The association of travel burden with prenatal care utilization, what happens after provider-selection.

BACKGROUND: Birthing people in the United States face numerous challenges when accessing adequate prenatal care (PNC), with transportation being a significant obstacle. Nevertheless, previous studies that relied solely on the distance to the nearest provider cannot differentiate the effects of travel burden on provider selection and care utilization. These may exaggerate the degree of inequality in access and fail to capture perceived travel burden. This study investigated whether travel distances to the initially visited provider, to the predominant PNC provider, and perceived travel burden (measured by the travel disadvantage index (TDI)) are associated with PNC utilization. METHODS: A retrospective cohort of people with live births were identified from South Carolina Medicaid claims files in 2015-2018. Travel distances were calculated using Google Maps. The estimated TDI was derived from local pilot survey data. PNC utilization was measured by PNC initiation and frequency. Repeated measure logistic regression test was utilized for categorical variables and one-way repeated measures ANOVA for continuous variables. Unadjusted and adjusted ordinal logistic regressions with repeated measure were utilized to examine the association of travel burdens with PNC usage. RESULTS: For 25,801 pregnancies among those continuously enrolled in Medicaid, birthing people traveled an average of 24.9 and 24.2 miles to their initial and predominant provider, respectively, with an average TDI of -11.4 (SD, 8.5). Of these pregnancies, 60% initiated PNC in the first trimester, with an average of 8 total visits. Compared to the specialties of initial providers, predominant providers were more likely to be OBGYN-related specialists (81.6% vs. 87.9%, p < .001) and midwives (3.5% vs. 4.3%, p < .001). Multiple regression analysis revealed that every doubling of travel distance was associated with less likelihood to initiate timely PNC (OR: 0.95, p < .001) and a lower visit frequency (OR: 0.85, p < .001), and every doubling of TDI was associated with less likelihood to initiate timely PNC (OR: 0.94, p = .04). CONCLUSIONS: Findings suggest that the association between travel burden and PNC utilization was statistically significant but of limited practical significance.

Who is your prenatal care provider? An algorithm to identify the predominant prenatal care provider with claims data.

BACKGROUND: Using claims data to identify a predominant prenatal care (PNC) provider is not always straightforward, but it is essential for assessing access, cost, and outcomes. Previous algorithms applied plurality (providing the most visits) and majority (providing majority of visits) to identify the predominant provider in primary care setting, but they lacked visit sequence information. This study proposes an algorithm that includes both PNC frequency and sequence information to identify the predominant provider and estimates the percentage of identified predominant providers. Additionally, differences in travel distances to the predominant and nearest provider are compared. METHODS: The dataset used for this study consisted of 108,441 live births and 2,155,076 associated South Carolina Medicaid claims from 2015-2018. Analysis focused on patients who were continuously enrolled throughout their pregnancy and had any PNC visit, resulting in 32,609 pregnancies. PNC visits were identified with diagnosis and procedure codes and specialty within the estimated gestational age. To classify PNC providers, seven subgroups were created based on PNC frequency and sequence information. The algorithm was developed by considering both the frequency and sequence information. Percentage of identified predominant providers was reported. Chi-square tests were conducted to assess whether the probability of being identified as a predominant provider for a specific subgroup differed from that of the reference group (who provided majority of all PNC). Paired t-tests were used to examine differences in travel distance. RESULTS: Pregnancies in the sample had an average of 7.86 PNC visits. Fewer than 30% of the sample had an exclusive provider. By applying PNC frequency information, a predominant provider can be identified for 81% of pregnancies. After adding sequential information, a predominant provider can be identified for 92% of pregnancies. Distance was significantly longer for pregnant individuals traveling to the identified predominant provider (an average of 5 miles) than to the nearest provider. CONCLUSIONS: Inclusion of PNC sequential information in the algorithm has increased the proportion of identifiable predominant providers by 11%. Applying this algorithm reveals a longer distance for pregnant individuals travelling to their predominant provider than to the nearest provider.

