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1.  Statin Prescribing Patterns in a Cohort of Cancer Patients with Poor Prognosis 
Journal of Palliative Medicine  2013;16(4):412-418.
There are no evidence-based recommendations for statin continuation or discontinuation near the end of life. However, some expert opinion recommends continuing statins prescribed for secondary versus primary prevention of cardiovascular disease.
Our aim was to explore statin prescribing patterns in a longitudinal cohort of individuals with life-limiting illness, and to evaluate differences in these patterns based on secondary versus primary prevention of cardiovascular disease.
Design and setting
This study was a retrospective cohort analysis of 539 persons in an integrated, not-for-profit health maintenance organization (HMO) setting who were receiving statins at diagnosis of a cancer with 0% to 25% predicted 5-year survival. Of the cohort patients, 343 were taking statins for secondary prevention and 196 for primary prevention of cardiovascular disease. Measurements included number and timing of statin refills between diagnosis and date of death, disenrollment, or the end of the observation period.
Four hundred and ninety-six cohort members died within the observation period. Fifty-eight percent of the secondary prevention and 62% of the primary prevention group had at least one statin refill after diagnosis. There were no significant differences between groups for number of days between diagnosis and last refill, or between last refill and death. Two deaths were attributable to cardiovascular causes in each group.
Our retrospective cohort analysis of persons with incident poor-prognosis cancer describes diminished, but persistent statin refills after diagnosis. Neither timing of statin discontinuation nor cardiovascular mortality differed by prescribing indication. There may be an opportunity to reevaluate medication burden in persons taking statins for primary prevention, and it is unclear whether continuing statins prescribed for secondary prevention affects cardiovascular outcomes.
PMCID: PMC3612279  PMID: 23305190
2.  Using Community Data to Test the Discriminate Validity of Ethnic/Racial Group IATs 
Zeitschrift fur Psychologie  2010;218(1):10.1027/0044-3409/a000006.
The present study used a multi-method, multi-measure, multi-group approach to investigate the discriminant validity of prejudice-related IATs. Community members from three ethnic/racial groups in the U.S. completed IATs and explicit measures of attitudes toward African Americans and Latinos, with Whites used as the comparison group. The results of this study provided strong support for the discriminant validity of the IATs by showing, (a) expected patterns of variation among the three participant groups that were unique to each IAT, (b) unique relations between responses on each IAT and corresponding (same-group) explicit measures of prejudice, and (c) invariance across the three participant groups in the degree to which the attitude measures loaded on two latent factors, indicating distinct attitudes toward African Americans and Latinos.
PMCID: PMC3882026  PMID: 24404433
3.  An Assessment of Biases Against Latinos and African Americans Among Primary Care Providers and Community Members 
American journal of public health  2012;103(1):10.2105/AJPH.2012.300812.
This study assessed implicit and explicit bias against both Latinos and African Americans, among experienced primary care providers (PCPs) and community members (CMs) in the same geographic area.
210 PCPs and 190 CMs from three health care organizations in the Denver metro area completed Implicit Association Tests and self-report measures of implicit and explicit bias, respectively.
With a 60% participation rate, the PCPs demonstrated substantial implicit bias against both Latinos and African Americans, but this was no different from CMs. Explicit bias was largely absent in both groups. Adjustment for background characteristics showed the PCPs to have slightly weaker ethnic/racial bias than CMs.
This research provides the first evidence of implicit bias against Latinos in health care, as well as confirming prior findings of implicit bias against African Americans. The lack of substantive differences in bias between the experienced PCPs and CMs suggests a wider societal problem. At the same time, the wide range of implicit bias suggests that bias in healthcare is neither uniform nor inevitable, and important lessons may be learned from providers who do not exhibit bias.
PMCID: PMC3518332  PMID: 23153155
4.  HIV risk after release from prison: a qualitative study of former inmates 
Former prison inmates are at risk for HIV and Hepatitis C (HCV). This study was designed to understand how former inmates perceived their risk of HIV and HCV after release from prison, the behaviors and environmental factors that put patients at risk for new infection and the barriers to accessing health care.
Qualitative study utilizing individual, face-to-face, semi-structured interviews exploring participants’ perceptions and behaviors putting them at risk for HIV and HCV and barriers to engaging in regular medical care after release. Interview transcripts were coded and analyzed utilizing a team-based general inductive approach.
