Exploring biorepository donation patterns, experiences, and recommendations: a mixed-methods study among Appalachian adults enrolled in a sugary drink reduction program.

Background: Under-represented subgroups in biomarker research linked to behavioral health trials may impact the promise of precision health. This mixed methods study examines biorepository donations across an Appalachian sample enrolled in a sugary drink reduction intervention trial. Methods: Participants enrolled in the behavioral trial were asked to join an optional biomarker study and were tracked for enrollment and biospecimen returns (stool and/or buccal sample). At 6 months, participants completed a summative interview on decision-making process, experiences collecting samples, and recommendations to encourage biospecimen donation. Return rates were analyzed across demographics (i.e., age, gender, race, education, income, health literacy status, and rurality status) using chi-squares. Qualitative data were content coded with differences compared by biomarker study enrollment and donation choices. Results: Of the 249 invited participants, 171 (61%) enrolled, and 63% (n = 157) returned buccal samples and 49% (n = 122) returned stool samples. Metro residing participants were significantly more likely (56%) to return stool samples compared to non-metro (39%) counterparts [x2(1) = 6.61; p = 0.01]. Buccal sample return had a similar trend, 67 and 57%, respectively for metro vs. non-metro [x2(1) = 2.84; p = 0.09]. An additional trend indicated that older (≥40 years) participants were more likely (55%) to donate stool samples than younger (43%) participants [x2(1) = 3.39; p = 0.07]. No other demographics were significantly associated with biospecimen return. Qualitative data indicated that societal (66-81%) and personal (41-51%) benefits were the most reported reasons for deciding to donate one or both samples, whereas mistrust (3-11%) and negative perceptions of the collection process (44-71%) were cited the most by those who declined one or both samples. Clear instructions (60%) and simple collection kits (73%) were donation facilitators while challenges included difficult stool collection kits (16%) and inconveniently located FedEx centers (16%). Recommendations to encourage future biorepository donation were to clarify benefits to science and others (58%), provide commensurate incentives (25%), explain purpose (19%) and privacy protections (20%), and assure ease in sample collection (19%). Conclusion: Study findings suggest the need for biomarker research awareness campaigns. Researchers planning for future biomarker studies in medically underserved regions, like Appalachia, may be able to apply findings to optimize enrollment.

Association between the social vulnerability index and breast, cervical, and colorectal cancer screening rates in Rhode Island.

BACKGROUND: Cancer screening is effective in reducing the burden of breast, cervical, and colorectal cancers, but not all communities have appropriate access to these services. In this study, we aimed to identify under-resourced communities by assessing the association between the Social Vulnerability Index (SVI) with screening rates for breast, cervical, and colorectal cancers in ZIP-code tabulation areas (ZCTAs) in Rhode Island. METHODS: This study leveraged deidentified health insurance claims data from HealthFacts RI, the state's all-payer claims database, to calculate screening rates for breast, cervical, and colorectal cancers using Healthcare Effectiveness Data and Information Set measures. We used spatial autoregressive Tobit models to assess the association between the SVI, its four domains, and its 15 component variables with screening rates in 2019, accounting for spatial dependencies. RESULTS: In 2019, 73.2, 65.0, and 66.1% of eligible individuals were screened for breast, cervical, and colorectal cancer, respectively. For every 1-unit increase in the SVI, screening rates for breast and colorectal cancer were lower by 0.07% (95% CI 0.01-0.08%) and 0.08% (95% CI 0.02-0.15%), respectively. With higher scores on the SVI's socioeconomic domain, screening rates for all three types of cancers were lower. CONCLUSION: The SVI, especially its socioeconomic domain, is a useful tool for identifying areas that are under-served by current efforts to expand access to screening for breast, cervical, and colorectal cancer. These areas should be prioritized for new place-based partnerships that address barriers to screening at the individual and community level.

Relative remoteness and wage differentials in the Canadian allied health professional workforce.

