Addressing Health Disparities: Is There a Role for Private Payers in Reducing the Incidence of Type 2 Diabetes Among U.S. Hispanics?

There is a role for private payers to play in reducing the incidence of type 2 diabetes among Hispanics in the United States. However, given the barriers to reducing or eliminating racial and ethnic health disparities in general that health plans currently face, successfully filling that role is a long-term proposition - one that must be preceded by much foundational work and patience by all stakeholders in the health care system. In the meantime, there is a more critical and immediate role that all private payers should play, if they have not begun to do so already - and that is to join the fight to reduce all racial and ethnic disparities in health and health care. Broader industry action will raise the level of the quality of care delivered to racial and ethnic minorities in general; improve the overall health of those populations; create additional momentum for necessary federal policy changes; enhance industry knowledge and expertise in addressing health disparities; increase the evidence base for program outcomes; and reduce the time it will take to solve this serious problem. The successful resolution of the overall problem of racial and ethnic health disparities, whether measured by prevalence or incidence, and regardless of the target population or the target disease, will require the involvement of and action by all health care system stakeholders - payers, providers, members, communities, the government, agencies, and foundations. Health plans are in a unique position to influence the majority of these players, through advocacy, strategies, interventions, incentives, partnerships, policies, and programs. This study presents a series of best and promising practices for health plans to take to begin to address racial and ethnic health disparities

Interventions to promote access to eyecare for non-dominant ethnic groups in high-income countries: a scoping review

Purpose People who are distinct from the dominant ethnic group within a country can experience a variety of barriers to accessing eyecare services. We conducted a scoping review to map published interventions aimed at improving access to eyecare for non-Indigenous, non-dominant ethnic groups residing in high-income countries. Methods We searched MEDLINE, Embase and Global Health for studies that described an intervention to promote access to eyecare for the target population. Two authors independently screened titles and abstracts followed by review of the full text of potentially relevant sources. For included studies, data extraction was carried out independently by two authors. Findings were summarised using a combination of descriptive statistics and thematic analysis. Results We screened 5220 titles/abstracts, of which 82 reports describing 67 studies met the inclusion criteria. Most studies were conducted in the USA (90%), attempted to improve access for Black (48%) or Latinx (28%) communities at-risk for diabetic retinopathy (42%) and glaucoma (18%). Only 30% included the target population in the design of the intervention; those that did tended to be larger, collaborative initiatives, which addressed both patient and provider components of access. Forty-eight studies (72%) evaluated whether an intervention changed an outcome measure. Among these, attendance at a follow-up eye examination after screening was the most common (n=20/48, 42%), and directly supporting patients to overcome barriers to attendance was reported as the most effective approach. Building relationships between patients and providers, running coordinated, longitudinal initiatives and supporting reduction of root causes for inequity (education and economic) were key themes highlighted for success. Conclusion Although research evaluating interventions for non-dominant, non-Indigenous ethnic groups exist, key gaps remain. In particular, the paucity of relevant studies outside the USA needs to be addressed, and target communities need to be involved in the design and implementation of interventions more frequently

IMPACT OF MOBILE HEALTH (MHEALTH) IN DIABETIC RETINOPATHY (DR) AWARENESS AND EYE CARE BEHAVIOR AMONG INDIGENOUS WOMEN

Diabetes is increasingly prevalent among Indigenous people and diabetic retinopathy (DR) is an eye complication of diabetes, and a common cause of blindness among adults in Canada. Indigenous women have a high risk of diabetes likewise increasing their risk for DR. The study examined factors that motivate and constrain Indigenous women from adopting healthy eye care behaviors and identified the changes in DR awareness and eye care behavior as a result of a mHealth education intervention among adult Indigenous women with diabetes or at-risk of diabetes (n=78). This was a pre-post-study which adopted an embedded concurrent mixed methods approach guided by self-determination theory and the medicine wheel. Pre-intervention DR awareness and eye care behavior information were collected from participants. Thereafter, participants received daily diabetes-eye related text messages for 12 weeks. Post-intervention, the impact of mHealth promotion on DR awareness and eye care behavior was assessed. Data was collected via sharing circles and surveys and underwent thematic and statistical analysis. Pre-intervention, participants indicated limited understanding of eye care costs/payment, guidelines, and eye complications and resolve to manage diabetes-eye conditions influenced eyecare. Also, fear originating from family history of diabetes, interaction with health care practitioners, and dependence on eye glasses affected their eye care. Participants requested information-resources on complications, prevention, and management of diabetes and DR which were included in the mHealth intervention. Age, diabetes status, and education level were significantly associated with DR knowledge, attitude, and practice scores. Post-intervention, the DR knowledge, attitude, and practice scores significantly improved. The DR attitude and practice post-score for individuals with diabetes increased compared to those at risk of diabetes. Women with higher education levels had higher pre-post-change in knowledge and practice score compared to women with low education levels. Older women had lower pre-post-change in practice score compared to younger women. Participants noted that voice or text messages via various mobile platforms, the telephone number used to send messages, the tone of messages, group activities, and message content were all important when using mHealth for health information. The mHealth intervention created awareness of DR and encouraged change in diabetes-eye care behavior. mHealth has the potential to be used for health education in different populations, and motivate, provide support, and empower individuals to prevent and manage chronic conditions and reduce the risk of complications

