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Personalization and localization as key expectations of digital health intervention in women pre- to post-pregnancy | npj Digital Medicine

Health behaviors before, during and after pregnancy can have lasting effects on maternal and infant health outcomes. Although digital health interventions (DHIs) have potential as a pertinent avenue to deliver mechanisms for a healthy behavior change, its success is reliant on addressing the user...
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Are older adults considered in asthma and chronic obstructive pulmonary disease mobile health research? A scoping review

Are older adults considered in asthma and chronic obstructive pulmonary disease mobile health research? A scoping review | Digitized Health | Scoop.it
We identified an overall lack of consideration for older age throughout the airways mHealth research cycle, even among COPD mHealth studies that predominantly included older adults.We also found a contrast between the perceptions of how older age might negatively influence mHealth use and available...
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dkNET | NIDDK's Data-Centric Challenge: Advancing AI-Ready Datasets for Diabetes Research

dkNET | NIDDK's Data-Centric Challenge: Advancing AI-Ready Datasets for Diabetes Research | Digitized Health | Scoop.it
NIDDK Central Repository announced NIDDK's Data-Centric Challenge - Enhancing NIDDK datasets for future Artificial Intelligence (AI) applications!Apply now to...
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Rapid Health Technology Assessment of Continuous Glucose Monitoring in Adults with Type 1 Diabetes Mellitus | HIQA

Search Filters Rapid Health Technology Assessment of Continuous Glucose Monitoring in Adults with Type 1 Diabetes Mellitus Status: Published on 29 Sep 2023 Download Document View Press Release Following a request from the office of the Chief Clinical Officer at the Health Service Executive (HSE), the Health Information and Quality Authority (HIQA) agreed to undertake a HTA of continuous glucose monitoring (CGM) focused exclusively on adults with type 1 diabetes mellitus (T1DM). The aim of this rapid HTA was to provide advice on the clinical-effectiveness, cost effectiveness, and budget impact of providing CGM for adults with T1DM. Background Methodology Advice to the Health Service Executive
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Partnership to provide AI-generated patient summaries in real time

Partnership to provide AI-generated patient summaries in real time | Digitized Health | Scoop.it
The collaboration brings together Orion Health's Orchestral Health Intelligence Platform and Pieces' AI technology to provide an AI solution that delivers comprehensive, locally derived data to clinicians and caregivers.
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Prebiotics Progress Shifts in the Intestinal Microbiome That Benefits Patients with Type 2 Diabetes Mellitus

Prebiotics Progress Shifts in the Intestinal Microbiome That Benefits Patients with Type 2 Diabetes Mellitus | Digitized Health | Scoop.it
Hypoglycemic medications that could be co-administered with prebiotics and functional foods can potentially reduce the burden of metabolic diseases such as Type 2 Diabetes Mellitus (T2DM).The efficacy of drugs such as metformin and sulfonylureas can be enhanced by the activity of the intestinal mic...
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Home | Global Diabetes Industry Platform

Home | Global Diabetes Industry Platform | Digitized Health | Scoop.it
Introducing Aging Analytics Agency's IT Platform dedicated to the Global Diabetes Industry, featuring our latest report, "Global Diabetes Industry Overview 2023." This platform serves as a central hub for resources and information, providing a comprehensive analysis of the diabetes market and...
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The Use of eHealth for Pharmacotherapy Management With Patients With Respiratory Disease, Cardiovascular Disease, or Diabetes: Scoping Review

The Use of eHealth for Pharmacotherapy Management With Patients With Respiratory Disease, Cardiovascular Disease, or Diabetes: Scoping Review | Digitized Health | Scoop.it
There is a wide variety of eHealth interventions combining various domains and features to target pharmacotherapy management in asthma or COPD, CVD, and diabetes. Results suggest feedback is key for a positive effect on clinician-reported clinical outcomes.
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Why personalised care plans should be a norm for long-term conditions

Dr Nilesh Bharakhada, is the Clinical Director for Health and Care at the Professional Record Standards Body (PRSB) There are over 26 million people in the UK living with at least one long-term condition and 10 million who have two or more1. Many of them are at different stages of their conditions, have different lifestyles and clinical issues that they’re concerned about. Taking a person-centred approach in their care is the way to ensure that people can live their lives and manage their conditions as best as possible. This is what personalised care and support plans help to achieve. Diabetes is a good example of how having a personalised care and support plan in place can make a difference and put the person in control of their condition. People with diabetes need to have their blood pressure, weight, foot checks and other measures regularly taken. However, there may be something they’ve noticed, such as changes in their eyesight, that should be raised with their clinician. They’re the experts in their condition, and so actively involving people in their care can improve both self-management and clinical care. In the past, people with co-morbidities often had several care plans, each for a different condition, with very condition-specific care plans which attenuated the person’s voice. As a result, people were less likely to actively engage in the self-management of their care, and struggled to make a change in health behaviour that was key to improving their long-term condition and helping them manage it more easily. PRSB’s Personalised Care and Support Plan Standard, is a generic care planning standard for recording and sharing person-centred care plans. It is flexible enough to accommodate plans for a person who has multiple long-term conditions without losing significant amounts of detail that are important to health care professionals. The plan focuses on the person’s priorities and grasps how these priorities relate to their care. A personalised care and support plan aims to empower individuals, putting them in control of their health, and used as a reference tool for health and care providers. For example – a nurse or a care home care worker may use it to understand what they need to do if something unplanned happens to the person, or to prevent problems from happening. When we developed the Personalised Care and Support Plan Standard, we created a structure which could then be expanded for various long-term conditions, with the personalised care and support plan being the backbone. For example – our Diabetes Record Information Standard includes information that should be incorporated within the person’s personalised care and support plan to ensure its relevant, specific and helpful for a person with diabetes. However, for this approach to deliver benefits to people, it’s important that we record care planning information in a uniform way, across various care settings. This will enable nursing staff, pharmacists, health coaches, link workers and GPs to provide the best support possible, working in a joined-up way across organisational boundaries. In an ideal scenario, we want a care plan that starts its life in one care setting, recorded in a structured way, so that it can then be retrieved in a different clinical setting, in a different system, and be added to and amended as needed, to reflect people’s care journey. Benefits of the person-centred approach to care are also invaluable to the health and care system. In total, 70% of the entire health and social care budget is spent on long term conditions2. Helping people stay in charge of their health helps improve the management of their conditions. Let’s go back to diabetes again – with a personalised care and support plan in place, possible complications, such as strokes, chronic renal failure, and heart disease, can be avoided by taking secondary prevention measures. System suppliers have a role to play in making all this a reality. By implementing and achieving conformance against the Personalised Care and Support Plan Standard and Diabetes Record Information Standard, they help ensure that a person’s information flows to everyone involved in their care, allowing for continuity of care across care settings, so that people don’t have to repeat their story to clinicians and carry paper copies of notes with them. In essence, we’ve got everything we need to make personalised care and support plans the norm for people with long-term conditions. The standards are an important enabler – but we need the efforts of the whole health and care system to make sure that people benefit from these plans as much as possible. Health and care professionals who would like to proactively develop their personalised care skills, in areas such as Shared Decision making or Personalised Care and Support Planning, can also access a range of high quality, peer-reviewed free training and resources on the Personalised Care Institute website. https://www.personalisedcareinstitute.org.uk/ References 1https://www.england.nhs.uk/blog/making-the-case-for-the-personalised-approach/#:~:text=There%20are%20over%2026%20million,health%20and%20social%20care%20system 2https://www.nuffieldtrust.org.uk/resource/care-and-support-for-long-term-conditions#:~:text=Care%20of%20people%20with%20long,need%20to%20go%20into%20hospital.
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Smart Medical Devices Analysis | Smart Solutions for Better Health