How rural is All of Us? Comparing characteristics of rural participants in the National Institute of Health's All of Us Research Program to other national data sources.

PURPOSE: The National Institute of Health's All of Us Research Program represents a national effort to develop a database to advance health research, especially among individuals historically underrepresented in research, including rural populations. The purpose of this study was to describe the rural populations identified in the All of Us Research Program using the only proxy measure currently available in the dataset. METHODS: Currently, the All of Us Research Program provides a proxy measure of rurality that identifies participants who self-reported delaying care due to far travel distances associated with living in rural areas. Using the All of Us Controlled Tier Dataset v6, we compared sociodemographic and health characteristics of All of Us rural participants identified via this proxy to rural US residents from nationally representative data sources using chi-squared tests. RESULTS: 3.1% of 160,880 All of Us participants were rural, compared to 15%-20% of US residents based on commonly accepted rural definitions. Proportionally more rural All of Us participants reported fair or poor health status, history of cancer, and history of heart disease (P<.01). CONCLUSIONS: The All of Us measure may capture a subset of underserved participants who live in rural areas and experience health care access barriers due to distance. Researchers who use this proxy measure to characterize rurality should interpret their findings with caution due to differences in population and health characteristics using this proxy measure rural compared to other commonly used rural definitions.

Examining the association between rurality and positive childhood experiences among a national sample.

PURPOSE: The present study examines the association between rurality and positive childhood experiences (PCEs) among children and adolescents across all 50 states and the District of Columbia. Recent work has quantified the prevalence of PCEs at the national level, but these studies have been based on public use data files, which lack rurality information for 19 states. METHODS: Data for this cross-sectional analysis were drawn from 2016 to 2018 National Survey of Children's Health (NSCH), using the full data set with restricted geographic data (n = 63,000). Descriptive statistics and bivariate analyses were used to calculate proportions and unadjusted associations. Multivariable regression models were used to examine the association between residence and the PCEs that were significant in the bivariate analyses. FINDINGS: Rural children were more likely than urban children to be reported as having PCEs: volunteering in their community (aOR 1.29; 95% CI 1.18-1.42), having a guiding mentor (aOR 1.75; 95% CI 1.45-2.10), residing in a safe neighborhood (aOR 1.97; 95% CI 1.54-2.53), and residing in a supportive neighborhood (aOR 1.10; 95% CI 1.01-1.20) than urban children. CONCLUSIONS: The assessment of rural-urban differences in PCEs using the full NSCH is a unique opportunity to quantify exposure to PCEs. Given the higher baseline rate of PCEs in rural than urban children, programs to increase opportunities for PCEs in urban communities are warranted. Future research should delve further into whether these PCEs translate to better mental health outcomes in rural children.

A national examination of poverty and interactive caregiving practices among parents of young children.

Interactive caregiving practices can be protective for the development of the brain in early childhood, particularly for children experiencing poverty. There has been limited research examining the prevalence of interactive caregiving practices in early childhood at the population level across the U.S. The purpose of this study was to describe the prevalence of three interactive caregiver activities: (1) reading, (2) telling stories/singing songs, and (3) eating a meal together, using the 2017-2018 National Survey of Children's Health, among a sample of children age five and younger, and to examine the relationship between these interactive caregiving practices across income levels and by selected potentially confounding household characteristics. Children living in families with incomes below the federal poverty level had lower odds of being read to every day compared to children living in families with incomes at 400% or more above the federal poverty level (aOR 0.70; 95% CI 0.53-0.92). Children living in families within incomes at 100-199% of the federal poverty level had lower odds of being sung to and told stories to every day than children living in families with incomes at 400% or above the federal poverty level (aOR 0.62; 95% CI 0.50-0.78).These findings have long-term implications for children, as interactive caregiving practices are known to improve cognitive activities such as language development, which is associated with educational attainment into adulthood. Finding ways to increase the adoption of interactive caregiving practices may be one way to mitigate disparities in education, especially among families experiencing poverty.

