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1.  Dental Opioid Prescribing and Multiple Opioid Prescriptions Among Dental Patients: Administrative data from the South Carolina Prescription Drug Monitoring Program 
Despite increased attention to dentists’ role in curbing opioid misuse, abuse, and diversion, information regarding prescribing practices and the frequency of multiple concurrent opioid prescriptions among dental patients is limited.
Prescription drug monitoring program (PDMP) data for South Carolina representing dispensed medication for patients prescribed at least one opioid by a dentist over the most recently available two-year frame (2012–2013) was reviewed. Descriptive analyses examined: (1) types, frequency of dental opioid prescriptions; and, (2) frequency of existing multiple concurrent opioid prescriptions among dental patients.
Nearly all dispensed dental opioid prescriptions (99.9%; n = 653,650) were for immediate release opioids and were initial fills (96.2%). Hydrocodone (76.1%) and oxycodone (12.2%) combination products were the most frequently dispensed opioids prescribed by dentists. Individuals under 21 years of age received 11.2% of dentist prescribed opioids dispensed. Patients with multiple concurrent opioid prescriptions were identified within 30-day (n=113,818), 90-day (n=166,124), and 180-day (n=205,576) timeframes.
Dentists prescribed a high volume of immediate release opioids dispensed in South Carolina. A notable minority of dental patients had incident(s) of multiple pre-existing opioid prescriptions, a factor implicated in patient misuse, abuse, overdose, and diversion
Practical Implications
Use of a PDMP prior to prescribing provides a record of controlled substances dispensed to a patient, and may inform prescribing, coordination of care, and addiction screening or referral. Patients should be provided information regarding misuse behaviors and their risks, as well as the importance of secure storage and disposal of leftover opioid medications.
PMCID: PMC4925262  PMID: 27055600
Oxycodone; Patient Education; Prescriptions; Drug
2.  Health Information Exchange in the ED: What Do ED Clinicians Think? 
Southern medical journal  2016;109(7):419-426.
Our regional health information exchange (HIE), known as Carolina eHealth Alliance (CeHA)-HIE, serves all major hospital systems in our region and is accessible to emergency department (ED) clinicians in those systems. We wanted to understand reasons for low CeHA-HIE utilization and explore options for improving it.
We implemented a 24-item user survey among ED clinician users of CeHA-HIE to investigate their perceptions of system usability and functionality, the quality of the information available through CeHA-HIE, the value of clinician time spent using CeHA-HIE, the ease of use of CeHA-HIE, and approaches for improving CeHA-HIE.
Of the 231 ED clinicians surveyed, 51 responded, and among those, 48 reported having used CeHA-HIE and completed the survey.
Results show most ED clinicians believed that CeHA-HIE was easy to use and added value to their work, but they also desired better integration of information available from CeHA-HIE into their system’s electronic medical record.
PMCID: PMC4933330  PMID: 27364028
health information exchange; emergency department; HIE user input; emergency department providers; system usability/functionality
3.  Endocrine therapy initiation among Medicaid-insured breast cancer survivors with hormone receptor-positive tumors 
Hormone receptor positive (HR+) cancers account for most breast cancer diagnoses and deaths. Among survivors with HR+ breast cancers, endocrine therapy (ET) reduces 5-year risk of recurrence by up to 40%. Observational studies in Medicare and privately-insured survivors suggest under-utilization of ET. We sought to characterize ET use in a low-income Medicaid-insured population in North Carolina.
Medicaid claims data were matched to state cancer registry records for survivors ages 18–64 diagnosed with stage 0-II HR+ breast cancer from 2003–2007, eligible for ET, and enrolled in Medicaid for at least 12 of 15 months post-diagnosis. We used multivariable logistic regression to model receipt of any ET medication during 15-months post-diagnosis controlling for age, race, tumor characteristics, receipt of other treatments, co-morbidity, residence, reason for Medicaid eligibility, involvement in the Breast and Cervical Cancer Control Program (BCCCP), and diagnosis year.
Of 222 women meeting inclusion criteria, only 50% filled a prescription for ET. Involvement in BCCCP and earlier year of diagnoses were associated with significantly higher odds of initiating guideline-recommended ET (Adjusted Odds Ratio [AOR] for BCCCP: 3.76, 95%CI: 1.67–8.48; AOR for 2004 relative to 2007: 2.80, 95%CI: 1.03–7.62; AOR for 2005 relative to 2007: 2.11, 95%CI: 0.92–4.85).
