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1.  Collaborative Care Management Reduces Disparities in Dementia Care Quality for Caregivers with Less Education 
Lower educational attainment among informal caregivers’ may be associated with poorer outcomes for patients with dementia.
To examine educational gradients in dementia care and whether the effect of a dementia collaborative care management intervention varied by the educational attainment of the informal caregiver.
Analysis of data from a cluster-randomized controlled trial.
Eighteen clinics across 3 healthcare organizations in Southern California.
Dyads of Medicare recipients, ages 65 years and older with a diagnosis of dementia, and an eligible caregiver.
Collaborative care management for dementia.
1) Caregiver educational attainment, 2) adherence to four dimensions of guideline-recommended processes of dementia care: Assessment, Treatment, Education/Support, and Safety pre- and post-intervention, and 3) the adjusted intervention effect (IE) for each dimension stratified by caregiver education. Each IE was estimated by subtracting the difference between pre- and post-intervention scores for the usual care participants from the difference in the intervention participants.
At baseline, caregivers with lower educational attainment had lower guideline-recommended processes of dementia care for the Treatment and Education dimensions than those with more education. However, less educated caregivers had significantly more improvement after the intervention on the Assessment, Treatment, and Safety dimensions. The IEs for those who had not graduated from high school compared to college graduates were 44.4 vs. 29.5 for the Assessment dimension (P<0.001), 36.9 vs. 15.7 for the Treatment dimension (P<0.001), and 52.7 vs. 40.9 for the Safety Dimension (P<0.001).
Collaborative care management was associated with reductions in disparities in dementia care quality among caregivers with lower educational attainment relative to more educated caregivers.
PMCID: PMC3772791  PMID: 23320655
Dementia; Caregivers; Care Management
2.  Neighborhood Disadvantage and Ischemic Stroke: The Cardiovascular Health Study (CHS) 
Background and Purpose
Neighborhood characteristics may influence the risk of stroke and contribute to socioeconomic disparities in stroke incidence. The objectives of this study were to examine the relationship between neighborhood socioeconomic status (NSES) and incident ischemic stroke and examine potential mediators of these associations.
We analyzed data from 3834 whites and 785 African Americans enrolled in the Cardiovascular Health Study, a multicenter, population-based, longitudinal study of adults ages ≥65 years from four U.S. counties. The primary outcome was adjudicated incident ischemic stroke. NSES was measured using a composite of six census tract variables. Race-stratified multilevel Cox proportional hazard models were constructed, adjusted for sociodemographic, behavioral, and biologic risk factors.
Among whites, in models adjusted for sociodemographic characteristics, stroke hazard was significantly higher among residents of neighborhoods in the lowest compared to the highest NSES quartile (Hazard Ratio [HR] =1.32; 95% CI 1.01-1.72), with greater attenuation of the HR after adjustment for biologic risk factors (HR=1.16; 0.88-1.52) than for behavioral risk factors (HR=1.30; 0.99-1.70). Among African Americans, we found no significant associations between NSES and ischemic stroke.
Higher risk of incident ischemic stroke was observed in the most disadvantaged neighborhoods among whites, but not among African Americans. The relationship between NSES and stroke among whites appears to be mediated more strongly by biologic than behavioral risk factors.
PMCID: PMC3781011  PMID: 21940966
3.  Recruiting and Retaining Primary Care Physicians in Urban Underserved Communities: The Importance of Having a Mission to Serve 
American journal of public health  2010;100(11):2168-2175.
We examined factors influencing physician practice decisions that may increase primary care supply in underserved areas.
We conducted in-depth interviews with 42 primary care physicians from Los Angeles County, California, stratified by race/ethnicity (African American, Latino, and non-Latino White) and practice location (underserved vs nonunderserved area). We reviewed transcriptions and coded them into themes by using standard qualitative methods.
Three major themes emerged in relation to selecting geographic- and population-based practice decisions: (1) personal motivators, (2) career motivators, and (3) clinic support. We found that subthemes describing personal motivators (e.g., personal mission and self-identity) for choosing a practice were more common in responses among physicians who worked in underserved areas than among those who did not. By contrast, physicians in nonunderserved areas were more likely to cite work hours and lifestyle as reasons for selecting their current practice location or for leaving an underserved area.
Medical schools and shortage-area clinical practices may enhance strategies for recruiting primary care physicians to underserved areas by identifying key personal motivators and may promote long-term retention through work–life balance.
PMCID: PMC2951944  PMID: 20935263
4.  Are Physician Reimbursement Strategies Associated with Processes of Care and Patient Satisfaction for Patients with Diabetes in Managed Care? 
Health Services Research  2006;41(4 Pt 1):1221-1241.
