Charles R. Drew University (CDU) and community partners wanted to create a structure to transcend traditional community–academic partnerships. They wanted community leaders integrated into CDU’s research goals and education of medical professionals.
Purpose of Article
To explain the establishment of the Community Faculty Program, a new model of community–academic partnership that integrates community and academic knowledge.
Using CBPR principles, CDU and community partners re-conceptualized the faculty appointment process and established the Division of Community Engagement (DCE). CDU initially offered academic appointments to nine community leaders. Community Faculty contributes to CDU’s governance, education, research, and publication goals. This model engaged communities in translational research and transformed the education of future healthcare professionals.
The Community Faculty Program is a new vision of partnership. Using a CBPR approach with committed partners, a Community Faculty Program can be created that embodies the values of both the community and the academy.
Community health research; process issues; community-based participatory research; faculty; faculty; medical
Editorials; blood pressure control; hypertension; underinsured; Hypertension; Health Services; Epidemiology
Developing effective Community-Academic Partnerships (CAPs) is challenging, and the steps to build and sustain them have not been well documented. This paper describes efforts to form and sustain the Healthy Community Neighborhood Initiative (HCNI), a CAP to improve health in a low-income community in South Los Angeles.
Moderated, semi-structured discussions with HCNI community and academic partners were used to develop a framework for CAP formation.
We identified two key features, shared values and respect, as critical to the decision to form the HCNI. Five elements were identified as necessary for building and sustaining the HCNI: trust, transparency, equity and fairness, adequate resources and developing protocols to provide structure. We also identified several challenges and barriers and the strategies used in the HCNI to mitigate these challenges.
We developed a framework to incorporate and reinforce the key elements identified as crucial in building and sustaining a CAP in a low-income community.
Building partnerships; Community-academic partnership; Community-based participatory research; Memorandum of understanding; Sustaining partnerships
Receipt of pre-end-stage renal disease (ESRD) clinical care can improve outcomes for patients treated with maintenance hemodialysis (MHD). The study addressed age-related variations in receipt of a composite of recommended care to include nephrologist and dietician care and use of arterio-venous fistula at first outpatient MHD. Less than 2% of patients treated with MHD received all three forms of pre-ESRD care, and 63.3% received none of the three elements of care. The mean number of pre-ESRD care elements received by the oldest group (≥80 years) did not differ from the youngest group (<55 years), but was less than the 55-66 and 67-79 years groups; adjusted ratios of 0.93 (0.92-0.94; p<0.001) and 0.94 (0.92-0.95; p<0.001), respectively. A major effort is needed to ensure comprehensive pre-ESRD care for all patients with advanced CKD, especially for the youngest and oldest patient groups, who were less likely to receive recommended pre-ESRD care.
hemodialysis; aging; end-stage renal disease (ESRD); chronic kidney disease (CKD); pre-ESRD care
In the United States, medical students must demonstrate a standard level
of “cultural competence,” upon graduation. Cultural competence
is most often defined as a set of congruent behaviors, attitudes, and policies
that come together in a system, organization, or among professionals that
enables effective work in cross-cultural situations. The Association of American
Medical Colleges developed the Tool for Assessing Cultural Competence Training
(TACCT) to assist schools in developing and evaluating cultural competence
curricula to meet these requirements. This review uses the TACCT as a guideline
to describe and assess pedagogical approaches to cultural competence training in
US medical education and identify content gaps and opportunities for curriculum
improvement. A total of 18 programs are assessed. Findings support previous
research that cultural competence training can improve the knowledge, attitudes,
and skills of medical trainees. However, wide variation in the
conceptualization, implementation, and evaluation of cultural competence
training programs exists, leading to differences in training quality and
outcomes. More research is needed to establish optimal approaches to
implementing and evaluating cultural competence training that incorporate
cultural humility, the social determinants of health, and broader structural
competency within the medical system.
Cultural competence; cultural humility; cultural competence training; medical education; Tool for Assessing Cultural Competence Training (TACCT); systematic review
In the general population African-Americans experience higher mortality than their white peers, attributed, in part, to their lower socio-economic status, reduced access to care and possibly intrinsic biologic factors. A notable exception are patients with kidney disease, among whom African-Americans experience lower mortality. It is unclear if similar differences affecting outcomes exist in patients with no kidney disease but with similar access to health care.
