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1.  Undiagnosed hepatitis C on the general medicine and trauma services of two urban hospitals★ 
The Journal of infection  2009;59(1):62-69.
The inpatient medical service may be an important location to identify undiagnosed hepatitis C virus (HCV) infection. We conducted a cross-sectional HCV prevalence study in consecutive patients aged 18–65 admitted in a three-month period to two urban hospitals’ general internal medicine and trauma services. Patient sera were anonymously screened for anti-HCV antibody with an enzyme-linked immunoassay and, when anti-HCV positive (+), for HIV. Health system records were examined for prior HCV testing or diagnosis or an HIV diagnosis then linked anonymously to test results. Multivariate logistic regression was used to examine associations of patient and health care factors with unknown HCV+ status. Of 786 unique patients tested (60.3% of all admitted patients), 62 (7.9%) were HCV+ without a prior HCV+ test or diagnosis while 61 patients (7.8%) tested HCV+ but had prior HCV+ test or diagnosis. Of 62 patients with unknown HCV+, 6 (9.7%) were HIV+ but only 3 had a prior HIV diagnosis; of 61 patients with known HCV+, all 9 (14.8%) HIV+ had been diagnosed. Among the 640 patients with prior unknown HCV status, an HCV+ test was strongly associated with age: 50–65 (adjusted odds ratio [AOR] 5.44, CI 2.20–13.48) and age 36–49 (AOR 4.65, CI 1.91–11.32) versus. 18–35. In this anonymous study, we could not obtain HCV risk factor data but the positive and negative predictive values of HCV testing all inpatients with an unknown HCV status were 99.3% and 99.0%, respectively. In similar urban general medicine and trauma services, broader efforts to test for HCV in inpatients aged 36–65 may be warranted.
PMCID: PMC4020138  PMID: 19473706
Seroprevalence; Epidemiology; HCV infections; Inpatients; Wounds and injuries
2.  Dissemination and implementation of comparative effectiveness evidence: key informant interviews with Clinical and Translational Science Award institutions 
To identify ongoing practices and opportunities for improving national comparative effectiveness research (CER) translation through dissemination and implementation (D&I) via NIH-funded Clinical and Translational Science Award (CTSA) institutions.
Materials & methods
Key informant interviews were conducted with 18 CTSA grantees sampled to represent a range of D&I efforts.
Results & conclusions
The institutional representatives endorsed fostering CER translation nationally via the CTSA Consortium. However, five themes emerged from the interviews as barriers to CER D&I: lack of institutional awareness, insufficient capacity, lack of established D&I methods, confusion among stakeholders about what CER actually is and limited funding opportunities. Interviewees offered two key recommendations to improve CER translation: development of a centralized clearing house to facilitate the diffusion of CER D&I resources and methods across CTSA institutions; and formalization of the national CTSA network to leverage existing community engagement relationships and resources for the purpose of adapting and disseminating robust CER evidence locally with providers, patients and healthcare systems.
PMCID: PMC3961460  PMID: 24236560
comparative effectiveness research; dissemination; implementation; NIH
3.  A Randomized Trial of Peer Coach and Office Staff Support to Reduce Coronary Heart Disease Risk in African-Americans with Uncontrolled Hypertension 
Journal of General Internal Medicine  2012;27(10):1258-1264.
Adopting features of the Chronic Care Model may reduce coronary heart disease risk and blood pressure in vulnerable populations. We evaluated a peer and practice team intervention on reduction in 4-year coronary heart disease risk and systolic blood pressure.
A single blind, randomized, controlled trial in two adjacent urban university-affiliated primary care practices. Two hundred eighty African-American subjects aged 40 to 75 with uncontrolled hypertension.
Three monthly calls from trained peer patients with well-controlled hypertension and, on alternate months, two practice staff visits to review a personalized 4-year heart disease risk calculator and slide shows about heart disease risks. All subjects received usual physician care and brochures about healthy cooking and heart disease.
Change in 4-year coronary heart disease risk (primary) and change in systolic blood pressure, both assessed at 6 months.
At baseline, the 136 intervention and 144 control subjects’ mean 4-year coronary heart disease risk did not differ (intervention = 5.8 % and control = 6.4 %, P = 0.39), and their mean systolic blood pressure was the same (140.5 mmHg, p = 0.83). Endpoint data for coronary heart disease were obtained for 69 % of intervention and 82 % of control subjects. After multiple imputation for missing endpoint data, the reduction in risk among all 280 subjects favored the intervention, but was not statistically significant (difference −0.73 %, 95 % confidence interval: -1.54 % to 0.09 %, p = 0.08). Among the 247 subjects with a systolic blood pressure endpoint (85 % of intervention and 91 % of control subjects), more intervention than control subjects achieved a >5 mmHg reduction (61 % versus 45 %, respectively, p = 0.01). After multiple imputation, the absolute reduction in systolic blood pressure was also greater for the intervention group (difference −6.47 mmHg, 95 % confidence interval: −10.69 to −2.25, P = 0.003). One patient died in each study arm.
Peer patient and office-based behavioral support for African-American patients with uncontrolled hypertension did not result in a significantly greater reduction in coronary heart disease risk but did significantly reduce systolic blood pressure.
