Impact of dermoscopy-aided pediatric teledermatology program on the accessibility and efficiency of dermatology care at community health centers.

BACKGROUND: There are few studies focusing on pediatric teledermatology, and the impact of a large-scale pediatric teledermatology program on the accessibility and efficiency of dermatology care remains unclear. This study evaluated the impact of a state-wide implementation of a store-and-forward teledermatology program augmented by the incorporation of dermoscopy in pediatric patients visiting community health centers. METHODS: It was a descriptive, retrospective cohort study of 876 pediatric dermatology referrals. RESULTS: In the traditional referral system, only 60 patients (17.6%) were seen by dermatologists with average waiting times of 75 days due to limited access. In comparison, with an implementation of dermoscopy-aided teledermatology, all 536 teledermatology referrals received dermatological care within 24 h, of which only 64 (12%) patients requires face-to-face (F2F) consultation. Patients referred for F2F consultation via eConsults had a much lower no-show rate as compared to the traditional referral system (39% vs. 71%). Side by side comparison between general population and pediatric population has demonstrated shared features in efficiency and access improvement but revealed specific characteristics of pediatric teledermatology in terms of diagnosis and treatment. CONCLUSION: Coordinated store-and-forward teledermatology platform with incorporation of dermoscopy between large community care network and dermatology provider can greatly improve access to pediatric dermatology care especially in underserved population. The efficiency of teledermatology in access improvement for pediatric population is comparable with adult population in eConsults. There are also unique features and challenges in pediatric teledermatology that require further research.

Injury and Psychiatric Disorder in Low-Income Women Experiencing Bidirectional Intimate Partner Violence.

This study compared severity of physical violence, intimate partner violence (IPV)-related injury, and lifetime diagnoses of psychiatric disorders among women in relationships with bidirectional, unidirectional, or no IPV. The sample includes 763 low-income women from community-based family planning clinics. Results showed that women in relationships with bidirectional IPV were more likely to experience severe physical violence and severe IPV-related injury compared to women in the unidirectional IPV category. These women were also more likely to be diagnosed with drug abuse and depression than women in relationships without IPV. Similarly, women in the bidirectional IPV category were more likely to be diagnosed with drug abuse when compared to women in the victim-only unidirectional IPV category. Recommendations for health-care providers are discussed.

Impact of dermatology eConsults on access to care and skin cancer screening in underserved populations: A model for teledermatology services in community health centers.

BACKGROUND: The clinical outcome of teledermatology with dermoscopy in large-scale primary care networks remains unclear. OBJECTIVE: We evaluate the impact of implementing a teledermatology consultation program with dermoscopy on a statewide scale, focusing on access to care and skin cancer screening for medically underserved populations. METHODS: Descriptive retrospective cohort study of 2385 dermatology referrals from primary care from June 2014 through November 2015. RESULTS: Before implementation of electronic consultations (eConsults), access to dermatology was limited; only 139 (11%) of 1258 referrals resulted in a confirmed appointment with a median wait time of 77 days. Post implementation, 499 of 1127 consults (44%) were sent electronically, and of those, 16% required a face-to-face visit with a median wait time of 28 days. Ten malignancies were identified via eConsults. Overall consult volume remained stable pre- and post-eConsult implementation. LIMITATIONS: We evaluated eConsults in medically underserved populations seeking care at community health centers. Results might not be generalizable to other populations or in other settings. CONCLUSION: eConsults increase access to dermatologic care and reduce wait times for patients receiving medical care at community health centers. Implementing dermoscopy into teledermatology could increase access to skin cancer screening and treatment for medically disadvantaged populations.

Delivery and Measurement of High-Value Care in Standardized Patient Encounters.