Results suggest substantial under-utilization of ET in this population. Interventions are needed to improve timely receipt of ET and to better support survivors taking ET.
Implications of cancer survivors
Low-income survivors should be counseled on the importance of ET and offered support services to promote initiation and long-term adherence.
PMCID: PMC4970579  PMID: 24866922
Endocrine Therapy; Breast Cancer; Medicaid; Survivorship
4.  A Comprehensive View of Frequent Emergency Department Users Based on Data from a Regional HIE 
Southern medical journal  2016;109(7):434-439.
A small but significant number of patients make frequent emergency department (ED) visits to multiple EDs within a region. We have a unique health information exchange (HIE) that includes every ED encounter in all hospital systems in our region. Using our HIE we were able to characterize all frequent ED users in our region, regardless of hospital visited or payer class. The objective of our study was to use data from an HIE to characterize patients in a region who are frequent ED users (FEDUs).
We constructed a database from a cohort of adult patients (18 years old or older) with information in a regional HIE for a 1-year period beginning March 2012.A Patients were defined as FEDUs (those who made four or more visits during the study period) and non-FEDUs (those who made fewer than four ED visits during the study period). Predictor variables included age, race, sex, payer class, county of residence, and International Classification of Diseases, Ninth Revision (ICD-9) codes. Bivariate (χ2) and multivariate (logistic regression) analyses were performed to determine associations between predictor variables and the outcome of being an FEDU.
The database contained 127,672 patients, 12,293 (9.6%) of whom were FEDUs. Logistic regression showed the following patient characteristics to be significantly associated with the outcome of being an FEDU: age 35 to 44 years; African American race; Medicaid, Medicare, and dual-pay payer class; and ICD-9 codes 630 to 679 (complications of pregnancy, childbirth, and puerperium), 780 to 799 (ill-defined conditions), 280 to 289 (diseases of the blood), 290–319 (mental disorders), 680 to 709 (diseases of the skin and subcutaneous tissue), 710 to 739 (musculoskeletal and connective tissueB disease), 460 to 519 (respiratory disease), and 520 to 579 (digestive disease). No significant differences were noted between men and women.
Data from an HIE can be used to describe all of the patients within a region who are FEDUs, regardless of the hospital system they visited. This information can be used to focus care coordination efforts and link appropriate patients to a medical home. Future studies can be designed to learn the reasons why patients become FEDUs, and interventions can be developed to address deficiencies in health care that result in frequent ED visits.
PMCID: PMC4933324  PMID: 27364030
health information exchange; physician adoption; information sharing; electronic medical record; information technology
5.  When Should ED Physicians Use an HIE? Predicting Presence of Patient Data in an HIE 
Southern medical journal  2016;109(7):427-433.
Health information exchanges (HIEs) make possible the construction of databases to characterize patients as multisystem users (MSUs), those visiting emergency departments (EDs) of more than one hospital system within a region during a 1-year period. HIE data can inform an algorithm highlighting patients for whom information is more likely to be present in the HIE, leading to a higher yield HIE experience for ED clinicians and incentivizing their adoption of HIE. Our objective was to describe patient characteristics that determine which ED patients are likely to be MSUs and therefore have information in an HIE, thereby improving the efficacy of HIE use and increasing ED clinician perception of HIE benefit.
Data were extracted from a regional HIE involving four hospital systems (11 EDs) in the Charleston, South Carolina area. We used univariate and multivariable regression analyses to develop a predictive model for MSU status.
Factors associated with MSUs included younger age groups, dual-payer insurance status, living in counties that are more rural, and one of at least six specific diagnoses: mental disorders; symptoms, signs, and ill-defined conditions; complications of pregnancy, childbirth, and puerperium; diseases of musculoskeletal system; injury and poisoning; and diseases of the blood and blood-forming organs. For patients with multiple ED visits during 1 year, 43.8% of MSUs had ≥4 visits, compared with 18.0% of non-MSUs (P < 0.0001).
This predictive model accurately identified patients cared for at multiple hospital systems and can be used to increase the likelihood that time spent logging on to the HIE will be a value-added effort for emergency physicians.
