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1.  Cost-Effectiveness of Nurse-Led Disease Management for Heart Failure in an Ethnically Diverse Urban Community 
Annals of internal medicine  2008;149(8):540-548.
Background
Randomized, controlled trials have shown that nurse-led disease management for patients with heart failure can reduce hospitalizations. Less is known about the cost-effectiveness of these interventions.
Objective
To estimate the cost-effectiveness of a nurse-led disease management intervention over 12 months, implemented in a randomized, controlled effectiveness trial.
Design
Cost-effectiveness analysis conducted alongside a randomized trial.
Data Sources
Medical costs from administrative records, and self-reported quality of life and nonmedical costs from patient surveys.
Participants
Patients with systolic dysfunction recruited from ambulatory clinics in Harlem, New York.
Time Horizon
12 months.
Perspective
Societal and payer.
Intervention
12-month program that involved 1 face-to-face encounter with a nurse and regular telephone follow-up.
Outcome Measures
Quality of life as measured by the Health Utilities Index Mark 3 and EuroQol-5D and cost-effectiveness as measured by the incremental cost-effectiveness ratio (ICER).
Results of Base-Case Analysis
Costs and quality of life were higher in the nurse-managed group than the usual care group. The ICERs over 12 months were $17 543 per EuroQol-5D–based quality-adjusted life-year (QALY) and $15 169 per Health Utilities Index Mark 3–based QALY (in 2001 U.S. dollars).
Results of Sensitivity Analysis
From a payer perspective, the ICER ranged from $3673 to $4495 per QALY. Applying national prices in place of New York City prices yielded a societal ICER of $13 460 to $15 556 per QALY. Cost-effectiveness acceptability curves suggest that the intervention was most likely cost-effective for patients with less severe (New York Heart Association classes I to II) heart failure.
Limitation
The trial was conducted in an ethnically diverse, inner-city neighborhood; thus, results may not be generalizable to other communities.
Conclusion
Over 12 months, the nurse-led disease management program was a reasonably cost-effective way to reduce the burden of heart failure in this community.
PMCID: PMC4312002  PMID: 18936502
2.  The Success of Recruiting Minorities, Women, and Elderly into a Randomized Controlled Effectiveness Trial 
Background
Heart failure, a leading cause of hospitalization among elderly people, disproportionately afflicts African-American and other non-White populations. Studies of health care interventions often do not include these groups in proportion to numbers in the patient population. Our objective was to assess whether a randomized controlled effectiveness trial enrolled patients by ethnicity/race, gender, and age in proportion to those eligible.
Methods
We conducted a randomized controlled trial comparing nurse management and usual care among ambulatory heart failure patients at the four hospitals in East and Central Harlem, New York. We incorporated culturally sensitive and age-appropriate strategies to enroll a demographically representative group into the trial. Recruitment proceeded in several steps: identifying patients with billing code and visit criteria, documenting systolic dysfunction, obtaining clinician permission and correct addresses, contacting patients, and enrolling eligible patients. We assessed differences by ethnicity/race and gender at successive steps in the recruitment process, and differences between enrollees and refusals regarding overall health, evaluation of medical care, and difficulty receiving care.
Results
We enrolled 406 ambulatory patients by ethnicity/race and gender in proportion to the numbers eligible to be contacted (46% African-American/Black, 33% Hispanic, and 47% female). Among patients contacted, however, those 18 through 74 years were 2.0 to 3.3 times more likely than those ≥75 years to enroll (p < 0.001).
Conclusions
The recruitment strategy successfully enrolled patients by ethnicity/race, gender, and age through 74 years, but not those ≥75 years. Registries of patients who refuse to enroll in trials could provide guidance for clinical and public policy.
doi:10.1002/msj.20014
PMCID: PMC4309672  PMID: 18306248
randomized controlled trial; recruitment; effectiveness trial; congestive heart failure; nurse management
3.  Effects of Nurse Management on the Quality of Heart Failure Care in Minority Communities 
Annals of internal medicine  2006;145(4):273-283.
Background
Despite therapies proven effective for heart failure with systolic dysfunction, the condition continues to cause substantial hospitalization, disability, and death, especially among African-American and other nonwhite populations.
Objective
To compare the effects of a nurse-led intervention focused on specific management problems versus usual care among ethnically diverse patients with systolic dysfunction in ambulatory care practices.
Design
Randomized effectiveness trial conducted from September 2000 to September 2002.
Setting
The 4 hospitals in Harlem, New York.
