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1.  Validation of a Questionnaire to Assess Self-Reported Colorectal Cancer Screening Status Using Face-to-Face Administration 
Digestive diseases and sciences  2008;54(6):1297-1306.
To assess the accuracy of an NCI-developed colorectal cancer screening questionnaire.
We conducted 36 cognitive interviews and made iterative changes to the questionnaire to improve comprehension. The revised questionnaire was administered face-to-face to 201 participants. The primary outcome was agreement between questionnaire responses and medical records for whether or not a participant was up-to-date for any colorectal cancer screening test.
Comprehension of descriptions and questions was generally good; however, the barium enema description required several revisions. The sensitivity of the questionnaire for up-to-date screening status was 94%, specificity was 63%, and concordance was 88%.
The modified questionnaire was highly sensitive for determining if a person was up-to date for any colorectal cancer screening test, although the specificity was low. Given the difficulty of obtaining all relevant records, self-report using this questionnaire is a reasonable option for identifying people who have undergone testing.
PMCID: PMC2754798  PMID: 18726152
colorectal neoplasms; mass screening; validation studies; questionnaires
2.  BRIEF REPORT: How Well Do Clinic-Based Blood Pressure Measurements Agree with the Mercury Standard? 
Obtaining accurate blood pressure (BP) readings is a challenge faced by health professionals. Clinical trials implement strict protocols, whereas clinical practices and studies that assess quality of care utilize a less rigorous protocol for BP measurement.
To examine agreement between real-time clinic-based assessment of BP and the standard mercury assessment of BP.
Prospective reliability study.
One hundred patients with an International Classification of Diseases—9th edition code for hypertension were enrolled.
Two BP measurements were obtained with the Hawksley random-zero mercury sphygmomanometer and averaged. The clinic-based BP was extracted from the computerized medical records.
Agreement between the mercury and clinic-based systolic blood pressure (SBP) was good, intraclass correlation coefficient (ICC)=0.91 (95% confidence interval (CI): 0.83 to 0.94); the agreement for the mercury and clinic-based diastolic blood pressure (DBP) was satisfactory, ICC=0.77 (95% CI: 0.62 to 0.86). Overall, clinic-based readings overestimated the mercury readings, with a mean overestimation of 8.3 mmHg for SBP and 7.1 mmHg for DBP. Based on the clinic-based measure, 21% of patients were misdiagnosed with uncontrolled hypertension.
Health professionals should be aware of this potential difference when utilizing clinic-based BP values for making treatment decisions and/or assessing quality of care.
PMCID: PMC1490157  PMID: 16050862
blood pressure measurement assessment; clinic method; mercury device
3.  Utility of Hemoglobin A1c in Predicting Diabetes Risk 
Journal of General Internal Medicine  2004;19(12):1175-1180.
There is controversy surrounding the issue of whether, and how, to screen adults for type 2 diabetes. Our objective was to measure the incidence of new diabetes among outpatients enrolled in a health care system, and to determine whether hemoglobin A1c (HbA1c) values would allow risk stratification for Patients' likelihood of developing diabetes over 3 years.
We conducted a prospective cohort study with 3-year follow-up at a single large, tertiary care, Department of Veterans Affairs Medical Center (VAMC). A convenience sample of 1,253 outpatients without diabetes, age 45 to 64, with a scheduled visit at the VAMC, were screened for diabetes using an initial HbA1c measurement. All subjects with HbA1c ≥ 6.0% (normal, 4.0% to 6.0%) were invited for follow-up fasting plasma glucose (FPG). We then surveyed patients annually for 3 years to ascertain interval diagnosis of diabetes by a physician. The baseline screening process was repeated 3 years after initial screening. After the baseline screening, new cases of diabetes were defined as either the self-report of a physician's diagnosis of diabetes, or by HbA1c ≥ 7.0% or FPG ≥ 7.0 mmol/L at 3-year follow-up. The incidence of diabetes was calculated as the number of new cases per person-year of follow-up.
One thousand two hundred fifty-three patients were screened initially, and 56 (4.5%) were found to have prevalent unrecognized diabetes at baseline. The 1,197 patients without diabetes at baseline accrued 3,257 person-years of follow-up. There were 73 new cases of diabetes over 3 years of follow-up, with an annual incidence of 2.2% (95% confidence interval [CI], 1.7% to 2.7%). In a multivariable logistic regression model, baseline HbA1c and baseline body mass index (BMI) were the only significant predictors of new onset diabetes, with HbA1c having a greater effect than BMI. The annual incidence of diabetes for patients with baseline HbA1c ≤ 5.5 was 0.8% (CI, 0.4% to 1.2%); for HbA1c 5.6 to 6.0, 2.5% (CI, 1.6% to 3.5%); and for HbA1c 6.1 to 6.9, 7.8% (CI, 5.2% to 10.4%). Obese patients with HbA1c 5.6 to 6.0 had an annual incidence of diabetes of 4.1% (CI, 2.2% to 6.0%).
HbA1c testing helps predict the likelihood that patients will develop diabetes in the future. Patients with normal HbA1c have a low incidence of diabetes and may not require rescreening in 3 years. However, patients with elevated HbA1c who do not have diabetes may need more careful follow-up and possibly aggressive treatment to reduce the risk of diabetes. Patients with high-normal HbA1c may require follow-up sooner than 3 years, especially if they are significantly overweight or obese. This predictive value suggests that HbA1c may be a useful test for periodic diabetes screening.
PMCID: PMC1492588  PMID: 15610327
diabetes; screening; hemoglobin A1c
4.  Screening for Diabetes in an Outpatient Clinic Population 
Opportunistic disease screening is the routine, asymptomatic disease screening of patients at the time of a physician encounter for other reasons. While the prevalence of unrecognized diabetes in community populations is well known, the prevalence in clinical populations is unknown.
To describe the prevalence, predictors, and clinical severity of unrecognized diabetes among outpatients at a major medical center.
A cross-sectional observational study at the Durham Veterans Affairs Medical Center.
Outpatients without recognized diabetes (N = 1,253).
We screened patients for diabetes by using an initial random Hemoglobin A1c (HbA1c) measurement, and then obtaining follow-up fasting plasma glucose (FPG) for all subjects with HbA1c ≥6.0%. A case of unrecognized diabetes was defined as either HbA1c ≥7.0% or FPG ≥7 mmol/L (126 mg/dL). Height and weight were obtained for all subjects. We also obtained resting blood pressure, fasting lipids, and urine protein in subjects with HbA1c ≥6.0%.
The prevalence of unrecognized diabetes was 4.5% (95% confidence interval [CI], 3.4 to 5.7). Factors associated with unrecognized diabetes were the diagnosis of hypertension (adjusted odds ratio [OR], 2.5; P = .004), weight >120% of ideal (adjusted OR, 2.2; P = .02), and history of a parent or sibling with diabetes (adjusted OR, 1.7; P = .06). Having a primary care provider did not raise or lower the risk for unrecognized diabetes (P = .73). Based on the new diagnosis, most patients (61%) found to have diabetes required a change in treatment either of their blood sugar or comorbid hypertension or hyperlipidemia in order to achieve targets recommended in published treatment guidelines. Patients reporting a primary care provider were no less likely to require a change in treatment (P = .20).
If diabetes screening is an effective intervention, opportunistic screening for diabetes may be the preferred method for screening, because there is substantial potential for case-finding in a medical center outpatient setting. A majority of patients with diabetes diagnosed at opportunistic screening will require a change in treatment of blood sugar, blood pressure, or lipids to receive optimal care.
PMCID: PMC1494994  PMID: 11903772
diabetes; disease screening; metabolic syndrome

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