Examining the influence of positive childhood experiences on childhood overweight and obesity using a national sample.

Positive childhood experiences (PCEs) promote healthy social development, improve overall wellness, and help to moderate and prevent exposure to adverse childhood experiences. There has been limited research examining the association between positive childhood experiences and overweight or obesity status in children. The purpose of this study was to examine whether experiencing positive childhood experiences are associated with lower rates of overweight or obesity status in children between 10 and 17 years of age, using cross-sectional data from the 2018-2019 National Survey of Children's Health (n = 28,771), a nationally representative mail and online survey. Frequencies, proportions, and unadjusted associations for each variable were calculated using descriptive statistics and bivariate analyses. To examine the association between overweight or obesity and PCEs, multivariable regression models were used. Compared to children who were underweight or had a healthy weight, children who were overweight or obese were less likely to: participate after school activities (78.1%, p < 0.0001), volunteer in their community, school, or church (45.6%, p < 0.0001), have a mentor they feel comfortable going to for guidance (87.0%, p = 0.02), live in a safe neighborhood (61.3%, p < 0.0001), live in a supportive neighborhood (50.4%, p < 0.0001), and to live with a resilient family (78.3%; p = 0.0099). In adjusted analysis, among children exposed to two or more ACEs, children residing in a supportive neighborhood were less likely to be overweight or obese (aOR 0.87; 0.77-0.98). Our findings suggest that certain PCEs may mitigate overweight and obesity when children have experienced at least some childhood trauma.

Chemical Sulfide Tethering Improves Low-Temperature Li-S Battery Cycling.

Demands for energy storage and delivery continue to rise worldwide, making it imperative that reliable performance is achievable in diverse climates. Lithium-sulfur (Li-S) batteries offer a promising alternative to lithium-ion batteries owing to their substantially higher specific capacity and energy density. However, improvements to Li-S systems are still needed in low-temperature environments where polysulfide clustering and solubility limitations prohibit complete charge/discharge cycles. We address these issues by introducing thiophosphate-functionalized metal-organic frameworks (MOFs), capable of tethering polysulfides, into the cathode architecture. Compared to cells with the parent MOFs, cells containing the functionalized MOFs exhibit greater capacity delivery and decreased polarization for a range of temperatures down to -10 °C. We conduct thorough electrochemical analyses to ascertain the origins of performance differences and report an altered Li-S redox mechanism enabled by the thiophosphate moiety. This investigation is the first low-temperature Li-S study using MOF additives and represents a promising direction in enabling energy storage in extreme environments.

Positive Childhood Experiences Promote School Success.

OBJECTIVES: Educational attainment has been demonstrated as a protective factor for the physical and mental health of children into adulthood, yet there has been limited research on the association between positive childhood experiences (PCEs) and school success. The purpose of this study is to examine the associations between PCEs and challenges to school success. METHODS: This cross-sectional study used data of 33,450 children from the 2017-2018 National Survey of Children's Health to examine PCEs and two challenges to school success (school absenteeism and repeated grades), using multivariable logistic regression analysis. RESULTS: The most prevalent types of PCEs were mentor for advice or guidance (89.8%), family resilience (81.1%), and after-school activity participation (79.8%). Children who participated in after-school activities had lower odds of reported school absenteeism (aOR 0.59; 95% CI 0.46-0.76) and repeating a grade (aOR 0.75; 95% CI 0.59-0.97) than their counterparts. Children who shared ideas with their caregiver had lower odds of repeating a grade (aOR 0.78; 95% CI 0.63-0.97) than children who did not share ideas with their caregiver. Children who lived in a supportive neighborhood were less likely to have reported school absenteeism than children who did not live in a supportive neighborhood (aOR 0.77; 95% CI 0.60-0.98). CONCLUSIONS FOR PRACTICE: Participation in after-school activities had optimal associations with both school absenteeism and repeated grade, suggesting its potential protective effect for school success. Promoting PCEs at the school, family, and community levels may help address school absenteeism and grade retention.

