Enrollment In Program Research Articles

Value-based versus usual care for heart failure patients leads to reduction in cost, hospital admissions and improved survival

Abstract Background OptumCare (OC) in our city, Nevada established a heart failure (HF) program comprised of a team of outpatient cardiologists including two who are board certified in advanced heart failure. Referred patients are enrolled in the HF program once HF is diagnosed by a cardiologist. Patients are managed by an interdisciplinary team of cardiologists, advanced practice clinicians (APC), registered nurse case managers (RNCM), and a social worker. Patients at higher risk for HF admissions are enrolled in remote patient telemonitoring. In contrast, OC in Arizona utilizes a "usual" care approach of fee-for-service contracted cardiology groups to manage HF patients in outpatient and in-patient settings. Purpose A head-to-head comparison was performed between the cohort of patients enrolled in HF program in OC Nevada (treatment group) and patients with HF diagnosis in OC Arizona (control group). The groups were compared on the following measures: medical cost, hospital admissions, and survival rates. Methods In this retrospective study, a 1:1 iterative propensity score (PS) matching was performed to closely approximate patient demographics and comorbidities, which resulted in 818 matched pairs (total n=1,636) of the patients with program enrollment or 1st HF diagnosis between March 1, 2019 and June 30, 2022. For Difference-in-Difference Analysis (Diff-in-Diff), generalized linear models were used on PS matched data to test the difference in difference in medical cost and utilizations changes between control and treatment group over a six month period. Log-Binomial regression was used to estimate the relative risk of post period 30-day readmission and hospice enrollment. Kaplan Meier Estimator was used to test the difference in survival rates over time. Results Average age of patients was 77.6 years old, and 49% were female. The treatment group resulted in significantly lower overall medical costs per member per month (PMPM), significantly less emergency room (ER) visits, less acute hospital and skilled nursing facility (SNF) admissions, and shorter overall hospital length of stays. The control group was twice as likely to be readmitted to the hospital. Lastly, the treatment group had a significantly better survival rate than the control group. 19% of the patients in the control group expired within 12 months of enrollment vs. 10% of the patients in the treatment group expired during the same time period. Average survival was 142 days in the control group vs. 200 days in the treatment group. Conclusions A value-based care approach involving a multidisciplinary team in an outpatient-based cardiology HF program resulted in statistically significant improvement in medical costs, acute care visits/admissions, and survival rates compared to "usual" care approach for HF patients.

State-level trends in access to Medicaid family planning services, 2008-2023.

To characterize the landscape of policies that determine eligibility for family planning services through Medicaid programs and describe trends in eligibility and its determinants over time. Secondary data were collected for all states in the United States for the years 2008 through 2023. Data on economic and demographic characteristics came from the American Community Survey (ACS). Our descriptive study characterized state adoptions of Medicaid family planning section 1115 waivers and state plan amendments (SPA) and their eligibility criteria. We then estimated the proportion of women aged 19-44 years who were eligible for family planning services through Medicaid and identified the key determinants of changes in eligibility, by state and year. Information on state Medicaid policies was extracted from documentation on the Centers for Medicare & Medicaid Services website. When estimating the eligible population sizes, the denominator was women aged 19-44 years, the group most likely to be eligible for Medicaid family planning programs. Supplemental data on program enrollment or utilization were collected from states' websites and reports. Though eligibility limits for family planning through Medicaid generally increased over time, the proportion of women aged 19-44 years eligible for at least limited benefits decreased from 45.0% in 2012 to 39.4% in 2022, largely because of increases in household income. Trends varied considerably across states and by eligibility pathway. Among women with incomes below the poverty level, the proportion who were not eligible for Medicaid family planning services decreased from 6.3% in 2013 to 1.5% in 2022. Our data demonstrated substantial geographic and temporal variation in eligibility for family planning services through Medicaid. We identified key drivers of eligibility changes that may have important implications for health services analyses of means-tested public programs.

Barriers to Cardiac Rehabilitation Enrollment and Secondary Prevention Adherence in Patients with Coronary Heart Disease Following Percutaneous Coronary Intervention: A Cross-sectional Survey.

