engagement, along with a marked improvement in the wound healing trajectory.

Insulin therapy among diabetic patients in rural communities of Sub-Saharan Africa: a perspective review.

In this perspective review, we describe a brief background on the status quo of diabetes mellitus-related therapies and glycemic control among patients in rural communities in sub-Saharan Africa. The article discusses insulin therapy as well as the difficulties in obtaining insulin and oral hypoglycemic medications for diabetic patients living in sub-Saharan Africa. We wrap up our discussion with suggestions on solutions and opportunities for future research to tackle this health challenge in these impoverished communities. We conducted a literature search from PubMed and Google Scholar up until August 2023. Key words were used to generate search terms used to retrieve the required information. All types of literature with pertinent information on the current topic were included in the study. Diabetes mellitus is on the rise in sub-Saharan Africa. Several studies have reported poor glycemic control, low screening rates for diabetes mellitus, cigarette smoking, high alcohol consumption, prescription of antidiabetic therapy, and associated costs as contributors to the uptake of antidiabetic treatment. Although there is paucity of data on the extent of insulin therapy uptake and its possible modifiable contributors among the diabetic patients in the region, the anticipated increase in the number of people with diabetes on the continent makes it critical for global leaders to address the research gaps in insulin therapy among rural communities of sub-Saharan Africa, thus reducing the burden of diabetes in these populations.

Evaluation of Nurse Navigator Support for Patients During Telehealth Neurosurgery Clinics.

Telehealth clinics have been used in many specialities, including neurosurgery, to improve access for patients in rural communities. The introduction of nurse navigators involved with the patient before, during and after the clinic was evaluated. Clinics were held in a rural hospital with a nurse navigator present in the clinic with the patient, and the physician consulting remotely. A patient satisfaction survey and audit were conducted following ten telehealth clinics. Twenty-one new patients were able to be contacted out of 31 (68%) with an 11 question structured survey. Eighteen out of 21 (86%) stated they were satisfied with the quality of the clinic compared with an in-person clinic. Overall satisfaction scores of 7-10 were scored by 18/21 patients (86%) on a scale of 1-10. An estimated 10785 km of travel was saved for patients going to a rural hospital clinic rather than the neurosurgical centre. This study shows that the supportive role of nurse navigators throughout the patient telehealth clinic pathway merits further continuing evaluation.

Abstract B104: The invisible divide: The impact of race and location on multiple myeloma outcomes in Arkansas

Abstract Cancer survival rates in the United States have seen remarkable improvements attributed to early detection, enhanced screening practices, and innovative treatments. However, these advancements have not translated equally to all communities, particularly among minorities and rural populations. This disparity is amplified by the prevalence of certain cancers, such as multiple myeloma (MM), which disproportionately affects older adults and exhibits significant ethnic disparities. Black people are 2-5 times more likely to develop the disease compared to those of European descent. MM is a malignancy of plasma cells and in 2023, it is expected that in the US there will be 35,730 new MM diagnoses and 12,590 associated deaths. This study focuses on MM patients in Arkansas, where racial segregation and rural population density contribute to healthcare access challenges and poorer outcomes. We retroactively analyzed a dataset composed of 4,639 patients treated at the University of Arkansas for Medical Sciences that have all received a transplant as part of their treatment. In this study, we performed a descriptive analysis of patients’ outcomes with MM treated in Arkansas. We look at the non-metro versus metro areas while also looking at racial differences in survival outcomes between Black and White patients. To pinpoint specific areas of Arkansas with high disparities, we divided the state into 6 regions. Taken in aggregate, there was no significant difference in progression-free survival (PFS) or overall survival (OS). Just looking at the best and worst performing regions, we compared the Central Arkansas region to the Lower Delta. A significant difference was observed in PFS and OS, with p-values of 0.00034 and 0.025, respectively. Patients from the Central region had a significantly higher survival probability. We observed a significant difference in PFS and OS by race (p-value 0.012 and 0.062). We see that Black patients from the Lower Delta had the worst PFS, and PFS was similar between Black and White patients from the Central region. Interestingly, White patients from the Lower Delta had the worst overall survival probability. Black patients from the Central region had the best OS. This research highlights the disparities between non-metro and metro MM patients, as well as the disparities between Black and White populations in Arkansas compared to the rest of the country. Rural region had the largest disparity in PFS and OS compared to the metro Central region of Arkansas. Black patients from the Lower Delta region have worse PFS than African Black patients from the Central region, and White patients from the Lower Delta region have worse OS than White patients from the Central region. These findings emphasize the importance of targeted education efforts aimed at physicians and patients in rural communities, which could potentially lead to significant improvements in MM outcomes and bridge the existing disparities. Citation Format: Michael A. Bauer, Mario Shootman, Chenghui Li, Frits Van Rhee, Samer Al Hadidi, Carolina D. Schinke, John D. Shaughnessy, Joseph L. Su, Fenghuang Zhan, Cody Ashby. The invisible divide: The impact of race and location on multiple myeloma outcomes in Arkansas [abstract]. In: Proceedings of the 16th AACR Conference on the Science of Cancer Health Disparities in Racial/Ethnic Minorities and the Medically Underserved; 2023 Sep 29-Oct 2;Orlando, FL. Philadelphia (PA): AACR; Cancer Epidemiol Biomarkers Prev 2023;32(12 Suppl):Abstract nr B104.

