Jessica A. Parascando

Purpose: Of the 88 million American adults with prediabetes, 1.5 million transition to type 2 diabetes annually. Lifestyle changes could delay progression to type 2 diabetes development. Glycemic Excursion Minimization/Glucose Everyday Matters (GEM) is a self-guided intervention that empowers individuals via a guide paired with a continuous glucose monitor and activity monitor to understand how dietary and activity choices impact their blood glucose excursions. This qualitative study aimed to explore participant perspectives and experiences of GEM. Design: Semi-structured qualitative interviews. Setting: The study was conducted at an urban medical center. Interviews took place via HIPAA compliant Zoom. Participants: Participants from a larger clinical trial who completed the GEM intervention for prediabetes (n = 16). Method: Interviews were audio-recorded and transcribed. Using two coders, iterative cycles of inductive thematic analysis was performed to yield overarching themes related to the GEM guide and intervention. Results: Analysis of 16 interviews revealed five major themes which highlighted the positive outcomes in health status, disease insight and support experienced during the GEM trial. Conclusion: Key findings included increased knowledge on the relationship between lifestyle choices and glucose excursions, and positive insight on the GEM intervention and its components. Feedback from this study will be incorporated into further adoption of the GEM intervention for a prediabetes population.

Few primary care practices have access to clinical pharmacists and certified diabetes care and education specialists (CDCESs), despite the critical role they play in diabetes management. Diabetes technologies, including Continuous Glucose Monitors (CGMs), are associated with improved patient outcomes; however, disparities exist in obtaining CGMs for primary care patients compared with endocrinology patients. To address this barrier, a virtual CGM Initiation Service (virCIS) was created and implemented in primary care practices in Colorado. Clinical pharmacists served key roles in service implementation, including leading virtual visits for CGM initiation and data interpretation, providing patient education about CGM results and potential therapy implications, creating education and actionable recommendations for primary care providers and assistance with the CGM prescription coverage process. Implementation of this model supported patient access to CGMs, while providing comprehensive patient and provider education about CGM use. Overcoming the multitude of CGM coverage barriers identified led to the development of recommended practices for CGM coverage.

The iLet Bionic Pancreas system can improve glycemia in individuals with type 1 diabetes with its simple interface, setup, and maintenance, making it practical for use in the primary care setting and via telehealth (TH). This multisite, random-order crossover trial included 40 adults with type 1 diabetes who received care either from an endocrinology or a primary care clinic and were seen either in person or via TH. Of these 40 participants, 97% achieved an average glucose (AG) <183 mg/dL, and 64% achieved an AG <154 mg/dL. These results suggest that the system can be initiated effectively by primary care providers and via TH, potentially expanding access to this technology to a broad population, including individuals who cannot easily access subspecialty diabetes care.

This qualitative substudy sought to identify and understand the experiences of primary care patients with type 1 diabetes using the iLet Bionic Pancreas (Beta Bionics, Inc.) during the first clinical trial testing the automated insulin delivery (AID) system in the primary care setting. Participants in that clinical trial completed a brief semi-structured interview after the trial’s completion, during which they were asked questions related to their perceptions of and experiences with using the iLet AID system. Analysis of 16 interviews revealed five major themes, which highlighted the positive and beneficial impact of the system on psychological and behavioral aspects of diabetes management.

Introduction: Inadequate scholarship is a common concern in graduate medical education. Many barriers to scholarship have been identified, but there are limited data on which are most important. A rank-order of barriers from learners’ perspectives would better enable programs to address perceived barriers. Methods: Given that learners are experts in their own perceptions, we applied the Delphi method of generating consensus expert opinion to construct ranked lists of physician-perceived barriers to scholarly activity at various sites. The survey was conducted within three separate health systems. Respondents were asked to identify their perceived barriers via free text and the listed barriers were consolidated by the research team. In the second round, respondents were presented with the consolidated lists and asked to rank them. In the third and final round, each respondent was shown a comparison of their own rankings to that of their peers and given an opportunity to make changes. Ranking differences between programs were compared using Rank Biased Overlap (RBO). Results: The Delphi method is a straightforward method to obtain a ranked list of perceived learner barriers to scholarly activity; its primary limitation is learner engagement and, of note in our study, high dropout rates. RBO is an effective method of ranking differences between programs and specialties. Top barriers across programs included time, overwhelm with the research process, and lack of interest or energy. Discussion: Several of the identified barriers may be addressed with enthusiastic mentors, streamlined administrative processes, and education. This could be done within a hospital system or on a national level through specialty organizations.

