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1.  Health Insurance Coverage Among People With and Without Diabetes in the U.S. Adult Population 
Diabetes Care  2012;35(11):2243-2249.
OBJECTIVE
To compare health insurance coverage and type of coverage for adults with and without diabetes.
RESEARCH DESIGN AND METHODS
The data used were from 2,704 adults who self-reported diabetes and 25,008 adults without reported diabetes in the 2009 National Health Interview Survey. Participants reported on their current type of health insurance coverage, demographic information, diabetes-related factors, and comorbidities. If uninsured, participants reported reasons for not having health insurance.
RESULTS
Among all adults with diabetes, 90% had some form of health insurance coverage, including 85% of people 18–64 years of age and ∼100% of people ≥65 years of age; 81% of people without diabetes had some type of coverage (vs. diabetes, P < 0.0001), including 78% of people 18–64 years of age and 99% of people ≥65 years of age. More adults 18–64 years of age with diabetes had Medicare coverage (14% vs. no diabetes, 3%; P < 0.0001); fewer people with diabetes had private insurance (58% vs. no diabetes, 66%; P < 0.0001). People 18–64 years of age with diabetes more often had two health insurance sources compared with people without diabetes (13 vs. 5%, P < 0.0001). The most common private plan was a preferred provider organization (PPO) followed by a health maintenance organization/independent practice organization (HMO/IPA) plan regardless of diabetes status. For participants 18–64 years of age, high health insurance cost was the most common reason for not having coverage.
CONCLUSIONS
Two million adults <65 years of age with diabetes had no health insurance coverage, which has considerable public health and economic impact. Health care reform should work toward ensuring that people with diabetes have coverage for routine care.
doi:10.2337/dc12-0257
PMCID: PMC3476921  PMID: 22787175
2.  A Behavioral Weight-Loss Intervention in Persons with Serious Mental Illness 
The New England journal of medicine  2013;368(17):1594-1602.
BACKGROUND
Overweight and obesity are epidemic among persons with serious mental illness, yet weight-loss trials systematically exclude this vulnerable population. Lifestyle interventions require adaptation in this group because psychiatric symptoms and cognitive impairment are highly prevalent. Our objective was to determine the effectiveness of an 18-month tailored behavioral weight-loss intervention in adults with serious mental illness.
METHODS
We recruited overweight or obese adults from 10 community psychiatric rehabilitation outpatient programs and randomly assigned them to an intervention or a control group. Participants in the intervention group received tailored group and individual weight-management sessions and group exercise sessions. Weight change was assessed at 6, 12, and 18 months.
RESULTS
Of 291 participants who underwent randomization, 58.1% had schizophrenia or a schizoaffective disorder, 22.0% had bipolar disorder, and 12.0% had major depression. At baseline, the mean body-mass index (the weight in kilograms divided by the square of the height in meters) was 36.3, and the mean weight was 102.7 kg (225.9 lb). Data on weight at 18 months were obtained from 279 participants. Weight loss in the intervention group increased progressively over the 18-month study period and differed significantly from the control group at each follow-up visit. At 18 months, the mean between-group difference in weight (change in intervention group minus change in control group) was −3.2 kg (−7.0 lb, P = 0.002); 37.8% of the participants in the intervention group lost 5% or more of their initial weight, as compared with 22.7% of those in the control group (P = 0.009). There were no significant between-group differences in adverse events.
CONCLUSIONS
A behavioral weight-loss intervention significantly reduced weight over a period of 18 months in overweight and obese adults with serious mental illness. Given the epidemic of obesity and weight-related disease among persons with serious mental illness, our findings support implementation of targeted behavioral weight-loss interventions in this high-risk population.
doi:10.1056/NEJMoa1214530
PMCID: PMC3743095  PMID: 23517118
3.  Diabetes Knowledge and Its Relationship With Achieving Treatment Recommendations in a National Sample of People With Type 2 Diabetes 
Diabetes Care  2012;35(7):1556-1565.
