Dissemination of Remote Patient Monitoring: An Academic-Community Primary Care Partnership in South Carolina.

CONTEXT: Remote patient monitoring (RPM) for diabetes and hypertension may reduce barriers to patient care, leading to improved disease control and decreased morbidity and mortality. PROGRAM: We describe the implementation of a community-academic partnership to improve diabetes and hypertension control for underserved populations using RPM. IMPLEMENTATION: In 2014, our academic medical center (AMC) began working with community health centers (CHCs) to implement a centrally monitored RPM program for patients with diabetes. AMC nurses recruited, trained, and supported community partners through regular communication. Community sites were responsible for enrollment, follow-up visits, and all treatment adjustments. EVALUATION: More than 1350 patients have been enrolled across 19 counties and 16 predominantly rural CHCs. The majority of patients reported low annual household income and African American or Hispanic background. It took about 6 to 9 months of planning at each CHC prior to first enrolled patient. More than 30% of patients utilizing the newer device continued to transmit glucose readings regularly at week 52 of enrollment. Hemoglobin A 1c data reporting was completed for more than 90% of patients at 6 and 12 months postenrollment. DISCUSSION: Partnering of our AMC with CHCs enabled dissemination of an effective, inexpensive tool that engaged underserved populations in rural South Carolina and improved chronic disease management. We supported implementation of clinically effective diabetes RPM programs at several CHCs, reaching a large number of historically underserved and underresourced rural CHC patients with diabetes. We summarize key steps to achieving a successful, collaborative RPM program through AMC-CHC partnerships.

Diabetes Remote Monitoring Program Implementation: A Mixed Methods Analysis of Delivery Strategies, Barriers and Facilitators.

Background: Remote patient monitoring (RPM) is being increasingly utilized as a type of telemedicine modality to improve access to quality health care, although there are documented challenges with this type of innovation. The goals of this study were to characterize clinic delivery strategies for an RPM program and to examine barriers and facilitators to program implementation in a variety of community clinic settings. Methods: Primary data were collected via individual and small group interviews and surveys of clinical staff from South Carolina primary care clinics participating in an RPM program for patients with diabetes mellitus type 2 in 2019. We used a parallel convergent mixed methods study design with six South Carolina primary care outpatient clinics currently participating in a diabetes remote monitoring program. Clinic staff participants completed surveys to define delivery strategies and experiences with the program in a variety of clinical settings. Interviews of clinic staff examined barriers and facilitators to program implementation guided by the Consolidated Framework for Implementation Research (CFIR). Quantitative survey data were summarized via descriptive statistics. Qualitative data from interviews were analyzed in a template analysis approach with primary themes identified and organized by two independent coders and guided by the CFIR. Quantitative and qualitative findings were then synthesized in a final step. Results: RPM program delivery strategies varied across clinic, patient population, and program domains, largely affected by staffing, leadership buy-in, resources, patient needs, and inter-site communication. Barriers and facilitators to implementation were linked to similar factors that influenced delivery strategy. Discussion: RPM programs were implemented in a variety of different clinic settings with program delivery tailored to fit within each clinic's workflow and meet patients' needs. By addressing the barriers identified in this study with focused training and support strategies, delivery processes can improve implementation of RPM programs and thus benefit patient outcomes in rural and community settings.

Racial, Ethnic, and Nativity Disparities in Physical Activity and Sedentary Time among Cancer Prevention Study-3 Participants.

