Medication assistance programs: do all in need benefit equally?

OBJECTIVE

To determine if medication assistance programs (MAPs) provided by pharmaceutical companies were used differently by African Americans and Whites.

RESEARCH DESIGN

A cross-sectional survey was conducted among patients of primary care practices from 2005 to 2007 within the Alabama Nonsteroidal Anti-Inflammatory Drug (NSAID) Patient Safety Study.

SETTING

Telephone survey.

PARTICIPANTS

Respondents were 568 African American and White patients reporting annual household incomes < $50,000.

MAIN OUTCOME MEASURE

Use of MAPs.

RESULTS

Of all patients, 12.8% used MAPs, 39.5% were African American, 75.2% were female, 69.1% were aged > 65 years, 79.8% had annual household incomes < $25,000, and 35.5% indicated that their income was inadequate to meet their basic needs. MAPs were used by 11.2% African-Americans and 14.0% Whites. After multivariable adjustment, MAP use was higher among respondents with incomes not adequate to meet basic needs (odds ratio [OR]: 2.19, 95% confidence interval [CI]: 1.17-4.08) but lower among African Americans than Whites (OR: 0.49, 95% CI: 0.25-0.95). Physician characteristics did not independently predict MAP use.

CONCLUSIONS

Overall MAP use was low even among the most vulnerable, and especially among African Americans. As currently used, MAPs may contribute to disparities in medication access.

Impact of content-specific email reminders on provider participation in an online intervention: a dental PBRN study

Engaging busy healthcare providers in online continuing education interventions is challenging. In an Internet-delivered intervention for dental providers, we tested a series of email-delivered reminders - cues to action. The intervention included case-based education and downloadable practice tools designed to encourage providers to increase delivery of smoking cessation advice to patients. We compared the impact of email reminders focused on 1) general project announcements, 2) intervention related content (smoking cessation), and 3) unrelated content (oral cancer prevention focused content). We found that email reminders dramatically increased participation. The content of the message had little impact on the participation, but day of the week was important - messages sent at the end of the week had less impact, likely due to absence from clinic on the weekend. Email contact, such as day of week an email is sent and notice of new content post-ing, is critical to longitudinal engagement. Further research is needed to understand which messages and how frequently, will maximize participation.

Adverse events among the elderly receiving chemotherapy for advanced non-small-cell lung cancer

PURPOSE

To describe chemotherapy use and adverse events (AEs) for advanced-stage, non-small-cell lung cancer (NSCLC) in community practice, including descriptions according to variation by age.

METHODS

We interviewed patients with newly diagnosed, stages IIIB and IV NSCLC in the population-based cohort studied by the Cancer Care Outcomes Research and Surveillance Consortium, and we abstracted the patient medical records. AEs were medical events occurring during chemotherapy. Using logistic regression, we assessed the association between age and chemotherapy; with Poisson regression, we estimated event rate ratios and adjusted the analysis for age, sex, ethnicity, radiation therapy, stage, histology, and presence and grade of 27 comorbidities.

RESULTS

Of 1,371 patients, 58% (95% CI, 55% to 61%) received chemotherapy and 35% (95% CI, 32% to 38%) had AEs. After adjustment, 72% (95% CI, 65% to 79%) of those younger than 55 years and 47% (95% CI, 42% to 52%) of those age 75 years and older received chemotherapy. Platinum-based therapies were less common in the older-age groups. Pretreatment medical event rates were 18.6% for patients younger than 55 years and were only 9.2% for those age 75 years and older (adjusted rate ratio, 0.49; 95% CI, 0.26 to 0.91). In contrast, older adults were more likely to have AEs during chemotherapy. The adjusted rate ratios compared with age younger than 55 years were 1.70 for 65- to 74-year-olds (95% CI, 1.19 to 2.43) and 1.34 for those age 75 years and older (95% CI, 0.90 to 2.00).

CONCLUSION

Older patients who received chemotherapy had fewer pretherapy events than younger patients and were less likely to receive platinum-based regimens. Nevertheless, older patients had more adverse events during chemotherapy, independent of comorbidity. Potential implicit trade-offs between symptom management and treatment toxicity should be made explicit and additionally studied.

Sex differences in mortality after acute myocardial infarction: changes from 1994 to 2006

BACKGROUND

Previous studies have shown that women younger than 55 years have higher hospital mortality rates after acute myocardial infarction (MI) than age-matched men. We examined whether such mortality differences have decreased in recent years.

METHODS

We investigated temporal trends in the hospital case-fatality rates of MI by sex and age from June 1, 1994, through December 31, 2006. The study population included 916,380 patients from the National Registry of Myocardial Infarction with a confirmed diagnosis of MI.

RESULTS

In-hospital mortality decreased markedly between 1994 and 2006 in all patients but more so in women than men. The mortality reduction in 2006 relative to 1994 was largest in women younger than 55 years (52.9%) and lowest in men younger than 55 years (33.3%). In patients younger than 55 years, the absolute decrease in mortality was 3 times larger in women than men (2.7% vs 0.9%). As a result, the excess mortality in younger women (<55 years) compared with men was less pronounced in 2004-2006 (unadjusted odds ratio, 1.32; 95% confidence interval, 1.07-1.67) than it was in 1994-1995 (unadjusted odds ratio, 1.93; 95% confidence interval, 1.67-2.24). The sex difference in mortality decrease was lower in older patients (P = .004 for the interaction among sex, age, and year). Changes in comorbidity and clinical severity features at admission accounted for more than 90% of these mortality trends.

CONCLUSIONS

In recent years, women, particularly younger ones, experienced larger improvements in hospital mortality after MI than men. The narrowing of the mortality gap between younger women and men is largely attributable to temporal changes in risk profiles.

Prospective association between C-reactive protein and fatigue in the coronary artery risk development in young adults study

BACKGROUND

Fatigue is highly prevalent and causes serious disruption in quality of life. Although the underlying biological mechanism is unknown, increases in inflammation have been implicated. This prospective study examined the association between C-reactive protein (CRP), a biomarker of systemic inflammation, and fatigue 5 years later.

METHODS

The Coronary Artery Risk Development in Young Adults (CARDIA) study is a population-based longitudinal study conducted in four U.S. cities. Highly sensitive CRP concentration and fatigue were measured in 2983 African American and white adults at both year 15 (2000-2001, ages 33-45 years) and year 20 (2005-2006) examinations. Fatigue was assessed using the vitality subscale of the 12-item Short Form Health Survey.

RESULTS

Plasma CRP concentration at baseline (i.e., CARDIA year 15) was a significant predictor of fatigue level 5 years later (unadjusted beta = .126, p < .001). After adjustment for potential confounders, this association remained significant (adjusted beta = .044, p = .033). Additionally, baseline CRP independently predicted fatigue in the subgroup of participants without medical comorbidity (adjusted beta = .051, p = .039). Fatigue was associated with a persistent elevation of CRP at both examinations but not with a transient elevation of CRP at only one of the examinations.

CONCLUSIONS

This is the first study to demonstrate a prospective association between an inflammatory marker and fatigue in a general population. Furthermore, the association between low-grade systemic inflammation and fatigue seems primarily driven by persistent immune activation and not explained by the presence or development of medical comorbidity.

Disentangling the influence of socioeconomic status on differences between African American and white women in unmet medical needs

OBJECTIVES

We sought to disentangle the relationships between race/ethnicity, socioeconomic status (SES), and unmet medical care needs.

METHODS

Data from the 2003-2004 Community Tracking Study Household Survey were used to examine associations between unmet medical needs and SES among African American and White women.

RESULTS

No significant racial/ethnic differences in unmet medical needs (24.8% of Whites, 25.9% of African Americans; P = .59) were detected in bivariate analyses. However, among women with 12 years of education or less, African Americans were less likely than were Whites to report unmet needs (odds ratio [OR] = 0.57; 95% confidence interval [CI] = 0.42, 0.79). Relative to African American women with 12 years of education or less, the odds of unmet needs were 1.69 (95% CI = 1.24, 2.31) and 2.18 (95% CI = 1.25, 3.82) among African American women with 13 to 15 years of education and 16 years of education or more, respectively. In contrast, the relationship between educational level and unmet needs was nonsignificant among White women.

