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Health Disparities

Emergency Medicine, Health Disparities, Public Health, Research

Texts may help people with diabetes manage care

flipphoneWhat if a doctor’s orders were as simple as two text messages a day to keep the ER at bay? A recent study published in Annals of Emergency Medicine used an automated mobile health (mHealth) program to reach low-income inner-city patients with type 2 diabetes and engage them in their own health and disease management outside of emergency facilities.

Researchers recruited 128 participants who had sought care for diabetes at the Los Angeles County Hospital of the University of Southern California ED. The study reported that the largest safety-net hospital in the county’s public care system annually serves 170,000 patients, 70 percent of them Latino. Study participants could choose English or Spanish versions of the messages, which offered tips on healthy behavior and disease management and did not require a smartphone to receive.

From a release:

For patients who received the text messages, blood glucose levels decreased by 1.05 percent and self-reported medication adherence improved from 4.5 to 5.4 (on an eight-point scale). Effects were even larger among Spanish speakers for both medication adherence and blood glucose levels. The proportion of patients who visited the emergency department was lower in the text messaging group (35.9 percent) than in the control group (51.6 percent). Almost all (93.6 percent) patients enrolled in the program reported enjoying it and 100 percent reported that they would recommend it to family and friends.

“Our goal is to transition our patients from crisis management to long-term diabetes management,” study lead author Sanjay Arora, MD, of USC’s Keck School of Medicine, said in a release. “The absence of other health care options, reaching our patients by text message makes us partners in handling their disease and improves their quality of life.”

Previously: Help from a virtual friend goes a long way in boosting older adults’ physical activityA look at the “Wild West” of medical apps and Mobile phone app helps manage diabetes
Photo by kiwanja

Emergency Medicine, Health Disparities, LGBT, Patient Care, Research

Study finds ER avoidance in transgender individuals needing care

ER2Past reports have found high levels of postponing medical care in transgender and non-gender-conforming people, owing to experiences including refusal of care, harassment and violence in medical settings, and lack of provider knowledge. A 2011 committee opinion from the American Colleges of Obstetricians and Gynecologists called the consequences of inadequate treatment among this population “staggering.”

Now, Canadian research on an Ontario transgender population shows levels of emergency-room avoidance by trans people. Published online in the Annals of Emergency Medicine, the study (subscription required) examined data from surveys in 408 transgender, transsexual, or transitioned people, many of them young (16-24 years); approximately half were male-to-female and half were female-to-male.

As described in a release:

“Patients who have had trans-specific negative experiences in other parts of the health care system may defer care until they are desperate and need the ER,” said lead study author Greta Bauer, PhD, MPH, of the Schulich School of Medicine & Dentistry in London, Ontario, Canada. “The good news is that nearly three-quarters of those who needed emergency care were able to get it in the ER. The bad news is that so many still were not.”

Almost one-quarter (21 percent) of trans patients reported ever avoiding the ER due to a perception that their trans status would negatively affect such an encounter. Negative experiences specifically related to being transgender were reported by 52 percent of trans patients.

Approximately 54 percent of trans patients reported having to educate their providers “some” or “a lot” regarding trans issues.

Bauer and her colleagues noted in the paper that their work “represents a first contribution on trans experiences within emergency medicine.” More research is needed, they said, “to better understand reasons for ED avoidance and to develop strategies to overcome this.”

Previously: Documentary on LGBT veterans’ PTSD, trauma and recovery premieres tomorrowDistinction with a difference: Transgender neurobiologist picked for National Academy of Science membershipA call for more training on LGBT health issues and Affordable Care Act prohibits discrimination against transgender patients 
Photo by robnguyen01

Health Disparities, History, Medicine and Society, Public Health, Rural Health, Stanford News

Broken promises: The state of health care on Native American reservations

Broken promises: The state of health care on Native American reservations

RosebudI traveled to Haiti a month after the 2010 earthquake to report on what was happening there for Stanford Medicine magazine. So when I went to the Rosebud Indian Reservation in South Dakota this year with a group of Stanford students, I was incredulous to learn that the average life expectancy in this community was one year lower than Haiti’s – 46 versus 47 - and a full 33 years shorter than the average American.

Statistically speaking, the poor health of Native Americans living the Great Plains of the United States rivals many developing countries. I had no idea. Diabetes, alcoholism, and depression rates are frighteningly high. Suicide rates are 10 times the national average.