PMCID: PMC3445668  PMID: 22570108
coronary heart disease; hypertension; African American; peer support
4.  Limited PSA testing in indigent men in South Texas: An appropriate care or missing a prevention opportunity? 
No previous study has examined racial-ethnic differences in prostate specific antigen (PSA) testing and follow-up in primary care practices serving an indigent population.
From electronic medical records of primary care practices affiliated with one health care system in San Antonio, we identified 9,267 men aged 50–74 with 2+ clinic visits from 2008 through 2010 and no prior prostate cancer diagnosis. Logistic regression was used to examine the association of race-ethnicity with the use of PSA testing and, if tested, with an abnormal result (≥4 ng/mL) adjusted for demographics, health care and clinical factors. Time to a follow-up activity after an abnormal PSA was assessed using Cox proportional models.
The race-ethnicity of this cohort was 63% Hispanic, 27% non-Hispanic White, 7% African-American, and 3% other. In a 3-year period, 26.8% of men had at least one PSA test. Compared with African-Americans, non-Hispanic Whites were less likely to be tested (OR=0.68; 95% CI:0.55,0.83) but Hispanics did not differ (OR=0.95; 95% CI:0.79,1.15). African-Americans were more likely to have an abnormal PSA than others (12.4% versus 5.2%, p<0.001) and the shortest adjusted time to follow-up (p=0.004).
In this 3-year indigent cohort, about one quarter had a PSA test, approximately half of the national testing rate.
African-Americans were more likely to be tested than non-Hispanic Whites but had more abnormal results, raising concerns about missed prevention opportunities. African-Americans with high PSA results had the shortest time until follow-up, reflecting awareness of the threat of prostate cancer for African-Americans by physicians.
PMCID: PMC3436949  PMID: 22822113
Prostate Specific Antigen (PSA) testing; primary health care; electronic medical records (EMR); low-income; comorbidity
5.  Characteristics of Older Adults Receiving Opioids in Primary Care: Treatment Duration and Outcomes 
Pain medicine (Malden, Mass.)  2010;11(7):1063-1071.
To describe characteristics of older adults who received opioids for chronic noncancer pain (CP), ascertain types of opioid treatments received, and examine associations between patient characteristics and treatment outcomes.
Retrospective cohort study.
Primary care practice in New York City.
Eligible patients were ≥ 65 and newly started on an opioid for CP.
Outcome Measures
Patient characteristics and provider treatments, as well as duration of opioid therapy, proportion discontinuing therapy, and evidence of pain reduction and continued use of opioid for more than one year. Other outcomes included the presence and type(s) of side effects, abuse/misuse behaviors, and adverse events.
Participants (N=133) had a mean age of 82 (range=65–105), were mostly female (84%) and white (74%). Common indications for opioid treatment included back pain (37%) and osteoarthritis (35%). Mean duration of opioid use was 388 days (range=0–1880). Short-acting analgesics were most commonly prescribed. Physicians recorded side effects in 40% of cases. Opioids were discontinued in 48% of cases, mostly due to side effects/lack of efficacy. Pain reduction was documented in 66% of patient records, while 32% reported less pain and continued treatment for ≥ 1 year. Three percent displayed abuse/misuse behaviors, and 5% were hospitalized due to opioid-related adverse events.
Over 50% of older patients with CP tolerated treatment. Treatment was discontinued in 48% of cases, mostly due to side effects and lack of analgesic efficacy. Efforts are needed to establish the long-term safety and efficacy of opioid treatment for CP in diverse older patient populations.
PMCID: PMC3697923  PMID: 20642732
Opioid analgesics; chronic non-cancer pain; elderly; safety; efficacy; abuse/misuse
6.  Qualitative Analysis of Peer Coaches’ Experiences with Counseling African Americans About Reducing Heart Disease Risk 
Despite mounting evidence that peer coaches can make significant contributions to patient health, little is known about factors that must be addressed to engage and retain them in their role.
To identify motivators and barriers to serving as a peer coach.
Open ended semi-structured interviews.
In a randomized trial of peer support, patients with well controlled hypertension and good interpersonal skills were recruited and trained to serve as peer coaches for African-American patients from the same practices who had poorly controlled hypertension. Peer coaches spoke by telephone at least three times with their same sex patient–clients on alternate months during the 6-month intervention and counseled about medication adherence as well as other healthy lifestyles.
Of 15 trained peer coaches, ten were contacted and agreed to participate in the qualitative interview. Peer coaches had a mean age of 66 years, 50% were women, and 80% were African-American. Themes regarding favorable aspects of the peer coach experience included: meaning and satisfaction derived from contributing to community health and the personal emotional and physical benefits derived from serving as a peer coach. Negative aspects centered on: challenges in establishing the initial telephone contact and wanting more information about their patient–clients’ personal health conditions and status. Peer coaches endorsed gender matching but were less clear about race-matching.
Programs that utilize peer support to enhance positive health behaviors should recognize that a spirit of volunteerism motivates many successful peer coaches. Program planners should acknowledge the special characteristics required of successful peer coaches when selecting, motivating and training individuals for this role.
