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1.  The Composition of Intern Work While on Call 
doi:10.1007/s11606-012-2317-9
PMCID: PMC3599036  PMID: 23319412
2.  Racial Differences in the Effect of a Telephone-Delivered Hypertension Disease Management Program 
Journal of General Internal Medicine  2012;27(12):1682-1689.
ABSTRACT
BACKGROUND
African Americans are significantly more likely than whites to have uncontrolled hypertension, contributing to significant disparities in cardiovascular disease and events.
OBJECTIVE
The goal of this study was to examine whether there were differences in change in blood pressure (BP) for African American and non-Hispanic white patients in response to a medication management and tailored nurse-delivered telephone behavioral program.
PARTICIPANTS
Five hundred and seventy-three patients (284 African American and 289 non-Hispanic white) primary care patients who participated in the Hypertension Intervention Nurse Telemedicine Study (HINTS) clinical trial.
INTERVENTIONS
Study arms included: 1) nurse-administered, physician-directed medication management intervention, utilizing a validated clinical decision support system; 2) nurse-administered, behavioral management intervention; 3) combined behavioral management and medication management intervention; and 4) usual care. All interventions were activated based on poorly controlled home BP values.
MAIN MEASURES
Post-hoc analysis of change in systolic and diastolic blood pressure. General linear models (PROC MIXED in SAS, version 9.2) were used to estimate predicted means at 6-month, 12-month, and 18-month time points, by intervention arm and race subgroups (separate models for systolic and diastolic blood pressure).
KEY RESULTS
Improvement in mean systolic blood pressure post-baseline was greater for African American patients in the combined intervention, compared to African American patients in usual care, at 12 months (6.6 mmHg; 95 % CI: -12.5, -0.7; p = 0.03) and at 18 months (9.7 mmHg; -16.0, -3.4; p = 0.003). At 18 months, mean diastolic BP was 4.8 mmHg lower (95 % CI: -8.5, -1.0; p = 0.01) among African American patients in the combined intervention arm, compared to African American patients in usual care. There were no analogous differences for non-Hispanic white patients.
CONCLUSIONS
The combination of home BP monitoring, remote medication management, and telephone tailored behavioral self-management appears to be particularly effective for improving BP among African Americans. The effect was not seen among non-Hispanic white patients.
Electronic supplementary material
The online version of this article (doi:10.1007/s11606-012-2138-x) contains supplementary material, which is available to authorized users.
doi:10.1007/s11606-012-2138-x
PMCID: PMC3509293  PMID: 22865016
hypertension; telemedicine; self-management; adherence; veterans
3.  The Effect of a Hypertension Self-Management Intervention on the Unintended Targets of Diabetes and Cholesterol Control 
The American journal of medicine  2009;122(7):639-646.
Background
Most patient chronic disease self-management interventions target single disease outcomes. We evaluated the effect of a tailored hypertension self-management intervention on the unintended targets of glycosylated hemoglobin (Hb A1c) and LDL cholesterol (LDL-C).
Methods
We examined 588 patients from the Veterans Study to Improve the Control of Hypertension (V-STITCH), a two year randomized controlled trial. Patients received either a hypertension self-management intervention delivered by a nurse over the telephone or usual care. Although the study focused on hypertension self-management, we compared changes in Hb A1c among a subgroup of 216 patients with diabetes and LDL-C among 528 patients with measurements during the study period. Changes in these lab values over time were compared between the two treatment groups using linear mixed-effects models.
Results
For the patients with diabetes, the hypertension self-management intervention resulted in a 0.46% reduction in Hb A1c over two years compared to usual care (95% CI: 0.04% to 0.89%; p=0.03). For LDL-C, the self-management intervention arm resulted in a reduction of 0.9mg/dl over two years compared to usual care (95% CI: -7.3mg/dl to 5.6mg/dl; p=0.79).
Conclusions
There was no evidence of a hypertension self-management intervention effect on LDL-C, but there was a modest effect of the intervention on the unintended target of Hb A1c. This effect was similar to that seen in self-management interventions specifically targeting diabetes management. Chronic disease self-management interventions may spill over into patients’ co-morbid diagnoses.
doi:10.1016/j.amjmed.2008.12.022
PMCID: PMC3766525  PMID: 19559166
Self-management; telemedicine; chronic disease; randomized controlled trial
4.  Informal and Formal Care Infrastructure and Perceived Need for Caregiver Training for Frail U.S. Veterans referred to Home and Community-Based Services 
Chronic illness  2010;6(1):57-66.
Objectives
To describe the informal care network of U.S. veterans referred to home and community-based services (Homemaker Home Health services, H/HHA, or Home-Based Primary Care, HBPC) at the Durham Veterans Affairs Medical Center (VAMC), including: quantity and types of tasks provided and desired content for caregiver training programs.
