Decades of historical practices like housing discrimination in Detroit have lasting impacts on communities. Perhaps the most explicit example is the practice of redlining in the 1930s, whereby lenders outlined financially undesirable neighborhoods, populated by minority families, on maps and prevented residents from moving to better resourced neighborhoods. Awareness of historical housing discrimination may improve research assessing the impacts of current neighborhood characteristics on health. Using the Detroit Neighborhood Health Study (DNHS), we assessed the association between two-year changes in home foreclosure rates following the 2007-2008 Great Recession, and residents’ five-year self-rated health trajectories (2008-2013); and estimated the confounding bias introduced by ignoring historical redlining practices in the city. We used both ecological and multilevel models to make inference about person- and community-level processes. In a neighborhood-level linear regression adjusted for confounders (including percent redlined); a 10 percentage-point slower foreclosure rate recovery was associated with an increase in prevalence of poor self-rated health of 0.31 (95% CI: −0.02-0.64). At the individual level, it was associated with a within-person increase in probability of poor health of 0.45 (95% CI: 0.15-0.72). Removing redlining from the model biased the estimated effect upward to 0.38 (95% CI: 0.07-0.69) and 0.56 (95% CI: 0.21-0.84) in the neighborhood and individual-level models, respectively. Stratum-specific foreclosure recovery effects indicate stronger influence in neighborhoods with a greater proportion of residents identifying as white and a greater degree of historic redlining. These findings support theory that structural discrimination has lasting influences on current neighborhood health effects, and suggests that historical redlining specifically may increase vulnerability to contemporary neighborhood foreclosures. Community interventions should consider historical discrimination in conjunction with current place-based indicators to more equitably improve population health.

Objectives With this study, we aimed to develop a mobile technology (mHealth) intervention to improve medication adherence among patients with coronary heart disease (CHD). Methods The study was conducted in two phases with CHD patients from a Cardiology Department of a hospital located in China. Each phase was independent from the other. Phase 1 tested the integration of the two apps — “WeChat” and “BB Reminder” — as an mHealth intervention. All participants received the same educational materials via WeChat every two days. Participants in the experimental group received a reminder from BB Reminder for every dose of their medications. The duration of Phase 1 was 30 days for each participant. Phase 2 refined the intervention, in which educational materials were sent every five days rather than every two days, and medication-taking reminders were sent daily rather than every dose. Results In Phase 1, an mHealth intervention was developed by integrating two mobile apps. In Phase 2, medication adherence increased at 30-day follow-up in both groups compared to baseline. At the 30-day follow-up, the mean of the decrease in medication non-adherence score in the experimental group ( M = −1.35, SD = 2.18, n = 36) was more than the decrease in control group ( M = −0.69, S D = 1.58, n = 36), which means the medication adherence improved more in the experimental group. Conclusion The feasibility of using mHealth to remind CHD patients to take their medications is high.

Background Palliative care focusing on pain and infection is recommended for patients who are terminally ill. It is difficult to implement this strategy in practice because of the lack of clear guidelines. The authors conducted a study to examine dental treatment provided to a group of long-term care (LTC) residents in the last year of life. Methods The authors retrospectively followed 197 LTC residents (60 years or older) in the last year of life to death. On the basis of the dental services patients received between the new patient examination and death, the authors categorized the patients into three groups: no care (NC), limited care (LC) and usual care (UC). The authors developed a multivariable continuation ratio logit model with shared regression coefficients across two logits to identify the factors associated with the end-of-life dental care pattern. Results The authors found that 50.8 percent of the patients received NC before death. Among those who received treatment, 62.9 percent received UC, and 60.7 percent of the patients in the UC group had completed their treatment in the last three months of life. A three-month increment in survival and having dental insurance resulted in 1.74 (95 percent confidence interval [CI], 1.32–2.30) and 2.59 (95 percent CI, 1.03–6.52) times greater odds, respectively, of receiving some dental treatment before death. Neither survival nor dental insurance, however, was associated with dental care intensity in the last year of life (that is, UC versus LC). Conclusions While most of the patients who were in the last year of life received insufficient dental care, comprehensive treatment was provided commonly to frail patients at the end of life, raising questions about quality of care.