PURPOSE: Understanding racial/ethnic and nativity disparities in physical activity (PA) is important, as certain subgroups bear a disproportionate burden of physical inactivity-related diseases. This descriptive study compared mean leisure-time moderate-to-vigorous intensity physical activity (LTMVPA) by race/ethnicity and nativity. METHODS: The Cancer Prevention Study-3 (78.1% women; age, 47.9 ± 9.7 yr) includes 4722 (1.9%) Asian/Pacific Islander; 1232 (0.5%) Black/Indigenous (non-White) Latino; 16,041 (6.5%) White Latino; 9295 (3.8%) non-Latino Black; 2623 (1.1%) Indigenous American; and 210,504 (85.7%) non-Latino White participants across the United States and Puerto Rico. Participants completed validated LTMVPA and 24-h time use surveys at enrollment (2006-2013). Differences in LTMVPA across race/ethnicity and nativity were examined by ANCOVA with paired Tukey tests adjusting for age and sex. The proportion of time spent sitting, sleeping, and on PA by race/ethnicity was also compared. RESULTS: There were significant differences in LTMVPA by race/ethnicity (race main effect, P < 0.001; nativity, P = 0.072; interaction, P < 0.001). Pairwise comparisons showed that White participants born abroad were the most active (23.8 MET-h·wk-1) and non-White Latino participants born abroad were the least active (17.9 MET-h·wk-1). Among Latinos, participants born in Puerto Rico were 6.6-7.3 MET-h·wk-1 less active than participants born in Mexico, the United States/Canada, or other countries. There were variations in time use by race/ethnicity, with the largest difference in time spent sitting while watching TV. Black participants spent 14.8% of the day (~3.5 h) sitting watching TV, which was 78 min longer than Asian/Pacific Islander participants. CONCLUSIONS: This study suggests that there are differences in LTMVPA accumulation by race, ethnicity, and nativity. Results can be used to identify demographic groups that may benefit from culturally tailored PA interventions.

Patient Demographics and Clinic Type Are Associated With Patient Engagement Within a Remote Monitoring Program.

Background: Remote physiological monitoring (RPM) is accessible, convenient, relatively inexpensive, and can improve clinical outcomes. Yet, it is unclear in which clinical setting or target population RPM is maximally effective. Objective: To determine whether patients' demographic characteristics or clinical settings are associated with data transmission and engagement. Methods: This is a prospective cohort study of adults enrolled in a diabetes RPM program for a minimum of 12 months as of April 2020. We developed a multivariable logistic regression model for engagement with age, gender, race, income, and primary care clinic type as variables and a second model to include first-order interactions for all demographic variables by time. The participants included 549 adults (mean age 53 years, 63% female, 54% Black, and 75% very low income) with baseline hemoglobin A1c ≥8.0% and enrolled in a statewide diabetes RPM program. The main measure was the transmission engagement over time, where engagement is defined as a minimum of three distinct days per week in which remote data are transmitted. Results: Significant predictors of transmission engagement included increasing age, academic clinic type, higher annual household income, and shorter time-in-program (p < 0.001 for each). Self-identified race and gender were not significantly associated with transmission engagement (p = 0.729 and 0.237, respectively). Conclusions: RPM appears to be an accessible tool for minority racial groups and for the aging population, yet engagement is impacted by primary care location setting and socioeconomic status. These results should inform implementation of future RPM studies, guide advocacy efforts, and highlight the need to focus efforts on maintaining engagement over time.

Cancer survivor worries about treatment disruption and detrimental health outcomes due to the COVID-19 pandemic.

PURPOSE: We examined cancer survivor worries about treatment, infection, and finances early in the U.S. COVID-19 pandemic. DESIGN: Closed- and open-ended online survey questions were collected from adult cancer survivors (N = 972). METHODS: Logistic regression identified factors associated with treatment, infection, and financial worry. Thematic qualitative analysis generated information around participants' experiences and worries related to COVID-19 and healthcare. FINDINGS: Characteristics including marital status, race/ethnicity, cancer type, time since last treatment, education, and age were associated with health and healthcare worry outcomes. Survivors commonly expressed uncertainty about future care, fears about in-person appointments, rationed COVID-19 care, recurrence due to care delays, and distress about untreated symptoms, including mental health issues. CONCLUSIONS: Early in the pandemic, survivors worried about and experienced cancer care delays, COVID infection, and how the pandemic would affect their prognosis. IMPLICATIONS: Healthcare professionals need to be aware of cancer survivors' concerns and uncertainties to provide appropriate care.

