Identifying priority and bright spot areas for improving diabetes care: a geospatial approach.

The objective of this study was to describe a novel geospatial methodology for identifying poor-performing (priority) and well-performing (bright spot) communities with respect to diabetes management at the ZIP Code Tabulation Area (ZCTA) level. This research was the first phase of a mixed-methods approach known as the focused rapid assessment process (fRAP). Using data from the Lehigh Valley Health Network in eastern Pennsylvania, geographical information systems mapping and spatial analyses were performed to identify diabetes prevalence and A1c control spatial clusters and outliers. We used a spatial empirical Bayes approach to adjust diabetes-related measures, mapped outliers and used the Local Moran\u27s I to identify spatial clusters and outliers. Patients with diabetes were identified from the Lehigh Valley Practice and Community-Based Research Network (LVPBRN), which comprised primary care practices that included a hospital-owned practice, a regional practice association, independent small groups, clinics, solo practitioners and federally qualified health centres. Using this novel approach, we identified five priority ZCTAs and three bright spot ZCTAs in LVPBRN. Three of the priority ZCTAs were located in the urban core of Lehigh Valley and have large Hispanic populations. The other two bright spot ZCTAs have fewer patients and were located in rural areas. As the first phase of fRAP, this method of identifying high-performing and low-performing areas offers potential to mitigate health disparities related to diabetes through targeted exploration of local factors contributing to diabetes management. This novel approach to identification of populations with diabetes performing well or poor at the local community level may allow practitioners to target focused qualitative assessments where the most can be learnt to improve diabetic management of the community

Identifying Priority and “Bright-Spot” Counties for Diabetes Preventive Care in Appalachia: An Exploratory Analysis

Introduction: Type 2 diabetes mellitus (T2DM) prevalence and mortality in Appalachian counties is substantially higher when compared to non-Appalachian counties, although there is significant variation within Appalachia. Purpose: The objectives of this research were to identify low-performing (priority) and high-performing (bright spot) counties with respect to improving T2DM preventive care. Methods: Using data from the Centers for Medicare and Medicaid (CMS), the Dartmouth Atlas of Health Care, and the Appalachia Regional Commission, conditional maps were created using county-level estimates for T2DM prevalence, mortality, and annual hemoglobin A1c (HbA1c) testing rates. Priority counties were identified using the following criteria: top 33rd percentile for T2DM mortality; top 33rd percentile for T2DM prevalence; bottom 50th percentile for A1c testing rates. Bright spot counties were identified as counties in the bottom 33rd percentile for T2DM mortality, the top 33rd percentile for T2DM prevalence; and the top 50th percentile for HbA1c testing rates. Results: Forty-one priority counties were identified (those with high T2DM mortality, high T2DM prevalence, and low HbA1c testing rates), which were located primarily in Central and North Central Appalachia; and 17 bright spot counties were identified (high T2DM prevalence, low T2DM mortality, and high HbA1c testing rates), which were scattered throughout Appalachia. Eight of the 17 bright spot counties were adjacent to priority counties. Implications: By employing conditional mapping to T2DM, multiple variables can be summarized into a single, easily interpretable map. This could be valuable for T2DM-prevention programs seeking to prioritize diagnostic and intervention resources for the management of T2DM in Appalachia

Cost-effectiveness of In-Home Cognitive Behavioral Therapy for low-income depressed mothers participating in early childhood prevention programs

To determine the cost-effectiveness of In-Home Cognitive Behavioral Therapy (IH-CBT) for low-income mothers enrolled in a home visiting program

31st Annual Meeting and Associated Programs of the Society for Immunotherapy of Cancer (SITC 2016) : part two