Patients
406 adults (45.8% were non-Hispanic black adults, 32.5% were Hispanic adults, 46.3% were women, and 36.7% were ≥65 years of age) who met eligibility criteria: systolic dysfunction, English- or Spanish-language speakers, community-dwelling patients, and ambulatory care practice patients.
Intervention
During a 12-month intervention, bilingual nurses counseled patients on diet, medication adherence, and self-management of symptoms through an initial visit and regularly scheduled follow-up telephone calls and facilitated evidence-based changes to medications in discussions with patients’ clinicians.
Measurements
Hospitalizations (in 406 of 406 patients during follow-up) and self-reported functioning (in 286 of 406 patients during follow-up) at 12 months.
Results
At 12 months, nurse management patients had had fewer hospitalizations (143 hospitalizations vs. 180 hospitalizations; adjusted difference, −0.13 hospitalization/person-year [95% CI, −0.25 to −0.001 hospitalization/person-year]) than usual care patients. They also had better functioning: The Short Form-12 physical component score was 39.9 versus 36.3, respectively (difference, 3.6 [CI, 1.2 to 6.1]), and the Minnesota Living with Heart Failure Questionnaire score was 38.6 versus 47.3, respectively (difference, −8.8 [CI, −15.3 to −2.2]). Through 12 months, 22 deaths occurred in each group and percentages of patients who were hospitalized at least once were similar in each group (30.5% of nurse management patients vs. 36.5% of control patients; adjusted difference, −7.1 percentage points [CI, −16.9 to 2.6 percentage points]).
Limitations
Three nurses at 4 hospitals delivered interventions in this modest-sized trial, and 75% of the participants were from 1 site. It is not clear which aspects of the complex intervention accounted for the results.
Conclusions
Nurse management can improve functioning and modestly lower hospitalizations in ethnically diverse ambulatory care patients who have heart failure with systolic dysfunction. Sustaining improved functioning may require continuing nurse contact.
PMCID: PMC4307780  PMID: 16908918
4.  Intravenous access during pre-hospital emergency care of non-injured patients: a population-based outcome study 
Annals of Emergency Medicine  2011;59(4):296-303.
Study objective
Advanced, pre-hospital procedures such as intravenous access are commonly performed by emergency medical services (EMS) personnel, yet little evidence supports their use among non-injured patients. We evaluated the association between pre-hospital, intravenous access and mortality among non-injured, non-arrest patients.
Methods
We analyzed a population-based cohort of adult (aged ≥18 years) non-injured, non-arrest patients transported by four advanced life support agencies to one of 16 hospitals from January 1, 2002 until December 31, 2006. We linked eligible EMS records to hospital administrative data, and used multivariable logistic regression to determine the risk-adjusted association between pre-hospital, intravenous access and hospital mortality. We also tested whether this association differed by patient acuity using a previously published, out-of-hospital triage score.
Results
Among 56,332 eligible patients, one half (N=28,978, 50%) received pre-hospital intravenous access from EMS personnel. Overall hospital mortality in patients who did and did not receive intravenous access was 3%. However, in multivariable analyses, the placement of pre-hospital, intravenous access was associated with an overall reduction in odds of hospital mortality (OR=0.68, 95%CI: 0.56, 0.81). The beneficial association of intravenous access appeared to depend on patient acuity (p=0.13 for interaction). For example, the OR of mortality associated with intravenous access was 1.38 (95%CI: 0.28, 7.0) among those with lowest acuity (score = 0). In contrast, the OR of mortality associated with intravenous access was 0.38 (95%CI: 0.17, 0.9) among patients with highest acuity (score ≥ 6).
Conclusions
In this population-based cohort, pre-hospital, intravenous access was associated with a reduction in hospital mortality among non-injured, non-arrest patients with the highest acuity.
doi:10.1016/j.annemergmed.2011.07.021
PMCID: PMC3227749  PMID: 21872970
5.  Lower use of carotid artery imaging at minority-serving hospitals 
Neurology  2012;79(2):138-144.
Objective:
We determined whether site of care explains a previously identified racial disparity in carotid artery imaging.
Methods:
In this retrospective cohort study, data were obtained from a chart review of veterans hospitalized with ischemic stroke at 127 Veterans Administration hospitals in 2007. Extensive exclusion criteria were applied to obtain a sample who should have received carotid artery imaging. Minority-serving hospitals were defined as the top 10% of hospitals ranked by the proportion of stroke patients who were black. Population level multivariate logistic regression models with adjustment for correlation of patients in hospitals were used to calculate predictive probabilities of carotid artery imaging by race and minority-service hospital status. Bootstrapping was used to obtain 95% confidence intervals (CIs).