Remote patient monitoring sustains reductions of hemoglobin A1c in underserved patients to 12 months.

AIMS: We sought to determine whether underserved patients enrolled in a statewide remote patient monitoring (RPM) program for diabetes achieve sustained improvements in hemoglobin A1c at 6 and 12 months and whether those improvements are affected by demographic and clinical variables. METHODS: Demographic and clinical variables were obtained at baseline, 6 months and 12 months. Baseline HbA1c values were compared with those obtained at 6 and 12 months via paired t-tests. A multivariable regression model was developed to identify patient-level variables associated with HbA1c change at 12 months. RESULTS: HbA1c values were obtained for 302 participants at 6 months and 125 participants at 12 months. Compared to baseline, HbA1c values were 1.8% (19 mmol/mol) lower at 6 months (p < 0.01) and 1.3% (14 mmol/mol) lower at 12 months (p < 0.01). Reductions at 12 months were consistent across clinical settings. A regression model for change in HbA1c showed no statistically significant difference for patient age, sex, race, household income, insurance, or clinic type. CONCLUSIONS: Patients enrolled in RPM had improved diabetes control at 6 and 12 months. Neither clinic type nor sociodemographic variables significantly altered the likelihood that patients would benefit from this type of technology. These results suggest the promise of RPM for delivering care to underserved populations.

Telehealth for the internal medicine resident: A 3-year longitudinal curriculum.

AIMS: Across the United States of America, patients are increasingly receiving healthcare using innovative telehealth technologies. As healthcare continues to shift away from traditional office-based visits, providers face new challenges. Telehealth champions are needed to adapt technologies to meet the needs of patients, providers and communities, especially within the realm of primary care specialties. Given these challenges, this intervention aimed to incorporate telemedicine into internal medicine resident training across multiple training years to prepare them for practice in the current and changing healthcare system. METHODS: Education and telehealth leaders at the Medical University of South Carolina identified key topics relevant to telehealth and the provision of general internal medicine services. With this as a framework, we developed a 3-year longitudinal telehealth curriculum for internal medicine resident physicians, consisting of an introduction to telemedicine equipment in the first year, didactic learning through in-person education and online modules in the second year and experiential learning through remote monitoring of chronic disease in the third year. Participants included approximately 100 internal medicine residents per year (2016-2019). Self-perceived knowledge, comfort and ability to provide telehealth services was assessed via a survey completed before and after participation in the curriculum. RESULTS: Resident physicians' self-reported knowledge of telehealth history, access to care, contributions of telehealth applications and quality of care and communication each improved after completion of the online curriculum. There were also significant improvements in resident comfort and perceived ability to provide telehealth services after participation in the curriculum, as assessed via a survey. Overall, 41% of residents felt their ability to utilize telehealth as part of their current or future practice was greater than average after completion of the online modules compared to only 2% at baseline (p<0.01). Results also show residents accurately identify barriers to telehealth adoption at the healthcare system level, including the lack of clinical time to implement services (67% post- vs 47% pre-curriculum, p = 0.02), unfamiliarity with concepts (65% post- vs 21% pre-curriculum, p<-0.01) and concerns about consistent provider reimbursement (74% post- vs 39% pre-curriculum, p < 0.01). CONCLUSION: Telemedicine and remote patient monitoring are an increasingly prevalent form of healthcare delivery. Internal medicine residents must be adept in caring for patients utilizing this technology. This curriculum was effective in improving resident comfort and self-efficacy in providing care through telehealth and provided residents with hands-on opportunities through supervised inclusion in remote patient-monitoring services. This curriculum model could be employed and evaluated within other internal medicine residency programmes to determine the feasibility at institutions with and without advanced telehealth centres.

The effect of remote patient monitoring on the primary care clinic visit frequency among adults with type 2 diabetes.