Participants were racially and ethnically diverse and consisted of 20 men and 9 women with an age range of 22–57 years who were interviewed within the first two months after their release from prison to the Denver, Colorado community. Four major themes emerged: 1) risk factors including unprotected sex, transactional sex, and drug use were prevalent in the post-release period; 2) engagement in risky behavior occurred disproportionately in the first few days after release; 3) former inmates had educational needs about HIV and HCV; and 4) former inmates faced major challenges in accessing health care and medications.
Risk factors for HIV and HCV were prevalent among former inmates immediately after release. Prevention efforts should focus on education, promotion of safe sex and needle practices, substance abuse treatment, and drug- free transitional housing. Improved coordination between correctional staff, parole officers and community health care providers may improve continuity of care.
PMCID: PMC3685495  PMID: 21522015
5.  A Pragmatic Framework for Single-site and Multisite Data Quality Assessment in Electronic Health Record-based Clinical Research 
Medical care  2012;50(0):10.1097/MLR.0b013e318257dd67.
Answers to clinical and public health research questions increasingly require aggregated data from multiple sites. Data from electronic health records and other clinical sources are useful for such studies, but require stringent quality assessment. Data quality assessment is particularly important in multisite studies to distinguish true variations in care from data quality problems.
We propose a “fit-for-use” conceptual model for data quality assessment and a process model for planning and conducting single-site and multisite data quality assessments. These approaches are illustrated using examples from prior multisite studies.
Critical components of multisite data quality assessment include: thoughtful prioritization of variables and data quality dimensions for assessment; development and use of standardized approaches to data quality assessment that can improve data utility over time; iterative cycles of assessment within and between sites; targeting assessment toward data domains known to be vulnerable to quality problems; and detailed documentation of the rationale and outcomes of data quality assessments to inform data users. The assessment process requires constant communication between site-level data providers, data coordinating centers, and principal investigators.
A conceptually based and systematically executed approach to data quality assessment is essential to achieve the potential of the electronic revolution in health care. High-quality data allow “learning health care organizations” to analyze and act on their own information, to compare their outcomes to peers, and to address critical scientific questions from the population perspective.
PMCID: PMC3833692  PMID: 22692254
data quality; data quality assessment; single-site studies; multisite studies
6.  Acculturation and Outcomes among Patients with Heart Failure 
Circulation. Heart failure  2012;5(2):160-166.
Acculturation to U.S. society among minority patients may influence health outcomes beyond race and ethnicity alone. In particular, those who are foreign-born and who do not speak English as their primary language may have greater challenges interacting with the health care system and thus be at greater risk for adverse outcomes.
Methods and Results
We studied patients hospitalized with a principal discharge diagnosis of HF between January 2000 and December 2007 in an integrated delivery system that cares for minority patients. Individuals were defined as having low acculturation if their primary language was not English and their country of birth was outside of the U.S. Multivariable logistic regression and Cox proportional hazards regression were used to determine the independent risk of 30-day rehospitalization and 1-year mortality, respectively. Candidate adjustment variables included demographics (age, gender, race/ethnicity), coexisting illnesses, laboratory values, left ventricular systolic function, and characteristics of the index admission. Of 1,268 patients, 30% (n=379) were Black, 39% (n=498) Hispanic, and 27% (n= 348) White. Eighteen percent (n=228) had low acculturation. After adjustment, low acculturation was associated with a higher risk of readmission at 30 days (OR 1.70; 95% CI 1.07-2.68) but not 1-year all-cause mortality (HR 0.69; 95% CI 0.42-1.14).
Patients with HF who are foreign-born and do not speak English as their primary language have a greater risk of rehospitalization, independent of clinical factors and race/ethnicity. Future studies should evaluate whether culturally concordant interventions focusing on such patients may improve outcomes for this patient population.