Methods and Results
We compared all-cause mortality, incident coronary heart disease (CHD) and incident ischemic stroke using multivariable adjusted Cox models in a nationwide cohort of 547,441 African-American and 2,525,525 white patients with baseline estimated glomerular filtration rate (eGFR) ≥60 ml/min/1.73m2 receiving care from the US Veterans Health Administration. In parallel analyses we compared outcomes in African-American vs. white individuals in the National Health and Nutrition Examination Survey 1999–2004 (NHANES). After multivariable adjustments in veterans, African-American race was associated with 24% lower all-cause mortality (adjusted hazard ratio (aHR), 95% confidence interval (CI): 0.76, 0.75–0.77, p<0.001) and 37% lower incidence of CHD (aHR, 95%CI: 0.63, 0.62–0.65, p<0.001), but similar incidence of ischemic stroke (aHR, 95%CI: 0.99, 0.97–1.01, p=0.3). African-American race was associated with a 42% higher adjusted mortality among individuals with eGFR≥60 ml/min/1.73m2 in NHANES (aHR, 95%CI: 1.42 (1.09–1.87)).
African-American veterans with normal eGFR have lower all-cause mortality and incidence of CHD, and similar incidence of ischemic stroke. These associations are in contrast with the higher mortality experienced by African-American individuals in the general US population.
Race; African-American; mortality; coronary heart disease; stroke; chronic kidney disease
Patients with chronic kidney disease (CKD) suffer from an increased prevalence of cardiovascular disease (CVD) risk factors, and a high rate of premature CV morbidity and mortality. The confluence of CV risk factors, in the context of cardio-metabolic perturbations that vary as renal function declines, complicates strategies for the care of patients with CKD. Understanding the existing evidence for effective CVD treatment strategies can help providers better care for these patients, navigate the complex treatment guidelines, which often differ across major organizations, and minimize the conflicting recommendations that new studies may pose. A pragmatic approach is to target a BP <140/90 mm Hg, which frequently requires more than two or three antihypertensive agents. Most guidelines recommend a combination of diuretic and angiotensin converting enzyme inhibitor or angiotensin receptor blockers, along with a dihydropyridine calcium channel blocker, beta blocker or other agent based on co-existing medical conditions. Consideration for a lower BP goal and/or other therapeutic interventions should be based on the etiology of CKD, stage of CKD, and/or presence of proteinuria. Finally, most patients with CKD, not on dialysis, would benefit from treatment with statins and non-pharmacologic lifestyle interventions should be promoted for all patients with CKD.
Blood Pressure; Hypertension; Cardiovascular Disease; Chronic Kidney Disease
African Americans have exceptionally high rates of hypertension and hypertension related complications. It is commonly reported that the blood pressure lowering efficacy of renin angiotensin system (RAS) inhibitors is attenuated in African Americans due to a greater likelihood of having a low renin profile. Therefore these agents are often not recommended as initial therapy in African Americans with hypertension. However, the high prevalence of comorbid conditions, such as diabetes, cardiovascular and chronic kidney disease makes treatment with RAS inhibitors more compelling. Despite lower circulating renin levels and a less significant fall in blood pressure in response to RAS inhibitors in African Americans, numerous clinical trials support the efficacy of RAS inhibitors to improve clinical outcomes in this population, especially in those with hypertension and risk factors for cardiovascular and related diseases. Here, we discuss the rationale of RAS blockade as part of a comprehensive approach to attenuate the high rates of premature morbidity and mortality associated with hypertension among African Americans.
African American; Blood pressure; Ethnicity; Hypertension; Renin; Angiotensin
This study used Community Partnered Participatory Research (CPPR) to address low participation of racial and ethnic minorities in medical research and the lack of trust between underrepresented communities and researchers.
Using a community and academic partnership in July 2012, residents of a South Los Angeles neighborhood were exposed to research recruitment strategies: referral by word-of-mouth, community agencies, direct marketing, and extant study participants.