INTRODUCTION: Health workforces around the world are characterized with geographic maldistribution, often leading to inequalities in rural health outcomes. Monetary incentives are frequently raised as a policy option to bolster recruitment of healthcare practitioners to rural and underserved communities; however, few rural health workforce studies focus on allied health professionals (AHPs), include urban comparators, integrate gender considerations, or measure rural diversity. This population-based observational study examines trends in the geographic and gender distribution and earnings of AHPs in Canada across the rural-urban continuum. METHODS: Nationally representative data from the 2006 and 2016 Canadian population censuses were pooled and linked with the geocoded Index of Remoteness for all inhabited communities. Five groups of university-educated AHPs providing prevention, diagnostic evaluation, therapy, and rehabilitation services were identified by occupation. Multiple linear regression models were used to estimate the associations between relative remoteness and annual earnings of AHPs aged 25-54 years, controlling for gender and other personal and professional characteristics. RESULTS: The density of AHPs was found to be 15 times higher in more urbanized and accessible parts of the country (23.6-25.6 per 10 000 population in 2016) compared to the most rural and remote areas (1.6 per 10 000 population), a pattern that changed little over the previous decade. A positive correlation was seen across occupations in terms of the degree of feminization and their geographic dispersion by relative remoteness. While pharmacists residing in more rural and remote communities earned 9% (95% confidence interval 4-15%) more than those in core urban centers, relative remoteness contributed little to wage differentials among dentists, physiotherapists and occupational therapists, or other AHPs in therapy and assessment (no significant difference at p<0.05). Women earned significantly less than men in dentistry, pharmacy, and physical or occupational therapy, after adjusting for remoteness and other characteristics. CONCLUSION: This study did not find consistent wage disparities by relative remoteness as characterizing allied health professions in Canada. The evidence base to support financial incentives to AHPs to reduce perceived opportunity costs associated with working and living in rural and underserved areas remains limited. More research is needed on the intersections of rurality, gender, and wage differentials among AHPs in different national contexts.

Race and Gender in Ophthalmology: A National Analysis of Medical Students with Intention to Pursue the Field.

Purpose The field of ophthalmology must become more reflective of the increasingly diverse U.S. population. This study characterizes students intending to pursue ophthalmology and practice in an underserved area versus other surgical and nonsurgical fields. Subjects Deidentified responses from 92,080 U.S. MD students who matriculated in the academic years beginning from 2007 to 2011 were obtained from the Association of American Medical Colleges (AAMC) Graduation Questionnaires. Methods Study participants were those who fully completed the AAMC Graduation Questionnaire. Chi-squared and multivariate logistical regressions were used for analyses. Results Ophthalmology intending graduates (OIG; n = 1,177) compared with other surgical intending graduates ( n = 7,955) were more likely to be female (adjusted odds ratio [aOR]: 1.46; 95% confidence interval [CI]: 1.28-1.66), Asian (1.71 [1.46-2.01]), and have conducted a research project with a faculty member (1.58 [1.26-1.98]). OIG compared with nonsurgery intending graduates ( n = 35,865) were more likely to have completed a research project with a faculty member (4.78 [3.86-5.92]), to be Asian (1.4 [1.21-1.62]), and have received scholarships (1.18 [1.04-1.34]). OIG were less likely to be female (0.64 [0.57-0.73]) and Black/African American (0.5 [0.33-0.74]). Among OIG, Black/African American students and multiracial students were more likely than non-Hispanic (NH) White students to report intention to practice in underserved areas (IPUA; 14.29 [1.82-111.88] and 2.5 [1.06-5.92]), respectively. OIG with global health experience were more likely to report IPUA (1.64 [1.2-2.25]). Conclusion Females and underrepresented in medicine (URM), respectively, were more likely to be nonsurgery intending graduates than OIG, which, if not addressed, may lead to a persistent underrepresentation of these groups in the field. In addition, URM students, including African American students, were more likely to report IPUA, which further emphasizes the importance of more URM students entering the field to address these growing gaps in medical care. Finally, we recommend increased mentorship to help address these disparities.

Promoting cultural competency and osteopathic medicine awareness among premedical students through a summer premedical rural enrichment program.

