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1.  Racial Variation in the Quality of Surgical Care for Prostate Cancer 
The Journal of urology  2012;188(4):1279-1285.
Difference in the quality of care may contribute to the less optimal prostate cancer treatment outcomes among Blacks compared with Whites. Our objective was to determine whether a racial quality of care gap exists in surgical care for prostate cancer, as evidenced by racial variation in the utilization of high-volume surgeons and facilities, and in certain outcome measures of care quality.
Materials and Methods
We performed cross-sectional and cohort analyses of administrative data from the Healthcare Cost and Utilization Project's all-payer State Inpatient Databases, encompassing all non-Federal hospitals in Florida, Maryland and New York State (1996-2007). Included were men 18 or older with a diagnosis of prostate cancer who underwent radical prostatectomy. We compared use of surgeons and/or hospitals in the top quartile of annual volume for this procedure, inpatient blood transfusion, complications, mortality and length of stay (LOS) between Black and White patients.
Among 105,972 cases, 81,112 (76.5%) were White, 14,006 (13.2%) were Black, 6,999 (6.6%) were Hispanic and 3,855 (3.6%) were All Other. In mixed effects multivariate models, Blacks had markedly lower use of high-volume hospitals (Odds Ratio [OR] = 0.73, 95% Confidence interval [0.70, 0.76]), and surgeons (0.67 [0.64, 0.70]) compared to Whites. Blacks also had a higher odds of receiving a blood transfusion (1.08 [1.01, 1.14]), of longer LOS (1.07 [1.06, 1.07]) and of inpatient mortality (1.73 [1.02, 2.92]).
Using an all-payer dataset, we identified concerning potential quality of care gaps between Blacks and Whites undergoing radical prostatectomy for prostate cancer.
PMCID: PMC3770766  PMID: 22902011
Health disparities; quality of care; prostate cancer; surgery
2.  Modified Rapid Sequence Induction and Intubation: A Survey of United States Current Practice 
Anesthesia and Analgesia  2011;115(1):95-101.
Rapid sequence induction and intubation (RSII) is a technique commonly used to resist regurgitation of gastric contents and protect the airway. A modification of this technique is implemented in certain clinical circumstances. However, there is currently no standard definition for a “modified RSII.” Therefore, we surveyed clinicians at academic centers across the United States to establish a working definition of a “modified RSII” as well as the clinical scenarios in which it is being used.
A survey was created that queried the use and definition of modified RSII, and validated with test respondents. We then mailed the survey to all 131 anesthesia residency training programs across the United States. Logistic regression models were created to estimate the percentage of affirmative responses among respondents that performed modified RSII procedures and answered survey items in a consistent manner. Similar quantities were calculated by physician status (resident and attending).
Four hundred ninety surveys were received from 58 institutions (44% institution response rate), 93% of respondents reported using a modified RSII, and of those 85% consistently completed the survey instrument. A majority of respondents (71%, CI: 63–77%) reported administering oxygen before anesthesia induction, applying cricoid pressure, and attempting to ventilate the lungs via a facemask before securing the airway. Respondents noted that they would use a modified RSII procedure if the patient were either moderately or morbidly obese (each ~59%, 53–64%), had a history but no current symptoms of gastroesophageal reflux disease (52%, 46–57%), had a hiatal hernia (42%, 36–48%) or were a trauma patient who had been NPO for at least 8 hours (39%, 33–45%). Similar RSII results were obtained when repeating the analysis on the subset that did not enforce the consistency requirements.
Based on our survey we have established three defining features of a modified RSII: (1) oxygen administration before induction; (2) the use of cricoid pressure; and (3) an attempt to ventilate the patient’s lungs before securing the airway. Although this definition seems intuitively obvious, no previous work has tested whether it is commonly accepted.
PMCID: PMC3270153  PMID: 22025487
3.  Functional Decline Associated With Polypharmacy and Potentially Inappropriate Medications in Community-Dwelling Older Adults With Dementia 
This study provides empirical evidence on whether polypharmacy and potentially inappropriate prescription medications (PIRx, as defined by the 2003 Beers criteria) increase the likelihood of functional decline among community-dwelling older adults with dementia. Data were from the National Alzheimer’s Coordinating Center, Uniform Data Set (9/2005–9/2009). Study sample included 1994 community-dwelling participants aged ≥65 with dementia at baseline. Results showed that participants having ≥5 medications were more likely to have functional decline than participants having <5 medications. However, the increased likelihood was only apparent in participants who did not have PIRx. Instead of magnifying the associated risk as hypothesized, PIRx appeared to have a protective effect albeit marginally statistically significant. Therefore, increased medication burden may be associated with functional decline in community-dwelling older adults with dementia who are not prescribed with PIRx. More research is needed to understand which classes of medications have the most deleterious effect on this population.
