Patients In Underserved Areas Research Articles

Impact of Hemodialysis on Sleep Disorders in Patients With End-Stage Renal Disease in a Tertiary Care Academic Hospital.

Although hemodialysis (HD) has prolonged the survival of patients with end-stage renal disease (ESRD), it has also adversely affected the sleep and emotional state of these patients. We evaluated the impact of HD on sleep duration, quality, and other sleep-related disorders. We recruited consecutive adult patients visiting our tertiary care dialysis unit. We included only ESRD patients who had an estimated glomerular filtration rate (eGFR) of <15 mL/min/1.73m2. We excluded patients with unrelated comorbidities or on medications that could affect sleep. Basic demographic information, anthropometric data, and appropriate lab investigations were obtained. Objective information related to their sleep duration and quality was asked using a predefined proforma. Subjective sleep scores were obtained by using the Pittsburgh sleep quality index (PSQI), Epworth sleepiness scale (ESS), and insomnia severity index (ISI). For comparison, the patients were divided into HD and conservative treatment (CT) groups based on their treatment modality. The baseline characteristics of the patients were noted. The Shapiro-Wilk test was used to test normality. Correlations were obtained by using Student's t-test for parameters that were normally distributed and the Mann-Whitney-Wilcoxon test for those that were not. Of the 56 patients we studied, 59% were males. The average age and body mass index (BMI) were 45.7 years and 20.98 kg/m2, respectively. Overall, 41% of patients were assigned to the HD group, and the remaining to the CT group. The CT group had fewer comorbidities compared to the HD group. The average sleep duration was similar in both groups (HD: 6.64 hours, CT: 6.49 hours). There was a weak-to-moderate positive correlation between the sleep scores. Overall, one-half of the patients had excessive daytime sleepiness (EDS) (46.43%) and insomnia (48.21%), and two-thirds of them were poor sleepers (66.07%). Symptoms suggestive of sleep-disordered breathing (SDB) were seen in 25% of patients, restless legs syndrome (RLS) in 19.64% of patients, and periodic limb movement disorder (PLMD) in 44.64% of patients. Patients undergoing HD had poorer sleep quality compared to the CT group (p=0.038). The odds of developing poor sleep were 3.6 times higher in the HD group. This cross-sectional study focuses on the quantification of objective and subjective deterioration of sleep quality in ESRD patients on HD. The prevalence of EDS (63.64%), insomnia (51.52%), and poor sleep quality (84.84%) in the HD group was more than the previously reported values. The PSQI, ESS, and ISI scores were higher in HD patients, indicating poorer sleep quality. Our study highlights the underestimation of sleep disorders in HD patients in underserved areas. Theresults warrant a meticulous evaluation of the same by a keen nephrologist, followed byreferral to sleep providers where necessary.

Iowa Funds Expansion of Rural Psychiatry Training, Services for Underserved Populations

Iowa Funds Expansion of Rural Psychiatry Training, Services for Underserved Populations

Incidence and Prevalence of Cough in a Rural Health System: A 20-Year Study.

Understanding the cough population is critical to addressing clinical needs and gaps in best practice. We sought to characterize and stratify cough patients with the hypothesis that there are opportunities to improve access to care in our health system and characterize the population. Following institutional review board exempt status, a retrospective electronic record review was performed on all patients coded with ICD-9 786.2 or ICD-10 is R05 from January 1, 2001 through December 31, 2020 at our health system. Inclusion criteria were one or more visits for cough. The subgroup with more than one visit in each of 2 years was classified as multiple encounters. Patients were characterized by sex, age at first cough encounter, number of cough encounters, smoking status, and insurance status. Results were stratified by year, calculating frequencies, and percentages. There were 302,284 unique patients diagnosed with cough, among 1,764,387 patients seen in our health system, representing an average incidence of 3.0% (2.7%-3.7%) and prevalence of 4.9% (3.1%-5.6%). New single encounter cough patients totaled 179,963, and new multiple encounter cough patients totaled 122,321. Of the 39,828,073 total encounters, there were 469,802 for new or existing cough (1.17%-1.73% annually). The age at initial presentation demonstrated 36.5% seen <10 years old, with an even distribution over the remaining decades of life. The majority were seen for cough once, but 23.8% of group two patients had two or more visits for cough in a year. We demonstrate a lower-than-expected incidence and prevalence of cough in our health population, suggesting challenges with access to care when compared to 10% prevalence and 3% of encounters previously documented in the literature. The study also provides a platform to explore the importance of pediatric cough, as well as population health and the longitudinal journey of cough patients in underserved areas. 3 Laryngoscope, 133:1191-1196, 2023.