Results:
The sample consisted of 1,534 white patients and 628 black patients. Nearly 40% of all black patients were admitted to 1 of 13 minority-serving hospitals. No racial disparity in receipt of carotid artery imaging was detected within nonminority serving hospitals. However, the predicted probability of receiving carotid artery imaging for white patients at nonminority-serving hospitals (89.7%, 95% CI [87.3%, 92.1%]) was significantly higher than both white patients (78.0% [68.3%, 87.8%] and black patients (70.5% [59.3%, 81.6%]) at minority-serving hospitals.
Conclusions:
Underuse of carotid artery imaging occurred most often among patients hospitalized at minority-serving hospitals. Further work is required to explore why site of care is a mechanism for racial disparities in this clinically important diagnostic test.
doi:10.1212/WNL.0b013e31825f04c5
PMCID: PMC3390541  PMID: 22700815
6.  Nurse-led Disease Management for Hypertension Control in a Diverse Urban Community: a Randomized Trial 
ABSTRACT
BACKGROUND
Treated but uncontrolled hypertension is highly prevalent in African American and Hispanic communities.
OBJECTIVE
To test the effectiveness on blood pressure of home blood pressure monitors alone or in combination with follow-up by a nurse manager.
DESIGN
Randomized controlled effectiveness trial.
PATIENTS
Four hundred and sixteen African American or Hispanic patients with a history of uncontrolled hypertension. Patients with blood pressure ≥150/95, or ≥140/85 for patients with diabetes or renal disease, at enrollment were recruited from one community clinic and four hospital outpatient clinics in East and Central Harlem, New York City.
INTERVENTION
Patients were randomized to receive usual care or a home blood pressure monitor plus one in-person counseling session and 9 months of telephone follow-up with a registered nurse. During the trial, the home monitor alone arm was added.
MAIN MEASURES
Change in systolic and diastolic blood pressure at 9 and 18 months.
KEY RESULTS
Changes from baseline to 9 months in systolic blood pressure relative to usual care was −7.0 mm Hg (Confidence Interval [CI], -13.4 to −0.6) in the nurse management plus home blood pressure monitor arm, and +1.1 mm Hg (95% CI, -5.5 to 7.8) in the home blood pressure monitor only arm. No statistically significant differences in systolic blood pressure were observed among treatment arms at 18 months. No statistically significant improvements in diastolic blood pressure were found across treatment arms at 9 or 18 months. Changes in prescribing practices did not explain the decrease in blood pressure in the nurse management arm.
CONCLUSIONS
A nurse management intervention combining an in-person visit, periodic phone calls, and home blood pressure monitoring over 9 months was associated with a statistically significant reduction in systolic, but not diastolic, blood pressure compared to usual care in a high risk population. Home blood pressure monitoring alone was no more effective than usual care.
doi:10.1007/s11606-011-1924-1
PMCID: PMC3358388  PMID: 22143452
hypertension; randomized trial; minority; nurse management; home blood pressure monitor
7.  The Causes of Racial and Ethnic Differences in Influenza Vaccination Rates among Elderly Medicare Beneficiaries 
Health Services Research  2005;40(2):517-538.
Objective
To explore three potential causes of racial/ethnic differences in influenza vaccination rates in the elderly: (1) resistant attitudes and beliefs regarding vaccination by African-American and Hispanic Medicare beneficiaries, (2) poor access to care during influenza vaccination weeks, and (3) discriminatory behavior by providers.
Data Sources
Medicare beneficiaries who responded to both the 1995 and 1996 Medicare Current Beneficiary Survey (MCBS) (n=6,746).
Study Design
We combined survey information from the MCBS with Medicare claims. We measured resistance to vaccination by self-reported reasons for not receiving vaccination, access to care by claims submitted during vaccination weeks, and discrimination by racial differences in vaccinations among beneficiaries who visited the same providers during vaccination weeks.
Principal Findings
White beneficiaries (66.6 percent) were more likely to self-report having received vaccination than were African Americans (43.3 percent) or Hispanics (52.5 percent). Resistance to vaccination plays a role in low vaccination rates of African-American (−11.8 percentage points), but not Hispanic beneficiaries. Unequal access accounts for <2 percent of the disparity. Minority beneficiaries remained unvaccinated despite having medical encounters with their usual providers on days when those same providers were administering vaccinations to white beneficiaries. This disparity is attributable not to provider discrimination but to a 1.6−5 × higher likelihood of white beneficiaries initiating encounters for the purpose of receiving vaccination.