CONCLUSIONS

Among African American women, the failure to recognize unmet medical needs is related to educational attainment and may be an important driver of health disparities, representing a fruitful area for future interventions.

Prepregnancy depressive mood and preterm birth in black and white women: findings from the CARDIA Study

OBJECTIVES

We examine associations among race, prepregnancy depressive mood, and preterm birth (<37 weeks gestation) in a cohort study of black and white women.

METHODS

We tested for mediation of the association between race and preterm birth by prepregnancy depressive mood among 555 women enrolled in the Coronary Artery Risk Development in Young Adults (CARDIA) Study.

RESULTS

Black women had significantly higher levels of prepregnancy depressive mood (modified CES-D score 13.0 vs. 9.5, t = -4.64, p < 0.001). After adjustment for covariates, black women had 2.70 times the odds of preterm birth as white women (95% confidence interval [CI] 1.41, 5.17). When adding prepregnancy depressive mood to this model, higher depressive mood was associated with greater odds of preterm birth (odds ratio [OR] 1.04; 95% CI 1.01, 1.07), and the effect of black race was attenuated (OR 2.47, 95% CI 1.28, 4.77).

CONCLUSIONS

Our data suggest that prepregnancy depressive mood may be a risk factor for preterm birth among black and white women.

Incarceration, incident hypertension, and access to health care: findings from the coronary artery risk development in young adults (CARDIA) study

BACKGROUND

Incarceration is associated with increased cardiovascular disease mortality, but prospective studies exploring mechanisms of this association are lacking.

METHODS

We examined the independent association of prior incarceration with incident hypertension, diabetes, and dyslipidemia using the Coronary Artery Risk Development in Young Adults (CARDIA) study-a cohort of young adults aged 18 to 30 years at enrollment in 1985-1986, balanced by sex, race (black and white), and education (high school education or less). We also examined the association of incarceration with left ventricular hypertrophy on echocardiography and with barriers to health care access.

RESULTS

Of 4350 participants, 288 (7%) reported previous incarceration. Incident hypertension in young adulthood was more common among former inmates than in those without incarceration history (12% vs 7%; odds ratio, 1.7 [95% confidence interval {CI}, 1.2-2.6]), and this association persisted after adjustment for smoking, alcohol and illicit drug use, and family income (adjusted odds ratio [AOR], 1.6 [95% CI, 1.0-2.6]). Incarceration was significantly associated with incident hypertension in those groups with the highest prevalence of prior incarceration, ie, black men (AOR, 1.9 [95% CI, 1.1-3.5]) and less-educated participants (AOR, 4.0 [95% CI, 1.0-17.3]). Former inmates were more likely to have left ventricular hypertrophy (AOR, 2.7, [95% CI, 0.9-7.9]) and to report no regular source for medical care (AOR, 2.5, [95% CI, 1.3-4.8]). Cholesterol levels and diabetes rates did not differ by history of incarceration.

CONCLUSIONS

Incarceration is associated with future hypertension and left ventricular hypertrophy among young adults. Identification and treatment of hypertension may be important in reducing cardiovascular disease risk among formerly incarcerated individuals.

Relationship of early life stress and psychological functioning to blood pressure in the CARDIA study

OBJECTIVE

Low childhood socioeconomic status (CSES) and a harsh early family environment have been linked with health disorders in adulthood. In this study, the authors present a model to help explain these links and relate the model to blood pressure change over a 10-year period in the Coronary Artery Risk Development in Young Adults sample.

DESIGN

Participants (N = 2,738) completed measures of childhood family environment, parental education, health behavior, and adult negative emotionality.

MAIN OUTCOME MEASURES

These variables were used to predict initial systolic and diastolic blood pressure (SBP and DBP, respectively) and the rate of blood pressure change over 10 years.

RESULTS

Structural equation modeling indicated that family environment was related to negative emotions, which in turn predicted baseline DBP and SBP and change in SBP. Parental education directly predicted change in SBP. Although African American participants had higher SBP and DBP and steeper increases over time, multiple group comparisons indicated that the strength of most pathways was similar across race and gender.

CONCLUSION

Low CSES and harsh family environments help to explain variability in cardiovascular risk. Low CSES predicted increased blood pressure over time directly and also indirectly through associations with childhood family environment, negative emotionality, and health behavior.

Relationship of early life stress and psychological functioning to blood pressure in the CARDIA study

OBJECTIVE

Low childhood socioeconomic status (CSES) and a harsh early family environment have been linked with health disorders in adulthood. In this study, the authors present a model to help explain these links and relate the model to blood pressure change over a 10-year period in the Coronary Artery Risk Development in Young Adults sample.

DESIGN

Participants (N = 2,738) completed measures of childhood family environment, parental education, health behavior, and adult negative emotionality.

MAIN OUTCOME MEASURES

These variables were used to predict initial systolic and diastolic blood pressure (SBP and DBP, respectively) and the rate of blood pressure change over 10 years.

RESULTS

Structural equation modeling indicated that family environment was related to negative emotions, which in turn predicted baseline DBP and SBP and change in SBP. Parental education directly predicted change in SBP. Although African American participants had higher SBP and DBP and steeper increases over time, multiple group comparisons indicated that the strength of most pathways was similar across race and gender.

CONCLUSION

Low CSES and harsh family environments help to explain variability in cardiovascular risk. Low CSES predicted increased blood pressure over time directly and also indirectly through associations with childhood family environment, negative emotionality, and health behavior.

The importance of measuring competency-based outcomes: standard evaluation measures are not surrogates for clinical performance of internal medicine residents

BACKGROUND

Despite recent emphasis on educational outcomes, program directors still rely on standard evaluation techniques such as tests of knowledge and subjective ratings.

PURPOSES

To assess the correlation of standard internal medicine (IM) residency evaluation scores (attending global evaluations, In-Training examination, and Mini-Clinical Examination Exercise) with documented performance of preventive measures for continuity clinic patients.

METHODS

Cross-sectional study of 132 IM residents attending an IM teaching clinic, July 2000 to June 2003, comparing standard evaluations with chart audit.

RESULTS

Mean resident performance ranged from 53% (SD = 24) through 89% (SD = 20) across the 6 preventive measures abstracted from 1,102 patient charts. We found weak and mostly not significant correlations between standard measures and performance of preventive services.

CONCLUSIONS

Standard measures are not adequate surrogates for measuring clinical outcomes. This supports the Accreditation Council for Graduate Medical Education's recommendations to incorporate novel Toolbox measures, like chart audit, into residency evaluations.

Characteristics that predict physician participation in a Web-based CME activity: the MI-Plus study

INTRODUCTION

Physician use of the Internet for practice improvement has increased dramatically over the last decade, but research shows that many physicians choose not to participate. The current study investigated the association of specific physician characteristics with enrollment rates and intensity of participation in a specific Internet-delivered educational intervention to improve care to post-myocardial infarction (MI) patients.

METHODS

Primary-care physicians were recruited for participation in a randomized controlled trial designed to compare effectiveness of an intervention Web site versus a control Web site in the management of adult chronic disease. Physicians were informed that the intervention focused on ambulatory post-myocardial infarction patients. Physician characteristics were obtained from a commercial vendor with data merged from the American Medical Association and Alabama State Licensing Board. Enrollment and Web use were tracked electronically.

RESULTS

Out of a sample of 1337 eligible physicians, 177 (13.2%) enrolled in the study. Enrollment was higher for physicians with more post-MI patients (> or = 20 vs < 20 patients, 15.3% vs 9.3%, P = .002) and for those practicing in rural compared to urban areas (16.3% vs 12.1%, P = .046). Intensity of use of the Internet courses after initial enrollment was not predicted by physician characteristics in the current sample.

DISCUSSION

Physicians with more post-MI patients and rural practice location were found to predict enrollment in an Internet-delivered continuing medical education (CME) intervention designed to improve care for post-MI patients. These factors predicted program interest but not program use. More research is needed to replicate these findings to investigate variables that determine physician engagement in Internet CME.

