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1.  Collaborative Care Management Reduces Disparities in Dementia Care Quality for Caregivers with Less Education 
BACKGROUND
Lower educational attainment among informal caregivers’ may be associated with poorer outcomes for patients with dementia.
OBJECTIVE
To examine educational gradients in dementia care and whether the effect of a dementia collaborative care management intervention varied by the educational attainment of the informal caregiver.
DESIGN
Analysis of data from a cluster-randomized controlled trial.
SETTING
Eighteen clinics across 3 healthcare organizations in Southern California.
PARTICIPANTS
Dyads of Medicare recipients, ages 65 years and older with a diagnosis of dementia, and an eligible caregiver.
INTERVENTION
Collaborative care management for dementia.
MEASUREMENTS
1) Caregiver educational attainment, 2) adherence to four dimensions of guideline-recommended processes of dementia care: Assessment, Treatment, Education/Support, and Safety pre- and post-intervention, and 3) the adjusted intervention effect (IE) for each dimension stratified by caregiver education. Each IE was estimated by subtracting the difference between pre- and post-intervention scores for the usual care participants from the difference in the intervention participants.
RESULTS
At baseline, caregivers with lower educational attainment had lower guideline-recommended processes of dementia care for the Treatment and Education dimensions than those with more education. However, less educated caregivers had significantly more improvement after the intervention on the Assessment, Treatment, and Safety dimensions. The IEs for those who had not graduated from high school compared to college graduates were 44.4 vs. 29.5 for the Assessment dimension (P<0.001), 36.9 vs. 15.7 for the Treatment dimension (P<0.001), and 52.7 vs. 40.9 for the Safety Dimension (P<0.001).
CONCLUSIONS
Collaborative care management was associated with reductions in disparities in dementia care quality among caregivers with lower educational attainment relative to more educated caregivers.
doi:10.1111/jgs.12079
PMCID: PMC3772791  PMID: 23320655
Dementia; Caregivers; Care Management
2.  Neighborhood Disadvantage and Ischemic Stroke: The Cardiovascular Health Study (CHS) 
Background and Purpose
Neighborhood characteristics may influence the risk of stroke and contribute to socioeconomic disparities in stroke incidence. The objectives of this study were to examine the relationship between neighborhood socioeconomic status (NSES) and incident ischemic stroke and examine potential mediators of these associations.
Methods
We analyzed data from 3834 whites and 785 African Americans enrolled in the Cardiovascular Health Study, a multicenter, population-based, longitudinal study of adults ages ≥65 years from four U.S. counties. The primary outcome was adjudicated incident ischemic stroke. NSES was measured using a composite of six census tract variables. Race-stratified multilevel Cox proportional hazard models were constructed, adjusted for sociodemographic, behavioral, and biologic risk factors.
Results
Among whites, in models adjusted for sociodemographic characteristics, stroke hazard was significantly higher among residents of neighborhoods in the lowest compared to the highest NSES quartile (Hazard Ratio [HR] =1.32; 95% CI 1.01-1.72), with greater attenuation of the HR after adjustment for biologic risk factors (HR=1.16; 0.88-1.52) than for behavioral risk factors (HR=1.30; 0.99-1.70). Among African Americans, we found no significant associations between NSES and ischemic stroke.
Conclusions
Higher risk of incident ischemic stroke was observed in the most disadvantaged neighborhoods among whites, but not among African Americans. The relationship between NSES and stroke among whites appears to be mediated more strongly by biologic than behavioral risk factors.
doi:10.1161/STROKEAHA.111.622134
PMCID: PMC3781011  PMID: 21940966
3.  Recruiting and Retaining Primary Care Physicians in Urban Underserved Communities: The Importance of Having a Mission to Serve 
American journal of public health  2010;100(11):2168-2175.
Objectives
We examined factors influencing physician practice decisions that may increase primary care supply in underserved areas.
Methods
We conducted in-depth interviews with 42 primary care physicians from Los Angeles County, California, stratified by race/ethnicity (African American, Latino, and non-Latino White) and practice location (underserved vs nonunderserved area). We reviewed transcriptions and coded them into themes by using standard qualitative methods.
Results
Three major themes emerged in relation to selecting geographic- and population-based practice decisions: (1) personal motivators, (2) career motivators, and (3) clinic support. We found that subthemes describing personal motivators (e.g., personal mission and self-identity) for choosing a practice were more common in responses among physicians who worked in underserved areas than among those who did not. By contrast, physicians in nonunderserved areas were more likely to cite work hours and lifestyle as reasons for selecting their current practice location or for leaving an underserved area.
Conclusions
Medical schools and shortage-area clinical practices may enhance strategies for recruiting primary care physicians to underserved areas by identifying key personal motivators and may promote long-term retention through work–life balance.
doi:10.2105/AJPH.2009.181669
PMCID: PMC2951944  PMID: 20935263
4.  Are Physician Reimbursement Strategies Associated with Processes of Care and Patient Satisfaction for Patients with Diabetes in Managed Care? 