Electronic supplementary material
The online version of this article (doi:10.1007/s11606-011-1883-6) contains supplementary material, which is available to authorized users.
PMCID: PMC3270244  PMID: 21953326
peer coach; peer counseling; navigator; risk counseling
7.  Low Use of Opioid Risk Reduction Strategies in Primary Care Even for High Risk Patients with Chronic Pain 
Experts recommend close oversight of patients receiving opioid analgesics for chronic non-cancer pain (CNCP), especially those at increased risk of misuse. We hypothesized that physicians employ opioid risk reduction strategies more frequently in higher risk patients.
Retrospective cohort using electronic medical records.
Patients on long-term opioids (≥3 monthly prescriptions in 6 months) treated for CNCP in eight primary care practices.
We examined three risk reduction strategies: (1) any urine drug test; (2) regular office visits (at least once per 6 months and within 30 days of modifying opioid treatment); and (3) restricted early refills (one or fewer opioid refills more than a week early). Risk factors for opioid misuse included: age <45 years old, drug or alcohol use disorder, tobacco use, or mental health disorder. Associations of risk factors with each outcome were assessed in non-linear mixed effects models adjusting for patient clustering within physicians, demographics and clinical factors.
Main Results
Of 1,612 patients, 8.0% had urine drug testing, 49.8% visited the office regularly, and 76.6% received restricted (one or fewer) early refills. Patient risk factors were: age <45 (29%), drug use disorder (7.6%), alcohol use disorder (4.5%), tobacco use (16.1%), and mental health disorder (48.4%). Adjusted odds ratios (AOR) of urine drug testing were significantly increased for patients with a drug use disorder (3.18; CI 1.94, 5.21) or a mental health disorder (1.73; CI 1.14, 2.65). However, the AOR for restricted early refills was significantly decreased for patients with a drug use disorder (0.56; CI 0.34, 0.92). After adjustment, no risk factor was significantly associated with regular office visits. An increasing number of risk factors was positively associated with urine drug testing (p < 0.001), but negatively associated with restricted early refills (p = 0.009).
Primary care physicians’ adoption of opioid risk reduction strategies is limited, even among patients at increased risk of misuse.
Electronic supplementary material
The online version of this article (doi:10.1007/s11606-011-1648-2) contains supplementary material, which is available to authorized users.
PMCID: PMC3157518  PMID: 21347877
opioid misuse; chronic pain; urine drug testing
8.  A Retrospective Cohort Study of the Potency of lipid-lowering therapy and Race-gender Differences in LDL cholesterol control 
Reasons for race and gender differences in controlling elevated low density lipoprotein (LDL) cholesterol may be related to variations in prescribed lipid-lowering therapy. We examined the effect of lipid-lowering drug treatment and potency on time until LDL control for black and white women and men with a baseline elevated LDL.
We studied 3,484 older hypertensive patients with dyslipidemia in 6 primary care practices over a 4-year timeframe. Potency of lipid-lowering drugs calculated for each treated day and summed to assess total potency for at least 6 and up to 24 months. Cox models of time to LDL control within two years and logistic regression models of control within 6 months by race-gender adjust for: demographics, clinical, health care delivery, primary/specialty care, LDL measurement, and drug potency.
Time to LDL control decreased as lipid-lowering drug potency increased (P < 0.001). Black women (N = 1,440) received the highest potency therapy (P < 0.001) yet were less likely to achieve LDL control than white men (N = 717) (fully adjusted hazard ratio [HR] 0.66 [95% CI 0.56-0.78]). Black men (N = 666) and white women (N = 661) also had lower adjusted HRs of LDL control (0.82 [95% CI 0.69, 0.98] and 0.75 [95% CI 0.64-0.88], respectively) than white men. Logistic regression models of LDL control by 6 months and other sensitivity models affirmed these results.
Black women and, to a lesser extent, black men and white women were less likely to achieve LDL control than white men after accounting for lipid-lowering drug potency as well as diverse patient and provider factors. Future work should focus on the contributions of medication adherence and response to treatment to these clinically important differences.
PMCID: PMC3197552  PMID: 21961563
dyslipidemia; anticholesterolemic agents; healthcare disparities; survival analysis
9.  Primary care providers' perspective on prescribing opioids to older adults with chronic non-cancer pain: A qualitative study 
BMC Geriatrics  2011;11:35.
The use of opioid medications as treatment for chronic non-cancer pain remains controversial. Little information is currently available regarding healthcare providers' attitudes and beliefs about this practice among older adults. This study aimed to describe primary care providers' experiences and attitudes towards, as well as perceived barriers and facilitators to prescribing opioids as a treatment for chronic pain among older adults.
Six focus groups were conducted with a total of 23 physicians and three nurse practitioners from two academically affiliated primary care practices and three community health centers located in New York City. Focus groups were audiotape recorded and transcribed. The data were analyzed using directed content analysis; NVivo software was used to assist in the quantification of identified themes.