Internet delivered support for tobacco control in dental practice: randomized controlled trial

Background

The dental visit is a unique opportunity for tobacco control. Despite evidence of effectiveness in dental settings, brief provider-delivered cessation advice is underutilized.

Objective

To evaluate an Internet-delivered intervention designed to increase implementation of brief provider advice for tobacco cessation in dental practice settings.

Methods

Dental practices (N = 190) were randomized to the intervention website or wait-list control. Pre-intervention and after 8 months of follow-up, each practice distributed exit cards (brief patient surveys assessing provider performance, completed immediately after the dental visit) to 100 patients. Based on these exit cards, we assessed: whether patients were asked about tobacco use (ASK) and, among tobacco users, whether they were advised to quit tobacco (ADVISE). All intervention practices with follow-up exit card data were analyzed as randomized regardless of whether they participated in the Internet-delivered intervention.

Results

Of the 190 practices randomized, 143 (75%) dental practices provided follow-up data. Intervention practices’ mean performance improved post-intervention by 4% on ASK (29% baseline, adjusted odds ratio = 1.29 [95% CI 1.17-1.42]), and by 11% on ADVISE (44% baseline, OR = 1.55 [95% CI 1.28-1.87]). Control practices improved by 3% on ASK (Adj. OR 1.18 [95% CI 1.07-1.29]) and did not significantly improve in ADVISE. A significant group-by-time interaction effect indicated that intervention practices improved more over the study period than control practices for ADVISE (P = 0.042) but not for ASK.

Conclusion

This low-intensity, easily disseminated intervention was successful in improving provider performance on advice to quit.

Trial Registration

clinicaltrials.gov NCT00627185; http://clinicaltrials.gov/ct2/show/NCT00627185 (Archived by WebCite at http://www.webcitation.org/5c5Kugvzj)

Does interhospital transfer improve outcome of acute myocardial infarction? A propensity score analysis from the Cardiovascular Cooperative Project

BACKGROUND

Many patients suffering acute myocardial infarction (AMI) are transferred from one hospital to another during their hospitalization. There is little information about the outcomes related to interhospital transfer. The purpose of this study was to compare processes and outcomes of AMI care among patients undergoing interhospital transfer with special attention to the impact on mortality in rural hospitals.

METHODS

National sample of Medicare patients in the Cooperative Cardiovascular Study (n = 184,295). Retrospective structured medical record review of AMI hospitalizations. Descriptive study using a retrospective propensity score analysis of clinical and administrative data for 184,295 Medicare patients admitted with clinically confirmed AMI to 4,765 hospitals between February 1994 and July 1995. Main outcome measure included: 30-day mortality, administration of aspirin, beta-blockers, ACE-inhibitors, and thrombolytic therapy.

RESULTS

Overall, 51,530 (28%) patients underwent interhospital transfer. Transferred patients were significantly younger, less critically ill, and had lower comorbidity than non-transferred patients. After propensity-matching, patients who underwent interhospital transfer had better quality of care anlower mortality than non-transferred patients. Patients cared for in a rural hospital had similar mortality as patients cared for in an urban hospital.

CONCLUSION

Transferred patients were vastly different than non-transferred patients. However, even after a rigorous propensity-score analysis, transferred patients had lower mortality than non-transferred patients. Mortality was similar in rural and urban hospitals. Identifying patients who derive the greatest benefit from transfer may help physicians faced with the complex decision of whether to transfer a patient suffering an acute MI.

Long-term risk of mortality and end-stage renal disease among the elderly after small increases in serum creatinine level during hospitalization for acute myocardial infarction

BACKGROUND

Although small changes in creatinine level during hospitalization have been associated with risk of short-term mortality, associations with posthospitalization end-stage renal disease (ESRD) and long-term mortality are unknown. We assessed the relationship between change in serum creatinine levels up to 3.0 mg/dL and death and ESRD among elderly survivors of hospitalization for acute myocardial infarction.

METHODS

Retrospective cohort study of a nationally representative sample of Medicare beneficiaries admitted with acute myocardial infarction to nonfederal US hospitals between February 1994 and July 1995. Outcomes were mortality and ESRD through June 2004.

RESULTS

The 87 094 eligible patients admitted to 4473 hospitals had a mean age of 77.1 years; for the 43.2% with some creatinine increase, quartiles of increase were 0.1, 0.2, 0.3 to 0.5, and 0.6 to 3.0 mg/dL. Incidence of ESRD and mortality ranged from 2.3 and 139.1 cases per 1000 person-years, respectively, among patients with no increase to 20.0 and 274.9 cases per 1000 person-years in the highest quartile of creatinine increase. Compared with patients without creatinine increase, adjusted hazard ratios by quartile of increase were 1.45, 1.97, 2.36, and 3.26 for ESRD and 1.14, 1.16, 1.26, and 1.39 for mortality, with no 95% confidence intervals overlapping 1.0 for either end point.

CONCLUSION

In a nationally representative sample of elderly patients discharged after hospitalization for acute myocardial infarction, small changes in serum creatinine level during hospitalization were associated with an independent higher risk of ESRD and death.

Association of neighborhood socioeconomic status with physical fitness in healthy young adults: the Coronary Artery Risk Development in Young Adults (CARDIA) study

BACKGROUND

Impaired physical fitness, a contributor to obesity and cardiovascular disease, has been associated with both an individual's socioeconomic status (SES) and with residence in disadvantaged neighborhoods. The aim of the study was to examine the extent to which neighborhood socioeconomic status (SES) is associated with impaired fitness, independent of clinical characteristics and individual-level SES.

METHODS

Two thousand five hundred five participants 25 to 42 years old examined in the CARDIA study from 1992 to 1993 underwent symptom-limited exercise stress testing. Physical fitness was considered impaired if metabolic equivalents were in the lowest sex-specific quintile. Neighborhood SES was determined for each census tract using 1990 census data. Generalized estimating equations assessed the association between neighborhood SES and physical fitness, before and after adjustments for individual SES, sociodemographic, and clinical characteristics, and accounted for clustering within census tracts.

RESULTS

Individuals in disadvantaged neighborhoods had lower educational attainment and income, and were more likely unemployed, black, and uninsured. The odds ratio (95% CI) for impaired physical fitness in the lowest vs highest tertile of neighborhood SES was 5.8 (3.7-7.3). These became 3.9 (2.7-5.7) after adjusting for individuals' educational attainment, personal income, employment status, and ability to pay for basic needs; and 1.9 (1.2-2.9) after additional adjustment for other sociodemographic and clinical factors.

CONCLUSIONS

Features of one's neighborhood of residence are relevant to cardiovascular health. A health policy perspective that looks beyond an individual's characteristics may therefore be useful in identifying more effective interventions to reduce the prevalence of low physical fitness and its consequences in young adults.

Racial/ethnic disparities in patient-reported nonsteroidal antiinflammatory drug (NSAID) risk awareness, patient-doctor NSAID risk communication, and NSAID risk behavior

OBJECTIVE

Nonsteroidal antiinflammatory drugs (NSAIDs) are commonly used and frequently lead to serious adverse events. Little is known about NSAID-related ethnic/racial disparities. We focused on differences in patient NSAID risk awareness, patient-doctor NSAID risk communication, and NSAID risk-avoidance behavior.

METHODS

We performed a cross-sectional analysis of survey data from the Alabama NSAID Patient Safety Study. Eligible patients were > or = 65 years old and currently taking prescription NSAIDs (Rx NSAIDS). Generalized linear latent and mixed models accounted for nesting of patients within physicians.

RESULTS

Of all 404 participants, 32% were African American and 73% were female. The mean +/- SD age was 72.8 +/- 7.5 years, and 64% reported an annual household income <$20,000. African American patients were less likely than white patients to recognize any risk associated with over-the-counter (OTC) NSAIDs (13.3% versus 29.3%; P = 0.001) and Rx NSAIDs (31.3% versus 49.6%; P = 0.001), report that their doctor discussed possible NSAID-related gastrointestinal problems (38.0% versus 52.4%; P = 0.007), and take medications to reduce ulcer risk (30.5% versus 50.2%; P = 0.001). Patients with lower income and education reported significantly less risk awareness for OTC and Rx NSAIDs. Racial/ethnic differences persisted after adjusting for multiple confounders.