Health Services Research  2006;41(4 Pt 1):1221-1241.
Objective
To examine associations between physician reimbursement incentives and diabetes care processes and explore potential confounding with physician organizational model.
Data Sources
Primary data collected during 2000–2001 in 10 managed care plans.
Study Design
Multilevel logistic regressions were used to estimate associations between reimbursement incentives and process measures, including the receipt of dilated eye exams, foot exams, influenza immunizations, advice to take aspirin, and assessments of glycemic control, proteinuria, and lipid profile. Reimbursement measures included the proportions of compensation received from salary, capitation, fee-for-service (FFS), and performance-based payment; the performance-based payment criteria used; and interactions of these criteria with the strength of the performance-based payment incentive.
Data Collection
Patient, provider group, and health plan surveys and medical record reviews were conducted for 6,194 patients with diabetes.
Principal Findings
Without controlling for physician organizational model, care processes were better when physician compensation was based primarily on direct salary rather than FFS reimbursement (four of seven processes were better, with relative risks ranging from 1.13 to 1.23) or capitation (six were better, with relative risks from 1.06 to 1.36); and when quality/satisfaction scores influenced physician compensation (three were better, with relative risks from 1.17 to 1.26). However, these associations were substantially confounded by organizational model.
Conclusions
Physician reimbursement strategies are associated with diabetes care processes, although their independent contributions are difficult to assess, due to high correlation with physician organizational model. Regardless of causality, a group's use of quality/satisfaction scores to determine physician compensation may indicate delivery of high-quality diabetes care.
doi:10.1111/j.1475-6773.2006.00533.x
PMCID: PMC1797087  PMID: 16899004
Provider financial incentives; reimbursement; quality of care; diabetes
5.  Exploring psychosocial pathways between neighbourhood characteristics and stroke in older adults: the cardiovascular health study 
Age and Ageing  2012;42(3):391-397.
Objectives: to investigate whether psychosocial pathways mediate the association between neighbourhood socioeconomic disadvantage and stroke.
Methods: prospective cohort study with a follow-up of 11.5 years.
Setting: the Cardiovascular Health Study, a longitudinal population-based cohort study of older adults ≥65 years.
Measurements: the primary outcome was adjudicated incident ischaemic stroke. Neighbourhood socioeconomic status (NSES) was measured using a composite of six census-tract variables. Psychosocial factors were assessed with standard measures for depression, social support and social networks.
Results: of the 3,834 white participants with no prior stroke, 548 had an incident ischaemic stroke over the 11.5-year follow-up. Among whites, the incident stroke hazard ratio (HR) associated with living in the lowest relative to highest NSES quartile was 1.32 (95% CI = 1.01–1.73), in models adjusted for individual SES. Additional adjustment for psychosocial factors had a minimal effect on hazard of incident stroke (HR = 1.31, CI = 1.00–1.71). Associations between NSES and stroke incidence were not found among African-Americans (n = 785) in either partially or fully adjusted models.
Conclusions: psychosocial factors played a minimal role in mediating the effect of NSES on stroke incidence among white older adults.
doi:10.1093/ageing/afs179
PMCID: PMC3633364  PMID: 23264005
neighbourhood; psychosocial factors; stroke; older adults
6.  Residential Relocation by Older Adults in Response to Incident Cardiovascular Health Events: A Case-Crossover Analysis 
Objective. We use a case-crossover analysis to explore the association between incident cardiovascular events and residential relocation to a new home address. Methods. We conducted an ambidirectional case-crossover analysis to explore the association between incident cardiovascular events and residential relocation to a new address using data from the Cardiovascular Health Study (CHS), a community-based prospective cohort study of 5,888 older adults from four U.S. sites beginning in 1989. Relocation was assessed twice a year during follow-up. Event occurrences were classified as present or absent for the period preceding the first reported move, as compared with an equal length of time immediately prior to and following this period. Results. Older adults (65+) that experience incident cardiovascular disease had an increased probability of reporting a change of residence during the following year (OR 1.6, 95% confidence interval (CI) = 1.2–2.1). Clinical conditions associated with relocation included stroke (OR: 2.0, 95% CI: 1.2–3.3), angina (OR: 1.6, 95% CI: 1.0–2.6), and congestive heart failure (OR: 1.5, 95% CI: 1.0–2.1). Conclusions. Major incident cardiovascular disease may increase the probability of residential relocation in older adults. Case-crossover analyses represent an opportunity to investigate triggering events, but finer temporal resolution would be crucial for future research on residential relocations.
doi:10.1155/2014/951971
PMCID: PMC3981061  PMID: 24782900
7.  Neighborhood socioeconomic disadvantage and mortality after stroke 
Neurology  2013;80(6):520-527.
