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1.  Performance of the Family Satisfaction with the End-of-Life Care (FAMCARE) measure in an ethnically diverse cohort: Psychometric analyses using item response theory 
The Family Satisfaction with End-of-Life Care (FAMCARE) has been used widely among caregivers to individuals with cancer. The aim of this study was to evaluate the psychometric properties of this measure using item response theory (IRT).
The analytic sample was comprised of caregivers to 1983 patients with advanced cancer. Among the patients, 56% were female, with mean age 59.9 (s.d. = 11.8); 20% were non-Hispanic Black. The majority were family members either living with (44%) or not living with (35%) the patient.
Factor analyses and IRT were used to examine the dimensionality, information and reliability of the FAMCARE.
Although a bi-factor model fit the data slightly better than did a unidimensional model, the loadings on the group factors were very low. Thus, a unidimensional model appears to provide adequate representation for the item set. The reliability estimates, calculated along the satisfaction (theta) continuum were adequate (>0.80) for all levels of theta for which subjects had scores.
Examination of the category response functions from IRT showed overlap in the lower categories with little unique information provided; moreover the categories were not observed to be interval. Based on these analyses, a three response category format was recommended: very satisfied, satisfied and not satisfied. Most information was provided in the range indicative of either dissatisfaction or high satisfaction.
These analyses support the use of fewer response categories, and provide item parameters that form a basis for developing shorter-form scales. Such a revision has the potential to reduce respondent burden.
PMCID: PMC4151612  PMID: 24091717
FAMCARE; patient; caregiver; satisfaction; item response theory; psychometric properties
2.  Depression is not associated with diabetes control in minority elderly 
We investigated the longitudinal association of depression, with and without cognitive dysfunction, with hemoglobin A1c (HbA1c), systolic blood pressure (SBP), and low-density lipoprotein (LDL) in a predominantly minority cohort.
There were 613 participants. Presence of depression was defined by a score ≥ 7 on the Short-CARE depression scale. We tested participants for executive dysfunction using the Color Trails Test (CTT), part 2, and for memory dysfunction using the total recall task of the Selective Reminding Test (TR-SRT). We classified performance in these tests as abnormal based on standardized score cutoffs (<16th percentile and one standard deviation below the sample mean). Random effects models were used to compare repeated measures of the diabetes control measures between those with depression versus those without depression and ever versus never cognitively impaired.
Baseline depression was present in 36% of participants. Over a median follow-up of 2 years, depression was not related to worse HbA1c, SBP, or LDL. The presence of (1) abnormal performance on a test of executive function and depression (n = 57) or (2) abnormal performance on a test of verbal recall and depression (n = 43) was also not associated with clinically significant worse change in diabetes control.
Depression, with or without low performance in tests of executive function and memory, may not affect clinically significant measures of diabetes control in the elderly.
PMCID: PMC4310458  PMID: 25156987
Diabetes; Depression; Diabetes control; Cognitive dysfunction; Older adults
3.  Center for stroke disparities solutions community- based care transition interventions: study protocol of a randomized controlled trial 
Trials  2015;16:32.
Racial and ethnic disparities persist in stroke occurrence, recurrence, morbidity and mortality. Uncontrolled hypertension (HTN) is the most important modifiable risk factor for stroke risk. Home health care organizations care for many patients with uncontrolled HTN and history of stroke; however, recurrent stroke prevention has not been a home care priority. We are conducting a randomized controlled trial (RCT) to compare the effectiveness, relative to usual home care (UHC), of two Community Transitions Interventions (CTIs). The CTIs aim to reduce recurrent stroke risk among post-stroke patients via home-based transitional care focused on better HTN management.
This 3-arm trial will randomly assign 495 black and Hispanic post-stroke home care patients with uncontrolled systolic blood pressure (SBP) to one of three arms: UHC, UHC complemented by nurse practitioner-delivered transitional care (UHC + NP) or UHC complemented by an NP plus health coach (UHC + NP + HC). Both intervention arms emphasize: 1) linking patients to continuous, responsive preventive and primary care, 2) increasing patients’/caregivers’ ability to manage a culturally and individually tailored BP reduction plan, and 3) facilitating the patient’s reintegration into the community after home health care discharge. The primary hypothesis is that both NP-only and NP + HC transitional care will be more effective than UHC alone in achieving a SBP reduction. The primary outcome is change in SPB at 3 and 12 months. The study also will examine cost-effectiveness, quality of life and moderators (for example, race/ethnicity) and mediators (for example, changes in health behaviors) that may affect treatment outcomes. All outcome data are collected by staff blinded to group assignment.