CONCLUSION

In this community-based study of low income elderly individuals receiving NSAIDs, we identified important racial/ethnic differences in risk awareness, communication, and behavior. Additional efforts are needed to promote safe NSAID use and reduce ethnic/racial disparities.

Patient complexity: more than comorbidity. the vector model of complexity

BACKGROUND

The conceptualization of patient complexity is just beginning in clinical medicine.

OBJECTIVES

This study aims (1) to propose a conceptual approach to complex patients; (2) to demonstrate how this approach promotes achieving congruence between patient and provider, a critical step in the development of maximally effective treatment plans; and (3) to examine availability of evidence to guide trade-off decisions and assess healthcare quality for complex patients.

METHODS/RESULTS

The Vector Model of Complexity portrays interactions between biological, socioeconomic, cultural, environmental and behavioral forces as health determinants. These forces are not easily discerned but exert profound influences on processes and outcomes of care for chronic medical conditions. Achieving congruence between patient, physician, and healthcare system is essential for effective, patient-centered care; requires assessment of all axes of the Vector Model; and, frequently, requires trade-off decisions to develop a tailored treatment plan. Most evidence-based guidelines rarely provide guidance for trade-off decisions. Quality measures often exclude complex patients and are not designed explicitly to assess their overall healthcare.

CONCLUSIONS/RECOMMENDATIONS

We urgently need to expand the evidence base to inform the care of complex patients of all kinds, especially for the clinical trade-off decisions that are central to tailoring care. We offer long- and short-term strategies to begin to incorporate complexity into quality measurement and performance profiling, guided by the Vector Model. Interdisciplinary research should lay the foundation for a deeper understanding of the multiple sources of patient complexity and their interactions, and how provision of healthcare should be harmonized with complexity to optimize health.

Self-reported racial discrimination and substance use in the Coronary Artery Risk Development in Adults Study

The authors investigated whether substance use and self-reported racial discrimination were associated in the Coronary Artery Risk Development in Young Adults (CARDIA) Study. Smoking status, alcohol consumption, and lifetime use of marijuana, amphetamines, and opiates were ascertained in 2000-2001, 15 years after baseline (1985-1986). Most of the 1,507 African Americans reported having experienced racial discrimination, 79.5% at year 7 and 74.6% at year 15, compared with 29.7% and 23.7% among the 1,813 Whites. Compared with African Americans experiencing no discrimination, African Americans reporting any discrimination had more education and income, while the opposite was true for Whites (all p < 0.001). African Americans experiencing racial discrimination in at least three of seven domains in both years had 1.87 (95% confidence interval (CI): 1.18, 2.96) and 2.12 (95% CI: 1.42, 3.17) higher odds of reporting current tobacco use and having any alcohol in the past year than did their counterparts experiencing no discrimination. With control for income and education, African Americans reporting discrimination in three or more domains in both years had 3.31 (95% CI: 1.90, 5.74) higher odds of using marijuana 100 or more times in their lifetime, relative to African Americans reporting no discrimination. These associations were similarly positive in Whites but not significant. Substance use may be an unhealthy coping response to perceived unfair treatment for some individuals, regardless of their race/ethnicity.

Relationships between skin color, income, and blood pressure among African Americans in the CARDIA Study

OBJECTIVES

We explored how income and skin color interact to influence the blood pressure of African American adults enrolled in the longitudinal Coronary Artery Risk Development in Young Adults (CARDIA) Study.

METHODS

Data were derived from 1893 African American CARDIA year-15 participants who had undergone skin reflectance assessments at year 7. We adjusted for age, gender, body mass index, smoking status, and use of antihypertensive medication to examine whether year-15 self-reported family incomes, in interaction with skin reflectance, predicted blood pressure levels.

RESULTS

Mean systolic and diastolic blood pressure levels were 117.1 (+/-16.07) and 76.9 (+/-12.5) mm Hg, respectively. After adjustment, the interaction between skin reflectance and income was significantly associated with systolic blood pressure (P< .01). Among lighter-skinned African Americans, systolic pressure decreased as income increased (b= -1.15, P<.001); among those with darker skin, systolic blood pressure increased with increasing income (b=0.10, P=.75).

CONCLUSIONS

The protective gradient of income on systolic blood pressure seen among African Americans with lighter skin is not observed to the same degree among those with darker skin. Psychosocial stressors, including racial discrimination, may play a role in this relationship.

Illicit drug use in young adults and subsequent decline in general health: the Coronary Artery Risk Development in Young Adults (CARDIA) Study

BACKGROUND

The long-term health consequences of drug use among healthy young adults in the general population are not well described. We assessed whether drug use predicted decline in general self-rated health (GSRH) in a community-based cohort, healthy at baseline.

METHODS

A prospective cohort of 3124 young adults (20-32 years old) from four US cities, the Coronary Artery Risk Development in Young Adults Study, was followed from 1987/1988 to 2000/2001. All reported "Good" or better GSRH at baseline, with reassessment in 2000/2001. Drug use in 1987/1988 was as follows: 812 participants were Never Users; 1554 Past Users Only; 503 Current Marijuana Users Only; 255 Current Hard Drug Users (e.g. cocaine, amphetamines, opiates). Analyses measured the association of drug use (1987/1988) with decline to "Fair" or "Poor" GSRH in 2000/2001, adjusting for biological and psychosocial covariates.

RESULTS

Reporting health decline were: 7.2% of Never Users; 6.5%, Past Use Only; 7.0%, Current Marijuana Only; 12.6%, Current Hard Drugs (p<0.01). After multivariable adjustment, Current Hard Drug Use in 1987/1988 remained associated with health decline (Odds Ratio (OR), referent Never Use: 1.83, 95% confidence interval (CI) 1.07-3.12). The health decline associated with Current Hard Drugs appeared to be partly mediated by tobacco smoking in 2000/2001, which independently predicted health decline (OR 1.66, 95% CI 1.08-2.50) and weakened the apparent effect of Current Hard Drugs (OR 1.21, 95% CI 0.62-2.36).

CONCLUSIONS

Hard drug use in healthy young adults, even when hard drug use stops, is associated with a subsequent decrease in general self-rated health that may be partially explained by persistent tobacco use.

Challenges in improving the quality of osteoporosis care for long-term glucocorticoid users: a prospective randomized trial

BACKGROUND

In light of widespread undertreatment for glucocorticoid-induced osteoporosis (GIOP), we designed a group randomized controlled trial to increase bone mineral density (BMD) testing and osteoporosis medication prescribing among patients receiving long-term glucocorticoid therapy.

METHODS

Using administrative databases of a large US health plan, we identified physicians who prescribed long-term glucocorticoid therapy to at least 3 patients. One hundred fifty-three participating physicians were randomized to receive a 3-module Web-based GIOP intervention or control course. Intervention modules focused on GIOP management and incorporated case-based continuing medical education and personalized audit and feedback of GIOP management compared with that of the top 10% of study physicians. In the year following the intervention, we compared rates of BMD testing and osteoporosis medication prescribing between intervention and control physicians.

RESULTS

Following the intervention, intent-to-treat analyses showed that 78 intervention physicians (472 patients) vs 75 control physicians (477 patients) had similar rates of BMD testing (19% vs 21%, P = .48; rate difference, -2%; 95% confidence interval [CI], -8% to 4%) and osteoporosis medication prescribing (32% vs 29%, P = .34; rate difference, 3%; 95% CI, -3% to 9%). Among 45 physicians completing all modules (343 patients), intervention physicians had numerically but not significantly higher rates of BMD testing (26% vs 16%, P =.04; rate difference, 10%; 95% CI, 1%-20%) and bisphosphonate prescribing (24% vs 17%, P =.09; rate difference, 7%; 95% CI, -1% to 16%) or met a combined end point of BMD testing or osteoporosis medication prescribing (54% vs 44%, P =.07; rate difference, 10%; 95% CI, -1% to 21%) compared with control physicians.

CONCLUSIONS

In the main analysis, a Web-based intervention incorporating performance audit and feedback and case-based continuing medical education had no significant effect on the quality of osteoporosis care. However, dose-response trends showed that physicians with greater exposure to the intervention had higher rates of GIOP management. New cost-effective modalities are needed to improve the quality of osteoporosis care.