This study aimed to evaluate adherence to secondary prevention measures and to identify barriers to cardiac rehabilitation enrolment among patients with coronary heart disease after percutaneous coronary intervention. An observational cross-sectional survey was conducted through computer-assisted telephone interviews to assess recently treated percutaneous coronary intervention patients at the Prince Sultan Cardiac Center in Saudi Arabia. Out of 104 surveyed patients with coronary heart disease, 85 (82%) were male, with an average age of 59.5 years. The obesity rate was 28% (n = 29), with a high prevalence of comorbidities: 82 (79%), 63 (61%), and 62 (60%) patients had hyperlipidemia, diabetes, and hypertension, respectively. Despite high medication compliance (97%), adherence to secondary prevention measures was low (21%). Adherence to physical exercise and weight monitoring for fluid body build-up was notably poor at 35% and 9%, respectively. Only 11 (10.6%) patients were referred for cardiac rehabilitation, of whom only four (36.4%) attended. Significant barriers such as a lack of staff contact, insufficient physician support, and distance to cardiac rehabilitation facilities were particularly noted by 69% of rural patients. This study underscores the significant cardiac risk factors and low adherence to secondary prevention measures among post revascularization patients with coronary heart disease in Saudi Arabia. Low referral and other organizational barriers, as well as the travel distance to hospital-based cardiac rehabilitation, hinder program enrolment. To improve cardiac rehabilitation accessibility, it is crucial to revise the discharge plans, implement automated referral systems, expand the services across all regions, and utilize alternative delivery models.

Gestational diabetes mellitus: ensuring healthy futures

Gestational diabetes mellitus is the most common medical condition in pregnancy, disproportionately affecting overweight or obese women and those from non-White populations. The lack of standardised screening and diagnostic consensus contributes to varying prevalence. Conventional risk factor-based screening can leave women undiagnosed, leading to increased risk of harm. If diet and lifestyle modifications fail to achieve glycaemic targets, prompt treatment should be initiated to manage glucose levels. A planned birth is crucial to ensure the best outcomes. Postpartum, women need screening for type 2 diabetes and other cardiometabolic risk factors, enrollment in diabetes prevention programmes, and counselling on the increased risk of future cardiometabolic disease for themselves and their offspring, highlighting the importance of ongoing prevention and management strategies.

Referral, Enrollment, and Health Care Use in a Comprehensive Patient-Centered Management Program for Osteoarthritis of the Hip and Knee

ObjectiveOsteoarthritis management programs (OAMPs) have become a more common way to deliver patient-centered care. However, there is limited information on real-world use of these programs to guide implementation, payment policy, accessibility, and scaling in the United States. This paper describes 5-year use metrics for the Duke Joint Health Program, an OAMP embedded within a US academic health system. MethodThis analysis includes patients referred into the Program between October 2017 and April 2022. We generated descriptive statistics of referral and enrollment totals, demographics and patient-reported measures of enrollees, retention and healthcare use metrics (e.g., office visit frequency), and data capture rates for patient-reported outcomes. ResultsDuring the study period, 6,863 patients were referred to the program and 4,162 (61%) enrolled. We observed statistically significant differences between those who did and did not enroll by age (mean difference ± SE: 2.49 ± 2.8 years), sex (70.0% vs 67.7% female), race (65.1% vs 55.3% Caucasian/White), employment status (50.0% vs 40.2% retired), and insurance type (53.5% vs 47.0% Medicare). The median (Q1, Q3) number of visits was 2 (1, 4) and ranged from 1 to 67. The median (Q1, Q3) number of days from first to last program visit was 23 (0, 84) days. Questionnaire completion rates were 72% at baseline, 46% at 6 weeks, 39% at 3 months, and 40% at 6 and 12 months. ConclusionFindings can guide the planning, development, and implementation of future OAMPs and inform policies to ensure programs are accessible and equitable.

Advance Care Planning in Nursing Homes: Comparing Characteristics and Outcomes of Participants and Non-Participants

Background There is an increasing need to integrate Advance Care Planning (ACP) in nursing homes (NH) due to rapid aging and burden of multimorbidity. This study examines differences in the characteristics and outcomes of NH residents enrolled in a palliative care programme who have completed ACP and those who did not. Method We conducted a retrospective cohort analysis of 294 deceased residents enrolled into a palliative programme from 8 nursing homes in Singapore. Comparison was made between residents who completed an ACP and those who did not. Treatment preferences and place of death preferences were examined and concordance to these preferences were analyzed. Results ACP completion rate was 81% in the cohort. Residents opting for comfort measures only had high concordance (92%) for their preferred place of death (PPOD). However, residents opting for limited intervention showed lower PPOD concordance (77%), with many dying in hospitals despite a preference for dying in the NH. Residents with ACP were significantly more likely to die in NH (68.2% vs. 36.4%) and had a longer median programme enrolment duration (131 vs. 53 days) compared to those who did not complete ACP. Conclusion Despite high ACP completion rate in our cohort, challenges remain in aligning treatment preferences with actual care provided, particularly for residents opting for limited intervention. Future efforts should focus on increasing ACP participation and addressing systemic barriers to improve end-of-life care outcomes for NH residents.