Risk of Severe Maternal Morbidity (SMM) in patients with Placenta Accreta Spectrum (PAS) disorders referred from rural communities to a regional PAS center.

The primary objective of this study was to assess the risk of Severe Maternal Morbidity (SMM) experienced by patients residing in rural communities when delivered by a multidisciplinary team within a single urban academic center for Placenta Accreta Spectrum (PAS). Subsequently, we aimed to determine a distance dependent relationship between PAS morbidity and distance travelled by patients in rural communities. This was a retrospective cohort study of patients who had PAS histopathologic confirmation and delivery at our institution from 2005-2022. Our objective was to determine the relationship between patient locations (rural vs. urban) and maternal morbidity associated with PAS delivery. Socio-geographic determination of rurality was determined using the National Center for Health Statistics and most recent national census population data. Distance travelled was calculated by patient zip code to our PAS center using global positioning system data. During the study period, 139 patients were managed by cesarean hysterectomy with confirmed PAS histopathology. Of these, ninety-four (67.6%) were from our urban community and forty-five (32.4%) were from surrounding rural communities. The overall SMM incidence was 85% including blood transfusion and 17% without blood transfusions. Patient from rural communities were more likely to experience SMM (28.9% vs. 12.8%, p=0.03) and this was driven by acute renal failure (1.1 vs 11.1%, p=0.01) and disseminated intravascular coagulopathy (1.1 vs 8.8%, p=0.04). SMM did reveal a a distance-dependent relationship with SMM rates of 13.2%, 33.3%, and 43.8% at 50, 100 and 150 miles, respectively (p=0.005). Patients with PAS experience high rates of SMM. Geographic distance to a PAS center appears to significantly impact the overall morbidity a patient experiences. Further research is warranted to address this disparity and optimize patient outcomes for patients in rural communities.

The complex impact of family caregiver kinship type on the rehabilitation of patients with mental disorders in rural communities of China.

In 2009, the Chinese government incorporated severe mental disorders into the central subsidized local health funding project for the effective management, treatment, and reintegration of patients with severe mental disorders from hospitals into the community (Project 686). The conditions that were classified as 'severe' by this project included: schizophrenia, schizoaffective disorders, paranoid disorders, bipolar disorders, mental disorders caused by epilepsy, and mental retardation accompanying mental disorders. Patients in rural communities received better care after project implementation, of which 62.91% were farmers. This paper attempts to investigate the complex impact of Project 686 on the levels of rehabilitation of patients by their families. The last follow-up visit of the community psychiatrists in city H in 2020 was used as the time point. Finally, 174 samples were used in the analysis model. The type of kinship between family caregivers and patients with mental disorders was operationalized according to the information provided under the 'primary caregiver' item within the basic information section of the follow-up form. The software Stata15 was used to perform descriptive statistics, baseline regression model analysis, and a robustness test on the types of kinship identified and patients' recovery. The types of kinship, current symptoms, and medication use all affected patients' recovery, were found to have regression coefficients of -0.148, -1.756, and 0.902, respectively. Parents of patients with mental disorders remain in the caregiver category with the largest proportion. Community acceptance of patients is high; current symptoms, medication use, and types of caregiver-patient relationships influence patients' recovery levels. Project 686 has solved some of the rehabilitation and living difficulties of patients with mental disorders in rural communities. The types of kinship between family caregivers and patients with mental disorders in rural communities affect patients' rehabilitation levels. Patients' current symptoms and medication use can effectively moderate the impact of kinship type on patients' recovery in terms of complete self-knowledge, productive work, and life and good social relationships. It is necessary for mental illness prevention-treatment organizations to establish supplemental, replacement, and substitution mechanisms for the life and rehabilitation of patients with mental disorders in rural communities. Furthermore, the sense of reward and concern for family caregivers should be actively enhanced, and greater scientific use of the rehabilitation function of the 'family care + village doctor management' model should be made.