Delivering Healthcare Through Teleconsultations: Implications for Offline Healthcare Disparity

In this study, we focus on the largely overlooked but important topic: social value created by teleconsultations. Many countries suffer from the geographic imbalance of their medical professionals: there are abundant resources in urban cities but too few in rural areas. Teleconsultations have emerged as a promising solution to reduce this disparity because they can remotely deliver healthcare without relocating medical professionals. Yet it is unclear whether teleconsultations actually mobilize healthcare to underserved areas. To answer this question, we collaborate with a large online healthcare platform and analyze its teleconsulting data together with offline healthcare and regional data. Our results indicate that teleconsultations tend to connect physicians in resourceful regions with patients in underserved areas—a desirable pattern that alleviates the geographic healthcare disparity. However, we also find that social, information, and geography frictions persist. For instance, teleconsultations are less likely to occur as regions become farther apart, and financial and information constraints limit rural patients’ access to teleconsultations. We uncover the underlying mechanisms that drive such frictions and provide recommendations to reduce the frictions that hinder teleconsultations.

Assessing Trauma Center Accessibility for Healthcare Equity Using an Anti-Covering Approach.

Motor vehicle accidents are one of the most prevalent causes of traumatic injury in patients needing transport to a trauma center. Arrival at a trauma center within an hour of the accident increases a patient’s chances of survival and recovery. However, not all vehicle accidents in Tennessee are accessible to a trauma center within an hour by ground transportation. This study uses the anti-covering location problem (ACLP) to assess the current placement of trauma centers and explore optimal placements based on the population distribution and spatial pattern of motor vehicle accidents in 2015 through 2019 in Tennessee. The ACLP models seek to offer a method of exploring feasible scenarios for locating trauma centers that intend to provide accessibility to patients in underserved areas who suffer trauma as a result of vehicle accidents. The proposed ACLP approach also seeks to adjust the locations of trauma centers to reduce areas with excessive service coverage while improving coverage for less accessible areas of demand. In this study, three models are prescribed for finding optimal locations for trauma centers: (a) TraCt: ACLP model with a geometric approach and weighted models of population, fatalities, and spatial fatality clusters of vehicle accidents; (b) TraCt-ESC: an extended ACLP model mitigating excessive service supply among trauma center candidates, while expanding services to less served areas for more beneficiaries using fewer facilities; and (c) TraCt-ESCr: another extended ACLP model exploring the optimal location of additional trauma centers.

Urology Residency Training in Medically Underserved Areas Through the Integration of a Federally Qualified Health Center Rotation

To identify workforce related barriers to urologic care in Medically Underserved Areas (MUA) and Health Professional Shortage Areas (HPSA). Federally Qualified Health Centers (FQHC) are community-based organizations that aim to close gaps, but little is known about exposure to underserved areas during residency training. The objective of this study was to characterize the experiences of urology residents who participated in a rotation within a FQHC. The study consisted of: (1) 12-item post-rotation self-assessment (2) review of career paths of former graduates who completed the rotation, and (3) retrospective review of patients treated at FQHC from 2016 to 2018. There were a total of 1735 patient visits, 97 were for cystoscopy, 76.36% of patients had Medicaid or no insurance. There were 1092 unique patients seen and 281 (25.73%) were referred for surgery. A majority of residents (100%) stated they had a better appreciation of treating patients in underserved areas. A majority of residents (71.6%) of residents said they were more likely to practice in an underserved area after residency. Among former graduates who rotated through the clinic, 100% (n = 4) were practicing in a MUA or HPSA. The integration of an FQHC during urology residency training was associated with highly favorable satisfaction by trainees. Given persistent workforce related shortages in urology, these findings support exposure to medically underserved areas during training.