OBJECTIVE
We examined the prevalence of knowledge of A1C, blood pressure, and LDL cholesterol (ABC) levels and goals among people with diabetes, its variation by patient characteristics, and whether knowledge was associated with achieving levels of ABC control recommended for the general diabetic population.
RESEARCH DESIGN AND METHODS
Data came from 1,233 adults who self-reported diabetes in the 2005–2008 National Health and Nutrition Examination Survey. Participants reported their last ABC level and goals specified by their physician (not validated by medical record data). Analysis included descriptive statistics and logistic regression.
RESULTS
Among participants tested in the past year, 48% stated their last A1C level. Overall, 63% stated their last blood pressure level and 22% stated their last LDL cholesterol level. Knowledge of ABC levels was greatest in non-Hispanic whites, lowest in Mexican Americans, and higher with more education and income (all P ≤ 0.02). Demographic associations were similar for those reporting physician-specified ABC goals at the American Diabetes Association–recommended levels (A1C <7%, blood pressure <130/80 mmHg, and LDL cholesterol <100 mg/dL). Nineteen percent of participants stated that their provider did not specify an A1C goal compared with 47% and 41% for blood pressure and LDL cholesterol goals, respectively. For people who self-reported A1C <7.0%, 83% had an actual A1C <7.0%. Otherwise, participant knowledge was not significantly associated with risk factor control, except for in those who knew their last LDL cholesterol level (P = 0.046 for A1C <7.0%). Results from logistic regression corroborated these findings.
CONCLUSIONS
Ample opportunity exists to improve ABC knowledge. Diabetes education should include behavior change components in addition to information on ABC clinical measures.
doi:10.2337/dc11-1943
PMCID: PMC3379593  PMID: 22498806
4.  Association of Walkability with Obesity in Baltimore City, Maryland 
American journal of public health  2010;101(Suppl 1):S318-S324.
Objectives
To investigate the association between walkability and obesity stratified by neighborhood race and socioeconomic status (SES) among adults residing in Baltimore City.
Methods
We conducted a cross-sectional study among 3,493 participants from the Healthy Aging in Neighborhoods of Diversity across the Life-Span (HANDLS) study. The Pedestrian Environment Data Scan (PEDS) was implemented to measure neighborhood walkability in 34 neighborhoods of varying racial and socioeconomic composition in which participants resided. Walkability was determined using confirmatory factor analysis. Prevalence ratios were calculated for the association between walkability and obesity using multilevel modeling.
Results
Among individuals living in predominately white and high-SES neighborhoods, residing in highly walkable neighborhoods was associated with a lower prevalence of obesity compared to individuals living in poorly walkable neighborhoods after adjusting for individual-level demographic variables (PR=0.58, p=<0.001; PR=0.80, p=0.004, respectively); prevalence ratios were similar after controlling for potential mediators. The association between walkability and obesity among individuals living in low-SES neighborhoods was not significant after accounting for main mode of transportation (PR=0.85, p=0.060).
Conclusion
Among some neighborhoods, high walkability was associated with less obesity.
doi:10.2105/AJPH.2009.187492
PMCID: PMC3097303  PMID: 21164099
Walkability; Obesity; Neighborhood; Socioeconomic Status; Racial Composition
5.  Associations between quality indicators of internal medicine residency training programs 
BMC Medical Education  2011;11:30.
Background
Several residency program characteristics have been suggested as measures of program quality, but associations between these measures are unknown. We set out to determine associations between these potential measures of program quality.
Methods
Survey of internal medicine residency programs that shared an online ambulatory curriculum on hospital type, faculty size, number of trainees, proportion of international medical graduate (IMG) trainees, Internal Medicine In-Training Examination (IM-ITE) scores, three-year American Board of Internal Medicine Certifying Examination (ABIM-CE) first-try pass rates, Residency Review Committee-Internal Medicine (RRC-IM) certification length, program director clinical duties, and use of pharmaceutical funding to support education. Associations assessed using Chi-square, Spearman rank correlation, univariate and multivariable linear regression.