Reduced Medication Access

Background and Purpose— Medication access is crucial to secondary stroke prevention. We assessed medication access and associated barriers to care across region and time in a national sample of US stroke survivors.

Methods— Among all 5840 black or white stroke survivors aged ≥45 years responding to the National Health Interview Survey years 1997 to 2004, we examined inability to afford medications within the last 12 months across region (Northeast, Midwest, West, South) and time. With logistic regression, we adjusted associations between medication inaffordability and region and time for age, sex, race, neurological disability, comorbidity, health status, insurance, income and out-of-pocket medical expenses.

Results— In 2004, ≈76 000 US stroke survivors were unable to afford medications. Lower medication affordability was reported among stroke survivors who were <65 years old, black, female, had high comorbidity or low health status. Compared with stroke survivors able to afford medications, those unable more frequently reported lack of transportation (15% versus 3%; P <0.001), no health insurance (16% versus 3%; P <0.001), no usual place of care (6% versus 2%; P =0.001), income <$20 000 (66% versus 40%; P <0.001) and out-of-pocket medical expenses ≥$2000 (35% versus 25%; P <0.001). From 1997 to 2004, inability to afford medications increased significantly from 8.1% to 12.7% (P trend =0.01) overall and increased in all US regions except the Northeast.

Conclusions— We identified a vulnerable stroke survivor population with reduced medication access and increased barriers to medical care. Membership in this population has grown substantially from 1997 to 2004, potentially leading to increased recurrent stroke incidence.

Multiple measures of provider participation in Internet delivered interventions

Evaluation of Internet-delivered continuing education for health care providers requires appropriate consideration of their level of participation. To fully assess participation requires multidimensional measures, including factors such as the volume of participation (page views), frequency (visits), variety (components accessed by each provider), and duration (months of activity). We calculated crude and refined (adjusted for study design) measures and then compared these measures across three longitudinal Internet-delivered continuing education to health care providers (N=429). We found that participation varied across study, varied by factor and varied by specific measure. Correlation between crude and refined measures within a factor and across factors differed significantly. Participation assessment of internet-delivered interventions varies by the selection of measure and factor. Further research assessing the potential for these measures to predict intervention effectiveness is needed.

Younger Stroke Survivors Have Reduced Access to Physician Care and Medications

BACKGROUND

More than 5 million US stroke survivors require comprehensive care for risk factor modification and secondary prevention. Younger stroke survivors may have reduced access to physician care and medications because they are more frequently uninsured.

OBJECTIVE

To assess age-related differences in access to physician care and medications among stroke survivors (aged 45-64 years vs > or = 65 years).

DESIGN

National Health Interview Survey from years 1998 to 2002.

SETTING

A US population-based survey.

PARTICIPANTS

Stroke survivors (n = 3681) aged 45 years and older among 159 985 survey respondents.

MAIN OUTCOME MEASURES

General doctor visit, medical specialist visit, and inability to afford medications within the last 12 months.

RESULTS

Compared with older stroke survivors, younger stroke survivors more frequently reported no general doctor visit (10% vs 14%, respectively; P = .002), no general doctor or medical specialist visit (5% vs 8%, respectively; P = .003), and the inability to afford medications (6% vs 15%, respectively; P<.001). Younger age was independently associated with no general doctor visit (odds ratio, 1.40; 95% confidence interval, 1.04-1.88), no general doctor or medical specialist visit (odds ratio, 1.69; 95% confidence interval, 1.14-2.52), and the inability to afford medications (odds ratio, 2.94; 95% confidence interval, 2.19-3.94) after adjusting for sex, race, income, neurological disability, health status, and comorbidity. With further adjustment for health insurance, younger age remained independently associated with the inability to afford medications but not the lack of physician visits.

CONCLUSIONS

Stroke survivors younger than 65 years reported worse access to physician care and medication affordability than older stroke survivors. Inadequate access among younger stroke survivors may lead to inadequate risk factor modification and recurrent cardiovascular events.

Cardiovascular disease risk factor knowledge in young adults and 10-year change in risk factors: the Coronary Artery Risk Development in Young Adults (CARDIA) Study

This study's objective was assessment of cardiovascular disease (CVD) risk factor knowledge in young adults, its association with 10-year changes in risk factor levels, and variables related to risk factor knowledge. A total of 4,193 healthy persons (55% female, 48% Black; mean age=30 years) from four urban US communities were queried about risk factor knowledge in 1990-1991 and were reexamined in 2000-2001. Of six risk factors considered (hypertension, hyperlipidemia, smoking, overweight, sedentary lifestyle, and unhealthy diet), participants mentioned a mean of two; more than 65% were not aware of any risk factors, and less than 35% recognized being overweight as a risk factor. After adjustment, variables associated with mentioning more than two CVD risk factors versus one or fewer were Black race (OR=0.52, 95% confidence interval (CI): 0.44, 0.61), having a high school education or less (OR=0.88, 95% CI: 0.80, 0.95), having one or two (vs. zero) risk factors (OR=1.27, 95% CI: 1.05, 1.53), and having three or more (vs. zero) risk factors (OR=1.79, 95% CI: 1.35, 2.38). More knowledge was marginally associated with less increase in body mass index 10 years later (p=0.06) but was unrelated to other risk factor changes. Knowledge of CVD risk factors was very low in these young adults but increased with the presence of risk factors. Knowledge alone did not predict 10-year changes in risk factors.

Incidence and antecedents of nonmedical prescription opioid use in four US communities. The Coronary Artery Risk Development in Young Adults (CARDIA) prospective cohort study

BACKGROUND

Nonmedical use of prescription opioids has emerged as a major public health problem during the last decade, but direct measures of incidence and predisposing factors are lacking.

METHODS

We prospectively measured incidence and antecedents of nonmedical prescription opioid use in The Coronary Artery Risk Development in Young Adults study among 28-40-year-old African- and European-American men and women with no prior history of nonmedical opioid use.

RESULTS

Among 3163 participants, 23 reported new nonmedical prescription opioid use in 2000-2001 (5-year incidence 0.7%; 95%CI: 0.4-1.0%). All 23 had previously reported marijuana use (p<0.001). Five-year incidence was significantly higher among European-American men (OR=3.3; 95%CI: 1.3-8.3), and among participants reporting a history of amphetamine use (OR=24; 95%CI: 6.9-83) or medical opioid use for treatment of pain (OR=8.6; 95%CI: 2.5-30). These associations remained strong when examined among marijuana users and after adjusting for demographics, social factors, and other antecedent substance use. Amphetamine use was the best single predictor of future nonmedical use (sensitivity 87%, specificity 79%).

CONCLUSIONS

Initiation of nonmedical prescription opioid use is generally rare in 28-40-year-old adults, but is observed to be more common with a previous history of substance abuse and legal access to opioids through prescription by a physician.

Menthol cigarettes, smoking cessation, atherosclerosis, and pulmonary function: the Coronary Artery Risk Development in Young Adults (CARDIA) Study

BACKGROUND

African American smokers are more likely to experience tobacco-related morbidity and mortality than European American smokers, and higher rates of menthol cigarette smoking may contribute to these disparities.

METHODS

We prospectively measured cumulative exposure to menthol and nonmenthol cigarettes and smoking cessation behavior (1985-2000), coronary calcification (2000), and 10-year change in pulmonary function (1985-1995) in African American and European American smokers recruited in 1985 for the Coronary Artery Risk Development in Young Adults Study.

