Reducing No-Shows and Late Cancellations in Primary Care

No-shows and late cancellations are a challenge across medical practices, resulting in costly, fragmented care. Many patients do not understand the impact that not showing or cancelling an appointment less than 48 hours prior to a visit can have. While reminding the patient of the appointment has been a known tactic to improve patient’s attendance, the most effective mode of the reminder can vary significantly across patient populations. Just as critical as reminding the patient of the appointment is to ensure they understand the purpose of the visit along with showing respect for their time and any competing priorities. This quality improvement initiative aimed to reduce the no-show rate of 21.4% and late cancellation rate of 21.1% for the MassHealth population by 5%. Learning from previous studies, a hybrid approach to meet this population’s needs included a 7-day reminder call with a Patient Engagement Coordinator (PEC) and a 2-day automated reminder. During the 7-day reminder call the PEC identified barriers to attending the appointment through concrete planning and motivational interviewing strategies. Appointments were rescheduled as needed, additional information was provided to solidify shared goals for the visit, and patient’s time/obligations were validated. The intervention resulted in positive feedback from the majority of patients and revealed concrete planning prompts to be a very effective communication form. The post-intervention data analysis revealed both the no-show and late cancellation results were reduced for the MassHealth population. Due to data and confounding variable limitations this study is recommended to be a basis for future investigation as the principal investigators enter into the next pilot phase of this model

Culvert Length and Interior Lighting Impacts to Topeka Shiner Passage

Culverts can act as barriers to fish passage for a number of reasons including insufficient water depth or excess velocity. In addition, concern is being raised over behavioral barriers where culvert conditions elicit an avoidance response that deters or slows fish movement. Long culverts can block sunlight creating a potential behavioral barrier as fish approach a long, dark culvert. Scant information exists on low light as a potential barrier to fish passage, particularly with warm water species, such as the federally endangered Topeka Shiner. As some older culverts are being replaced with longer total lengths to improve safety by extending the culvert through reengineered road embankments, information is needed to 1) determine when and if light mitigation strategies are necessary, and 2) to design appropriate light mitigation strategies if necessary. Based on literature review, field monitoring, and laboratory experiments, the effect of light on fish passage for Topeka Shiner and other small prairie stream fish was indiscernible. Therefore, no light mitigation for large box culverts (up to 150 feet in length) can be recommended for similar fish communities. Culverts that are very long or have very small openings may benefit from additional light

Exposure to Polyfluoroalkyl Chemicals and Cholesterol, Body Weight, and Insulin Resistance in the General U.S. Population

BACKGROUND. Polyfluoroalkyl chemicals (PFCs) are used commonly in commercial applications and are detected in humans and the environment worldwide. Concern has been raised that they may disrupt lipid and weight regulation. OBJECTIVES. We investigated the relationship between PFC serum concentrations and lipid and weight outcomes in a large publicly available data set. METHODS. We analyzed data from the 2003-2004 National Health and Nutrition Examination Survey (NHANES) for participants 12-80 years of age. Using linear regression to control for covariates, we studied the association between serum concentrations of perfluorooctanoic acid (PFOA), perfluorononanoic acid (PFNA), perfluorooctane sulfonic acid (PFOS), and perfluorohexane sulfonic acid (PFHxS) and measures of cholesterol, body size, and insulin resistance. RESULTS. We observed a positive association between concentrations of PFOS, PFOA, and PFNA and total and non-high-density cholesterol. We found the opposite for PFHxS. Those in the highest quartile of PFOS exposure had total cholesterol levels 13.4 mg/dL [95% confidence interval (CI), 3.8-23.0] higher than those in the lowest quartile. For PFOA, PFNA, and PFHxS, effect estimates were 9.8 (95% CI, -0.2 to 19.7), 13.9 (95% CI, 1.9-25.9), and -7.0 (95% CI, -13.2 to -0.8), respectively. A similar pattern emerged when exposures were modeled continuously. We saw little evidence of a consistent association with body size or insulin resistance. CONCLUSIONS. This exploratory cross-sectional study is consistent with other epidemiologic studies in finding a positive association between PFOS and PFOA and cholesterol, despite much lower exposures in NHANES. Results for PFNA and PFHxS are novel, emphasizing the need to study PFCs other than PFOS and PFOA.National Institute of Environmental Health Sciences (R21ES013724, T32ES014562

A recommended “minimum data set” framework for SD-OCT retinal image acquisition and analysis from the Atlas of Retinal Imaging in Alzheimer’s Study (ARIAS)