PMCID: PMC3786352  PMID: 22247483
heart failure; readmission; survival; risk factors; health disparities
7.  Health Disparities and the Criminal Justice System: An Agenda for Further Research and Action 
Although racial and ethnic minorities are more likely to be involved with the criminal justice system than whites in the USA, critical scientific gaps exist in our understanding of the relationship between the criminal justice system and the persistence of racial/ethnic health disparities. Individuals engaged with the criminal justice system are at risk for poor health outcomes. Furthermore, criminal justice involvement may have direct or indirect effects on health and health care. Racial/ethnic health disparities may be exacerbated or mitigated at several stages of the criminal justice system. Understanding and addressing the health of individuals involved in the criminal justice system is one component of a comprehensive strategy to reduce population health disparities and improve the health of our urban communities.
PMCID: PMC3284594  PMID: 21915745
Prisons; Health disparities; Health care delivery
8.  Simultaneous Control of Diabetes, Hypertension, and Hyperlipidemia in Two Health Systems 
Many individuals with diabetes, hypertension and hyperlipidemia have difficulty achieving control of all three conditions. We assessed the incidence and duration of simultaneous control of hyperglycemia, blood pressure, and low-density lipoprotein (LDL) cholesterol in patients from two health care systems in Colorado.
Methods and Results
Retrospective cohort study of adults at Denver Health (DH) and Kaiser Permanente Colorado (KP) with diabetes, hypertension, and hyperlipidemia from 2000 through 2008. Over a median of 4.0 and 4.4 years, 16% and 30% of individuals at DH and KP achieved the primary outcome (simultaneous control with a glycosylated hemoglobin (HbA1c) < 7.0%, blood pressure < 130/80 mmHg and LDL cholesterol < 100 mg/dL), respectively. With less strict goals (HbA1c < 8.0%, BP < 140/90 mmHg, and LDL cholesterol < 130 mg/dL), 44% and 70% of individuals at DH and KP achieved simultaneous control. Socio-demographic characteristics (increasing age, white ethnicity), and the presence of cardiovascular disease or other comorbidities were significantly but not strongly predictive of achieving simultaneous control in multivariable models. Simultaneous control was less likely as severity of the underlying conditions increased, and more likely as medication adherence increased.
Simultaneous control of diabetes, hypertension, and hyperlipidemia was uncommon and generally transient. Less stringent goals had a relatively large effect on the proportion achieving simultaneous control. Individuals who simultaneously achieve multiple treatment goals may provide insight into self-care strategies for individuals with comorbid health conditions.
PMCID: PMC3590111  PMID: 22851534
Diabetes mellitus; hypertension; hypercholesterolemia; epidemiology
9.  Returning to Work after Cancer: Quantitative Studies and Prototypical Narratives 
Psycho-oncology  2010;19(2):115-124.
A combination of quantitative data and illustrative narratives may allow cancer survivorship researchers to disseminate their research findings more broadly. We identified recent, methodologically rigorous quantitative studies on return to work after cancer, summarized the themes from these studies, and illustrated those themes with narratives of individual cancer survivors.
We reviewed English-language studies of return to work for adult cancer survivors through June, 2008, and identified 13 general themes from papers that met methodological criteria (population-based sampling, prospective and longitudinal assessment, detailed assessment of work, evaluation of economic impact, assessment of moderators of work return, and large sample size). We drew survivorship narratives from a prior qualitative research study to illustrate these themes.
Nine quantitative studies met 4 or more of our 6 methodological criteria. These studies suggested that most cancer survivors could return to work without residual disabilities. Cancer site, clinical prognosis, treatment modalities, socioeconomic status, and attributes of the job itself influenced the likelihood of work return. Three narratives - a typical survivor who returned to work after treatment, an individual unable to return to work, and an inspiring survivor who returned to work despite substantial barriers - illustrated many of the themes from the quantitative literature while providing additional contextual details.
Illustrative narratives can complement the findings of cancer survivorship research if researchers are rigorous and transparent in the selection, analysis, and retelling of those stories.
PMCID: PMC2818031  PMID: 19507264
Cancer; oncology; survivorship; work function; quality of life; qualitative research; narrative medidicne; review
10.  Return to drug use and overdose after release from prison: a qualitative study of risk and protective factors 
Former inmates are at high risk for death from drug overdose, especially in the immediate post-release period. The purpose of the study is to understand the drug use experiences, perceptions of overdose risk, and experiences with overdose among former prisoners.