To examine associations between physician reimbursement incentives and diabetes care processes and explore potential confounding with physician organizational model.
Data Sources
Primary data collected during 2000–2001 in 10 managed care plans.
Study Design
Multilevel logistic regressions were used to estimate associations between reimbursement incentives and process measures, including the receipt of dilated eye exams, foot exams, influenza immunizations, advice to take aspirin, and assessments of glycemic control, proteinuria, and lipid profile. Reimbursement measures included the proportions of compensation received from salary, capitation, fee-for-service (FFS), and performance-based payment; the performance-based payment criteria used; and interactions of these criteria with the strength of the performance-based payment incentive.
Data Collection
Patient, provider group, and health plan surveys and medical record reviews were conducted for 6,194 patients with diabetes.
Principal Findings
Without controlling for physician organizational model, care processes were better when physician compensation was based primarily on direct salary rather than FFS reimbursement (four of seven processes were better, with relative risks ranging from 1.13 to 1.23) or capitation (six were better, with relative risks from 1.06 to 1.36); and when quality/satisfaction scores influenced physician compensation (three were better, with relative risks from 1.17 to 1.26). However, these associations were substantially confounded by organizational model.
Physician reimbursement strategies are associated with diabetes care processes, although their independent contributions are difficult to assess, due to high correlation with physician organizational model. Regardless of causality, a group's use of quality/satisfaction scores to determine physician compensation may indicate delivery of high-quality diabetes care.
PMCID: PMC1797087  PMID: 16899004
Provider financial incentives; reimbursement; quality of care; diabetes
5.  Successful Schools and Risky Behaviors Among Low-Income Adolescents 
Pediatrics  2014;134(2):e389-e396.
We examined whether exposure to high-performing schools reduces the rates of risky health behaviors among low-income minority adolescents and whether this is due to better academic performance, peer influence, or other factors.
By using a natural experimental study design, we used the random admissions lottery into high-performing public charter high schools in low-income Los Angeles neighborhoods to determine whether exposure to successful school environments leads to fewer risky (eg, alcohol, tobacco, drug use, unprotected sex) and very risky health behaviors (eg, binge drinking, substance use at school, risky sex, gang participation). We surveyed 521 ninth- through twelfth-grade students who were offered admission through a random lottery (intervention group) and 409 students who were not offered admission (control group) about their health behaviors and obtained their state-standardized test scores.
The intervention and control groups had similar demographic characteristics and eighth-grade test scores. Being offered admission to a high-performing school (intervention effect) led to improved math (P < .001) and English (P = .04) standard test scores, greater school retention (91% vs 76%; P < .001), and lower rates of engaging in ≥1 very risky behaviors (odds ratio = 0.73, P < .05) but no difference in risky behaviors, such as any recent use of alcohol, tobacco, or drugs. School retention and test scores explained 58.0% and 16.2% of the intervention effect on engagement in very risky behaviors, respectively.
Increasing performance of public schools in low-income communities may be a powerful mechanism to decrease very risky health behaviors among low-income adolescents and to decrease health disparities across the life span.
PMCID: PMC4187228  PMID: 25049339
disparities; education; risk-taking behavior
6.  Potential Savings Associated with Drug Substitution in Medicare Part D: The Translating Research into Action for Diabetes (TRIAD) Study 
Drug substitution is a promising approach to reducing medication costs.
To calculate the potential savings in a Medicare Part D plan from generic or therapeutic substitution for commonly prescribed drugs.
Cross-sectional, simulation analysis.
Low-income subsidy (LIS) beneficiaries (n = 145,056) and non low-income subsidy (non-LIS) beneficiaries (n = 1,040,030) enrolled in a large, national Part D health insurer in 2007 and eligible for a possible substitution.
Using administrative data from 2007, we identified claims filled for brand-name drugs for which a direct generic substitute was available. We also identified the 50 highest cost drugs separately for LIS and non-LIS beneficiaries, and reached consensus on which drugs had possible therapeutic substitutes (27 for LIS, 30 for non-LIS). For each possible substitution, we used average daily costs of the original and substitute drugs to calculate the potential out-of-pocket savings, health plan savings, and when applicable, savings for the government/LIS subsidy.
Overall, 39 % of LIS beneficiaries and 51 % of non-LIS beneficiaries were eligible for a generic and/or therapeutic substitution. Generic substitutions resulted in an average annual savings of $160 in the case of LIS beneficiaries and $127 in the case of non-LIS beneficiaries. Therapeutic substitutions resulted in an average annual savings of $452 in the case of LIS beneficiaries and $389 in the case of non-LIS beneficiaries.