PMCID: PMC3298080  PMID: 22207646
Beers criteria; Alzheimer’s disease; prescription drug utilization
4.  Sleep Disturbance in Dementia with Lewy Bodies and Alzheimer's Disease: A Multicenter Analysis 
Evidence suggests that patients with dementia with Lewy bodies (DLB) may have more nocturnal sleep disturbance than patients with Alzheimer's disease (AD). We sought to confirm such observations using a large, prospectively collected, standardized, multicenter-derived database, i.e. the National Alzheimer's Coordinating Center Uniform Data Set.
Nocturnal sleep disturbance (NSD) data, as characterized by the Neuropsychiatric Inventory Questionnaire (NPI-Q), were derived from 4,531 patients collected between September 2005 and November 2008 from 32 National Institute on Aging participating AD centers. Patient and informant characteristics were compared between those with and without NSD by dementia diagnosis (DLB and probable AD). Finally, a logistic regression model was created to quantify the association between NSD status and diagnosis while adjusting for these patient/informant characteristics, as well as center.
NSD was more frequent in clinically diagnosed DLB relative to clinically diagnosed AD (odds ratio = 2.93, 95% confidence interval = 2.22–3.86). These results were independent from the gender of the patient or informant, whether the informant lived with the patient, and other patient characteristics, such as dementia severity, depressive symptoms, and NPI-Q-derived measures of hallucinations, delusions, agitation and apathy. In AD, but not DLB, patients, NSD was associated with more advanced disease. Comorbidity of NSD with hallucinations, agitation and apathy was higher in DLB than in AD. There was also evidence that the percentage of DLB cases with NSD showed wide variation across centers.
As defined by the NPI-Q, endorsement of the nocturnal behavior item by informants is more likely in patients with DLB when compared to AD, even after the adjustment of key patient/informant characteristics.
PMCID: PMC3085031  PMID: 21474933
Dementia with Lewy bodies; Alzheimer's disease; Sleep; Neuropsychiatric Inventory Questionnaire
5.  Polypharmacy and Potentially Inappropriate Medication Use among Community-Dwelling Elders with Dementia 
This cross-sectional study examines the association between total prescription medication use and potentially inappropriate medication use (PIRx) among community-dwelling elderly patients with and without dementia. Data (9/2005-9/2007) were from the NIA-funded National Alzheimer's Coordinating Center Uniform Data Set (UDS). The study analyzed the UDS initial visits of 4,518 community-dwelling subjects aged 65+ with and without dementia (2,665 and 1,853, respectively). PIRx was defined using a partial list of the 2003 Beers criteria. Generalized linear mixed models were applied to estimate the association between PIRx and polypharmacy. In both groups (with and without dementia), subjects who received PIRx on average took more medications than those taking no PIRx. As the total number of medications used increased, the odds of having PIRx also increased, controlling for dementia diagnosis and other subject characteristics. Our key findings were consistent after considering two definitions of PIRx (with or without oral estrogens) and accounting for missing data. In summary, the total number of medications used is associated with PIRx among ADC's community-dwelling elderly patients with and without dementia, with polypharmacy increasing the risk of PIRx. Ensuring appropriate medication use in this population is clinically important because of the significant risks for institutionalization.
PMCID: PMC2837122  PMID: 19561441
prescription drugs; Beers criteria; Alzheimer's disease
6.  Older Patients' Perceptions of Medication Importance and Worth: An Exploratory Study 
Drugs & aging  2008;25(12):1061-1075.
Cost-related medication non-adherence may be influenced by patients' perceived importance of their medications. This exploratory study addresses three related but distinct questions: Do patients perceive different levels of importance among their medications? What factors influence perceptions of medication importance? Is perceived importance associated with medications' worth, and does expense impact that association?
Study participants included individuals aged 60 and older who were taking three or more prescription drugs. Semi-structured, in-person interviews were conducted to measure how patients rated their medications in terms of importance, expense, and worth. Factors that influence medication importance were identified using qualitative analysis. Ordinal logistic regression analyses were employed to examine the association between perceived importance and worth of medications, and the impact of expense on that association.
Among 143 prescription drugs reported among 20 participants, the weighted mean rating of medication importance was 8.2 (SD=1.04) on a scale from 0 (not important at all) to 10 (most important). Of all medications, 38% were considered expensive. The weighted mean rating of worth was 8.4 (SD=1.46) on a scale from 0 (not worth it at all) to 10 (definitely worth it). Three major factors influenced medication importance: drug-related (characteristics, indications, effects, and alternatives); patient-related (knowledge, attitudes, and health); and external (the media, healthcare and family caregivers, and peers). Regression analyses showed an association between perceived importance and worth for inexpensive medications (OR=2.23; p=0.002) and an even greater association between perceived importance and worth for expensive medications (OR=4.29; p<0.001).
This study provides preliminary evidence that elderly patients perceive different levels of importance among their medications based on factors beyond clinical efficacy and their perception of importance influences how they perceive their medications' worth, especially for medications of high costs. Understanding how patients perceive medication importance may help develop interventions to reduce cost-related non-adherence.
PMCID: PMC2747735  PMID: 19021304
medication prioritization; essential drugs; nonadherence; medication adherence

Results 1-6 (6)