A Quantitative and Qualitative Study on Patient and Physician Perceptions of Nephrology Telephone Consultation During COVID-19

Background: COVID-19 required rapid adoption of virtual modalities to provide care for patients with a chronic disease. Care was initially provided by telephone, which has not been evaluated for its effectiveness by patients and providers. This study reports patients’ and nephrologists’ perceptions and preferences surrounding telephone consultation in a chronic kidney disease (CKD) clinic. Objective: To evaluate patient and physician perspectives on the key advantages and disadvantages of telephone consultations in a nephrology out-patient clinic setting. Design: Cross-sectional observational survey study. Setting: General nephrology clinic and a multidisciplinary kidney care clinic in London, Ontario, Canada. Participants: Patients with CKD who were fluent in English and participated in at least one telephone consultation with a nephrologist during the COVID-19 pandemic. Methods and measurements: Nephrologists’ and participants’ input facilitated the development of both patient and nephrologist surveys. Participants provided self-reported measures in 5 domains of satisfaction: user experience, technical quality, perceived effectiveness on well-being, perceived usefulness, and effect on interaction. Nephrologists provided self-reported measures within 6 categories: general experience, time management, medication changes, quality of care, job satisfaction, and challenges/strengths. Descriptive statistics were used to present data. Content analysis was performed on 2 open-ended responses. Results: Of the 372 participants recruited, 235 participated in the survey (63% response). In all, 79% of the participants were ≥65 years old and 91% were white. Telephone consultation was a comfortable experience for 68%, and 73% felt it to be a safer alternative during the pandemic. Although 65% perceived no changes to health care access, most reported spending less time and fewer resources on transit and parking. Disadvantages to telephone consultation included a lack of physical examination and reduced patient-physician rapport. Eleven of 14 nephrologists were surveyed, with most reporting confidence in the use of telephone consultation. Physician barriers to telephone consultation included challenges with communications and lack of technology to support telephone clinics. Limitations: Our survey included a majority of older, white participants, which may not be generalizable to other participants particularly those of other ages and ethnicity. Conclusion: Although both patients and nephrologists adapted to telephone consultations, there remain opportunities to further explore populations and situations that would be better facilitated with an in-person visit. Future research in virtual care will require measurement of health care outcomes and economics. Trial registration: Not applicable as this was a survey.

Impact of COVID-19 Pandemic on (Health) Care Situation of People with Parkinson’s Disease in Germany (Care4PD)

The Care4PD study examined the impact of the COVID-19 pandemic on the care situation of people (PwP) with Parkinson’s disease in Germany. A comprehensive, nationwide, anonymous questionnaire for PwP was distributed by the members’ journal of the German Parkinson’s Disease Association and in several PD specialized in- and outpatient institutions. PwP subjectively evaluated their general care situation and individual impairments during the pandemic. We analyzed 1269 eligible out of 1437 returned questionnaires (88.3%) and compared PwP with (p-LTC) and without (np-LTC) professional long-term care. Both groups rated the general pandemic-related consequences as being rather mild to moderate (e.g., worsening of symptom or concerns). However, familial/social contact restrictions were indicated as most compromising, whereas access to outpatient professional health care providers was less affected. PwP with professional LTC reported more impairment than those without. COVID-19 vaccination rates and acceptance were generally high (p-LTC: 64.3%, np-LTC: 52.3%) at the time of the study, but realization of sanitary measures—especially wearing masks as a patient during care sessions—still needs to be improved. Technical options for telemedicine were principally available but only rarely used. Altogether, during the COVID-19 pandemic, PwP in Germany seemed to have a relatively stable health care access, at least in outpatient settings, while mainly social isolation compromised them. The p-LTC group was more impaired in everyday live compared with the np-LTC group.

