Personal Doctor Research Articles

Is patient experience of care associated with treatment choices for women with early-stage breast cancer?

289 Background: For women diagnosed with early stage breast cancer, lumpectomy followed by radiation therapy is a guideline-recommended treatment. However, lumpectomy followed by hormonal therapy is also an approved treatment regimen for certain women. It is unclear what patient-driven factors are related to the decision to receive radiation therapy. This study examined the relationship between patient-reported experience of care, an important dimension of health care quality, and receipt of radiation therapy following lumpectomy among women with breast cancer. Methods: We used the SEER-CAHPS data resource (NCI Surveillance Epidemiology and End Results [SEER] data linked to Medicare Consumer Assessment of Healthcare Providers and Systems (CAHPS) survey responses) to examine experiences of care among women diagnosed with local or regional stage breast cancer in 2000-2017 who received lumpectomy, were enrolled in fee-for-service Medicare, completed a CAHPS survey within 18 months of diagnosis, and survived for this study period. Experience of care was assessed by patient-provided numeric scores for overall care, health plan, physicians, customer service, doctor communication, care coordination, and other aspects of care. Multivariable logistic regression models assessed associations of receipt of radiation therapy with care experience and patient sociodemographic and clinical characteristics. Results: The study population included 825 women; 651 (79%) received radiation therapy. Approx. 84% were diagnosed with localized (vs. regional) breast cancer. Women with higher experience scores for their personal doctor or for care coordination were significantly more likely to have received any radiation therapy. In contrast, among women enrolled in Medicare Part D plans, those who reported higher scores for their prescription drug plan were significantly less likely to have received radiation therapy. Conclusions: Patient experience of care was significantly associated with receipt of radiation therapy following lumpectomy among women with breast cancer. While these results do not show causality, future quality improvement initiatives may want to explore the role of patient experience of care in facilitating patient decision making and improving quality of care.

Medicaid can and should play an active role in advancing health equity.

Medicaid can and should play an active role in advancing health equity.

The impact of Medicaid funding structures on inequities in health care access for Latinos in New York, Florida, and Puerto Rico.

To study the impact of Medicaid funding structures before and after the implementation of the Affordable Care Act (ACA) on health care access for Latinos in New York (Medicaid expansion), Florida (Medicaid non-expansion), and Puerto Rico (Medicaid block grant). Pooled state-level data for New York, Florida, and Puerto Rico from the 2011-2019 Behavioral Risk Factor Surveillance System and data from the 2011-2019 American Community Survey and Puerto Rico Community Survey. Cross-sectional study using probit with predicted margins to separately compare four health care access measures among Latinos in New York, Florida, and Puerto Rico (having health insurance coverage, having a personal doctor, delayed care due to cost, and having a routine checkup). We also used difference-in-differences to measure the probability percent change of having any health insurance and any public health insurance before (2011-2013) and after (2014-2019) the ACA implementation among citizen Latinos in low-income households. The sample consisted of Latinos aged 18-64 residing in New York, Florida, and Puerto Rico from 2011 to 2019. Latinos in Florida had the lowest probability of having health care access across all four measures and all time periods compared with those in New York and Puerto Rico. While Latinos in Puerto Rico had greater overall health care access compared with Latinos in both states, health care access in Puerto Rico did not change over time. Among citizen Latinos in low-income households, New York had the greatest post-ACA probability of having any health insurance and any public health insurance, with a growing disparity with Puerto Rico (9.7% any [1.6 SE], 5.2% public [1.8 SE]). Limited Medicaid eligibility (non-expansion of Florida's Medicaid program) and capped Medicaid funds (Puerto Rico's Medicaid block grant) contributed to reduced health care access over time, particularly for citizen Latinos in low-income households.

Medicaid expansion, managed care plan composition, and enrollee experience.