Our findings indicate that drug substitution, particularly therapeutic substitution, could result in significant cost savings. There is a need for additional studies evaluating the acceptability of therapeutic substitution interventions within Medicare Part D.
PMCID: PMC3889972  PMID: 23975059
pharmacoeconomics; Medicare; health care policy
7.  Patterns of prescription drug expenditures and medication adherence among medicare part D beneficiaries with and without the low-income supplement 
The association between the Medicare Part D low-income subsidy (LIS), gap coverage, and outcomes such as medical expenditures, prescription fills, and medication adherence is not well understood. The purpose of this study was to examine the relationship between the LIS and these measures for patients within a large, national Part D plan in the United States.
In this cross-sectional, retrospective analysis, we compared total and plan expenditures, out-of-pocket costs, and medication fills and adherence for three categories of Medicare beneficiaries: non-LIS beneficiaries without gap coverage (non-LIS/non-GC), non-LIS beneficiaries with gap coverage (non-LIS/GC), and LIS beneficiaries (LIS).
LIS beneficiaries, relative to non-LIS/non-GC and non-LIS/GC beneficiaries, had higher total expenditures ($1,887 vs. $1,360 vs. $1,341); lower out-of-pocket costs ($148 vs. $546 vs. $570); more expenditures exceeding the gap threshold (27.6% vs. 18.4% vs. 16.9%); and slightly higher adherence to blood pressure (65.6% vs. 64.2% vs. 62.4%); diabetes (62.5% vs. 57.7 vs. 57.4%); and lipid-lowering (59.6% vs. 57.0 vs. 55.6%) medications.
LIS beneficiaries had higher total expenditures, lower out-of-pocket costs, and modestly better adherence to diabetes medications than non-LIS/non-GC and non-LIS/GC beneficiaries.
PMCID: PMC4302141  PMID: 25526892
Medicare Part D; Low-income subsidy; Gap coverage; Health care expenditures; Adherence to medications
8.  Correlates of depression among people with diabetes: The Translating Research Into Action for Diabetes (TRIAD) study 
Primary care diabetes  2010;4(4):215-222.
The broad objective of this study was to examine multiple dimensions of depression in a large, diverse population of adults with diabetes. Specific aims were to measure the association of depression with: (1) patient characteristics; (2) outcomes; and (3) diabetes-related quality of care.
Cross-sectional analyses were performed using survey and chart data from the Translating Research Into Action for Diabetes (TRIAD) study, including 8790 adults with diabetes, enrolled in 10 managed care health plans in 7 states. Depression was measured using the Patient Health Questionnaire (PHQ-8). Patient characteristics, outcomes and quality of care were measured using validated survey items and chart data.
Nearly 18% of patients had major depression, with prevalence 2-3 times higher among patients with low socioeconomic status. Pain and limited mobility were strongly associated with depression, controlling for other patient characteristics. Depression was associated with slightly worse glycemic control, but not other intermediate clinical outcomes. Depressed patients received slightly fewer recommended diabetes-related processes of care.
In a large, diverse cohort of patients with diabetes, depression was most prevalent among patients with low socioeconomic status and those with pain, and was associated with slightly worse glycemic control and quality of care.
PMCID: PMC4269468  PMID: 20832375
9.  Exploring psychosocial pathways between neighbourhood characteristics and stroke in older adults: the cardiovascular health study 
Age and Ageing  2012;42(3):391-397.
Objectives: to investigate whether psychosocial pathways mediate the association between neighbourhood socioeconomic disadvantage and stroke.
Methods: prospective cohort study with a follow-up of 11.5 years.
Setting: the Cardiovascular Health Study, a longitudinal population-based cohort study of older adults ≥65 years.
Measurements: the primary outcome was adjudicated incident ischaemic stroke. Neighbourhood socioeconomic status (NSES) was measured using a composite of six census-tract variables. Psychosocial factors were assessed with standard measures for depression, social support and social networks.
Results: of the 3,834 white participants with no prior stroke, 548 had an incident ischaemic stroke over the 11.5-year follow-up. Among whites, the incident stroke hazard ratio (HR) associated with living in the lowest relative to highest NSES quartile was 1.32 (95% CI = 1.01–1.73), in models adjusted for individual SES. Additional adjustment for psychosocial factors had a minimal effect on hazard of incident stroke (HR = 1.31, CI = 1.00–1.71). Associations between NSES and stroke incidence were not found among African-Americans (n = 785) in either partially or fully adjusted models.
Conclusions: psychosocial factors played a minimal role in mediating the effect of NSES on stroke incidence among white older adults.