Introduction: We propose a minimum data set framework for the acquisition and analysis of retinal images for the development of retinal Alzheimer\u27s disease (AD) biomarkers. Our goal is to describe methodology that will increase concordance across laboratories, so that the broader research community is able to cross‐validate findings in parallel, accumulate large databases with normative data across the cognitive aging spectrum, and progress the application of this technology from the discovery stage to the validation stage in the search for sensitive and specific retinal biomarkers in AD. Methods: The proposed minimum data set framework is based on the Atlas of Retinal Imaging Study (ARIAS), an ongoing, longitudinal, multi‐site observational cohort study. However, the ARIAS protocol has been edited and refined with the expertise of all co‐authors, representing 16 institutions, and research groups from three countries, as a first step to address a pressing need identified by experts in neuroscience, neurology, optometry, and ophthalmology at the Retinal Imaging in Alzheimer\u27s Disease (RIAD) conference, convened by the Alzheimer\u27s Association and held in Washington, DC, in May 2019. Results: Our framework delineates specific imaging protocols and methods of analysis for imaging structural changes in retinal neuronal layers, with optional add‐on procedures of fundus autofluorescence to examine beta‐amyloid accumulation and optical coherence tomography angiography to examine AD‐related changes in the retinal vasculature. Discussion: This minimum data set represents a first step toward the standardization of retinal imaging data acquisition and analysis in cognitive aging and AD. A standardized approach is essential to move from discovery to validation, and to examine which retinal AD biomarkers may be more sensitive and specific for the different stages of the disease severity spectrum. This approach has worked for other biomarkers in the AD field, such as magnetic resonance imaging; amyloid positron emission tomography; and, more recently, blood proteomics. Potential context of use for retinal AD biomarkers is discussed

Association of urinary phthalate metabolite concentrations with body mass index and waist circumference: a cross-sectional study of NHANES data, 1999–2002

BACKGROUND: Although diet and activity are key factors in the obesity epidemic, laboratory studies suggest that endocrine disrupting chemicals may also affect obesity. METHODS: We analyzed associations between six phthalate metabolites measured in urine and body mass index (BMI) and waist circumference (WC) in National Health and Nutrition Examination Survey (NHANES) participants aged 6–80. We included 4369 participants from NHANES 1999–2002, with data on mono-ethyl (MEP), mono-2-ethylhexyl (MEHP), mono-n-butyl (MBP), and mono-benzyl (MBzP) phthalate; 2286 also had data on mono-2-ethyl-5-hydroxyhexyl (MEHHP) and mono-2-ethyl-5-oxohexyl (MEOHP) phthalate (2001–2002). Using multiple regression, we computed mean BMI and WC within phthalate quartiles in eight age/gender specific models. RESULTS: The most consistent associations were in males aged 20–59; BMI and WC increased across quartiles of MBzP (adjusted mean BMI = 26.7, 27.2, 28.4, 29.0, p-trend = 0.0002), and positive associations were also found for MEOHP, MEHHP, MEP, and MBP. In females, BMI and WC increased with MEP quartile in adolescent girls (adjusted mean BMI = 22.9, 23.8, 24.1, 24.7, p-trend = 0.03), and a similar but less strong pattern was seen in 20–59 year olds. In contrast, MEHP was inversely related to BMI in adolescent girls (adjusted mean BMI = 25.4, 23.8, 23.4, 22.9, p-trend = 0.02) and females aged 20–59 (adjusted mean BMI = 29.9, 29.9, 27.9, 27.6, p-trend = 0.02). There were no important associations among children, but several inverse associations among 60–80 year olds. CONCLUSION: This exploratory, cross-sectional analysis revealed a number of interesting associations with different phthalate metabolites and obesity outcomes, including notable differences by gender and age subgroups. Effects of endocrine disruptors, such as phthalates, may depend upon endogenous hormone levels, which vary dramatically by age and gender. Individual phthalates also have different biologic and hormonal effects. Although our study has limitations, both of these factors could explain some of the variation in the observed associations. These preliminary data support the need for prospective studies in populations at risk for obesity.National Institutes of Environmental Health Sciences (R21ES013724

Social disparities in exposures to bisphenol A and polyfluoroalkyl chemicals: a cross-sectional study within NHANES 2003-2006

<p>Abstract</p> <p>Background</p> <p>Bisphenol A (BPA) and polyfluoroalkyl chemicals (PFCs) are suspected endocrine disrupting compounds known to be ubiquitous in people's bodies. Population disparities in exposure to these chemicals have not been fully characterized.</p> <p>Methods</p> <p>We analyzed data from the 2003-2006 National Health and Nutrition Examination Survey. Using multivariable linear regression we examined the association between urinary concentrations of BPA, serum concentrations of four PFCs, and multiple measures of socioeconomic position (SEP): family income, education, occupation, and food security. We also examined associations with race/ethnicity.</p> <p>Results</p> <p>All four PFCs were positively associated with family income, whereas BPA was inversely associated with family income. BPA concentrations were higher in people who reported very low food security and received emergency food assistance than in those who did not. This association was particularly strong in children: 6-11 year-olds whose families received emergency food had BPA levels 54% higher (95% CI, 13 to 112%) than children of families who did not. For BPA and PFCs we saw smaller and less consistent associations with education and occupation. Mexican Americans had the lowest concentrations of any racial/ethnic group of both types of chemicals; for PFCs, Mexican Americans not born in the U.S. had much lower levels than those born in the U.S.</p> <p>Conclusions</p> <p>People with lower incomes had higher body burdens of BPA; the reverse was true for PFCs. Family income with adjustment for family size was the strongest predictor of chemical concentrations among the different measures of SEP we studied. Income, education, occupation, and food security appear to capture different aspects of SEP that may be related to exposure to BPA and PFCs and are not necessarily interchangeable as measures of SEP in environmental epidemiology studies. Differences by race/ethnicity were independent of SEP.</p