To examine changes in plan composition and enrollee experience associated with Medicaid expansion among Medicaid managed care organization (MCO) enrollees. Using 2012-2018 Adult Medicaid Consumer Assessment of Healthcare Providers and Systems surveys, we estimated changes in MCO enrollee characteristics and 4 outcomes: having access to needed care, having a personal doctor, having timely access to a checkup, and having timely access to specialty care. We estimated multivariable linear probability models comparing pre- vs postexpansion changes in expansion vs nonexpansion states. The postexpansion period was modeled as an event-study regression to account for changes over time. The coefficient of interest was a Medicaid expansion-by-year term. Medicaid expansion was associated with statistically significant decreases in the proportion of female enrollees (-8.4 percentage points [PP]; P < .01) and increases in the proportion of enrollees who were aged 55 to 64 years (6.8 PP; P < .01) and were non-Hispanic White (4.4 PP; P < .01). Relative to enrollees in nonexpansion states, MCO enrollees in expansion states were significantly less likely to report access to a personal doctor (-1.6 PP; 95% CI, -3.0 to -0.1 PP) and less likely to report timely access to specialty care (-2.1 PP; 95% CI, -3.4 to -0.8 PP; P < .01) in the first year after expansion. Differences were not statistically significant by the second year post expansion. There were not significant changes in the other 2 outcomes. State policy makers may need to account for the role that Medicaid expansion may have in changing Medicaid MCO enrollee composition to prevent unfair penalization on performance metrics.

Участь українських адвокатів у справі Ольги Басараб

Based on archival sources and historiography, the author examines the participation lawyers Stepan Shukhevych and Volodymyr Bachynsky from Lviv in clarifying the circumstances of Olga Basarab’s death. The defeat of the Ukrainian liberation movement during the Polish-Ukrainian war caused aggravation of relations between Ukrainians and Poles. In the early 1920s, Polish police conducted audits and arrests among Ukrainian students in Lviv. During one of those audits, there are was made an arrest, which later led to the death of O. Basarab in prison. In the article the author reveals the course of events connected with the death of O. Basarab, which took place in February 1924 in Lviv. At the beginning of February 1924, on 34 Vispyanskoho st., in O. Basarab's apartment, representatives of the police information department conducted searches, finding a significant quantity of intelligence materials. The excluded materials were perceived by the Polish police as a spy agent materials from a secret military organization known as the Ukrainian Military Organization. The detainee was interrogated, but she denied belonging to the spy network. O. Basarab died in prison after interrogation and torture. The police did not inform the family and society about the death of the prisone. Lawyers' statements were filed against a criminal case fabricated by Polish police to cover up a cynical death. At the Lviv District Criminal Court, lawyers, together with the victim's family and judges, heard forensic expert Wlodzimierz Sieradski, who found traces of the beating on the body of the deceased. After hearing the conclusion, lawyers of V. Bachynsky and S. Shukhevych filed a criminal offense. In the statement, they demanded the immediate exhumation of the body and a re-autopsy, through the personal doctor of the deceased Marian Panchyshyn; additional hearing of V. Seradsky and all those who was at the first autopsy; interrogation of prisoners who were in the prison on February 13 and 14, where O. Basarab died. Lawyers also applied for access to police records to find out who questioned the victim and was present during the interrogation. The problems faced by the lawyers during the consideration of the criminal case protocols were identified. The judge did not take into account all the facts mentioned by the lawyers. At numerous oral and written requests to Judge Kazimierz Angelsky by V. Bachynsky and S. Shukhevych never received the originals files of the case and the protocol of the judicial autopsy of the body of the deceased. But under pressure from family, lawyers and the public, the judge ruled that the body tour was on February 26. Lawyers S. Shukhevych and V. Bachynsky arrived at the appointed time. However, the exhumation was carried out before the arrival of the lawyers, and they were not allowed to examine the body, because according to the court ruling, the lawyers had the right to be only during the exhumation of the body. By doing so, the Polish authorities avoided the presence of lawyers to provide an alibi during the exhumation process. Thus, despite the resonance of the case and the exhumation of the body, it was not possible to find out whether the deceased actually committed suicide or was tortured in prison during interrogations. The fact that the Polish police concealed death and probable staging of suicide was proved by the lawyers efforts. Thanks to the hard work of S. Shukhevych and V. Bachynsky, the torture of Ukrainian prisoners was reported, especially in political cases.