Results
Fifty one of 67 programs responded (response rate 76.1%), including 29 (56.9%) community teaching and 17 (33.3%) university hospitals, with a mean of 68 trainees and 101 faculty. Forty four percent of trainees were IMGs. The average post-graduate year (PGY)-2 IM-ITE raw score was 63.1, which was 66.8 for PGY3s. Average 3-year ABIM-CE pass rate was 95.8%; average RRC-IM certification was 4.3 years. ABIM-CE results, IM-ITE results, and length of RRC-IM certification were strongly associated with each other (p < 0.05). PGY3 IM-ITE scores were higher in programs with more IMGs and in programs that accepted pharmaceutical support (p < 0.05). RRC-IM certification was shorter in programs with higher numbers of IMGs. In multivariable analysis, a higher proportion of IMGs was associated with 1.17 years shorter RRC accreditation.
Conclusions
Associations between quality indicators are complex, but suggest that the presence of IMGs is associated with better performance on standardized tests but decreased duration of RRC-IM certification.
doi:10.1186/1472-6920-11-30
PMCID: PMC3126786  PMID: 21651768
program quality; Residency Review Committee; American Board of Internal Medicine Certifying Examination
6.  Healthy food availability and the association with body mass index in Baltimore City, Maryland 
Public health nutrition  2011;14(6):1001-1007.
Objective
Previous literature has shown that the availability of healthy food in neighborhoods is associated with area characteristics and dietary quality. This study investigated the association between the availability of healthy foods and body mass index (BMI) among 2,616 participants living in Baltimore City.
Method
Trained staff collected demographic information, height, weight and 24-hr dietary recalls between 2004 and 2008. Healthy food availability was determined in 34 census tracts of varying racial and SES composition using the Nutrition Environment Measures Survey- Stores in 2007. Multilevel linear regression was used to estimate associations between healthy food availability and BMI.
Results
Among individuals living in predominately white neighborhoods, high availability of healthy foods was associated with significantly higher BMI compared to individuals living in low healthy food availability neighborhoods after adjustment for demographic variables (β=3.22, p=0.001). Associations were attenuated but remained significant after controlling for dietary intake (β=2.81, p=0.012).
Conclusion
Contrary to expectations, there was a positive association between the availability of healthy food and higher BMI among individuals living in predominately white neighborhoods. This result could be due to individuals in low healthy food availability areas traveling outside their neighborhood to obtain healthy food.
doi:10.1017/S1368980010003812
PMCID: PMC3089686  PMID: 21272422
Body mass index; Healthy Food Availability; Obesity; BMI; Neighborhood; Racial Composition; Socioeconomic Status
7.  Randomized trial of achieving healthy lifestyles in psychiatric rehabilitation: the ACHIEVE trial 
BMC Psychiatry  2010;10:108.
Background
Overweight and obesity are highly prevalent among persons with serious mental illness. These conditions likely contribute to premature cardiovascular disease and a 20 to 30 percent shortened life expectancy in this vulnerable population. Persons with serious mental illness need effective, appropriately tailored behavioral interventions to achieve and maintain weight loss. Psychiatric rehabilitation day programs provide logical intervention settings because mental health consumers often attend regularly and exercise can take place on-site. This paper describes the Randomized Trial of Achieving Healthy Lifestyles in Psychiatric Rehabilitation (ACHIEVE). The goal of the study is to determine the effectiveness of a behavioral weight loss intervention among persons with serious mental illness that attend psychiatric rehabilitation programs. Participants randomized to the intervention arm of the study are hypothesized to have greater weight loss than the control group.
Methods/Design
A targeted 320 men and women with serious mental illness and overweight or obesity (body mass index ≥ 25.0 kg/m2) will be recruited from 10 psychiatric rehabilitation programs across Maryland. The core design is a randomized, two-arm, parallel, multi-site clinical trial to compare the effectiveness of an 18-month behavioral weight loss intervention to usual care. Active intervention participants receive weight management sessions and physical activity classes on-site led by study interventionists. The intervention incorporates cognitive adaptations for persons with serious mental illness attending psychiatric rehabilitation programs. The initial intensive intervention period is six months, followed by a twelve-month maintenance period in which trained rehabilitation program staff assume responsibility for delivering parts of the intervention. Primary outcomes are weight loss at six and 18 months.