Reconstructive surgery:Risk factors, outcomes and advanced indications

The first part of this thesis investigates outcomes in reconstructive flap surgery using big data analysis. Firstly, outcomes after flap reconstructive surgery for diabetic patients compared to non-diabetic ones, highlighting higher risks of complications for diabetic patients, especially those with insulin-dependent diabetes. Additionally, it examines the impact of age and frailty on postoperative outcomes, emphasizing the importance of considering frailty scores instead of age alone in surgical planning for elderly patients. This thesis also delves into the incidence and risk factors of sepsis following reconstructive flap surgery, revealing significant associations with various patient factors. Moreover, racial disparities in outcomes after breast reconstructive surgery are explored, showing no differences in outcomes between different ethnicities. In the second part of this thesis, alternative surgical approaches for managing complications post-rectal/pelvic cancer surgery are discussed. These include the use of gluteal turnover flaps for perineal closure and a dorsal approach with partial sacrectomy followed by gluteal V-Y fasciocutaneous advancement flaps for treating chronic pelvic sepsis. Both techniques show promise in reducing complications and promoting wound healing. The effectiveness of gluteal fasciocutaneous flaps in treating chronic pelvic sepsis is highlighted specifically, offering a feasible and successful alternative for patients with limited options due to previous surgeries or (chemo)radiotherapy. Limitations of the studies, such as their retrospective nature and diverse patient populations, are acknowledged throughout

Reconstructive surgery:Risk factors, outcomes and advanced indications

The first part of this thesis investigates outcomes in reconstructive flap surgery using big data analysis. Firstly, outcomes after flap reconstructive surgery for diabetic patients compared to non-diabetic ones, highlighting higher risks of complications for diabetic patients, especially those with insulin-dependent diabetes. Additionally, it examines the impact of age and frailty on postoperative outcomes, emphasizing the importance of considering frailty scores instead of age alone in surgical planning for elderly patients. This thesis also delves into the incidence and risk factors of sepsis following reconstructive flap surgery, revealing significant associations with various patient factors. Moreover, racial disparities in outcomes after breast reconstructive surgery are explored, showing no differences in outcomes between different ethnicities. In the second part of this thesis, alternative surgical approaches for managing complications post-rectal/pelvic cancer surgery are discussed. These include the use of gluteal turnover flaps for perineal closure and a dorsal approach with partial sacrectomy followed by gluteal V-Y fasciocutaneous advancement flaps for treating chronic pelvic sepsis. Both techniques show promise in reducing complications and promoting wound healing. The effectiveness of gluteal fasciocutaneous flaps in treating chronic pelvic sepsis is highlighted specifically, offering a feasible and successful alternative for patients with limited options due to previous surgeries or (chemo)radiotherapy. Limitations of the studies, such as their retrospective nature and diverse patient populations, are acknowledged throughout