Influence of Internet Health Information on Patient Compliance in Dermatology

Background: Many patients use the Internet to self-diagnose and find treatment options, thus avoiding the need to visit a doctor in person. Objectives: This study was done with the primary objective to determine how Internet health information impacts the patient–physician relationship, compliance, and its effect on patient treatment. Materials and Methods: It was a cross-sectional study, done at the Department of Dermatology, Venereology, and Leprosy, over a period of 6 months from January to June 2019. All patients with any dermatological diseases above the age of 12 years, who conducted an Internet search for the disease were included in the study. Participants were provided with an information sheet, outlining the details of the study. They were asked to fill out a questionnaire in their vernacular language. The questionnaire had questions about the patient's perspective toward his health as well as the doctor's advice before and after Internet usage. Descriptive analysis was used for statistical analysis. Results: A total of 110 patients were included in the study with 56.36% of males and 34.54% between 21 and 40 years of age group. Wikipedia was used by 51.81% of participants, followed by 40% who used Google. After Internet use, participants strongly agree that doctors possess more information than the information on Internet in 39.09%, while 61.81% of participants believe that there is good communication between doctor and patient. After Internet use, a maximum of 48.18% agree and followed the doctor's recommended medication. Conclusion: Online medical information has a positive effect on patient disease status and on patients' relationships with their physicians. Doctors should be more aware of the health information available online and should be able to guide patients to accurate and reliable websites.

Patient Autonomy in Direct Primary Care

Patient Autonomy in Direct Primary Care

Avoidance of Emergency Care in the Southeastern United States During the COVID-19 Pandemic.

In a low-income cohort in the Southeastern United States, 5% of participants avoided emergency medical care during the coronavirus disease 2019 pandemic, primarily due to fear and visitor restrictions. Younger age, self-perceived lower health status, lack of a personal doctor, and decreased income were associated with greater likelihood of deferring emergency care.

Evidence and Implications of the Affordable Care Act for Racial/Ethnic Disparities in Diabetes Health During and Beyond the Pandemic.

Amid the global pandemic, it becomes more apparent that diabetes is a pressing health concern because racial/ethnic minorities with underlying diabetes conditions have been disproportionately affected. The study proposes a multiyear examination to document the role of the Affordable Care Act (ACA) in racial/ethnic disparities in diabetes health. Using the Behavioral Risk Factor Surveillance System from 2011 to 2019, the study with a pre-post design investigated changes in access to care and diabetes health among non-White minorities compared with Whites before and after the ACA by conducting multivariable linear regression, with state-fixed effects and robust standard errors. Compared with Whites, racial/ethnic minorities showed significant improvements in health insurance coverage, having a personal doctor, and not seeing a doctor because of cost. Blacks (3.2% points, P ≤ 0.000), Hispanics (1.6% points, P = 0.001), and "other" racial/ethnic group (1.5% points, P = 0.003) experienced a greater increase in diagnosed prediabetes than Whites, whereas no and small differences were found in diagnosed diabetes and obesity, respectively. The yearly comparisons of changes in diagnosed prediabetes showed that Blacks compared with Whites had a growing increase from 1.2% points (P = 0.001) in 2014 to 3.3% points (P = 0.001) in 2019. Insurance coverage has declined after 2016, and obesity had an increasing trend across race/ethnicity. The ACA had a positive role in improving access to care and identifying those at risk for diabetes to a larger extent among racial/ethnic minorities. However, the policy impacts have been diminishing in recent years. Continued efforts are needed for sustained policy effects.

Dioecy in Flowering Plants: From the First Observations of Prospero Alpini in the XVI Century to the Most Recent Advances in the Genomics Era

Prospero Alpini was an Italian physician, botanist and scientist. Born in Marostica, in the Republic of Venice, in his youth he served in the Milanese army, but in 1574 he decided to study medicine at the University of Padova, where he graduated in 1578. After a short period as a doctor in Camposampiero (Padova, Italy), he became the personal doctor of Giorgio Emo, the appointed consul in Cairo in Egypt. In this way, he was able to devote himself to the study of botany. In this country, from the cultivation practices of the date palm, he described for the first time the sexual dimorphism in plants, later adopted as the basis of Linnaeus’ scientific classification system. Since then, this behavior, termed dioecy, has been described in other plant species, and many advances have been made in understanding the molecular mechanisms underlying this phenomenon, especially with the advent of genomics. Starting from a brief description of Prospero’s life and his pioneering scientific contribution, we illustrated the two main models explaining dioecism. This was achieved by taking a cue from two plant species, grapevine and poplar, in which genomics and single molecule sequencing technologies played a pivotal role in scientific advance in this field.