Smart Medical Devices Analysis | Smart Solutions for Better Health | Digitized Health | Scoop.it
Smart medical devices seamlessly blend technology, intelligence, and connectivity to improve patient care and treatment outcomes.
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AI Effective in Screening for Referable Diabetic Retinopathy

AI Effective in Screening for Referable Diabetic Retinopathy | Digitized Health | Scoop.it
In a real-world setting, artificial intelligence (AI) proved to be effective in screening for referable diabetic retinopathy.
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Access to Evidence-Based Diabetes Programs in US Pediatric Hospitals

Access to Evidence-Based Diabetes Programs in US Pediatric Hospitals | Digitized Health | Scoop.it
The following is a summary of "Availability of Evidence-Based Diabetes Programs in U.S. Children’s Hospitals," published in the July 2023 issue of Primary Care by Hughes, et al. Diabetes has a widespread impact on individuals throughout their lives, necessitating individual and community-level...
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Navigating AI Ethics in Healthcare: An Innovative Guide

Navigating AI Ethics in Healthcare: An Innovative Guide | Digitized Health | Scoop.it
Hello Valued Subscribers, Welcome to this week's edition, "Navigating AI Ethics in Healthcare: An Innovative Guide." Today, we explore the ethical challenges that come with AI’s transformative role in healthcare.
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Imprecision nutrition? Duplicate meals result in unreliable individual glycemic responses measured by continuous glucose monitors across three dietary patterns in adults without diabetes

Imprecision nutrition? Duplicate meals result in unreliable individual glycemic responses measured by continuous glucose monitors across three dietary patterns in adults without diabetes | Digitized Health | Scoop.it
Individual postprandial CGM responses to duplicate meals were unreliable in adults without diabetes. Personalized diet advice based on CGM measurements in adults without diabetes requires more reliable methods involving aggregated repeated measurements.
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Structural Model of Biomedical and Contextual Factors Predicting In-Hospital Mortality due to Heart Failure

Structural Model of Biomedical and Contextual Factors Predicting In-Hospital Mortality due to Heart Failure | Digitized Health | Scoop.it
<span><i>Background</i>: Among the clinical predictors of a heart failure (HF) prognosis, different personal factors have been established in previous research, mainly age, gender, anemia, renal insufficiency and diabetes, as well as mediators (pulmonary embolism, hypertension, chronic obstructive...
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Religion and health: complexities and contradictions | The BMJ