This study targets care gaps affecting a particularly vulnerable black/Hispanic population characterized by persistent stroke disparities. It focuses on care transitions, a juncture when patients are particularly susceptible to adverse events. The CTI is innovative in adapting for stroke patients an established transitional care model shown to be effective for HF patients, pairing the professional NP with a HC, implementing a culturally tailored intervention, and placing primary emphasis on longer-term risk factor reduction and community reintegration rather than shorter-term transitional care outcomes.
Trial registration NCT01918891; Registered 5 August 2013.
PMCID: PMC4322449  PMID: 25622823
Care transitions; Home health; Stroke; Hypertension; Blood pressure; Health disparities; Trial design
4.  Mild Cognitive Dysfunction Does Not Affect Diabetes Mellitus Control in Minority Elderly Adults 
To determine whether older adults with type 2 diabetes mellitus and cognitive dysfunction have poorer metabolic control of glycosylated hemoglobin, systolic blood pressure, and low-density lipoprotein cholesterol than those without cognitive dysfunction.
Prospective cohort study.
A minority cohort in New York City previously recruited for a trial of telemedicine.
Persons aged 73.0 ± 3.0 (N = 613; 69.5% female; 82.5% Hispanic, 15.5% non-Hispanic black).
Participants were classified with executive or memory dysfunction based on standardized score cutoffs (<16th percentile) for the Color Trails Test and Selective Reminding Test. Linear mixed models were used to compare repeated measures of the metabolic measures and evaluate the rates of change in individuals with and without dysfunction.
Of the 613 participants, 331 (54%) had executive dysfunction, 202 (33%) had memory dysfunction, and 96 (16%) had both. Over a median of 2 years, participants with executive or memory dysfunction did not exhibit significantly poorer metabolic control than those without executive function or memory type cognitive dysfunction.
Cognitive dysfunction in the mild range did not seem to affect diabetes mellitus control parameters in this multiethnic cohort of older adults with diabetes mellitus, although it cannot be excluded that cognitive impairment was overcome through assistance from formal or informal caregivers. It is possible that more-severe cognitive dysfunction could affect control.
PMCID: PMC4288580  PMID: 25439094
cognition; diabetes mellitus; control; elderly
5.  Disparities in Symptom Burden and Renal Transplant Eligibility: A Pilot Study 
Journal of Palliative Medicine  2013;16(11):1459-1465.
Patients with end-stage renal disease (ESRD) on hemodialysis (HD) suffer from a high symptom burden. However, there is significant heterogeneity within the HD population; certain subgroups, such as the elderly, may experience disproportionate symptom burden.
The study's objective was to propose a category of HD patients at elevated risk for symptom burden (those patients who are not transplant candidates) and to compare symptomatology among transplant ineligible versus eligible HD patients.
This was a cross-sectional study.
English-speaking, cognitively intact patients receiving HD and who were either transplant eligible (n=25) or ineligible (n=32) were recruited from two urban HD units serving patients in the greater New York City region.
In-person interviews were conducted to ascertain participants' symptom burden using the Dialysis Symptom Index (DSI), perceived symptom bother and attribution (whether the symptom was perceived to be related to HD treatment), and quality of life using the SF-36. Participants' medical records were reviewed to collect demographic and clinical data.
Transplant ineligible (versus eligible) patients reported an average of 13.9±4.6 symptoms versus 9.2±4.4 symptoms (p<0.01); these differences persisted after adjustment for multiple factors. A greater proportion of transplant ineligible (versus eligible) patients attributed their symptoms to HD and were more likely to report greater bother on account of the symptoms. Quality of life was also significantly lower in the transplant ineligible group.
Among HD patients, transplant eligibility is associated with symptom burden. Our pilot data suggest that consideration be given to employing transplant status as a method of identifying HD patients at risk for greater symptom burden and targeting them for palliative interventions.
PMCID: PMC3822373  PMID: 24111782
6.  Using Qualitative Methods to Develop a Measure of Resident-to-Resident Elder Mistreatment in Nursing Homes 
International psychogeriatrics / IPA  2013;25(8):1245-1256.
Despite expansion of research on elder mistreatment, limited attention has been paid to the development of improved measurement instruments. This gap is particularly notable regarding measurement of mistreatment in long-term care facilities. This article demonstrates the value of qualitative methods used in item development of a Resident-to-Resident Elder Mistreatment (R-REM) measure for use in nursing homes and other care facilities. It describes the development strategy and the modification and refinement of items using a variety of qualitative methods.
A combination of qualitative methods was used to develop close-ended items to measure R-REM, including review by a panel of experts, focus groups, and in-depth cognitive interviews.