Exploring Potential Challenges in Implementing a Standardized Curriculum for the Physician Associate Program in India: Insights From Stakeholder Discussions

Introduction This article explores the potential challenges in implementing a national-level standardized curriculum for physician associate (PA) programs in India, an initiative under the directions of the National Commission for Allied and Healthcare Professionals Act of 2021. Methods Initiated in August 2023, a multistage process began with emailing a draft curriculum for review to key stakeholders, followed by a virtual meeting on September 3. Key stakeholders, including faculty from various universities, participated in focus group discussions (FGDs) at the International Association of Physician Associate Educators and the Indian Association of Physician Assistants annual conference on September 21, 2023, in Gandhinagar. Results Four major themes emerged: (1) faculty development, (2) faculty recruitment, (3) alignment with the National Educational Policy, and (4) the necessity of master's degree programs for PAs. Challenges identified included shortage of qualified faculty, uncompetitive salaries for academic roles, and low enrollment in master's programs. Recommendations included increasing financial compensation for teaching PAs, developing more PA educators through additional master's programs, encouraging hospitals to mandate clinical and teaching roles for recruits, and introducing pedagogical training for PAs interested in teaching. Discussion Implementing a standardized curriculum for PAs faces significant challenges, especially in faculty recruitment and retention. Engaging a broader range of stakeholders is essential for the successful rollout of the curriculum and for meeting India's evolving health care needs.

Decomposing Variation in Vocabulary and Listening Comprehension Task Performance in Spanish and English Into Person, Ecological, and Assessment Differences for Spanish-English Bilingual Children in the United States.

We investigated the contributions of person, ecological, and assessment characteristics to one's performance on vocabulary and listening comprehension tasks in English and Spanish. Person characteristics included English learner status, ecological characteristics included instructional program enrollment (bilingual vs. English immersion) and poverty status, and assessment characteristics included the language of assessment (Spanish vs. English) and linguistic grain size (vocabulary vs. listening comprehension). Data were from 208 Spanish-English emergent bilingual children in Grade 1 in the United States and were analyzed using explanatory item response models. Substantial variance in the tasks across both languages was attributable to the random effects of assessment/item (74%) and person (26%). English learner status was a significant student predictor of language performance, and the instructional program was a significant ecological predictor of language performance. Regarding assessment characteristics, both the language of assessment and linguistic grain size explained the variance in performance. There were no differences in performance on English assessments between children in the Spanish-English bilingual program and children in the English immersion program. However, on the Spanish tasks, children in the bilingual program outperformed their peers in the English immersion program. These findings highlight the importance of considering not only person/child characteristics but also ecological and assessment characteristics for Spanish-English bilingual children's performance on oral language tasks. https://doi.org/10.23641/asha.26972749.

West Virginia forest landowners’ preferences for forest carbon offset programs

Several carbon offset programs allow West Virginia (WV) forest landowners to manage their forests to mitigate climate change and promote forest sustainability while providing an opportunity to earn extra income through carbon offset credits. While this market has grown rapidly, accessibility issues for small family forest owners remain. This study examines WV forest landowners’ insights and understanding of forest carbon offset programs and program preferences through an online survey of WV's Managed Timberland Program participants. Results showed that 97 % of respondents find it important to keep their land forested and 41 % think that carbon offset programs will help keep their land forested. However, the majority have no knowledge of carbon offset programs (55 %) nor an understanding the credit generation process (60 %). An econometric model was estimated to examine the influence of program attributes to landowners’ decision to enroll in a carbon offset program. Survey results suggest that landowners will more likely participate in carbon offset programs that require shorter time commitment (1–5 years), pay higher revenues, allow harvest or limited harvest restrictions, and do not charge an early withdrawal penalty. For example, a $1 increase in revenue payment raises the probability of enrolling in a carbon offset program by 1.2 %. However, extending the time commitment from 1 to 5 years to 40 years or 100 years decreases the probability of enrollment by 10.3 % and 17.4 %, respectively. Additionally, prohibiting harvest and imposing an early withdrawal penalty decrease the probability of enrollment by 18.1 % and 9.5 %, respectively. Landowners expressed greater willingness to enroll if they believe it is important to keep their land forested, they have familiarity and knowledge of the carbon offset market, and they believe carbon offset programs will help keep their land forested. Age, educational level, and length of ownership were also found to be significant factors in influencing landowner participation in forest carbon offset programs. Lastly, a welfare estimate, or landowners’ willingness-to-accept (WTA), was estimated for each of the program attributes. Surveyed landowners’ WTA payment for a carbon program was $22/ha/year or $37/ha/year greater if program duration increased from 1 to 5 years to 40 years or 100 years, respectively. In addition, landowners’ WTA payment was $39/ha/year greater if a “no harvest” requirement is implemented and $19/ha/year more if a penalty for early withdrawal is imposed. This study shows how factors like duration, payment, harvest restrictions, and withdrawal penalties influence landowner enrollment in carbon offset programs. By examining the preferences and decision-making processes of forest owners, this research fills a critical gap in the literature by providing insights into the drivers of program participation. The findings contribute to a better understanding of how to design more effective carbon programs that align with landowner motivations, ultimately supporting climate mitigation goals and sustainable forest management practices.