Religion and health: complexities and contradictions | The BMJ | Digitized Health | Scoop.it
Nasim Mavaddat, senior research associate1, Nahal Mavaddat, associate professor, head of discipline of general practice2, Peymané Adab, professor of chronic disease epidemiology and public health3, Shirin Fozdar, GP partner41Department of Public Health and Primary Care, University of Cambridge, Cambridge, UK2School of Medicine, University of Western Australia, Australia3Institute of Applied Health Research, University of Birmingham, Birmingham, UK4Ridgeway View Family Practice, Wroughton, UKnm274{at}cam.ac.ukWe agree with Idler and colleagues’ analysis on the influence of religion on health.1 We believe, however, that the role of religion is much more far-reaching. By virtue of its character building and unifying capacity, religion has the potential to transform people and societies. It empowers individuals to build communities and provides tools for creating just and equitable societies.2The concept of fundamental causality34 explains why the relation between socioeconomic status and health has persisted over time despite changes in diseases, risk factors, and treatments. Technological advances alone are insufficient to combat disease, while social determinants are key factors in health inequities. Yet clinicians and scientists feel powerless to tackle many of the contributing societal problems.The pervasive impacts of greed and materialism on health are evident, whether through poverty, climate change, or pandemics. Applying the spiritual principles of unity and justice is a way to remedy the problems of our society. By recognising that all humanity has been created “from the same dust,”5 whatever their race, religion, or nationality, we can overcome the paralysis that prevents us from coming together to tackle the complex and inter-related problems facing our planet.Religion has the driving power and influence to tackle root causes of social inequality and eliminate the most pervasive determinants of ill health. Religions’ ethical and spiritual teachings are a powerful impulse for generosity, selflessness, and charitable actions. If those who profess a religion follow its spiritual tenets and work collaboratively, they can transform society at every level,26 support cooperative action on an international scale, and strengthen global institutions and governance imperative for tackling global health challenges.Idler and colleagues suggest that “religion is here to stay.” Why not harness this power, so readily available to us at the grassroots, for the good of our global health?FootnotesThe authors are affiliated with the Baha’i International community.Competing interests: None declared.Full response at: www.bmj.com/content/382/bmj-2023-076817/rr-2.References↵Idler E, Jalloh MF, Cochrane J, Blevins J. Religion as a social force in health: complexities and contradictions. BMJ2023;382:e076817. doi:10.1136/bmj-2023-076817 pmid:37463697OpenUrlFREE Full Text↵Baha’i International community. https://bic.org.↵Link BG, Phelan J. Social conditions as fundamental causes of disease. J Health Soc Behav1995;(Spec No):80-94. doi:10.2307/2626958 pmid:7560851OpenUrlCrossRefPubMed↵Lutfey K, Freese J. Toward some fundamentals of fundamental causality: socioeconomic status and health in the routine clinic visit for diabetes. Am J Sociol2005;110:1326-72doi:10.1086/428914OpenUrlCrossRef↵Baháʼu’lláh. The hidden words of Baháʼu’lláh. 1858. www.bahai.org/library/authoritative-texts/bahaullah/hidden-words/2#472999964↵All-party Parliamentary Group on Faith and Society. The faith covenant. 4 July 2023. www.faithandsociety.org/covenant.
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Sensors that monitor salivary metabolic changes to rapidly diagnose diabetes

Sensors that monitor salivary metabolic changes to rapidly diagnose diabetes | Digitized Health | Scoop.it
A sensor for non-invasive glucose determination in body fluids such as saliva.
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Leveraging Big Data and Technology in Diabetes Care Management

Leveraging Big Data and Technology in Diabetes Care Management | Digitized Health | Scoop.it
Effective diabetes care management is vital for the life for those diagnosed and reducing the economic burden on healthcare systems.
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Prediabetes and type 2 diabetes mellitus: Evidence for effect of yoga - PMC