Availability of Audiology Services in Assisted Living Communities in Florida

Florida has one of the largest populations of older adults in the U.S., and as a result the state also has a high prevalence of hearing loss. Given the growth of assisted living as a housing option for older adults, the purpose of this study was to determine the availability of audiology services in assisted living communities (ALCs) across Florida. Data on ALC location, characteristics and audiology service availability were collected from the Florida Agency for Health Care Administration (AHCA). County socioeconomic data were collected from the U.S. Department of Labor. Logistic regression and chi2 tests were used to examine the relationship between county socioeconomics and whether an ALC provided audiology services. We found that of the 3090 ALCs in Florida, audiology services were present in only 57 (3.2%). ALCs with audiology services were significantly more likely to be located in counties with a higher education level and a higher average income. This suggests a shortage of ALCs with audiology services in counties where residents have fewer resources. The results are concerning, given that individuals with fewer resources are less able to pay for audiology services on their own and evidence showing that poor hearing health late in life impacts individuals’ health and quality of life. Policy implications will be discussed, including the need for more ALCs to provide audiology services in counties with fewer resources. One possible solution is tele-audiology, which would enable a single audiologist to diagnose and prescribe hearing aids to patients in underserved areas.

High impact of a national psoriasis telementoring clinic on medical practices for patients in underserved areas.

Argentina is a large country in which important asymmetries exist in the knowledge and management of psoriasis. For this reason, in 2015 we launched Project ECHO Psoriasis, a telementoring strategy for dermatologists aimed at providing best medical practices in this population. The main objective of this study was to explore the reasons why the physicians participating in Project ECHO Psoriasis Argentina sought remote assistance. Cross-sectional study of the consultations made by dermatologists to the panel of experts. 213 consultations, which involved 158 patients in 60 teleclinics, were analyzed. The most frequent reasons for consultation were to implement changes in ongoing treatment, to support the treating physician approach to the patient, and to choose a de novo treatment, which were observed in 63 (39.9%), 47 (29.7%) and 46 (29.1%) consultations, respectively. The experts suggested modifying the approach to the patients in two thirds of the consultations (69.6%; 95% CI 61.8-76.7). Complete and partial compliance with the suggestions were observed in 66.4% (95% CI 56.7-75.1) and in 4.5% (95% CI 1.5-10.3), respectively. The main barriers identified were adherence by the patients and health services access issues. Telementoring for psoriasis is useful in reducing asymmetries in knowledge between dermatologists and ensuring access to the best clinical practices.

Lessons in Leadership From 3 Nurse Practitioners at the Boston Health Care for the Homeless Program.

Nurse practitioners play an integral role in the care of patients in underserved areas. At the Boston Health Care for the Homeless Program, many nurses have been promoted into leadership positions. Three nurse practitioners were asked to discuss their career paths, talk about leadership in the context of their career trajectory, and do so while considering how their training and clinical work prepared them to take on leadership roles.

Innovative Technology and Collaboration Move Cancer Diagnostics to the Forefront in Sub‐Saharan Africa

ASCP President David N.B. Lewin, MD, FASCP, left, and ASCP CEO E. Blair Holladay, PhD, SCT(ASCP)™, review the first biopsied breast cancer image uploaded from Rwanda. As African economic development improves, the prevalence of non‐communicable diseases (NCDs) will increase, with cancer at the forefront. NCDs such as cardiovascular disease, cancer, chronic respiratory diseases, and diabetes are often associated with the “globalization of unhealthy lifestyles such as unhealthy diets, physical inactivity, exposure to tobacco smoke, or the effects of alcohol.1 Over the next five years, the annual number of new cancer cases is predicted to increase to 1 million.2 The economic costs associated with cancer—both immediate healthcare costs and loss of productivity—are threatening continued development and prosperity. Deaths from preventable cancers mean catastrophic health expenditures, lower household income, and potential impoverishment. Globally, the World Economic Forum projects that the NCD epidemic will inflict $21.3 trillion in losses in developing countries over the next two decades.3 Pathology is important for diagnosing and treating cancer, but the countries in Sub‐Saharan Africa lack pathologists and trained laboratory personnel, infrastructure, and adequate opportunities for professional training. In October 2015, the American Society for Clinical Pathology (ASCP) and a coalition of partners committed to provide patients in underserved areas of Sub‐Saharan …

If a Patient's Cancer Is So Advanced, Who Decides Whether to Provide Palliative Care or Aggressively Treat It?