Association of rurality with utilization of palliative care and hospice among Medicare beneficiaries who died from pancreatic cancer: A cohort study.

Pancreatic cancer has a 5-year survival of just 10%. Services such as palliative care and hospice are thus crucial in this population, yet their geographic accessibility and utilization remains unknown. We studied the association between rurality of patient residence and the use of palliative care and hospice. Cohort study of continuously enrolled fee-for-service Medicare beneficiaries aged ≥65 diagnosed with incident pancreatic cancer between 04/01/2016-08/31/2018 and who died by 12/31/2018. In this decedent cohort of 31,460 patients, 77% lived in metropolitan areas, 11% in micropolitan areas, 7% in small towns, and 5% in rural areas. Patient demographics were largely similar across rurality; however, the proportion of White, non-Hispanic patients and social deprivation was highest in rural areas and lowest in metropolitan areas. Overall, 33% of patients used any palliative care and 77% received hospice services. After risk adjustment, there were no statistically significant differences in the use of palliative care for patients residing in metropolitan versus micropolitan, small town, or rural areas. Patients in small town (OR = 0.77, 95% CI: 0.69-0.86) and rural areas (OR = 0.75, 95% CI: 0.66-0.85) had lower adjusted odds of receiving hospice care compared to patients in metropolitan areas. The use of palliative care services captured in Medicare was low, representing either underutilization or failure to accurately measure the extent of services used. While the overall level of hospice enrollment was high, patients in rural communities had relatively lower use of hospice services compared to those in metropolitan areas.

Health-Seeking Behavior of Diabetic and Hypertensive Patients in Rural Communities of Ghana

Background: This study examined the health-seeking behaviors of patients with diabetes and hypertension in rural communities in Ghana. In Ghana, most studies on diabetes and hypertension are clinically oriented. However, medical-sociological truism suggests that attitudes towards health and illnesses, such as hypertension and diabetes, have a social-cultural perspective.&#x0D; Method: This study adopted a qualitative approach where twenty (20) participants who were either diabetic, hypertensive, or both were interviewed.&#x0D; Results: One of the study's significant findings was that diabetics/hypertensives use only orthodox hospitals to treat their conditions. Another finding was that the problems and challenges diabetics and hypertensives face include financial difficulties, social isolation, and stigmatization.&#x0D; Conclusion: Recommendations were made based on these findings. For instance, the registered traditional medicine practitioners should collaborate with the Ghana Health Service to intensify education on the importance of using certified traditional medicines in the treatment and management of diabetes and hypertension and provide customer-age-factor services at the various health facilities for persons with chronic diseases such as diabetics and hypertension.

Patient Reported Factors Influencing Decisions on Radiotherapy vs. Mohs Surgery for Non-Melanoma Skin Cancer of Cosmetically Challenging Head and Neck Sites at a Rural Radiation Satellite Facility

<h3>Purpose/Objective(s)</h3> Regional satellite radiotherapy facilities of major academic cancer centers serve cancer patients in rural communities well by bringing high-quality radiation treatments closer to home. Non-melanoma skin cancer is one of the most common cancer types treated at our satellite facility in rural upstate New York. Here we report outcomes of a telephone questionnaire and investigate factors that influence patient decision making between surgery and radiation for post-biopsy treatment of Non-Melanoma Skin Cancers (NMSC) of the head and neck (H&N). We also report treatment outcomes after radiation therapy (RT) for NMSC in cosmetically challenging areas of H&N, at a rural RT facility of our academic medical center. <h3>Materials/Methods</h3> Patients with NMSC of the H&N that were deemedat risk for poor cosmetic outcome with traditional resection, have been given the option for RT or Mohs surgery. We identified 79 patients that elected to undergo RT at our rural clinic from 2017-2021. 47 patients completed an 8-question telephone survey. We asked: On a scale from 1 (unimportant) to 5 (very important), how much did the following factors: overall health, medication concerns, cosmetic outcomes, fear of pain, healing concern, transportation concern (distance to surgery vs. RT facility), prior history of NMSC, and prior surgical experience, influence your decision to have RT instead of Mohs surgery. The average distance from patient's primary residence to a Mohs surgeon and to the RT facility was measured using Google maps. <h3>Results</h3> The average age was 76 y/o with 77% male. There was a 70%/30% split between BCC and SCC. 91% were T1 stage, and all were Caucasian. A total of 62 sites were treated with 77%/23% being treated with orthovoltage vs. electrons. There was a local recurrence in 2 patients with a 96% LC rate over a 28m median follow up time. Physician reported cosmetic outcomes were satisfactory or excellent in 94% of cases, and 98% of patients reported satisfaction with their treatment. Concerns about transportation, overall health, and cosmetic outcomes were the top 3 factors in choosing RT over surgery, with average scores of 4.47, 3.30, and 2.91 respectively (1-5 scale). The average distance for patients to RT facility vs. a Mohs surgeon was significantly shorter, 9.7 miles vs. 32.6 miles (p<0.05). <h3>Conclusion</h3> Our experience with RT for H&N NMSC treated at our rural satellite facility shows excellent local control, cosmetic outcomes, and patient satisfaction. While Mohs surgery remains one of the preferred options for managing cosmetically challenging NMSC, many patients still prefer RT. In our rural, elderly cohort, we have identified that concerns about transportation is the primary factor for patients electing to undergo RT over surgery.