Methods
All primary care patients referred to H/HHA or HBPC during the preceding 3 months were sent questionnaires in May 2007. Additionally, caregivers were sent questionnaires if a patient gave permission. Descriptive statistics and chi-squared tests were performed.
Results
On average, patients received 5.6 hours of VA care and 47 hours of informal care per week. 26% of patients (38% of patients with caregiver proxy respondents) and 59% of caregivers indicated the caregiver would be interested in participating in a training program by phone or on-site. Significant barriers to participation existed. The most common barriers were: transportation; no time due to caregiving or work demands; caregiver's own health limitations; and no need.
Conclusions
Caregiver training needs to be tailored to overcome barriers to participate. Overcoming these barriers may be possible through in-home phone or internet training outside traditional business hours, and by tailoring training to accommodate limiting health problems among caregivers.
doi:10.1177/1742395309352694
PMCID: PMC3728281  PMID: 20308351
Informal care; caregiver training programs; VA patients; frail elderly
5.  Racial Differences in Two Self Management Hypertension Interventions 
The American journal of medicine  2011;124(5):468.e1-468.e8.
Background
Only one-half of Americans have their blood pressure controlled and there continue to be significant racial differences in blood pressure control. The goal of this study was to examine the effectiveness of two patient-directed interventions designed to improve blood pressure control within white and non-white subgroups (49% African Americans).
Methods
Post-hoc analysis of a 2 by 2 randomized trial with two-year follow-up in 2 university-affiliated primary care clinics. Within white and non-white patients (n=634), four groups were examined: 1) usual care; 2) home blood pressure monitoring (three times per week); 3) tailored behavioral self-management intervention administered via telephone by a nurse every other month; or, 4) a combination of the two interventions.
Results
The overall race by time by treatment group effect suggested differential intervention effects on blood pressure over time for whites and non-whites (systolic blood pressure, p=0.08; diastolic blood pressure, p=0.01). Estimated trajectories indicated that among the 308 whites, there was no significant effect on blood pressure at either 12 or 24 months for any intervention compared to control group. At 12 months, the non-whites (n=328) in all three intervention groups had systolic blood pressure decreases of 5.3–5.7 mm hg compared to usual care (p<0.05). At 24 months, in the combined intervention, non-whites had sustained lower systolic blood pressure as compared to usual care (7.5 mm hg; p<0.02). A similar pattern was observed for diastolic blood pressure.
Conclusion
Combined home blood pressure monitoring and a telephone tailored-behavioral intervention appeared to be particularly effective for improving blood pressure in non-white patients.
doi:10.1016/j.amjmed.2010.11.024
PMCID: PMC3086723  PMID: 21531237
Hypertension; Lifestyle; Clinical Trial; Self-management; Adherence; Disparities
6.  Association Between Blood Lead and the Risk of Amyotrophic Lateral Sclerosis 
American Journal of Epidemiology  2010;171(10):1126-1133.
The authors conducted a 2003–2007 case-control study including 184 cases and 194 controls to examine the association between blood lead and the risk of amyotrophic lateral sclerosis (ALS) among US veterans and to explore the influence on this association of bone turnover and genetic factors related to lead toxicokinetics. Blood lead, plasma biomarkers of bone formation (procollagen type 1 amino-terminal peptide (PINP)) and resorption (C-terminal telopeptides of type 1 collagen (CTX)), and the K59N polymorphism in the δ-aminolevulinic acid dehydratase gene, ALAD, were measured. Odds ratios and 95% confidence intervals for the association of blood lead with ALS were estimated with unconditional logistic regression after adjustment for age and bone turnover. Blood lead levels were higher among cases compared with controls (P < 0.0001, age adjusted). A doubling of blood lead was associated with a 1.9-fold increased risk of ALS (95% confidence interval: 1.3, 2.7) after adjustment for age and CTX. Additional adjustment for PINP did not alter the results. Significant lead-ALS associations were observed in substrata of PINP and CTX levels. The K59N polymorphism in the ALAD gene did not modify the lead-ALS association (P = 0.32). These results extend earlier findings by accounting for bone turnover in confirming the association between elevated blood lead level and higher risk of ALS.
doi:10.1093/aje/kwq063
PMCID: PMC2877471  PMID: 20406759
amyotrophic lateral sclerosis; bone and bones; bone resorption; lead; odds ratio; osteogenesis
7.  Association of ALS with Head Injury, Cigarette Smoking and APOE Genotypes 
Objective
An increased risk of ALS has been reported for US veterans, but the cause is unknown. Since head injury and cigarette smoking are two previously implicated environmental risk factors that are more common in military than civilian study populations, we tested their association with ALS in a US veteran study population.