![Graphic][1] ![Graphic][2] Aron Rose, MD, is an ophthalmologist specializing in cataract and glaucoma surgery. He has treated patients and been invited to teach worldwide, including in China, Uzbekistan, India, Mongolia, Bhutan, Indonesia, Ghana, Myanmar, Gambia, and Liberia, and is an expert on blindness prevention and treatment in the developing world. The previous director of residency training and an associate clinical professor at the Yale University Schools of Medicine and Nursing, Dr. Rose also lectures regularly at the Yale Multidisciplinary Center for Bioethics. ![Graphic][3] He also chairs the Bioethics Steering Committee of the American Society for Clinical Pathology (ASCP)‐led Partners for Cancer Diagnosis and Treatment in Africa, a Clinton Global Initiative: Commitment to Action that provides patients in underserved areas of Sub‐Saharan Africa access to rapid cancer diagnostics and appropriate care and treatment. Annually, approximately 650,000 people develop cancer and about 510,000 cancer deaths occur in Africa due to limited treatment and resources. More than one‐third of cancer deaths in Africa are from cancers that are easily preventable and/or treatable, if detected early. This initiative brings together organizations with the expertise necessary to diagnose cancer earlier and provide appropriate treatment, as well as establish a sustainable laboratory infrastructure to address these issues in the future. By leveraging leapfrog technology, and the skills and experience of ASCP members, clinicians in Sub‐Saharan Africa can have access to … [1]: /embed/inline-graphic-1.gif [2]: /embed/inline-graphic-2.gif [3]: /embed/inline-graphic-3.gif

Partners for Cancer Diagnosis and Treatment in Africa Launches First Phase

The new, ASCP-led Partners for Cancer Diagnosis and Treatment in Africa, a Clinton Global Initiative Commitment to Action, has launched its first phase: providing patients in underserved areas of Sub-Saharan Africa access to rapid cancer diagnostics and appropriate care and treatment. In mid-January, the coalition delivered histotechnology equipment to Butaro District Hospital, in the city of Butaro in northern Rwanda. The equipment enables rapid diagnostics and review of patient material for therapy with a team of pathologists in the United States. Currently, there is no permanent pathologist in Butaro. Clinicians rely on either static image telepathology, visiting pathologists from the United States, or visits from local Rwandan pathologists, which takes them away from providing services in their own communities. Automated histopathology and telepathology systems are delivered to the Butaro District Hospital in the city of Butaro, Rwanda. Equipment was rolled into the lab space on logs. During this initial phase, four other hospitals in Rwanda also now have access to the equipment that enables them to share access to rapid diagnoses and advance consultants. These hospitals are the Central University Hospital of Kigali, Rwanda …

Improving Patient Care

![Graphic][1] Last October at the ASCP Annual Meeting in Long Beach, Calif., ASCP announced a groundbreaking global initiative: Partners for Cancer Diagnosis and Treatment in Africa. This effort will provide patients in underserved areas of Sub-Saharan Africa with access to rapid anatomic pathology cancer diagnostics and appropriate care and treatment. The goal is to use digital slide technology and a cloud-based system to allow ASCP member pathologists to make histologic-based diagnoses of Sub-Saharan African patients, issue a report within 48 hours, and allow local providers to care for and treat the patients. Non-communicable diseases (NCDs) have become the leading cause of death in Sub-Saharan Africa. Increases in life expectancy, changes in diet and lifestyle, and a lower burden of communicable diseases promise to increase this cancer burden.1 Data from the … [1]: /embed/inline-graphic-1.gif

Use of and interest in mobile health for diabetes self-care in vulnerable populations