Information gathered from the multiple methods aided in flagging problematic items, helped to highlight the nature of the problems in measures, and provided suggestions for item modification and improvement.
The method employed is potentially useful for future attempts to develop better measures of elder mistreatment. The employment of previously established measurement items drawn from related fields, modified through an intensive qualitative research strategy, is an effective strategy to improve elder mistreatment measurement.
PMCID: PMC4178930  PMID: 23506835
qualitative methods; measure development; resident-to-resident elder mistreatment; long-term care
7.  Managing resident to resident elder mistreatment (R-REM) in nursing homes: the SEARCH approach 
This article describes an educational program to inform nursing and care staff in the management of resident-to-resident elder mistreatment (R-REM) in nursing homes, using the SEARCH approach. Although relatively little research has been conducted on this form of abuse, there is mounting interest in R-REM, as such aggression has been found to be extensive and can have both physical and psychological consequences for residents and staff. The aim of the SEARCH approach is to support staff in the identification and recognition of R-REM, and suggesting recommendations for management. The education program and the SEARCH approach are described. Three case studies from the research project are presented, illustrating how the SEARCH approach can be used by nurses and care staff to manage R-REM in nursing homes. Resident- and staff safety and well-being can be enhanced by the use of the evidence-based SEARCH approach.
PMCID: PMC4178932  PMID: 24548656
8.  Modifying Measures Based on Differential Item Functioning (DIF) Impact Analyses 
Journal of aging and health  2012;24(6):1044-1076.
Measure modification can impact comparability of scores across groups and settings. Changes in items can affect the percent admitting to a symptom.
Using item response theory (IRT) methods, well-calibrated items can be used interchangeably, and the exact same item does not have to be administered to each respondent, theoretically permitting wider latitude in terms of modification.
Recommendations regarding modifications vary, depending on the use of the measure. In the context of research, adjustments can be made at the analytic level by freeing and fixing parameters based on findings of differential item functioning (DIF). The consequences of DIF for clinical decision making depend on whether or not the patient’s performance level approaches the scale decision cutpoint. High-stakes testing may require item removal or separate calibrations to ensure accurate assessment.
Guidelines for modification based on DIF analyses and illustrations of the impact of adjustments are presented.
PMCID: PMC4030595  PMID: 22422759
differential item functioning; DIF; factorial invariance; impact of DIF; ethnicity; measure modification
10.  Verbal and Physical Aggression Directed at Nursing Home Staff by Residents 
Little research has been conducted on aggression directed at staff by nursing home residents.
To estimate the prevalence of resident-to-staff aggression (RSA) over a 2-week period.
Prevalent cohort study.
Large urban nursing homes.
Population-based sample of 1,552 residents (80 % of eligible residents) and 282 certified nursing assistants.
Main Outcome Measures
Measures of resident characteristics and staff reports of physical, verbal, or sexual behaviors directed at staff by residents.
The staff response rate was 89 %. Staff reported that 15.6 % of residents directed aggressive behaviors toward them (2.8 % physical, 7.5 % verbal, 0.5 % sexual, and 4.8 % both verbal and physical). The most commonly reported type was verbal (12.4 %), particularly screaming at the certified nursing assistant (9.0 % of residents). Overall, physical aggression toward staff was reported for 7.6 % of residents, the most common being hitting (3.9 % of residents). Aggressive behaviors occurred most commonly in resident rooms (77.2 %) and in the morning (84.3 %), typically during the provision of morning care. In a logistic regression model, three clinical factors were significantly associated with resident-to-staff aggression: greater disordered behavior (OR = 6.48, 95 % CI: 4.55, 9.21), affective disturbance (OR = 2.29, 95 % CI: 1.68, 3.13), and need for activities of daily living morning assistance (OR = 2.16, 95 % CI: 1.53, 3.05). Hispanic (as contrasted with White) residents were less likely to be identified as aggressors toward staff (OR = 0.57, 95 % CI: 0.36, 0.91).
Resident-to-staff aggression in nursing homes is common, particularly during morning care. A variety of demographic and clinical factors was associated with resident-to-staff aggression; this could serve as the basis for evidence-based interventions. Because RSA may negatively affect the quality of care, resident and staff safety, and staff job satisfaction and turnover, further research is needed to understand its causes and consequences and to develop interventions to mitigate its potential impact.