AIMS: Healthcare organizations are increasingly using technology to assist in diabetes management based on telemedicine's proven ability to improve glycemic regulation, decrease cost, and overcome barriers to effective healthcare. Nevertheless, it remains unclear how telemedicine intersects with primary care. We aim to measure the impact of a remote monitoring program for diabetes on primary care delivery through analysis of primary care office visit frequency. METHODS: Patients eligible to participate in our institution's remote diabetes monitoring program were identified and classified as enrolled or not enrolled (i.e. "usual care"). The number of scheduled and completed primary care office visits in the 12 months prior to and after the index date were measured for both groups. The index date was the enrollment date or, for the patients who received usual care, the next available enrollment session after eligibility screen. Two-sample t-tests were used to examine the change in frequency of office visits prior to and after enrollment for participants, as well as the difference in visit frequency between enrolled patients versus patients receiving usual care. RESULTS: There was no statistical difference in the number of scheduled or completed primary care clinic visits before or after enrollment in telehealth. Furthermore, there was no difference in the number of scheduled or completed primary care visits between patients enrolled in telehealth versus those receiving usual care. CONCLUSION: Participation in telehealth has been shown to be associated with significant HbA1c reductions in prior work, yet our data suggest that remote monitoring is not associated with a change in primary care office visit frequency. This suggests that telehealth may improve diabetes management independently of primary care visits.

Estimating the Economic Burden of Acute Myocardial Infarction in the US: 12 Year National Data.

BACKGROUND: Acute myocardial infarction (AMI) carries a substantial mortality and morbidity burden. The purpose of this study is to provide annual mean cost per patient and national level estimates of direct and indirect costs (lost productivity from morbidity and premature mortality) associated with AMI. METHODS: Nationally representative data spanning 12 years (2003-2014) with a sample of 324,869 patients with AMI from the Medical Expenditure Panel Survey (MEPS) were analyzed. A novel 2-part model was used to examine the excess direct cost associated with AMI, controlling for covariates. To estimate lost productivity from morbidity, an adjusted Generalized Linear Model was used for the differential in wage earnings between participants with and without AMI. Lost productivity from premature mortality was estimated based on published data. RESULTS: The total annual cost of AMI in 2016 dollars was estimated to be $84.9 billion, including $29.8 billion in excess direct medical expenditures, $14.6 billion in lost productivity from morbidity and $40.5 billion in lost productivity from premature mortality between 2003 and 2014. In the adjusted regression, the overall excess direct medical expenditure of AMI was $7,076 (95% confidence interval [CI] $6,028-$8,125) higher than those without AMI. After adjustment, annual wages for patients with AMI were $10,166 (95% CI -$12,985 to -$7,347) lower and annual missed work days were 5.9 days (95% CI 3.57-8.27) higher than those without AMI. CONCLUSIONS: The study finds that the economic burden of AMI is substantial, for which effective prevention could result in significant health and productivity cost savings.

Survey Item Response Rates by Survey Modality, Language, and Sociodemographic Factors in a Large U.S. Cohort.

BACKGROUND: Large-scale prospective cohorts traditionally use English, paper-based, mailed surveys, but Web-based surveys can lower costs and increase data quality, and multi-language surveys may aid in capturing diverse populations. Little evidence exists examining item response for multiple survey modalities or languages in epidemiologic cohorts. METHODS: A total of 254,475 men and women completed a comprehensive lifestyle and medical survey at enrollment (2006-2013) for the Cancer Prevention Study-3, a U.S.-based prospective cohort. Web-based (English only) or paper (Spanish or English) surveys were offered. Using generalized linear models, differences in item response rates overall and by topical areas (e.g., reproductive history) by modality and language were examined. We further examined whether differences in response quality by sociodemographic characteristics within each survey modality existed. RESULTS: Overall, English Web-based surveys had the highest average item response rate (97.6%), followed by English paper (95.5%) and Spanish paper (83.1%). Lower item response rates were seen among nonwhite, lower income, or less-educated participants. When examining individual survey sections by topic, results varied the most for residential history, with the lowest item response rate among Spanish language respondents (women, 62.7% and men, 64.3%) and the highest in English language Web-based, followed by paper respondents (women, 94.6% and men, 95.3%; and women, 92.8% and men, 92.1%, respectively). CONCLUSIONS: This study supports that utilizing multimodal survey approaches in epidemiologic studies does not differentially affect data quality. However, for some topic areas, further analysis should be considered for assessing data quality differences in Spanish language surveys. IMPACT: Multimodal survey administration is effective in nondifferentially capturing high-quality data.See all articles in this CEBP Focus section, "Modernizing Population Science."