BACKGROUND: Residencies have incorporated high-value care (HVC) training to contain health care expenditures. Assessment methods of HVC curricula are limited. OBJECTIVE: In our clinical skills laboratory, we evaluated the effectiveness of HVC curricula using standardized patients (SPs) to determine if there is a correlation with performance in counseling, history and physical, HVC knowledge, and demographics. METHODS: Through ambulatory cases, SPs evaluated postgraduate year 2 (PGY-2) residents using checklists to determine if they obtained the chief complaint, medical and social history, focused physical examination, and conveyed information regarding patient management. Investigators scored knowledge-based questions on the need for imaging in low back pain, annual stress testing in coronary artery disease, and chest x-ray for gastroesophageal reflux disease. Univariate analysis was used to calculate percentage distribution of residents' ordering of inappropriate tests. RESULTS: All 56 PGY-2 residents participated in the study and completed at least 2 of 3 HVC cases. Analysis showed that 48% (27 of 56) ordered at least 1 inappropriate test. Residents who ordered unnecessary testing had similar performance in history and physical as well as knowledge of HVC. Inappropriate ordering was significantly associated with poorer performance in counseling (mean percentage counseling score of 68% versus 56% for those who ordered inappropriately, P < .001) and communication skills (mean percentage communication score of 74% versus 71% for those who ordered inappropriately, P < .003). There were no patterns for ordering by demographics. CONCLUSIONS: Our evaluation of residents during SP encounters found a correlation between the use of inappropriate testing and lower counseling and communication skills.

Sleep Quality Among Low-Income Young Women in Southeast Texas Predicts Changes in Perceived Stress Through Hurricane Ike.

STUDY OBJECTIVES: To document the time course of perceived stress among women through the period of a natural disaster, to determine the effect of sleep quality on this time course, and to identify risk factors that predict higher levels of perceived stress. DESIGN: Longitudinal study from 2006-2012. SETTING: Community-based family planning clinics in southeast Texas. PARTICIPANTS: There were 296 women aged 18-31 y who experienced Hurricane Ike, September 2008. MEASUREMENTS AND RESULTS: Cohen Perceived Stress Scale (PSS) was administered every 2 mo from 6 mo before to 12 mo after Hurricane Ike. Sleep quality was assessed 1 mo after Hurricane Ike using the Pittsburg Sleep Quality Index (PSQI). Good sleep was defined as a PSQI summary score < 5, and poor sleep as a score ≥ 5. Hurricane Ike stressors (e.g., property damage, subjective stressors) and pre-Ike lifetime major life events and emotional health (e.g., emotional dysregulation, self-control) were also assessed. RESULTS: Over the entire period of 18 mo (6 mo before and 12 mo after the hurricane), perceived stress was significantly higher among poor sleepers compared to good sleepers, and only good sleepers showed a significant decrease in perceived stress after Hurricane Ike. In addition, a higher level of perceived stress was positively associated with greater Ike damage among poor sleepers, whereas this correlation was not observed among good sleepers. In the final multivariate longitudinal model, Ike-related subjective stressors as well as baseline major life events and emotional dysregulation among poor sleepers predicted higher levels of perceived stress over time; among good sleepers, additional factors such as lower levels of self-control and having a history of a psychiatric disorder also predicted higher levels of perceived stress. CONCLUSIONS: Sleep quality after Hurricane Ike, an intense natural disaster producing substantial damage, impacted changes in perceived stress over time. Our findings suggest the possibility that providing victims of disasters with effective interventions to improve sleep quality could help to reduce their perceived stress over time.

Customized versus Population Fetal Growth Norms and Adverse Outcomes Associated with Small for Gestational Age Infants in a High-Risk Cohort.