Methods
We used logistic regression to examine the association of ALS with head injury and cigarette smoking in 241 incident cases and 597 controls. Since APOE is a plausible ALS candidate gene, we also tested its main effect and its statistical interaction with these environmental exposures.
Results
Cigarette smoking was not associated with ALS in this predominantly male and Caucasian population. Veterans who had experienced head injuries during the last 15 years before the reference date had an adjusted odds ratio of 2.33 (95% confidence interval 1.18–4.61), relative to veterans without any head injuries. This association was strongest in APOE-4 carriers.
Conclusions
Our results add to the body of evidence suggesting that head injuries may be a risk factor for multiple neurodegenerative diseases, including ALS. We hypothesize that the strength of association between head injuries and ALS may depend upon APOE genotype.
doi:10.1016/j.jns.2010.01.011
PMCID: PMC2840700  PMID: 20129626
case-control study; US veterans; candidate gene; gene-environment interaction; neurodegeneration
8.  Comparison of Medicine Resident Diabetes Care Between Veterans Affairs and Academic Health Care Systems 
ABSTRACT
BACKGROUND
Although others have reported national disparities in the quality of diabetes care between the Veterans Affairs (VA) and private health care delivery systems, it is not known whether these differences persist among internal medicine resident providers in academic settings.
OBJECTIVE
We compared the quality of diabetes primary care delivered by resident physicians in either a private academic health care system (AHS) or its affiliated VA health care system.
DESIGN
Cross-sectional observational study
PARTICIPANTS
We included patients who: had a diagnosis of diabetes, had >2 primary care visits with the same resident provider during 2005, and were not separately managed by an attending physician or endocrinologist. A total of 640 patients met our criteria and were included in the analysis.
MEASUREMENTS AND RESULTS
Compared to the VA, patients in the AHS were more likely to be younger, female, have fewer medications, and be treated with insulin, but had less comorbidity. Patients in the VA were more likely to be referred for an annual eye exam (94% vs. 78%), receive lipid screening (88% vs. 74%), receive proteinuria screening (63% vs. 34%), and receive a complete foot exam (85% vs. 32%) in analyses adjusted for patient demographics and comorbidities (p-value <0.001 for all comparisons). In adjusted analyses, there were no significant differences in HbA1c, blood pressure, or LDL cholesterol control.
CONCLUSIONS
In spite of similar resident providers and practice models, there were substantial differences in the diabetes quality of care delivered in the VA and AHS. Understanding how these factors influence subsequent practice patterns is an important area for study.
doi:10.1007/s11606-009-1048-z
PMCID: PMC2710481  PMID: 19551447
9.  Economic Evaluation of Home Blood Pressure Monitoring With or Without Telephonic Behavioral Self-Management in Patients With Hypertension 
American journal of hypertension  2009;23(2):142-148.
Background
The Take Control of Your Blood Pressure trial evaluated the effect of a multicomponent telephonic behavioral lifestyle intervention, patient self-monitoring, and both interventions combined compared with usual care on reducing systolic blood pressure during 24 months. The combined intervention led to a significant reduction in systolic blood pressure compared with usual care alone. We examined direct and patient time costs associated with each intervention.
Methods
We conducted a prospective economic evaluation alongside a randomized controlled trial of 636 patients with hypertension participating in each study intervention. Medical costs were estimated using electronic data representing medical services delivered within the health system. Intervention-related costs were derived using information collected during the trial, administrative records, and published unit costs.
Results
During 24 months, patients incurred a mean of $6965 (SD, $22,054) in inpatient costs and $8676 (SD, $9368) in outpatient costs, with no significant differences among the intervention groups. With base-case assumptions, intervention costs were estimated at $90 (SD, $2) for home blood pressure monitoring, $345 (SD, $64) for the behavioral intervention ($31 per telephone encounter), and $416 (SD, $93) for the combined intervention. Patient time costs were estimated at $585 (SD, $487) for home monitoring, $55 (SD, $16) for the behavioral intervention, and $741 (SD, $529) for the combined intervention.
Conclusions
Our analysis demonstrated that the interventions are cost-additive to the health care system in the short term and that patients’ time costs are nontrivial.
doi:10.1038/ajh.2009.215
PMCID: PMC2901769  PMID: 19927132
Costs and Cost Analysis; Hypertension; Patient Compliance
10.  A two-stage genome-wide association study of sporadic amyotrophic lateral sclerosis 
Human Molecular Genetics  2009;18(8):1524-1532.