Prediabetes and type 2 diabetes mellitus: Evidence for effect of yoga - PMC | Digitized Health | Scoop.it
Indian J Endocrinol Metab. 2014 Nov-Dec; 18(6): 745–749. doi: 10.4103/2230-8210.141318PMCID: PMC4192976PMID: 25364666Prediabetes and type 2 diabetes mellitus: Evidence for effect of yogaViveka P. JyotsnaAuthor information Copyright and License information PMC DisclaimerINTRODUCTIONThe growing epidemic of lifestyle-related diseases like type 2 diabetes in spite of all new drugs that are now available has drawn attention to the research on effects of yoga in diabetes prevention and treatment.[1,2,3,4,5,6]The word Yoga is derived from the Sanskrit word ‘Yuj’ meaning union of the body, breath and mind. Good health due to Yogic practices could be the effect of right thought and action. Yoga as a way of life is more true to its ancient tenets. It constitutes asanas, regulated breathing (pranayama), and awareness of yoga sutras (principles) that govern the mind.[7] Regular practice of yoga enhances awareness of mind and body,[3] which is needed in the self-management of diet and exercise plan in diabetes.Since change in lifestyle requires more effort on the part of the patient, health care provider and the social system as a whole compared to just popping a pill, more efforts and longer follow-up is required in such research.How does yoga benefit in diabetes? Landmark studies have shown an important role of lifestyle modification in the prevention of type 2 diabetes.[8,9,10,11] How to bring about change in and sustain a healthy lifestyle in times of urbanization, easy availability of calorie-dense fast food, mechanization, less open space for exercise is the question. Mere awareness about healthy living do not alone amount to implementation at the individual and society level.Could practice of yoga be a factor to build awareness and then build this gap between awareness and implementation at an individual level in the choice of food and exercise? Patients with diabetes may be unable or unwilling to participate in conventional types of physical activity (gymnasium based and vigorous strength training) due to limited joint mobility, capsulitis, and physical unfitness associated with overweight and sedentary lifestyle. In such a scenario, gentle yogic stretches performed under guidance with mind, body, and breath awareness might bring the body/mind back in condition fit again for more vigorous exercises required to have a direct effect on lowering plasma glucose. Limitations and barriers in enrollment and follow-up from the previous studies[11] tell us that these stretches and asanas need to be tailored according to the participant's need. Here, we discuss the evidence we have for the different effects of yoga on diabetes.Evidence of effect of yoga on diet, food intake and glycemic controlDiet intake affects glycemic control: A recent study has shown the effect of mindfulness yoga on eating and exercise in gestational diabetes.[12] Community-based yoga intervention showed beneficial effect on oxidative stress,[13] glycemic parameters, weight reduction[14] and lipids.[15]Leptin[16] plays a pro-inflammatory role while adiponectin has anti-inflammatory properties. Leptin was found to be significantly higher among novices compared to regular practitioners of yoga. Frequency of yoga practice had significant negative relationship with leptin.[16] Adiponectin levels were higher among practitioners of yoga. This raised the possibility that long-term/more intensive yoga practice could have beneficial health consequences by altering leptin and adiponectin. Apart from these, there are a number of studies that show the beneficial effect of different methods of yoga on glycemic control and lipid profile in diabetes.[17,18,19,20,21,22] Could yoga be a trigger in self-awareness and awareness for adapting healthy eating habits? Only studies with long-term follow-up can answer this.Evidence of interrelation of depression/anxiety with metabolic syndrome and of yoga to improve bothMood affects food intake: Depression and/or anxiety are risk factors for the development of diabetes[23,24] and vice versa.[25,26] This may occur due to genetic, epigenetic or environmental conditions. Regular practice of yoga has been shown to be beneficial in reducing depression and anxiety[27,28,29,30] and therefore may affect diabetes in an indirect manner.Evidence of effects of yoga in improving physical health, weight loss and adherence to physical activityPhysical activity can lower the risk of type 2 diabetes, but it is difficult to establish whether muscle-strengthening, stretching activities are beneficial for the prevention of type 2 diabetes. Total 99,316 women for 8 years from the Nurses’ Health Study (aged 53-81 years, 2000-2008) and Nurses’ Health Study II (aged 36-55 years, 2001-2009), mainly of European ethnicity, who were free of diabetes, were prospectively followed up. Participants reported weekly time spent on resistance exercise, lower intensity muscular conditioning exercises (yoga, stretching, toning), and aerobic moderate and vigorous physical activity at baseline and in 2004-2005. This is the only long-term follow-up study on yoga and more of this kind is required.This study suggests that engagement in muscle-strengthening and conditioning activities (resistance exercise, yoga, stretching, toning) is associated with a lower risk of type 2 diabetes. Engagement in both aerobic moderate and vigorous physical activity and muscle-strengthening type activity is associated with a substantial reduction in the risk of diabetes in middle-aged and older women.[31]Lifestyle changes though difficult to sustain, prevents type 2 diabetes. A randomized trial with one-year follow-up comparing restorative yoga vs. stretching among underactive adults with the metabolic syndrome at the Universities of California, San Francisco and San Diego showed that restorative yoga was marginally better than stretching for improving fasting glucose.[32]Yoga has been useful in geriatric type 2 diabetes where vigorous exercise may not be acceptable.[33]Though yoga of only 40 days has shown to decrease weight and improve well-being and anxiety[34] in one study, a two-month yoga program was insufficient to bring about a consistent change in physical activity in another study.[35] This stresses the need for a follow-up with revision and reinforcement on a regular long-term basis.Subjective variation of yoga practice limits interpretation. Another factor is the variation of method of yoga being practiced, which varies across studies. Further research is necessary to explore the influence of yoga on behavioral health outcomes among prediabetes and diabetes.A review[36] indicates that yoga has a positive short-term effect on multiple diabetes-related outcomes; however, long-term effects of yoga therapy on diabetes management warrant further research. The context of the social environment, including interpersonal relationships, community characteristics, and discrimination, influences the adoption and maintenance of health behaviors such as physical activity, including yoga practice.Yoga practice of for 3 months was found to be beneficial as weight loss strategy in a predominately Hispanic population.[37]In a randomized controlled study, it was found that participation in a two-month yoga intervention was feasible and resulted in greater weight loss and reduction in waist circumference when compared to controls assigned walking.[38] They concluded that yoga offers a promising lifestyle intervention for decreasing weight-related type 2 diabetes risk factors and potentially increasing psychological well-being.