Objective:
Residence in a socioeconomically disadvantaged community is associated with mortality, but the mechanisms are not well understood. We examined whether socioeconomic features of the residential neighborhood contribute to poststroke mortality and whether neighborhood influences are mediated by traditional behavioral and biologic risk factors.
Methods:
We used data from the Cardiovascular Health Study, a multicenter, population-based, longitudinal study of adults ≥65 years. Residential neighborhood disadvantage was measured using neighborhood socioeconomic status (NSES), a composite of 6 census tract variables representing income, education, employment, and wealth. Multilevel Cox proportional hazard models were constructed to determine the association of NSES to mortality after an incident stroke, adjusted for sociodemographic characteristics, stroke type, and behavioral and biologic risk factors.
Results:
Among the 3,834 participants with no prior stroke at baseline, 806 had a stroke over a mean 11.5 years of follow-up, with 168 (20%) deaths 30 days after stroke and 276 (34%) deaths at 1 year. In models adjusted for demographic characteristics, stroke type, and behavioral and biologic risk factors, mortality hazard 1 year after stroke was significantly higher among residents of neighborhoods with the lowest NSES than those in the highest NSES neighborhoods (hazard ratio 1.77, 95% confidence interval 1.17–2.68).
Conclusion:
Living in a socioeconomically disadvantaged neighborhood is associated with higher mortality hazard at 1 year following an incident stroke. Further work is needed to understand the structural and social characteristics of neighborhoods that may contribute to mortality in the year after a stroke and the pathways through which these characteristics operate.
doi:10.1212/WNL.0b013e31828154ae
PMCID: PMC3589286  PMID: 23284071
8.  A Study of National Physician Organizations’ Efforts to Reduce Racial and Ethnic Health Disparities in the United States 
Purpose
To characterize national physician organizations’ efforts to reduce health disparities and identify organizational characteristics associated with such efforts.
Method
This cross-sectional study was conducted between September 2009 and June 2010. The authors used two-sample t tests and chi-square tests to compare the proportion of organizations with disparity-reducing activities between different organizational types (e.g., primary care versus subspecialty organizations, small [<1,000 members] versus large [>5,000 members]). Inclusion criteria required physician organizations to be (1) focused on physicians, (2) national in scope, and (3) membership based.
Results
The number of activities per organization ranged from 0 to 22. Approximately half (53%) of organizations had 0 or 1 disparity-reducing activities. Organiza-tional characteristics associated with having at least 1 disparity-reducing effort included membership size (88% of large groups versus 58% of small groups had at least 1 activity; P = .004) and the presence of a health disparities committee (95% versus 59%; P < .001). Primary care (versus subspecialty) organizations and racial/ethnic minority physician organizations were more likely to have disparity-reducing efforts, although findings were not statistically significant. Common themes addressed by activities were health care access, health care disparities, workforce diversity, and language barriers. Common strategies included education of physicians/trainees and patients/general public, position statements, and advocacy.
Conclusions
Despite the national priority to eliminate health disparities, more than half of national physician organizations are doing little to address this problem. Primary care and minority physician organizations, and those with disparities committees, may provide leadership to extend the scope of disparity-reduction efforts.
doi:10.1097/ACM.0b013e318253b074
PMCID: PMC3785372  PMID: 22534593
9.  Through Our Eyes: Exploring African-American Men’s Perspective on Factors Affecting Transition to Manhood 
BACKGROUND
Premature mortality and disparities in morbidity observed in African-American men may be associated with factors in their social, economic, and built environments that may be especially influential during the transition to adulthood.
OBJECTIVE
To have young, African-American men from Los Angeles County identify and prioritize factors associated with their transition to manhood using photovoice methodology and pile-sorting exercises.
DESIGN
Qualitative study using community-based participatory research (CBPR) and photovoice
PARTICIPANTS
Twelve African-American men, ages 16–26 years, from Los Angeles County, California.
APPROACH
We used CBPR principles to form a community advisory board (CAB) whose members defined goals for the partnered project, developed the protocols, and participated in data collection and analysis. Participants were given digital cameras to take 50–300 photographs over three months. Pile-sorting techniques were used to facilitate participants’ identification and discussion of the themes in their photos and selected photos of the group. Pile-sorts of group photographs were analyzed using multidimensional scaling and hierarchical cluster analysis to systematically compare participants’ themes and identify patterns of associations between sorted photographs. Sub-themes and related quotes were also elicited from the pile-sorting transcripts. The CAB and several study participants met periodically to develop dissemination strategies and design interventions informed by study findings.
KEY RESULTS
Four dominant themes emerged during analysis: 1) Struggles face during the transition to manhood, 2) Sources of social support, 3) Role of sports, and 4) Views on Los Angeles lifestyle. The project led to the formation of a young men’s group and community events featuring participants.