Objective We aimed to assess use of and interest in mobile health (mHealth) technology and in-person services for diabetes self-care in vulnerable populations. Methods We delivered a self-administered cross-sectional survey. Participants were recruited at two primary care practices (P1 and P2) with P1 located in a medically underserved area and P2 in an affluent suburb. Two-sample t-tests and chi-square tests were used with p < 0.05 significant. In addition, a secondary analysis was performed to analyse differences in use and interest in mHealth by age. Results Of 75 eligible patients, 60 completed the survey (80% response rate). P1 patients had significantly higher interest in three of five categories of in-person diabetes support services, one of four categories of health-related text messages (TM), and three of eight categories of mHealth applications (p < 0.05). Smartphone users reported higher interest in TM (p = 0.004) and mHealth applications for diabetes self-care (p = 0.004). Younger patients were more likely to have a smartphone (p < 0.006), use the Internet (p < 0.0012), use smartphone applications (p < 0.0004), and to be interested in using applications to manage their diabetes (p < 0.004). Discussion This study shows substantial patient interest in TM and mHealth applications for diabetes self-care and suggests that patients in underserved areas may have particularly high interest in using mHealth solutions in primary care. Younger patients and smartphone users were more likely to be interested in using applications to manage their diabetes. As more patients use smartphones, interest in using mHealth to support patient self-care and strengthen primary care infrastructure will continue to grow.

Promoting seamless transfer-of-care for stroke patients in primary care: development of the integrated care pathway for post stroke services

Background Post-stroke care after hospital discharge suffers from lack of intersectoral collaboration within the public health sectors. Hence, primary care remains the only option in managing stroke patients in underserved areas in Malaysia. This study aimed to identify the areas, which can be better coordinated to deliver optimal poststroke care in community setting. A seamless transfer of care model known as integrated Care Pathway for Post Stroke patients (iCaPPS) was designed to address this issue.

Teledermatology: A Tool for Nurse Practitioner Practice?

Teledermatology is the practice of dermatology from a distance and can be used in several ways. This emerging technology has the potential to impact the current health care delivery system and provide dermatology care to a greater number of patients in underserved areas. Current research shows that the diagnostic concordance rates and accuracy rates are high, but there are also limitations with teledermatology use. Nurse practitioners have the potential to become active participants in the practice of teledermatology and ensure the provision of dermatology services to underserved populations.

Tele-Dysphagia Management: An Opportunity for Prevention, Cost-Savings and Advanced Training

Many patients survive severe stroke because of aggressive management in intensive care units. However, acquiring pneumonia during the post-onset phase significantly reduces both the quality and likelihood of survival. Aspiration pneumonia (AP), a relatively recent addition to the list of the pneumonias, is associated with dysphagia, a swallowing disorder that may cause aspiration of swallowed food or liquids mixed with bacterial pathogens common to saliva, or by aspiration of gastric contents due to emesis or gastroesophageal reflux. While it is within the purview of speech-language pathologists to provide evaluation, treatment, and management of dysphagia, the number of patients with dysphagia is growing faster than the number of qualified dysphagia clinicians. Because dysphagia consultations via telepractice are feasible and relatively accessible from a technological standpoint, they offer a promising strategy to bring the expertise of distant dysphagia experts to patients in underserved areas. Tele-dysphagia management has the potential to increase patients’ survival, enhance the expertise of primary, local clinicians, and reduce healthcare costs. Even a modest reduction in either hospital admissions for aspiration pneumonia, or in the length of stay for AP, could save the US health care system hundreds of millions of dollars each year. Wide spread tele-dysphagia management offers significant opportunities for prevention, cost-savings and advanced training, and is therefore worthy of consideration by stakeholders in the health care system and university training programs.

Telemedicine Consultation for Patients with Upper Extremity Disorders Is Reliable

Telemedicine is a valuable resource for the delivery of health care to patients in underserved areas. The purpose of this study was to assess the reliability of asynchronous teleconsultation in the diagnosis and establishment of treatment plans for patients with disorders of the upper extremity. One hundred patients with disorders of the upper extremity were prospectively evaluated. Initial patient evaluations, done by an independent evaluator, involved a medical history, physical examination, digital images of the patient, and digitized radiographic studies. This patient information was presented electronically to two hand surgeons 6 months after one surgeon independently evaluated the patients in the outpatient clinic. The physicians formulated diagnosis and treatment plans for the patients based on the blinded electronic information. These findings then were compared with the treatment plans made by the physicians at the time of the patients' visits. Telemedicine consultation resulted in excellent agreement within observers (kappa = .92) and between observers (kappa = .86). Telemedicine consultation seems to be a reliable method for diagnosis and establishment of treatment plans in the management of upper extremity disorders. Diagnostic study, Level I-1 (testing of previously developed diagnostic criteria in series of consecutive patients--with universally applied reference gold standard). See the Guidelines for Authors for a complete description of levels of evidence.