This qualitative study included former prison inmates (N = 29) who were recruited within two months after their release. Interviewers conducted in-person, semi-structured interviews which explored participants' experiences and perceptions. Transcripts were analyzed utilizing a team-based method of inductive analysis.
The following themes emerged: 1) Relapse to drugs and alcohol occurred in a context of poor social support, medical co-morbidity and inadequate economic resources; 2) former inmates experienced ubiquitous exposure to drugs in their living environments; 3) intentional overdose was considered "a way out" given situational stressors, and accidental overdose was perceived as related to decreased tolerance; and 4) protective factors included structured drug treatment programs, spirituality/religion, community-based resources (including self-help groups), and family.
Former inmates return to environments that strongly trigger relapse to drug use and put them at risk for overdose. Interventions to prevent overdose after release from prison may benefit from including structured treatment with gradual transition to the community, enhanced protective factors, and reductions of environmental triggers to use drugs.
PMCID: PMC3414824  PMID: 22966409
Drug use; Overdose; Prisoners; Relapse; Prison re-entry
11.  Construction of a Multisite DataLink Using Electronic Health Records for the Identification, Surveillance, Prevention, and Management of Diabetes Mellitus: The SUPREME-DM Project 
Electronic health record (EHR) data enhance opportunities for conducting surveillance of diabetes. The objective of this study was to identify the number of people with diabetes from a diabetes DataLink developed as part of the SUPREME-DM (SUrveillance, PREvention, and ManagEment of Diabetes Mellitus) project, a consortium of 11 integrated health systems that use comprehensive EHR data for research.
We identified all members of 11 health care systems who had any enrollment from January 2005 through December 2009. For these members, we searched inpatient and outpatient diagnosis codes, laboratory test results, and pharmaceutical dispensings from January 2000 through December 2009 to create indicator variables that could potentially identify a person with diabetes. Using this information, we estimated the number of people with diabetes and among them, the number of incident cases, defined as indication of diabetes after at least 2 years of continuous health system enrollment.
The 11 health systems contributed 15,765,529 unique members, of whom 1,085,947 (6.9%) met 1 or more study criteria for diabetes. The nonstandardized proportion meeting study criteria for diabetes ranged from 4.2% to 12.4% across sites. Most members with diabetes (88%) met multiple criteria. Of the members with diabetes, 428,349 (39.4%) were incident cases.
The SUPREME-DM DataLink is a unique resource that provides an opportunity to conduct comparative effectiveness research, epidemiologic surveillance including longitudinal analyses, and population-based care management studies of people with diabetes. It also provides a useful data source for pragmatic clinical trials of prevention or treatment interventions.
PMCID: PMC3457753  PMID: 22677160
12.  Characteristics of Patients with Primary Non-adherence to Medications for Hypertension, Diabetes, and Lipid Disorders 
Information comparing characteristics of patients who do and do not pick up their prescriptions is sparse, in part because adherence measured using pharmacy claims databases does not include information on patients who never pick up their first prescription, that is, patients with primary non-adherence. Electronic health record medication order entry enhances the potential to identify patients with primary non-adherence, and in organizations with medication order entry and pharmacy information systems, orders can be linked to dispensings to identify primarily non-adherent patients.
This study aims to use database information from an integrated system to compare patient, prescriber, and payment characteristics of patients with primary non-adherence and patients with ongoing dispensings of newly initiated medications for hypertension, diabetes, and/or hyperlipidemia.
This is a retrospective observational cohort study.
Participants of this study include patients with a newly initiated order for an antihypertensive, antidiabetic, and/or antihyperlipidemic within an 18-month period.
Proportion of patients with primary non-adherence overall and by therapeutic class subgroup. Multivariable logistic regression modeling was used to investigate characteristics associated with primary non-adherence relative to ongoing dispensings.
The proportion of primarily non-adherent patients varied by therapeutic class, including 7% of patients ordered an antihypertensive, 11% ordered an antidiabetic, 13% ordered an antihyperlipidemic, and 5% ordered medications from more than one of these therapeutic classes within the study period. Characteristics of patients with primary non-adherence varied across therapeutic classes, but these characteristics had poor ability to explain or predict primary non-adherence (models c-statistics = 0.61–0.63).