PMCID: PMC3631060  PMID: 23225256
nursing home; dementia-related behaviors; elder abuse; staff mistreatment
In 2004 NIH awarded contracts to initiate the development of high quality psychological and neuropsychological outcome measures for improved assessment of health-related outcomes. The workshop introduced these measurement development initiatives, the measures created, and the NIH supported resource (Assessment Center) for internet or tablet-based test administration and scoring. Presentation covered: (a) item response theory (IRT) and assessment of test bias, (b) construction of item banks and computerized adaptive testing, and (c) the different ways in which qualitative analyses contribute to the definition of construct domains and the refinement of outcome constructs. The panel discussion included questions about representativeness of samples, and assessment of cultural bias.
PMCID: PMC4004066  PMID: 23570428
12.  Telemedicine Home Blood Pressure Measurements Predict Progression of Albuminuria in Elderly People with Diabetes 
Hypertension  2008;51(5):10.1161/HYPERTENSIONAHA.107.108589.
We assessed whether home blood pressure monitoring improved the prediction of progression of albuminuria when added to office measurements, and compared it to ambulatory blood pressure monitoring in a multiethnic cohort of older people (n=392) with diabetes mellitus, without macroalbuminuria, participating in the telemedicine arm of the Informatics for Diabetes Education and Telemedicine (IDEATel) study. Albuminuria was assessed by measuring the spot urine albumin-to-creatinine ratio at baseline and annually for three years. Ambulatory sleep/wake systolic blood pressure ratio was categorized as dipping (ratio≤0.9), non-dipping (ratio>0.9 -1), and nocturnal rise (ratio>1). In a repeated measures mixed linear model, after adjustment that included office pulse pressure, home pulse pressure was independently associated with higher follow-up albumin-to-creatinine ratio (p=0.001). That association persisted (p=0.01) after adjusting for 24-hour pulse pressure, and nocturnal rise, which were also independent predictors (p=0.02 and p=0.03, respectively). Cox proportional hazards models examined progression of albuminuria (n=74) as defined by cutoff values used by clinicians. After adjustment for office pulse pressure the hazards ratio (95% CI) per 10 mmHg increment of home pulse pressure was 1.34 (1.1-1.7), p=0.01. Home pulse pressure was not an independent predictor in the model including ambulatory monitoring data—a nocturnal rise was the only independent predictor (p=0.035). However, Cox models built separately for home pulse pressure and ambulatory monitoring exhibited similar calibration and discrimination. In conclusion, home blood pressure adds to office measurements and may substitute for ambulatory monitoring to predict worsening of albuminuria in elderly people with diabetes.
PMCID: PMC3855674  PMID: 18378859
Albuminuria; Diabetes mellitus; Home Blood Pressure; Ambulatory Blood Pressure
13.  The Counseling Older Adults to Control Hypertension (COACH) Trial: design and methodology of a group-based lifestyle intervention for hypertensive minority older adults 
Contemporary clinical trials  2013;35(1):70-79.
The disproportionately high prevalence of hypertension and its associated mortality and morbidity in minority older adults is a major public health concern in the United States. Despite compelling evidence supporting the beneficial effects of therapeutic lifestyle changes on blood pressure reduction, these approaches remain largely untested among minority elders in community-based settings. The Counseling Older Adults to Control Hypertension trial is a two-arm randomized controlled trial of 250 African-American and Latino seniors, 60 years and older with uncontrolled hypertension, who attend senior centers. The goal of the trial is to evaluate the effect of a therapeutic lifestyle intervention delivered via group classes and individual motivational interviewing sessions versus health education, on blood pressure reduction. The primary outcome is change in systolic and diastolic blood pressure from baseline to 12 months. The secondary outcomes are blood pressure control at 12 months; changes in levels of physical activity; body weight; and number of daily servings of fruits and vegetables from baseline to 12 months. The intervention group will receive 12 weekly group classes followed by individual motivational interviewing sessions. The health education group will receive an individual counseling session on healthy lifestyle changes and standard hypertension education materials. Findings from this study will provide needed information on the effectiveness of lifestyle interventions delivered in senior centers. Such information is crucial in order to develop implementation strategies for translation of evidence-based lifestyle interventions to senior centers, where many minority elders spend their time, making the centers a salient point of dissemination.
PMCID: PMC3805359  PMID: 23462343
Hypertension; Minority Elders; Senior Centers; Therapeutic Lifestyle Changes
14.  Adiponectin and All-Cause Mortality in Elderly People With Type 2 Diabetes 
Diabetes Care  2012;35(9):1858-1863.
To assess the association between serum adiponectin level and all-cause mortality in people with type 2 diabetes. Because of the insulin-sensitizing, anti-inflammatory, and antiatherogenic effects of adiponectin, we hypothesized that higher adiponectin level would be associated with lower all-cause mortality.