Most participants (96%) employed opioids as therapy for some of their older patients with chronic pain, although not as first-line therapy. Providers cited multiple barriers, including fear of causing harm, the subjectivity of pain, lack of education, problems converting between opioids, and stigma. New barriers included patient/family member reluctance to try an opioid and concerns about opioid abuse by family members/caregivers. Studies confirming treatment benefit, validated tools for assessing risk and/or dosing for comorbidities, improved conversion methods, patient education, and peer support could facilitate opioid prescribing. Participants voiced greater comfort using opioids in the setting of delivering palliative or hospice care versus care of patients with chronic pain, and expressed substantial frustration managing chronic pain.
Providers perceive multiple barriers to prescribing opioids to older adults with chronic pain, and use these medications cautiously. Establishing the long-term safety and efficacy of these medications, generating improved prescribing methods, and implementing provider and patient educational interventions could help to improve the management of chronic pain in later life.
PMCID: PMC3212901  PMID: 21752299
10.  Outcomes Associated with Opioid Use in the Treatment of Chronic Non-Cancer Pain Among Older Adults: A Systematic Review and Meta-Analysis 
This systematic review summarizes existing evidence regarding the efficacy, safety, and abuse/misuse potential of opioids as treatment for chronic non-cancer pain (CP) in older adults. Multiple databases were searched to identify relevant studies published in English (1/1/80-7/1/09) with a mean study population age of 60 years or above. Forty-three articles were identified and retained for review. The weighted mean subject age was 64.1 years (mean age range: 60-73). Studies enrolled patients with osteoarthritis (70%), neuropathic pain (13%), or other pain-producing disorders (17%). The mean duration of treatment studies (n=40) was 4 weeks (range = 1.5–156 weeks), and only 5 (12%) lasted longer than 12 weeks. In meta-analyses, effect sizes were −0.557 (p<0.001) for pain reduction, −0.432 (p<0.001) for physical disability reduction, and 0.859 (p=0.309) for improved sleep. The effect size for the SF-36 physical component score was 0.191 (p = 0.171) and −0.220 (p =0.036) for the mental component score. Adults ages 65 and above (vs. less than 65) were equally likely to benefit from treatment. Common adverse events included constipation (median frequency of occurrence = 30%), nausea (28%), dizziness (22%), and prompted opioid discontinuation in 25% of cases. Abuse/misuse behaviors were negatively associated with advancing age. Among older adults with CP and no significant comorbidity, short-term use of opioids is associated with reductions in pain intensity, improved physical functioning, but decreased mental health functioning. The long-term safety, efficacy, and abuse potential of this treatment practice in diverse populations of older persons remain to be determined.
PMCID: PMC3114446  PMID: 20533971
opioid; pain; older adults
11.  Association of alcohol consumption with selected cardiovascular disease outcomes: a systematic review and meta-analysis 
Objective To conduct a comprehensive systematic review and meta-analysis of studies assessing the effect of alcohol consumption on multiple cardiovascular outcomes.
Design Systematic review and meta-analysis.
Data sources A search of Medline (1950 through September 2009) and Embase (1980 through September 2009) supplemented by manual searches of bibliographies and conference proceedings.
Inclusion criteria Prospective cohort studies on the association between alcohol consumption and overall mortality from cardiovascular disease, incidence of and mortality from coronary heart disease, and incidence of and mortality from stroke.
Studies reviewed Of 4235 studies reviewed for eligibility, quality, and data extraction, 84 were included in the final analysis.
Results The pooled adjusted relative risks for alcohol drinkers relative to non-drinkers in random effects models for the outcomes of interest were 0.75 (95% confidence interval 0.70 to 0.80) for cardiovascular disease mortality (21 studies), 0.71 (0.66 to 0.77) for incident coronary heart disease (29 studies), 0.75 (0.68 to 0.81) for coronary heart disease mortality (31 studies), 0.98 (0.91 to 1.06) for incident stroke (17 studies), and 1.06 (0.91 to 1.23) for stroke mortality (10 studies). Dose-response analysis revealed that the lowest risk of coronary heart disease mortality occurred with 1–2 drinks a day, but for stroke mortality it occurred with ≤1 drink per day. Secondary analysis of mortality from all causes showed lower risk for drinkers compared with non-drinkers (relative risk 0.87 (0.83 to 0.92)).
Conclusions Light to moderate alcohol consumption is associated with a reduced risk of multiple cardiovascular outcomes.
PMCID: PMC3043109  PMID: 21343207
12.  Effect of alcohol consumption on biological markers associated with risk of coronary heart disease: systematic review and meta-analysis of interventional studies 
Objective To systematically review interventional studies of the effects of alcohol consumption on 21 biological markers associated with risk of coronary heart disease in adults without known cardiovascular disease.
Design Systematic review and meta-analysis.
Data sources Medline (1950 to October 2009) and Embase (1980 to October 2009) without limits.
Study selection Two reviewers independently selected studies that examined adults without known cardiovascular disease and that compared fasting levels of specific biological markers associated with coronary heart disease after alcohol use with those after a period of no alcohol use (controls). 4690 articles were screened for eligibility, the full texts of 124 studies reviewed, and 63 relevant articles selected.