PMCID: PMC3633364  PMID: 23264005
neighbourhood; psychosocial factors; stroke; older adults
10.  Residential Relocation by Older Adults in Response to Incident Cardiovascular Health Events: A Case-Crossover Analysis 
Objective. We use a case-crossover analysis to explore the association between incident cardiovascular events and residential relocation to a new home address. Methods. We conducted an ambidirectional case-crossover analysis to explore the association between incident cardiovascular events and residential relocation to a new address using data from the Cardiovascular Health Study (CHS), a community-based prospective cohort study of 5,888 older adults from four U.S. sites beginning in 1989. Relocation was assessed twice a year during follow-up. Event occurrences were classified as present or absent for the period preceding the first reported move, as compared with an equal length of time immediately prior to and following this period. Results. Older adults (65+) that experience incident cardiovascular disease had an increased probability of reporting a change of residence during the following year (OR 1.6, 95% confidence interval (CI) = 1.2–2.1). Clinical conditions associated with relocation included stroke (OR: 2.0, 95% CI: 1.2–3.3), angina (OR: 1.6, 95% CI: 1.0–2.6), and congestive heart failure (OR: 1.5, 95% CI: 1.0–2.1). Conclusions. Major incident cardiovascular disease may increase the probability of residential relocation in older adults. Case-crossover analyses represent an opportunity to investigate triggering events, but finer temporal resolution would be crucial for future research on residential relocations.
PMCID: PMC3981061  PMID: 24782900
11.  Neighborhood socioeconomic disadvantage and mortality after stroke 
Neurology  2013;80(6):520-527.
Residence in a socioeconomically disadvantaged community is associated with mortality, but the mechanisms are not well understood. We examined whether socioeconomic features of the residential neighborhood contribute to poststroke mortality and whether neighborhood influences are mediated by traditional behavioral and biologic risk factors.
We used data from the Cardiovascular Health Study, a multicenter, population-based, longitudinal study of adults ≥65 years. Residential neighborhood disadvantage was measured using neighborhood socioeconomic status (NSES), a composite of 6 census tract variables representing income, education, employment, and wealth. Multilevel Cox proportional hazard models were constructed to determine the association of NSES to mortality after an incident stroke, adjusted for sociodemographic characteristics, stroke type, and behavioral and biologic risk factors.
Among the 3,834 participants with no prior stroke at baseline, 806 had a stroke over a mean 11.5 years of follow-up, with 168 (20%) deaths 30 days after stroke and 276 (34%) deaths at 1 year. In models adjusted for demographic characteristics, stroke type, and behavioral and biologic risk factors, mortality hazard 1 year after stroke was significantly higher among residents of neighborhoods with the lowest NSES than those in the highest NSES neighborhoods (hazard ratio 1.77, 95% confidence interval 1.17–2.68).
Living in a socioeconomically disadvantaged neighborhood is associated with higher mortality hazard at 1 year following an incident stroke. Further work is needed to understand the structural and social characteristics of neighborhoods that may contribute to mortality in the year after a stroke and the pathways through which these characteristics operate.
PMCID: PMC3589286  PMID: 23284071
12.  A Study of National Physician Organizations’ Efforts to Reduce Racial and Ethnic Health Disparities in the United States 
To characterize national physician organizations’ efforts to reduce health disparities and identify organizational characteristics associated with such efforts.
This cross-sectional study was conducted between September 2009 and June 2010. The authors used two-sample t tests and chi-square tests to compare the proportion of organizations with disparity-reducing activities between different organizational types (e.g., primary care versus subspecialty organizations, small [<1,000 members] versus large [>5,000 members]). Inclusion criteria required physician organizations to be (1) focused on physicians, (2) national in scope, and (3) membership based.
The number of activities per organization ranged from 0 to 22. Approximately half (53%) of organizations had 0 or 1 disparity-reducing activities. Organiza-tional characteristics associated with having at least 1 disparity-reducing effort included membership size (88% of large groups versus 58% of small groups had at least 1 activity; P = .004) and the presence of a health disparities committee (95% versus 59%; P < .001). Primary care (versus subspecialty) organizations and racial/ethnic minority physician organizations were more likely to have disparity-reducing efforts, although findings were not statistically significant. Common themes addressed by activities were health care access, health care disparities, workforce diversity, and language barriers. Common strategies included education of physicians/trainees and patients/general public, position statements, and advocacy.
Despite the national priority to eliminate health disparities, more than half of national physician organizations are doing little to address this problem. Primary care and minority physician organizations, and those with disparities committees, may provide leadership to extend the scope of disparity-reduction efforts.