Primary non-adherence varies by therapeutic class. Healthcare delivery systems should pursue linking medication orders with dispensings to identify primarily non-adherent patients. We encourage conduct of research to determine interventions successful at decreasing primary non-adherence, as characteristics available from databases provide little assistance in predicting primary non-adherence.
PMCID: PMC3250550  PMID: 21879374
medication adherence; primary non-adherence; antihypertensive adherence; antidiabetic adherence; antihyperlipidemic adherence
14.  The Effect of Incident Cancer, Depression and Pulmonary Disease Exacerbations on Type 2 Diabetes Control 
Little is known about how the development of a new chronic health condition affects management of existing chronic conditions over time. New conditions might worsen management of existing conditions because of competing demands or improve management of existing conditions because of increased engagement with heath care. We assessed the effect of incident stage 0, 1, 2 or 3 breast, colon or prostate cancer; incident depression; or an exacerbation of chronic pulmonary disease on control of type 2 diabetes (DM2).
We conducted a longitudinal, historical cohort study within an integrated, not-for-profit HMO. Of a cohort of persons with diagnoses of DM2 between 1998 and 2008, 582, 2,959 and 2,332 developed incident cancer, depression or pulmonary disease exacerbation, respectively. We assessed change in hemoglobin A1c (A1c) as a function of the occurrence of the incident comorbidity in each subcohort for a period of 1 to 5 years after the occurrence of the incident comorbidity. Secondary outcomes were systolic blood pressure (SBP) and low density lipoprotein (LDL) levels. Multivariate linear regression was adjusted for demographics, morbidity level, BMI, numbers of primary and specialty visits, and continuity of primary care. Latent class analyses assessed post-comorbidity outcome trajectories. All time-varying covariates were calculated for a 24-month pre-diagnosis period and 0 to 24- and 24 to 60-month post-diagnosis periods.
For each condition, A1c did not change significantly from before to after the incident comorbidity. This was confirmed by latent class growth curve analyses that grouped patients by their A1c trajectories. SBP and LDL were also not significantly changed pre- and post-diagnosis of the incident comorbidities.
Although incident comorbidities inevitably will affect patients’ and clinicians’ care priorities, we did not observe changes in these particular outcomes. Additional investigation of interactions between diseases will inform changes in care that benefit complex patient populations.
PMCID: PMC3101974  PMID: 21203859
15.  The Spectrum of Engagement in HIV Care and its Relevance to Test-and-Treat Strategies for Prevention of HIV Infection 
Poor engagement in HIV care is common in the United States and worsens HIV treatment outcomes. In addition, poor engagement in care is likely to drastically reduce the effectiveness of “test and treat” HIV prevention strategies.
(See the editorial commentary by Lange, on pages 801–802.)
For individuals with human immunodeficiency virus (HIV) infection to fully benefit from potent combination antiretroviral therapy, they need to know that they are HIV infected, be engaged in regular HIV care, and receive and adhere to effective antiretroviral therapy. Test-and-treat strategies for HIV prevention posit that expanded testing and earlier treatment of HIV infection could markedly decrease ongoing HIV transmission, stemming the HIV epidemic. However, poor engagement in care for HIV-infected individuals will substantially limit the effectiveness of test-and-treat strategies. We review the spectrum of engagement in care for HIV-infected individuals in the United States and apply this information to help understand the magnitude of the challenges that poor engagement in care will pose to test-and-treat strategies for HIV prevention.
PMCID: PMC3106261  PMID: 21367734
16.  Antiretroviral medication adherence and the development of class-specific antiretroviral resistance 
AIDS (London, England)  2009;23(9):1035-1046.
To assess the association between antiretroviral adherence and the development of class-specific antiretroviral medication resistance.
Design and methods:
Literature and conference abstract review of studies assessing the association between adherence to antiretroviral therapy and the development of antiretroviral medication resistance.
Factors that determine class-specific adherence–resistance relationships include antiretroviral regimen potency, viral fitness or more specifically the interplay between the fold-change in resistance and fold-change in fitness caused by drug resistance mutations, and the genetic barrier to antiretroviral resistance. During multidrug therapy, differential drug exposure increases the likelihood of developing resistance. In addition, antiretroviral medications with higher potency and higher genetic barriers to resistance decrease the incidence of resistance for companion antiretroviral medications at all adherence levels.