CONCLUSIONS
CBPR and photovoice are effective methods to engage young, African-American men to identify and discuss factors affecting their transition to manhood, contextualize research findings, and participate in intervention development.
doi:10.1007/s11606-011-1836-0
PMCID: PMC3270242  PMID: 21910088
race/ethnicity; men’s health; socioeconomic factors; qualitative research
10.  Evaluation of risk equations for prediction of short-term coronary heart disease events in patients with long-standing type 2 diabetes: the Translating Research into Action for Diabetes (TRIAD) study 
Background
To evaluate the U.K. Prospective Diabetes Study (UKPDS) and Framingham risk equations for predicting short-term risk of coronary heart disease (CHD) events among adults with long-standing type 2 diabetes, including those with and without preexisting CHD.
Methods
Prospective cohort of U.S. managed care enrollees aged ≥ 18 years and mean diabetes duration of more than 10 years, participating in the Translating Research into Action for Diabetes (TRIAD) study, was followed for the first occurrence of CHD events from 2000 to 2003. The UKPDS and Framingham risk equations were evaluated for discriminating power and calibration.
Results
A total of 8303 TRIAD participants, were identified to evaluate the UKPDS (n = 5914, 120 events), Framingham-initial (n = 5914, 218 events) and Framingham-secondary (n = 2389, 374 events) risk equations, according to their prior CHD history. All of these equations exhibited low discriminating power with Harrell’s c-index <0.65. All except the Framingham-initial equation for women and the Framingham-secondary equation for men had low levels of calibration. After adjsusting for the average values of predictors and event rates in the TRIAD population, the calibration of these equations greatly improved.
Conclusions
The UKPDS and Framingham risk equations may be inappropriate for predicting the short-term risk of CHD events in patients with long-standing type 2 diabetes, partly due to changes in medications used by patients with diabetes and other improvements in clinical care since the Frmaingham and UKPDS studies were conducted. Refinement of these equations to reflect contemporary CHD profiles, diagnostics and therapies are needed to provide reliable risk estimates to inform effective treatment.
doi:10.1186/1472-6823-12-12
PMCID: PMC3433369  PMID: 22776317
11.  Competing Demands for Time and Self-Care Behaviors, Processes of Care, and Intermediate Outcomes Among People With Diabetes 
Diabetes Care  2011;34(5):1180-1182.
OBJECTIVE
To determine whether competing demands for time affect diabetes self-care behaviors, processes of care, and intermediate outcomes.
RESEARCH DESIGN AND METHODS
We used survey and medical record data from 5,478 participants in Translating Research Into Action for Diabetes (TRIAD) and hierarchical regression models to examine the cross-sectional associations between competing demands for time and diabetes outcomes, including self-management, processes of care, and intermediate health outcomes.
RESULTS
Fifty-two percent of participants reported no competing demands, 7% reported caregiving responsibilities only, 36% reported employment responsibilities only, and 6% reported both caregiving and employment responsibilities. For both women and men, employment responsibilities (with or without caregiving responsibilities) were associated with lower rates of diabetes self-care behaviors, worse processes of care, and, in men, worse HbA1c.
CONCLUSIONS
Accommodations for competing demands for time may promote self-management and improve the processes and outcomes of care for employed adults with diabetes.
doi:10.2337/dc10-2038
PMCID: PMC3114509  PMID: 21464464
12.  Association of Perceived Neighborhood Safety on Body Mass Index 
American journal of public health  2010;100(11):2296-2303.
Objectives
We sought to determine whether there is an association between perceived neighborhood safety and body mass index (BMI), accounting for endogeneity.
Methods
A random sample of 2255 adults from the Los Angeles Family and Neighborhood Survey 2000–2001 was analyzed using instrumental variables. The main outcome was BMI using self-reported height and weight, and the main independent variable was residents’ report of their neighborhood safety.
Results
In adjusted analyses, individuals who perceived their neighborhoods as unsafe had a BMI that was 2.81 kg/m2 (95% confidence interval [CI]=0.11, 5.52) higher than did those who perceived their neighborhoods as safe.
Conclusions
Our results suggest that clinical and public health interventions aimed at reducing rates of obesity may be enhanced by strategies to modify the physical and social environment that incorporate residents’ perceptions of their communities.
doi:10.2105/AJPH.2009.183293
PMCID: PMC2951920  PMID: 20864717
13.  The Vulnerability of Older Middle Age and Elderly Adults in a Multi-Ethnic, Low Income Area: Contributions of Age, Ethnicity, and Health Insurance 
This community partnered study was developed and fielded in partnerships with key community stakeholders, describes age and race-related variation in delays in care and preventive service utilization among middle-aged and older adults living in South Los Angeles. The survey sample included adults ages 50 years and older who self-identified as African-American or Latino and lived in zip-codes of South Los Angeles (N=708). Dependent variables were self-reported delays in care and use of preventive services. Insured participants ages 50–64 years were more likely to report any delay in care (adjusted predicted percent (APP) 18%, 95% CI 14, 23) and problems getting needed medical care (APP 15%, 95% CI 12, 20) than those ages 65 years or older. Uninsured participants ages 50–64 years reported even greater delays in care (APP 45%, 95% CI 33, 56) and problems getting needed medical (APP 33%,95% CI 22, 45) and specialty care (APP 26%, 95% CI 16, 39) than those age 65 and over. Compared to older participants, those age 50–64 years were generally less likely to receive preventive services, including influenza or pneumococcal vaccines and colonoscopy, but women were more likely to receive mammograms. Persons ages 50–64 years had more problems obtaining recommended preventive care and faced more delays in care than persons age 65 years and older, particularly if uninsured. Providing insurance coverage for this group may improve access to preventive care and promote wellness.