CONTEXT: Premedical preparatory programs at osteopathic medical schools that recruit students from medically underserved areas (MUAs) may promote interest in practicing osteopathic medicine in underserved or rural areas. In these programs, emphasis on cultural competency may increase diversity among medical school applicants and decrease healthcare disparities in the future. OBJECTIVES: The goal of this study is to determine whether a summer premedical rural enrichment program (PREP) held at an osteopathic medical school located in a MUA will foster greater prioritization of cultural competency in medicine, enhance interest in practicing in rural or underserved areas, and increase familiarity with osteopathic medicine. METHODS: An eight-week summer PREP was hosted at the California Health Sciences University College of Osteopathic Medicine (CHSU-COM) in Clovis, California. Seventy-eight diverse participants were recruited from the Central Valley, an underserved region of California. Attendees were required to finish the formal application process and were recommended to have completed medical school prerequisite courses. The curriculum included Medical College Admission Test (MCAT) preparation through team-based learning sessions, introduction to the osteopathic medical school curriculum, osteopathic philosophy, and osteopathic manipulative medicine, as well as integrated anatomy and physiology sessions, medical school application workshops, mock interviews, simulation workshops, and sociology and cultural competency sessions. Data were collected via a voluntary and anonymous survey administered before and after the program with questions about familiarity with osteopathy, interest in practicing in underserved areas, medical school preparedness, and a post-course survey about cultural competency. The surveys had students rate statements on a Likert scale. RESULTS: Seventy-four of the 78 premedical students (95%) completed the pre-and postsurvey. There was a significant increase in agreement to statements evaluating medical school preparedness, osteopathic familiarity, and desire to practice medicine locally in the postprogram survey, compared to the preprogram survey. In the cultural competency postsurvey, 75.0% of the responses to questions that evaluated the positive effect of the course were "Agree" or "Strongly Agree." Of the reported postcourse outcomes, the average MCAT score was 504 ± 6.2 (38 students reported, 50.7%). Of the 27 participants who reported matriculation, 16 (59.2%) were admitted to osteopathic medical schools, 9 (33.3%) to allopathic medical schools, and 2 to other health programs. CONCLUSIONS: After completing the PREP program, premedical participants reported that they have better understanding of cultural competency and improvement in preparation for medical school, including familiarity with osteopathic medicine, and interest in serving MUAs. These findings indicate that similar programs may have a positive impact on MUAs. These programs may help create diverse and culturally competent osteopathic physicians.

Use of Online Newborn Screening Educational Resources for the Education of Expectant Parents: An Improvement in Equity.

Educating parents about the newborn screening (NBS) process is critical in ensuring that families are aware of their child's NBS, which could contribute to better outcomes for the baby and experiences for the family. Successful education efforts result in expecting parents understanding the importance of NBS, feeling comfortable with the NBS process, and being aware of their choices after NBS is complete. Educating parents prenatally is challenging for many NBS programs for a variety of reasons. The COVID-19 pandemic added additional barriers to NBS programs' ability to educate parents prenatally about NBS. By initiating a department-wide partnership among other programs with a similar target audience, Michigan's NBS Program was able to host a virtual baby fair. Since the inaugural event, Michigan's NBS Program has hosted seven virtual fairs with 15 participating programs. A total of 692 participants registered for the baby fair and received a resource packet, over 157 participants joined one of the live presentations, and 211 have viewed the YouTube videos of recorded fairs. Virtual baby fairs are a cost-effective and convenient approach to education that could be implemented in any NBS program to educate parents prenatally about NBS.

Feasibility of a Brief Intervention to Increase Rapid Primary Care Follow-Up Among African American Patients With Uncontrolled Diabetes.

The management of diabetes, like many other chronic conditions, depends on effective primary care engagement. Patients with diabetes without a usual source of care have a higher risk of uncontrolled disease, hospitalizations, and early death. Our objective was to study the effect of a brief intervention to help patients in medically underserved areas obtain rapid primary care follow-up appointments following hospitalization. We performed a pilot pragmatic randomized controlled trial of adult patients with uncontrolled diabetes who had been admitted to one of three hospitals in the Memphis, TN, area. The enhanced usual care arm received a list of primary care clinics, whereas the intervention group had an appointment made for them preceding their index discharge. Patients in both groups were evaluated for primary care appointment attendance within seven and fourteen days of index discharge. In addition, we examined barriers patients encounter to receiving rapid primary care follow-up using a secret shopper approach to assess wait times when calling primary care offices. Twelve patients were enrolled with six in each trial arm. Baseline demographics, access to medical care, and health literacy were similar across the groups. Primary care follow-up was also similar across the groups; no improvements in follow-up rates were seen in the group receiving assistance with making appointments. Identified barriers to making primary care follow-up appointments included inability to schedule an urgent appointment, long hold times when calling doctor's offices and lack of transportation. Additionally, hold times when calling primary care offices were found to be excessively long in the medically underserved areas studied. The study demonstrates the feasibility of providing patient assistance with scheduling rapid primary care follow-up appointments at the time of discharge and the potential to improve care transitions and access to primary care among patients living in medically underserved areas. Larger pragmatic trials are needed to further test alternative approaches for insuring rapid primary care follow-up in vulnerable patients with ambulatory care-sensitive chronic conditions.