Among 258 community members exposed to recruitment strategies, 79.8% completed the study. Exposed individuals identified their most important method for learning about the study as referral by study participants (39.8%), community agencies (30.6%), word-of-mouth (17.5%), or direct marketing promotion (12.1%). Study completion rates varied by recruitment method: referral by community agencies (88.7%), referral by participants (80.4%), direct marketing promotion (86.2%), word of mouth (64.3%).
Although African American and Latino communities are often described as difficult to engage in research, we found high levels of research participation and completion when recruitment strategies emerged from the community itself. This suggests recruitment strategies based on CPPR principles represent an important opportunity for addressing health disparities and our high rates of research completion should provide optimism and a road map for next steps.
Community Partnered Participatory Research; Translational science; Recruitment; Trust; African American; Latino
To describe the design and rationale of the Healthy Community Neighborhood Initiative (HCNI), a multi-component study to understand and document health risk and resources in a low-income and minority community.
A community-partnered participatory research project.
A low-income, biethnic African American and Latino neighborhood in South Los Angeles
Adult community residents aged >18 years.
Main Outcome Measures
Household survey and clinical data collection; neighborhood characteristics; neighborhood observations; and community resources asset mapping.
We enrolled 206 participants (90% of those eligible), of whom 205 completed the household interview and examination, and 199 provided laboratory samples. Among enrollees, 82 (40%) were aged >50 years and participated in functional status measurement. We completed neighborhood observations on 93 street segments; an average of 2.2 (SD=1.6) study participants resided on each street segment observed. The community asset map identified 290 resources summarized in a Community Resource Guide given to all participants.
The HCNI community-academic partnership has built a framework to assess and document the individual, social, and community factors that may influence clinical and social outcomes in a community at high-risk for preventable chronic disease. Our project suggests that a community collaborative can use culturally and scientifically sound strategies to identify community-centered health and social needs. Additional work is needed to understand strategies for developing and implementing interventions to mitigate these disparities.
Design; Rationale; Community-Partnered Research; African American; Latino; Under-resourced Communities; Community Assets; Chronic Disease
Obesity has been shown to have implications for chronic kidney disease (CKD); however, it has received minimal attention from scientists studying CKD among African Americans.
The purpose of this study was to examine the manner in which weight status has implications for CKD among this group through analysis of data drawn from the Jackson Heart Study (JHS).
Cross-sectional analysis of a single-site longitudinal population-based cohort.
The data for this study were drawn from the baseline examination of the Jackson Heart Study. The analytic cohort consisted of 3,430 African American men and women (21-84 years of age) living in the tri-county area of the Jackson, Mississippi metropolitan areas with complete data to determine CKD status.
The primary dependent variable was CKD (defined as the presence of albuminuria or reduced estimated glomerular filtration rate (eGFR) <60 ml/min/1.73m2). Weight status, the primary predictor, was a four-category measure based on body mass index (BMI).
Associations were explored through bivariable analyses and multivariable logistic regression analyses adjusting for CKD, weight status, diabetes, hypertension, and cardiovascular disease risk factors as well as demographic factors. The prevalence of CKD in the JHS was 20%. The proportion of overweight, class I, and class II obese individuals was 32.5%, 26.9% and 26.2% respectively. In the pooled model, weight status was not found to be associated with CKD; however, subgroup analysis revealed that class II obesity was associated with CKD among males (OR 2.37, CI 1.34–4.19) but not among females (OR 1.32, CI 0.88–1.98). The relationship between CKD prevalence and diabetes and CKD prevalence and hypertension varied by gender and differed across weight categories.
Weight status has implications for CKD among JHS participants and this study underscores the need for additional research investigating the relationship between weight status, gender, and CKD among African Americans.
Kidney Disease; Obesity; Gender; African Americans; Jackson Heart Study
The retrieval and manipulation of data from large public databases like the U.S. National Health and Nutrition Examination Survey (NHANES) may require sophisticated statistical software and significant expertise that may be unavailable in the university setting. In response, we have developed the Data Retrieval And Manipulation System (DReAMS), an automated information system to handle all processes of data extraction and cleaning and then joining different subsets to produce analysis-ready output. The system is a browser-based data warehouse application in which the input data from flat files or operational systems are aggregated in a structured way so that the desired data can be read, re-coded, queried and extracted efficiently. The current pilot implementation of the system provides access to a limited amount of NHANES database. We plan to increase the amount of data available through the system in the near future and to extend the techniques to other large databases from CDU archive with a current holding of about 53 databases.