Knowledge of class-specific adherence–resistance relationships may help clinicians and patients tailor therapy to match individual patterns of adherence in order to minimize the development of resistance at failure. In addition, this information may guide the selection of optimal drug combinations and regimen sequences to improve the durability of antiretroviral therapy.
PMCID: PMC2704206  PMID: 19381075
adherence; antiretroviral resistance; antiretroviral therapy; genetic barrier to resistance; HIV; potency; replication capacity
17.  Pneumococcal Vaccination in General Internal Medicine Practice: Current Practice and Future Possibilities 
Journal of General Internal Medicine  2008;23(12):2010-2013.
Pneumococcal vaccine (PPV) is recommended for adults ≥65 years and those with chronic illness, but there are potential advantages of universal vaccination of adults age 50–64 years.
To assess reported (1) recommendations and administration practices of general internists for PPV, (2) barriers to vaccination, and (3) willingness to expand vaccination to all adults ≥50 years.
National survey of general internists representative of the American College of Physicians.
Response rate was 74% (N = 326). Although 99% reported giving PPV, less than 20% used a computerized database to identify eligible patients by age or diagnoses and only 6% recalled patients. Major barriers included acute problems taking precedence over preventive care (39%), difficulty determining vaccination history (30%), not thinking of it/not a priority (20%), and inadequate reimbursement for vaccine (19%). If ACIP expanded recommendations, 60% would definitely and 37% would probably institute this change.
Most general internists reported giving PPV, but delivery was hindered by competing demands, lack of systems to identify patients needing vaccination, and reimbursement issues. Barriers might be decreased by a policy of universal vaccination of adults ≥50 years, and the majority of physicians reported they would follow such a recommendation if it were made.
Electronic supplementary material
The online version of this article (doi:10.1007/s11606-008-0800-0) contains supplementary material, which is available to authorized users.
PMCID: PMC2596512  PMID: 18830765
immunization delivery; pneumococcal vaccine; pneumococcus; pneumonia
18.  Incident chronic kidney disease and the rate of kidney function decline in individuals with hypertension 
Background. Little is known about the decline of kidney function in patients with normal kidney function at baseline. Our objectives were to (i) identify predictors of incident chronic kidney disease (CKD) and (ii) to estimate rate of decline in kidney function.
Methods. The study used a retrospective cohort of adult patients in a hypertension registry in an inner-city health care delivery system in Denver, Colorado. The primary outcome was development of incident CKD, and the secondary outcome was rate of change of estimated glomerular filtration rate (eGFR) over time.
Results. After a mean follow-up of 45 months, 429 (4.1%) of 10 420 patients with hypertension developed CKD. In multivariate models, factors that independently predicted incident CKD were baseline age [odds ratio (OR) 1.13 per 10 years, 95% confidence interval (CI), 1.03–1.24], baseline eGFR (OR 0.69 per 10 units, 95% CI 0.65–0.73), diabetes (OR 3.66, 95% CI 2.97–4.51) and vascular disease (OR 1.67, 95% CI 1.32–2.10). We found no independent association between age, gender or race/ethnicity and eGFR slope. In patients who did not have diabetes or vascular disease, eGFR declined at 1.5 mL/min/1.73 m2 per year. Diabetes at baseline was associated with an additional decline of 1.38 mL/min/1.73 m2.
Conclusions. Diabetes was the strongest predictor of both incident CKD as well as eGFR slope. Rates of incident CKD or in decline of kidney function did not differ by race or ethnicity in this cohort.
PMCID: PMC2828608  PMID: 19889870
chronic kidney disease; hypertension; progression
19.  Left Ventricular Hypertrophy and Cardiovascular Mortality by Race and Ethnicity 
The American journal of medicine  2008;121(10):870-875.
Left ventricular hypertrophy is a major independent risk factor for cardiovascular mortality. The contribution of left ventricular hypertrophy to racial and ethnic differences in cardiovascular mortality is poorly understood.
We used data from the Third National Health and Nutrition Examination Survey and from the National Death Index to compare mortality for those with an electrocardiographic (ECG) diagnosis of left ventricular hypertrophy to those without left ventricular hypertrophy separately for whites, African Americans, and Latinos. We used Cox proportional hazards regression to control for other known prognostic factors.