Use of radiological information system data in Clinical Portal database to screen for missed abdominal aortic aneurysms.

New Zealand lacks a formal abdominal aortic aneurysm screening programme and owing to its rural nature, many patients have limited access to vascular surgery. Patients with vascular emergencies often have limited treatment options locally, especially if they present perimortem. In our small hospital in Whanganui, with the nearest vascular centre more than 150km away, there are cases of aneurysms diagnosed incidentally on radiology reporting but lost to follow-up. Clinical Portal (CP) is a widely used patient-centred dashboard for viewing health information that is managed by Orion Health. A search strategy utilising the CP common database was devised that aimed to find aneurysms which were not followed up. This search was performed retrospectively for all imaging within a 5-month period. Some 294 scans were flagged and 53 patients with aneurysms were found. Of these patients, 36 had follow-up by the ordering provider and 17 (32%) were found to have been lost to follow-up. Our pilot study demonstrated high rates of loss to follow-up and a lack of communication of important health information across multiple health disciplines in the region, and represents a potential method for identifying 'lost' aneurysms. For patients in rural communities, this may be critical to preventing future complications from aneurysmal disease.

Home isolation deaths during the third wave of COVID-19 pandemic in Kerala: a descriptive study

Background: The state government directed its efforts to mitigate transmission of new variant SARS-CoV-2 called Omicron. This study aimed to describe pathways and characteristics of home isolation (HI) deaths reported in Kerala during third wave of pandemic.Methods: The study adopted retrospective cross sectional descriptive approach, conducted among HI patients who died from January15th to February 15th 2022. The sociodemographic, clinical characteristics and the events that happened prior to deaths were collected through verbal autopsy. The state declared 106 HI deaths with case fatality rate of 2% (95% CI 1.5-2.50%). After screening, 70 HI deaths (54 home deaths and 16 in-transit deaths) were studied.Results: Majority were home deaths (84.29%) followed by in-transit deaths (15.71%). Mortality was higher among older persons (94.28%), females (51.42%), unemployed (68.57%) and patients in rural community. Majority had comorbidities (80%) mainly diabetes mellitus (55.35%). The median interval from symptom onset to death was five days (IQR) 4-8) and that from diagnosis to death was four days (IQR 2-8). Majority reported red flag signs (83.07%) commonly breathlessness (83.34%). Most of the deceased (80%) did not monitor oxygen saturation. The study identified four patterns of HI deaths, primarily due to delay in identification of red flag signs and hospitalization.Conclusions: Non-compliance to oxygen monitoring, slow response towards red flag signs and delay in hospitalization were the main reasons for HI deaths. Stringent monitoring mechanism for HI patients at primary health care and meteoric referral strategy can prevent fatalities in future.

A Digitally Capable Mobile Health Clinic to Improve Rural Health Care in America: A Pilot Quality Improvement Study

ObjectiveTo address the problem of limited health care access for patients in rural southern Minnesota, a digitally capable mobile health clinic (MHC) quality improvement initiative was launched in a rural community-based health system. MethodsThis project was designed and implemented according to our institutional strategic plan, guiding principles for virtual community care, and existing approved standards of care. A quality improvement development and pilot implementation framework was rapidly developed using Agile methodology. ResultsThe resulting technology and equipment selection, overall clinic design, vehicle vendor selection, clinical schedule and workflows, staffing model, equipment and technology selection, and testing were achieved in 12 months. The pilot site communities were chosen on the basis of size, interest, and lack of existing access. Four underserved rural communities now have access to telehealth consultations, laboratory testing, and in-person primary care examinations. By April 30, 2022, the MHC had provided 1498 patient appointments while maintaining our standards of care. Newly established broadband internet access for these communities and their residents was a valuable secondary outcome. ConclusionBy designing and implementing an MHC quality improvement intervention that provides both in-person and advanced telehealth options for patients in rural communities, our institution rapidly provided a potential solution for the rural health care crisis. The MHC not only replaces traditional brick-and-mortar facilities but also expands service offerings and access to technology for rural communities and the people who live and work in them.