First-Generation Low-Income Individuals in Medicine: A Scoping Review.

This comprehensive scoping review of the medical literature on first-generation low-income (FGLI) individuals in medicine aimed to synthesize the highest levels of evidence to inform medical education stakeholders. Database searches were conducted in Academic Search Premier, Education Research Premier, ERIC, Ovid MEDLINE, Ovid Embase, Professional Development Collection, PubMed, Scopus, Google Scholar, and Web of Science Core Collection from database inception through March 15, 2023. English-language articles on first-generation or low-income individuals in medicine from U.S. medical schools were included. Articles were evaluated for level of evidence and themes chosen. Database searches resulted in 27,075 citations, 247 of which qualified for data extraction. The articles were classified by evidence level: level I (n = 2), level II (n = 17), level III (n = 90), level IV (n = 78), and level V (n = 60). Publications reported on 9 major outcomes: exam performance (n = 108), medical school performance (n = 63), residency and fellowship performance (n = 7), honor society status (n = 12), leave of absence (n = 9), withdrawal, dismissal, and attrition (n = 20), medical education graduation (n = 37), career choice (n = 109), and intent to practice in disadvantaged and rural communities (n = 60). Compared with their peers, FGLI individuals had lower medical school and standardized exam scores, enrollment in national medical honor societies and multiple degree programs, and graduate medical education performance and higher rates of leaves of absence, incompletion of medical education, pursuing primary care and family medicine specialties, and intent to practice in underserved communities. Despite an increase in the number of FGLI individuals in medicine, there remains significant opportunity to improve their inclusion and support. Multi-institutional, prospective, risk-adjusted, observational studies are required to determine how to best support FGLI individuals through all medical career stages.

Correlates of fentanyl preference among people who use drugs in Rhode Island

BackgroundFentanyl is increasingly pervasive in the unregulated drug supply and is a driver of drug overdose deaths in the United States. The aims of this study were to characterize and identify correlates of fentanyl preference among people who use drugs (PWUD) in Rhode Island (RI).MethodsUsing bivariate analysis, we examined associations between fentanyl preference and sociodemographic and psychosocial characteristics at baseline among participants enrolled in the RI Prescription Drug and Illicit Drug Study from August 2020-February 2023. Fentanyl preference was operationalized based on responses to a five-point Likert scale: “I prefer using fentanyl or drugs that have fentanyl in them.” Participants who responded that they “strongly disagree,” “disagree,” or were “neutral” with respect to this statement were classified as not preferring fentanyl, whereas participants who responded that they “agree” or “strongly agree” were classified as preferring fentanyl.ResultsAmong 506 PWUD eligible for inclusion in this analysis, 15% expressed a preference for fentanyl or drugs containing fentanyl as their drug of choice. In bivariate analyses, preference for fentanyl was positively associated with younger age, white race, lifetime history of overdose, history of injection drug use, past month enrollment in a substance use treatment program, past month treatment with medications for opioid use disorder, and preferences for heroin and crystal methamphetamine (all p < 0.05). Descriptive data yielded further insight into reasons for fentanyl preference, the predominant having to do with perceived effects of the drug and desire to avoid withdrawal symptoms.ConclusionsOnly a relatively small subset of study participants preferred drugs containing fentanyl. Given the increased prevalence of fentanyl contamination across substances within the unregulated drug market, the result for PWUD is increasingly less agency with respect to choice of drug; for example, people may be forced to use fentanyl due to restricted supply and the need to mitigate withdrawal symptoms, or may be using fentanyl without intending to do so. Novel and more effective interventions for PWUD, including increased access to age-appropriate harm reduction programs such as fentanyl test strips and overdose prevention centers, are needed to mitigate fentanyl-related harms.