Data Retrieval System; Data Retrieval and Manipulation System; Secondary Large Database Retrieval and Analysis; Information Storage and Retrieval; Data Storage; Data Retrieval; Information Retrieval
Background and purpose
Placement of an arteriovenous fistula (AVF) prior to initiating dialysis can affect clinical outcomes for patients who subsequently initiate chronic hemodialysis treatments. Age-related variation in receipt of a functioning AVF prior to initiating dialysis is not well known. The purpose of this study was to examine age-related rates in use of AVF at the first outpatient dialysis treatment among U.S. incident patients on hemodialysis.
Among 526,145 identified, the use of AVF at the first outpatient dialysis treatment was lower in the youngest (<55 year) and oldest (≥80 year) vs. both 55–66 year and 67–79 year age groups. These findings persisted after adjusting for demographics, lifestyle behavior, employment and insurance status, physical/functional conditions, and comorbid conditions.
The presence of a functioning AVF at initial dialysis treatment varies by age. Modifying healthcare policy and/or expanding the role of the renal nurse practitioner should be considered to address this issue.
This report retrospectively examines the structure of an emerging community-academic participatory research (PR) partnership that was not sustainable, despite attempts to adhere to PR principles and demonstrable success in research outcomes. The influence of community and academic parent organizations on the PR process and outcomes is presented in the context of the Donabedian Model. We dissected the structural elements contributed by parent organizations to forming the structure of the PR partnership (memorandum of understanding, policy environment, human resources and effort, community and academic resources, expertise and experience, and funding) and explored the influence of potential and actual conflicts on the PR partnership’s sustainability. The effect of potential and actual conflict on the PR process and quality of PR outcomes is discussed. Based on this, we conclude by proposing seven core standards for the establishment and development of emerging community-academic PR partnerships.
Core Standards; Participatory Research; Organizational Structure; Disambiguation; Conflict Resolution
Dialysis remains the predominant form of renal replacement therapy in the U.S., but the optimal timing for the initiation of dialysis remains poorly defined. Not only clinical factors such as signs/symptoms of uremia, co-existing cardiovascular disease, and presence of diabetes, but also key demographic characteristics including age, gender, race/ethnicity and socioeconomics have all been considered as potential modifying factors in the decision for the timing of dialysis initiation. The 2012 Kidney Disease: Improving Global Outcomes (KDIGO) Clinical Practice Guideline for the Evaluation and Management of Chronic Kidney Disease (CKD) suggests that dialysis be initiated when signs/symptoms attributable to kidney failure such as serositis, acid-base or electrolyte abnormalities, pruritus, poorly controlled volume status or blood pressure, deteriorating nutritional status despite dietary intervention, or cognitive impairment are visible or noted. These signs/symptoms typically occur when the glomerular filtration rate (GFR) is in the range of 5 to 10 ml/min/1.73 m2, although they may occur at higher levels of GFR. We review recent data on the timing of dialysis initiation, their implications for managing patients with late stage CKD, and the important role of considering key demographics in making patient-centered decisions for the timing of dialysis initiation.
Timing dialysis initiation; race; ethnicity; demographics
Chronic kidney disease (CKD) is a national public health problem that afflicts persons of all segments of society. While racial/ethnic disparities in advanced CKD including dialysis dependent populations have been well established, the finding of differences in CKD incidence, prevalence and progression across different socioeconomic groups and racial and ethnic strata has only recently started to receive significant attention. Socioeconomics may exert both interdependent and independent effects on CKD and its complications, and may confound racial and ethnic disparities. Socioeconomic constellations influence not only access to quality care for CKD risk factors and CKD treatment, but may mediate many of the cultural and environmental determinants of health that are becoming more widely recognized as impacting complex medical disorders. In this manuscript we have reviewed the available literature pertaining to the role of socioeconomic status and economic factors in both non-dialysis dependent CKD and end-stage-renal disease. Advancing our understanding of the role of socioeconomic factors in patients with or at risk for CKD can lead to improved strategies for disease prevention and management.