My goal in writing my in-depth story, which appears in the current issue of Stanford Medicine and was just recommended as a Longreads pick, was to try to understand how this could possibly be true, and to lend some perspective as to what could be done to change it. What I found was a toxic mix of causative factors: isolation, poverty, poor nutrition, poor education - each of which has its roots in history. What became strikingly clear during my visit to the federally funded Rosebud Indian Health Service Hospital on the reservation was that the United States government has never kept its promises, made in multiple treaties, to provide health care to Native Americans in exchange for land.

From my piece:

One afternoon during a visit to the hospital, I walk from the ER to a separate wing to find the CEO, [Sophie Two Hawk, MD, who also happens to be the first Native American to graduate from the University of South Dakota's medical school]. Her door’s ajar, and she waves me in. She’s dressed in the military-style uniform of the U.S. Public Health Service Commissioned Corps, her long, gray hair pulled back in a braid that drops down her back. She’s doing paperwork — denying a pile of requests from her physicians for additional care for their patients. The requests are appropriate, she says, but the hospital just doesn’t have the money to pay for the care. “If someone shows up with a torn ACL, we can’t afford to fix it,” she says. “He will walk with a limp.” Two Hawk, like many others, links the poor health statistics of Native Americans not only to the lack of adequate (federal) funding but to the community’s tragic history. The hopelessness, the despair — it’s rooted in history.

The story delves into some of that history, including the forced relocation of Native American children to faraway boarding schools, another particularly ugly chapter in history that I knew nothing about. This forced relocation led to “cultural distortion, physical, emotional and sexual abuse, and the ripple effect of loss of parenting skills and communal grief,” a government study states. Hope on the second poorest county in the country – neighboring Pine Ridge Indian Reservation comes in first place – is a struggle to find. But it’s there, particularly in the strong bonds of the community itself:

Leaving Two Hawk, I head to the office next door where another Native American hospital employee, psychologist Rebecca Foster, PhD, works. When I knock on her office door, she’s taking a break to cradle her week-old grandson. Foster and her husband, Dan, also Native and a psychologist at the hospital, have 14 children — seven of those adopted from relatives on the reservation who were unable to care for them. All seven of those children are special needs, like the baby’s father, who was born with fetal alcohol syndrome… ” I see a lot of kids who are depressed, who talk about suicide,” she says, then pauses to look into the eyes of her grand baby. “And yet, kids are still resilient. They still have a desire to have a good life, to be happy, to accomplish things. No matter where you come from, you can never completely destroy that. There are very few kids here who don’t have a dream. What I tell young people is that there is a difference between having to stay here because you are trapped and choosing to be here because you have something to give. One’s a prison, the other is a home.”

Previously: Finding hope on the Rosebud Indian Reservation, Getting back to the basics: A student’s experience working with the Indian Health Service, Lessons from a reservation: Clinic provides insight on women’s health issues, Lessons from a reservation: South Dakota trip sheds light on a life in rural medicine and Lessons from a  reservation: Visit to emergency department shows patient care challenges
Illustration by Jeffrey Decoster

Autoimmune Disease, Health Disparities, Research, Women's Health

Many lupus patients on Medicaid fail to take medication as prescribed, study shows

Many lupus patients on Medicaid fail to take medication as prescribed, study shows

pillsA study of medication compliance in people who have lupus has found that poorer patients on Medicaid were often not taking medications as prescribed. Lupus is a serious autoimmune disease in which the body attacks its own tissue as if it were a foreign invader. It affects more women than men, and women of color are two to three times as likely to have lupus as are Caucasian women. Immune suppressors and other drugs are often prescribed to prevent organ damage and to manage symptoms, which include fatigue, pain and joint inflammation.

HealthDay News reports on the recent study:

“It’s alarming,” said lead researcher [Jinoos Yazdany, MD, MPH,]  of the University of California, San Francisco. “These medications have a proven track record of improving patients’ outcomes.”

The study used pharmacy claims data, so it’s not possible to say why people were not taking their medication as prescribed, Yazdany said.

But money could be one factor. Medicaid covers the drugs, Yazdany noted, but even a small co-pay could be a barrier for low-income patients.

Drug side effects could be another issue, Yazdany said, as could a lack of education about the medications. “Some people may not be fully aware of the benefits of these drugs,” she said.

The findings, which were presented on Saturday at the American College of Rheumatology‘s annual meeting in San Diego, were drawn from a study of 23,187 Medicaid patients who were prescribed one or more medications for lupus. As outlined in the article, during the six-month study period patients “picked up enough medication to cover only 31 percent to 57 percent of the days.”