Conclusion
Disparities in access to care and provider discrimination play little role in explaining racial/ethnic disparities in influenza vaccination. Eliminating missed opportunities for vaccination in 1995 would have raised vaccination rates in three racial/ethnic groups to the Healthy People 2000 goal of 60 percent vaccination.
doi:10.1111/j.1475-6773.2005.00370.x
PMCID: PMC1361154  PMID: 15762905
Influenza; vaccination; racial disparities; preventable diseases; discrimination
9.  AN APPROACH TO VALIDATE CRITERIA FOR PROTEINURIC FLARE IN SYSTEMIC LUPUS ERYTHEMATOSUS GLOMERULONEPHRITIS 
Arthritis and rheumatism  2011;63(7):2031-2037.
Objective
The published criteria for the proteinuria increase that constitutes a proteinuric flare in lupus glomerulonephritis (SLE GN) vary widely, likely because they are largely based on expert opinion. Ideally, the threshold for proteinuric flare should be set sufficiently high so that spontaneous variation in proteinuria does not likely explain the increase, but not so high that the patient is needlessly exposed to prolonged heavy proteinuria before a flare is declared and therapy is increased. Here we describe an evidence-based approach to setting the threshold for proteinuric flare based on quantifying the spontaneous variation in urine protein/creatinine (P/C) ratio of SLE GN patients who are not experiencing SLE flare.
Methods
SLE GN patients (N = 71) followed in the Ohio SLE Study (OSS) were tested at pre-specified bimonthly intervals within windows of ± 1 week, median follow-up > 44 mo, visit compliance > 90%. To assess spontaneous P/C ratio variation under no-flare conditions, we excluded P/C ratios measured within ± 4 month of renal flare.
Results
For those with mean no-flare P/C ratios ≤ 0.5, the published flare thresholds are set well above the 99% confidence interval (CI) of the no-flare P/C ratios. The opposite is seen in those with patients whose mean no-flare P/C ratios ≥ 1.0.
Conclusions
Current thresholds for proteinuric flare appear to be set either too high or too low. A randomized trial would be needed to test whether re-setting the thresholds would result in faster remission, less therapy, and less chronic kidney disease.
doi:10.1002/art.30345
PMCID: PMC3117977  PMID: 21400484
10.  Hypertension Management in Minority Communities: A Clinician Survey 
BACKGROUND
Rates of blood pressure (BP) control are lower in minority populations compared to whites.
OBJECTIVE
As part of a project to decrease health-related disparities among ethnic groups, we sought to evaluate the knowledge, attitudes, and management practices of clinicians caring for hypertensive patients in a predominantly minority community.
DESIGN/PARTICIPANTS
We developed clinical vignettes of hypertensive patients that varied by comorbidity (type II diabetes mellitus, chronic renal insufficiency, coronary artery disease, or isolated systolic hypertension alone). We randomly assigned patient characteristics, e.g., gender, age, race/ethnicity, to each vignette. We surveyed clinicians in ambulatory clinics of the 4 hospitals in East/Central Harlem, NY.
MEASUREMENTS
The analysis used national guidelines to assess the appropriateness of clinicians’ stated target BP levels. We also assessed clinicians’ attitudes about the likelihood of each patient to achieve adequate BP control, adhere to medications, and return for follow-up.
RESULTS
Clinicians’ target BPs were within 2 mm Hg of the recommendations 9% of the time for renal disease patients, 86% for diabetes, 94% for isolated systolic hypertension, and 99% for coronary disease. BP targets did not vary by patient or clinician characteristics. Clinicians rated African-American patients 8.4% (p = .004) less likely and non-English speaking Hispanic patients 8.1% (p = .051) less likely than white patients to achieve/maintain BP control.
CONCLUSIONS
Clinicians demonstrated adequate knowledge of recommended BP targets, except for patients with renal disease. Clinicians did not vary management by patients’ sociodemographics but thought African-American, non-English-speaking Hispanic and unemployed patients were less likely to achieve BP control than their white counterparts.
doi:10.1007/s11606-007-0413-z
PMCID: PMC2173923  PMID: 18040744
hypertension; clinician; survey; quality of care; disparities

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