doi:10.1111/j.1532-5415.2010.03189.x
PMCID: PMC3058402  PMID: 21143445
preventive services; delays; community based participatory research; insurance
14.  Neighborhood Socioeconomic Status, Depression, and Health Status in the Look AHEAD (Action for Health in Diabetes) Study 
BMC Public Health  2011;11:349.
Background
Depression and diminished health status are common in adults with diabetes, but few studies have investigated associations with socio-economic environment. The objective of this manuscript was to evaluate the relationship between neighborhood-level SES and health status and depression.
Methods
Individual-level data on 1010 participants at baseline in Look AHEAD (Action for Health in Diabetes), a trial of long-term weight loss among adults with type 2 diabetes, were linked to neighborhood-level SES (% living below poverty) from the 2000 US Census (tracts). Dependent variables included depression (Beck Inventory), and health status (Medical Outcomes Study (SF-36) scale). Multi-level regression models were used to account simultaneously for individual-level age, sex, race, education, personal yearly income and neighborhood-level SES.
Results
Overall, the % living in poverty in the participants' neighborhoods varied, mean = 11% (range 0-67%). Compared to their counterparts in the lowest tertile of neighborhood poverty (least poverty), those in the highest tertile (most poverty) had significantly lower scores on the role-limitations(physical), role limitations(emotional), physical functioning, social functioning, mental health, and vitality sub-scales of the SF-36 scale. When evaluating SF-36 composite scores, those living in neighborhoods with more poverty had significantly lower scores on the physical health (β-coefficient [β] = -1.90 units, 95% CI: -3.40,-0.039), mental health (β = -2.92 units, -4.31,-1.53) and global health (β = -2.77 units, -4.21,-1.33) composite scores.
Conclusion
In this selected group of weight loss trial participants, lower neighborhood SES was significantly associated with poorer health status. Whether these associations might influence response to the Look AHEAD weight loss intervention requires further investigation.
doi:10.1186/1471-2458-11-349
PMCID: PMC3111582  PMID: 22182286
15.  Medical Students’ Perceptions of Their Teachers’ and Their Own Cultural Competency: Implications for Education 
Journal of General Internal Medicine  2010;25(Suppl 2):91-94.
BACKGROUND
Enhancing the cultural competency of students is emerging as a key issue in medical education; however, students may perceive that they are more able to function within cross-cultural situations than their teachers, reducing the effectiveness of cultural competency educational efforts.
OBJECTIVE
The purpose of our study was to compare medical students’ perceptions of their residents, attendings, and their own cultural competency.
DESIGN
Cross-sectional study.
MAIN MEASURES
A questionnaire containing previously validated instruments was administered to end-of-third-year medical students at four institutions throughout the US. Repeated measures multivariate analysis was used to determine differences in student ratings.
PARTICIPANTS
Three hundred fifty-eight medical students from four schools participated, for an overall response rate of 65%.
RESULTS
Analysis indicated overall statistically significant differences in students’ ratings (p < 0.001, η2 = 0.33). Students rated their own cultural competency as statistically significantly higher than their residents, but similar to their attendings. For reference, students rated the patient care competency of themselves, their residents, and their attendings; they rated their attendings’ skills as statistically significantly higher than residents, and residents as statistically significantly higher than themselves. There were differences between cultural competency and patient care ratings.
CONCLUSIONS
Our results indicate that students perceive the cultural competency of their attendings and residents to be the same or lower than themselves. These findings indicate that this is an important area for future research and curricular reform, considering the vital role that attendings and residents play in the education of medical students.
doi:10.1007/s11606-009-1245-9
PMCID: PMC2847104  PMID: 20352500
cultural competency; medical education; medical education-undergraduate
16.  A Strategy for Improving Health Disparities Education in Medicine 
Journal of General Internal Medicine  2010;25(Suppl 2):160-163.
Introduction
A health disparities curriculum that uses evidence-based knowledge rooted in pedagogic theory is needed to educate health care providers to meet the needs of an increasingly diverse U.S. population.