Context Osteopathic manipulative treatment (OMT) is utilized by clinicians to diagnose and treat a variety of musculoskeletal conditions including acute and chronic pain, and other medical conditions. Previous studies have examined attitudes of allopathic (MD) residents toward OMT and have implemented residency-based curricula; however, literature is lacking on the attitudes of MD students toward OMT. Objectives The objective of this study was to determine MD students’ familiarity with OMT and to evaluate their interest in an elective osteopathic curriculum. Methods A 15-item online survey was electronically sent to 600 MD students at a large allopathic academic medical center. The survey assessed familiarity with OMT, interest in OMT and in participating in an OMT elective, educational format preference, and interest in pursuing primary care. Educational demographics were also collected. Descriptive statistics and Fisher’s exact test were utilized for categorical variables, and nonparametric tests were utilized for the ordinal and continuous variables. Results A total of 313 MD students submitted responses (response rate=52.1 %), of which 296 (49.3 %) responses were complete and utilized for analysis. A total of 92 (31.1 %) students were aware of OMT as a modality in treating musculoskeletal disorders. Among the respondents who indicated “very interested” in learning a new pain treatment modality, the majority: (1) observed OMT in a prior clinical or educational setting (85 [59.9 %], p=0.02); (2) had a friend or family member treated by a DO physician (42 [71.2 %], p=0.01); (3) were pursuing a primary care specialty (43 [60.6 %], p=0.02); or (4) interviewed at an osteopathic medical school (47 [62.7 %], p=0.01). Among those interested in developing some OMT competency, the majority: (1) were pursuing a primary care specialty (36 [51.4 %], p=0.01); (2) applied to osteopathic schools (47 [54.0], p=0.002); or (3) interviewed at an osteopathic medical school (42 [56.8 %], p=0.001). A total of 230 (82.1 %) students were somewhat or very interested in a 2-week elective course in OMT; among all respondents, hands-on labs were the preferred method for delivery of OMT education (272 [94.1 %]). Conclusions The study found a strong interest in an OMT elective by MD students. These results will inform OMT curriculum development aimed at interested MD students and residents in order to provide them with OMT-specific theoretical and practical knowledge.

Objective: Pre-exposure prophylaxis (PrEP) is a recommended strategy for HIV prevention, yet PrEP prescribing rates in primary care remain low. The aim of this study was to further describe the current knowledge, attitudes, and prescribing behaviors of HIV PrEP in primary care providers with a focus on the perceived barriers and facilitators to PrEP prescribing. Methods: Cross-sectional survey of primary care providers at rural and suburban practices in a large academic institution. Results: Survey response rate was 48.0% (n = 134). Most respondents (96.3%) reported little clinical experience in care of persons living with HIV. Respondents self-reported positive attitudes and high overall knowledge of PrEP with low prescribing rates and less comfort with lab testing. More respondents are asked about PrEP by patients (54%) than start conversations about PrEP with patients (39%). Family Physicians and providers 5 to 10 years from completion of training overall reported higher knowledge, attitudes and prescribing behaviors. Lack of PrEP education was identified as the greatest barrier and an electronic medical record order set as the greatest facilitator to prescribing PrEP. Conclusions: With the goal to end the HIV epidemic, PrEP provision in nonurban primary care settings may be an important strategy for increased access to PrEP and reduced HIV transmission. This study, which includes a variety of providers that possess high knowledge, yet low experience prescribing PrEP, likely demonstrates the limitations of interventions which solely focus on provider education. System-based practice solutions, such as order sets, may be needed to target infrequent prescribers of PrEP.

Nutrition is an integral part of diabetes management. Caregiver nutritional knowledge has been implicated in glycemic management of youth with type 1 diabetes. This study assessed the nutritional knowledge of parents/caregivers of children newly diagnosed with type 1 diabetes. Findings suggest there is a need for more targeted support and training during the initial diagnosis and a desire for more technology-related resources such as virtual nutritionist-guided grocery shopping visits. Integrating these interventions into routine care for children with type 1 diabetes will help address the current gaps in caregiver nutritional literacy and their ability to provide appropriate care.