A total of 609 men and women aged 72 ± 6.3 years with type 2 diabetes and information on total and high molecular weight adiponectin were followed for a median of 5 years. The longitudinal association between adiponectin and all-cause mortality was analyzed with Cox proportional hazards models with time from adiponectin measurement to death as the time-to-event variable. Analyses were adjusted for demographic variables and significant diabetes parameters, significant cardiovascular parameters, and significant diabetes medications.
Total and high molecular weight adiponectin were highly correlated. The highest adiponectin quartile was strongly associated with higher all-cause mortality compared with the lowest quartile (hazard ratio = 4.0 [95% CI: 1.7–9.2]) in the fully adjusted model. These results did not change in analyses stratified by sex and thiazolidinedione use, after exclusion of people who died within one year of adiponectin measurement, or when change in weight before adiponectin measurement was considered.
Contrary to our hypothesis, higher adiponectin level was related to higher all-cause mortality. This association was not explained by confounding by other characteristics, including medications or preceding weight loss.
PMCID: PMC3424994  PMID: 22773703
15.  Effects of Electronic Health Information Technology Implementation on Nursing Home Resident Outcomes 
Journal of aging and health  2011;24(1):92-112.
To examine the effects of electronic health information technology (HIT) on nursing home residents.
The study evaluated the impact of implementing a comprehensive HIT system on resident clinical, functional, and quality of care outcome indicators, as well as measures of resident awareness of and satisfaction with the technology. The study used a prospective, quasi-experimental design, directly assessing 761 nursing home residents in 10 urban and suburban nursing homes in the greater New York City area.
No statistically significant impact of the introduction of HIT on residents was found on any outcomes, with the exception of a significant negative effect on behavioral symptoms. Residents' subjective assessment of the HIT intervention were generally positive.
The absence of effects on most indicators is encouraging for the future development of HIT in nursing homes. The single negative finding suggests that further investigation is needed on possible impact on resident behavior.
PMCID: PMC3677697  PMID: 21646551
Long-Term Care; Technology; Quality of Care
16.  A staff intervention targeting resident-to-resident elder mistreatment (R-REM) in long-term care increased staff knowledge, recognition and reporting: Results from a cluster randomized trial 
Elder abuse in long term care has received considerable attention; however, resident-to-resident elder mistreatment (R-REM) has not been well researched. Preliminary findings from studies of R-REM suggest that it is sufficiently widespread to merit concern, and is likely to have serious detrimental outcomes for residents. However, no evidence-based training, intervention and implementation strategies exist that address this issue.
The objective was to evaluate the impact of a newly developed R-REM training intervention for nursing staff on knowledge, recognition and reporting of R-REM.
The design was a prospective cluster randomized trial with randomization at the unit level.
A sample of 1405 residents (685 in the control and 720 in the intervention group) from 47 New York City nursing home units (23 experimental and 24 control) in 5 nursing homes was assessed. Data were collected at three waves: baseline, 6 and 12 months. Staff on the experimental units received the training and implementation protocols, while those on the comparison units did not. Evaluation of outcomes was conducted on an intent-to-treat basis using mixed (random and fixed effects) models for continuous knowledge variables and Poisson regressions for longitudinal count data measuring recognition and reporting.
There was a significant increase in knowledge post-training, controlling for pre-training levels for the intervention group (p<0.001), significantly increased recognition of R-REM (p<0.001), and longitudinal reporting in the intervention as contrasted with the control group (p=0.0058).
A longitudinal evaluation demonstrated that the training intervention was effective in enhancing knowledge, recognition and reporting of R-REM. It is recommended that this training program be implemented in long term care facilities.
PMCID: PMC3677710  PMID: 23159018
Resident-to-resident elder mistreatment (R-REM); nursing homes; long term care; older people; elder abuse; staff education; staff training
17.  A comparison of item response theory-based methods for examining differential item functioning in object naming test by language of assessment among older Latinos 
Object naming tests are commonly included in neuropsychological test batteries. Differential item functioning (DIF) in these tests due to cultural and language differences may compromise the validity of cognitive measures in diverse populations. We evaluated 26 object naming items for DIF due to Spanish and English language translations among Latinos (n=1,159), mean age of 70.5 years old (Standard Deviation (SD)±7.2), using the following four item response theory-based approaches: Mplus/Multiple Indicator, Multiple Causes (Mplus/MIMIC; Muthén & Muthén, 1998–2011), Item Response Theory Likelihood Ratio Differential Item Functioning (IRTLRDIF/MULTILOG; Thissen, 1991, 2001), difwithpar/Parscale (Crane, Gibbons, Jolley, & van Belle, 2006; Muraki & Bock, 2003), and Differential Functioning of Items and Tests/MULTILOG (DFIT/MULTILOG; Flowers, Oshima, & Raju, 1999; Thissen, 1991). Overall, there was moderate to near perfect agreement across methods. Fourteen items were found to exhibit DIF and 5 items observed consistently across all methods, which were more likely to be answered correctly by individuals tested in Spanish after controlling for overall ability.