OBJECTIVE: To compare population versus customized fetal growth norms in identifying neonates at risk for adverse perinatal and neonatal outcomes (AOs) associated with small for gestational age (SGA) in high-risk women. DESIGN: Secondary analysis to a multicenter treatment trial of pregnant women at high risk for preeclampsia using low-dose aspirin versus placebo. The associations between SGA by population (SGApop) and customized (SGAcust) norms and AOs were evaluated. RESULTS: A total of 2,289 mother/infant pairs were included in the analysis. The rates of SGA in the aspirin and placebo groups were similar by the customized (22.8% vs 23.9%; p = 0.55) or population (8.7% vs 7.5%; p = 0.54) norms; however, they were lower using population norms compared with customized norms (p < 0.001). SGAcust, but not SGApop, was associated with spontaneous preterm birth (odds ratio [OR]: 1.44, 95% confidence interval [CI]: 1.15-1.81; p < 0.001), preterm premature rupture of membranes (OR 1.42 95% CI 1.05-1.92; p = 0.02), and cesarean delivery (OR: 1.35, 95% CI: 1.11-1.64; p = 0.002). Both SGAcust and SGApop were associated with the composite neonatal outcome, indicated preterm delivery before 32, 35, and 37 weeks, oligohydramnios, fetal distress, as well as decreased risk of oxygen requirement. Neither was associated with preeclampsia. CONCLUSION: Customized approach for assessment of fetal growth was associated with higher SGA rates and better identification of SGA neonates at risk for AOs.

Intervention for fetal distress among obstetricians, registered nurses, and residents: similarities, differences, and determining factors.

OBJECTIVE: To explore the factors possibly associated with the intrapartum management of nonreassuring fetal status and the factors affecting the decision to expedite delivery for fetal distress among different obstetric health care providers. METHODS: In a cross-sectional study, a standardized hypothetical clinical scenario of management of fetal distress was presented by a study investigator to labor and delivery personnel, including faculty obstetricians, residents, and registered nurses (N=52). An intervention index was calculated for each faculty by dividing the number of cesarean and operative deliveries for nonreassuring fetal status by the actual number of laboring patients supervised by each faculty in 2008. RESULTS: Selection of the timing of delivery and characterization of nonreassuring fetal heart rate patterns was not different among the different providers (P=.3). However, compared with residents, registered nurses notified the attending obstetricians at an earlier stage and in response to different fetal heart rate tracing scenarios suggestive of fetal distress (P<.001). Personal or professional experience, type of clinical practice, and psychological traits did not affect the management of the standardized clinical scenario or the intervention index (P=.3-.9). CONCLUSION: Different providers practicing in the same environment may develop a similar approach in the setting of nonreassuring fetal status that overcomes individual differences and follows the current guidelines on electronic fetal monitoring. LEVEL OF EVIDENCE: II.

Ecstasy use and its correlates among young, low-income women.

We examined the association of illicit drug use with stress and sexual behaviors among 407 women, aged 18?31, who attended family-planning clinics in southeast Texas between June 2002 and May 2003 (n = 407). Paired comparisons of each of three types of drug users (of ecstasy, marijuana only, and other illicit drugs except ecstasy) with nonusers were assessed by logistic regressions. After controlling for demographics, both ecstasy users and marijuana-only users had a higher score on the stress scale than nonusers. All drug users were at higher risk of more lifetime sexual partners than those who had never used drugs, while those who had used ecstasy were more than twice as likely to have had prior sexually transmitted infections as those who had never used drugs. This study demonstrates that young, low-income women who use ecstasy experience higher levels of stress than nonusers. Stress level is correlated with drug use and participation in risky sexual behaviors. If stress is associated with drug use and risky sexual behavior, interventions designed to reduce substance use and risky sexual behavior in these women may need to also address factors that lead to increased stress. The study's limitations were noted.

Patterns and perceptions of ecstasy use among young, low-income women.

A significant number of young, low-income women experiment with ecstasy outside of club or rave settings. The current study examined patterns and risk factors of ecstasy use among this group of women. A cross-sectional survey was conducted among 696 women aged 18 to 31 who sought gynecological care from two university clinics in southeast Texas between December 1, 2001, and May 30, 2003. Fifteen percent of participants reported ever using ecstasy. Of those, over 90% used it at a friend's home. Compared with women who used only marijuana or other illicit drugs, ecstasy users were more likely to be white, use a larger number of other drugs, be willing to use drugs in the future, and have more friends who used drugs. Fewer ecstasy users strongly disapproved of adult drug use than users of other illicit drugs. Future interventional efforts should target young, low-income women to prevent future experimentation with illicit drugs.