The cause of sporadic amyotrophic lateral sclerosis (ALS) is largely unknown, but genetic factors are thought to play a significant role in determining susceptibility to motor neuron degeneration. To identify genetic variants altering risk of ALS, we undertook a two-stage genome-wide association study (GWAS): we followed our initial GWAS of 545 066 SNPs in 553 individuals with ALS and 2338 controls by testing the 7600 most associated SNPs from the first stage in three independent cohorts consisting of 2160 cases and 3008 controls. None of the SNPs selected for replication exceeded the Bonferroni threshold for significance. The two most significantly associated SNPs, rs2708909 and rs2708851 [odds ratio (OR) = 1.17 and 1.18, and P-values = 6.98 × 10−7 and 1.16 × 10−6], were located on chromosome 7p13.3 within a 175 kb linkage disequilibrium block containing the SUNC1, HUS1 and C7orf57 genes. These associations did not achieve genome-wide significance in the original cohort and failed to replicate in an additional independent cohort of 989 US cases and 327 controls (OR = 1.18 and 1.19, P-values = 0.08 and 0.06, respectively). Thus, we chose to cautiously interpret our data as hypothesis-generating requiring additional confirmation, especially as all previously reported loci for ALS have failed to replicate successfully. Indeed, the three loci (FGGY, ITPR2 and DPP6) identified in previous GWAS of sporadic ALS were not significantly associated with disease in our study. Our findings suggest that ALS is more genetically and clinically heterogeneous than previously recognized. Genotype data from our study have been made available online to facilitate such future endeavors.
doi:10.1093/hmg/ddp059
PMCID: PMC2664150  PMID: 19193627
11.  Racial Differences in Blood Pressure Control: Potential Explanatory Factors 
Summary
Objective
The objective of the study was to identify potential explanatory factors for racial differences in blood pressure (BP) control.
Design
The design of the study was a cross-sectional study
Patients/Participants
The study included 608 patients with hypertension who were either African American (50%) or white (50%) and who received primary care in Durham, NC.
Measurements and Main Results
Baseline data were obtained from the Take Control of Your Blood pressure study and included clinical, demographic, and psychosocial variables potentially related to clinic BP measures. African Americans were more likely than whites to have inadequate baseline clinic BP control as defined as greater than or equal to 140/90 mmHg (49% versus 34%; unadjusted odds ratio [OR] 1.8; 95% confidence interval [CI] 1.3–2.5). Among factors that may explain this disparity, being older, reporting hypertension medication nonadherence, reporting a hypertension diagnosis for more than 5 years, reporting high levels of stress, being worried about hypertension, and reporting an increased number of medication side effects were related to inadequate BP control. In adjusted analyses, African Americans continue to have poor BP control relative to whites; the magnitude of the association was reduced (OR = 1.5; 95% CI 1.0–2.1). Medication nonadherence, worries about hypertension, and older age (>70) continued to be related to poor BP control.
Conclusions
In this sample of hypertensive patients, there were a number of factors associated with poor BP control that partially explained the observed racial disparity in hypertension control including age, medication nonadherence, and worry about BP. Medication nonadherence is of particular interest because it is a potentially modifiable factor that might be used to reduce the racial disparity in BP control.
doi:10.1007/s11606-008-0547-7
PMCID: PMC2324164  PMID: 18288540
racial disparity; hypertension; adherence; psychosocial
12.  Correlation of Symptoms to Function in Older Adults with Comorbidity 
Objectives
To (1) describe the relationship between symptom scores and mobility function measures, (2) assess whether symptom scores and disease scores are similarly associated with mobility function, and (3) identify clusters of symptoms that are most strongly associated with functional status in older adults
Design
Secondary analysis of cross-sectional data from three cohorts
Setting
Academic medical center
Participants
195 community-dwelling subjects with poor flexibility or cardiorespiratory fitness (fitness cohort), 211 female retirement community residents with vertebral fractures (VF cohort), and 61 subjects with Parkinson's disease (PD cohort)
Measurements
20-item self-reported symptom scale, 17-item self-reported disease scale, Short Form 36 (SF-36) Physical Functioning Scale, 5-item Nagi Disability scale, 10-meter walk time, supine to stand time
Results
Symptom scores correlated with mobility function measures (Spearman correlation coefficients range from 0.222 to 0.509) at least as strongly as, if not more strongly than did disease scores. Symptom scores remained associated with functional outcomes after controlling for disease score and demographic variables. Adding symptom scores to models that contained disease scores significantly increased the association with functional outcomes. In the fitness cohort, muscle weakness was the most explanatory single symptom, associated with an average decrease of 17.8 points on the Physical Functioning Scale. A model that included only muscle weakness, pain, and shortness of breath accounted for 21.2% of the variability in the Physical Functioning Score.