J-1 Visa Extension Likely To Become Law

Back to table of contents Previous article Next article Government NewsFull AccessJ-1 Visa Extension Likely To Become LawChristine LehmannChristine LehmannSearch for more papers by this authorPublished Online:19 Nov 2004https://doi.org/10.1176/pn.39.22.00390011Legislation to renew the federal J-1 visa waiver program sailed through Congress last month and is headed for the president's signature.APA and the American Medical Association supported passage of the Access to Rural Physicians Improvement Act of 2004 (HR 4453/S 2302), which renewed the program that expired on June 1 for two years, until 2006.AMA Executive Vice President Michael Maves, M.D., wrote to House Speaker Dennis Hastert (R-Ill.) last month that “HR 4453 would help ensure that physicians are placed in appropriate settings to serve patients in underserved areas,” according to an AMA press release.Nearly every state participates in the J-1 visa waiver program in which noncitizen foreign-trained physicians who finish residency training are recruited to work in underserved rural and/or urban areas. About 20 million Americans live in areas where there are not enough physicians to meet their medical needs (Psychiatric News, August 2, 2002).The waiver of the J-1 visa residency requirement is attractive to many international medical graduates (IMGs) who prefer to work in the United States after finishing their postgraduate training rather than return home for two years and apply for a different type of visa.However, the original intent of the J-1 visa program, administered by the U.S. Information Agency (USIA) in the 1960s,was to encourage educational and cultural exchanges between the United States and foreign countries in the post–cold war era.IMGs could apply for nonimmigrant temporary status to obtain postgraduate medical training in the United States if they stated that they intended to return to their home countries after training.“The goal was to give people training and experience in the U.S. they could use to benefit their home countries,” the AMA stated in its June 2002 “Report on J-1 Visa Waivers.”But by the early 1970s, the J-1 visa policy was widely criticized for encouraging IMGs to immigrate to the United States, thus creating a brain drain of physicians from developing countries, according to the AMA report. In 1982 the AMA called for an end to preferential immigration policies for foreign medical graduatesCongress tightened preferential immigration policies and laws between 1976 and the early 1980s, according to the report.In 1999 the USIA was merged with the U.S. Department of State, which reviews applications for waivers on a case-by-case basis. Physicians who came to the United States on a J-1 visa for graduate medical training could apply to have the requirement that they return to their home country waived if they anticipated persecution or exceptional hardship to a spouse or child. In addition, “an interested U.S. government agency can request the waiver because the visitors' acquired skills are in short supply within the U.S.,” according to the report.Several government agencies have served as interested parties requesting waivers, including the Department of Agriculture (USDA). Between 1994 and 2001, the USDA requested about 3,000 waivers. The USDA withdrew from the waiver program in late 2001, stating that it lacked the resources to conduct security background checks on all applicants following the September 11 attacks. The Department of Health and Human Services has attempted to fill the void left by the USDA and began reviewing J-1 visa waiver applications last year.In 2002, 46 states participated in the federal J-1 visa waiver program.The State Department continues to conduct security checks on all J-1 visa waiver applicants before it makes recommendations to the Bureau of Citizenship and Immigration Services in the Department of Homeland Security.The “AMA Report on J-1 Visa Waivers” is posted online at<www.ama-assn.org/ama/pub/category/print/12882.html>. The J-1 visa waiver application and related information are posted online at<http://travel.state.gov/visa/tempvisitors_info_waivers.html>.▪ ISSUES NewArchived

Promotora Telemedicine Project

The Promotora Telemedicine Project utilizes a telemedicine network to link diabetic patients in underserved areas with teams of physicians and Certified Diabetes Educators who deliver state-of-the-art health care services. Care is assisted by a support network of Spanish-speaking facilitators who serve as a cultural interface between Latino patients and diabetes care providers. This project is designed to test the hypothesis that new technology can be combined with culturally sensitive programs to improve access to high-quality care and to reduce the cost of diabetes care in Santa Clara County, California.