Impact of Patient-Level Characteristics on In-hospital Mortality After Interhospital Transfer to Medicine Services: an Observational Study.

BACKGROUND: National administrative datasets have demonstrated increased risk-adjusted mortality among patients undergoing interhospital transfer (IHT) compared to patients admitted through the emergency department (ED). OBJECTIVE: To investigate the impact of patient-level data not available in larger administrative datasets on the association between IHT status and in-hospital mortality. DESIGN: Retrospective cohort study with logistic regression analyses to examine the association between IHT status and in-hospital mortality, controlling for covariates that were potential confounders. Model 1: IHT status, admit service. Model 2: model 1 and patient demographics. Model 3: model 2 and disease-specific conditions. Model 4: model 3 and vital signs and laboratory data. PARTICIPANTS: Nine thousand three hundred twenty-eight adults admitted to Medicine services. MAIN MEASURES: Interhospital transfer status, coded as an unordered categorical variable (IHT vs ED vs clinic), was the independent variable. The primary outcome was in-hospital mortality. Secondary outcomes included unadjusted length of stay and total cost. KEY RESULTS: IHT patients accounted for 180 out of 484 (37%) in-hospital deaths, despite accounting for only 17% of total admissions. Unadjusted mean length of stay was 8.4 days vs 5.6 days (p < 0.0001) and mean total cost was $22,647 vs $12,968 (p < 0.0001) for patients admitted via IHT vs ED respectively. The odds ratios (OR) for in-hospital mortality for patients admitted via IHT compared to the ED were as follows: model 1 OR, 2.06 (95% CI 1.66-2.56, p < 0.0001); model 2 OR, 2.07 (95% CI 1.66-2.58, p < 0.0001); model 3 OR, 2.07 (95% CI 1.63-2.61, p < 0.0001); model 4 OR, 1.70 (95% CI 1.31-2.19, p < 0.0001). The AUCs of the models were as follows: model 1, 0.74; model 2, 0.76; model 3, 0.83; model 4, 0.88, consistent with a good prediction model. CONCLUSIONS: Patient-level characteristics affect the association between IHT and in-hospital mortality. After adjusting for patient-level clinical characteristics, IHT status remains associated with in-hospital mortality.

When Do Clinicians Follow-up Abnormal Liver Tests in Primary Care?

BACKGROUND: Many guidelines addressing the approach to abnormal liver chemistries, including bilirubin, transaminases and alkaline phosphatase, recommend repeating the tests. However, when clinicians repeat testing is unknown. MATERIAL AND METHODS: This retrospective study followed adult patients with abnormal liver chemistries in a patient-centered medical home (PCMH) from 2007 to 2016. All PCMH patients possessing at least 1 abnormal liver test (total bilirubin, aminotransferases and alkaline phosphatase) were included. Patients were followed from the index abnormal liver chemistry until the next liver test result, or the end of the study period. The primary predictor variable of interest was the number of abnormal chemistries (out of 4) on index testing. Demographic and clinical variables served as other potential predictors of outcome. A Cox proportional hazards model was applied to investigate associations between the predictor variables and the time to repeat liver chemistry testing. RESULTS: Of 9,545 patients with at least 2 PCMH visits and 1 liver test abnormality, 6,489 (68%) obtained repeat testing within 1 year, and 80% of patients had follow-up tests within 2 years. Patients with multiple abnormal liver tests and those with higher degrees of abnormality were associated with shorter time to repeat testing. CONCLUSIONS: A large proportion of patients with abnormal liver tests still lack repeat testing at 1 year. The number of liver abnormal liver tests and degree of elevation were inversely associated with the time to repeat testing.