RESULTS

We identified 1535 smokers in 1985 (972 menthol and 563 nonmenthol); 89% of African Americans preferred menthol vs 29% of European Americans (P<.001). After adjustment for ethnicity, demographics, and social factors, we found nonsignificant trends in menthol smokers toward lower cessation (odds ratio [OR], 0.71; 95% confidence interval [CI], 0.49-1.02; P = .06) and recent quit attempt (OR, 0.77; 95% CI, 0.56-1.06; P = .11) rates and a significant increase in the risk of relapse (OR, 1.89; 95% CI, 1.17-3.05; P = .009). Per pack-year of exposure, however, we found no differences from menthol in tobacco-related coronary calcification (adjusted OR, 1.27; 95% CI, 1.01-1.60 for menthol cigarettes and 1.33; 95% CI, 1.06-1.68 for nonmenthol cigarettes per 10-pack-year increase; P = .75 for comparison) or 10-year pulmonary function decline (adjusted excess decline in forced expiratory volume in 1 second, 84 mL; 95% CI, 32-137 for menthol cigarettes and 80 mL; 95% CI, 30-129 for nonmenthol cigarettes, per 10-pack-year increase; P = .88 for comparison).

CONCLUSION

Menthol and nonmenthol cigarettes seem to be equally harmful per cigarette smoked in terms of atherosclerosis and pulmonary function decline, but menthol cigarettes may be harder to quit smoking.

Relationship of early life stress and psychological functioning to adult C-reactive protein in the coronary artery risk development in young adults study

BACKGROUND

Low socioeconomic status (SES) and a harsh family environment in childhood have been linked to mental and physical health disorders in adulthood. The objective of the present investigation was to evaluate a developmental model of pathways that may help explain these links and to relate them to C-reactive protein (CRP) in the Coronary Artery Risk Development in Young Adults (CARDIA) dataset.

METHODS

Participants (n = 3248) in the CARDIA study, age 32 to 47 years, completed measures of childhood SES (CSES), early family environment (risky families [RF]), adult psychosocial functioning (PsyF, a latent factor measured by depression, mastery, and positive and negative social contacts), body mass index (BMI), and C-reactive protein.

RESULTS

Structural equation modeling indicated that CSES and RF are associated with C-reactive protein via their association with PsyF (standardized path coefficients: CSES to RF, RF to PsyF, PsyF to CRP, CSES to CRP, all p < .05), with good overall model fit. The association between PsyF and CRP was partially mediated by BMI (PsyF to BMI, BMI to CRP, both p < .05).

CONCLUSIONS

Low childhood SES and a harsh early family environment appear to be related to elevated C-reactive protein in adulthood through pathways involving psychosocial dysfunction and high body mass index.

Self-reported health, perceived racial discrimination, and skin color in African Americans in the CARDIA study

This study investigates the association between self-reported physical and mental health and both perceived racial discrimination and skin color in African American men and women. We used data from the longitudinal coronary artery risk development in young adults study (CARDIA) in African American men and women (n=1722) in the USA. We assessed self-reported mental and physical health status and depressive symptoms at the Year 15 (2000-2001) follow-up examination using the Medical Outcomes Study Short Form (SF-12) and the Center for Epidemiologic Studies Depression scale. Skin color was measured at the Year 7 examination (1992-1993). To assess racial discrimination, we used a summary score (range 0-21) for 7 questions on experiencing racial discrimination: at school, getting a job, getting housing, at work, at home, getting medical care, on the street or in a public setting. Self-reported racial discrimination was more common in men than in women (78.1% versus 73.0%, p<0.05) and in those with higher educational attainment, independent of gender. Discrimination was statistically significantly associated with worse physical and mental health in both men and women, before and after adjustment for age, education, income, and skin color. For example, mental health (0-100 scale) decreased an average of 0.29 units per unit increase in racial discrimination score in men; this became 0.32 units after adjustment. There was no association between self-reported physical and mental health and skin color. Further studies of the health consequences of discrimination will require investigation of both the upstream determinants of discrimination and the downstream mechanisms by which perceived discrimination affects health outcomes.

Survival Advantage of Black Patients with Kidney Disease after Acute Myocardial Infarction

Black individuals have a disproportionate incidence of ESRD when compared with white individuals, and among patients with ESRD, black patients experience better survival. The aim of this analysis is to assess, in a nationally representative sample of patients with cardiovascular disease, ethnic differences in survival among predialysis patients with kidney disease. A retrospective cohort analysis was conducted of Cooperative Cardiovascular Project data of Medicare patients who were aged > 65 yr and admitted for incident acute myocardial infarction and had 3 yr of mortality follow-up. Cox regression models and Kaplan Meier estimates were performed to examine differences in survival between black and white patients stratified by severity of kidney disease. Of 57,942 patients, 7.3% were black. Black patients were younger and more likely to be female and were less likely to have decreased kidney function. A significant interaction between race and kidney function existed with respect to mortality among patients who survived to discharge. The adjusted hazard ratios for death, black compared with white patients, were 1.00 (95% confidence interval 0.90 to 1.11) among patients with a GFR > or = 60 ml/min per 1.73 m2 and decreased monotonically among patients with lower GFR to 0.79 (95% confidence interval 0.61 to 0.97) among patients with a GFR 15 to 29 ml/min per 1.73 m2. Among patients with incident acute myocardial infarction, black patients with more severe kidney disease, when compared with their white counterparts, experience better survival. Further investigation into the reasons for ethnic differences in survival and progression of kidney disease is warranted.

Active and passive smoking and development of glucose intolerance among young adults in a prospective cohort: CARDIA study

OBJECTIVE

To assess whether active and passive smokers are more likely than non-smokers to develop clinically relevant glucose intolerance or diabetes.

DESIGN

Coronary artery risk development in young adults (CARDIA) is a prospective cohort study begun in 1985-6 with 15 years of follow-up.

SETTING

Participants recruited from Birmingham, Alabama; Chicago, Illinois; Minneapolis, Minnesota; and Oakland, California, USA.

PARTICIPANTS

Black and white men and women aged 18-30 years with no glucose intolerance at baseline, including 1386 current smokers, 621 previous smokers, 1452 never smokers with reported exposure to secondhand smoke (validated by serum cotinine concentrations 1-15 ng/ml), and 1113 never smokers with no exposure to secondhand smoke.

MAIN OUTCOME MEASURE

Time to development of glucose intolerance (glucose > or = 100 mg/dl or taking antidiabetic drugs) during 15 years of follow-up.

RESULTS

Median age at baseline was 25, 55% of participants were women, and 50% were African-American. During follow-up, 16.7% of participants developed glucose intolerance. A graded association existed between smoking exposure and the development of glucose intolerance. The 15 year incidence of glucose intolerance was highest among smokers (21.8%), followed by never smokers with passive smoke exposure (17.2%), and then previous smokers (14.4%); it was lowest for never smokers with no passive smoke exposure (11.5%). Current smokers (hazard ratio 1.65, 95% confidence interval 1.27 to 2.13) and never smokers with passive smoke exposure (1.35, 1.06 to 1.71) remained at higher risk than never smokers without passive smoke exposure after adjustment for multiple baseline sociodemographic, biological, and behavioural factors, but risk in previous smokers was similar to that in never smokers without passive smoke exposure.

CONCLUSION

These findings support a role of both active and passive smoking in the development of glucose intolerance in young adulthood.

Education, 15-year risk factor progression, and coronary artery calcium in young adulthood and early middle age: the Coronary Artery Risk Development in Young Adults study

CONTEXT

The inverse association between education and cardiovascular disease is well established, but little is known about the relationship between education and subclinical disease, which is free from medical access and treatment-related influences, or about possible mediating pathways for these relationships.

OBJECTIVE

To examine the association of education with coronary artery calcium (CAC), an indicator of subclinical atherosclerosis, and cardiovascular risk factors, and their changes as potential mediators.

DESIGN, SETTING, AND PARTICIPANTS

A population-based, prospective, observational study (Coronary Artery Risk Development in Young Adults [CARDIA]) of 2913 eligible participants (44.9% black; 53.9% women) recruited from 4 metropolitan areas (Birmingham, Ala; Chicago, Ill; Minneapolis, Minn; and Oakland, Calif) in both the baseline (1985-1986, ages 18-30 years) and year 15 examinations (2000-2001, ages 33-45 years). Education (year 15) was classified into less than high school (n = 128), high school graduate (n = 498), some college (n = 902), college graduate (n = 764), and more than college (n = 621).

MAIN OUTCOME MEASURE

Presence of CAC, measured twice by computed tomography (mean total Agatston score >0) at year 15.