Examining the Relationship Between Adverse Childhood Experiences and ADHD Diagnosis and Severity.

OBJECTIVE: Although prior research has examined the prevalence of ACEs among children with attention deficit-hyperactivity disorder (ADHD), little is known about the household and family settings of children with ADHD. Our study utilizes a recent nationally representative dataset to examine the association between adverse childhood experiences (ACEs), child and household characteristics, and ADHD diagnosis and severity. METHODS: Using the 2017-2018 National Survey of Children's Health (NSCH), our sample consisted of children three years of age or older, as this is the youngest age at which the NSCH begins to ask caregivers if a child has been diagnosed with ADHD (n = 42,068). Multivariable logistic regression was used to examine the association between ACE type, score, and ADHD and ADHD severity, controlling for child and household characteristics. RESULTS: Children exposed to four or more ACEs had higher odds of ADHD (aOR 2.16; 95% CI 1.72-2.71) and moderate to severe ADHD (aOR 1.89; 95% CI 1.31-2.72) than children exposed to fewer than four ACEs. Other child characteristics positively associated with ADHD included age and public insurance; other Non-Hispanic races compared to Non-Hispanic White had lower odds of ADHD. Of children reported with ADHD, public insurance was also associated with caregiver-reported moderate to severe ADHD. CONCLUSIONS: Children with ADHD have a higher prevalence of ACEs, making this study important for understanding the relationship between ACEs and ADHD at the population level.

Rural-Urban Differences in Positive Childhood Experiences Across a National Sample.

PURPOSE: The purpose of this study was to examine the prevalence of positive childhood experience (PCE) and adverse childhood experience (ACE) exposures in 31 states plus the District of Columbia and to estimate exposure differences between rural and urban children. METHODS: A cross-sectional study was conducted with a sample of 19,251 respondents from the 2017-2018 National Survey of Children's Health (NSCH), a nationally representative sample of US children. Sociodemographic information, residence, and PCE and ACE responses were utilized. To calculate frequencies, proportions, and unadjusted associations for each variable, descriptive statistics and bivariate analyses were used. Multivariable regression models were used to examine the association between residence and PCEs that showed significance in bivariate analyses. FINDINGS: In adjusted analyses of PCEs, there was no significant difference between rural and urban children for after-school activities. However, rural children were more likely to volunteer in the community, school, or church than were urban children (aOR 1.32; 95% CI: 1.14-1.54). Rural children also had greater odds of having a mentor for advice or guidance, compared to urban children (aOR 1.8; 95% CI: 1.40-2.52). CONCLUSIONS: An examination of both PCEs and ACEs provides policy makers, program developers, and other stakeholders the opportunity to determine needs of rural children and where to target interventions. Furthering the understanding of PCEs and ACEs is important to bring individuals, families, and communities together to both address childhood adversity and utilize existing family and community-level assets.

Point-of-Care Ultrasound in Family Medicine Residencies 5-Year Update: A CERA Study.

BACKGROUND AND OBJECTIVES: In 2014, family medicine residency programs began to integrate point-of-care ultrasound (POCUS) into training, although very few had an established POCUS curriculum. This study aimed to evaluate the resources, barriers, and scope of POCUS training in family medicine residencies 5 years after its inception. METHODS: Questions regarding current training and use of POCUS were included in the 2019 Council of Academic Family Medicine Educational Research Alliance (CERA) survey of family medicine residency program directors, and results compared to similar questions on the 2014 CERA survey. RESULTS: POCUS is becoming a core component of family medicine training programs, with 53% of program directors reporting establishing or an established core curriculum. Only 11% of program directors have no current plans to add POCUS training to their program, compared to 41% in 2014. Despite this increase in training, the reported clinical use of POCUS remains uncommon. Only 27% of programs use six of the eight surveyed POCUS modalities more than once per year. The top three barriers to including POCUS in residency training in 2019 have not changed since 2014, and are (1) a lack of trained faculty, (2) limited access to equipment, and (3) discomfort with interpreting images without radiologist review. CONCLUSIONS: Training in POCUS has increased in family medicine residencies over the last 5 years, although practical use of this technology in the clinical setting may be lagging behind. Further research should explore how POCUS can improve outcomes and reduce costs in the primary care setting to better inform training for this technology.