Results Of 63 eligible studies, 44 on 13 biomarkers were meta-analysed in fixed or random effects models. Quality was assessed by sensitivity analysis of studies grouped by design. Analyses were stratified by type of beverage (wine, beer, spirits). Alcohol significantly increased levels of high density lipoprotein cholesterol (pooled mean difference 0.094 mmol/L, 95% confidence interval 0.064 to 0.123), apolipoprotein A1 (0.101 g/L, 0.073 to 0.129), and adiponectin (0.56 mg/L, 0.39 to 0.72). Alcohol showed a dose-response relation with high density lipoprotein cholesterol (test for trend P=0.013). Alcohol decreased fibrinogen levels (−0.20 g/L, −0.29 to −0.11) but did not affect triglyceride levels. Results were similar for crossover and before and after studies, and across beverage types.
Conclusions Favourable changes in several cardiovascular biomarkers (higher levels of high density lipoprotein cholesterol and adiponectin and lower levels of fibrinogen) provide indirect pathophysiological support for a protective effect of moderate alcohol use on coronary heart disease.
PMCID: PMC3043110  PMID: 21343206
13.  Methodological Challenges and Limitations of Research on Alcohol Consumption and Effect on Common Clinical Conditions: Evidence from Six Systematic Reviews 
Journal of General Internal Medicine  2009;24(10):1156-1160.
Despite the high prevalence of alcohol consumption in the US, ‘mainstream’ physicians generally consider it to be peripheral to most patient care. This may be due in part to a dearth of rigorous research on alcohol’s effect on common diseases.
To evaluate this issue, we examined six systematic reviews, four of which were conducted as part of a research initiative supported by the Robert Wood Johnson Foundation, the Program of Research to Integrate Substance Use Information into Mainstream Healthcare (PRISM). PRISM aimed to assimilate and improve the evidence on the medical impact of alcohol (and other drugs of abuse) on common chronic conditions.
From these reviews, we summarize the methodological limitations of research on alcohol’s impact on development and/or clinical course of depression, hypertension, diabetes, bone disease, dementia, and sexually transmitted diseases. The studies included in these reviews were largely fair to good quality, and few were in primary care settings. Syntheses were hampered by the myriad of definitions of alcohol consumption from any/none to seven levels and a plethora of types of alcohol use disorders.
We recommend more high-quality observational and experimental studies in primary care settings as well as a more standard approach to quantifying alcohol use and to defining alcohol use disorders.
PMCID: PMC2762504  PMID: 19672662
alcohol; standardized measurement; medical impacts; research limitations; alcohol drinking/adverse effects
14.  The Impact of Concordant and Discordant Conditions on the Quality of Care for Hyperlipidemia 
Journal of General Internal Medicine  2008;23(8):1208-1213.
Physician treatment of cardiovascular risk factors may be affected by specific types of patient comorbidities.
To examine the relationship between discordant comorbidities and LDL-cholesterol management in hypertensive patients not previously treated with lipid-lowering therapy; to determine whether the presence of cardiovascular (concordant) conditions mediates this relationship.
We performed a retrospective cohort study of 1,935 hypertensive primary care patients (men >45 years of age, women >55 years of age) with documented elevated low-density lipoprotein (LDL) cholesterol and no lipid-lowering therapy at baseline. The outcome was guideline-consistent hyperlipidemia management defined as optimal value on repeat LDL cholesterol testing or initiation of lipid-lowering therapy. Using generalized estimating equations (GEE), we examined the association of concordant and discordant comorbidities with guideline-consistent hyperlipidemia management over a 2-year follow-up period, adjusting for patient characteristics.
Guideline-consistent hyperlipidemia management was achieved in 1,236 patients (64%). In the fully adjusted model, each additional discordant condition resulted in a 19% lower adjusted odds ratio of guideline-consistent hyperlipidemia management (p < 0.001) when compared with no discordant conditions. The dampening effect of discordant conditions on guideline-consistent management persisted even in the presence of concordant conditions, but each additional concordant condition was associated with a 37% increase in the adjusted odds of guideline-consistent hyperlipidemia management (p < 0.001).
In this cohort of hypertensive primary care patients, the number of conditions discordant with cardiovascular risk was strongly negatively associated with guideline-consistent hyperlipidemia management even in patients at the highest risk for cardiovascular events and cardiac death.
Electronic supplementary material
The online version of this article (doi:10.1007/s11606-008-0647-4) contains supplementary material, which is available to authorized users.
PMCID: PMC2517982  PMID: 18465174
hyperlipidemia; quality of care; comorbidity
15.  Overcoming Poor Attendance to First Scheduled Colonoscopy: A Randomized Trial of Peer Coach or Brochure Support 
Among patients unlikely to attend a scheduled colonoscopy, we examined the impact of peer coach versus educational brochure support and compared these with concurrent patients who did not receive support.
From health system data, we identified 275 consecutive patients aged >50 who kept <75% of visits to 4 primary care practices and scheduled for a first colonoscopy from February 1, 2005 to August 31, 2006. Using block randomization, we assigned consenting patients to a phone call by a peer coach trained to address barriers to attendance or to a mailed colonoscopy brochure. Study data came from electronic medical records. Odds ratios of colonoscopy attendance were adjusted for demographic, clinical, and health care factors.