ECG left ventricular hypertrophy was significantly associated with ten-year cardiovascular mortality in all three racial/ethnic groups, both unadjusted and adjusted for other known prognostic factors. The hazard ratio for this association was significantly greater for African Americans (2.31, 95% CI 1.55–3.42) than for whites and Latinos (1.32, 95% CI 1.14–1.76 and 2.11, 95% CI 1.35–3.30 respectively) independent of systolic blood pressure.
ECG left ventricular hypertrophy contributes more to the risk of cardiovascular mortality in African Americans than it does in Whites. Using regression of ECG left ventricular hypertrophy as a goal of therapy might be a means to reduce racial differences in cardiovascular mortality; prospective validation is required.
PMCID: PMC2574427  PMID: 18823858
left ventricular hypertrophy; electrocardiography; cardiovascular risk assessment; racial/ethnic differences
20.  Processes of care desired by elderly patients with multimorbidities 
Family Practice  2008;25(4):287-293.
Background. Most recommended care for chronic diseases is based on the research of single conditions. There is limited information on ‘best’ processes of care for persons with multiple morbidities. Our objective was to explore processes of care desired by elderly patients who have multimorbidities that may present competing demands for patients and providers.
Methods. Qualitative investigation using one-on-one interviews of 26 community-dwelling HMO members aged 65–84 (50% male) who had, at a minimum, the combined conditions of diabetes, depression and osteoarthritis. Participants were chosen from a stratified random sample to have a range of 4–16 chronic medical conditions.
Results. Participants’ desired processes of care included: the need for convenient access to providers (telephone, internet or in person), clear communication of individualized care plans, support from a single coordinator of care who could help prioritize their competing demands and continuity of relationships. They also desired providers who would listen to and acknowledge their needs, appreciate that these’ needs were unique and fluctuating and have a caring attitude.
Conclusions. These respondents describe an ideal process of care that is patient centered and individualized and that supports their unique constellations of problems, shifting priorities and multidimensional decision making. Individual and ongoing care coordination managed by a primary contact person may meet some of these needs. Achieving these goals will require developing efficient methods of assessing patient care needs and flexible care management support systems that can respond to patients’ needs for different levels of support at different times.
PMCID: PMC2504745  PMID: 18628243
Care management; comorbidity; geriatrics
21.  Thresholds in the Relationship between Mortality and Left Ventricular Hypertrophy Defined by Electrocardiography 
Journal of electrocardiology  2008;41(4):342-350.
Electrocardiographic criteria for the diagnosis of left ventricular hypertrophy in current use were defined using autopsy results or echocardiography; criteria defined using mortality might be more clinically meaningful.
Using data from NHANES III, we selected electrocardiographic measures that best differentiated those surviving at five years from those who did not. We identified voltage thresholds using regression techniques, and then compared survival for subjects above and below the thresholds.
Cornell voltage, Cornell product, and Novacode estimate of left ventricular mass index were discriminative for mortality and had identifiable thresholds present in their relationships with mortality. Independent of systolic blood pressure, there were significant associations with five-year mortality for Novacode index above threshold; hazard ratios were 1.58 for women and 1.27 for men, and for five-year cardiovascular mortality were 1.78 for women and 2.34 for men.
Electrocardiographic criteria for left ventricular hypertrophy validated against mortality might be clinically useful.
PMCID: PMC2556300  PMID: 18342879
22.  Using Stories to Disseminate Research: The Attributes of Representative Stories 
Journal of General Internal Medicine  2007;22(11):1603-1607.
When researchers communicate their findings to patients, clinicians, policy-makers, or media, they may find it helpful to supplement quantitative data with stories about individuals who represent themes in their research. Whether such stories are gathered during the research itself or identified from other sources, researchers must develop strategies for assessing their representativeness. This paper proposes 5 attributes of representative stories: (1) expression of important themes in the research, (2) explicit location in the “distribution” of stories that exemplify the theme, (3) verifiability, (4) acknowledgment of uncertainty, and (5) compelling narration. This paper summarizes research on substance abuse among physicians, and uses these 5 attributes to assess the representativeness of a published case report and a fictional short story about addicted physicians. While neither story is fully representative of the research, the process of evaluating these stories illustrates an approach to identifying representative stories for use in disseminating research.