Abstract WP59: Sex And Age Specific Differences In Rehabilitation Attendance Between Rural And Urban Stroke Patients In The United States

Background: Stroke rehabilitation (SR) has been outlined in ASA/AHA guidelines as a critical component of post-acute care. US studies from the 2000s have found associations between rural residence and lower SR attendance, but contemporary information about SR attendance across geographic areas and patient subgroups is limited. Methods: Using the most recent 2011, 2013, 2015, and 2017 self-reported Behavioral Risk Factor Surveillance System (BRFSS) Surveys with SR data, we identified US adult stroke patients in 20 states. Rural/urban residence was classified by the Metropolitan Statistical Area codes. We compared SR attendance (Yes/No) among rural and urban stroke patients by sex and age groups (18-44y, 45-64y, 65+y). Logistic regression was used to examine the association between rural/urban residence and SR while controlling for key sociodemographic factors. Survey weighting was applied to all analyses. Results: Among 7878 stroke patients (40.8% rural, 62.2% women), slightly less rural residents attended SR compared to urban ones (30.8% vs 32.6%, p=0.357) ( Figure ). Rural/urban residence was not associated with SR prior to and after adjustment for sex, age, race, education, income, insurance status, and having a personal doctor (OR: 0.96, 95% CI: 0.80-1.15). In stratified analyses, women, patients 18-44y, and 45-64y who live in rural areas were less likely to attend SR than their urban counterparts. Women also had lower SR than men, irrespective of rural/urban residence. Conclusions: On average, a third of US stroke patients went to SR with no association found between rural/urban residence and SR attendance. However, a pattern of lower SR rates was observed across some sex and age subgroups in rural areas and in women regardless of residence status. Targeted interventions are needed to address rural/urban disparities and optimize secondary stroke prevention utilization, especially among women and young to middle aged patients in US rural areas.

Trust in COVID-19 information sources and perceived risk among smokers: A nationally representative survey.

BackgroundPublic health officials have classified smoking as a risk factor for COVID-19 disease severity. Smokers generally have less trust in health experts than do nonsmokers, leading to reduced risk perceptions. This study addresses smokers’ trust in information sources about COVID-19 and how trust is associated with perceived COVID-19 susceptibility and severity among smokers.Methods and findingsA nationally representative sample of 1,223 current smokers were surveyed between October and November 2020, indicating their level of trust in COVID-19 information sources, and their perceptions of risk from COVID-19. Multiple differences in trustworthiness emerged; smokers trusted their personal doctor for information about COVID-19 more than other information sources, while news media were generally distrusted. In addition, the FDA was trusted less than the NIH and CDC. Several “trust gaps” were observed, indicating disparities in levels of trust associated with gender, ethnicity, education, and political orientation, which had the strongest association with trust of all factors. Political orientation was also a significant predictor of COVID-19 risk perceptions, but there was no independent effect of political orientation when accounting for trust, which was predictive of all risk perception outcomes.ConclusionsTrusted sources, such as personal doctors, may most effectively convey COVID-19 information across political orientations and sociodemographic groups. News media may be ineffective at informing smokers due to their low credibility. The results suggest that trust may explain the apparent effect of political orientation on COVID-19 risk perceptions. Implications for researchers, communication professionals, and policy makers are discussed.

Physician selfcare or the cobblers of Montaigne

A recent survey conducted in the French-speaking part of Switzerland ("Romandie") showed that only about half of the primary care physicians (PCP) in Romandie had a personal doctor. Moreover, 37 % of the PCP declared they had foregone consulting a doctor for a health problem or a check-up during the past year. Finally, 29 % of them had chosen to continue working despite being ill. The literature describes multiple origins for these behaviors, both systemic (especially workload) and individual (denial, fear of social and peer judgment, culture of invincibility…). There is room for improvement for this still too often overlooked problem, in order to enhance the PCP's health (or well-being), and consequently the quality of care.

