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Can telehealth solve rural health issues? Maybe. But only with a mindful approach.

Telehealth’s untapped potential in rural America

Screening for Type 1 diabetes (T1D) may help reduce the risk of people getting seriously ill at the time of diagnosis, yet very few adults are even aware screening exists. In fact, just 14% of adults with T1D say they were screened with an autoantibody test prior to their diagnosis, according to “The Cost of Not Knowing” survey from Beyond Type 1 and commissioned by Sanofi. What’s more, among those who did not screen or whose loved one did not screen, 72% of adults with T1D and 66% of caregivers to children under the age of 18 who live with T1D say they were unaware a T1D autoantibody test was available.

This awareness gap has caused many in the T1D community to find out about their 

 in an emergency setting. Consider that up to 40% of cases of diabetic ketoacidosis (DKA) — a complication of T1D that can be life-threatening — occur in people who are newly diagnosed. In an instant, lives are often turned upside down after a diagnosis of T1D, a chronic autoimmune condition with no known cure that requires 24/7 monitoring and management. With this in mind, it should come as no surprise that 92% of adults with T1D and 96% of caregivers recommend that friends and family members get screened with an early autoantibody test for T1D in order to better understand their risk of developing the condition.

In reality, no one should have to experience the impacts of a sudden diagnosis. People often learn they have 

 only after symptoms are present, but early screening has the power to change that paradigm. It’s time we come together as patient advocates, health care professionals, legislators and more to help build an infrastructure that promotes T1D screening at both a national and local level. We all have a role to play in bridging the gaps. Here’s how health care professionals can support this effort:

Because it occurs in stages, T1D is elusive and can often take months or even years for symptoms to present noticeably, and by that time, someone is likely already in a late stage of the condition. Educating individuals of all ages about not only the symptoms but also the risk factors of T1D is critical, ensuring that those at risk have the knowledge and tools as early as possible to take control of their health.

Accordingly, health care providers (HCPs) can help by proactively making information about T1D and related risk factors readily accessible during annual, routine appointments. As one notable example, T1D has long been referred to as “juvenile diabetes”; however, considering that more than half of new cases of T1D are diagnosed in adults, it’s clear that screening information can (and should) be discussed with people of all ages. Additionally, while health care professionals should absolutely pay close attention to those with a family history of T1D — given that their risk of developing the disease is up to 15 times higher — it’s also important to consider that 90% of people with T1D have no family history at all. By widening the scope of T1D education, health care professionals can make sure as many people as possible are informed about T1D risk factors and help families feel empowered to get screened early.

For many, a sudden diagnosis brings with it significant tangible burdens — like DKA — as well as intangible burdens. According to “The Cost of Not Knowing,” 64% of adults with T1D say their emotional health declined when they first received their diagnosis. Moreover, nearly 9 in 10 caregivers (87%) gave up some of their interests or future plans when they learned of their loved one’s diagnosis, which is also true for 71% of adults with T1D when they learned of their own diagnosis.

Thankfully, knowing sooner can make a difference. A staggering 85% of adults with T1D say their life may have been different had they screened early for T1D and known sooner about their diagnosis, with more than 1 in 3 (34%) stating they may have felt more in control of their health, 28% sharing they may have had more time to prepare, and 20% noting they may have avoided the stress that comes with not knowing. For health care professionals, understanding the value of early detection and its ability to alleviate some of the emotional and social burdens, in addition to the physical tolls, that result from a sudden diagnosis is key to having meaningful discussions with adults and caregivers about why time to prepare for the future could be truly life changing.

Despite the clear benefits of early detection, autoantibody screening for T1D is a largely uncommon practice, which in part can be traced to perceived barriers preventing access. For instance, among adults with T1D and caregivers who were aware of autoantibody tests prior to their diagnosis, 84% of adults with T1D and 78% of caregivers said that barriers prevented them from getting screened. These disparities highlight a clear disconnect between availability and interest that we must collectively address regarding T1D screening. Of course, no single entity can solve this problem alone. However, by working together with HCPs to improve awareness of and access to T1D screening, we can give more individuals valuable insights into their health.

When it comes to T1D, early knowledge is power. Thankfully, as indicated in findings from “The Cost of Not Knowing” survey, knowing sooner has a clear impact, mitigating both the invisible and visible burdens brought on by a sudden T1D diagnosis. For too long, caring for T1D has been reactive. Changing the course of T1D care will require a collective effort to establish an infrastructure that supports proactive screening. Health care professionals are on the front lines of this fight and are key to making this vision a reality.

Kristian Hurley is the senior vice president of programs, advocacy and health equity at Beyond Type 1.