Discussion
Evidence-based approaches to the high burden of obesity and cardiovascular disease risk in person with serious mental illness are urgently needed. The ACHIEVE Trial is tailored to persons with serious mental illness in community settings. This multi-site randomized clinical trial will provide a rigorous evaluation of a practical behavioral intervention designed to accomplish and sustain weight loss in persons with serious mental illness.
Trial Registration
Clinical Trials.gov NCT00902694
doi:10.1186/1471-244X-10-108
PMCID: PMC3016313  PMID: 21144025
8.  Perceived Discrimination and Adherence to Medical Care in a Racially Integrated Community 
Background
Past research indicates that access to health care and utilization of services varies by sociodemographic characteristics, but little is known about racial differences in health care utilization within racially integrated communities.
Objective
To determine whether perceived discrimination was associated with delays in seeking medical care and adherence to medical care recommendations among African Americans and whites living in a socioeconomically homogenous and racially integrated community.
Design
A cross-sectional analysis from the Exploring Health Disparities in Integrated Communities Study.
Participants
Study participants include 1,408 African-American (59.3%) and white (40.7%) adults (≥18 years) in Baltimore, Md.
Measurements
An interviewer-administered questionnaire was used to assess the associations of perceived discrimination with help-seeking behavior for and adherence to medical care.
Results
For both African Americans and whites, a report of 1–2 and >2 discrimination experiences in one’s lifetime were associated with more medical care delays and nonadherence compared to those with no experiences after adjustment for need, enabling, and predisposing factors (odds ratio [OR] = 1.8, 2.6; OR = 2.2, 3.3, respectively; all P < .05). Results were similar for perceived discrimination occurring in the past year.
Conclusions
Experiences with discrimination were associated with delays in seeking medical care and poor adherence to medical care recommendations INDEPENDENT OF NEED, ENABLING, AND PREDISPOSING FACTORS, INCLUDING MEDICAL MISTRUST; however, a prospective study is needed. Further research in this area should include exploration of other potential mechanisms for the association between perceived discrimination and health service utilization.
doi:10.1007/s11606-006-0057-4
PMCID: PMC1824749  PMID: 17356974
discrimination; health care utilization; health disparities; adherence
9.  Perceived Discrimination and Adherence to Medical Care in a Racially Integrated Community 
Background
Past research indicates that access to health care and utilization of services varies by sociodemographic characteristics, but little is known about racial differences in health care utilization within racially integrated communities.
Objective
To determine whether perceived discrimination was associated with delays in seeking medical care and adherence to medical care recommendations among African Americans and whites living in a socioeconomically homogenous and racially integrated community.
Design
A cross-sectional analysis from the Exploring Health Disparities in Integrated Communities Study.
Participants
Study participants include 1,408 African-American (59.3%) and white (40.7%) adults (≥18 years) in Baltimore, Md.
Measurements
An interviewer-administered questionnaire was used to assess the associations of perceived discrimination with help-seeking behavior for and adherence to medical care.
Results
For both African Americans and whites, a report of 1–2 and >2 discrimination experiences in one’s lifetime were associated with more medical care delays and nonadherence compared to those with no experiences after adjustment for need, enabling, and predisposing factors (odds ratio [OR] = 1.8, 2.6; OR = 2.2, 3.3, respectively; all P < .05). Results were similar for perceived discrimination occurring in the past year.
Conclusions
Experiences with discrimination were associated with delays in seeking medical care and poor adherence to medical care recommendations INDEPENDENT OF NEED, ENABLING, AND PREDISPOSING FACTORS, INCLUDING MEDICAL MISTRUST; however, a prospective study is needed. Further research in this area should include exploration of other potential mechanisms for the association between perceived discrimination and health service utilization.
doi:10.1007/s11606-006-0057-4
PMCID: PMC1824749  PMID: 17356974
discrimination; health care utilization; health disparities; adherence

Results 1-9 (9)