Understanding the Barriers to Clinical Trial Referral and Enrollment Among Oncology Providers Within the Veterans Health Administration.

Clinical trials are essential for advancing treatment options in oncology while providing cancer patients with innovative care; however, few cancer patients are referred to clinical trials. System-, provider-, and patient-level barriers to clinical trial participation have been described but have not been studied in the Veterans Health Administration (VHA). Although the VHA has engaged in several initiatives to improve Veteran's access to clinical trials, including the National Cancer Institute and VA Interagency Group to Accelerate Trials Enrollment program and VHA work on the White House Cancer Moonshot, further research is needed to understand the multifaceted challenges underlying limited enrollment for Veterans who receive care in the VHA system. This research aims to evaluate VHA oncology providers' attitudes toward and experiences with referral and enrollmentof Veterans with cancer into clinical trials, for the purpose of informing actions that could be taken to enhance Veterans' access to clinical trials as well as the VHA's contributions to clinical research. This research comprised the administration of an electronic 34-item survey and semistructured interviews among oncology care providers in the VHA nationally, between May 2022 and August 2023. The survey was introduced via a presentation at VHA Oncology Office Hours and aimed to capture VHA oncology care providers' perceptions of and experiences with referral and enrollment to clinical trials. The semistructured interviews explored providers' perceived barriers to clinical trial participation and recruitment bias, as well as inquired about potentially modifiable factors for improving clinical trial enrollment at the VHA, such as providers' concerns, motivations for and facilitators of enrollment of patients into clinical trials, and the manner in which they communicate about clinical trials with their patients. Thirty-eight oncology care providers completed the survey, and eight completed the semistructured interview, including 5 staff physicians, 1 fellow, 1 nurse practitioner, and 1 physician assistant. Thirty-four survey respondents identified their specialty as medical oncology, one respondent identified the specialty as radiation oncology, and three identified the specialty as hematology. Nineteen respondents identified as women and 14 as men; the remainder did not provide their gender. Three respondents identified as Hispanic or Latino individuals, 11 as Asians, 3 as Black individuals, and 17 as White individuals. Five interview participants reported holding an individual academic affiliation. Participants identified and described various barriers to clinical trial referral and enrollment at multiple levels, including lack of appropriate trials, strict patient eligibility criteria, difficulties in understanding and managing the referral process for trials outside the VHA system, challenges with obtaining information and identifying available clinical trials, Veterans' financial and logistical concerns, lack of trust in the medical establishment, lack of adequate social support, and Veterans' psychological and physical comorbidities. They also highlighted opportunities for system-level change that can overcome some of these barriers, including academic affiliations, patient support from internal and external nurse navigators, and dedicated research coordinators. The insights gleaned from this research can guide VHA in its efforts to optimize access to clinical trials for Veterans.

Heightened migraine risk in patients with rheumatoid arthritis: A national retrospective cohort study.

This study aimed to evaluate the association between rheumatoid arthritis (RA) and subsequent migraine risk using the Korean National Health Insurance Service database. Migraine may be related to immune dysfunction and previous studies have suggested an association with chronic inflammatory rheumatic diseases; however, the relationship between RA and migraine remains unclear. This was a population-based, nationwide, retrospective, longitudinal cohort study. Participants were enrolled from 2010 to 2017 and followed up until 2019. A total of 42,674 patients who had undergone a health checkup within 2 years prior to the initial diagnosis of RA were included in the study, after applying the exclusion criteria (previous migraine, other rheumatic disease, missing variables of interest). A non-RA control was obtained by age and sex-matching (1:5). Finally, 42,644 patients with RA were enrolled, with 213,370 individuals without RA included as controls. Among the patients with RA, 29,744 had seropositive RA (SPRA), and 12,900 had seronegative RA (SNRA). SPRA was defined by the International Classification of Diseases 10th revision (ICD-10) code M05, prescription of disease-modifying anti-rheumatic drugs (DMARDs), and enrollment in a special copayment reduction program. SNRA was defined by the ICD-10 code M06 and prescription of any DMARD. The primary endpoint was the occurrence of migraine incidents, defined using the ICD-10 code of migraine (G43). A total of 22,294 migraine cases (17,912/213,370 [8.3%] in controls and 4382/42,674 [10.2%] in RA) were reported during a mean follow-up of 4.4 years after a 1-year lag period. Patients with RA had a 1.2-fold higher risk of migraine compared with controls (adjusted hazard ratio [aHR] 1.21, 95% confidence interval [CI] 1.17-1.26). Increased risk of migraine was found in both patients with SNRA and SPRA compared with controls (aHR 1.20, CI 1.15-1.24 in SPRA; aHR 1.26, CI 1.19-1.34 in SNRA). Compared to patients with SNRA, those with SPRA did not demonstrate a heightened risk (aHR 0.94, CI 0.88-1.01). A significant interaction was confirmed between covariates (male, current smoker, those with diabetes mellitus, and dyslipidemia) and the risk of migraine (p for interaction of <0.05). RA was linked to a higher migraine risk, regardless of seropositivity.