Colonoscopy attendance by the peer coach group (N = 70) and brochure group (N = 66) differed by 11% (68.6% vs 57.6%, respectively). Compared with the brochure group, the peer coach group had over twofold greater adjusted odds ratio (AOR) of attendance (2.14, 95% confidence interval [CI] = 0.99–4.63) as did 49 patients who met the prespecified criteria for needing no support (2.68, 95%CI = 1.05–6.82) but the AORs did not differ significantly for 41 patients who declined support (0.61, 95%CI = 0.25–1.45) and 49 patients who could not be contacted (0.85, 95%CI = 0.36–2.02). Attendance was less likely for black versus white race (AOR = 0.37, 95%CI = 0.19–0.72) but more likely for patients with high versus low primary care visit adherence (AOR = 2.30, 95%CI = 1.04–5.07).
For patients who often fail to keep appointments, peer coach support appears to promote colonoscopy attendance more than an educational brochure.
PMCID: PMC2173918  PMID: 18030540
compliance; colonoscopy; colorectal neoplasms; minority groups; patient-centered care; peer support
16.  Measuring Quality of Care in Patients With Multiple Clinical Conditions: Summary of a Conference Conducted by the Society of General Internal Medicine 
Journal of General Internal Medicine  2007;22(8):1206-1211.
Performance measurement has been widely advocated as a means to improve health care delivery and, ultimately, clinical outcomes. However, the evidence supporting the value of using the same quality measures designed for patients with a single clinical condition in patients with multiple conditions is weak. If clinically complex patients, defined here as patients with multiple clinical conditions, present greater challenges to achieving quality goals, providers may shun them or ignore important, but unmeasured, clinical issues. This paper summarizes the proceedings of a conference addressing the challenge of measuring quality of care in the patient with multiple clinical conditions with the goal of informing the implementation of quality measurement systems and future research programs on this topic. The conference had three main areas of discussion. First, the potential problems caused by applying current quality standards to patients with multiple conditions were examined. Second, the advantages and disadvantages of three strategies to improve quality measurement in clinically complex patients were evaluated: excluding certain clinically complex patients from a given standard, relaxing the performance target, and assigning a greater weight to some measures based on the expected clinical benefit or difficulty of reaching the performance target. Third, the strengths and weaknesses of potential novel measures such change in functional status were considered. The group concurred that, because clinically complex patients present a threat to the implementation of quality measures, high priority must be assigned to a research agenda on this topic. This research should evaluate the impact of quality measurement on these patients and expand the range of quality measures relevant to the care of clinically complex patients.
PMCID: PMC2305741  PMID: 17516106
performance measurement; quality measures; clinically complex patients
17.  Effectiveness of Complete Diagnostic Examination in Clinical Practice Settings 
Cancer detection and prevention  2006;30(6):545-551.
Thorough follow-up of a positive fecal occult blood test (FOBT) result, or a complete diagnostic evaluation (CDE), is recommended as routine care on the basis of findings from colorectal cancer (CRC) screening trials. CDE involves either colonoscopy or the combination of flexible sigmoidoscopy and double contrast barium enema x-ray. However, little evidence outside clinical screening trial settings has been reported in the literature to support CDE performance. The focus of this study was to determine the impact of CDE in primary care practice settings.
We determined diagnostic outcomes for 461 adult patients with a positive FOBT result in 318 primary care practices in southeastern Pennsylvania and southern New Jersey. Sociodemographic data were collected and CDE status was ascertained for these patients. Polytomous logistic regression models were used to identify whether having CDE was associated with subsequently being diagnosed with lower gastrointestinal “neoplastic disease” or “other gastrointestinal disease” as compared to “normal findings.”
Patients who underwent CDE were significantly more likely to have a reported diagnosis of colorectal neoplasia than normal findings (adjusted odds ratio = 3.65, 95% confidence interval = 1.58-8.39, p=0.02). CDE performance did not result in the differential diagnosis of other gastrointestinal disease.
Patients with a positive screening FOBT who underwent CDE were more likely to be diagnosed with colorectal neoplasia than with less serious conditions or have normal findings. Results support the use of CDE in CRC screening.
PMCID: PMC1861814  PMID: 17113240
Colorectal neoplasm; occult blood; fecal occult blood test; mass screening; cancer screening; follow-up studies; complete diagnostic evaluation; abnormal findings; chart audit; diagnosis
18.  Effect of Dysthymia on Receipt of HAART by Minority HIV-infected Women 
Journal of General Internal Medicine  2006;21(12):1235-1241.
Receipt of highly active antiretroviral therapy (HAART) differs by gender and racial/ethnic group and may reflect an effect of mood disorders.
We examined the effects of dysthymia and major depression on HAART use by 6 groups defined by gender and race/ethnicity (white, black, Hispanic).
Self-reported HAART use in the past 6 months.
Interview data from the HIV Cost and Services Utilization Study (HCSUS). Independent variables measured in or before the first half of 1997, and HAART use measured in the second half of 1997.
Multivariate logistic regression of depression and dysthymia on HAART use by 6 patient groups.
One thousand nine hundred and eighty-two HIV-infected adults in HIV care in 1996 and with a CD4 count <500 in 1997.