poverty; chronic kidney disease; disparities; socio-economics; end-stage renal disease
Cardiovascular disease (CV) remains the leading cause of death worldwide. Low levels of vitamin D are associated with high risk of myocardial infarction, even after controlling for factors associated with coronary artery disease. A growing body of evidence suggests that vitamin D plays an important role in CV related signaling pathways. However, little is known about the molecular mechanism by which vitamin D modulates cardiac development. The Wnt signaling pathway plays a pivotal role in tissue development by controlling stem cell renewal, lineage selection and even more importantly heart development. In this study, we examined the role of 1,25-D3 (active form of vitamin D) on cardiomyocyte proliferation, apoptosis, cell phenotype, cell cycle progression and differentiation into cardiomyotubes. We determined that the addition of 1,25-D3 to cardiomyocytes cells: 1) Inhibits cell proliferation without promoting apoptosis; 2) Decreases expression of genes related to the regulation of the cell cycle; 3) Promotes cardiomyotubes formation; 4) Induces the expression of Casein kinase-1-α1, a negative regulator of the canonical Wnt signaling pathway; and 5) Increases the expression of the noncanonical Wnt11, which it has been demonstrated to induce cardiac differentiation during embryonic development in adult cells. In conclusion, we postulate that vitamin D promotes cardiac differentiation through a negative modulation of the canonical Wnt signaling pathway and by up-regulating the expression of Wnt11. These results suggest that vitamin D repletion to prevent and/or improve cardiovascular disorders that are linked to abnormal cardiac differentiation, such as post infarction cardiac remodeling, deserve further study.
VDR; Wnt11; Csnk1α1; β-catenin; Gsk3β; APC
Purpose of review
Persons with chronic kidney disease (CKD) exhibit a disproportionate burden of elevated blood pressure (BP) with a high prevalence of premature end-stage renal disease and cardiovascular events.
Results of recent randomized controlled clinical trials suggest that most patients with reduced estimated glomerular filtration rate (eGFR) and hypertension experience optimal clinical outcomes when SBP is less than 140 mmHg and DBP is less than 90 mmHg. The benefit of additional lowering of SBP to less than 130 mmHg and DBP to less than 80 mmHg remains controversial, and appears to be of most benefit to the subset of CKD patients with proteinuria (>300 mg/day). The combination of a diuretic and an angiotensin receptor blocker (ARB) or angiotensin-converting enzyme inhibitor (ACEI) has demonstrated particular promise in patients with reduced eGFR and proteinuria.
A practical approach in clinical practice for the treatment of elevated BP in persons with CKD is to achieve a BP less than 140/90 mmHg with a combination of diuretic and an ARB or ACEI. Consideration for a lower BP goal and other therapeutic and nontherapeutic interventions can be made based on the cause of CKD, presence of proteinuria, or other coexisting medical conditions.
chronic kidney disease; high blood pressure; hypertension
Elderly individuals with chronic kidney disease (CKD) have high rates of comorbid conditions, including cardiovascular disease and its risk factors, and CKD-related complications. In individuals aged ≥ 65 years, we sought to describe the prevalence of CKD determined from laboratory test results in the Kidney Early Evaluation Program (KEEP; n = 27,017) and National Health and Nutrition Examination Survey (NHANES) 1999-2006 (n = 5,538) and the prevalence of diagnosed CKD determined from billing codes in the Medicare 5% sample (n = 1,236,946). In all 3 data sources, we also explored comorbid conditions and CKD-related complications.
CKD was identified as decreased estimated glomerular filtration rate (<60 mL/min/1.73 m2) or increased albumin-creatinine ratio in KEEP and NHANES; CKD was identified using International Classification of Diseases, Ninth Revision, Clinical Modification codes in Medicare. Investigated comorbid conditions included diabetes, hypertension, high cholesterol level, coronary artery disease, congestive heart failure, cerebrovascular disease, peripheral vascular disease, and cancer, and CKD-related complications included anemia, hypocalcemia, hyperphosphatemia, and hyperparathyroidism.