Abstract PO-013: Racial differences in smoking rates among low-income adults living in a large urban area

Abstract PURPOSE While smoking rates have decreased nationally, they remain elevated in underserved communities. The purpose of this study was to investigate smoking rates among race/ethnic groups in Chicago and for lower income levels across segregated neighborhoods served by a network of 6 federally qualified health center clinics. METHODS The Healthy Chicago Survey, an annual telephone survey of adults conducted by the Chicago Department of Public Health (2014-2018), was used to obtain rates and correlates of smoking using weighted analyses and linearized standard errors to account for the complex survey design and differential nonresponse. We examined city-wide estimates as well as a subsample composed of lower income (defined as &amp;lt;200% of the poverty level) residents of 3 geographic areas which represent roughly a quarter of Chicago adults (n=3,544 weighted to represent 517,271). RESULTS City-wide Chicago adults are 36% non-Hispanic (NH) White, 29% NH Black, and 26% Hispanic/Latino and have a smoking rate of 18.6% with 60% being daily smokers. The subsample results were 7% NH White, 49% NH Black, and 39% Hispanic Latino; smoking rate 26.8%. Background characteristics most associated with smoking include middle age (30-64 years), male sex, lesbian/gay/bisexual orientation, unmarried/no partner, NH Black, some college or less education, has no personal doctor, and experiences psychological distress. These relationships were consistent citywide and within the subsample except race/ethnic differences were less pronounced for those with lower income. NH Blacks, nearly half our low-income subsample, had the highest smoking rate (35.9%; 95% CI [33.1, 38.7]), followed by NH Whites (31.0 [23.6, 39.4]) with lower rates among Hispanic/Latinos (16.0 [13.4, 19.0]). The subsample comprised three distinct regions within the city with varying levels of race/ethnic diversity. CONCLUSION While tobacco use has declined over recent years there are significant disparities based on race and income. Among lower-income adults, NH Blacks, middle-aged, and males are at greater risk for smoking-related health conditions. Our findings demonstrate the higher rates of smoking among Black, medically underserved adults in low-income communities that contribute to health disparities. Citation Format: Alana D. Steffen, Larisa A. Burke, Cherdsak Duangchan, Karriem S. Watson, Alicia K. Watson. Racial differences in smoking rates among low-income adults living in a large urban area [abstract]. In: Proceedings of the AACR Virtual Conference: 14th AACR Conference on the Science of Cancer Health Disparities in Racial/Ethnic Minorities and the Medically Underserved; 2021 Oct 6-8. Philadelphia (PA): AACR; Cancer Epidemiol Biomarkers Prev 2022;31(1 Suppl):Abstract nr PO-013.

Razvoj srpske medicine u XIX veku

With the fall of the medieval Serbian state under Turkish rule, every culture, including medicine, died out, and the people resorted to folk medicine and self-taught doctors, i.e. empiricists. Serbs began to get educated in Vienna and Pest, and there were Serbian doctors in Novi Sad already at the beginning of the 18th century. At that time, the first doctors with diplomas appeared in Serbia, but mostly as personal doctors of the Belgrade pasha or Knez Miloš, i.e. his brother Jevrem in Šabac. In the fourth decade of the 19th century, the first military doctors set out, and the newly created four military district commands got their doctors. The Serbian Medical Association started the first medical journal, "Serbian Archives" in 1874. Josif Pancic is writing the first textbook in natural sciences, and Dr. Acim Medovic is writing the first textbook on forensic medicine. Before the First Serbian-Turkish War, the civilian ambulance numbered 69 doctors, 10 medical assistants, 26 pharmacists, and five pharmacy assistants, while the military ambulance had 19 doctors, five medical assistants, one pharmacist, and four pharmacy assistants. Health was initiated but also the establishment of the Ministry of Health and the higher education institution of the Medical Faculty in Belgrade. Guided by the oath, expertise, and experience, the doctors of that time made a significant effort to improve and develop medicine in Serbia in the 19th century.

Disparities of Access, Use, and Barriers to Seeking Health Care Services in Arizona.