RESULTS

Overall CAC prevalence in this sample was 9.3%. After adjusting for age, race, and sex, the odds ratios (ORs) for having CAC were 4.14 (95% confidence interval [CI], 2.33-7.35) for less than high school education, 1.89 (95% CI, 1.23-2.91) for high school graduate, 1.47 (95% CI, 0.99-2.19) for some college, and 1.24 (95% CI, 0.84-1.85) for college graduate compared with those participants with more than a college education (P for trend<.001). This was also consistent within each of the 4 race-sex groups. Adjustment for baseline systolic blood pressure, smoking, waist circumference, physical activity, and total cholesterol reduced the ORs to 2.61 (95% CI, 1.40-4.85) for less than high school, 1.38 (95% CI, 0.88-2.17) for high school graduate, 1.17 (95% CI, 0.78-1.77) for some college, and 1.13 (95% CI, 0.76-1.69) for college graduate compared with more than a college education (P for trend = .01), and only slightly attenuated by further adjustment for 15-year changes in risk factors.

CONCLUSION

Education was inversely associated with the prevalence of CAC, an association partially explained by baseline risk factors and minimally by 15-year changes in risk factors.

Measuring resident physicians' performance of preventive care. Comparing chart review with patient survey

BACKGROUND

The Accreditation Council for Graduate Medical Education has suggested various methods for evaluation of practice-based learning and improvement competency, but data on implementation of these methods are limited.

OBJECTIVE

To compare medical record review and patient surveys on evaluating physician performance in preventive services in an outpatient resident clinic.

DESIGN

Within an ongoing quality improvement project, we collected baseline performance data on preventive services provided for patients at the University of Alabama at Birmingham (UAB) Internal Medicine Residents' ambulatory clinic.

PARTICIPANTS

Seventy internal medicine and medicine-pediatrics residents from the UAB Internal Medicine Residency program.

MEASUREMENTS

Resident- and clinic-level comparisons of aggregated patient survey and chart documentation rates of (1) screening for smoking status, (2) advising smokers to quit, (3) cholesterol screening, (4) mammography screening, and (5) pneumonia vaccination.

RESULTS

Six hundred and fifty-nine patient surveys and 761 charts were abstracted. At the clinic level, rates for screening of smoking status, recommending mammogram, and for cholesterol screening were similar (difference <5%) between the 2 methods. Higher rates for pneumonia vaccination (76% vs 67%) and advice to quit smoking (66% vs 52%) were seen on medical record review versus patient surveys. However, within-resident (N=70) comparison of 2 methods of estimating screening rates contained significant variability. The cost of medical record review was substantially higher ($107 vs $17/physician).

CONCLUSIONS

Medical record review and patient surveys provided similar rates for selected preventive health measures at the clinic level, with the exception of pneumonia vaccination and advising to quit smoking. A large variation among individual resident providers was noted.

Disparities by insurance status in quality of care for elderly patients with unstable angina

CONTEXT

Treatment disparities for socioeconomically disadvantaged populations have been widely reported, but few studies have sought explanations for these disparities.

OBJECTIVE

To compare the quality of care for patients insured by Medicare alone, Medicare plus Medicaid, or Medicare plus private insurance and investigate mediators for potential disparities.

DESIGN, SETTING, AND PARTICIPANTS

Retrospective, random chart review of 3122 African American or White Medicare patients >65 years of age hospitalized for unstable angina in 22 Alabama hospitals, 1993-1999.

MAIN OUTCOME MEASURES

Echocardiogram within 20 minutes of presentation; evaluation by a cardiologist; appropriate anti-platelet therapy within 24 hours of admission and at discharge, heparin for high-risk patients, beta-blockers during hospitalization, and performance of appropriate coronary angiography.

RESULTS

182 (5.8%) had Medicare only, 433 (13.9%) had Medicare plus Medicaid, and 2507 (80.3%) had Medicare plus private insurance. Medicaid patients were more frequently Black, female, >85 years old, had multiple co-morbidities, or were admitted to hospitals without cardiac catheterization facilities (P<.001). Fewer Medicaid patients were admitted to hospitals with cardiac catheterization capabilities. Even after adjustment for demographics and hospital characteristics, Medicaid patients were less likely to see a cardiologist (odds ratio [OR] .57, 95% confidence interval [CI] .44-.73), receive antiplatelet therapy within 24 hours of admission (OR .66, 95% CI .50-.87), or heparin (OR .71, 95% CI .53-.97). No differences were seen with regard to having an electrocardiogram within 20 minutes of admission. Beta-blockers were used least in the Medicare-only patients, with only 37.7% receiving them (P=.04). Suitable Medicaid patients received coronary angiography less often, even after adjustment for demographics, co-morbidity, and prior revascularization (OR .68, 95% CI .48-.97). However, when adjusted for hospital characteristics, this finding was no longer observed (OR .94, 95% CI .64-1.39).

CONCLUSIONS

Elderly Medicaid patients appear to receive poorer quality of care. This finding is partially, but not completely, explained by characteristics of the facilities where they are hospitalized.

Predictors of wound infection in ventral hernia repair

BACKGROUND

Postoperative wound infection is a significant risk factor for recurrence after ventral hernia repair (VHR). The current study examines patient- and procedure-specific variables associated with wound infection.

METHODS

A cohort of subjects undergoing VHR from 13 regional Veterans Health Administration (VHA) sites was identified. Patient-specific risk variables were obtained from National Surgical Quality Improvement Program (NSQIP) data. Operative variables were obtained from physician-abstracted operative notes. Univariate and multivariable logistic regression analysis was used to model predictors of postoperative wound infection.

RESULTS

A total of 1505 VHR cases were used for analysis; wound infection occurred in 5% (n = 74). Best-fit logistic regression models demonstrated that steroid use, smoking, prolonged operative time, and use of absorbable mesh, acting as a surrogate marker for a more complex procedure, were significant independent predictors of wound infection.

CONCLUSION

Permanent mesh placement was not associated with postoperative wound infection. Smoking was the only modifiable risk factor and preoperative smoking cessation may improve surgical outcomes in VHR.

Cocaine and coronary calcification in young adults: the Coronary Artery Risk Development in Young Adults (CARDIA) Study

BACKGROUND

Cocaine use is associated with myocardial ischemia and infarction, but it is unclear whether this is only because of the acute effects of cocaine on heart rate, blood pressure, and vasomotor tone or whether accelerated atherosclerosis from long-term exposure to cocaine also contributes.

METHODS

We sought to measure the association between cocaine exposure and coronary calcification, a marker for atherosclerosis, among participants in the CARDIA Study who received computed tomography scanning and answered questions about illicit drug use at the year 15 examination in 2000-2001.

RESULTS

Among 3038 CARDIA participants (age 33-45 years, 55% women and 45% black), past cocaine exposure was reported by 35% and was more common among men, smokers, drinkers, and participants with less education. Powdered cocaine exposure was more common among whites, crack cocaine among blacks. Before adjustment, cocaine exposure was strongly associated with coronary calcification. After adjusting for age, sex, ethnicity, socioeconomic status, family history, and habits, however, these associations disappeared: adjusted odds ratios for coronary calcification were 0.9 (95% CI 0.6-1.3) for 1 to 10, 1.2 (95% CI 0.8-1.7) for 11 to 99, and 1.0 (95% CI 0.6-1.6) for > or =100 lifetime episodes of cocaine use, in comparison with none. Sex, tobacco, and alcohol use appeared to be primarily responsible for the confounding we observed in unadjusted models.

CONCLUSION

We found no evidence of a causal relationship between long-term exposure to cocaine and coronary calcification and conclude that acute nonatherogenic mechanisms probably explain most cocaine-associated myocardial infarction.

Relation of childhood socioeconomic status and family environment to adult metabolic functioning in the CARDIA study

OBJECTIVE

Low SES and a conflict-ridden, neglectful, or harsh family environment in childhood have been linked to a high rate of physical health disorders in adulthood. The objective of the present investigation was to evaluate a model of the pathways that may help to explain these links and to relate them to metabolic functioning (MF) in the Coronary Artery Risk Development In Young Adults (CARDIA) dataset.