How physicians can help close the awareness gap and support families to screen for type 1 diabetes

Topics

The cost of not knowing about type 1 diabetes

New research from the American Association of Nurse Practitioners (AANP) suggests that the current state of the U.S. health care system is not adequate for helping patients with staying up to date on health screenings and immunizations. The latest AANP survey comes after previous research in April 2023, which found more than 25% of adults had waited more than two months for an appointment with a health care provider. All data come from 

“New Poll Shows a Large Number of Patients Are Not Getting Health Screenings”

The American Association of Nurse Practitioners (AANP) highlights inadequacies in the U.S. healthcare system regarding timely health screenings and immunizations. Recent findings indicate that over 25% of adults experienced delays exceeding two months for healthcare appointments. This underscores systemic inefficiencies impacting patient access to essential preventive services. The data emphasizes the need for improvements in healthcare delivery to ensure timely access to screenings and immunizations, which are crucial for maintaining public health and preventing disease progression.

New research from the American Association of Nurse Practitioners affirms the current problems of the U.S. health care system, as well as some improvements from 2023.

Patient Retention

Lack of patient health screenings – findings from the American Association of Nurse Practitioners

Rebecca Hartman, MD, MPH, explains how Dermasensor works to identify skin cancer

The first health care professional to examine a skin lesion that appears suspicious to a patient is most frequently the primary care clinician. Whether the lesion is of greater concern than a normal dermatologic variation or perhaps an age-related change will be the frontline clinician's next assessment, followed by a decision to watch or to make a referral to a specialist.

® dermatologist Rebecca Hartman, MD, MPH, described 

, a new FDA-approved handheld, AI-based device designed to scan and assess skin lesions in the primary care clinical setting. The device returns 1 of 2 responses following a scan: “Investigate Further,” indicating a referral, or “Monitor,” an outcome which could help rule out a majority of unnecessary referrals for benign lesions.

In the short video above, Hartman describes the device technology and highlights its sensitivity and specificity when used in primary care.

Primary care clinicians are often the first to evaluate suspicious skin lesions, determining whether they warrant further investigation or specialist referral. DermaSensor, a newly FDA-approved handheld AI device, assists in this decision-making process by scanning lesions and providing a recommendation to either "Investigate Further" or "Monitor." This tool aims to reduce unnecessary referrals for benign lesions. Dermatologist Rebecca Hartman, MD, MPH, emphasizes the device's sensitivity and specificity, making it a valuable asset in primary care settings for assessing skin lesions.

DermaSensor is a new FDA-approved handheld that is designed to scan and assess skin lesions in the primary care clinical setting. Rebecca Hartman, MD, MPH, describes how it works.

A new handheld device uses AI to screen for skin cancer: Dermatologist explains how it works

 out of Dell Medical School at The University of Texas at Austin and CommUnityCare Health Centers, is working to overcome barriers to care for low-income, uninsured and minority populations in Central Texas. The effort aims to reduce disparities in lung cancer outcomes. The patient-first approach offers bilingual support, mailed outreach and no-cost screening for patients.

“Federally Qualified Health Centers like CommUnityCare serve a higher-risk population, making them great places to offer cancer screening and help people quit smoking,” Brandon Altillo, M.D., assistant professor of internal medicine and population health at Dell Medical School and a provider at CommUnityCare, said in a news release. “But there are still significant barriers, including the cost of screening and limited access to specialists. Many patients also face stress from poverty, which can make it harder to focus on preventative care.”

American Journal of Preventative Medicine

. More than 700 eligible patients aged 55 to 77 with at least a 20-year history of smoking, were identified in the program. From 2020 to 2023, team members from Dell Medical School implemented a multicomponent intervention, promoting equitable access to lung cancer screenings by intentionally removing any financial, language and logistical barriers. 

Of the patients who agreed to the screening, 83% completed their low-dose CT scans. The report did not indicate any significant differences in completion rates across age groups, genders, races/ethnicities or insurance statuses. Nearly half (49%) of current smokers engaged in cessation counseling, and 31% of them reported that they were quitting smoking.

“Our focus was not just on increasing lung cancer screenings, but on ensuring that those most at risk – particularly those with financial or language barriers – could access care,” Altillo said. “This program demonstrates that with targeted interventions, we can close gaps in health care and save lives.”

According to the release, lung cancer is the deadliest form of cancer in the U.S., with more than 125,000 deaths projected by the end of 2024. Black, low-income, and less-educated populations face even higher mortality rates. The program was funded by a grant from the Cancer Prevention & Research Institute of Texas, and has plans to expand to more Texans, offering lung cancer screenings and smoking cessation support for high-risk communities across the state.

A lung cancer screening initiative by Dell Medical School and CommUnityCare Health Centers targets low-income, uninsured, and minority populations in Central Texas to reduce disparities in lung cancer outcomes. The program offers bilingual support, mailed outreach, and no-cost screenings, addressing financial, language, and logistical barriers. From 2020 to 2023, over 700 eligible patients were identified, with 83% completing low-dose CT scans. Nearly half of current smokers engaged in cessation counseling. The initiative aims to expand statewide, supported by a grant from the Cancer Prevention & Research Institute of Texas.