The Lancet Global Health Commission on Global Eye Health: vision beyond 2020

Eye health and vision have widespread and profound implications for many aspects of life, health, sustainable development, and the economy. Yet nowadays, many people, families, and populations continue to suffer the consequences of poor access to high-quality, affordable eye care, leading to vision impairment and blindness. In 2020, an estimated 596 million people had distance vision impairment worldwide, of whom 43 million were blind. Another 510 million people had uncorrected near vision impairment, simply because of not having reading spectacles. A large proportion of those affected (90%), live in low-income and middle-income countries (LMICs). However, encouragingly, more than 90% of people with vision impairment have a preventable or treatable cause with existing highly cost-effective interventions. Eye conditions affect all stages of life, with young children and older people being particularly affected. Crucially, women, rural populations, and ethnic minority groups are more likely to have vision impairment, and this pervasive inequality needs to be addressed. By 2050, population ageing, growth, and urbanisation might lead to an estimated 895 million people with distance vision impairment, of whom 61 million will be blind. Action to prioritise eye health is needed now. This Commission defines eye health as maximised vision, ocular health, and functional ability, thereby contributing to overall health and wellbeing, social inclusion, and quality of life. Eye health is essential to achieve many of the Sustainable Development Goals (SDGs). Poor eye health and impaired vision have a negative effect on quality of life and restrict equitable access to and achievement in education and the workplace. Vision loss has substantial financial implications for affected individuals, families, and communities. Although high-quality data for global economic estimates are scarce, particularly for LMICs, conservative assessments based on the latest prevalence figures for 2020 suggest that annual global productivity loss from vision impairment is approximately US$410·7 billion purchasing power parity. Vision impairment reduces mobility, affects mental wellbeing, exacerbates risk of dementia, increases likelihood of falls and road traffic crashes, increases the need for social care, and ultimately leads to higher mortality rates. By contrast, vision facilitates many daily life activities, enables better educational outcomes, and increases work productivity, reducing inequality. An increasing amount of evidence shows the potential for vision to advance the SDGs, by contributing towards poverty reduction, zero hunger, good health and wellbeing, quality education, gender equality, and decent work. Eye health is a global public priority, transforming lives in both poor and wealthy communities. Therefore, eye health needs to be reframed as a development as well as a health issue and given greater prominence within the global development and health agendas. Vision loss has many causes that require promotional, preventive, treatment, and rehabilitative interventions. Cataract, uncorrected refractive error, glaucoma, age-related macular degeneration, and diabetic retinopathy are responsible for most global vision impairment. Research has identified treatments to reduce or eliminate blindness from all these conditions; the priority is to deliver treatments where they are most needed. Proven eye care interventions, such as cataract surgery and spectacle provision, are among the most cost-effective in all of health care. Greater financial investment is needed so that millions of people living with unnecessary vision impairment and blindness can benefit from these interventions. Lessons from the past three decades give hope that this challenge can be met. Between 1990 and 2020, the age-standardised global prevalence of blindness fell by 28·5%. Since the 1990s, prevalence of major infectious causes of blindness—onchocerciasis and trachoma—have declined substantially. Hope remains that by 2030, the transmission of onchocerciasis will be interrupted, and trachoma will be eliminated as a public health problem in every country worldwide. However, the ageing population has led to a higher crude prevalence of age-related causes of blindness, and thus an increased total number of people with blindness in some regions. Despite this progress, business as usual will not keep pace with the demographic trends of an ageing global population or address the inequities that persist in each country. New threats to eye health are emerging, including the worldwide increase in diabetic retinopathy, high myopia, retinopathy of prematurity, and chronic eye diseases of ageing such as glaucoma and age-related macular degeneration. With the projected increase in such conditions and their associated vision loss over the coming decades, urgent action is needed to develop innovative treatments and deliver services at a greater scale than previously achieved. Good eye health at the community and national level has been marginalised as a luxury available to only wealthy or urban areas. Eye health needs to be urgently brought into the mainstream of national health and development policy, planning, financing, and action. The challenge is to develop and deliver comprehensive eye health services (promotion, prevention, treatment, rehabilitation) that address the full range of eye conditions within the context of universal health coverage. Accessing services should not bring the risk of falling into poverty and services should be of high quality, as envisaged by the WHO framework for health-care quality: effective, safe, people-centred, timely, equitable, integrated, and efficient. To this framework we add the need for services to be environmentally sustainable. Universal health coverage is not universal without eye care. Multiple obstacles need to be overcome to achieve universal coverage for eye health. Important issues include complex barriers to availability and access to quality services, cost, major shortages and maldistribution of well-trained personnel, and lack of suitable, well maintained equipment and consumables. These issues are particularly widespread in LMICs, but also occur in underserved communities in high-income countries. Strong partnerships need to be formed with natural allies working in areas affected by eye health, such as non-communicable diseases, neglected tropical diseases, healthy ageing, children's services, education, disability, and rehabilitation. The eye health sector has traditionally focused on treatment and rehabilitation, and underused health promotion and prevention strategies to lessen the impact of eye disease and reduce inequality. Solving these problems will depend on solutions established from high quality evidence that can guide more effective implementation at scale. Evidence-based approaches will need to address existing deficiencies in the supply and demand. Strategic investments in discovery research, harnessing new findings from diverse fields, and implementation research to guide effective scale up are needed globally. Encouragingly, developments in telemedicine, mobile health, artificial intelligence, and distance learning could potentially enable eye care professionals to deliver higher quality care that is more plentiful, equitable, and cost-effective. This Commission did a Grand Challenges in Global Eye Health prioritisation exercise to highlight key areas for concerted research and action. This exercise has identified a broad set of challenges spanning the fields of epidemiology, health systems, diagnostics, therapeutics, and implementation. The most compelling of these issues, picked from among 3400 suggestions proposed by 336 people from 118 countries, can help to frame the future research agenda for global eye health. In this Commission, we harness lessons learned from over two decades, present the growing evidence for the life-transforming impact of eye care, and provide a thorough understanding of rapid developments in the field. This report was created through a broad consultation involving experts within and outside the eye care sector to help inform governments and other stakeholders about the path forward for eye health beyond 2020, to further the SDGs (including universal health coverage), and work towards a world without avoidable vision loss. The next few years are a crucial time for the global eye health community and its partners in health care, government, and other sectors to consider the successes and challenges encountered in the past two decades, and at the same time to chart a way forward for the upcoming decades. Moving forward requires building on the strong foundation laid by WHO and partners in VISION 2020 with renewed impetus to ultimately deliver high quality universal eye health care for all