522-P: Qualitative Findings of a Culturally Tailored Rural Diabetes One-Day DSMES Program in Eastern Colorado

DSMES is an essential component to equip people with diabetes to improve health behaviors and outcomes, and accessing culturally tailored and accessible DSMES services in rural communities is challenging. The Rural Diabetes One-Day (R-D1D) intervention used CBPR to adapt complex clinical information about diabetes into locally-relevant, actionable messages and materials. The products accompanied the implementation of a one-day 5-hour long DSMES program tailored to a rural community delivered to English and Spanish-speaking adults with diabetes in eastern Colorado. A second cohort will take place in Spring 2022. As part of an iterative design, key informant interviews were conducted with healthcare professionals and staff from participating clinics. A trained member of the study team used a semi-structured interview guide to collect qualitative data from clinical staff. A total of 6 individuals were interviewed from two clinics. Key themes included close-knit relationships between clinical staff and their patients with diabetes, lack of resources for patients in rural communities, and ongoing need for DSMES programs available through primary care clinics - particularly for patients with newly-diagnosed diabetes. Practice staff reflections on the R-D1D program were positive. Interviewees appreciated having a program offered to both English and Spanish-speaking patients to address disparities among their patient population. Staff reported patients appreciated meeting as a group - in a supportive setting - and enjoyed having access to a professional class made for them and offered to them. Changes recommended included setting the intervention date in advance, offering a program overview at a staff meeting to ensure all team members were aware of the program and felt comfortable discussing it with patients, and offering the class in the requested language. R-D1D will undergo iterations, as guided by these interviews, in the next phase of this research. Disclosure K.Curcija: None. G.Latendresse: None. T.Oser: Advisory Panel; Cecelia Health, Dexcom, Inc. M.L.Litchman: None. B.Kwan: None. L.K.Zittleman: None. J.Neuberger: None. C.Sutter: None. E.Iacob: None. S.J.Gonzalez: None. Funding National Institute of Nursing Research 1R56NR019466-01

Strategies for Improving Access to Cancer Services in Rural Communities: A Pre-implementation Study.

Implementation science is defined as the scientific study of methods and strategies that facilitate the uptake of evidence-based practice into regular use by practitioners. Failure of implementation is more common in resource-limited settings and may contribute to health disparities between rural and urban communities. In this pre-implementation study, we aimed to (1) evaluate barriers and facilitators for implementation of guideline-concordant healthcare services for cancer patients in rural communities in Upstate New York and (2) identify key strategies for successful implementation of cancer services and supportive programs in resource-poor settings. The mixed methods study was guided by the Consolidated Framework for Implementation Research (CFIR). Using engagement approaches from Community-Based Participatory Research, we collected qualitative and quantitative data to assess barriers and facilitators to implementation of rural cancer survivorship services (three focus groups, n = 43, survey n = 120). Information was collected using both in-person and web-based approaches and assessed attitude and preferences for various models of cancer care organization and delivery in rural communities. Stakeholders included cancer survivors, their families and caregivers, local public services administrators, health providers, and allied health-care professionals from rural and remote communities in Upstate New York. Data was analyzed using grounded theory. Responders reported preferences for cross-region team-based cancer care delivery and emphasized the importance of connecting local providers with cancer care networks and multidisciplinary teams at large urban cancer centers. The main reported barriers to rural cancer program implementation included regional variation in infrastructure and services delivery practices, inadequate number of providers/specialists, lack of integration among oncology, primary care and supportive services within the regions, and misalignment between clinical guideline recommendations and current reimbursement policies. Our findings revealed a unique combination of community, socio-economic, financial, and workforce barriers to implementation of guideline-concordant healthcare services for cancer patients in rural communities. One strategy to overcome these barriers is to improve provider cross-region collaboration and care coordination by means of teamwork and facilitation. Augmenting implementation framework with provider team-building strategies across and within regions could improve rural provider confidence and performance, minimize chances of implementation failure, and improve continuity of care for cancer patients living in rural areas.