PMCID: PMC3785372  PMID: 22534593
13.  Through Our Eyes: Exploring African-American Men’s Perspective on Factors Affecting Transition to Manhood 
Premature mortality and disparities in morbidity observed in African-American men may be associated with factors in their social, economic, and built environments that may be especially influential during the transition to adulthood.
To have young, African-American men from Los Angeles County identify and prioritize factors associated with their transition to manhood using photovoice methodology and pile-sorting exercises.
Qualitative study using community-based participatory research (CBPR) and photovoice
Twelve African-American men, ages 16–26 years, from Los Angeles County, California.
We used CBPR principles to form a community advisory board (CAB) whose members defined goals for the partnered project, developed the protocols, and participated in data collection and analysis. Participants were given digital cameras to take 50–300 photographs over three months. Pile-sorting techniques were used to facilitate participants’ identification and discussion of the themes in their photos and selected photos of the group. Pile-sorts of group photographs were analyzed using multidimensional scaling and hierarchical cluster analysis to systematically compare participants’ themes and identify patterns of associations between sorted photographs. Sub-themes and related quotes were also elicited from the pile-sorting transcripts. The CAB and several study participants met periodically to develop dissemination strategies and design interventions informed by study findings.
Four dominant themes emerged during analysis: 1) Struggles face during the transition to manhood, 2) Sources of social support, 3) Role of sports, and 4) Views on Los Angeles lifestyle. The project led to the formation of a young men’s group and community events featuring participants.
CBPR and photovoice are effective methods to engage young, African-American men to identify and discuss factors affecting their transition to manhood, contextualize research findings, and participate in intervention development.
PMCID: PMC3270242  PMID: 21910088
race/ethnicity; men’s health; socioeconomic factors; qualitative research
14.  Evaluation of risk equations for prediction of short-term coronary heart disease events in patients with long-standing type 2 diabetes: the Translating Research into Action for Diabetes (TRIAD) study 
To evaluate the U.K. Prospective Diabetes Study (UKPDS) and Framingham risk equations for predicting short-term risk of coronary heart disease (CHD) events among adults with long-standing type 2 diabetes, including those with and without preexisting CHD.
Prospective cohort of U.S. managed care enrollees aged ≥ 18 years and mean diabetes duration of more than 10 years, participating in the Translating Research into Action for Diabetes (TRIAD) study, was followed for the first occurrence of CHD events from 2000 to 2003. The UKPDS and Framingham risk equations were evaluated for discriminating power and calibration.
A total of 8303 TRIAD participants, were identified to evaluate the UKPDS (n = 5914, 120 events), Framingham-initial (n = 5914, 218 events) and Framingham-secondary (n = 2389, 374 events) risk equations, according to their prior CHD history. All of these equations exhibited low discriminating power with Harrell’s c-index <0.65. All except the Framingham-initial equation for women and the Framingham-secondary equation for men had low levels of calibration. After adjsusting for the average values of predictors and event rates in the TRIAD population, the calibration of these equations greatly improved.
The UKPDS and Framingham risk equations may be inappropriate for predicting the short-term risk of CHD events in patients with long-standing type 2 diabetes, partly due to changes in medications used by patients with diabetes and other improvements in clinical care since the Frmaingham and UKPDS studies were conducted. Refinement of these equations to reflect contemporary CHD profiles, diagnostics and therapies are needed to provide reliable risk estimates to inform effective treatment.
PMCID: PMC3433369  PMID: 22776317
15.  Competing Demands for Time and Self-Care Behaviors, Processes of Care, and Intermediate Outcomes Among People With Diabetes 
Diabetes Care  2011;34(5):1180-1182.
To determine whether competing demands for time affect diabetes self-care behaviors, processes of care, and intermediate outcomes.
We used survey and medical record data from 5,478 participants in Translating Research Into Action for Diabetes (TRIAD) and hierarchical regression models to examine the cross-sectional associations between competing demands for time and diabetes outcomes, including self-management, processes of care, and intermediate health outcomes.
Fifty-two percent of participants reported no competing demands, 7% reported caregiving responsibilities only, 36% reported employment responsibilities only, and 6% reported both caregiving and employment responsibilities. For both women and men, employment responsibilities (with or without caregiving responsibilities) were associated with lower rates of diabetes self-care behaviors, worse processes of care, and, in men, worse HbA1c.
Accommodations for competing demands for time may promote self-management and improve the processes and outcomes of care for employed adults with diabetes.
PMCID: PMC3114509  PMID: 21464464
16.  Association of Perceived Neighborhood Safety on Body Mass Index 
American journal of public health  2010;100(11):2296-2303.
We sought to determine whether there is an association between perceived neighborhood safety and body mass index (BMI), accounting for endogeneity.