Conclusion
Symptoms represent useful indicators of disability burden in older adults and are promising targets for interventions to improve function in complex patients.
doi:10.1111/j.1532-5415.2009.02178.x
PMCID: PMC2674624  PMID: 19392960
symptom; function; disability; comorbidity
13.  Take Control of Your Blood pressure (TCYB) study: A multifactorial tailored behavioral and educational intervention for achieving blood pressure control 
Patient education and counseling  2007;70(3):338-347.
Objectives
Evaluating a randomized controlled trial involving a tailored behavioral intervention conducted to improve blood pressure control.
Methods
Adults with hypertension from two outpatient primary care clinics were randomly allocated to receive a nurse-administered behavioral intervention or usual care. In this ongoing study, patients receive the tailored behavioral intervention bi-monthly for two years via telephone; the goal of the intervention is to promote medication adherence and improve hypertension-related health behaviors. Patient factors targeted in the tailored behavioral intervention include perceived risk of hypertension and knowledge, memory, medical and social support, patients' relationship with their health care provider, adverse effects of medication therapy, weight management, exercise, diet, stress, smoking, and alcohol use.
Results
The sample randomized to the behavioral intervention consisted of 319 adults with hypertension (average age = 60.5 years; 47% African-American). A comparable sample of adults was assigned to usual care (n=317). We had a 96% retention rate for the overall sample for the first 6 months of the study (93% at 12 months). The average phone call has lasted 18 minutes (range 2 to 51 minutes). From baseline to six months, self-reported medication adherence increased by 9% in the behavioral group vs. 1% in the non-behavioral group.
Conclusion
The intervention is easily implemented and is designed to enhance adherence with prescribed hypertension regimen. The study includes both general and patient-tailored information based upon need assessment. The study design ensures internal validity as well as the ability to generalize study findings to the clinic settings.
Practice Implications
Despite knowledge of the risks and acceptable evidence, a large number of hypertensive adults still do not have their blood pressure under effective control. This study will be an important step in evaluating a tailored multibehavioral intervention focusing on improving blood pressure control.
doi:10.1016/j.pec.2007.11.014
PMCID: PMC2276731  PMID: 18164894
Behavioral Intervention; hypertension; adherence; tailored; health communication
14.  Genes and Environmental Exposures in Veterans with ALS (GENEVA): Rationale, Study Design and Demographic Characteristics 
Neuroepidemiology  2008;30(3):191-204.
Recent reports of a potentially increased risk of amyotrophic lateral sclerosis (ALS) for veterans deployed to the 1990-91 Persian Gulf War prompted the Department of Veterans Affairs to establish a National Registry of Veterans with ALS, charged with the goal of enrolling all US veterans with a neurologist-confirmed diagnosis of ALS (Allen et al., this issue). The GENEVA study (Genes and Environmental Exposures in Veterans with ALS) is a case-control study presently enrolling cases from the VA registry and a representative sample of veteran controls to evaluate the joint contributions of genetic susceptibility and environmental exposures to the risk of sporadic ALS. The GENEVA study design, recruitment strategies, and methods of collecting DNA samples and environmental risk factor information are described here, along with a summary of demographic characteristics of the participants (537 cases, 292 controls) enrolled to date.
doi:10.1159/000126911
PMCID: PMC2645711  PMID: 18421219
case-control study; recruitment methods; gene-environment interaction
15.  Study protocol: Couples Partnering for Lipid Enhancing Strategies (CouPLES) – a randomized, controlled trial 
Trials  2009;10:10.
Background
Almost 50% of Americans have elevated low-density lipoprotein cholesterol (LDL-C). The behaviors required to lower LDL-C levels may be difficult to adhere to if they are inconsistent with spouses' health practices, and, alternatively, may be enhanced by enlisting support from the spouse. This trial extends previous trials by requiring spouse enrollment, teaching spouses how to provide emotional and instrumental support, allowing patients to decide which component of the intervention they would like to receive, and having patients determine their own goals and action plans.
Methods
Veteran outpatients with above-goal LDL-C (N = 250) and their spouses are randomized, as a couple, to receive printed education materials only or the materials plus an 11-month, nurse-delivered, telephone-based intervention. The intervention contains four modules: medication adherence, diet, exercise, and patient-physician communication. Patients decide which modules they complete and in which order; modules may be repeated or omitted. Telephone calls are to patients and spouses separately and occur monthly. During each patient telephone call, patients' progress is reviewed, and patients create goals and action plans for the upcoming month. During spouse telephone calls, which occur within one week of patient calls, spouses are informed of patients' goals and action plans and devise strategies to increase emotional and instrumental support.
The primary outcome is patients' LDL-C, measured at baseline, 6 months, and 11 months. Linear mixed models will be used to test the primary hypothesis that an 11-month, telephone-based patient-spouse intervention will result in a greater reduction in LDL-C as compared to printed education materials. Various process measures, including social support, self-efficacy, medication adherence, dietary behavior, and exercise, are also assessed to explain any change, or lack thereof, in LDL-C.