PMCID: PMC4933325  PMID: 27364029
health information exchange; physician adoption; information sharing; electronic medical record; information technology
6.  Bridging Research, Practice, and Policy: The ‘Evidence Academy’ Conference Model 
Innovative models to facilitate more rapid uptake of research findings into practice are urgently needed. Community members who engage in research can accelerate this process by acting as adoption agents. We implemented an Evidence Academy conference model bringing together researchers, health professionals, advocates, and policy makers across North Carolina to discuss high-impact, life-saving study results. The overall goal is to develop dissemination and implementation strategies for translating evidence into practice and policy. Each one-day, single-theme, regional meeting focuses on a leading community-identified health priority. The model capitalizes on the power of diverse local networks to encourage broad, common awareness of new research findings. Furthermore, it emphasizes critical reflection and active group discussion on how to incorporate new evidence within and across organizations, health care systems, and communities. During the concluding session, participants are asked to articulate action plans relevant to their individual interests, work setting, or area of expertise.
PMCID: PMC4550583  PMID: 25723874
7.  Dental opioid prescribing practices and risk mitigation strategy implementation: Identification of potential targets for provider-level intervention 
Substance abuse  2015;37(1):9-14.
Given the regular use of immediate release opioids for dental pain management, as well as documented opioid misuse among dental patients, the dental visit may provide a viable point of intervention to screen, identify, and educate patients regarding the risks associated with prescription opioid misuse and diversion. The aims of this statewide survey of dental practitioners were to assess: (a) awareness of the scope of prescription opioid misuse and diversion; (b) current opioid prescribing practices; (c) use of and opinions regarding risk mitigation strategies; and, (d) use and perceived utility of drug monitoring programs.
This cross-sectional study surveyed dentists (N=87) participating in statewide professional and alumni organizations. Dentists were invited via email and listserv announcement to participate in a one-time, online, 59-item, self-administered survey.
A majority of respondents reported prescribing opioids (n=66; 75.8%). A minority of respondents (n=38; 44%) reported regularly screening for current prescription drug abuse. Dentists reported low rates of requesting prior medical records (n=5; 5.8%). Only 38% (n=33) of respondents had ever accessed a prescription drug-monitoring program (PDMP), and only 4 (4.7%) consistently used a PDMP. Dentists reporting prior training in drug diversion were significantly more likely to have accessed their PDMP, p<0.01. Interest in continuing education regarding assessment of prescription drug abuse/diversion and use of drug monitoring programs was high.
Although most dentists received training related to prescribing opioids, findings identified a gap in existing dental training in the assessment/identification of prescription opioid misuse and diversion. Findings also identified gaps in the implementation of recommended risk mitigation strategies, including screening for prescription drug abuse, consistent provision of patient education, and use of a PDMP prior to prescribing opioids.
PMCID: PMC4816206  PMID: 26675303
Prescription opioids; Dentists; Prescription drug monitoring program
8.  Race and prevalence of large bowel polyps among the low-income and uninsured in South Carolina 
Digestive diseases and sciences  2015;61(1):265-272.
Compared to whites, blacks have higher colorectal cancer (CRC) incidence and mortality rates and are at greater risk for early onset disease. The reasons for this racial disparity are poorly understood, but one contributing factor could be differences in access to high quality screening and medical care.
The present study was carried out to assess whether a racial difference in prevalence of large bowel polyps persists within a poor and uninsured population (n=233, 124 blacks, 91 whites, 18 other) undergoing screening colonoscopy.
Eligible patients were uninsured, asymptomatic, had no personal history of colorectal neoplasia, and were between the ages 45–64 years (blacks) or 50–64 years (whites, other). We examined the prevalence of any adenoma (conventional, serrated) and then difference in adenoma/polyp type by race and age categories.
Prevalence for ≥ 1 adenoma was 37% (95% CI 31%–43%) for all races combined and 36% in blacks < 50 years, 38% in blacks ≥ 50 years, 35% in whites. When stratified by race, blacks had a higher prevalence of large conventional proximal neoplasia (8%) compared to whites (2%) (p-value =0.06) but a lower prevalence of any serrated-like polyp (blacks 18%, whites 32%); p-value=0.02) and sessile serrated adenomas/polyps (blacks 2%, whites 8% chi-square p-value; p=0.05).