Rural-Urban Differences in Breast Cancer Stage at Diagnosis.

Purpose: To analyze the extent to which rural-urban differences in breast cancer stage at diagnosis are explained by factors including age, race, tumor grade, receptor status, and insurance status. Methods: Using the National Cancer Institute's Surveillance, Epidemiology, and End Results (SEER) 18 database, analysis was performed using data from women aged 50-74 diagnosed with breast cancer between the years 2013 and 2016. Patient rurality of residence was coded according to SEER's Rural-Urban Continuum Code 2013: Large Urban (RUCC 1), Small Urban (RUCC 2,3), and Rural (RUCC 4,5,6,7,8,9). Stage at diagnosis was coded according to SEER's Combined Summary Stage 2000 (2004+) criteria: Localized (0,1), Regional (2,3,4,5), and Distant (7). Descriptive statistics were analyzed, and variations were tested for across rural-urban categories using Kruskall-Wallis and Kendall's tau-b tests. Additionally, odds ratios (ORs) and 95% confidence intervals for the three ordinal levels of rural-urban residence were calculated while adjusting for other independent variables using ordinal logistic regression. Results: The rural residence category showed the largest proportion of women diagnosed with distant stage breast cancer. Additionally, we determined that patients with residence in both large and small urban areas had statistically significantly lower odds of higher stage diagnosis compared to rural patients even after controlling for age, race, tumor grade, receptor status, and insurance status. Conclusions: Rural women with breast cancer show small but statistically significant disparities in stage-at-diagnosis. Further research is needed to understand local area variation in these disparities across a wide range of rural communities, and to identify the most effective interventions to eliminate these disparities.

Impact of the COVID-19 Pandemic on the Pediatric Hospital Visits: Evidence from the State of Florida.

Although early evidence reported a substantial decline in pediatric hospital visits during COVID-19, it is unclear whether the decline varied across different counties, particularly in designated Medically Underserved Areas (MUA). The objective of this study is to explore the state-wide impact of COVID-19 on pediatric hospital visit patterns, including the economic burden and MUA communities. We conducted a retrospective observational study of pediatric hospital visits using the Florida State all-payer Emergency Department (ED) and Inpatient dataset during the pandemic (April-September 2020) and the same period in 2019. Pediatric Treat-and-Release ED and inpatient visit rates were compared by patient demographics, socioeconomic, diagnosis, MUA status, and hospital characteristics. Pediatric hospital visits in Florida decreased by 53.7% (62.3% in April-June, 44.2% in July-September) during the pandemic. The Treat-and-Release ED and inpatient visits varied up to 5- and 3-fold, respectively, across counties. However, changes in hospital visits across MUA counties were similar compared with non-MUA counties except for lower Treat-and-Release ED volume in April-May. The disproportional decrease in visits was notable for the underserved population, including Hispanic and African American children; Medicaid coverages; non-children's hospitals; and diagnosed with respiratory diseases, appendicitis, and sickle-cell. Florida Hospitals experienced a USD 1.37 billion (average USD 8.3 million) decline in charges across the study period in 2020. Disproportionate decrease in hospital visits, particularly in the underserved population, suggest a combined effect of the persistent challenge of care access and changes in healthcare-seeking behavior during the pandemic. These findings suggest that providers and policymakers should emphasize alternative interventions/programs ensuring adequate care during the pandemic, particularly for high-risk children.

International medical graduate dermatologists in rural and medically underserved areas: a national cross-sectional analysis.