PMCID: PMC3588164  PMID: 23471423
Item response theory; differential item functioning; object naming test; Hispanic/Latinos; Spanish
18.  Resident-to-Resident Aggression in Nursing Homes: Results from a Qualitative Event Reconstruction Study 
The Gerontologist  2011;52(1):24-33.
Despite its prevalence and negative consequences, research on elder abuse has rarely considered resident-to-resident aggression (RRA) in nursing homes. This study employed a qualitative event reconstruction methodology to identify the major forms of RRA that occur in nursing homes.
Design and methods:
Events of RRA were identified within a 2-week period in all units (n = 53) in nursing homes located in New York City. Narrative reconstructions were created for each event based on information from residents and staff who were involved as well as other sources. The event reconstructions were analyzed using qualitative methods to identify common features of RRA events.
Analysis of the 122 event reconstructions identified 13 major forms of RRA, grouped under five themes. The resulting framework demonstrated the heterogeneity of types of RRA, the importance of considering personal, environmental, and triggering factors, and the potential emotional and physical harm to residents.
These results suggest the need for person-centered and environmental interventions to reduce RRA, as well as for further research on the topic.
PMCID: PMC3265555  PMID: 22048811
Abuse/neglect; Behavior; Long-term care; Aggression
19.  Are Clinical Diagnoses of Alzheimer’s Disease and Other Dementias Affected by Education and Self-Reported Race? 
Psychological assessment  2012;24(3):531-544.
A randomized controlled trial examined whether the diagnostic process for Alzheimer’s disease and other dementias may be influenced by knowledge of the patient’s education and/or self-reported race. Four conditions were implemented: diagnostic team knows (a) race and education, (b) education only, (c) race only, or (d) neither. Diagnosis and clinical staging was established at baseline, at Wave 2, and for a random sample of Wave 3 respondents by a consensus panel. At study end, a longitudinal, “gold standard” diagnosis was made for patients with follow-up data (71%). Group differences in Diagnostic and Statistical Manual of Mental Disorders (4th ed.; American Psychiatric Association, 1994) diagnosis were estimated using logistic regression and generalized estimating equations. Sensitivity and specificity were examined for baseline diagnosis in relation to the gold standard, longitudinal diagnosis. Despite equivalent status on all measured variables across waves, members of the “knows race only” group were less likely than those of other groups to receive a diagnosis of dementia. At final diagnosis, 19% of the “knows race only” group was diagnosed with dementia versus 38% to 40% in the other 3 conditions (p = .038). Examination of sensitivities and specificities of baseline diagnosis in relation to the gold standard diagnosis showed a nonsignificant trend for lower sensitivities in the knowing race conditions (0.3846), as contrasted with knowing education only (0.480) or neither (0.600). The finding that knowledge of race may influence the diagnostic process in some unknown way is timely, given the recent State-of-the-Science conference on Alzheimer’s disease prevention, the authors of which called for information about and standardization of the diagnostic process.
PMCID: PMC3518032  PMID: 22309001
Alzheimer’s disease; clinical diagnosis; bias; self-reported race; education
20.  Advancing PROMIS’s methodology: results of the Third Patient-Reported Outcomes Measurement Information System (PROMIS®) Psychometric Summit 
In 2002, the NIH launched the ‘Roadmap for Medical Research’. The Patient-Reported Outcomes Measurement Information System (PROMIS®) is one of the Roadmap’s key aspects. To create the next generation of patient-reported outcome measures, PROMIS utilizes item response theory (IRT) and computerized adaptive testing. In 2009, the NIH funded the second wave of PROMIS studies (PROMIS II). PROMIS II studies continue PROMIS’s agenda, but also include new features, including longitudinal analyses and more sociodemographically diverse samples. PROMIS II also includes increased emphasis on pediatric populations and evaluation of PROMIS item banks for clinical research and population science. These aspects bring new psychometric challenges. To address this, investigators associated with PROMIS gathered at the Third Psychometric Summit in September 2010 to identify, describe and discuss pressing psychometric issues and new developments in the field, as well as make analytic recommendations for PROMIS. The summit addressed five general themes: linking, differential item functioning, dimensionality, IRT models for longitudinal applications and new IRT software. In this article, we review the discussions and presentations that occurred at the Third PROMIS Psychometric Summit.