A random sample of 2255 adults from the Los Angeles Family and Neighborhood Survey 2000–2001 was analyzed using instrumental variables. The main outcome was BMI using self-reported height and weight, and the main independent variable was residents’ report of their neighborhood safety.
In adjusted analyses, individuals who perceived their neighborhoods as unsafe had a BMI that was 2.81 kg/m2 (95% confidence interval [CI]=0.11, 5.52) higher than did those who perceived their neighborhoods as safe.
Our results suggest that clinical and public health interventions aimed at reducing rates of obesity may be enhanced by strategies to modify the physical and social environment that incorporate residents’ perceptions of their communities.
PMCID: PMC2951920  PMID: 20864717
17.  The Vulnerability of Older Middle Age and Elderly Adults in a Multi-Ethnic, Low Income Area: Contributions of Age, Ethnicity, and Health Insurance 
This community partnered study was developed and fielded in partnerships with key community stakeholders, describes age and race-related variation in delays in care and preventive service utilization among middle-aged and older adults living in South Los Angeles. The survey sample included adults ages 50 years and older who self-identified as African-American or Latino and lived in zip-codes of South Los Angeles (N=708). Dependent variables were self-reported delays in care and use of preventive services. Insured participants ages 50–64 years were more likely to report any delay in care (adjusted predicted percent (APP) 18%, 95% CI 14, 23) and problems getting needed medical care (APP 15%, 95% CI 12, 20) than those ages 65 years or older. Uninsured participants ages 50–64 years reported even greater delays in care (APP 45%, 95% CI 33, 56) and problems getting needed medical (APP 33%,95% CI 22, 45) and specialty care (APP 26%, 95% CI 16, 39) than those age 65 and over. Compared to older participants, those age 50–64 years were generally less likely to receive preventive services, including influenza or pneumococcal vaccines and colonoscopy, but women were more likely to receive mammograms. Persons ages 50–64 years had more problems obtaining recommended preventive care and faced more delays in care than persons age 65 years and older, particularly if uninsured. Providing insurance coverage for this group may improve access to preventive care and promote wellness.
PMCID: PMC3058402  PMID: 21143445
preventive services; delays; community based participatory research; insurance
18.  Neighborhood Socioeconomic Status, Depression, and Health Status in the Look AHEAD (Action for Health in Diabetes) Study 
BMC Public Health  2011;11:349.
Depression and diminished health status are common in adults with diabetes, but few studies have investigated associations with socio-economic environment. The objective of this manuscript was to evaluate the relationship between neighborhood-level SES and health status and depression.
Individual-level data on 1010 participants at baseline in Look AHEAD (Action for Health in Diabetes), a trial of long-term weight loss among adults with type 2 diabetes, were linked to neighborhood-level SES (% living below poverty) from the 2000 US Census (tracts). Dependent variables included depression (Beck Inventory), and health status (Medical Outcomes Study (SF-36) scale). Multi-level regression models were used to account simultaneously for individual-level age, sex, race, education, personal yearly income and neighborhood-level SES.
Overall, the % living in poverty in the participants' neighborhoods varied, mean = 11% (range 0-67%). Compared to their counterparts in the lowest tertile of neighborhood poverty (least poverty), those in the highest tertile (most poverty) had significantly lower scores on the role-limitations(physical), role limitations(emotional), physical functioning, social functioning, mental health, and vitality sub-scales of the SF-36 scale. When evaluating SF-36 composite scores, those living in neighborhoods with more poverty had significantly lower scores on the physical health (β-coefficient [β] = -1.90 units, 95% CI: -3.40,-0.039), mental health (β = -2.92 units, -4.31,-1.53) and global health (β = -2.77 units, -4.21,-1.33) composite scores.
In this selected group of weight loss trial participants, lower neighborhood SES was significantly associated with poorer health status. Whether these associations might influence response to the Look AHEAD weight loss intervention requires further investigation.
PMCID: PMC3111582  PMID: 22182286
19.  Medical Students’ Perceptions of Their Teachers’ and Their Own Cultural Competency: Implications for Education 
Journal of General Internal Medicine  2010;25(Suppl 2):91-94.
Enhancing the cultural competency of students is emerging as a key issue in medical education; however, students may perceive that they are more able to function within cross-cultural situations than their teachers, reducing the effectiveness of cultural competency educational efforts.
The purpose of our study was to compare medical students’ perceptions of their residents, attendings, and their own cultural competency.
Cross-sectional study.
A questionnaire containing previously validated instruments was administered to end-of-third-year medical students at four institutions throughout the US. Repeated measures multivariate analysis was used to determine differences in student ratings.
Three hundred fifty-eight medical students from four schools participated, for an overall response rate of 65%.