Previously: Rheumatoid arthritis patients not getting necessary medication, Research shows why lupus may be more common in black, Asian people and Consumers’ behavior responsible for $163 billion in wasteful pharmacy-related costs
Photo by rockbadger

Cancer, Health Disparities, Patient Care, Research, Stanford News

Stanford researchers examine disparities in use of quality cancer centers

Stanford researchers examine disparities in use of quality cancer centers

In past studies, hospitals recognized by the National Cancer Institute (NCI) have demonstrated better quality of care and better outcomes for cancer than other general acute, adult hospitals in California. These facilities, as Stanford colorectal surgeon Kim Rhoads, MD, MPH, told me, provide “everything a patient with cancer needs in order to insure the best outcome after treatment – such things as clinical services, research, clinical trials, interdisciplinary collaboration, and survivorship programs.”

Not all patients seek care or choose these facilities for treatment, though, and Rhoads and her colleagues in the medical school’s Department of Surgery and Stanford Cancer Institute recently investigated factors that influenced whether patients of various racial and ethnic minority groups with a specific type of cancer sought care at an NCI-recognized center.

The researchers looked at an all-payer, all-age, and racially and ethnically diverse dataset containing clinical information for 80,000 patients with colorectal cancer, of whom slightly fewer than five percent sought care in one of California’s nine NCI-recognized facilities. (Stanford is NCI-designated and serves San Mateo and Santa Clara Counties.) According to the study, colorectal cancer was selected because it is a high-incident cancer found in both men and women and treated in many types of hospital settings.

Using a linked dataset containing elements from the California Cancer Registry and from California’s patient discharge data, the study focused on geographic, socioeconomic and clinical characteristics that predicted use of NCI centers.

What the researchers found was that although minority groups tend to live closer to NCI-designated facilities than whites do, some minorities are less likely to use them. Of those who lived within five miles of an NCI center, 10 percent were white compared with 26 percent Asian-Pacific Islander (API), 14 percent Hispanic and 12 percent black. Researchers found that, within a patient population living nearby an NCI center, Hispanics were 29 percent less likely to use the center, while API were 41 percent more likely to go, compared with whites.

Travel distance was found to be a barrier to seeking treatment at an NCI center for all groups – as was lack of insurance. However, neighborhood education level proved to be a more important determinant. Patients who lived in neighborhoods with high levels of college education were 42 percent more likely to seek care at an NCI-designated facility than those who did not.

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Health Costs, Health Disparities, Public Health, Rural Health

“Mountain Dew mouth” rots teeth, costs taxpayers

"Mountain Dew mouth" rots teeth, costs taxpayers

1527462651_903a291406“Blecch! Ew! Sheesh! I’ll take a crab juice,” replied a thirsty Homer Simpson to a vendor’s alternative offer of Mountain Dew. I side with Homer on most issues, including this one. But whatever you think of the taste, you’d be hard-pressed to argue in favor of the soft drink’s nutritional value.

Soda has a bad reputation for being high in empty calories that contribute to some of the nation’s public-health problems, such as obesity and diabetes. NPR’s The Salt blog reports today on a phenomenon widespread in Appalachia of rotting teeth owing to frequent consumption of soda. The incidence is called “Mountain Dew mouth” – “after the region’s favorite drink,” which was invented in Tennessee, the piece notes.

Public-health advocates point out a burden of cost imposed by the Dew, which can be acquired with food stamps (now called the Supplemental Nutrition Assistance Program). Greater access to the drink and limited availability of dental care contribute to “Mountain Dew mouth,” which is reinforced by cultural issues in the area.

From the piece:

Many people don’t trust the well water in their homes because of pollution concerns and probably drink more soda because of it, [Priscilla Harris, JD, an associate professor at the Appalachian College of Law], says. She’s received a grant from the Robert Wood Johnson Foundation to study the problem.

And there’s another reason why soda mouth is so pervasive in Appalachia, Harris says: the region’s distinct culture of sipping soda constantly throughout the day. Singer adds, “Here in West Virginia, you see people carrying around bottles of Mountain Dew all the time — even at a public health conference.”

The article reports statistics about the region’s rate of tooth decay as 26 percent for pre-schoolers, and tooth extraction because of decay or erosion as 15 percent for 18- to 24-year-olds. In West Virginia, Centers for Disease Control and Prevention numbers show 67 percent of residents age 65 and over having lost six or more teeth from tooth decay or gum disease.

Previously: Sugar intake, diabetes and kids: Q&A with a pediatric obesity expert and Dental health a major problem for many
Photo by uberculture

Cardiovascular Medicine, Health Disparities, Public Health, Research, Women's Health

Heart attacks and chest pain: Understanding the signs in young women

Heart attacks and chest pain: Understanding the signs in young women

4357257999_17b19c2770I’ll be honest: Though I knew that young people can have heart attacks and the symptoms can be difficult to recognize in women, I’d never given much thought to the topic. But this press release on chest pain and heart attacks in young men and women has gotten me thinking.