The approach offers bilingual support, mailed outreach, and no-cost screening.

New lung cancer screening initiative looks to increase access to care

Over the course of the past 40 years, the 

 (USPSTF or Task Force), an independent, volunteer panel of national experts in the fields of prevention, primary care and evidence-based medicine, has offered nearly 300 evidence-based recommendations meant to improve the quality of care provided to people of all ages. Recently, the organization released its

, in which they commemorated the past 40 years with a continued focus on public health across the nation, specifically calling attention to key research gaps in seven of their recommendations from the past year.

The following areas are those identified by the USPSTF in their report as requiring future research to fill gaps which may result in new recommendations, thereby improving the health of patients nationwide:

Primary care interventions to prevent child maltreatment

The USPSTF called for additional research into their recommendation regarding 

primary care interventions to prevent child maltreatment

. The organization believes more studies are required to provide primary care clinicians with a comprehensive understanding of child maltreatment, including possible red flags to look out for, benefits of intervention, intervention methods that effectively prevent child maltreatment and how social factors, race and ethnicity should impact their understanding of situations in order to reduce unintended risk, harm or bias.

Screening for speech and language delay and disorders in children

They also recognized the need for further research into the recommendation to 

screen children for speech and language delay and disorders

. Specifically, they call for additional studies on the treatment of screen-detected children over short and longer periods of time to detect potential improvement in outcomes, like academic performance, social and emotional health or child and family well-being. They advise focusing on high-risk populations in these studies. Further, the Task Force calls for standardization of outcome measurements across studies and research into potential harms of screening and treatment, including possible stigma or anxieties. 

Interventions for high body mass index in children and adolescents

interventions when children and adolescents have high body mass index

 (BMI), the Task Force called for studies to determine how beneficial behavioral and pharmacotherapy interventions are after two years, as well as the long-term harms of behavioral interventions and pharmacotherapy, respectively. They would also like to establish best practices for both initial and ongoing weight-related discussions with children, adolescents and their families, in addition to the ideal timing for interventions regarding weight management, hoping to understand whether there are ideal ages throughout childhood and adolescents when interventions would provide the greatest benefit.

Screening and preventive interventions for oral health in children, adolescents and adults

The USPSTF advocated for screening and preventative interventions for oral health in 

. They have now expressed their interest in additional studies which provide information on the effectiveness and potential downsides of primary care-based oral health screening strategies and oral health outcomes. Further, they want to know how accurate primary care-based oral examinations are in predicting and identifying oral health conditions in children, in addition to the effectiveness of various oral health preventive interventions and the impact that oral health education has on oral health outcomes.

Screening and supplementation for iron deficiency and iron deficiency anemia during pregnancy

The Task Force also expressed the need for additional research into their recommendation of 

screening and supplementation for iron deficiency anemia during pregnancy

. Specifically, they’re curious whether changes in the mother’s iron status result in improved health outcomes for the mother or the infant in primary care settings. They also wish to fill gaps regarding the potential benefits and harms of screening for iron deficiency during pregnancy, routine iron supplementation in asymptomatic pregnant persons and treating for iron deficiency in asymptomatic, screen-detected populations. The USPSTF would also like to uncover any possible relationship between social determinants of health (SDOH) and risk factors for iron deficiency.

The organization also advocated for additional research into their recommendation that primary care clinicians 

. They would like to learn more about the benefits and harms of breast cancer screens in women age 75 and older. The group would also like to establish the best strategy for breast cancer screening in women found to have dense breasts on a screening mammogram, a common occurrence, as well as the benefits and harms of supplemental screening compared with supplemental care for women with dense breasts.

Regarding higher-risk populations, they called for additional research into why breast cancer mortality is higher among Black women, why Black women are more likely to be diagnosed with breast cancers that have biomarker patterns indicating poor health outcomes, how variations in care result in increased risk of breast cancer morbidity and mortality in Black women and whether benefits differ for annual vs biennial breast cancer screenings among women overall, when compared with Black women, specifically. More research is also advised regarding approaches to reduce the risk of overdiagnosis leading to overtreatment of breast lesions, which may not otherwise be as harmful, including ductal carcinoma in situ (DCIS), as well as further research into DCIS, and its potential to progress to invasive breast cancer.

Interventions for falls prevention in community-dwelling older adults

The USPSTF recommends that primary care clinicians 

talk with community-dwelling older adults for the purpose of preventing falls

. They expressed the need for additional research into feasible risk assessment tools for accurate risk predictions for falls in community-dwelling adults over 65 years old. They would also like to compare the benefits and harms of interventions involving exercise, methods to potentially improve the availability of fall prevention interventions, the effectiveness and harms of interventions in different functional groups and the benefits and harms of interventions that are solely educational and psychological.