Access to health care (HC) services is important for promoting and maintaining health, preventing and managing disease, reducing unnecessary disability and premature death, and achieving health equity for all persons. We assess social indicators among people living in Arizona that are associated with access, use, and barriers to seeking HC services. We analyzed data (n=8073) from the 2018 Behavioral Risk Factor Surveillance System (BRFSS) to describe demographic and health characteristics among persons by HC access and use, and for whom costs were a barrier to seeking care. Among Arizona adults, 13.5% reported lacking HC coverage, 28.7% reported lacking a personal doctor, and medical costs were a barrier to seeking care for 14.1%. Arizonans aged 18-34 years or with a high school education or less more often reported lacking HC coverage, a personal doctor, or not visiting a doctor because of costs. Past year medical and dental checkups were less common among less educated (≤high school) and never married persons. Hispanic persons more often reported lacking HC coverage or not visiting a doctor because of costs, and less often reported past year dental checkups. BRFSS can be analyzed to identify and quantify unique HC disparities, and the findings can serve as the basis for improving HC in communities. Expansion of HC services and providers may be achieved, in part, through incentives for providers to work in designated health professional shortage areas and/or leveraging telehealth/telemedicine in rural and urban underserved communities.

The Telemedicine Experience for Individuals with Sickle Cell Disease

IntroductionIndividuals with Sickle Cell Disease (SCD) require regular, and specialized treatment to manage their health. The COVID-19 pandemic disrupted in person medical visits for all individuals, with a rapid transition to telemedicine to provide medical care. Emerging data shows that the use of telemedicine may provide easier access to care and remove barriers to clinic attendance and improve access to appropriate medical care.ObjectiveThe purpose of this study was to use qualitative methods to understand the patients' experiences with telemedicine, identify patient preferences for type of appointment, and possible suggestions to improve telemedicine care.MethodsPatients from the Johns Hopkins Sickle Cell Center for Adults who had at least one telemedicine visit were invited to participate in a semi structured interview via zoom meeting or telephone. The interview asked participants about their satisfaction with telemedicine care, barriers to telemedicine, benefits and risks of telemedicine and possible telemedicine improvements. Interviews were recorded, transcribed and coded by two independent raters using thematic analyses to understand the experiences of telemedicine during the COVID-19 pandemic.ResultsOverall, 30 adults with SCD who had at least one telemedicine visit were invited to participate and completed their interview (mean age 41 years ± xx, 67% female, 93% Black/African American, 3% Multi-Race, 3% Other). “...I can't ignore the convenience of not having to worry about transportation ... that there's nothing to stop me from getting there.” During a SCD pain crisis it can it challenging to move and receive treatment as one participant reported “Maybe sometimes I might have pain...then moving around makes it difficult. So, getting in the car and finding somebody to drive you to a hospital or to whatever clinic would be difficult”. Being able to access specialized SCD care even while in pain is important. Having the option of either having telemedicine or in person visits was important to SCD patients “I could treat my crisis here at home. I don't have to go to the emergency room for it. So, if I can see my doctor in the tele-visit appointment and it's going to be constantly every day ... And when it's getting worse, then I could go to the emergency room more if needed. If it's not needed, I don't even need to go”. Another emerging theme amongst participants was despite the benefits from telemedicine, they also wanted to continue having in-person visits when they needed. SCD participants felt due to their SCD they still needed to see their doctor in person but it did not have to be for every visit “Well, I think telemedicine, for me, can be used in a setting where there's no such an emergency. Like if I'm having a routine exam, I don't mind having the telemedicine. But if ... I'm not feeling well ... I don't want to be having a telemedicine”. SCD participants felt they needed a physical exam periodically. “The only thing I didn't like about it was if I'm having some discomfort or some pain... there was no way for the physician to physically examine me”. Along with the lack of physical exam, there were concerns about the lack of vital signs “... the drawbacks would be the lack of the vitals beingtaken or there's not the personal touch and stuff”.ConclusionThe COVID-19 pandemic has presented many obstacles for patients to receive care. People living with SCD found telemedicine to be a positive tool to receive treatment. Patients reported the desire to continue with telemedicine even after the COVID -19 pandemic. Telemedicine allows for more accessibility for a group of individuals who already have numerous barriers to treatment. Future research can seek to identify the impact that telemedicine has on no-show rates, health care utilization, and the impact telemedicine has on patient reported quality of life. DisclosuresLanzkron: Teva: Current holder of individual stocks in a privately-held company; Shire: Research Funding; GBT: Research Funding; CSL Behring: Research Funding; Novo Nordisk: Consultancy; Bluebird Bio: Consultancy; Pfizer: Current holder of individual stocks in a privately-held company; Imara: Research Funding; Novartis: Research Funding.