[38]A consensus statement from the British Association of Sports and Exercise recommends that weight training, circuit classes, yoga, and other muscle-strengthening activities offer additional health benefits and may help older adults to maintain physical independence.[39]Evidence of benefit of yoga on cardiovascular riskLong duration practice of yoga has shown to have a beneficial effect on cardiovascular reactivity.[40,41]A randomized controlled trial showed that in a 6-month period, practice of comprehensive yogic breathing had beneficial effects on cardiac autonomic functions in patients with diabetes who followed the comprehensive yogic breathing program compared to those who were on standard therapy alone.[42,43] Since cardiac dysfunction has been implicated in sudden cardiac death in diabetes, this finding may translate to practice of yogic breathing program being useful in delaying sudden cardiac death.A recent review[42] observed that most studies have several limitations like lack of adequate controls, small sample size, inconsistencies in baseline, and different methodologies, therefore large trials with improved methodologies are required to confirm these findings. In view of the existing knowledge and yoga being a cost-effective technique without side effects, it appears appropriate to incorporate yoga/meditation for primary and secondary prevention of cardiovascular disease.[42] A recent meta-analysis revealed evidence of beneficial effects of yoga on cardiovascular risk and concluded that yoga is beneficial for patients with increased risk of cardiovascular disease.[43,44,45]Evidence of benefit of yoga on quality of life/well-beingAny chronic disease like diabetes leads to a decrease in quality of life. Poor quality of life may affect compliance with treatment. A randomized controlled trial has shown that practice of comprehensive yogic breathing program significantly improves physical, psychological, and social domains, and total quality of life.[46] Other studies have also shown increased feeling of well-being with practice of yoga.[11,34,47]Evidence of mechanism of action of yogaApart from the above-discussed mechanisms, other ways by which yoga affects mind-body system have been explored. Sudarshan Kriya yoga and Pranayam program have been found to have a rapid and significantly greater effect on gene expression in peripheral blood mononuclear cells compared with the control regimen, which constituted nature walk and relaxing music.[48] This suggests that yoga and related practices result in rapid gene expression alterations, which may be the basis for their longer-term health effects.Evidence for prevention of prediabetesLifestyle modification is the most effective, cheaper and safer approach to type 2 diabetes prevention.[8,9,10,11]Studies[13,38,49] indicate that a yoga program would be a possible risk reduction option for adults at high risk for type 2 diabetes. In addition, yoga holds promise as an approach to reducing cardiometabolic risk factors and increasing exercise self-efficacy for this group. Among Indians with elevated fasting blood glucose, we found that participation in an 8-week yoga intervention was feasible and resulted in greater weight loss and reduction in waist circumference when compared to a walking control. Yoga offers a promising lifestyle intervention for decreasing weight-related type 2 diabetes risk factors and potentially increasing psychological well-being.Lessons learnt for future researchThe challenges faced in the previous studies have been in recruitment; practical issues for class attendance; physical barriers for engaging in the exercises; motivation issues, inadequate intensity, and/or duration of yoga intervention; and insufficient personalization of exercises to individual needs. Though community-based studies are found feasible, not only in India but abroad as well, these factors should be considered when designing future trials.[50]CONCLUSIONIn a review on prevention of diabetes in developing countries,[51] it was noted that programs adapted to their specific needs are lacking. Low-cost strategies to identify at-risk individuals, followed by the implementation of group-based, inexpensive lifestyle interventions, seem to be the best options. Widespread implementation of type 2 prevention in developing countries will require coordinated efforts throughout society, along with comprehensive government policies and novel funding sources.Yoga is being tried for its benefit not only in India[52] where it is traditionally familiar but in US, UK and Australia as well. In view of the benefits it has shown in short-term studies, long-term studies with support for yoga practice and follow-up are required and this requires a collective effort on the part of the researcher, government, society, and the funding agency.FootnotesSource of Support: Nil Conflict of Interest: None declared.REFERENCES1. Bali HK. Yoga - an ancient solution to a modern epidemic. Ready for prime time? Indian Heart J. 2013;65:132–6. [PMC free article] [PubMed] [Google Scholar]2. Yang K. A review of yoga programs for four leading risk factors of chronic diseases. Evid Based Complement Alternat Med. 2007;2:487–91. [PMC free article] [PubMed] [Google Scholar]3. Zope SA, Zope RA. Sudarshan kriya yoga: Breathing for health. Int J Yoga. 2013;6:4–10. [PMC free article] [PubMed] [Google Scholar]4. Sherman KJ, Innes KE. Yoga for metabolic risk factors: Much ado about nothing or new form of adjunctive care? J Diabetes Complications. 2014;28:253–4. 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[PMC free article] [PubMed] [Google Scholar]10. Tuomilehto J, Lindström J, Eriksson JG, Valle TT, Hämäläinen H, Ilanne-Parikka P, et al. Finnish Diabetes Prevention Study Group. Prevention of type 2 diabetes mellitus by changes in lifestyle among subjects with impaired glucose tolerance. N Engl J Med. 2001;344:1343–50. [PubMed] [Google Scholar]11. Ramachandran A, Snehalatha C, Mary S, Mukesh B, Bhaskar AD, Vijay V Indian Diabetes Prevention Programme (IDPP) The Indian Diabetes Prevention Programme shows that lifestyle modification and metformin prevent type 2 diabetes in Asian Indian subjects with impaired glucose tolerance (IDPP-1) Diabetologia. 2006;49:289–97. [PubMed] [Google Scholar]12. Youngwanichsetha S, Phumdoung S, Ingkathawornwong T. The effects of mindfulness eating and yoga exercise on blood sugar levels of pregnant women with gestational diabetes mellitus. Appl Nurs Res. 2014 [PubMed] [Google Scholar]13. Hegde SV, Adhikari P, Shetty S, Manjrekar P, D’Souza V. Effect of community-based yoga intervention on oxidative stress and glycemic parameters in prediabetes: A randomized controlled trial. Complement Ther Med. 2013;21:571–6. [PubMed] [Google Scholar]14. Rioux JG, Ritenbaugh C. Narrative review of yoga intervention clinical trials including weight-related outcomes. Altern Ther Health Med. 2013;19:32–46. [PubMed] [Google Scholar]15. Shantakumari N, Sequeira S, El deeb R. Effects of a yoga intervention on lipid profiles of diabetes patients with dyslipidemia. Indian Heart J. 2013;65:127–31. [PMC free article] [PubMed] [Google Scholar]16. Kiecolt-Glasor JK, Christian LM, Andridge R, Hwang BS, Malarkey WB, Belury MA, et al. Adiponectin, leptin and yoga practice. Physiol Behav. 2012;107:809–13. [PMC free article] [PubMed] [Google Scholar]17. Telles S, Naveen VK, Balkrishna A. 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Health centres and social determinants of health: an analysis of enabling services provision and clinical quality | Family Medicine and Community Health