Within this uninsured population the overall prevalence of adenomas was high and nearly equal by race, but the racial differences observed between serrated and conventional polyp types emphasizes the importance of taking polyp type into account in future research on this topic.
PMCID: PMC5125220  PMID: 26386856
race; colorectal adenomas; serrated polyps; socioeconomic status; screening
9.  Up in Smoke: Vanishing Evidence of Tobacco Disparities in the Institute of Medicine's Report on Sexual and Gender Minority Health 
American journal of public health  2012;102(11):2041-2043.
The Institute of Medicine (IOM) released a groundbreaking report on lesbian, gay, bisexual, and transgender (LGBT) health in 2011, finding limited evidence of tobacco disparities. We examined IOM search terms and used 2 systematic reviews to identify 71 articles on LGBT tobacco use. The IOM omitted standard tobacco-related search terms. The report also omitted references to studies on LGBT tobacco use (n = 56), some with rigorous designs. The IOM report may underestimate LGBT tobacco use compared with general population use.
PMCID: PMC3477969  PMID: 22994185
10.  Predictors of Participation in Mammography Screening among Non-Hispanic Black, Non-Hispanic White, and Hispanic Women 
Many factors influence women’s decisions to participate in guideline-recommended screening mammography. We evaluated the influence of women’s socioeconomic characteristics, health-care access, and cultural and psychological health-care preferences on timely mammography screening participation.
Materials and methods
A random digit dial survey of United States non-Hispanic Black, non-Hispanic White, and Hispanic women aged 40–75, from January to August 2009, determined self-reported time of most recent mammogram. Screening rates were assessed based on receipt of a screening mammogram within the prior 12 months, the interval recommended at the time by the American Cancer Society.
Thirty-nine percent of women reported not having a mammogram within the last 12 months. The odds of not having had a screening mammography were higher for non-Hispanic White women than for non-Hispanic Black (OR = 2.16, 95% CI = 0.26, 0.82, p = 0.009) or Hispanic (OR = 4.17, 95% CI = 0.12, 0.48, p = 0.01) women. Lack of health insurance (OR = 3.22, 95% CI = 1.54, 6.73, p = 0.002) and lack of usual source of medical care (OR = 3.37, 95% CI = 1.43, 7.94, p = 0.01) were associated with not being screened as were lower self-efficacy to obtain screening (OR = 2.43, 95% CI = 1.26, 4.73, p = 0.01) and greater levels of religiosity and spirituality (OR = 1.42, 95% CI = 1.00, 2.00, p = 0.05). Neither perceived risk nor present temporal orientation was significant.
Odds of not having a mammogram increased if women were uninsured, without medical care, non-Hispanic White, older in age, not confident in their ability to obtain screening, or held passive or external religious/spiritual values. Results are encouraging given racial disparities in health-care participation and suggest that efforts to increase screening among minority women may be working.
PMCID: PMC5012250  PMID: 27656640
risk factors; cancer; mammography; screening; health knowledge; attitudes; practice
11.  Promoting Tobacco Use Cessation for Lesbian, Gay, Bisexual, and Transgender People 
Lesbian, gay, bisexual, and transgender (LGBT) people are at increased risk for the adverse effects of tobacco use given their high prevalence of use, especially smoking. Evidence regarding cessation is limited. To determine if efficacious interventions are available and to aid the development of interventions, a systematic review was conducted of gray and peer-reviewed literature describing clinical, community, and policy interventions as well as knowledge, attitudes, and behaviors regarding tobacco use cessation among LGBT people.
Evidence acquisition
Eight databases for articles from 1987 to April 23, 2014 were searched. In February–November 2013, authors and researchers were contacted to identify gray literature.
Evidence synthesis
The search identified 57 records, of which 51 were relevant and 22 were from the gray literature; these were abstracted into evidence tables, and a narrative synthesis was conducted in October–May 2014. Group cessation curricula tailored for LGBT populations were found feasible to implement and show evidence of effectiveness. Community interventions have been implemented by and for LGBT communities; although these interventions showed feasibility, no rigorous outcome evaluations exist. Clinical interventions show little difference between LGBT and heterosexual people. Focus groups suggest that care is needed in selecting messaging used in media campaigns.