Rural-Urban Differences in Adverse Childhood Experiences Across a National Sample of Children.

PURPOSE: The purpose of this study was to examine the prevalence of adverse childhood experiences (ACEs) exposure in 34 states and the District of Columbia, and whether exposure differs between rural and urban residents. METHODS: This cross-sectional study used data from the 2016 National Survey of Children's Health (NSCH), restricted to states in which rural versus urban residence was indicated in the public use data (n = 25,977 respondents). Bivariate analyses were used to estimate unadjusted associations. Multivariable regression models were run to examine the association between residence (rural or urban) and ACE counts of 4 or more. FINDINGS: Compared to urban children, rural children had higher rates of exposure to the majority of the ACEs examined: parental separation/divorce, parental death, household incarceration, household violence, household mental illness, household substance abuse, and economic hardship. In adjusted analysis, there was no significant difference for rural children compared to urban children. The odds of 4 or more ACEs decrease as poverty levels decline, with children residing 0%-99% below the federal poverty line more likely to have reported 4 or more ACEs, compared to children residing 400% or above the federal poverty line (aOR 4.02; CI: 2.65-6.11). CONCLUSIONS: Our findings suggest that poverty is a key policy lever that may mitigate the burden of ACE exposure. The findings of this study may be instructive for policymakers and program planners as they develop interventions to stop, reduce, or mitigate ACE exposure and the long-term impact of ACEs among children in rural America.

What Is Rural? Challenges And Implications Of Definitions That Inadequately Encompass Rural People And Places.

Monitoring and improving rural health is challenging because of varied and conflicting concepts of just what rural means. Federal, state, and local agencies and data resources use different definitions, which may lead to confusion and inequity in the distribution of resources depending on the definition used. This article highlights how inconsistent definitions of rural may lead to measurement bias in research, the interpretation of research outcomes, and differential eligibility for rural-focused grants and other funding. We conclude by making specific recommendations on how policy makers and researchers could use these definitions more appropriately, along with definitions we propose, to better serve rural residents. We also describe concepts that may improve the definition of and frame the concept of rurality.

Summary of Selected Healthcare Encounters among a Selection of Patients with Myotonic Muscular Dystrophy.

OBJECTIVE: Research has not examined the use of health care by patients with myotonic muscular dystrophy (MMD), but it would provide insights into this population, which is prone to comorbidities and high service needs. This study is an analysis of this understudied subgroup, using a unique linked dataset to examine the characteristics and healthcare utilization patterns for people with MMD. METHODS: This analysis used 3 South Carolina datasets (2009-2014). The subjects included individuals with at least 1 encounter with an International Classification of Diseases, Ninth Revision, Clinical Modification code of 359.21. The variables included sex, race, visit type, payer, and diagnoses. The analyses examined characteristics and number of encounters. RESULTS: The subjects were predominately female, white, and 45 to 64 years old. A total of 44.6% of the study population had at least 1 inpatient visit, whereas 64.2% had at least 1 emergency department visit. A majority of the subjects had at least 1 office visit (55.0%), and most (85.3%) did not have a home health encounter. CONCLUSIONS: Investigation of the reasons for these inpatient and emergency department encounters may be helpful in identifying ways to deliver high-quality care.

Prevalence of adverse childhood experiences (ACEs) among US children.