PMCID: PMC3312372  PMID: 22098283
computerized adaptive testing; dimensionality; factor analysis; item response theory; patient-reported outcomes; PROMIS; psychometrics; structural equation modeling
21.  The Northern Manhattan Caregiver Intervention Project: a randomised trial testing the effectiveness of a dementia caregiver intervention in Hispanics in New York City 
BMJ Open  2012;2(5):e001941.
Dementia prevalence and its burden on families are increasing. Caregivers of persons with dementia have more depression and stress than the general population. Several interventions have proven efficacy in decreasing depression and stress in selected populations of caregivers. Hispanics in New York City tend to have a higher burden of dementia caregiving compared to non-Hispanic whites (NHW) because Hispanics have a higher prevalence of dementia, tend to have high family involvement, and tend to have higher psychosocial and economic stressors. Thus, we chose to test the effectiveness of a dementia caregiving intervention, the New York University Caregiver Intervention (NYUCI), with demonstrated efficacy in spouse caregivers in Hispanic relative caregivers of persons with dementia. Including the community health worker (CHW) intervention in both arms alleviates general psychosocial stressors and allows the assessment of the effectiveness of the intervention. Compared to two original efficacy studies of the NYUCI, which included only spouse caregivers, our study includes all relative caregivers, including common law spouses, children, siblings, a nephew and nieces. This study will be the first randomised trial to test the effectiveness of the NYUCI in Hispanic caregivers including non-spouses.
Methods and analysis
The design of the study is a randomised controlled trial (RCT). Participants are randomised to two arms: case management by a CHW and an intervention arm including the NYUCI in addition to case management by the CHW. The duration of intervention is 6 months. The main outcomes in the trial are changes in the Geriatric Depression Scale (GDS) and the Zarit Caregiver Burden Scale (ZCBS) from baseline to 6 months.
Ethics and dissemination
This trial is approved by the Columbia University Medical Center Institutional Review Board (AAAI0022), and funded by the National Institute on Minority Health and Health Disparities. The funding agency has no role in dissemination.
Trial Registration NCT01306695.
PMCID: PMC3467593  PMID: 22983877
Mental Health
22.  Multiple, correlated covariates associated with differential item functioning (DIF): Accounting for language DIF when education levels differ across languages 
Ageing research  2011;2(1):19-25.
Differential item functioning (DIF) occurs when a test item has different statistical properties in subgroups, controlling for the underlying ability measured by the test. DIF assessment is necessary when evaluating measurement bias in tests used across different language groups. However, other factors such as educational attainment can differ across language groups, and DIF due to these other factors may also exist. How to conduct DIF analyses in the presence of multiple, correlated factors remains largely unexplored. This study assessed DIF related to Spanish versus English language in a 44-item object naming test. Data come from a community-based sample of 1,755 Spanish- and English-speaking older adults. We compared simultaneous accounting, a new strategy for handling differences in educational attainment across language groups, with existing methods. Compared to other methods, simultaneously accounting for language- and education-related DIF yielded salient differences in some object naming scores, particularly for Spanish speakers with at least 9 years of education. Accounting for factors that vary across language groups can be important when assessing language DIF. The use of simultaneous accounting will be relevant to other cross-cultural studies in cognition and in other fields, including health-related quality of life.
PMCID: PMC3418868  PMID: 22900138
cognitive testing; item response theory; logistic regression; test bias; translation
23.  Improved diabetes control in the elderly delays global cognitive decline 
to examine whether improved diabetes control is related to better cognitive outcomes.
randomized control trial
a randomized trial of telemedicine vs. usual care in elderly persons with type 2 diabetes.
Participants were 2169 persons 55 years and older with type 2 diabetes from New York City and Upstate New York.
The diabetes case management intervention was implemented by a diabetes nurse, via a telemedicine unit in the participant’s home, and in coordination with the primary care physician.
Hemoglobin A1c (HbA1c), systolic blood pressure (SBP), and low density lipoprotein cholesterol (LDL), were measured at a baseline visit and at up to 5 annual follow-up visits. Global cognition was measured at those visits with the Comprehensive Assessment and Referral Evaluation (CARE).
In mixed models the intervention was related to slower global cognitive decline in the intervention group (p = 0.01). Improvements in HbA1c (p = 0.03), but not SBP or LDL, mediated the effect of the intervention on cognitive decline.
Improved diabetes control in the elderly following existing guidelines through a telemedicine intervention was associated with less global cognitive decline. The main mediator of this effect seemed to be improvements in HbA1c.