Community Health Assessment findings on Diabetes among Adults in Nyeri County, Kenya, 2019

Background: The global prevalence of diabetes among adults was 8.5% in 2014. Kenya’s prevalence is at 3.3%, according to WHO. Nyeri County has an estimated prevalence of 7.2% which is significantly higher than the national prevalence. Methods: A cross- sectional study was conducted in Mukurweini Sub County, Nyeri. Systematic random sampling was used to recruit participants from a sampling frame of all adult community members. A sample of 190 households calculated at a confidence level of 95 and a 5% error margin. Every 7th household was picked and respondents were household heads. Data was collected using structured questionnaires, Key informant interviews and Focus group discussions. Knowledge levels, health seeking behavior, health care access, physical activity and nutrition were assessed. Data was analyzed and rated using the CDC CHANGE tool. Findings: Low education levels with 65% at primary and below hence low levels of knowledge on diabetes, poor uptake of physical activity as 51% never engaged in any and inappropriate dietary choices and meal timing. Low screening levels for diabetes with only 36% having ever been screened. There were no clear policies on community engagement in physical activity. Easy access to health facilities, friendly health care workers and availability of health services and medication were identified as the assets. Conclusion: Assessing the community’s knowledge, attitudes, behavior and resources provides information on how to improve diabetes prevention and treatment. It helps to inform future interventions

On challenges to respect for autonomous decision making in primary care

Primary health care is characterised by timely and appropriate health care access, delivered continuously over time to a specific population, providing a comprehensive service, with coordination of care for those that need it. Practitioners deal with a multiplicity of clinical issues within longitudinal relationships, embedded in the context of families and communities. We propose that these aspects of primary care have a bearing on how matters of decision making are considered and implemented. Further, the standard account of autonomous decision making is not wholly adequate when applied to clinician–patient encounters in primary care. We add considerations of the impact of illness (however defined) and self-identity as also relevant to a more measured and full account. The context of primary care is quite different from that of secondary care. Although there are generalists who work in hospitals, we argue that this aspect and the other attributes of primary care generate special ethical considerations. One of these is how autonomy, or more fully, how respect for the principle of autonomy is considered and operationalised in community practice. In this study, we describe some theoretical aspects of autonomy and seek to apply, and challenge, these aspects in the context of clinical work in primary care. In doing so we will review the descriptors of primary care: why in essence it is different from other contexts of clinical work.

Women Empowerment in Punjab: Dimensions, Determinants, and Implications for Access to Healthcare

In developing countries like Pakistan, because of the complex cultural and socio-demographic milieu women empowerment always remained the contested issue. Overall major indicators of human development of women have been considered lower rather than men. In Pakistan, some considerable measures have focused on women's empowerment however, their status is still miserable specifically in rural areas. This study was aimed to find out, the extent of rural women empowerment and the effect of women empowerment regarding access to healthcare in the Vehari district of Southern Punjab, Pakistan. The study used data of 240 married women respondents and employed Cronbach’s alpha and OLS approaches for various analyses of the study components. Scores of various components regarding women's empowerment were regressed over the scores of women's access to healthcare in the final analysis of the study. The finding of the study indicated that the power of decision-making (0.87), self-esteem (0.79), and mobility (0.89) has positive and significant effects on access to health care whereas control over the resource (0.73) estimates indicated positive while the insignificant impact on health access. Education access, adequate job opportunities, and media information approach considered more appropriate and feasible measures for adequate women empowerment and health care access. Emergency-based State-based policy measures need to be applied such as women schooling at doorstep, increasing females' priority-based job opportunities, and proper access to media for increasing awareness regarding their rights and significant role in society.

Effects of the 2014 Affordable Care Act Medicaid Expansions on Health Care Access and Health Status of Poor Adults Aged 60-64 Years: Evidence from the First Six Years

Background and Objectives Little is known on effects of the Affordable Care Act (ACA) Medicaid expansions on health care access and health status of adults closest to 65. This study examines the effects of ACA Medicaid expansion on access and health status of poor adults aged 60-64 years. Research Design and Methods The study employs a difference-in-differences design comparing states that expanded Medicaid in 2014 under the ACA and non-expansion states over six years post expansion. The data are from the 2011-2019 Behavioral Risk Factor Surveillance System for individuals aged 60–64 years below the Federal Poverty Level. Results Having any health care coverage rate increased by 8.5 percentage-points (p<0.01), while the rate of forgoing a needed doctor’s visit due to cost declined by 6.6 percentage points (p<0.01). Similarly, rates of having a personal doctor/provider and completing a routine checkup increased by 9.1 (p<0.01) and 4.8 (p<0.1) percentage-points, respectively. Moreover, days not in good physical health in the past 30 declined by 1.5 days (p<0.05), with suggestive evidence for decline in days not in good mental health and improvement in self-rated health. Discussion and Implications The ACA Medicaid expansions have improved health care access and health status of poor adults aged 60-64 years. Expanding Medicaid in the states that have not yet done so would reduce barriers to care and address unmet health needs for this population. Bridging coverage for individuals 60-64 years old by lowering Medicare eligibility age could have long-term effects on wellbeing and health services utilization.