OBJECTIVE: The purpose of this study was to estimate the prevalence of adverse childhood experiences (ACEs) among children in the United States and to examine the relationship between child and family characteristics and the likelihood of reported exposure to ACEs. METHODS: Data were drawn from the nationally representative 2016 National Survey of Children's Health (NSCH). Parent-reported child ACE exposure was measured using counts of those reporting zero ACEs, one to three ACEs, and four or more ACEs. RESULTS: The study sample included 45,287 children. The most prevalent types of ACE exposure experienced by children were economic hardship (22.5%) and parent or guardian divorce or separation (21.9%). Older children (34.7%), Non-Hispanic African American children (34.7%), children with special health care needs (SHCN; 36.3%), children living in poverty (37.2%), and children living in rural areas (30.5%) were more likely to be exposed to parental divorce or separation than their counterparts. Five cross-cutting factors emerged as important across outcomes: child's age, family structure, poverty, type of health insurance, and SHCN status. CONCLUSIONS: We found high prevalence rates of economic hardship on a national level. Our findings of higher prevalence among rural children further suggest the importance of the intersection of place and ACEs. Therefore, the geographic component of ACEs must be considered by policymakers. The identification of predictive factors related to high ACE exposure can inform early interventions at the national level.

Community-level electronic prescribing and adverse drug event hospitalizations among older adults.

This study sought to determine how the proportion of physicians using electronic prescribing in nine US states was associated with the hospitalization rate for adverse drug events among older adult patients. A discharge-level analysis of the relationship between county electronic prescribing and adverse drug event hospitalization rates was conducted. Data from the 2011 State Inpatient Databases, the Office of the National Coordinator Health IT Dashboard, and the Area Health Resource File were obtained for nine US states. The analysis examined the odds that a discharge for older adults would have been adverse drug event associated, versus other causes, using multivariable logistic regression models. After adjusting for patient, provider, health infrastructure, and community factors, the lowest county electronic prescribing rate quartile was associated with significantly greater odds of an adverse drug event hospitalization (odds ratio: 1.10; 95% confidence interval: 1.02-1.19). Early results indicate greater odds of adverse drug event hospitalizations among older adults living in counties with low electronic prescribing rates when compared to those in high electronic prescribing counties.

30-day all-cause readmission rates among a cohort of individuals with rare conditions.

BACKGROUND: There is a need to examine health care utilization of individuals with the rare conditions muscular dystrophies, spina bifida, and fragile X syndrome. These individuals have a greater need for health care services, particularly inpatient admissions. Prior studies have not yet assessed 30-day all-cause readmission rates. OBJECTIVE: To estimate 30-day hospital readmission rates among individuals with three rare conditions. HYPOTHESIS: Rare conditions patients will have a higher 30-day all-cause readmission rate than those without. METHODS: Data from three sources (2007-2014) were combined for this case-control analysis. A cohort of individuals with one of the three conditions was matched (by age in 5 year age groups, gender, and race) to a comparison group without a rare condition. Inpatient utilization and 30-day all-cause readmission rates were compared between the two groups. Logistic regression analyses compared the odds of a 30-day all-cause readmission across the two groups, controlling for key covariates. RESULTS: A larger proportion in the rare condition group had at least one inpatient visit (46.1%) vs. the comparison group (23.6%), and a higher 30-day all-cause readmission rate (Spina Bifida-46.7%, Muscular Dystrophy-39.7%, and Fragile X Syndrome-35.8%) than the comparison group (13.4%). Logistic regression results indicated that condition status contributed significantly to differences in readmission rates. CONCLUSIONS: Higher rates of inpatient utilization and 30-day all-cause readmission among individuals with rare conditions vs. those without are not surprising, given the medical complexity of these individuals, and indicates an area where unfavorable outcomes may be improved with proper care coordination and post discharge care.