Patient perception of obesity versus physician documentation of obesity: A quality improvement study.

As the prevalence of obesity increases, the prevalence of associated comorbid diseases, obesity-related mortality rates and healthcare costs rise concordantly. Two main factors that hinder efforts to treat obesity include a lack of recognition by patients and documentation by physicians. This study evaluates the relationship between patient perception of obese weight and physician documentation of obesity. This quality improvement observational study surveyed patients of an academic internal medicine clinic on their perception of obesity. Responses were compared to longitudinal physician documentation of obesity and body mass index (BMI). A total of 59.9% of patients with obesity perceived their weight as obese. While 33.7% of patients with a BMI of 30 to 34.9 kg/m2 perceived themselves as having obesity, 71.4% of patients with a BMI of 45 to 49.9 kg/m2 perceived themselves as having obesity. A total of 42.4% of patients with obesity had physician documentation of obesity in the last year. While 25% of patients with a BMI of 30 to 34.9 kg/m2 had physician documentation of obesity, 85.7% of patients with a BMI of 45 to 49.9 kg/m2 had physician documentation of obesity. For patients with a BMI ≥50 kg/m2 , 52.9% perceived their weight to be obese and 76.5% had physician documentation of obesity in the last year. Both patient perception and physician documentation of obesity were significantly less than the prevalence of obesity. Patient perception of obesity and provider documentation of obesity increased as BMI increased until a BMI ≥50 kg/m2 . Both patients and providers must improve recognition of this disease.

Evaluation of liver test abnormalities in a patient-centered medical home: do liver test patterns matter?

Abnormal liver tests are extremely common in clinical practice, present with varying patterns and degrees of elevation, and can signal liver injury from a variety of causes. Responding to these abnormalities requires complex medical decision-making and merits investigation in primary care. This retrospective study investigates the association of patterns of liver test abnormality with follow-up in primary care. Using administrative data, this study includes patients with abnormal liver tests seen between 2007 and 2016 in a patient-centered medical home. Liver tests examined include serum bilirubin, aspartate aminotransferase, alanine aminotransferase, and alkaline phosphatase. Patients entered the cohort on the first liver test elevation. The outcome examined was completion of repeat testing, and the proportions of patients without follow-up were compared by patterns of index abnormality. 9545 patients met the inclusion criteria. Of these, 6155 (64.5%) possessed one liver test abnormality and 3390 (35.5%) possessed multiple abnormalities on index testing. Overall 1119 (11.7%) patients did not have repeat testing performed during the study period. A greater proportion of patients with lone abnormalities lacked repeat testing compared with those patients with multiple abnormalities. Differences in repeat testing appeared when comparing clinical patterns of abnormality, with higher proportions of follow-up in patients with testing suggestive of cholestasis. Over 11% of patients with abnormal liver tests did not undergo repeat testing during the study period. Repeat testing occurred more often in patients with multiple abnormalities and in clinical patterns suggestive of cholestasis. This study highlights a potential opportunity to improve quality of care.

Trends in Healthcare Expenditures Among US Adults With Hypertension: National Estimates, 2003-2014.