LGBT-serving organizations should implement existing evidence-based tobacco dependence treatment and clinical systems to support treatment of tobacco use. A clear commitment from government and funders is needed to investigate whether sexual orientation and gender identity moderate the impacts of policy interventions, media campaigns, and clinical interventions.
PMCID: PMC4255587  PMID: 25455123
12.  Promoting Public Health Through State Cancer Control Plans: A Review of Capacity and Sustainability 
The Centers for Disease Prevention and Control’s National Comprehensive Cancer Control (CCC) Program oversee CCC programs designed to develop and implement CCC plans via CCC coalitions, alliances, or consortia of program stakeholders. We reviewed 40 up-to-date plans for states and the District of Columbia in order to assess how capacity building and sustainability, two evidence-based practices necessary for organizational readiness, positive growth, and maintenance are addressed. We employed an electronic key word search, supplemented by full text reviews of each plan to complete a content analysis of the CCC plans. Capacity is explicitly addressed in just over half of the plans (53%), generally from a conceptual point of view, with few specifics as to how capacity will be developed or enhanced. Roles and responsibilities, timelines for action, and measurements for evaluation of capacity building are infrequently mentioned. Almost all (92%) of the 40 up-to-date plans address sustainability on at least a cursory level, through efforts aimed at funding or seeking funding, policy initiatives, and/or partnership development. However, few details as to how these strategies will be implemented are found in the plans. We present the Texas plan as a case study offering detailed insight into how one plan incorporated capacity building and sustainability into its development and implementation. Training, technical assistance, templates, and tools may help CCC coalition members address capacity and sustainability in future planning efforts and assure the inclusion of capacity building and sustainability approaches in CCC plans at the state, tribal, territorial, and jurisdiction levels.
PMCID: PMC4364080  PMID: 25853114
cancer prevention and control; capacity; sustainability; state plans; evidence-based practices
13.  Impact of a Health Information Exchange on Resource Use and Medicare-Allowable Reimbursements at 11 Emergency Departments in a Midsized City 
Use clinician perceptions to estimate the impact of a health information exchange (HIE) on emergency department (ED) care at four major hospital systems (HS) within a region. Use survey data provided by ED clinicians to estimate reduction in Medicare-allowable reimbursements (MARs) resulting from use of an HIE.
We conducted the study during a one-year period beginning in February 2012. Study sites included eleven EDs operated by four major HS in the region of a mid-sized Southeastern city, including one academic ED, five community hospital EDs, four free-standing EDs and 1 ED/Chest Pain Center (CPC) all of which participated in an HIE. The study design was observational, prospective using a voluntary, anonymous, online survey. Eligible participants included attending emergency physicians, residents, and mid-level providers (PA & NP). Survey items asked clinicians whether information obtained from the HIE changed resource use while caring for patients at the study sites and used branching logic to ascertain specific types of services avoided including laboratory/microbiology, radiology, consultations, and hospital admissions. Additional items asked how use of the HIE affected quality of care and length of stay. The survey was automated using a survey construction tool (REDCap Survey Software © 2010 Vanderbilt University). We calculated avoided MARs by multiplying the numbers and types of services reported to have been avoided. Average cost of an admission from the ED was based on direct cost trends for ED admissions within the region.
During the 12-month study period we had 325,740 patient encounters and 7,525 logons to the HIE (utilization rate of 2.3%) by 231 ED clinicians practicing at the study sites. We collected 621 surveys representing 8.25% of logons of which 532 (85.7% of surveys) reported on patients who had information available in the HIE. Within this group the following services and MARs were reported to have been avoided [type of service: number of services; MARs]: Laboratory/Microbiology:187; $2,073, Radiology: 298; $475,840, Consultations: 61; $6,461, Hospital Admissions: 56; $551,282. Grand total of MARs avoided: $1,035,654; average $1,947 per patient who had information available in the HIE (Range: $1,491 – $2,395 between HS). Changes in management other than avoidance of a service were reported by 32.2% of participants. Participants stated that quality of care was improved for 89% of patients with information in the HIE. Eighty-two percent of participants reported that valuable time was saved with a mean time saved of 105 minutes.