Background The immunological escape of tumors represents one of the main ob- stacles to the treatment of malignancies. The blockade of PD-1 or CTLA-4 receptors represented a milestone in the history of immunotherapy. However, immune checkpoint inhibitors seem to be effective in specific cohorts of patients. It has been proposed that their efficacy relies on the presence of an immunological response. Thus, we hypothesized that disruption of the PD-L1/PD-1 axis would synergize with our oncolytic vaccine platform PeptiCRAd. Methods We used murine B16OVA in vivo tumor models and flow cytometry analysis to investigate the immunological background. Results First, we found that high-burden B16OVA tumors were refractory to combination immunotherapy. However, with a more aggressive schedule, tumors with a lower burden were more susceptible to the combination of PeptiCRAd and PD-L1 blockade. The therapy signifi- cantly increased the median survival of mice (Fig. 7). Interestingly, the reduced growth of contralaterally injected B16F10 cells sug- gested the presence of a long lasting immunological memory also against non-targeted antigens. Concerning the functional state of tumor infiltrating lymphocytes (TILs), we found that all the immune therapies would enhance the percentage of activated (PD-1pos TIM- 3neg) T lymphocytes and reduce the amount of exhausted (PD-1pos TIM-3pos) cells compared to placebo. As expected, we found that PeptiCRAd monotherapy could increase the number of antigen spe- cific CD8+ T cells compared to other treatments. However, only the combination with PD-L1 blockade could significantly increase the ra- tio between activated and exhausted pentamer positive cells (p= 0.0058), suggesting that by disrupting the PD-1/PD-L1 axis we could decrease the amount of dysfunctional antigen specific T cells. We ob- served that the anatomical location deeply influenced the state of CD4+ and CD8+ T lymphocytes. In fact, TIM-3 expression was in- creased by 2 fold on TILs compared to splenic and lymphoid T cells. In the CD8+ compartment, the expression of PD-1 on the surface seemed to be restricted to the tumor micro-environment, while CD4 + T cells had a high expression of PD-1 also in lymphoid organs. Interestingly, we found that the levels of PD-1 were significantly higher on CD8+ T cells than on CD4+ T cells into the tumor micro- environment (p < 0.0001). Conclusions In conclusion, we demonstrated that the efficacy of immune check- point inhibitors might be strongly enhanced by their combination with cancer vaccines. PeptiCRAd was able to increase the number of antigen-specific T cells and PD-L1 blockade prevented their exhaus- tion, resulting in long-lasting immunological memory and increased median survival

Health Economic Analysis of Two-Layer Bandage System for Treatment of Chronic Venous Insufficiency

**Background:** Compression therapy is the gold standard for the treatment of chronic venous insufficiency (CVI). Two-layer bandage (2LB) systems have been shown to be a safe and effective treatment option. **Objective:** To estimate the total cost per response (CPR) for the resolution of edema and wounds in patients with CVI treated with a 2LB system as part of their overall wound healing regimen. **Methods:** A probabilistic decision tree model was developed to estimate the incremental CPR for a 2LB system. The model simulated 10 000 patients to estimate the CPR for the resolution of edema and wound healing. The analysis was performed using clinical data from a published single-arm, multicenter prospective study of CVI indicated for compression therapy. The response outcomes of interest were resolution of edema and rate of wound healing. The follow-up time was a maximum of 6 weeks, and the perspective of the study was a US outpatient treatment center. Economic data for compression therapy were based on the public prices of a 2LB system. Dressing changes occurred per manufacturer instructions for use. **Results:** The study comprised 702 patients (56% female), with a total of 414 wounds. The median duration of the wounds was 42 days, and the median size at the initial visit was 3.5 cm2. The average pain reduction fell by 67% using a visual analog score. Bandages were typically changed once or twice a week (51.7%). Wound healing occurred in 128 of the 414 wounds (30.9%). The expected incremental CPR of a 2LB system for the resolution of edema was $65.67 (range,$16.67-$124.32). The expected incremental CPR of a 2LB system for the healing of a wound was$138.71 (range, $35.71-$273.53). **Conclusion:** This economic evaluation complements previous clinical effectiveness and safety studies of 2LB systems for the treatment of CVI. The results demonstrate that the costs of incorporating 2LB into standard wound-healing protocols are negligible compared with overall treatment costs. Two-layer bandages may be considered a cost-effective first-line system for the treatment of wounds caused by CVI

Identifying diabetes management opportunity areas in the USA

Using adherence to diabetes management guidelines as a case study, this paper applied a novel geospatial hot- spot and cold- spot methodology to identify priority counties to target interventions. Data for this study were obtained from the Dartmouth Atlas of Healthcare, the United States Census Bureau’s American Community Survey and the University of Wisconsin County Health Rankings. A geospatial approach was used to identify four tiers of priority counties for diabetes preventive and management services: diabetes management cold- spots, clusters of counties with low rates of adherence to diabetes preventive and management services (Tier D); Medicare spending hot- spots, clusters of counties with high rates of spending and were diabetes management cold- spots (Tier C); preventable hospitalisation hot- spots, clusters of counties with high rates of spending and are diabetes management cold- spots (Tier B); and counties that were located in a diabetes management cold- spot cluster, preventable hospitalisation hot- spot cluster and Medicare spending hot- spot cluster (Tier A). The four tiers of priority counties were geographically concentrated in Texas and Oklahoma, the Southeast and central Appalachia. Of these tiers, there were 62 Tier A counties. Rates of preventable hospitalisations and Medicare spending were higher in Tier A counties compared with national averages. These same counties had much lower rates of adherence to diabetes preventive and management services. The novel geospatial mapping approach used in this study may allow practitioners and policy makers to target interventions in areas that have the highest need. Further refinement of this approach is necessary before making policy recommendations