The Importance of Rural Hospitals: Transfers and 30-day Readmissions Among Rural Residents and Patients Presenting at Rural Hospitals.

The purpose was to examine factors associated with transfers and readmissions among Medicare patients initially presenting at rural facilities. Data from the 2013 Medicare Claims file were used to identify fee-for-service patients with a hospital admission (n = 298,783) or an emergency department visit immediately followed by a hospital admission (117,416), for a total of 416,199. Transfers were defined as hospitalization at a different facility within 1 day of a discharge from a prior inpatient or emergency department encounter. For analysis of 30-day readmission, beneficiaries who died before discharge were excluded, for a total of 416,198 observations. Overall, 4.8% of index encounters resulted in a transfer. The transfer rate was higher for patients living in rural areas (9.8%, P < 0.0001), with the highest among residents of small rural areas (10.1%). The transfer rate was higher among those initial encounters in an urban facility (5.3%) than those admitted to a rural facility (2.7%, P < 0.0001). In adjusted analysis, beneficiaries with index encounters in rural or critical access facilities had higher odds of being transferred than those seen at urban facilities. The 30-day readmission rate was lower among patients presenting initially at rural versus urban hospitals (12.1% versus 19.2%). Although transfer status slightly increased the odds of rehospitalization in adjusted analysis, initial presentation at a rural facility was associated with reduced odds. The relatively high rate of transfers from rural hospitals to urban institutions suggests that systems must ensure that their patients' follow-up care meets their needs.

Uptake of Supplemental Nutrition Assistance Program Benefits by Participants in a Home Visiting Program.

In 2015, over 15 percent of U.S. households with children were food insecure at some point during the year. The largest program created to address food insecurity in the United States is the Supplemental Nutritional Assistance Program (SNAP). However, research has suggested that safety net programs such as SNAP may be underutilized by eligible families. This secondary data analysis examined receipt of SNAP benefits among 2,249 SNAP-eligible participants in a South Carolina home visiting program. Benefit status was obtained at program enrollment and six months post-enrollment. Results showed that 15.6 percent of home visiting program participants without SNAP benefits at program enrollment were receiving benefits by six months post-enrollment. Unmarried caregivers were least likely to obtain SNAP benefits. Programs such as home visiting can be important to ensuring that eligible families receive federal assistance promoting food security, and targeted efforts to overcome barriers to SNAP enrollment continue to be important.

Community Paramedicine Applied in a Rural Community.

RESEARCH OBJECTIVE: Abbeville County Emergency Management Services (ACEMS) began a community paramedicine (CP) program to utilize trained paramedics to serve patients who frequently use the emergency department (ED) and have 1 or more of the following diagnoses: hypertension, diabetes, chronic heart failure, asthma, and chronic obstructive pulmonary disease. The objective of this study was to determine if the CP program reduced ED visits in Abbeville while improving patient outcomes. DESIGN: A pre/posttest with a comparison group study design was used to evaluate the CP program. The study population had 193 patients (68 enrollees and 125 comparisons) who resided in Abbeville County, South Carolina. Frequent users of the ED were recruited and enrolled in the program by Abbeville Area Medical Center (AAMC) staff starting in October 2013. Records from both AAMC and ACEMS were examined to determine the impact of the CP program. RESULTS: Hypertensive patients decreased an average of 7.2 mmHg (P < .0001) in systolic blood pressure and 4.0 mmHg (p < .0001) in diastolic blood pressure. Diabetic patients decreased blood glucose by an average of 33.7 mmol/L (p = .0013). Following enrollment into the program, CP participants decreased ED visits by 58.7% and inpatient visits by 68.8%. Conversely, the comparison group increased ED visits by 4.0% and inpatient visits by 187.5%. CONCLUSIONS: The CP program demonstrated a meaningful difference in the health of participants while reducing their health care utilization. CP patients reduced their ED and inpatient use, required less intensive care, had better health outcomes, and reduced health expenses to the community.