International medical graduates (IMGs) comprise a quarter of the United States (US) physician workforce but are a diminishing minority among dermatologists. Studies on IMGs in other specialties have demonstrated their importance in addressing provider shortage in rural and medically underserved areas (MUAs), but this trend has not been systematically explored within dermatology. This study aims to assess the state-by-state distribution of IMG dermatologists in the US as compared to US medical graduates (USMGs) with focus on provider density in rural settings and MUAs. A national cross-sectional study was performed on actively practicing dermatologists who submitted Medicare claims within 1 year of July 2020; rural and MUA-serving status were determined based on federally designated rural-urban Continuum Codes and Census Bureau data. Nationally, the density of dermatologists has increased from 3.4 per 100,000 persons in 2016 to 3.66 per 100,000 persons in 2020. However, 70% of US states continue to have fewer than 4 dermatologists per 100,000 persons, the estimated minimum necessary to adequately care for a population. Among 12,009 dermatologists, only 576 (4.8%) are IMGs, with disparate distribution across the US: Kansas has the greatest percentage of IMGs with the latter comprising 8.3% of its state dermatology workforce, whereas 8 states have no IMGs. Notably, a significantly greater percentage of IMG dermatologists (43.9%) work in areas designated as MUAs compared to USMGs (37.4%) (P < 0.01). In contrast, a lower percentage of IMG dermatologists (2.8%) work in rural settings compared to USMGs (4.8%) (P = 0.03). Interestingly, no significant difference was observed when rural dermatologists were further stratified by MUA-serving status. These findings corroborate the importance of IMGs in providing greater access to dermatological care in areas with healthcare provider shortage. Further studies on the underlying causes of the decline of IMGs within dermatology are needed.

Patients From Medically Underserved Areas Are at Increased Risk for Nonhome Discharge and Emergency Department Return After Total Joint Arthroplasty.

BACKGROUND: Maryland Health Enterprise Zones (MHEZs) were introduced in 2012 and encompass underserved areas and those with reduced access to healthcare providers. Across the United States many underserved and minority populations experience poorer total joint arthroplasty (TJA) outcomes seemingly because they reside in underserved areas. The purpose of this study is to identify and quantify the relationship between living in an MHEZ and TJA outcomes. METHODS: Retrospective review of 11,451 patients undergoing primary TJA at a single institution from July 1, 2014 to June 30, 2020 was conducted. Patients were classified based on whether they resided in an MHEZ. Statistical analyses were used to compare outcomes for TJA patients who live in MHEZ and those who do not. RESULTS: Of the 11,451 patients, 1057 patients lived in MHEZ and 10,394 patients did not. After risk adjustment, patients who live in an MHEZ were more likely to return to the emergency department within 90 days postoperatively and were less likely to be discharged home than those patients who do not live in an MHEZ. CONCLUSION: Total joint arthroplasty patients residing in MHEZ appear to present with poorer overall health as measured by increased American Society of Anesthesiologists and Hierarchical Condition Categories scores, and they are less likely to be discharged home and more likely to return to the emergency department within 90 days. Several factors associated with these findings such as socioeconomic factors, household composition, housing type, disability, and transportation may be modifiable and should be targets of future population health initiatives.

Success of a Community-Based Delivery at Recruiting Individuals from Underserved Communities for an Observational Cohort Study of an Advance Care Planning Intervention.

BACKGROUND: Underserved and minority populations are often reluctant to engage in advance care planning and/or research often due to distrust in healthcare and/or research institutions. AIM: To determine if use of a community-based delivery model can facilitate recruitment of individuals from underserved communities in research about advance care planning. DESIGN: Recruitment data are presented from a prospective, mixed methods observational cohort study that examined the feasibility and preliminary efficacy of a community-based delivery model involving an end-of-life conversation game to motivate participants to complete advance care planning behaviors. Event attendance and research participation data are reported. SETTING/PARTICIPANTS: Game events were held in community venues in 27 states across the US in 2018-2019. The model involved leveraging existing social networks to recruit attendees and research participants to community game day events. Attendees were eligible for research if they were adults who read/spoke English. RESULTS: A total of 1,122 individuals attended events at 53 sites. Participants generally reported low income (48% reported $30,000 annual income). At sites with research assistants, there was a 90% consent rate (92% were Black). At community outreach sites, 45% agreed to a follow-up research phone call (49% were Black). CONCLUSIONS: Use of the community-based delivery model successfully engaged undeserved communities in a research-based advance care planning related community outreach event. This model may be useful for overcoming underserved and minority populations' skepticism and distrust of healthcare and research that is a common barrier to progress in health agendas, especially advance care planning.