Description
The Health Disparities Education: Beyond Cultural Competency Precourse, along with its accompanying Train the Trainer Guide: Health Disparities Education (2008), developed by the Society of General Internal Medicine (SGIM) Disparities Task Force (DTF), is a comprehensive tool to facilitate developing, implementing and evaluating health disparities education. The curriculum includes five modules highlighting several fundamental concepts in health disparities, suggestions for teaching about health disparities in a wide range of settings and strategies for curriculum evaluation. The modules are Disparities Foundations, Teaching Disparities in the Clinical Setting, Disparities Beyond the Clinical Setting, Teaching about Disparities Through Community Involvement, and Curriculum Evaluation.
Evaluation
All five modules were delivered as a precourse at the 31st Annual SGIM Annual Meeting in Pittsburgh, PA and received the “Best Precourse Award”. This award is given to the most highly rated precourse based on participant evaluations. The modules have also been adapted into a web-based guide that has been downloaded at least 59 times.
Conclusion
Ultimately, the modules are designed to develop a professional commitment to eliminating racial and ethnic disparities in health care quality, promote an understanding of the role of health care providers in reducing health care disparities through comprehensive education and training, and provide a framework with which providers can address the causes of disparities in various educational settings.
doi:10.1007/s11606-010-1283-3
PMCID: PMC2847114  PMID: 20352512
health disparities; medical education; faculty development
17.  Primary Language, Income and the Intensification of Anti-glycemic Medications in Managed Care: the (TRIAD) Study 
ABSTRACT
BACKGROUND
Patients who speak Spanish and/or have low socioeconomic status are at greater risk of suboptimal glycemic control. Inadequate intensification of anti-glycemic medications may partially explain this disparity.
OBJECTIVE
To examine the associations between primary language, income, and medication intensification.
DESIGN
Cohort study with 18-month follow-up.
PARTICIPANTS
One thousand nine hundred and thirty-nine patients with Type 2 diabetes who were not using insulin enrolled in the Translating Research into Action for Diabetes Study (TRIAD), a study of diabetes care in managed care.
MEASUREMENTS
Using administrative pharmacy data, we compared the odds of medication intensification for patients with baseline A1c ≥ 8%, by primary language and annual income. Covariates included age, sex, race/ethnicity, education, Charlson score, diabetes duration, baseline A1c, type of diabetes treatment, and health plan.
RESULTS
Overall, 42.4% of patients were taking intensified regimens at the time of follow-up. We found no difference in the odds of intensification for English speakers versus Spanish speakers. However, compared to patients with incomes <$15,000, patients with incomes of $15,000-$39,999 (OR 1.43, 1.07-1.92), $40,000-$74,999 (OR 1.62, 1.16-2.26) or >$75,000 (OR 2.22, 1.53-3.24) had increased odds of intensification. This latter pattern did not differ statistically by race.
CONCLUSIONS
Low-income patients were less likely to receive medication intensification compared to higher-income patients, but primary language (Spanish vs. English) was not associated with differences in intensification in a managed care setting. Future studies are needed to explain the reduced rate of intensification among low income patients in managed care.
Electronic supplementary material
The online version of this article (doi:10.1007/s11606-010-1588-2) contains supplementary material, which is available to authorized users.
doi:10.1007/s11606-010-1588-2
PMCID: PMC3077478  PMID: 21174165
18.  Patient-provider communication regarding drug costsin Medicare Part D beneficiaries with diabetes: a TRIAD Study 
Background
Little is known about drug cost communications of Medicare Part D beneficiaries with chronic conditions such as diabetes. The purpose of this study is to assess Medicare Part D beneficiaries with diabetes' levels of communication with physicians regarding prescription drug costs; the perceived importance of these communications; levels of prescription drug switching due to cost; and self-reported cost-related medication non-adherence.
Methods
Data were obtained from a cross-sectional survey (58% response rate) of 1,458 Medicare beneficiaries with diabetes who entered the coverage gap in 2006; adjusted percentages of patients with communication issues were obtained from multivariate regression analyses adjusting for patient demographics and clinical characteristics.
Results
Fewer than half of patients reported discussing the cost of medications with their physicians, while over 75% reported that such communications were important. Forty-eight percent reported their physician had switched to a less expensive medication due to costs. Minorities, females, and older adults had significantly lower levels of communication with their physicians regarding drug costs than white, male, and younger patients respectively. Patients with < $25 K annual household income were more likely than higher income patients to have talked about prescription drug costs with doctors, and to report cost-related non-adherence (27% vs. 17%, p < .001).
Conclusions
Medicare Part D beneficiaries with diabetes who entered the coverage gap have low levels of communication with physicians about drug costs, despite the high perceived importance of such communication. Understanding patient and plan-level characteristics differences in communication and use of cost-cutting strategies can inform interventions to help patients manage prescription drug costs.
doi:10.1186/1472-6963-10-164
PMCID: PMC2893177  PMID: 20546616
19.  Neighborhood and weight-related health behaviors in the Look AHEAD (Action for Health in Diabetes) Study 
BMC Public Health  2010;10:312.