Forced migration and reproductive rights: Pregnant women fleeing Venezuela

Numerous pregnant Venezuelan women have fled Venezuela, given the health system crisis that has increased risk to their lives and their children. Thousands of them have arrived in Colombia in search of reproductive health care. Notwithstanding Colombia’s government efforts to provide some relief measures to the massive influx of Venezuelan migrants, pregnant women are not receiving the prenatal and postnatal care they need. One of the primary barriers to health care access is their immigration status and the health system structure regarding migrants. Therefore, this paper studies Colombia’s international human rights obligations concerning their immigration status and the right to reproductive health to conclude that government measures have been insufficient to meet these obligations.

Geographic, Health Care Access, Racial Discrimination, and Socioeconomic Determinants of Maternal Mortality in Georgia, United States

Over the past decade, the United States has been taking steps to reduce its rising maternal mortality rate. However, these steps have yet to produce positive results in the state of Georgia, which tops the list of all 50 states with the highest maternal mortality rate of 46.2 maternal deaths per 100,000 live births for all women, and a maternal mortality rate of 66.6 deaths per 100,000 live births for African American women. In Georgia, several social determinants of health such as the physical environment, economic stability, health care access, and the quality of maternal care contribute to the high maternal mortality rate. Addressing these determinants will help to reduce the state’s maternal mortality rate. This commentary discusses the relationship between social determinants of health and maternal mortality rates in Georgia. It also proposes strategies for reversing the trend.We conducted an ecological study of the relationship between social determinants of health and maternal mortality in Georgia. We searched PubMed and Google Scholar and reviewed 80 English articles published between 2005 and 2021. We identified five key social determinants associated with high maternal mortality rates in Georgia - geographic location of obstetric services, access to health care providers, socioeconomic status, racism, and discrimination. We found that expanding Medicaid coverage, reducing maternal health care disparities among the races, providing access to maternal care for women in rural areas, and training a culturally competent health workforce, will help to reduce Georgia’s high maternal mortality rate. Copyright © 2021 Armstrong-Mensah et al. Published by Global Health and Education Projects, Inc. This is an open-access article distributed under the terms of the Creative Commons Attribution License CC BY 4.0.

Artificial Intelligence Support for Skin Lesion Triage in Primary Care and Dermatology (Preprint)

BACKGROUND Primary care providers, dermatology specialists, and health care access are key components of primary prevention, early diagnosis, and treatment of skin cancer. Artificial intelligence (AI) offers the promise of diagnostic support for nonspecialists, but real-world clinical validation of AI in primary care is lacking. OBJECTIVE We aimed to (1) assess the reliability of an AI-based clinical triage algorithm in classifying benign and malignant skin lesions and (2) evaluate the quality of images obtained in primary care using the study camera (3Gen DermLite Cam v4 or similar). METHODS This was a single-center, prospective, double-blinded observational study with a predetermined study design. We recruited participants with suspected skin cancer in 20 primary care practices who were referred for assessment via teledermatology. A second set of photographs taken using a standardized camera was processed by the AI algorithm. We evaluated the image quality and compared two teledermatologists’ diagnoses by consensus (the “gold standard”) with AI and histology where applicable. RESULTS Our primary outcome assessment stratified 391 skin lesions by management as benign, uncertain, or malignant. Uncertain lesions were not included in the sensitivity and specificity analyses. Uncertain lesions included lesions that had either diagnostic or management uncertainties. For the remaining 242 lesions, the sensitivity was 97.26% (95% CI 93.13%-99.25%) and the specificity was 97.92% (95% CI 92.68%-99.75%). The AI algorithm was compared with the histological diagnoses for 123 lesions. The sensitivity was 100% (95% CI 95.85%-100%) and the specificity was 72.22% (95% CI 54.81%-85.80%). CONCLUSIONS The AI algorithm demonstrates encouraging results, with high sensitivity and specificity, concordant with previous AI studies. It shows potential as a triage tool in conjunction with teledermatology to augment health care and improve access to dermatology. Further real-life studies need to be conducted on a larger scale to assess the reliability, usability, and cost-effectiveness of the algorithm in primary care.