Effectiveness and efficiency of patient care while enrolled in an orthopedic physical therapy fellowship program

Rationale: Post-professional orthopedic manual physical therapy education programs have proliferated, in part due to increasing therapist demand. Despite the time, effort, and money required to complete these programs, there is scant research addressing their impact. We investigated whether physical therapists enrolled in an accredited manual physical therapy fellowship program achieved better outcomes, determined by patient changes in function, number of physical therapy visits, and episode of care duration while enrolled in the program. We also examined whether outcomes varied by clinician demographics, clinician life circumstances, and clinic characteristics. Methods: Forty-two therapists contributed patient data addressing functional status, number of visits, and episode of care duration. We compared data from the first 30 patients with data from the last 30 patients seen by each therapist while enrolled in the program. We also surveyed therapists regarding their demographics, life circumstances, and clinic characteristics. Results: There were no clinically meaningful or statistically significant differences in change in functional status when comparing results from the first 30 patients with the last 30 patients seen by therapists. However, there was a significant reduction in the number of visits and episode of care duration. Outcomes were influenced by entry-level degree and the presence of children at home. Conclusion: In our study, enrollment in a physical therapy fellowship program did not improve patient functional status but did reduce the number of visits and episode of care duration. Outcomes were influenced by some clinician life circumstances and clinic characteristics.

Evaluation of the Veterans Health Administration's Digital Divide Consult for Tablet Distribution and Telehealth Adoption: Cohort Study.

Video telehealth offers a mechanism to help Veterans Health Administration (VHA) patients overcome health care access barriers; however, many veterans lack a suitable device and sufficient internet connectivity. To address disparities in technology access, VHA established a Connected Device Program that offers veterans loaned video-capable tablets and internet service. In 2020, VHA introduced a national Digital Divide Consult to facilitate and standardize referrals for this resource. We sought to evaluate the reach and impact of VHA's Connected Device Program, leveraging Digital Divide Consult data to determine whether resources are supporting veterans with health care needs and access barriers. We examined the reach of VHA's Connected Device Program using national secondary data from VHA's electronic health records among 119,926 tablet recipients who received a tablet (April 1, 2020, to February 28, 2023) and 683,219 veterans from the general VHA population. We assessed changes in tablet recipients' demographic and clinical characteristics before and after implementation of the Digital Divide Consult compared with the general VHA population. We examined the impact of tablets and the consult on adoption of telehealth (ie, video visit use and number of visits) adjusting for differences between tablet recipients and the general VHA population. Finally, we evaluated consult implementation by assessing the use of video-based services by tablet referral reason. Common reasons for tablet referral included mental health diagnoses (50,367/79,230, 63.9%), distance from a VHA facility >30 miles (17,228/79,230, 21.7%), and social isolation (16,161/79,230, 20.4%). Moreover, 63.0% (49,925/79,230) of individuals who received a tablet after implementation of the Digital Divide Consult had a video visit in the first 6 months of tablet receipt. Some consult reasons were associated with a higher-than-average percentage of video telehealth use, including enrollment in evidence-based mental health programs (74.8% [830/1100] with video use), living >30 miles from a VHA facility (68.3% [10,557/17,228] with video use), and having a mental health diagnosis (68.1% [34,301/50,367] with video use). Tablet recipients had nearly 3 times the likelihood of having a video visit within a month once provided a tablet compared to the general VHA population, with an adjusted risk ratio of 2.95 (95% CI 2.91-2.99) before consult implementation and 2.73 (95% CI 2.70-2.76) after consult implementation. Analyses of telehealth adoption suggested that veterans receiving tablets for mental health care and evidence-based programs have higher rates of video visits, while those who are homebound or receiving tablets for hospice have higher rates of nonuse. This evaluation of VHA's Connected Device Program suggests that tablets are facilitating video-based care among veterans with complex needs. Standardization of referrals through the Digital Divide Consult has created opportunities to identify groups of tablet recipients with lower telehealth adoption rates who might benefit from a targeted intervention.