Discussion
Given the social context in which self-management occurs, interventions that teach spouses to provide instrumental and emotional support may help patients initiate and adhere to behaviors that lower their LDL-C levels. Moreover, allowing patients to retain autonomy by deciding which behaviors they would like to change and how may improve adherence and clinical outcomes.
Trial Registration
The ClinicalTrials.gov registration number is NCT00321789.
doi:10.1186/1745-6215-10-10
PMCID: PMC2652451  PMID: 19200384
16.  Adverse Health Outcomes After Discharge from the Emergency Department—Incidence and Risk Factors in a Veteran Population 
Journal of General Internal Medicine  2007;22(11):1527-1531.
Background
An Emergency Department (ED) visit represents a time of significant risk for an older adult; however, little is known about adverse outcomes after an ED visit in the VA system.
Objectives
1) To describe the frequency and type of adverse health outcomes among older veterans discharged from the ED, and 2) To determine risk factors associated with adverse outcomes.
Design
Retrospective, cohort study at an academically affiliated VA medical center.
Patients
A total of 942 veterans ≥ 65 years old discharged from the ED.
Measurements and Main Results
Primary dependent variable was adverse outcome, defined as a repeat VA ED visit, hospitalization, and/or death within 90 days. Overall, 320 (34.0%) patients experienced an adverse outcome: 245 (26%) returned to the VA ED but were not admitted, 125 (13.3%) were hospitalized, and 23 (2.4%) died. In adjusted analyses, higher score on the Charlson Comorbidity Index (hazard ratio [HR] 1.11; 95% CI 1.03, 1.21), ED visit within the previous 6 months (HR 1.64; 95% CI 1.30, 2.06), hospitalization within the previous 6 months (HR 1.70, 95% CI 1.30, 2.22), and triage to the emergency unit (compared to urgent care clinic) (HR 1.76, 95% CI 1.32, 2.36) were independently associated with higher risk of adverse outcomes.
Conclusion
More than 1 in 3 older veterans discharged from the ED experienced a significant adverse outcome within 90 days of ED discharge. Identifying veterans at greatest risk for adverse outcomes after ED discharge can inform the design and targeting of interventions to reduce morbidity and costs in this group.
doi:10.1007/s11606-007-0343-9
PMCID: PMC2219800  PMID: 17828432
health outcomes; emergency department; elderly; quality of care
17.  Literacy and blood pressure – do healthcare systems influence this relationship? A cross-sectional study 
Background
Limited literacy is common among patients with chronic conditions and is associated with poor health outcomes. We sought to determine the association between literacy and blood pressure in primary care patients with hypertension and to determine if this relationship was consistent across distinct systems of healthcare delivery.
Methods
We conducted a cross-sectional study of 1224 patients with hypertension utilizing baseline data from two separate, but similar randomized controlled trials. Patients were enrolled from primary care clinics in the Veterans Affairs healthcare system (VAHS) and a university healthcare system (UHS) in Durham, North Carolina. We compared the association between literacy and the primary outcome systolic blood pressure (SBP) and secondary outcomes of diastolic blood pressure (DBP) and blood pressure (BP) control across the two different healthcare systems.
Results
Patients who read below a 9th grade level comprised 38.4% of patients in the VAHS and 27.5% of the patients in the UHS. There was a significant interaction between literacy and healthcare system for SBP. In adjusted analyses, SBP for patients with limited literacy was 1.2 mmHg lower than patients with adequate literacy in the VAHS (95% CI, -4.8 to 2.3), but 6.1 mmHg higher than patients with adequate literacy in the UHS (95% CI, 2.1 to 10.1); (p = 0.003 for test of interaction). This literacy by healthcare system interaction was not statistically significant for DBP or BP control.
Conclusion
The relationship between patient literacy and systolic blood pressure varied significantly across different models of healthcare delivery. The attributes of the healthcare delivery system may influence the relationship between literacy and health outcomes.
doi:10.1186/1472-6963-8-219
PMCID: PMC2600788  PMID: 18947408
18.  Selective adherence to antihypertensive medications as a patient-driven means to preserving sexual potency 
Objective
To describe hypertensive patients’ experiences with sexual side effects and their consequences for antihypertensive medication adherence.
Methods
Data were from a study conducted to identify facilitators of and barriers to adherence to blood pressure-lowering regimens. Participants were 38 married and unmarried veterans with a diagnosis of hypertension and 13 female spouses. Eight patient and four spouse focus groups were conducted. A directed approach to content analysis was used to determine the facilitators of and barriers to adherence. For this report, all discussion concerning the topic of sexual relations was extracted.