A research team led by scientists at the Research Institute of the McGill University Health Centre in Canada found that women under the age of 55 are more likely to have a heart attack without chest pain than men.

Until recently, little was known about the signs of Acute Coronary Syndrome (ACS), a condition that includes heart attack and chest pain, or how these signs may differ between younger men and women. To explore signs of ACS in men and women, the research team studied a group of 1015 patients (approximately 30 percent of them women) under the age of 55 who had been hospitalized for ACS.

The researchers found that chest pain was the most common sign of ACS in men and women, but women were more likely to have ACS with little or no chest pain than men. Patients who had ACS without chest pain tended to report fewer symptoms overall. Yet, chest pain was not associated with the severity of the patient’s ACS.

From the study, which was published online in JAMA Internal Medicine:

Chest pain is the hallmark and critical distinguishing symptom used to initiate diagnostic testing for acute coronary syndrome (ACS) and urgent lifesaving therapy. However, up to 35% of patients with ACS do not report chest pain. These patients are more likely to have a misdiagnosis in the emergency department and a higher risk of death compared with those with chest pain.

The senior author described the significance of these results in the release:

“We need to move away from the image of an older man clutching his chest, when we think about acute coronary syndrome (ACS — the umbrella term referring to heart attacks and angina), says senior author of the study, Dr. Louise Pilote, director of the Division of General Internal Medicine at the MUHC and McGill University and professor of medicine at McGill University.

Our study demonstrates that young people and women who come into the emergency without chest pain, but other telltale ACS symptoms such as weakness, shortness of breath and/or rapid heartbeats are in crisis. We need to be able to recognize this and adapt to new standard assessments in previously unrecognized groups such as young women.”

This study highlights the importance of recognizing that men and women may show signs of heart attack, and other diseases, differently. Since the symptoms of ACS can be misleadingly mild for young women, women should take care to learn how heart attacks present themselves in women, and be sure to speak up if they have these symptoms.

Holly MacCormick is a writing intern in the medical school’s Office of Communication & Public Affairs. She is a graduate student in ecology and evolutionary biology at University of California-Santa Cruz.

Previously: Paper highlights major differences in disease between men and womenThe road to diagnosis: How to be insistent, persistent and consistentAsk Stanford Med: Cardiologist Jennifer Tremmel responds to questions on women’s heart healthA focus on women’s heart healthUnderstanding and preventing women’s heart disease and Gap exists in women’s knowledge of heart disease
Photo by Sebastian Anthony

Cancer, Health Disparities, Pain, Research

Identifying disparities in palliative care among cancer and non-cancer patients

Earlier this month, the New York Times reported on financial and ethical considerations for entering a hospital’s palliative care unit, which serves people with chronic illnesses near the end of life who need comfort more than intensive care but are not yet ready for hospice.

Now a study conducted in the U.K. has found that only 20 percent of non-cancer patients there (those with advanced stages of heart, lung, liver or kidney conditions, or dementia) requested or were properly identified as candidates to receive palliative care. That’s compared with 75 percent of cancer patients.

The study (subscription required), published in the European Journal of Palliative Care, examined 684 patients under general practitioner care in Scotland. Researchers found that most of the non-cancer patients began receiving palliative care too late to fully benefit from it – usually eight weeks before dying – and that non-cancer conditions were more difficult to prescribe palliative care for during a less-clear decline.

In a release, Scott Murray, MD, who leads the Primary Palliative Care Research Group at the University of Edinburgh, commented:

Patients with cancer are generally well served by palliative care services, while people with other conditions often miss out on this opportunity for more psychological, emotional, spiritual and practical support. Better and earlier identification of all patients who may benefit from these services is vital so that they can receive the care they need, and not slip through the net.

hospiceAfter hearing about the study, I asked palliative care expert VJ Periyakoil, MD, director of the Stanford Palliative Care Education & Training Program and the Stanford Hospice & Palliative Medicine Fellowship Program, to comment on the findings. She replied:

The study results aren’t surprising. Clinicians refer their seriously ill patients to hospice care based on their functional status, which is defined as an individual’s ability to perform normal daily activities required to meet basic needs, fulfill usual roles. As you can see in the image here, most cancer patients have a clear and steady decline in functional status when they get closer to death. Thus when people with advanced cancer spend most of the day in bed and are not able to care for themselves, it’s pretty clear that they’re nearing death and need to be referred to hospice. However, in non-cancer illnesses like end stage heart disease, end stage lung disease, the patient’s functional status undulates (i.e. when they have an infection their functional status becomes temporarily low only to rebound when they recover from the infection). Thus, it’s hard to predict when the patients are in the last six months of their life, and so they’re often referred too late to hospice care. We can overcome these challenges easily by providing concurrent palliative care along with disease directed care for all seriously ill patients.