Highly active antiretroviral therapy receipt was the highest for white men (68.6%) and the lowest for Hispanic women (52.7%) and black women (55.4%). Dysthymia was more prevalent in women (Hispanic, 46%; black, 27%; white, 31%) than men (Hispanic, 23%; black, 18%; white, 15%). The prevalence of major depression was greater in whites (women, 35%; men, 31%) than minorities (women, 26%; men, 21%). Compared with white men without dysthymia, the adjusted odds ratios (AORs) of HAART were significantly lower for black women (0.50 [95% confidence interval [95% CI] 0.29 to 0.87]) and Hispanic women (0.45 [95% CI 0.25, 0.79]). Among patients with depression and no dysthymia, minority women had HAART use (AOR=1.28 [95% CI 0.48 to 3.43]) similar to white men.
Self-report data from the early era of HAART use; causation cannot be proven; mental health diagnoses may not meet full DSM IV criteria.
Dysthymia is highly prevalent in minority women and associated with a 50% reduction in the odds of receiving HAART. This underrecognized condition may contribute more than depression to the “gender disparity” in HAART use.
PMCID: PMC1924745  PMID: 17105522
HIV; AIDS; HAART; dysthymia; disparities; women
19.  Principles to Consider in Defining New Directions in Internal Medicine Training and Certification 
SGIM endoreses seven principles related to current thinking about internal medicine training: 1) internal medicine requires a full three years of residency training before subspecialization; 2) internal medicine residency programs must dramatically increase support for training in the ambulatory setting and offer equivalent opportunities for training in both inpatient and outpatient medicine; 3) in settings where adequate support and time are devoted to ambulatory training, the third year of residency could offer an opportunity to develop further expertise or mastery in a specific type or setting of care; 4) further certification in specific specialties within internal medicine requires the completion of an approved fellowship program; 5) areas of mastery in internal medicine can be demonstrated through modified board certification and recertification examinations; 6) certification processes throughout internal medicine should focus increasingly on demonstration of clinical competence through adherence to validated standards of care within and across practice settings; and 7) regardless of the setting in which General Internists practice, we should unite to promote the critical role that this specialty serves in patient care.
PMCID: PMC1828096  PMID: 16637826
education; medical; graduate; certification; internal medicine; hospitalists; ambulatory care
20.  Seasonal Variation in Undiagnosed HIV Infection on the General Medicine and Trauma Services of Two Urban Hospitals 
To examine the seroprevalence of undiagnosed HIV and variation by season among patients admitted to the general internal medicine (GIM) and trauma services of two urban hospitals.
A cross-sectional blinded HIV-1 seroprevalence survey.
A 725-bed academic medical center's hospital and an affiliated 324-bed tertiary care hospital.
Residual serological specimens were obtained for unique patients aged 17 to 65 to study services in summer (June 16 to September 4, 2001) and fall to winter (November 1, 2001 to January 8, 2002).
Hospital files provided data on demographics, service type, and discharge clinical categories (fall–winter group only). HIV ELISA (enzyme-linked immunosorbent assay) tests with confirmatory Western blot were linked to subjects' de-identified files. We excluded 34 subjects with known HIV. Of the remaining unique admissions in summer (n=604) and fall–winter (n=978), 60% and 55% were tested, respectively. Predictors of undiagnosed HIV infection were examined using multivariate analysis.
The summer cohort (n=362) had significantly lower unadjusted seroprevalence of undiagnosed HIV infection (1.4%; 95% confidence interval [CI], 0.4% to 3.2%) than the fall–winter cohort (n=539; 3.7%; 95% CI, 2.3% to 5.7%; P=.04). Overall, undiagnosed HIV was somewhat less likely in women (adjusted odds ratio [AOR], 0.45; 95% CI, 0.19 to 1.07) but more likely in black patients (AOR, 3.46; 95% CI, 0.70 to 17.06). In the fall–winter cohort, undiagnosed HIV was more likely for discharges with the following clinical categories versus those with a cardiac condition: dermatologic/breast (AOR, 14.90; 95% CI, 1.20 to 184.77), renal/urological (AOR, 22.43; 95% CI, 2.12 to 236.75), or infectious (AOR, 31.08; 95% CI, 2.40 to 402.98).
The higher seroprevalence of undiagnosed HIV in the fall–winter admissions to GIM and trauma services supports especially targeting HIV testing in these months.
PMCID: PMC1490100  PMID: 15857488
seroprevalence; epidemiology; HIV infections; inpatients; wounds and injuries
21.  Relationship of Gender, Depression, and Health Care Delivery With Antiretroviral Adherence in HIV-infected Drug Users 
Antiretroviral adherence is worse in women than in men, and depression can influence medication adherence.
To evaluate the relationship of gender, depression, medical care, and mental health care to adherence in HIV-infected drug users.
Retrospective cohort study.
New York State Medicaid program.
One thousand eight hundred twenty-seven female and 3,246 male drug users on combination antiretroviral therapy for more than 2 months in 1997.