Health centres and social determinants of health: an analysis of enabling services provision and clinical quality | Family Medicine and Community Health | Digitized Health | Scoop.it
WHAT IS ALREADY KNOWN ON THIS TOPICHealth centres offer enabling services, which seek to address non-clinical barriers to care and increase use of health centre services.Patients of health centres in areas of higher deprivation use more enabling services, and health centres in areas of higher deprivation have better clinical quality process performance for some measures.WHAT THIS STUDY ADDSAfter adjusting for service area deprivation and other patient and organisational differences, health centres with higher patient use of enabling services perform significantly better on most clinical process measures but not the clinical quality outcomes.HOW THIS STUDY MIGHT AFFECT RESEARCH, PRACTICE OR POLICYBetter clinical process performance by health centres with higher utilisation of enabling services shows that enabling services can help health centres address cold spots and mitigate some effects of social determinants of health.More research is needed to determine why increased use of enabling services improves process quality measures but not outcome quality measures and how staffing, funding and organisational capabilities, along with service area deprivation, influence these findings.IntroductionIt is well known that social determinants of health (SDOH) such as poverty, education, transportation and housing are more important predictors of health outcomes than biology, genes, behaviour or medical care.1–3 Further, these determinants are complex and often co-occur among populations and within neighbourhoods previously referred to as ‘cold spots’, defined as communities ‘that do not provide the essential opportunities for health: safe sidewalks, good air quality, social integration, grocery stores, education, employment, public health’.4 Improving health outcomes in these cold spots requires population health interventions (both clinical and non-clinical) that address issues such as housing and food insecurity, language translation and transportation.5–7 One successful care delivery model that addresses social determinants and their role in the health of populations living in cold spots is Community Oriented Primary Care (COPC). This model, wherein providers consider themselves responsible for the health of the community as a whole, was first introduced in the USA in the 1940s. Current COPC models integrate concepts from both public health and primary care and focus on addressing community-level determinants such as education, employment and housing to improve the health of the community.8 Full implementation of the COPC model requires data-driven identification of a community-level problem, intervention implementation and ongoing evaluation.9 The potential of effectively delivering this care model, particularly in a standardised way, has evolved with the advent of the electronic health record, readily available and accessible data, and innovative geospatial tools.9 10The health centre movement in the USA, embodied by the Health Resources and Services Administration’s (HRSA) Health Centre Programme, is built on the same principles that guide the COPC model. HRSA-funded health centres (henceforth referred to as health centres) are Federally Qualified Health Centres (FQHCs) receiving HRSA funding through Section 330 of the Public Health Service Act. Health centres serve the most vulnerable populations regardless of patients’ ability to pay and, in 2018, were nested in communities with higher proportions of racial/ethnic minorities (63%), poverty (91% at or below 200% federal poverty guideline, FPG) and Medicaid (49%) or uninsured (23%) patients. Nationwide in 2018, nearly 1400 health centre organisations served over 28 million patients at approximately 12 000 service delivery sites.11 This programme further exemplifies the COPC model by focusing on SDOH and community-oriented care, including their use of community and patient governing boards.12 13One way that health centres address potential barriers posed by SDOH is by providing enabling services. Enabling services are non-clinical supports, including transportation, interpretation, case management, home visits, benefit counselling, health education and community outreach, intended to increase access to care and improve health outcomes.14 Each health centre offers enabling services to best address specific SDOH needs within a community, and these vary by health centre.13 While the services mentioned above, as well as food and housing supports, are among those offered, most health centre enabling services staff deliver case management and community education and outreach. Although health centres are required to provide enabling services,12 they are often not reimbursed fully and funding for these services is often precarious.15 16 In fact, a recent survey showed that enabling services are among the first services health centres consider cutting when faced with budget issues.17 Having sustainable financial support for health centre enabling services is important, as research shows that addressing SDOH with enabling services further improves access to care and health outcomes as well as patient satisfaction across various healthcare settings.18 19Multiple studies have illustrated that providing access to transportation19 and translation services18 increases utilisation of preventive care and improves outcomes. Wright et al found that screening for and subsequently providing housing for people experiencing homelessness reduced healthcare spending, increased primary care visits, reduced emergency department visits and even increased subjective well-being.20 Research also shows that screening for food insecurity and making appropriate referrals improves health outcomes in children21 and adults.22Specific to health centres, researchers have found that patients who use enabling services are more likely to make visits, obtain routine checkups and receive influenza vaccinations.23 Additionally, research shows that pregnant health centre patients receive prenatal care earlier and have better perinatal outcomes when they have access to enabling services.24 Lastly, research shows that enabling services help reduce racial and ethnic disparities in healthcare access by removing the barriers these populations are most likely to face.25While research has shown the effectiveness of enabling services in terms of increased utilisation, better health outcomes and increased satisfaction, little is known about the relationship between enabling services and health centre clinical quality performance as it pertains to chronic condition management and preventive services. Our previous research found that health centres with higher levels of service area-level social deprivation, measured using an index composed of education, housing, poverty and race,26 provided more enabling services and had better clinical quality process performance for some measures.27 This led us to question whether enabling services have a mitigating effect on community-level social deprivation. Thus, we explore whether health centres with higher percentages of patients using enabling services have better clinical quality outcomes. More specifically, we test whether health centres with higher percentages of patients using enabling services perform better than expected for clinical quality measures after adjusting for patient, health centre and service area characteristics.MethodsDataWe used 2018 Uniform Data System (UDS) data for Health Centre Programme awardees.28 Variables included two clinical quality outcome measures, including the percentage of hypertensive patients ages 18–84 with high blood pressure (BP) that is controlled (BP<140/90 mm Hg) and the percentage of diabetic patients ages 18–74 with poor haemoglobin A1c control (>9%). We also explored ten process measures, including the percentage of patients 18 years and older with body mass index (BMI) documented and follow-up plan documented if BMI is outside normal parameters (BMI screening and follow-up plan for adults), the percentage of women ages 23–64 who were screened for cervical cancer (cervical cancer screening), the percentage of children 2 years of age who received age appropriate vaccines by their second birthday (childhood immunisation status), the percentage of patients 50–74 years of age who had appropriate screening for colorectal cancer (colorectal cancer screening), the percentage of patients ages 21 and older at high risk of cardiovascular events who were prescribed or were on statin therapy (statin therapy), the percentage of patients ages 18 and older with diagnosis of ischaemic vascular disease (IVD) or acute myocardial