Patient Satisfaction with Pharmacist-Provided Health-Related Services in a Primary Care Clinic.

(1) Background: Patient satisfaction plays an important role in the perceived value, sustained utilization, and coverage of healthcare services by payers and clinics. (2) Methods: A 33-question survey was designed to assess patient satisfaction and perceived value for healthcare services provided by a clinical pharmacist in a single primary care facility. It included general items from validated patient satisfaction surveys (i.e., PROMIS®, CAHPS) and pharmacist-specific items identified in selected literature. It was offered to all patients who were presenting for a new, unique visit with the clinical pharmacist at the medical clinic between May 2019 and April 2020. (3) Results: A total of 66 patients agreed to take the survey (RR = 100%), and the responses were overwhelmingly positive. However, men were more likely than women to report higher satisfaction (X2(1, n = 920) = 0.67, p = 0.027), and new patients reported higher satisfaction than existing patients (X2(1, n = 1211) = 1.698, p = 0.037). (4) Conclusions: The findings of this study indicate a high degree of patient satisfaction with pharmacist-provided healthcare services in the primary care setting.

Medically underserved areas: are primary care teams efficient at attracting and retaining general practitioners?

The geographical imbalances of General Practitioners (GPs) may affect their accessibility for populations, especially in medically underserved areas. We investigate the effect of the dramatic and recent diffusion of Primary Care Teams (PCTs), especially in medically underserved areas, in order to attract and retain GPs through an improvement of their working conditions. We analyze the evolution of GPs and young GPs density between 2004 and 2017 according to a spatial taxonomy of French living areas in 6 clusters. Based on a quasi-experimental design comparing living areas, depending on the clusters, with PCTs (treated) and without PCTs (control), we used difference-in-differences models to estimate the impact of PCT new settlements on the evolution of both attraction and retention of GPs. Our results show that PCT settlements are efficient to attract young GPs and that the magnitude of the effects depends on the living area clusters. Results call for specific policies to address geographical inequalities of GPs that consider the type of place and also, in France, for new measures to attract and retain GPs in rural fringes.

[Factors and interventions that affect working conditions and environment to increase the attraction, recruitment and retention of human resources for health at the primary care level in rural, remote or underserved areas]. / Factores e intervenciones que inciden en las condiciones y medio ambiente de trabajo para incrementar la atracción, captación y retención de recursos humanos en salud en el primer nivel de atención de áreas rurales, remotas o desatendidas.

OBJECTIVE: To identify and systematize available empirical evidence on factors and interventions that affect working conditions and environment in order to increase the attraction, recruitment and retention of human resources for health at the primary care level in rural, remote or underserved areas. METHODS: Rapid review of reviews selected according to relevance, eligibility and inclusion criteria. The search was conducted on electronic and manual databases, including grey literature. AMSTAR I was used to assess the quality of systematic reviews and a thematic analysis for synthesis of the results. RESULTS: Sixteen reviews were included, one of which contained 14 reviews. Of the total, 20 reviews analyzed factors and 9 evaluated the effectiveness of interventions. The evidence on factors is abundant, but of limited quality. Individual, family and "previous exposure to a rural setting" factors were associated with higher recruitment; organizational and external context factors were important for human resource retention. Networking and professional support influenced recruitment and retention. Evidence on the effectiveness of interventions was limited, both in quantity and quality. The most frequently used intervention was incentives. CONCLUSIONS: Evidence on factors that are positively related to recruitment and retention of workers at the first level of care in rural, remote or underserved areas is sufficient and should be taken into account when designing interventions. Quality evidence on the effectiveness of interventions is scarce. More controlled studies with methodological rigor are needed, particularly in the Americas.

The management of diabetes in everyday life study: Design and methods for a pragmatic randomized controlled trial comparing the effectiveness of text messaging versus health coaching.

