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An Osteopathic Approach to Leveraging Community Support for Prevention and Management of Chronic Disease in Rural and Appalachian Virginia
Slaymaker, K. A. [1]
Meacham, S. [1]
Horn, R. [1]
Goessl, C. [1]
Meisha, D. [1]
Mahaney, J. [1]

Journal: Journal of Osteopathic Medicine Date: 2018/11, 118(11):Pages: e159-e161. doi: Subito , type of study: longitudinal study

Full text    (https://www.degruyter.com/document/doi/10.7556/jaoa.2018.163/html)

Keywords:

chronic pain [204]
longitudinal study [28]
patients [80]
rural healthcare [10]
USA [1086]

Abstract:

Research Question(s)/Hypotheses: Central Appalachian communities continue to experience poor health outcomes in the setting of persistent poverty despite efforts by numerous organizations to address these disparities over the past 50 years. In 2011, Edward Via College of Osteopathic Medicine initiated a longitudinal study with the goal of identifying demographic, geographic, economic, and social determinants of health contributing to persistently high prevalence of certain chronic health conditions in Appalachian regions in southern Virginia. The overarching goal of this research is to characterize individual communities and target key factors to address in future intervention programs designed to improve the health and well-being of communities in Central Appalachia. Collection and analysis of quantitative and qualitative patient-centered data have been completed and a complementary provider-focused dataset is currently being collected and analyzed. This phase aims to answer questions regarding (1) impact of chronic disease, (2) perceived barriers to improving chronic health conditions in patients and communities of practice, and (3) identification of osteopathic tenets employed in practice. These results, in addition to input collected from focus groups in each area, will ultimately inform the design of targeted interventions in each of the 6 regions studied. This project, which aims to look deeply within and engage with each individual community to formulate problems as well as solutions, is osteopathic at its core. Methods: Longitudinal and cohort studies were conducted in rural Virginia through analysis of agency mortality data (Virginia Department of Health) and individual electronic health records. Six facilities in 4 health disparity regions of southern Virginia were identified and agreements to participate confirmed for a cross-sectional study. An IRB-approved protocol provided for the systematic random selection and de-identification of protected medical records of admitted patients aged 18 years or older. An interdisciplinary team designed, pretested, and revised a survey tool in Qualtrics, LLC, specifically for the efficient extraction of data from selected records with a focus on 9 chronic diseases and a nonchronic disease (mild mental illnesses) using International Classification for Disease codes. Cases were further reviewed for family histories, lifestyle behaviors, social history, physical examination notes, and clinical and laboratory test results. Interdisciplinary steering committees were formed to include health care providers and interested parties in each distinct region to provide feedback toward the development of a 35-item survey to be distributed to providers across the 6 regions and to later convene as focus groups in each region to further provide complementary qualitative data. Data Analysis: Longitudinal data (1960-2012) were obtained from the Virginia Department of Health (n=∼60,000). Cohort data were extracted from 2012 inpatient electronic health records from 6 hospitals. Records were selected via systematic randomization (n=∼1400). Data analysis controlled for age, gender, and ethnicity. Data compared southwest Virginia to comparison areas and identified social, behavioral, environmental, and clinical confounders. Nine chronic disease mortality conditions and 1 nonchronic, external cause of death were studied. Statistical analyses included paired t tests, Pearson correlations, Rao-Scott χ2, and Nagelkerke (NK) analyses; significance was α=0.05 using SPSS software. Results: Results for the electronic health record reviews indicated inpatients in southwest Virginia had greater likelihoods of diagnoses with neoplasms (9.40% vs 7.50%, NK=3.6) (P<.01) and diabetes (30.40% vs 13.90%, NK=4.3) (P<.0001) compared with their eastern Virginia counterparts. Prevalence of mental disorders was 42.80% in southwest Virginia and 30.30% in eastern VA (NK=16.8) (P<.0001). Overall rates of chronic bronchitis were increased in the coal mining region of southwest Virginia when compared with eastern Virginia (29.90% vs 1.50%, NK=21.5) (P<.0001) while individuals employed as coal miners had lower rates of hypertension, heart disease complications, and asthma than non-coal miners. Although inpatients in southwest Virginia were less likely to experience kidney disease than inpatients in eastern Virginia (9.30% vs 10.10%), kidney disease was most prevalent in the south side region at 18.40% (NK=9.4) (P<.0001). Smoking and alcohol use status yielded no statistically significant differences between regions. Preliminary analysis of qualitative data collected from interviews with primary care providers in the single region of Buchanan County indicates that physicians in this region experience difficulty in securing referrals to specialists, patient compliance, patient transportation, and balancing best practice with the financial constraints of the patient population. Preliminary analysis also indicates that physicians are very receptive to assistance in addressing these issues.Conclusion: While each of the 6 regions of southern Virginia studied is similar in the presence of poor health outcomes and poverty, the quantitative results from the review of electronic health records highlight the unique and complex interplay between demographic, geographic, economic, and social determinants of health faced by each community. Providers have indicated that they are struggling to provide optimal care and are open to assistance. It is our hope that identifying and addressing each region as a unique entity will allow for the design of lasting and meaningful interventions that maximize the inherent strengths and minimize the weaknesses of each individual community. Considered as a pilot project, this study will continue to offer valuable insight into next steps to include development of a reproducible modular system to facilitate the efficient and thorough assessment of needs to inform individualized interventions toward improved health outcomes in any community.

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