A pharmacy-based measure of adherence was defined as ≥95% days covered by at least 2 prescribed antiretroviral drugs. Independent variables were: depression, regular drug treatment (≥6 months), regular medical care (2+ and >35% of visits), HIV-focused care (2+ visits), psychiatric care (2+ visits), and antidepressant therapy.
Women were less adherent than men (18% vs 25%, respectively, P < .001) and more likely to be diagnosed with depression (34% vs 29%). In persons with depression, the adjusted odds ratio (AOR) for adherence was greater for those with psychiatric care alone (AOR 1.52; 95% confidence interval [95% CI], 1.03 to 2.26) or combined with antidepressants (AOR 1.49; 95% CI, 1.04 to 2.15). In separate models by gender in persons with depression, psychiatric care plus antidepressants had a slightly stronger association with adherence in women (AOR 1.92; 95% CI, 1.00 to 3.68) than men (AOR, 1.26; 95% CI, 0.81 to 1.98). In drug users without depression, antidepressants alone were associated with greater adherence (AOR, 1.23; 95% CI, 1.02 to 1.49) with no difference by gender. Regular drug treatment was positively associated with adherence only in men.
In this drug-using cohort, women had worse pharmacy-measured antiretroviral adherence than men. Mental health care was significantly associated with adherence in women, while regular drug treatment was positively associated with adherence in men.
PMCID: PMC1494846  PMID: 12709091
HIV infection; antiretroviral therapy; adherence; compliance; mental health services
22.  The effect of ethnicity and maternal birthplace on small-for-gestational-age deliveries to HIV-infected women 
To examine the relative role of ethnicity and maternal birthplace on small-for-gestational-age (SGA) deliveries of a cohort of mothers in New York who were infected with human immunodeficiency virus.
Medicaid claims and linked vital statistics records were examined for 2,525 singleton deliveries to HIV-infected women from 1993 through 1996. We estimated adjusted odds ratios (AORs) and 95% confidence intervals (CIs) of SGA delivery associated with ethnicity (i.e., white, white-Latina, black, and black-Latina) and maternal birthplace (i.e., native US/Puerto Rican vs. foreign born) in a series of multivariate regression models to which we sequentially added demographic, health services, and lifestyle factors (i.e., alcohol, tobacco, and illicit drug use).
Of the deliveries, 10% were SGA. The odds of SGA infants for black and white women did not differ by maternal birthplace. Foreign-born white-Latinas and black-Latinas had lower unadjusted odds of a SGA delivery than their US-born counterparts (OR 0.29, CI 0.14, 0.61 and OR 0.22, CI 0.07, 0.71, respectively). After adjustment for maternal lifestyle characteristics, the odds of SGA delivery were 0.50 (CI 0.23, 1.09) for white-Latina mothers and 0.60 (CI 0.17, 2.08) for black-Latina mothers.
SGA outcomes did not differ by maternal birthplace for black and white women. Differences in lifestyle factors appear to contribute to lower odds of SGA delivery for foreign-born versus US-born white- and black-Latina HIV-infected women.
PMCID: PMC3456377  PMID: 11937623
African American; Hispanic American; HIV Infection; Medicaid; Small for Gestational Age; Substance Abuse-Related Disorders
23.  Effects of Drug Abuse and Mental Disorders on Use and Type of Antiretroviral Therapy in HIV-infected Persons 
To distinguish the effects of drug abuse, mental disorders, and problem drinking on antiretroviral therapy (ART) and highly active ART (HAART) use.
Prospective population-based probability sample of 2,267 (representing 213,308) HIV-infected persons in care in the United States in early 1996.
Self-reported ART from first (January 1997–July 1997) to second (August 1997–January 1998) follow-up interviews. Drug abuse/dependence, severity of abuse, alcohol use, and probable mental disorders assessed in the first follow-up interview. Adjusted odds ratios (AORs) and 95% confidence intervals (CIs) estimated from weighted models for 1) receipt of any ART, and 2) receipt of HAART among those on ART.
Of our study population, ART was reported by 90% and HAART by 61%. Over one third had a probable mental disorder and nearly half had abused any drugs, but drug dependence (9%) or severe abuse (10%) was infrequent. Any ART was less likely for persons with dysthymia (AOR, 0.74; CI, 0.58 to 0.95) but only before adjustment for drug abuse. After full adjustment with mental health and drug abuse variables, any ART was less likely for drug dependence (AOR, 0.58; CI, 0.34 to 0.97), severe drug abuse (AOR, 0.52; CI, 0.32 to 0.87), and HIV risk from injection drug use (AOR, 0.55; CI, 0.39 to 0.79). Among drug users on ART, only mental health treatment was associated with HAART (AOR, 1.57; CI, 1.11 to 2.08).
Drug abuse-related factors were greater barriers to ART use in this national sample than mental disorders but once on ART, these factors were unrelated to type of therapy.
PMCID: PMC1495260  PMID: 11556944
anti-HIV agents; substance-related disorders; substance abuse, intravenous drug abuse; mental disorders; HIV infections
24.  Differences Between Generalists and Specialists 
PMCID: PMC1495225  PMID: 11422641
25.  The Good (Gatekeeper), the Bad (Gatekeeper), and the Ugly (Situation) 
PMCID: PMC1496578  PMID: 10337044

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