BACKGROUND: One in 3 US adults has high blood pressure, or hypertension. As prior projections suggest hypertension is the costliest of all cardiovascular diseases, it is important to define the current state of healthcare expenditures related to hypertension. METHODS AND RESULTS: We used a nationally representative database, the Medical Expenditure Panel Survey, to calculate the estimated annual healthcare expenditure for patients with hypertension and to measure trends in expenditure longitudinally over a 12-year period. A 2-part model was used to estimate adjusted incremental expenditures for individuals with hypertension versus those without hypertension. Sex, race/ethnicity, education, insurance status, census region, income, marital status, Charlson Comorbidity Index, and year category were included as covariates. The 2003-2014 pooled data include a total sample of 224 920 adults, of whom 36.9% had hypertension. Unadjusted mean annual medical expenditure attributable to patients with hypertension was $9089. Relative to individuals without hypertension, individuals with hypertension had $1920 higher annual adjusted incremental expenditure, 2.5 times the inpatient cost, almost double the outpatient cost, and nearly triple the prescription medication expenditure. Based on the prevalence of hypertension in the United States, the estimated adjusted annual incremental cost is $131 billion per year higher for the hypertensive adult population compared with the nonhypertensive population. CONCLUSIONS: Individuals with hypertension are estimated to face nearly $2000 higher annual healthcare expenditure compared with their nonhypertensive peers. This trend has been relatively stable over 12 years. Healthcare costs associated with hypertension account for about $131 billion. This warrants intense effort toward hypertension prevention and management.

The American Cancer Society's Cancer Prevention Study 3 (CPS-3): Recruitment, study design, and baseline characteristics.

BACKGROUND: Prospective cohort studies contribute importantly to understanding the role of lifestyle, genetic, and other factors in chronic disease etiology. METHODS: The American Cancer Society (ACS) recruited a new prospective cohort study, Cancer Prevention Study 3 (CPS-3), between 2006 and 2013 from 35 states and Puerto Rico. Enrollment took place primarily at ACS community events and at community enrollment "drives." At enrollment sites, participants completed a brief survey that included an informed consent, identifying information necessary for follow-up, and key exposure information. They also provided a waist measure and a nonfasting blood sample. Most participants also completed a more comprehensive baseline survey at home that included extensive medical, lifestyle, and other information. Participants will be followed for incident cancers through linkage with state cancer registries and for cause-specific mortality through linkage with the National Death Index. RESULTS: In total, 303,682 participants were enrolled. Of these, 254,650 completed the baseline survey and are considered "fully" enrolled; they will be sent repeat surveys periodically for at least the next 20 years to update exposure information. The remaining participants (n = 49,032) will not be asked to update exposure information but will be followed for outcomes. Twenty-three percent of participants were men, 17.3% reported a race or ethnicity other than "white," and the median age at enrollment was 47 years. CONCLUSIONS: CPS-3 will be a valuable resource for studies of cancer and other outcomes because of its size; its diversity with respect to age, ethnicity, and geography; and the availability of blood samples and detailed questionnaire information collected over time. Cancer 2017;123:2014-2024. © 2017 American Cancer Society.

Sustained Improvement in Blood Pressure Control for a Multiracial Cohort: Results of a Patient-centered Medical Home Quality Improvement Initiative.

BACKGROUND: Patient-centered medical homes incorporate strategies to increase healthcare access as a means of improving health at the patient and population level. We hypothesized that quality improvement initiatives based in a patient-centered medical home would improve hypertension control for adult patients, regardless of race. METHODS: This prospective cohort study included patients of a hospital-based Internal Medicine practice in the southeastern U.S. whose systolic blood pressure was uncontrolled (criteria ≥140mmHg) prior to patient-centered medical home certification. Mean systolic blood pressure and hypertension control rates were calculated from the average of the four quarterly means prior to patient-centered medical home designation and again from the last 4 quarters of the five-year study period (final). Quality improvement interventions included patient identification, multidisciplinary team meetings, targeted outreach, and dedicated office visits for addressing hypertension. Primary outcomes included the change in systolic blood pressure and the change in the proportion of the cohort with hypertension control. Chi-square, two sample t-tests, and ANOVA were used for comparison (SAS 9.3). RESULTS: The inception cohort had 1,702 patients (64% nonwhite, 36% white) with systolic blood pressure ≥140mmHg. Mean systolic blood pressure significantly decreased while hypertension control rates increased in both races after patient-centered medical home certification. White adults had lower mean systolic blood pressure and higher control rates at baseline and study conclusion compared to nonwhite adults. Similar trends persisted regardless of the number of office visits. CONCLUSIONS: The analysis of blood pressure before and after designation of an Internal Medicine clinic as a patient-centered medical home reveals disparities in rates of chronic disease control. Team-based outreach improves hypertension control for patients regardless of race or visit number. These findings suggest that patient-centered medical homes and a multidisciplinary care approach, not limited to increased access, improve chronic disease control and should be considered for diverse outpatient clinics.