The prevalence of CKD was ~44% in both KEEP and NHANES participants, and the prevalence of diagnosed CKD was 7% in Medicare beneficiaries. In all 3 data sets, the prevalence of CKD or diagnosed CKD was higher in participants aged ≥ 80 years and those with comorbid conditions. For KEEP and NHANES participants, the prevalence of most comorbid conditions and CKD complications increased with decreasing estimated glomerular filtration rate. For participants with CKD stages 3-5, a total of 29.2% (95% CI, 27.8-30.6) in KEEP and 19.9% (95% CI, 17.0-23.1) in NHANES had anemia, 0.7% (95% CI, 0.4-0.9) and 0.6% (95% CI, 0.3-1.3) had hypocalcemia, 5.4% (95% CI, 4.7-6.1) and 6.4% (95% CI, 5.1-8.0) had hyperphosphatemia, and 52.0% (95% CI, 50.4-53.6) and 30.0% (95% CI, 25.9-34.3) had hyperparathyroidism, respectively.
CKD is common in the elderly population and is associated with high frequencies of concomitant comorbid conditions and biochemical abnormalities. Because CKD is not commonly diagnosed, greater emphasis on physician education may be beneficial.
Aged; chronic kidney disease; comorbidity
Substantial changes in not only access to care, cost, and quality of care, but also health professions education are needed to ensure effective national healthcare reform. Since the actionable determinants of health such as personal beliefs and behaviors, socioeconomic factors, and the environment disproportionately affect the poor (and often racial/ethnic minorities), many have suggested that focusing efforts on this population will both directly and indirectly improve the overall health of the nation. Key to the success of such strategies are the ongoing efforts by historically black medical schools (HBMSs) as well as other minority serving medical and health professional schools, who produce a disproportionate percentage of the high-quality and diverse health professionals that are dedicated to maintaining the health of an increasingly diverse nation. Despite their public mission, HBMSs receive limited public support threatening their ability to not only meet the increasing minority health workforce needs but to even sustain their existing contributions. Substantial changes in health education policy and funding are needed to ensure HBMSs as well as other minority-serving medical and health professional schools can continue to produce the diverse, high-quality health professional workforce necessary to maintain the health of an increasingly diverse nation. We explore several model initiatives including focused partnerships with legislative and business leaders that are urgently needed to ensure the ability of HBMSs to maintain their legacy of providing compassionate, quality care to the communities in greatest need.
historically black colleges and universities; minority; health disparities
Both anemia and secondary hyperparathyroidism are reflections of hormonal failure in chronic kidney disease (CKD). While the association of elevated levels of parathyroid hormone (PTH) and anemia has been studied among those with advanced CKD, less is known about this association in mild-to-moderate CKD.
In a cross-sectional analysis, the relationship between PTH and hemoglobin levels was investigated in 10,750 participants in the National Kidney Foundation's Kidney Early Evaluation Program with an estimated glomerular filtration rate (eGFR) <60 ml/min/1.73 m2.
In the unadjusted analysis, higher PTH levels were associated with lower hemoglobin levels. However, after multivariable adjustment for age, race, gender, smoking status, education, cardiovascular disease, diabetes, hypertension, cancer, albuminuria, BMI, baseline eGFR, calcium, and phosphorus, the direction of association changed. As compared to the first PTH quintile, hemoglobin levels were 0.09 g/dl (95% CI: 0.01-0.18), 0.15 g/dl (95% CI: 0.07-0.24), 0.18 g/dl (95% CI: 0.09-0.26), and 0.13 g/dl (95% CI: 0.07-0.25) higher for the second, third, fourth, and fifth quintiles, respectively. Similarly, each standard deviation increase in natural log transformed PTH was associated with a 0.06 g/dl (95% CI: 0.03-0.09, p = 0.0003) increase in hemoglobin. However, a significant effect modification was seen for diabetes (p = 0.0003). Each standard deviation increase in natural log transformed PTH was associated with a 0.10 g/dl (95% CI: 0.054-0.138, p < 0.0001) increase in hemoglobin, while no association was seen among those without diabetes mellitus.
After multivariable adjustment, there was a small positive association between PTH and hemoglobin among diabetics but not among nondiabetics.
Chronic kidney disease; Anemia; Secondary hyperparathyroidism