infarction with aspirin or another platelet (IVD: use of aspiring or another platelet), the percentage of patients ages 12 and older who were screened positive for depression and had follow-up plan documented (screening for depression and follow-up plan), the percentage of patients ages 18 and older who were screened for yes tobacco and received cessation counselling intervention, the percentage of patients 5–64 identified as having persistent asthma and were appropriately ordered medication (use of appropriate medications for asthma), and the percentage of patients ages 3–16 with BMI percentile and counselling on nutrition and physical activity documented (weight assessment and counselling for nutrition and physical activity for children and adolescents). We controlled for variables reflecting differences in the patient population (the percentage of uninsured patients, the percentage of ethnic and racial minority patients, the percentage of patients ages 65 and older and the percentage of patients with hypertension), variations in health centre size (a categorical variable for ‘large’ health centres defined by health centres with greater than the median number of patients), and disparity of the surrounding community (weighted service area-level social deprivation, an index composed of education, housing, poverty and race variables, previously used by researchers to identify cold spots).26 We selected performance and control variables and constructs based on previous research, and created a correlation matrix consisting of several variables that have been shown to influence health centre performance. Health centres were also stratified by quartile based on the percentage of patients using enabling services, which are defined as ‘non-clinical services that aim to increase access to healthcare, and improve health outcomes’.25 Enabling services include visits for services such as language interpretation or translation, food and housing assistance, transportation, programme eligibility assistance, child care and case management.AnalysisFirst, we calculated a service area social deprivation score for each health centre organisation, weighted by the number of patients (see online supplemental file for detailed methods27). Next, we removed all health centres that were missing data for clinical quality measures (n=184). We removed health centres that received homeless funding (n=272) as they have significantly different patient characteristics than other health centres and many of these health centres had outlier values for clinical quality measures. Next, we used ordinary least squares to calculate adjusted clinical quality measures controlling for health centre patient characteristics, size and service area characteristics. Finally, we performed an analysis of variance to compare clinical quality outcome and process measures across enabling services quartiles to determine whether health centres providing more enabling services had better performance for clinical quality measures.Supplemental material[fmch-2023-002227supp001.pdf]ResultsTable 1 shows patient and organisational characteristics of 875 health centres sorted by utilisation of enabling services with quartile 1 (Q1) representing the quartile of health centres with lowest utilisation of enabling services and quartile 4 (Q4) representing the highest. Health centres with higher utilisation tended to be larger with more patients (22 462 patients in Q4 vs 13 557 in Q1), more full-time equivalents (63.8 medical FTEs vs 40.2 medical FTEs), and received larger grants through HRSA (US$3.3M vs US$2.4M). Social Deprivation Index (SDI) service area scores were also higher among health centres with higher utilisation of enabling services. When comparing patients in health centres with more utilisation of enabling services, patients were more likely to be between ages of 18–64 years old (compared with less than 18 or over 65), and most were racial/ethnic minorities (64.8% in Q4 vs 42.9% in Q1). More specifically, patients in health centres with high utilisation of enabling services were more likely to be (non-Hispanic) black (23.7% in Q4 vs 16.8% in Q1), (non-Hispanic) Asian (6.7% vs 2.8%), (non-Hispanic) Native Hawaiian/Other Pacific Islander (1.6% vs 1.1%) and Hispanic/Latino (36% vs 18.9%). Health centres with high utilisation of enabling services also had more patients who are best served in a language other than English (11.8% in Q1 vs 26.6% in Q4). Health centres with higher utilisation of enabling services had more patients that were uninsured (29.0% in Q4 vs 22.5% in Q1) or were on Medicaid (41.8% vs 39.3%) and were more likely to be serving patients of lower income with 64.8% at or below 100% FPG in Q4 vs 58.4% in Q1.View inline View popup Table 1 Characteristics by enabling services quartileTable 2 displays health centre unadjusted clinical quality measures by enabling service quartile. For most of the clinical quality process measures, the unadjusted results show a linear relationship across enabling services quartiles—meaning that the health centres providing more enabling services performed better than health centres providing fewer enabling services. However, while health centres in the lowest quartile (Q1) for enabling services provision had the worst quality scores for all measures, health centres in the second or third quartile (Q3) for enabling services performed better than health centres in the fourth quartile (Q4) for several process measures, including lipid therapy for patients with coronary artery disease patients and use of appropriate medications for asthma, and for both outcome measures. The largest differences between the fourth and first quartile were seen in cervical cancer screening (9.0% difference between Q4 and Q1), child/adolescent weight assessment and counselling (8.5% difference), and childhood immunisations (8.1% difference). Taking a closer look at outcome measures, there were statistically significant differences across enabling services quartiles where health centres in the lowest quartile for enabling services performed the worst for both outcome measures.View inline View popup Table 2 Quality measures by enabling services quartileTable 3 displays the adjusted values for clinical quality measures. After adjusting for patient characteristics (the percentage of uninsured patients, the percentage of ethnic and racial minority patients, the percentage of patients ages 65 and older and the percentage of patients with hypertension), health centre size and social deprivation, we found significant differences across enabling services quartiles for all process measures, with health centres in the highest enabling services quartile performing significantly better than health centres in the lowest enabling services quartile for all measures except IVD patients use of aspirin or another antiplatelet. Similar to the unadjusted results, clinical quality process scores were mostly linear across health centre enabling services quartiles—though health centres in the second (Q2) or third (Q3) quartile performed better than health centres in the fourth quartile (Q4) for colorectal cancer screening, IVD patients use of aspirin or another antiplatelet, and tobacco use screening and cessation. While results were statistically significant for outcome measures, health centres with highest utilisation of enabling services did worse in controlling high BP (1.3% lower) and had more (2.2%) patients with uncontrolled diabetes. As in the unadjusted measures, the biggest differences across quartiles are seen in child/adolescent weight assessment and counselling (2.8%), childhood immunisations (2.7%) and cervical cancer screening (2.6%).View inline View popup Table 3 Adjusted quality measures by enabling services quartileDiscussionThe patient characteristics associated with health centres providing more enabling services suggest these health centres serve racially and ethnically diverse communities and serve larger percentages of medically underserved populations as indicated by higher SDI, rates of uninsured or Medicaid patients, and proportion of patients with incomes below FPGs. Despite this, health centres with highest utilisation of enabling services indicated statistically significant improvements in clinical quality measures. These measures can be grouped by preventive screening measures (adult BMI screening and counselling, child/adolescent weight screening and counselling), adherence to clinical guidelines for treatment (lipid therapy, appropriate use for aspirin, appropriate medications for asthma, childhood immunisation) and cancer screening (cervical and colorectal). Improvements in clinical diabetes outcomes were significant in bivariate and multivariate analyses. After adjusting for characteristics that