Self-concept in first grade and academic performance trajectories: roles of gender and dual-language immersion versus English-medium program enrollment

ABSTRACT This longitudinal study examined the latent structure of self-concept and its association with academic performance for elementary-aged students enrolled in dual-language immersion (DLI) and English-medium instruction (EMI) programs. Participants were 30 students in a Spanish-English DLI program and 40 peers in the same school’s EMI classrooms. The present study used confirmatory factor analysis to examine the structure of self-concept and multilevel growth modeling to investigate the effect of self-concept on academic performance tested in English. Results confirmed a three-factor self-concept construct and differences in several factors by program enrollment. Gender moderated the association between different factors of self-concept and academic performance. These findings suggest important educational implications: more attention to students’ early self-concept may be required as it plays a prominent role in students’ on-going academic achievement.

Factors influencing forest landowner enrollment in preferential property tax programs

One of the most common approaches to conserving forestland in the US are state-run programs offering reduced property taxes on forestland. Although some form of preferential forest property tax program exists in all 50 states of the US, few studies have examined factors associated with landowners’ enrollment in such programs. As interest increases in incentivizing forestland owners to address various environmental or ecological goals, such as enhancing carbon storage or ecosystem services via private forest management, the need for improved knowledge about factors that influence landowners to participate in such programs grows. We examined factors associated with NIPF owner enrollment in preferential property tax programs in Oregon (US). Oregon currently has two primary preferential forest property tax programs. The Forestland Program is the default program for most forestland owners, and the Small Tract Forestland Option (STF), which is a voluntary program wherein landowners pay reduced annual property taxes and an additional timber harvest severance tax. We used a survey to gather information from 1190 Oregon Small Woodlands Association (OSWA) members owning between 10 and 5000 acres of forestland in western Oregon. Respondents were asked about their socio-demographic characteristics and forest management, as well as their enrollment status in Oregon's preferential property tax programs. Our econometric analysis of survey data indicate that preferential property tax programs enable long-term forest ownership, extended rotation ages, and investment in stewardship activities, suggesting that these programs are likely an effective tool for encouraging environmental or ecological goals among NIPF owners in Oregon.

S14-3: The adoption and implementation of a physical activity referral pathway integrated into a major U.S. health system

Abstract Background Regular physical activity (PA) is highly effective in improving mental, physical, and emotional health; yet, health systems experience challenges integrating PA referral pathways connecting eligible patients to health-enhancing PA resources and programs. Purpose To examine the adoption of a clinic-to-community PA referral pathway in primary care clinics in a major U.S. health system and identify provider- and patient-level barriers and facilitators associated with its implementation. Methods Exercise is Medicine Greenville® (EIMG®) is a clinic-to-community model that connects primary care patients to a 12-week, evidence-informed, PA program in community PA facilities. Resumption of EIMG® in March 2021 after COVID-19 closures provided a unique opportunity to comprehensively evaluate the PA referral pathway from inception. Referral provision, utilization, and program enrollment were tracked from reopening through September 2022 in twelve primary care clinics. Semi-structured interviews were conducted with providers (informed by the i-PARIHS framework) and referred patients who declined enrollment (informed by the COM-B model). Interviews were recorded, transcribed, and themes identified. Results Twenty-six providers completed interviews. Referral barriers included a lack of knowledge about EIMG®, a perceived time-consuming referral process, and placing incomplete referrals. Facilitators included acknowledgment of a high value for PA in healthcare, desire to incorporate EIMG® into patient visits, and the work of the EIMG® nurse navigator. Twenty-eight patients completed interviews. Enrollment barriers included time, financial constraints, inconvenient locations, disruptions due to COVID-19, and suboptimal communication. Facilitators included aligning EIMG® with patients’ health goals, enhanced trust due to provider referral, group-based format of the PA program, and friendly staff. Conclusions Improving communication, conducting refresher trainings, simplifying the referral process, and providing more resources (for providers), along with providing more program details, and offering more program times, locations, and financial support (for patients), may increase success of PA referral pathways implemented in primary care settings. Practical implications This work identifies modifiable factors that can guide improvements in the adoption and implementation of PA referral models in health settings. Funding The Duke Endowment and the National Heart, Lung, and Blood Institute (NHLBI)