Tomato handling practices in restaurants.

In recent years, multiple outbreaks of Salmonella infection have been associated with fresh tomatoes. Investigations have indicated that tomato contamination likely occurred early in the farm-to-consumer chain, although tomato consumption occurred mostly in restaurants. Researchers have hypothesized that tomato handling practices in restaurants may contribute to these outbreaks. However, few empirical data exist on how restaurant workers handle tomatoes. This study was conducted to examine tomato handling practices in restaurants. Members of the Environmental Health Specialists Network (EHS-Net) observed tomato handling practices in 449 restaurants. The data indicated that handling tomatoes appropriately posed a challenge to many restaurants. Produce-only cutting boards were not used on 49% of tomato cutting observations, and gloves were not worn in 36% of tomato cutting observations. Although tomatoes were washed under running water as recommended in most (82%) of the washing observations, tomatoes were soaked in standing water, a practice not recommended by the U.S. Food and Drug Administration (FDA), in 18% of observations, and the temperature differential between the wash water and tomatoes did not meet FDA guidelines in 21% of observations. About half of all batches of cut tomatoes in holding areas were above 41 degrees F (5 degrees C), the temperature recommended by the FDA. The maximum holding time for most (73%) of the cut tomatoes held above 41 degrees F exceeded the FDA recommended holding time of 4 h for unrefrigerated tomatoes (i.e., tomatoes held above 41 degrees F). The information provided by this study can be used to inform efforts to develop interventions and thus prevent tomato-associated illness outbreaks.

Systematic environmental evaluations to identify food safety differences between outbreak and nonoutbreak restaurants.

Restaurants are important settings for foodborne disease transmission. The Environmental Health Specialists Network (EHS-Net) was established to identify underlying factors contributing to disease outbreaks and to translate those findings into improved prevention efforts. From June 2002 through June 2003, EHS-Net conducted systematic environmental evaluations in 22 restaurants in which outbreaks had occurred and 347 restaurants in which outbreaks had not occurred. Norovirus was the most common foodborne disease agent identified, accounting for 42% of all confirmed foodborne outbreaks during the study period. Handling of food by an infected person or carrier (65%) and bare-hand contact with food (35%) were the most commonly identified contributing factors. Outbreak and nonoutbreak restaurants were similar with respect to many characteristics. The major difference was in the presence of a certified kitchen manager (CKM); 32% of outbreak restaurants had a CKM, but 71% of nonoutbreak restaurants had a CKM (odds ratio of 0.2; 95% confidence interval of 0.1 to 0.5). CKMs were associated with the absence of bare-hand contact with foods as a contributing factor, fewer norovirus outbreaks, and the absence of outbreaks associated with Clostridium perfringens. However, neither the presence of a CKM nor the presence of policies regarding employee health significantly affected the identification of an infected person or carrier as a contributing factor. These findings suggest a lack of effective monitoring of employee illness or a lack of commitment to enforcing policies regarding ill food workers. Food safety certification of kitchen managers appears to be an important outbreak prevention measure, and managing food worker illnesses should be emphasized during food safety training programs.