Results
Male patients viewed sexual intercourse as a high priority and felt that a lack of sexual intercourse was unnatural. They pursued strategies to preserve their potency, including discontinuing or selectively adhering to their medications and obtaining treatments for impotence. In contrast, spouses felt that sexual intercourse was a low priority and that a lack of sexual intercourse was natural. They discouraged their husbands from seeking treatments for impotence.
Conclusion
Although the primary study was not designed to explore issues of sexual function, the issue emerged spontaneously in the majority of discussions, indicating that sexuality is important in this context for both male patients and their spouses. Physicians should address sexual side effects of antihypertensive medications with patients, ideally involving spouses.
PMCID: PMC2770379  PMID: 19920964
hypertension; sexual side effects; antihypertensive medication; adherence; blood pressure
19.  A Multidimensional Integrative Medicine Intervention to Improve Cardiovascular Risk 
BACKGROUND
Integrative medicine is an individualized, patient-centered approach to health, combining a whole-person model with evidence-based medicine. Interventions based in integrative medicine theory have not been tested as cardiovascular risk-reduction strategies. Our objective was to determine whether personalized health planning (PHP), an intervention based on the theories and principles underlying integrative medicine, reduces 10-year risk of coronary heart disease (CHD).
METHODS
We conducted a randomized, controlled trial among 154 outpatients age 45 or over, with 1 or more known cardiovascular risk factors. Subjects were enrolled from primary care practices near an academic medical center, and the intervention was delivered at a university Center for Integrative Medicine. Following a health risk assessment, each subject in the intervention arm worked with a health coach and a medical provider to construct a personalized health plan. The plan identified specific health behaviors important for each subject to modify; the choice of behaviors was driven both by cardiovascular risk reduction and the interests of each individual subject. The coach then assisted each subject in implementing her/his health plan. Techniques used in implementation included mindfulness meditation, relaxation training, stress management, motivational techniques, and health education and coaching. Subjects randomized to the comparison group received usual care (UC) without access to the intervention. Our primary outcome measure was 10-year risk of CHD, as measured by a standard Framingham risk score, and assessed at baseline, 5, and 10 months. Differences between arms were assessed by linear mixed effects modeling, with time and study arm as independent variables.
RESULTS
Baseline 10-year risk of CHD was 11.1% for subjects randomized to UC (n = 77), and 9.3% for subjects randomized to PHP (n = 77). Over 10 months of the intervention, CHD risk decreased to 9.8% for UC subjects and 7.8% for intervention subjects. Based on a linear mixed-effects model, there was a statistically significant difference in the rate of risk improvement between the 2 arms (P = 0.04). In secondary analyses, subjects in the PHP arm were found to have increased days of exercise per week compared with UC (3.7 vs 2.4, P = 0.002), and subjects who were overweight on entry into the study had greater weight loss in the PHP arm compared with UC (P = 0.06).
CONCLUSIONS
A multidimensional intervention based on integrative medicine principles reduced risk of CHD, possibly by increasing exercise and improving weight loss.
doi:10.1111/j.1525-1497.2006.00495.x
PMCID: PMC1924710  PMID: 16808774
integrative medicine; randomized-controlled trial; cardiovascular risk reduction
20.  Perceived Discrimination and Reported Delay of Pharmacy Prescriptions and Medical Tests 
BACKGROUND
Access to health care varies according to a person's race and ethnicity. Delaying treatment is one measure of access with important health consequences.
OBJECTIVE
Determine whether perceptions of unfair treatment because of race or ethnicity are associated with reported treatment delays, controlling for economic constraints, self-reported health, depression, and demographics.
DESIGN
Cross-sectional, observational study.
PARTICIPANTS
A randomly selected community sample of 181 blacks, 148 Latinos, and 193 whites in Durham County, NC.
MEASUREMENTS
A phone survey conducted in 2002 to assess discrimination, trust in medical care, quality of care, and access to care. Treatment delays were measured by whether or not a person reported delaying or forgoing filling a prescription and delaying or forgoing having a medical test/treatment in the past 12 months. Perceived discrimination was measured as unfair treatment in health care and as racism in local health care institutions.
RESULTS
The odds of delaying filling prescriptions were significantly higher (odds ratio (OR)=2.02) for persons who perceived unfair treatment, whereas the odds of delaying tests or treatments were significantly higher (OR=2.42) for persons who thought racism was a problem in health care locally. People with self-reported depression and people who reported not working had greater odds of delaying both types of care.