Previously: Examining end-of-life practices and Katy Butler’s “Knocking on Heaven’s Door”How a Stanford physician became a leading advocate for palliative careOn a mission to transform end-of-life care and The importance of patient/doctor end-of-life discussions

Health Disparities, Infectious Disease, Public Health, Research, Women's Health

Study shows racial disparities in HPV vaccination

Study shows racial disparities in HPV vaccination

Much has been written here and elsewhere about the lower-than-ideal number of women and girls who get vaccinated for human papillomavirus (HPV). (The concern, of course, is that these patients are missing out on the opportunity to reduce their risk of sexually transmitted disease and cancer.) Now, a study out of University of Pittsburgh School of Medicine appearing in the Journal of Adolescent Health shows (as has past research) that some young women of color are even less likely than their white counterparts to get vaccinated.

As described in a press release:

Led by [Sonya Borrero, MD], researchers used data from the 2006-2010 National Survey of Family Growth (NSFG), a nationwide cross-sectional survey administered by the U.S. Department of Health and Human Services, to examine the effect of race/ethnicity on HPV vaccine initiation in adolescent girls and young women and to determine whether access to health care influences this relationship.

In this nationally representative sample of 2,168 females aged 15 to 24, African-Americans were significantly less likely than whites to have initiated HPV vaccination, 18.2 percent vs. 33.1 percent respectively. That disparity persisted even after taking into account socio-demographic factors and access to health care. Observed disparities in HPV vaccination for Hispanics, on the other hand, were largely explained by socio-demographic and health care access variables, the researchers found.

Referencing their finding that African-American patients are also less likely than white patients to have a health-care provider recommend the vaccine, Borrero and her co-authors suggest that improving access to health care among this population might not do the trick in solving the problem. “Perhaps, addressing negative attitudes and beliefs and increasing provider recommendation for HPV vaccination will be fruitful in increasing HPV vaccination rates in this population,” they write.

Previously: HPV-associated cancers are rising, HPV vaccination rates still too low, new national report says, Only one-third of teenage girls get HPV vaccine to prevent cervical cancer and The cost of forgoing routine vaccinations

Aging, Health and Fitness, Health Disparities, Research, Stanford News

Help from a virtual friend goes a long way in boosting older adults’ physical activity

Help from a virtual friend goes a long way in boosting older adults' physical activity

Last year I wrote about a Stanford study showing that computer-generated phone calls were an effective, low-cost way to encourage inactive adults to exercise. Now the researcher of that study, Abby King, PhD, has found that physical-activity tips, reminders, and encouragement from an interactive computer character - this one named Carmen, who introduces herself in the video above - can also get adults moving. King’s study involved 40 inactive and low-income adults, ages 55 and older, from a primarily Latino population in San Jose, Calif., who:

…were randomly assigned to a four-month walking intervention, coached by Carmen the virtual adviser, or to a control group. Those in the intervention program were taught to use a pedometer to track their daily steps. During weekly sessions, Carmen evaluated their pedometer information to provide them with personalized feedback, problem-solving and goal-setting. Participants were encouraged to interact weekly with Carmen, who was made available to them through a computer at a local senior center.

The researchers looked at the change in walking behavior at two months and four months, and also assessed whether the participants were adopting any strategies taught by Carmen. After four months, the researchers found that participants increased the amount of time they walked by an average of about 253 minutes each week — eight times more than the increase in the control group.

King says she and her colleagues expected that Carmen – who was designed to fit in with local Latino culture and to offer interactions in English or Spanish – would be popular among study participants. But she was “surprised and gratified” that those in the intervention group did so well, and that so many participants requested continued access to Carmen after the study period ended.

King and her Northeastern University colleagues, whose work appears online today in Journal of Health Communication, are now planning a larger study to assess Carmen’s effectiveness as a personal adviser over a longer time period. “We believe that, with some additional development and larger-scale testing, these types of virtual adviser programs have the potential for wide adoption and dissemination throughout other communities,” King told me.

Previously: What type of smartphone apps are effective for promoting healthy habits among older adults?, Computer-generated phone calls shown to help inactive adults get – and keep – moving, Eat a carrot and exercise – or your iBird dies and Research shows remote weight loss interventions equally effective as face-to-face coaching programs

Video by Relational Agents Group, Northeastern University

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