A Feasibility Study to Develop an Integrated Diabetic Retinopathy Screening Programme in the Western Province of Sri Lanka

Background: Diabetic retinopathy (DR) is a common microvascular complication of diabetes mellitus which can lead to sight loss, if not detected and treated in time. Objectives: This study aimed to assess the feasibility of integrating DR screening (DRS) services into free public sector health care in Sri Lanka. The objectives were to identify barriers to access DRS, to determine the most appropriate DRS modality and to assess acceptability of a health educational intervention (HEI). Methods: The study was conducted using mixed methods. The barriers were assessed through systematic literature search and qualitative studies. A systematic literature review and meta-analysis was conducted to assess the diagnostic accuracy of DRS using digital retinal imaging. Based on the results of the formative stages, a local context specific DRS modality was defined and validated at a tertiary level medical clinic by trained physician graders. Finally, a HEI was adapted and acceptability was assessed using participatory approach. Results: The formative studies revealed that lack of knowledge and awareness on DR, lack of skilled human resources and DRS imaging infrastructure as the main barriers. In the meta-analysis, highest sensitivity was observed in mydriatic more than two field strategy (92%, 95% CI 90-94%). In the validation study, sensitivity of the defined referable DR was 88.7% for grader 1 and 92.5% for grader 2, using mydriatic imaging. The specificity was 94.9% for grader 1 and 96.4% for grader 2. The overall acceptability of the HEI material was satisfactory. Conclusions: Knowing the barriers to access DRS is a pre-requisite in development of a DRS program. Non-mydriatic 2-field strategy is a more pragmatic approach in implementing DRS programs in low income non-ophthalmic settings, with dilatation of pupils of those who have ungradable images. The process of adapting HEI was not simply translation into local language, instead a tailored approach for the local context

ACCF/AHA 2011 Expert Consensus Document on Hypertension in the Elderly: A Report of the American College of Cardiology Foundation Task Force on Clinical Expert Consensus Documents

This document was written with the intent to be a complete reference at the time of publication on the topic of managing hypertension in the elderly. This document has been developed as an expert consensus document by the American College of Cardiology Foundation (ACCF) and the American Heart Association (AHA), in collaboration with the American Academy of Neurology (AAN), the American College of Physicians (ACP), the American Geriatrics Society (AGS), the American Society of Hypertension (ASH), the American Society of Nephrology (ASN), the American Society for Preventive Cardiology (ASPC), the Association of Black Cardiologists (ABC), and the European Society of Hypertension (ESH). Expert consensus documents are intended to inform practitioners, payers, and other interested parties of the opinion of ACCF and document cosponsors concerning evolving areas of clinical practice and/or technologies that are widely available or new to the practice community

The postpartum visit: an overlooked opportunity for prevention

Women's postpartum health needs affect the woman, her ability to care for her infant, and the health of babies she may have in the future. The postpartum visit provides an opportunity to help women transition from pregnancy to well-woman care, playing an important role in continuity of health services. This dissertation included a comprehensive literature review of the postpartum visit. Using the data from key informant interviews, surveys, and a chart review, this study examined factors that impact the postpartum visit provided by the University of North Carolina's Obstetric Program, including: a) the health care system; b) provider attitudes and practice; c) the content of care; and d) the woman's medical needs and access to care. The study found that certain populations of patients are less likely to receive a postpartum visit and when they do receive a visit they receive fewer services than other mothers. The content of the visit is variable and not as complete as it could be. Postpartum screening for conditions such as gestational diabetes and hypertension warrants further attention. Communication among providers across the system is incomplete. Low-income mothers are likely to leave their postpartum visit without a plan in place for follow up services. The research determined that there are things that could be done within the UNC Obstetric Clinic to improve the postpartum visit and the care new mothers receive. Eight recommendations for improvements were generated from this study, including: 1) developing a comprehensive interconception care initiative; 2) building a University-wide research consortium; 3) marketing the postpartum visit to mothers; 4) improving postpartum visit compliance by strengthening the continuity of care given by providers; 5) improving the information available about mothers at the postpartum visit by adopting an electronic prenatal medical record; 6) enhancing the quality of the postpartum visit by implementing improvement initiatives; 7) expanding the information mothers receive at the postpartum visit by increasing the number of educational materials they receive; and 8) linking low-income mothers back to local health departments and clinics after their postpartum visit. The postpartum visit is key in the journey toward improved interconception care for mothers