CONCLUSIONS
A prospective cohort study with both personal and macro measures of discrimination, as well as more refined measures of treatment delays, would help us better understand the relationship between perceived discrimination and treatment delays.
doi:10.1111/j.1525-1497.2005.0123.x
PMCID: PMC1490147  PMID: 16050850
perceived discrimination; perceived racism; delay of treatment; pharmacy prescriptions; African American; black; Latino
21.  BRIEF REPORT: How Well Do Clinic-Based Blood Pressure Measurements Agree with the Mercury Standard? 
BACKGROUND
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.
OBJECTIVE
To examine agreement between real-time clinic-based assessment of BP and the standard mercury assessment of BP.
DESIGN
Prospective reliability study.
PATIENTS
One hundred patients with an International Classification of Diseases—9th edition code for hypertension were enrolled.
MEASURES
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.
RESULTS
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.
CONCLUSIONS
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.
doi:10.1111/j.1525-1497.2005.0105.x
PMCID: PMC1490157  PMID: 16050862
blood pressure measurement assessment; clinic method; mercury device
22.  Racial differences in health concern. 
An understanding of racial differences in risk-related affect may help explain racial differences in health behaviors and outcomes and provide additional opportunities for intervention. In phone interviews with a random community sample of 197 whites, 155 blacks and 163 Latinos, we assessed concern that respondents' health would be hurt by their diet, an inability to exercise, an inability to follow a doctor's recommendations and disease. A multivariate analysis of variance with follow-up profile analysis revealed that whites were less concerned than blacks and Latinos about an inability to follow their doctors' recommendations (ps < 0.01). There were no racial differences in the other health concern variables. Interventions to inform blacks and Latinos about their health risks must strike a balance between creating enough health concern to encourage health behavior but not so much that it interferes with health-promoting behaviors.
PMCID: PMC2594806  PMID: 16532976
23.  Utility of Hemoglobin A1c in Predicting Diabetes Risk 
Journal of General Internal Medicine  2004;19(12):1175-1180.
BACKGROUND
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.
METHODS
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.
RESULTS
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%).
CONCLUSIONS
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.
doi:10.1111/j.1525-1497.2004.40178.x
PMCID: PMC1492588  PMID: 15610327
diabetes; screening; hemoglobin A1c
24.  Screening for Diabetes in an Outpatient Clinic Population 
BACKGROUND
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.
OBJECTIVE
To describe the prevalence, predictors, and clinical severity of unrecognized diabetes among outpatients at a major medical center.
DESIGN AND SETTING
A cross-sectional observational study at the Durham Veterans Affairs Medical Center.
SUBJECTS
Outpatients without recognized diabetes (N = 1,253).
METHODS
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%.
RESULTS
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).
CONCLUSIONS
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.
doi:10.1046/j.1525-1497.2002.10420.x
PMCID: PMC1494994  PMID: 11903772
diabetes; disease screening; metabolic syndrome
25.  Primary Care for Patients Infected with Human Immunodeficiency Virus 
OBJECTIVE
To measure the impact of a teaching intervention and to compare process and outcomes of care for HIV-infected patients randomly assigned to a general medicine clinic (GMC) or an infectious disease clinic (IDC) for primary care.
DESIGN
Prospective, randomized, controlled trial.
SETTING
University hospital in Durham, NC.
PATIENTS
Two hundred fourteen consecutive HIV-infected patients presenting for primary care.
INTERVENTION
Physicians at the GMC received HIV-related training and evidence-based practice guidelines.
MEASUREMENTS
Utilization of services, health-related quality of life, preventive and screening measures, and antiretroviral use for one year.
RESULTS
At baseline GMC patients were more likely to be African American (85% vs 71%; P = .03) and had lower baseline CD4+ cell counts than IDC patients (262 ± 269 vs 329 ± 275; P = .05). A similar and high proportion of patients in both groups received appropriate preventive care services including Pneumocystis carinii pneumonia (PCP) prophylaxis, pneumococcal vaccination, and antiretroviral therapy. Screening for TB was more frequent in GMC (89% vs 68%; P = .001). In the year following randomization, GMC patients made more visits to the emergency department than IDC patients (1.6 ± 3.0 vs 0.7 ± 1.5; P = .05). Hospital use was higher for GMC patients with average length of stay 7.8 ± 6.3 days compared to 5.7 ± 3.8 days for IDC patients (P = .01). In analyses, which adjust for potential baseline imbalances, these differences remained.
CONCLUSIONS
Targeted education in GMC achieved similar provision of primary care for GMC patients, yet use of health care services was higher for this group. The delivery of adequate primary care is necessary but not sufficient to produce changes in health care utilization.
doi:10.1046/j.1525-1497.2001.016009573.x
PMCID: PMC1495270  PMID: 11556937
HIV infections; physician practice patterns; health services accessibility; continuity of patient care; ambulatory care; primary health care

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