Background
Previous studies have shown that neighborhood factors are associated with obesity, but few studies have evaluated the association with weight control behaviors. This study aims to conduct a multi-level analysis to examine the relationship between neighborhood SES and weight-related health behaviors.
Methods
In this ancillary study to Look AHEAD (Action for Health in Diabetes) a trial of long-term weight loss among individuals with type 2 diabetes, individual-level data on 1219 participants from 4 clinic sites at baseline were linked to neighborhood-level data at the tract level from the 2000 US Census and other databases. Neighborhood variables included SES (% living below the federal poverty level) and the availability of food stores, convenience stores, and restaurants. Dependent variables included BMI, eating patterns, weight control behaviors and resource use related to food and physical activity. Multi-level models were used to account for individual-level SES and potential confounders.
Results
The availability of restaurants was related to several eating and weight control behaviors. Compared to their counterparts in neighborhoods with fewer restaurants, participants in neighborhoods with more restaurants were more likely to eat breakfast (prevalence Ratio [PR] 1.29 95% CI: 1.01-1.62) and lunch (PR = 1.19, 1.04-1.36) at non-fast food restaurants. They were less likely to be attempting weight loss (OR = 0.93, 0.89-0.97) but more likely to engage in weight control behaviors for food and physical activity, respectively, than those who lived in neighborhoods with fewer restaurants. In contrast, neighborhood SES had little association with weight control behaviors.
Conclusion
In this selected group of weight loss trial participants, restaurant availability was associated with some weight control practices, but neighborhood SES was not. Future studies should give attention to other populations and to evaluating various aspects of the physical and social environment with weight control practices.
doi:10.1186/1471-2458-10-312
PMCID: PMC2897795  PMID: 20525373
20.  Identifying Risk Factors for Racial Disparities in Diabetes Outcomes: the Translating Research into Action for Diabetes (TRIAD) Study 
Medical care  2009;47(6):700-706.
Background
Versus whites, blacks with diabetes have poorer control of hemoglobin A1c (HbA1c), higher systolic blood pressure (SBP), and higher low-density lipoprotein (LDL) cholesterol as well as higher rates of morbidity and microvascular complications.
Objective
To examine whether several mutable risk factors were more strongly associated with poor control of multiple intermediate outcomes among blacks with diabetes than among similar whites.
Design
Case-control study.
Subjects
A total of 764 blacks and whites with diabetes receiving care within 8 managed care health plans.
Measures
Cases were patients with poor control of at least two of three intermediate outcomes (HbA1c≥8.0%, SBP≥140 mmHg, LDL cholesterol≥130 mg/dl) and controls were patients with good control of all three (HbA1c<8.0%, SBP<140 mmHg, LDL cholesterol<130 mg/dl). In multivariate analyses, we determined whether each of five potentially mutable risk factors, including depression, low health literacy, poor adherence to medication, low self-efficacy for reducing cardiovascular risk, and poor patient-provider communication, predicted case or control status.
Results
Among blacks but not whites, in multivariate analyses depression (odds ratio [OR] 2.28, 95% confidence interval [CI] 1.09-4.75) and having missed medication doses (OR 1.96, 95% CI 1.01-3.81) were associated with greater odds of being a case rather than a control. None of the other risk factors were associated for either blacks or whites.
Conclusions
Depression and missing medication doses are more strongly associated with poor diabetes control among blacks than in whites. These two risk factors may represent important targets for patient-level interventions to address racial disparities in diabetes outcomes.
PMCID: PMC2743318  PMID: 19480090
Diabetes; Racial/Ethnic Groups; Health Outcomes
21.  Introduction 
Journal of General Internal Medicine  2010;25(Suppl 2):79-81.
doi:10.1007/s11606-010-1312-2
PMCID: PMC2847112  PMID: 20352497
22.  Body Mass Index, Neighborhood Fast Food and Restaurant Concentration, and Car Ownership 
Eating away from home and particularly fast food consumption have been shown to contribute to weight gain. Increased geographic access to fast food outlets and other restaurants may contribute to higher levels of obesity, especially in individuals who rely largely on the local environment for their food purchases. We examined whether fast food and restaurant concentrations are associated with body mass index and whether car ownership might moderate this association. We linked the 2000 US Census data and information on locations of fast food and other restaurants with the Los Angeles Family and Neighborhood Study database, which consists of 2,156 adults sampled from 63 neighborhoods in Los Angeles County. Multilevel modeling was used to estimate associations between body mass index (BMI), fast food and restaurant concentration, and car ownership after adjustment for individual-level factors and socioeconomic characteristics of residential neighborhoods. A high concentration of local restaurants is associated with BMI. Car owners have higher BMIs than non-car owners; however, individuals who do not own cars and reside in areas with a high concentration of fast food outlets have higher BMIs than non-car owners who live in areas with no fast food outlets, approximately 12 lb more (p = 0.02) for an individual with a height of 5 ft. 5 in. Higher restaurant density is associated with higher BMI among local residents. The local fast food environment has a stronger association with BMI for local residents who do not have access to cars.
doi:10.1007/s11524-009-9379-y
PMCID: PMC2729867  PMID: 19533365
Multilevel; Fast food; BMI; Obesity; Mobility; Neighborhood; Restaurant
23.  The Neighborhood Food Resource Environment and the Health of Residents with Chronic Conditions 
Journal of General Internal Medicine  2008;23(8):1137-1144.