Observational data provided by ED clinicians practicing at eleven EDs in a mid-sized Southeastern city showed an average reduction in MARs of $1,947 per patient who had information available in an HIE. The majority of reduced MARs were due to avoided radiology studies and hospital admissions. Over 80% of participants reported that quality of care was improved and valuable time was saved.
PMCID: PMC4251219  PMID: 25493118
14.  Provider Advice About Weight Loss and Physical Activity in the Postpartum Period 
Journal of Women's Health  2010;19(3):397-406.
To explore the association between healthcare provider advice about weight loss and physical activity in the postpartum period and weight retention and activity levels in women assessed at 3 months postpartum.
Using data from a prospective cohort study, we explored the association of advice with postpartum weight retention and activity levels in 688 women at 3 months postpartum. Data from home visits included anthropometric measurements and information collected from sociodemographic, health behavior, and psychosocial questionnaires. Weight retention was calculated as weight at 3 months postpartum minus prepregnancy weight; activity levels and advice were based on maternal self-report. Linear regression and Poisson regression were used to explore associations.
The majority of the population was white (76%), had a greater than high school education (83%), and had an income >185% of the federal poverty level (81%). Women ranged in age from 17 to 48 years. Most women reported receiving no weight loss (89.1%) and no physical activity advice (77.4%) from a healthcare provider during the 3-month postpartum period. After adjustment, we found no association between provider advice and weight retention. When compared with those who reported no advice, following provider advice showed an association with recreational activity above the median (RR 1.50, 95% confidence interval [CI] 1.24, 1.80).
Provider advice may influence physical activity but may not be enough to help postpartum women lose pregnancy weight. Instead, women may benefit more from individualized counseling and follow-up beyond the usual 6-week postpartum visit.
PMCID: PMC2867629  PMID: 20156083
15.  Costs of a Smoking Cessation Counseling Intervention for Pregnant Women: Comparison of Three Settings 
Public Health Reports  2006;121(2):120-126.
Although the rate of smoking among women giving birth in the United States has declined steadily from 19.5% in 1989 to 11.4% in 2002, it still far exceeds the Healthy People 2010 goal of 1%. The objective of this study was to estimate the costs of a recommended five-step smoking cessation counseling intervention for pregnant women.
Costs were compared across three settings: a clinical trial, a quit line, and a rural managed care organization. Cost data were collected from August 2002 to September 2003. Intervention costs were compared with potential neonatal cost savings from averted adverse outcomes using data from the Centers for Disease Control and Prevention's Maternal and Child Health Smoking-Attributable Mortality, Morbidity, and Economics Costs software.
The costs of implementing the intervention ranged from $24 to $34 per pregnant smoker counseled across the three settings. Potential neonatal cost savings that could be accrued from women who quit smoking during pregnancy were estimated at $881 per maternal smoker. Assuming a 30% to 70% increase over baseline quit rates, interventions could net savings up to $8 million within the range of costs per pregnant smoker.
Costs may vary depending on the intensity and nature of the intervention; however, this analysis found a surprisingly narrow range across three disparate settings. Cost estimates presented here are shown to be low compared with potential cost savings that could be accrued across the quit rates that could be achieved through use of the 5A's smoking cessation counseling intervention.
PMCID: PMC1525265  PMID: 16528943
16.  Treatment of Tobacco Use in Preconception Care 
Maternal and Child Health Journal  2006;10(Suppl 1):147-148.
PMCID: PMC1592147  PMID: 16897373
Keywords; Smoking; Pregnancy; Preconception care
17.  Smoking Among Medicaid Insured Mothers: What are the Neonatal Expenses? 
Health Care Financing Review  2004;26(2):105-118.
Approximately 13 percent of all pregnant women smoke during pregnancy despite known adverse health effects. Medicaid Programs pay for an estimated 27-53 percent of all births, yet little is known about smoking prevalence nor resulting expenses in this population. Findings indicate that pregnant women with deliveries paid by Medicaid are more than twice as likely to smoke as privately insured women; two-thirds of the estimated $366 million in 1996 neonatal expenses attributable to maternal smoking accrues to Medicaid Programs and these estimates vary widely across States. In light of these estimates, States should carefully consider targeted interventions and appropriate policies.
PMCID: PMC4194872  PMID: 25372786

Results 1-17 (17)