What motivates patients to change general practitioners in the Pleven region, Bulgaria?

Abstract Problem The World Health Organization's 2008 World Health Report, entitled ‘Primary care now more than ever,' clearly states the need of knowledge about primary care not as one of the ordinary structures of the national health system, but as its leading priority. Description of the problem Since the start of health reform in Bulgaria, the choice and change of a GP by patients is most often spontaneous, random, and without enough specific information about the qualities of the GP. This reduces the effectiveness of the free choice of a doctor. The purpose of this study was to analyze the patient's motives for changing their GP. A survey was conducted among respondents in the period from September 1st to 30th, 2018 in the Pleven Region, Bulgaria. Patients who visited their GPs during the study period were interviewed. The results were processed using Microsoft Office Excel 2007. Results It was established that 830 (78.8%) of the 1053 respondents in the territory of Pleven Region have changed their personal doctor. The three leading motives were: long waiting times in front of the GP's office - 30.2%, change of residence - 19%, and lack of sufficient referrals from a physician to the specialist - 11.7%. Most of the surveyed patients assessed their GP as having a positive attitude toward them. 132 (12.6%) of the participants rate their personal doctor as rude, always being in a hurry, and nervous or not giving them any answers at all. Lessons When choosing a GP, the patient's prior information about the qualities and competencies of the personal physician of his\her choice is very low. It is necessary to create a system for the informed choice of a personal physician which will have a double effect, 1) a more adequate and more critically justified choice of a GP by the patient, and 2) a clearer, more stable commitment and responsibility of the GPs to the patients who chose them. Key messages It is necessary to improve the overall organization of the work of GPs. Healthcare is a type of interaction between the doctor and the patient during the diagnostic and treatment process.

Literary tourism and its role in the study of culture (based on the material of the life and work of Dusan Makovitsky)

The article deals with the issues of literary tourism in Slovakia based on the material of the life and work of the personal doctor of the great Russian writer L.N. Tolstoy, the famous Tolstovian, Dusan Makovitsky. The first part contains a theoretical overview of the phenomenon of literary and cultural tourism. The second part of the article examines its advantages in the context of education, and also provides specific examples of destinations with a great tourism potential for admirers and literary researchers of L.N. Tolstoy. Authentic places and artefacts related to the life of L.N. Tolstoy and D. Makovitsky allow expanding knowledge on this topic in such fields of science as history, religious studies, cultural studies, geography, etc. The article presents new ways and opportunities for teaching and studying history, culture and literature within the framework of specific aspects of Russian-Slovak cultural relations, as well as world culture in general.

Health Disparities Among Lesbian, Gay, Bisexual, Transgender, and Nonbinary Adults 50 Years Old and Older in the United States

Purpose: The purpose of this study was to examine health disparities among LGBT and nonbinary adult subgroups of those 50 years old and older. Methods: This was a cross-sectional analysis of data from the 2019 Behavioral Risk Factor Surveillance System survey. Access to health care, disabilities, health risk and healthy behaviors, and general health and chronic diseases and conditions were compared between gay men, bisexual men, lesbian/gay women, bisexual women, transgender women, transgender men, and nonbinary adults 50 years old and older. Rao-Scott corrected chi-square tests were utilized to determine significant differences between subgroups using weighted data. Multiple comparisons adjusted p values (Bonferroni) analyses were conducted when chi-square tests were significant. Results: Health disparities were identified among subgroups of LGBT and nonbinary older adults, with those who identified as nonbinary or as transgender women being the most vulnerable. Older nonbinary adults, transgender women, and bisexual men were more likely to not have a personal doctor or to not have had a medical checkup in the past 2 years, and nonbinary older adults were more likely to report disabilities, poor mental and physical health, depression, and asthma. Conclusion: Public health professionals and health care providers can use this information to target interventions to specific groups. Subgroup analyses of LGBT and nonbinary adults who are 50 years old and older need to continue with a focus on the most vulnerable groups. In addition, more research is needed that disaggregates transgender and nonbinary older adults to identify the unique health concerns of each group.