Background
Residence in disadvantaged neighborhoods is associated with poorer access to healthy foods.
Objective
To understand associations between the neighborhood food resource environment and residents’ health status and body mass index (BMI) for adults with and without chronic conditions.
Design
Cross-sectional multilevel analysis.
Participants
2,536 adults from the 2000–2001 Los Angeles Family and Neighborhood Survey.
Measurements
The food resource environment was defined as the number of chain supermarkets, independent supermarkets, small markets, or convenience stores per roadway miles in the census tract. The main dependent variables were self-rated health, dichotomized as excellent or fair/poor, and body mass index (BMI). Multilevel regression models examined the association between the food resource environment and both BMI and the odds of reporting excellent health after adjustment for neighborhood SES and individual characteristics.
Results
More chain supermarkets per roadway mile in a census tract was associated with higher adjusted rates of reporting excellent health (33%, 38%, and 43% for those in the lowest, middle, and highest tertiles of chain supermarkets) and lower adjusted mean BMI (27, 26, and 25 kg/m2) for residents without a chronic condition, but not those with a chronic condition. In contrast, having more convenience stores per roadway mile was associated with lower health ratings only among adults with a chronic condition (39%, 32%, and 27% for the lowest to highest tertile of convenience stores).
Conclusion
Health status and BMI are associated with the local food environment, but the associations differ by type of market and presence of a chronic condition.
doi:10.1007/s11606-008-0601-5
PMCID: PMC2517955  PMID: 18483833
chronic diseases; community health; health status
24.  Predictors of Sustained Walking among Diabetes Patients in Managed Care: The Translating Research into Action for Diabetes (TRIAD) Study 
Journal of General Internal Medicine  2008;23(8):1194-1199.
BACKGROUND
Although patients with diabetes may benefit from physical activity, few studies have examined sustained walking in this population.
OBJECTIVE
To examine the factors associated with sustained walking among managed care patients with diabetes.
DESIGN
Longitudinal, observational cohort study with questionnaires administered 2.5 years apart.
PARTICIPANTS
Five thousand nine hundred thirty-five patients with diabetes walking at least 20 minutes/day at baseline.
MEASUREMENTS
The primary outcome was the likelihood of sustained walking, defined as walking at least 20 minutes/day at follow-up. We evaluated a logistic regression model that included demographic, clinical, and neighborhood variables as independent predictors of sustained walking, and expressed the results as predicted percentages.
RESULTS
The absence of pain was linked to walking behavior, as 62% of patients with new pain, 67% with ongoing pain, and 70% without pain were still walking at follow-up (p = .03). Obese patients were less likely (65%) to sustain walking than overweight (71%) or normal weight (70%) patients (p = .03). Patients ≥65 years (63%) were less likely to sustain walking than patients between 45 and 64 (70%) or ≤44 (73%) years (p = .04). Only 62% of patients with a new comorbidity sustained walking compared with 68% of those who did not (p < .001). We found no association between any neighborhood variables and sustained walking in this cohort of active walkers.
CONCLUSIONS
Pain, obesity, and new comorbidities were moderately associated with decreases in sustained walking. Whereas controlled intervention studies are needed, prevention, or treatment of these adverse conditions may help patients with diabetes sustain walking behavior.
doi:10.1007/s11606-008-0629-6
PMCID: PMC2517953  PMID: 18452046
sustained walking; diabetes patients; managed care; TRIAD study; pain; obesity; comorbidities
25.  Transforming Clinical Practice to Eliminate Racial–Ethnic Disparities in Healthcare 
Racial–ethnic minorities receive lower quality and intensity of health care compared with whites across a wide range of preventive, diagnostic, and therapeutic services and disease entities. These disparities in health care contribute to continuing racial–ethnic disparities in the burden of illness and death. Several national medical organizations and the Institute of Medicine have issued position papers and recommendations for the elimination of health care disparities. However, physicians in practice are often at a loss for how to translate these principles and recommendations into specific interventions in their own clinical practices. This paper serves as a blueprint for translating principles for the elimination of racial–ethnic disparities in health care into specific actions that are relevant for individual clinical practices. We describe what is known about reducing racial–ethnic disparities in clinical practice and make recommendations for how clinician leaders can apply this evidence to transform their own practices.
doi:10.1007/s11606-007-0481-0
PMCID: PMC2324135  PMID: 18196352
racial disparities; race; ethnicity; health care delivery; cultural competence; ethnic groups; continental population groups

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