PMCID: PMC2219793  PMID: 17763914
research translation; substance abuse; evidence-based medicine; narrative medicine; health policy
23.  Testing Electronic Algorithms to Create Disease Registries in a Safety Net System 
Electronic disease registries are a critical feature of the chronic disease management programs that are used to improve the care of individuals with chronic illnesses. These registries have been developed primarily in managed care settings; use in safety net institutions—organizations whose mission is to serve the uninsured and underserved—has not been described. We sought to assess the feasibility of developing disease registries from electronic data in a safety net institution, focusing on hypertension because of its importance in minority populations. We compared diagnoses obtained from algorithms utilizing electronic data, including laboratory and pharmacy records, against diagnoses derived from chart review. We found good concordance between diagnoses identified from electronic data and those identified by chart review, suggesting that registries of patients with chronic diseases can be developed outside the setting of closed panel managed care organizations.
PMCID: PMC2561200  PMID: 18469416
Hypertension; safety net; chronic disease; disease registries
24.  Impact of prescription size on statin adherence and cholesterol levels 
Therapy with 3-Hydroxy-3-methylglutaryl Co-enzyme A reductase inhibitors (statins) improve outcomes in a broad spectrum of patients with hyperlipidemia. However, effective therapy requires ongoing medication adherence; restrictive pharmacy policies may represent a barrier to successful adherence, particularly among vulnerable patients. In this study we sought to assess the relationship between the quantity of statin dispensed by the pharmacy with patient adherence and total cholesterol.
We analyzed a cohort of 3,386 patients receiving more than one fill of statin medications through an integrated, inner-city health care system between January 1, 2000 and December 31, 2002. Our measure of adherence was days of drug acquisition divided by days in the study for each patient, with adequate adherence defined as ≥ 80%. Log-binomial regression was used to determine the relative risk of various factors, including prescription size, on adherence. We also assessed the relationship between adherence and total cholesterol using multiple linear regression.
After controlling for age, gender, race, co-payment, comorbidities, and insurance status, patients who obtained a majority of fills as 60-day supply compared with 30-day supply were more likely to be adherent to their statin medications (RR 1.41, 95% CI 1.28–1.55, P < 0.01). We found that statin non-adherence less than 80% was predictive of higher total serum cholesterol by 17.23 ± 1.64 mg/dL (0.45 ± 0.04 mmol/L).
In a healthcare system serving predominantly indigent patients, the provision of a greater quantity of statin medication at each prescription fill contributes to improved adherence and greater drug effectiveness.
PMCID: PMC2174936  PMID: 17961256
25.  What do Attending Physicians Contribute in a House Officer-Based Ambulatory Continuity Clinic? 
To study the educational contributions of attending physicians in an internal medicine house staff ambulatory clinic.
Cross-sectional, self-administered survey.
University-affiliated general internal medicine practice.
Internal medicine residents and attendings.
Attending and resident perceptions of whether attendings made contributions to teaching points, diagnosis (DX), therapy (RX), and health care maintenance (HCM) were assessed in 428 patient encounters. Resident assessments significantly exceeded attending self-assessments of contributions to teaching points (82% vs 74%, P = .001), DX (44% vs 34%, P = .001), RX (61% vs 55%, P = .02), and HCM (19% vs 15%, P = .04). Both residents and attendings perceived that contributions declined progressively with increasing resident year (P<.05). Primary care and categorical residents assessed attending contributions comparably. However, attendings perceived contributing more to RX and HCM for categorical residents than primary care (P<.05). Male and female residents assessed attending contributions comparably. However, attendings perceived contributing generally more to DX in male residents than female (P = .003). In 8% of encounters, either residents or attendings felt that patient evaluation by the attending was needed. In these encounters with personal patient evaluation by attendings, both residents and attendings felt that attendings made more contributions to DX (P = .001) and teaching points than in other encounters.
Attending physicians consistently underestimate their perceived contributions to house officer ambulatory teaching. Their personal patient evaluation increases assistance with DX and teaching points. Given perceived declining contributions by training year, attendings may need to identify other teaching strategies for interactions with senior residents.
PMCID: PMC1484778  PMID: 16704384
medical education; ambulatory care; internship and residency; bedside training

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