PMCID: PMC3328757  PMID: 21623465
Diabetes treatment; cognitive impairment; clinical trials
24.  Protocol for the Northern Manhattan Diabetes Community Outreach Project. A randomised trial of a community health worker intervention to improve diabetes care in Hispanic adults 
BMJ Open  2012;2(2):e001051.
Hispanics in the USA are affected by the diabetes epidemic disproportionately, and they consistently have lower access to care, poorer control of the disease and higher risk of complications. This study evaluates whether a community health worker (CHW) intervention may improve clinically relevant markers of diabetes care in adult underserved Hispanics.
Methods and analysis
The Northern Manhattan Diabetes Community Outreach Project (NOCHOP) is a two-armed randomised controlled trial to be performed as a community-based participatory research study performed in a Primary Care Setting in Northern Manhattan (New York City). 360 Hispanic adults with poorly controlled type 2 diabetes mellitus (haemoglobin A1c >8%), aged 35–70 years, will be randomised at a 1:1 ratio, within Primary Care Provider clusters. The two study arms are (1) a 12-month CHW intervention and (2) enhanced usual care (educational materials mailed at 4-month intervals, preceded by phone calls). The end points, assessed after 12 months, are primary = haemoglobin A1c and secondary = blood pressure and low-density lipoprotein-cholesterol levels. In addition, the study will describe the CHW intervention in terms of components and intensity and will assess its effects on (1) medication adherence, (2) medication intensification, (3) diet and (4) physical activity.
Ethics and dissemination
All participants will provide informed consent; the study protocol has been approved by the Institutional Review Board of Columbia University Medical Center. CHW interventions hold great promise in improving the well-being of minority populations who suffer from diabetes mellitus. The NOCHOP study will provide valuable information about the efficacy of those interventions vis-à-vis clinically relevant end points and will inform policy makers through a detailed characterisation of the programme and its effects.
Clinical trial registration number
NCT00787475 at
Article summary
Article focus
Randomised controlled trial.
CHW intervention.
Diabetes care.
Key messages
This community-based participatory research study is a collaboration between a community organisation and a university in Northern Manhattan, New York City.
The goal is to assess whether the CHW worker intervention may improve diabetes care in underserved adult Hispanics from the community.
The primary outcome of interest is haemoglobin A1c, a marker of diabetes control; secondary outcomes are blood pressure and low-density lipoprotein cholesterol levels.
Strengths and limitations of this study
This study will examine effects of the CHW intervention after 12 months, a longer time period than in previous studies.
The CHW intervention protocol was developed in a culturally appropriate manner to address the needs of Hispanics residing in our community.
If proven efficacious, it will warrant examination in other cultural socioeconomic milieus.
PMCID: PMC3330252  PMID: 22454189
25.  Glycemic Control and Health Disparities in Older Ethnically Diverse Underserved Adults With Diabetes 
Diabetes Care  2011;34(2):274-279.
The Informatics for Diabetes Education and Telemedicine (IDEATel) project randomized ethnically diverse underserved older adults with diabetes to a telemedicine intervention or usual care. Intervention participants had lower A1C levels over 5 years. New analyses were performed to help better understand this difference.
IDEATel randomized Medicare beneficiaries with diabetes (n = 1,665) to receive home video visits with a diabetes educator and upload glucose levels every 4–6 weeks or usual care (2000–2007). Annual measurements included BMI, A1C (primary outcome), and completion of questionnaires. Mixed-model analyses were performed using random effects to adjust for clustering within primary care physicians.
At baseline, A1C levels (mean ± SD) were 7.02 ± 1.25% in non-Hispanic whites (n = 821), 7.58 ± 1.78% in non-Hispanic blacks (n = 248), and 7.79 ± 1.68% in Hispanics (n = 585). Over time, lower A1C levels were associated with more glucose uploads (P = 0.02) and female sex (P = 0.002). Blacks, Hispanics, and insulin-users had higher A1C levels than non-Hispanic whites (P < 0.0001). BMI was not associated with A1C levels. Blacks and Hispanics had significantly fewer uploads than non-Hispanic whites over time. Hispanics had the highest baseline A1C levels and showed the greatest improvement in the intervention, but, unlike non-Hispanic whites, Hispanics did not achieve A1C levels <7.0% at 5 years.
Racial/ethnic disparities were observed in this cohort of underserved older adults with diabetes. The IDEATel telemedicine intervention was associated with improvement in glycemic control, particularly in Hispanics, who had the highest baseline A1C levels, suggesting that telemedicine has the potential to help reduce disparities in diabetes management.
PMCID: PMC3024333  PMID: 21270184

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