Background Sickle cell disease (SCD) is an inherited blood disorder associated with acute pain crisis and other complications that lead to frequent emergency department (ED) visits. To improve outcomes, the National Heart, Lung and Blood Institute (NHLBI) published recommendations for management of acute pain crisis. NHLBI also funded eight centers across the United States to participate in the Sickle Cell Disease Implementation Consortium. This six-year effort consists of two phases. Phase one involved conducting needs assessments of barriers and facilitators to SCD care. The aim of this study was to describe challenges and facilitators to caring for SCD from the perspective of ED providers in central North Carolina (NC). Methods and findings We conducted a needs assessment survey with ED providers throughout NC. We also conducted focus groups and an interview with ED providers from three healthcare facilities in central NC. One hundred and eleven surveys (60.6% physicians, 26% registered nurses, 13.5% physician assistants) were completed and 13 providers participated in 3 focus groups and 1 interview. Slightly more than half (50. 4%) utilized individualized dosing protocols to treat sickle cell pain. Only 32.4% of the providers were aware of the NHLBI SCD recommendations. Barriers to care from the survey included: patient behavior (67.57%), the opioid epidemic (67.57%), overcrowding (64.86%), and concern about addiction (49.55%). Perceived barriers to care identified in the focus groups and interview included: high patient volumes, lack of SCD care protocols, poor communication among providers and stigma. Facilitators to care included: individualized pain plans, comfort prescribing opioids and electronic medical records. Conclusion SCD care is influenced by many factors. Our results illuminate the need for increased use of the NHLBI SCD recommendations, individualized pain protocols, and use of electronic medical records and other care-interventions, specifically geared towards improving provider knowledge and mitigating provider bias.

Background: Sickle-cell disease (SCD) causes significant morbidity, premature mortality, and high disease burden, resulting in frequent health care use. Comanagement may improve utilization and patient adherence with treatments such as Hydroxyurea. The purpose of this study was to describe acute-care utilization in Medicaid-enrolled patients with SCD, patient factors associated with comanagement, and adherence to Hydroxyurea.Methods: Data from 2790 patients diagnosed with SCD, age 1 to 65؉ years, enrolled at least 1 month in North Carolina Medicaid between March 2016 and February 2017, were analyzed. Outpatient visits were categorized as primary care, hematologist, and nonhematologist specialist. Nurse practitioners or physician assistants with unidentified specialty type or family practice were categorized separately. Comanagement was defined as a minimum of 1 primary care and 1 hematologist visit/patient during the study period.Results: There were notable age-related differences in utilization of health care services. Only 34.82% of the sample was comanaged. Comanagement was higher in the 1-to-9-year-old (44.88%) and 10-to-17-year-old groups (39.22%) versus the 31-to-45-year-old (30.26%) and 65؉-year-old (18.75%) age groups. Age had the greatest influence (AUC ‫؍‬ 0.599) on whether or not a patient was comanaged. Only a third of the sample (32.24%) had at least 1 Hydroxyurea (HU) prescription. Age was the most predictive factor of good HUadherence (AUC ‫؍‬ 0.6503). Prediction by comanagement was minimal with an AUC ‫؍‬ 0.5615.Conclusion : Comanagement was a factor in predicting HUadherence, but further studies are needed to identify the frequency and components of comanagement needed to increase adherence and reduce acute care utilization. (J Am Board Fam Med 2020;33:91-105.)Sickle-cell disease (SCD) is a genetic disorder and the most common rare blood disease in the United States. 1 Patients suffer from complications, includ-ing but not limited to stroke, acute chest syndrome, and severe painful crisis that contributes to morbidity and premature mortality. Individuals also suffer from significant disease burden, often resulting in a high number of hospitalizations, readmissions, emergency department (ED) visits, and other associated costs to the health care system. In 2006 people with SCD had an estimated 232,382 ED visits, 68,410 hospitalizations from the ED, accounting for an estimated $2.4 billion dollars. 2 In 2010, SCD was associated with the highest 30-day readmission rate (31.9%) among all diagnoses excluding cancer and cancer-related conditions. 3 Other national data representing about 1 ⁄3 of the SCD population found a similar 30-day readmis-This article was externally peer reviewed.