791. ONLY HALF OF THE PATIENTS TREATED ENDOSCOPICALLY FOR EARLY BARRETT RELATED NEOPLASIA IS DETECTED DURING BARRETT SURVEILLANCE

Abstract Background Barrett’s esophagus (BE) with early neoplasia is an indication for endoscopic treatment. Patients with non-dysplastic BE are typically enrolled in an endoscopic surveillance program to enable early detection, and treatment, of BE related neoplasia. In contrast, a subset of patients with early BE neoplasia is concurrently diagnosed with BE and early neoplasia. Our goal was to distinguish cases detected through endoscopic surveillance programs (i.e. initial detection of non-dysplastic BE with progression to neoplasia later in time (metachronous neoplasia)) from cases where BE and neoplasia were diagnosed simultaneously (synchronous neoplasia). Methods We obtained data from the Dutch Barrett Expert Center Registry, a comprehensive nationwide registry encompassing data from all BE patients who underwent endoscopic treatment in Barrett expert Centers in the Netherlands. To enhance data completeness, we supplemented the registry with pathology reports sourced from the national pathology registry (PALGA). Primary endpoint was the proportion of patients diagnosed with BE and neoplasia simultaneously (synchronous neoplasia). Enrollment in an endoscopic surveillance program was defined as the presence of at least one endoscopy with non-dysplastic BE ≥12 months prior to endoscopic treatment initiation. Results A total of 2,091 patients were identified from the registry with a mean age of 66 years (SD±10) and 81% of the cohort being male. Median BE length was C2M5 (IQR 0-6; 3-8) and treatment indication encompassed low-grade dysplasia (LGD; 23%), high-grade dysplasia (HGD; 25%), or cancer (52%). Overall, 1149/2,091 patients (55%) underwent an endoscopy that revealed a new diagnosis of BE with synchronous neoplasia. Conversely, the remaining 942/2,091 patients (45%) were enrolled in endoscopic surveillance programs at the moment neoplasia was diagnosed, with a median duration of endoscopic surveillance prior to neoplasia detection of 8 years (IQR 4-13). The proportion of patients with new BE and synchronous neoplasia increased along with more severe histology at the moment of neoplasia detection. Specifically, the proportion of patients with synchronous neoplasia was 42% (198/475) for a treatment indication of LGD, 50% (260/520) for HGD and 63% (690/1096) for cancer (P &amp;lt;0.01). There was no significant difference observed concerning varying lengths of BE. Conclusions Remarkably, less than half of the patients with early Barrett’s neoplasia and neoplasia, receive a neoplasia diagnosis following enrollment in endoscopic surveillance programs, while the remaining patients present with de novo diagnosis of BE containing synchronous neoplasia. Notably, for patients with more severe histologic changes at the moment of neoplasia detection, the proportion of de novo BE with synchronous neoplasia is even higher. These findings support further critical view regarding the benefits of BE surveillance.

Impact of Pharmacist-Led Interventions on Hypertension Management in Cancer Patients Undergoing Chemotherapy

Background: Hypertension (HT) is a common cardiovascular condition, particularly prevalent among cancer patients, with approximately 40% exhibiting concurrent diseases. This study aimed to investigate the relationship between hypertension and cancer, focusing on how anticancer treatments contribute to hypertension and its cardiovascular complications. Methods: A retrospective analysis was conducted at a specialized pharmacy involving adults receiving oral chemotherapy. Participants were divided into control (n=50) and intervention (n=29) groups, based on their enrollment in a pharmacist-led hypertension management program. Data were collected on blood pressure (BP) measurements and interventions, with statistical analyses employed to assess differences between groups. Results: The intervention group demonstrated significant improvement in BP management, with 19 out of 29 patients achieving controlled BP by February 2023 (p=0.04), compared to 21 out of 50 in the control group. Continuous monitoring led to a gradual decline in average BP measurements in the intervention group, indicating effective management. Pharmacists made recommendations to physicians, achieving a 100% acceptance rate for medication adjustments. Conclusion: Integrating pharmacist-led interventions in managing hypertension among cancer patients significantly improves BP control and patient outcomes. Given the rising prevalence of hypertension in this population, further research is necessary to explore the long-term effects of such interventions and their broader implementation in clinical practice.