Analysis indicated overall statistically significant differences in students’ ratings (p < 0.001, η2 = 0.33). Students rated their own cultural competency as statistically significantly higher than their residents, but similar to their attendings. For reference, students rated the patient care competency of themselves, their residents, and their attendings; they rated their attendings’ skills as statistically significantly higher than residents, and residents as statistically significantly higher than themselves. There were differences between cultural competency and patient care ratings.
Our results indicate that students perceive the cultural competency of their attendings and residents to be the same or lower than themselves. These findings indicate that this is an important area for future research and curricular reform, considering the vital role that attendings and residents play in the education of medical students.
PMCID: PMC2847104  PMID: 20352500
cultural competency; medical education; medical education-undergraduate
20.  A Strategy for Improving Health Disparities Education in Medicine 
Journal of General Internal Medicine  2010;25(Suppl 2):160-163.
A health disparities curriculum that uses evidence-based knowledge rooted in pedagogic theory is needed to educate health care providers to meet the needs of an increasingly diverse U.S. population.
The Health Disparities Education: Beyond Cultural Competency Precourse, along with its accompanying Train the Trainer Guide: Health Disparities Education (2008), developed by the Society of General Internal Medicine (SGIM) Disparities Task Force (DTF), is a comprehensive tool to facilitate developing, implementing and evaluating health disparities education. The curriculum includes five modules highlighting several fundamental concepts in health disparities, suggestions for teaching about health disparities in a wide range of settings and strategies for curriculum evaluation. The modules are Disparities Foundations, Teaching Disparities in the Clinical Setting, Disparities Beyond the Clinical Setting, Teaching about Disparities Through Community Involvement, and Curriculum Evaluation.
All five modules were delivered as a precourse at the 31st Annual SGIM Annual Meeting in Pittsburgh, PA and received the “Best Precourse Award”. This award is given to the most highly rated precourse based on participant evaluations. The modules have also been adapted into a web-based guide that has been downloaded at least 59 times.
Ultimately, the modules are designed to develop a professional commitment to eliminating racial and ethnic disparities in health care quality, promote an understanding of the role of health care providers in reducing health care disparities through comprehensive education and training, and provide a framework with which providers can address the causes of disparities in various educational settings.
PMCID: PMC2847114  PMID: 20352512
health disparities; medical education; faculty development
21.  Primary Language, Income and the Intensification of Anti-glycemic Medications in Managed Care: the (TRIAD) Study 
Patients who speak Spanish and/or have low socioeconomic status are at greater risk of suboptimal glycemic control. Inadequate intensification of anti-glycemic medications may partially explain this disparity.
To examine the associations between primary language, income, and medication intensification.
Cohort study with 18-month follow-up.
One thousand nine hundred and thirty-nine patients with Type 2 diabetes who were not using insulin enrolled in the Translating Research into Action for Diabetes Study (TRIAD), a study of diabetes care in managed care.
Using administrative pharmacy data, we compared the odds of medication intensification for patients with baseline A1c ≥ 8%, by primary language and annual income. Covariates included age, sex, race/ethnicity, education, Charlson score, diabetes duration, baseline A1c, type of diabetes treatment, and health plan.
Overall, 42.4% of patients were taking intensified regimens at the time of follow-up. We found no difference in the odds of intensification for English speakers versus Spanish speakers. However, compared to patients with incomes <$15,000, patients with incomes of $15,000-$39,999 (OR 1.43, 1.07-1.92), $40,000-$74,999 (OR 1.62, 1.16-2.26) or >$75,000 (OR 2.22, 1.53-3.24) had increased odds of intensification. This latter pattern did not differ statistically by race.
Low-income patients were less likely to receive medication intensification compared to higher-income patients, but primary language (Spanish vs. English) was not associated with differences in intensification in a managed care setting. Future studies are needed to explain the reduced rate of intensification among low income patients in managed care.
Electronic supplementary material
The online version of this article (doi:10.1007/s11606-010-1588-2) contains supplementary material, which is available to authorized users.
PMCID: PMC3077478  PMID: 21174165
22.  Patient-provider communication regarding drug costsin Medicare Part D beneficiaries with diabetes: a TRIAD Study 
Little is known about drug cost communications of Medicare Part D beneficiaries with chronic conditions such as diabetes. The purpose of this study is to assess Medicare Part D beneficiaries with diabetes' levels of communication with physicians regarding prescription drug costs; the perceived importance of these communications; levels of prescription drug switching due to cost; and self-reported cost-related medication non-adherence.
Data were obtained from a cross-sectional survey (58% response rate) of 1,458 Medicare beneficiaries with diabetes who entered the coverage gap in 2006; adjusted percentages of patients with communication issues were obtained from multivariate regression analyses adjusting for patient demographics and clinical characteristics.