Background African American patients with uncontrolled diabetes living in medically underserved areas need effective clinic-based interventions to improve self-care behaviors. Text messaging (TM) and health coaching (HC) are among the most promising low-cost population-based approaches, but little is known about their comparative effectiveness in real-world clinical settings. Objective Use a pragmatic randomized controlled trial design to determine the comparative effectiveness of TM and HC with enhanced usual care (EC) in African American adults with uncontrolled diabetes and multiple chronic health conditions. Methods/design The Management of Diabetes in Everyday Life (MODEL) study is randomizing 646 patients (n = 581with anticipated 90% retention) to 3 intervention arms: TM, HC, and EC. Participants are African American adults living in medically underserved areas of the Mid-South, age ≥ 18, with uncontrolled diabetes (A1c ≥ 8), one or more additional chronic conditions, and who have a phone with texting and voicemail capability. Primary outcome measures: the general diet, exercise, and medication adherence subscales of the revised Summary of Diabetes Self-Care Activities questionnaire assessed at one year. Secondary outcomes: diabetes-specific quality of life, primary care engagement, and average blood sugar (A1c). The study will also assess heterogeneity of treatment effects by six key baseline participant characteristics. Conclusions We describe the design and methods of the MODEL study along with design revisions required during implementation in a pragmatic setting. This trial, upon its conclusion, will allow us to compare the effectiveness of two promising low-cost primary care-based strategies for supporting self-care behaviors among African Americans individuals with uncontrolled diabetes. ClinicalTrials.gov registration number: NCT02957513.

Rural-Urban Disparities in Pancreatic Cancer Stage of Diagnosis: Understanding the Interaction With Medically Underserved Areas.

PURPOSE: To estimate differences in pancreatic cancer diagnosis stage by rurality of patient residence and residence in a medically underserved area (MUA). METHODS: Using 2010-2016 Pennsylvania Cancer Registry data, we restrict our analysis to adults diagnosed with pancreatic cancer. We categorize each patient's residence by Rural-Urban Continuum Codes (RUCC): (1) metro; (2) nonmetro adjacent with population ≥20,000; (3) nonmetro adjacent with population <20,000; (4) nonmetro nonadjacent, and (5) completely rural; also by whether the county was a full MUA, partial MUA, or non-MUA. We examine the percent of patients diagnosed with local and locoregional stage of disease for each residential rurality and MUA status grouping. We estimate multivariate linear probability models of local and locoregional stage of diagnosis while controlling for demographics, insurance type, year, rurality, and MUA status. Finally, we estimate models interacting rurality with MUA status to disentangle the relative impact of each on diagnostic stage. FINDINGS: We find that no pancreatic patients living in completely rural areas were diagnosed at the local stage, the lowest of all categories of rurality. In adjusted models, we find that patients living in completely rural areas have significantly lower rates of local and local/regional stage of diagnosis. The estimates are attenuated slightly when controlling for MUA. CONCLUSIONS: We find significantly lower rates of early stage pancreatic cancer diagnosis for patients living in completely rural areas. While lack of primary medical care resources is an important factor, rural residence remains an important independent predictor in later stage of diagnosis.

The Uneven Distribution of Medically Underserved Areas in Chicago.

Purpose: Safety net health services, such as federally funded health clinics, are interventions that aim to mitigate inequality in resource distribution, thus primarily clustered in poor areas with lack of access to health care. However, not all neighborhoods with the most needs benefit from safety net health services. In this article, we explore the distribution of a federally funded health service intervention designed to serve impoverished areas, the medically underserved areas (MUAs), and the relationship between MUA designation and neighborhood sociodemographic characteristics. Methods: We explore the spatial distribution of MUAs. The 2010 U.S. census data including 868 census tracts in Chicago were used for the analysis. We then examined the likelihood of being designated as an MUA using census tract level neighborhood demographic variables. Results: We found that the likelihood of obtaining MUA designation increases for neighborhoods with higher levels of poverty, the likelihood of being designated as an MUA begins to decline beyond the tipping point, whereas the proportion of black residents continues to increase. In census tracts that were eligible but not designated, there was a greater proportion of black residents compared with white residents (p<0.01). The census tracks also had higher mean disadvantage scores (p<0.01) and lower social capital (p<0.01). Furthermore, MUA eligible areas that were not designated as MUAs were predominantly black neighborhoods in poverty. Conclusion: Studies have documented that receiving MUA designation substantially reduces disparities in access to health care, and yet, our study finding indicates that the most racially segregated poor neighborhoods are excluded from the benefits of having such federal health safety net program. Seemingly race-neutral safety net health services may still be distributed in a way that perpetuates racial inequality in health.