may be attributed to economies of scale such as the size of health centres and controlling for patient characteristics and community factors reflected in SDI, health centres with high utilisation of enabling services demonstrated statistically better performance in 8 of the 10 process measures but worse performance in outcome measures.Previous research on process measures23 suggests that health centres are mitigating some effects of SDOH and contributing to health equity by using enabling services.25 Enabling services focus on a community’s unique assets and vulnerabilities and can help address cold spots, as exemplified by the COPC model.8 Addressing these cold spots, rather than individual high-risk patients, has been shown to better improve health outcomes. These findings emphasise the importance of how enabling services (eg, translation services, transportation) can address unmet social needs and improve utilisation of health services. While health centres have been offering enabling services for decades, an increasing number of other types of organisations are also offering non-clinical supports.15 29 These programmes, which currently have limited research on clinical outcomes,29 could look to the Health Centre Programme as a model which successfully offers services to address non-clinical barriers to care. Further, this research supports a broader view of clinical care that includes non-clinical solutions (ie, enabling services that address SDOH) for addressing self-management if true improvements in clinical outcomes are to be achieved.30As mentioned above, even when controlling for size differences, disproportionate representation of certain conditions, and sociodemographic differences in the patient population and surrounding communities across health centres, health centres with high utilisation of enabling services showed worse performance in controlling hypertension and diabetes. These findings suggest enabling services may have a stronger positive correlation with process measures than with outcome measures. It is unlikely that enabling services have a detrimental effect on outcome measures, and more plausible that enabling services are unable to attenuate the poorer outcomes in more vulnerable populations.27 This is not surprising, as health centres are intentionally nested in communities of greatest need. Furthermore, we were unable to account for the temporal aspects of the dynamic relationship between enabling services provision and measures of health outcomes given the cross-sectional nature of the UDS. More research is needed to better understand how structural measures such as staffing mix or organisational capabilities, clinical process measures and clinical outcome measures are related.There were a few limitations in this study. While data on FTEs in enabling services were available, we did not have data on patient utilisation of enabling services, meaning that we know if patients were using some type of enabling service but do not have details on the type of enabling service being provided. Improving data granularity to capture utilisation (patients or visits) of specific types of enabling services provided would allow researchers to measure the mitigation efforts of providing enabling services on SDOH. This research was limited to less than 80% of all health centres due to missing data and elimination of health centres with only homeless funding. Future research ideas include examining which enabling services have the most impact on quality, whether the provision of enabling services impacts quality in health centres in or next to public housing facilities, and what geographical variation, if any, exists in the impact of enabling services on quality. Further, exploring the impact of enabling services for health centres with homeless funding is an area of future inquiry. An additional limitation is related to how enabling services utilisation are defined as patients receiving care from enabling services providers, which in some cases are referrals for housing or food assistance. There are no data related to whether patients followed through on the referral and received those services.This research provides further evidence on the effectiveness of enabling services, both in addressing SDOH and in improving health outcomes. Yet, health centres face many difficulties in funding these services. While research shows that the provision of enabling services saves money long term,20 enabling services are not adequately funded.12 13 15 31 In fact, enabling services are the first programmes cut during financially difficult times.17 32–34 This study provides insights to address the importance of enabling services and their financial sustainability.HRSA currently supplements the provision of enabling services through the HRSA National Training and Technical Assistance Partners programme, which supports health centres in several areas including working with individuals and families experiencing housing insecurity and targeted support for underserved populations and the social insecurities they may encounter. Beyond this, while some health centres were primarily established as community supports, others have turned to creative ways to fund enabling services, including cross-sector collaborations.35 Health centres are successfully partnering with food banks, grocery stores,36 supportive housing providers37 and local transit systems38 to deliver enabling services. Enabling services can continue to assist health centres in serving the most vulnerable populations, addressing cold spots and delivering community-oriented primary care, all of which reduce overall healthcare spending and contribute to the overarching goal of health equity.23 39ConclusionAs demonstrated, health centres with higher utilisation of enabling services demonstrate statistically significant improvements in process measures. The higher utilisation of enabling services also allows health centres to address cold spots and mitigate some effects of SDOH by promoting health equity. These key findings underscore the importance of enabling services, especially in communities with the highest need.Even though current reimbursement policy for providing enabling services is lacking, health centres understand the value of providing enabling services due to their ability to positively influence patient health outcomes. Financial support provided to FQHCs in the form of 330 grant dollars are particularly important to help offset the cost of enabling services for health centres with less financial support and less profit.By using the Health Centre Programme as a model, the case for long-term, sustainable financial support of enabling service programmes is one of the many elements needed in order to improve the health of the most vulnerable populations and start addressing health inequities. Future research is needed on the influence of staffing, funding and organisational capabilities on clinical outcomes in the most vulnerable communities.Data availability statementData may be obtained from a third party and are not publicly available.Ethics statementsPatient consent for publicationNot applicable.Ethics approvalThis research involved secondary data analysis of health centre administrative -level data and did not require approval from an institutional review board (IRB).References↵Braveman PA, Cubbin C, Egerter S, et al. Socioeconomic disparities in health in the United States: what the patterns tell us. Am J Public Health 2010;100 Suppl 1:S186–96. doi:10.2105/AJPH.2009.166082OpenUrlPubMed↵Braveman P, Gottlieb L. The social determinants of health: it's time to consider the causes of the causes. Public Health Rep 2014;129 Suppl 2:19–31. doi:10.1177/00333549141291S206OpenUrlCrossRefPubMed↵Marmot MG, Wilkinson RG. Social determinants of health2nd edn. Oxford: Oxford University Press, 2006. doi:10.1093/acprof:oso/9780198565895.001.0001↵Westfall JM. Cold-spotting: linking primary care and public health to create communities of solution. J Am Board Fam Med 2013;26:239–40. doi:10.3122/jabfm.2013.03.130094OpenUrlAbstract/FREE Full Text↵Taylor LA, Tan AX, Coyle CE, et al. Leveraging the social determinants of health: what works PLoS One 2016;11:e0160217. doi:10.1371/journal.pone.0160217↵Baum FE, Legge DG, Freeman T, et al. The potential for multi-disciplinary primary health care services to take action on the social determinants of health: actions and constraints. BMC Public Health 2013;13:460. doi:10.1186/1471-2458-13-460↵Andermann A. Screening for social determinants of health in clinical care: moving from the margins to the mainstream. Public Health Rev 2018;39:19. doi:10.1186/s40985-018-0094-7↵Folsom Group. Communities of solution: the Folsom report revisited. 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