The Task Force concluded their report by discussing their plans over the coming year, which include developing and releasing new recommendation statements and coordinating with partners to develop and disseminate their new recommendations. Specifically, they shared their plans to continue work on 23 topics currently 

, work on three topics from the public topic nomination process, post four draft research plans, eight draft recommendation statements with evidence reports for public comments and publish ten final and official recommendation statements. The organization will coordinate with the USPSTF Dissemination and Implementation Partners and Federal Liaisons to disseminate recommendations to primary care clinicians, continue work to address key research gaps and produce next year's 15th Annual Report to Congress.

The U.S. Preventive Services Task Force (USPSTF) has released its 14th Annual Report, highlighting key research gaps in seven areas to improve public health. These areas include primary care interventions for child maltreatment, screening for speech and language disorders, interventions for high BMI in youth, oral health screenings, iron deficiency screening during pregnancy, breast cancer screening, and fall prevention in older adults. The report outlines plans for future research and collaboration to address these gaps, aiming to enhance healthcare outcomes and develop new recommendations for primary care clinicians.

The U.S. Preventive Services Task Force highlights key research gaps in their recommendations intended to promote public health for all.

USPSTF releases the 14th Annual Report to Congress on High-Priority Evidence Gaps for Clinical Preventive Services

Primary care practitioners (PCPs) are often the first health care professionals to encounter cognitive concerns in patients, and therefore play a crucial role in recognizing cognitive impairment. However, most cases of Alzheimer’s disease (AD) and mild cognitive impairment (MCI) are not diagnosed by their PCPs, meaning that these individuals do not receive interventions that could slow or prevent further decline or address other health risks related to cognitive impairment. AD and related dementias (ADRD) are a major cause of morbidity and mortality, in addition to being one of the costlier conditions to society.

Thus far, two risk assessment tools have been developed, although neither have been validated in primary care settings. A third tool, which uses electronic health record (EHR) data, is currently being tested. There are several cognitive screening tests currently available, but further research is required to determine their accuracy, particularly in cases of MCI in primary care settings.

, hosted by the National Academy of Neuropsychology, analyzed and presented key points and knowledge gaps regarding methods for detecting cognitive impairment in primary care settings. Summit participants propose a novel workflow to facilitate improved detection of cognitive impairment during routine primary care visits, focused on the annual wellness visit, which is available to Medicare beneficiaries, in addition to further opportunities for clinical practice and research.

The global population is getting older, thus the prevalence of cognitive impairment impacting overall health and independence is also rising dramatically. According to a study published in 

Alzheimer’s & Dementia: The Journal of The Alzheimer’s Association

, the number of people living with AD is projected to double to as many as 14 million people by 2060 in the United States alone. Despite increased prevalence of cognitive impairment, it remains under-recognized and under-treated, with as many as 

 going undetected by PCPs. For patients who are Black or Hispanic, have early-onset dementia or mild MCI, detection rates are even lower.

Currently, the most frequently used cognitive screening test in primary care is the Mini-Mental State Examination (MMSE), which, according to the article, is outperformed by other tests and is recommended to be replaced. The Montreal Cognitive Assessment (MoCA) is the most well validated cognitive screening test in population-based cohorts, yet its validity is limited in heterogenous groups of older adults.

 projects there to be nearly 95 million people aged older than 65 by 2060. Despite this, there are only approximately 500,000 PCPs. Therefore, screening the entire population of people aged older than 65, annually, is neither feasible nor supported by any evidence available in the research. Participants of the 2022 summit instead recommend using a tool to identify a higher-prevalence and at-risk pool of the population to be screened.

No one screening approach will meet the needs of the entire population, and more research is required to tailor screenings to the settings in which they are used. That said, the ideal cognitive screening test would be automated—to save PCPs time and avoid human error in scoring and interpretation—and include each of the following criteria:

Minimal training required to administer, score and interpret.

Minimally affected by external factors unrelated to cognitive impairment.

Primary care practitioners are pivotal in identifying cognitive impairment, yet many Alzheimer's and mild cognitive impairment cases remain undiagnosed, missing opportunities for early intervention. Current cognitive screening tools lack validation in primary care, necessitating further research. The aging population exacerbates the prevalence of cognitive impairment, with significant under-detection, especially among minority groups. Summit participants propose a workflow for early detection, emphasizing risk stratification and a multi-visit assessment pathway. Engaging stakeholders, including healthcare systems and families, is crucial for effective management and early detection of cognitive impairment in primary care settings.

14 million Americans will have Alzheimer’s disease by 2060, and many cases of cognitive impairment go undetected by PCPs. Key points from a recent summit offer new insights into screening methods. 

Deanna Larson

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