Fewer than half of patients reported discussing the cost of medications with their physicians, while over 75% reported that such communications were important. Forty-eight percent reported their physician had switched to a less expensive medication due to costs. Minorities, females, and older adults had significantly lower levels of communication with their physicians regarding drug costs than white, male, and younger patients respectively. Patients with < $25 K annual household income were more likely than higher income patients to have talked about prescription drug costs with doctors, and to report cost-related non-adherence (27% vs. 17%, p < .001).
Medicare Part D beneficiaries with diabetes who entered the coverage gap have low levels of communication with physicians about drug costs, despite the high perceived importance of such communication. Understanding patient and plan-level characteristics differences in communication and use of cost-cutting strategies can inform interventions to help patients manage prescription drug costs.
PMCID: PMC2893177  PMID: 20546616
23.  Neighborhood and weight-related health behaviors in the Look AHEAD (Action for Health in Diabetes) Study 
BMC Public Health  2010;10:312.
Previous studies have shown that neighborhood factors are associated with obesity, but few studies have evaluated the association with weight control behaviors. This study aims to conduct a multi-level analysis to examine the relationship between neighborhood SES and weight-related health behaviors.
In this ancillary study to Look AHEAD (Action for Health in Diabetes) a trial of long-term weight loss among individuals with type 2 diabetes, individual-level data on 1219 participants from 4 clinic sites at baseline were linked to neighborhood-level data at the tract level from the 2000 US Census and other databases. Neighborhood variables included SES (% living below the federal poverty level) and the availability of food stores, convenience stores, and restaurants. Dependent variables included BMI, eating patterns, weight control behaviors and resource use related to food and physical activity. Multi-level models were used to account for individual-level SES and potential confounders.
The availability of restaurants was related to several eating and weight control behaviors. Compared to their counterparts in neighborhoods with fewer restaurants, participants in neighborhoods with more restaurants were more likely to eat breakfast (prevalence Ratio [PR] 1.29 95% CI: 1.01-1.62) and lunch (PR = 1.19, 1.04-1.36) at non-fast food restaurants. They were less likely to be attempting weight loss (OR = 0.93, 0.89-0.97) but more likely to engage in weight control behaviors for food and physical activity, respectively, than those who lived in neighborhoods with fewer restaurants. In contrast, neighborhood SES had little association with weight control behaviors.
In this selected group of weight loss trial participants, restaurant availability was associated with some weight control practices, but neighborhood SES was not. Future studies should give attention to other populations and to evaluating various aspects of the physical and social environment with weight control practices.
PMCID: PMC2897795  PMID: 20525373
24.  Identifying Risk Factors for Racial Disparities in Diabetes Outcomes: the Translating Research into Action for Diabetes (TRIAD) Study 
Medical care  2009;47(6):700-706.
Versus whites, blacks with diabetes have poorer control of hemoglobin A1c (HbA1c), higher systolic blood pressure (SBP), and higher low-density lipoprotein (LDL) cholesterol as well as higher rates of morbidity and microvascular complications.
To examine whether several mutable risk factors were more strongly associated with poor control of multiple intermediate outcomes among blacks with diabetes than among similar whites.
Case-control study.
A total of 764 blacks and whites with diabetes receiving care within 8 managed care health plans.
Cases were patients with poor control of at least two of three intermediate outcomes (HbA1c≥8.0%, SBP≥140 mmHg, LDL cholesterol≥130 mg/dl) and controls were patients with good control of all three (HbA1c<8.0%, SBP<140 mmHg, LDL cholesterol<130 mg/dl). In multivariate analyses, we determined whether each of five potentially mutable risk factors, including depression, low health literacy, poor adherence to medication, low self-efficacy for reducing cardiovascular risk, and poor patient-provider communication, predicted case or control status.
Among blacks but not whites, in multivariate analyses depression (odds ratio [OR] 2.28, 95% confidence interval [CI] 1.09-4.75) and having missed medication doses (OR 1.96, 95% CI 1.01-3.81) were associated with greater odds of being a case rather than a control. None of the other risk factors were associated for either blacks or whites.
Depression and missing medication doses are more strongly associated with poor diabetes control among blacks than in whites. These two risk factors may represent important targets for patient-level interventions to address racial disparities in diabetes outcomes.
PMCID: PMC2743318  PMID: 19480090
Diabetes; Racial/Ethnic Groups; Health Outcomes
25.  Introduction 
Journal of General Internal Medicine  2010;25(Suppl 2):79-81.
PMCID: PMC2847112  PMID: 20352497

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