Context: The COVID-19 pandemic created unique challenges for medical education, especially when providing clinical experiences for students in Accelerated Pathway Programs (APP). To accommodate these accelerated medical students, Penn State’s Family Medicine Department used its experience with virtual rounds to create an authentic clinical experience (ACE), complete with interdisciplinary education with pharmacy students. Objective: Provide a virtual ACE for APP students during a period of quarantine to better prepare them for return to in-person clinical encounters. Study Design: Qualitative study with post-interview debriefings. Setting: Inpatient Family Medicine Acute Care Unit (FAMCU). Population: APP students on their Family Medicine clerkship. Intervention: Virtual rounds using a secure HIPAA-compliant Zoom connection with pharmacy students were conducted on patients admitted to the FAMCU. The ACE included pre-rounding and chart review, patient interviews, post-interview debriefing, and completion of a brief recorded virtual handoff (transitional care note) for the patient’s primary provider. Outcome Measures: Competencies of Communication with the Care Team and Communication with Patients/Families. Students received immediate feedback on their interview and communication with the patient during the post-interview debriefing. Results: Six accelerated students participated in this program. The APP students found virtual rounds to be a valuable experience to prepare them for future clinical encounters during a time when quarantine prevented in-person clinical encounters. Conclusions: The post virtual round debriefings were conducted by either the unit Pharmacist or the Associate Medical Director of the FAMCU, and included the Pharmacy and APP students. During the debriefings both the Pharmacy and APP students reported an appreciation for remotely interviewing real patients versus completing a simulated exercise or case study, and they valued the ability to interact and learn from other disciplines. The virtual learning experiences that have been utilized to supplement medical education during the COVID-19 pandemic have proven their worth for enhancing student engagement and ensuring achievements of necessary competencies. While virtual clinical experiences cannot fully take the place of in-person clinical education, virtual activities can definitely add value to medical education and training.

Background: Self-management of type 1 diabetes (T1D) requires numerous decisions and actions by people with T1D and their caregivers and poses many daily challenges. For those with T1D and a developmental disorder such as autism spectrum disorder (ASD), more complex challenges arise, though these remain largely unstudied. Objective: This study aimed to better understand the barriers and facilitators of raising a child with T1D and ASD. Secondary analysis of web-based content (phase 1) and telephone interviews (phase 2) were conducted to further expand the existing knowledge on the challenges and successes faced by these families. Methods: Phase 1 involved a qualitative analysis of publicly available online forums and blog posts by caregivers of children with both T1D and ASD. Themes from phase 1 were used to create an interview guide for further in-depth exploration via interviews. In phase 2, caregivers of children with both T1D and ASD were recruited from Penn State Health endocrinology clinics and through the web from social media posts to T1D-focused groups and sites. Interested respondents were directed to a secure web-based eligibility assessment. Information related to T1D and ASD diagnosis, contact information, and demographics were collected. On the basis of survey responses, participants were selected for a follow-up telephone interview and were asked to complete the adaptive behavior assessment system, third edition parent form to assess autism severity and upload a copy of their child’s most recent hemoglobin A1c (HbA1c) result. Interviews were transcribed, imported into NVivo qualitative data management software, and analyzed to determine common themes related to barriers and facilitators of raising a child with both ASD and T1D. Results: For phase 1, 398 forum posts and blog posts between 2009 and 2016 were analyzed. Common themes related to a lack of understanding by the separate ASD and T1D caregiver communities, advice on coping techniques, rules and routines, and descriptions of the health care experience. For phase 2, 12 eligible respondents were interviewed. For interviewees, the average age of the child at diagnosis with T1D and ASD was 7.92 years and 5.55 years, respectively. Average self-reported and documented HbA1c levels for children with T1D and ASD were 8.6% (70 mmol/mol) and 8.7% (72 mmol/mol), respectively. Common themes from the interviews related to increased emotional burden, frustration surrounding the amount of information they are expected to learn, and challenges in the school setting. Conclusions: Caregivers of children with both T1D and ASD face unique challenges, distinct from those faced by caregivers of individuals who have either disorder alone. Understanding these challenges may help health care providers in caring for this unique population. Referral to the diabetes online community may be a potential resource to supplement the care received by the medical community.