METHODS

Participants (n = 3225) in the year 15 assessment of CARDIA, age 33 to 45 years, completed measures of childhood socioeconomic status (SES), risky early family environment (RF), adult psychosocial functioning (PsyF, a latent factor measured by depression, hostility, positive and negative social contacts), and adult SES. Indicators of the latent factor MF were assessed, specifically, cholesterol, insulin, glucose, triglycerides, and waist circumference.

RESULTS

The overall prevalence of metabolic syndrome was 9.7%. Structural equation modeling indicated that childhood SES and RF are associated with MF via their association with PsyF (standardized path coefficients: childhood SES to RF -0.13, RF to PsyF 0.44, PsyF to MF 0.09, all p < .05), but also directly (coefficient from childhood SES to MF -0.12, p < .05), with good overall model fit. When this model was tested separately for race-sex subgroups, it fit best for white women, fit well for African-American women and white men, but did not fit well for African-American men.

CONCLUSIONS

These results indicate that childhood SES and early family environment contribute to metabolic functioning through pathways of depression, hostility, and poor quality of social contacts.

Delay in Time to Receipt of Thrombolytic Medication Among Medicare Patients With Kidney Disease

BACKGROUND

Patients with kidney disease and acute myocardial infarction (AMI) receive standard therapy, including thrombolytic medication, less frequently than patients with normal kidney function. Our goal is to identify potential differences in thrombolytic medication delays and thrombolytic-associated bleeding events by severity of kidney disease.

METHODS

This is a retrospective cohort analysis of Cooperative Cardiovascular Project data for all Medicare patients with AMI from 4,601 hospitals. Outcome measures included time to administration of thrombolytic medication censored at 6 hours and bleeding events.

RESULTS

Of 109,169 patients (mean age, 77.4 years; 50.6% women), 13.9% received thrombolysis therapy. Average time to thrombolytic therapy was longer in patients with worse kidney function. Adjusted hazard ratios for minutes to thrombolytic therapy were 0.83 (95% confidence interval [CI], 0.79 to 0.87) for patients with a serum creatinine level of 1.6 to 2.0 mg/dL (141 to 177 micromol/L) and 0.58 (95% CI, 0.53 to 0.63) for patients with a creatinine level greater than 2.0 mg/dL (>177 micromol/L) or on dialysis therapy compared with those with normal kidney function. Odds ratios for bleeding events in patients administered thrombolytics versus those who were not decreased with worse kidney function: adjusted odds ratios, 2.28 (95% CI, 2.16 to 2.42) in patients with normal kidney function and 1.84 (95% CI, 1.09 to 3.10) in dialysis patients.

CONCLUSION

Patients with worse kidney function experienced treatment delays, but were not at greater risk for thrombolysis-associated excess bleeding events. Physician concerns of thrombolytic-associated bleeding may not be sufficient reason to delay the administration of thrombolytic medication.

Improving physician performance through Internet-based interventions: who will participate?

Background

The availability of Internet-based continuing medical education is rapidly increasing, but little is known about recruitment of physicians to these interventions.

Objective

The purpose of this study was to examine predictors of physician participation in an Internet intervention designed to increase screening of young women at risk for chlamydiosis.

Methods

Eligibility was based on administrative claims data, and eligible physicians received recruitment letters via fax and/or courier. Recruited offices had at least one physician who agreed to participate in the study by providing an email address. After one physician from an office was recruited, intensive recruitment of that office ceased. Email messages reminded individual physicians to participate by logging on to the Internet site.

Results

Of the eligible offices, 325 (33.2%) were recruited, from which 207 physicians (52.8%) participated. Recruited versus nonrecruited offices had more eligible patients (mean number of eligible patients per office: 44.1 vs 33.6; P < .001), more eligible physicians (mean number of eligible physicians per office: 6.2 vs 4.1; P < .001), and fewer doctors of osteopathy (mean percent of eligible physicians per office who were doctors of osteopathy: 20.5% vs 26.4%; P = .02). Multivariable analysis revealed that the odds of recruiting at least one physician from an office were greater if the office had more eligible patients and more eligible physicians. More participating versus nonparticipating physicians were female (mean percent of female recruited physicians: 39.1% vs 27.0%; P = .01); fewer participating physicians were doctors of osteopathy (mean percent of recruited physicians who were doctors of osteopathy: 15.5% vs 23.9%; P = .04) or international medical graduates (mean percent of recruited physicians who were international graduates: 12.3% vs 23.8%; P = .003). Multivariable analysis revealed that the odds of a physician participating were greater if the physician was older than 55 years (OR = 2.31; 95% CI = 1.09–4.93) and was from an office with a higher Chlamydia screening rate in the upper tertile (OR = 2.26; 95% CI = 1.23–4.16).

Conclusions

Physician participation in an Internet continuing medical education intervention varied significantly by physician and office characteristics.

Differences in preventive health quality by residency year. Is seniority better?

BACKGROUND

It is assumed that the performance of more senior residents is superior to that of interns, but this has not been assessed objectively.

OBJECTIVE

To determine whether adherence to national guidelines for outpatient preventive health services differs by year of residency training.

DESIGN

Cross-sectional study.

PARTICIPANTS

One hundred twenty Internal Medicine residents, postgraduate year (PGY)- 1 and PGY -2, attending a University Internal Medicine teaching clinic between June 2000 and May 2003.

MEASUREMENTS

We studied 6 preventive health care services offered or received by patients by abstracting data from 1,017 patient records. We examined the differences in performance between PGY-1 and PGY-2 residents.

RESULTS

Postgraduate year-2 residents did not statistically outperform PGY-1 residents on any measure. The overall proportion of patients receiving appropriate preventive health services for pneumococcal vaccination, advising tobacco cessation, breast and colon cancer screening, and lipid screening was similar across levels of training. PGY-1s outperformed PGY-2s for tobacco use screening (58%, 51%, P = .03). These results were consistent after accounting for clustering of patients within provider and adjusting for patient age, gender, race and insurance, resident gender, and number of visits during the measurement year.

CONCLUSIONS

Overall, patients cared for by PGY-2 residents did not receive more outpatient preventive health services than those cared for by PGY-1 residents. Efforts should be made to ensure quality patient care in the outpatient setting for all levels of training.

Report of the National Heart, Lung, and Blood Institute Working Group on Outcomes Research in Cardiovascular Disease

The National Heart, Lung, and Blood Institute convened a working group on outcomes research in cardiovascular disease (CVD). The working group sought to provide guidance on research priorities in outcomes research related to CVD. For the purposes of this document, "outcomes research" is defined as investigative endeavors that generate knowledge to improve clinical decision making and healthcare delivery to optimize patient outcomes. The working group identified the following priority areas: (1) national surveillance projects for high-prevalence CV conditions; (2) patient-centered care; (3) translation of the best science into clinical practice; and (4) studies that place the cost of interventions in the context of their real-world effectiveness. Within each of these topics, the working group described examples of initiatives that could serve the Institute and the public. In addition, the group identified the following areas that are important to the field: (1) promotion of the use of existing data; (2) facilitation of collaborations with other federal agencies; (3) investigations into the basic science of outcomes research, with an emphasis on methodological advances; (4) strengthening of appropriate study sections with individuals who have expertise in outcomes research; and (5) expansion of opportunities to train new outcomes research investigators. The working group concluded that a dedicated investment in CV outcomes research could directly improve the care delivered in the United States.

Chlamydia Screening of At-Risk Young Women in Managed Health Care: Characteristics of Top-Performing Primary Care Offices

OBJECTIVES

Despite effective approaches for managing chlamydial infection, asymptomatic disease remains highly prevalent. We linked administrative data with physician data from the American Medical Association physician survey to identify characteristics of primary care offices associated with best chlamydia screening practices.

STUDY

Criteria from the National Committee for Quality Assurance provided chlamydia screening rates. We defined top-performing offices as those with rates in the top decile among 978 primary care offices from 26 states.

RESULTS

Offices screened an average of 16.2% of at-risk, young women, but top-performing offices screened 42.2%. Top-performing offices on average had more black physicians (12.5%, 5.1%, P = 0.001) and were more often located in zip code areas with median income less than $30,000 (22.6%, 5.5%, P = 0.001).

CONCLUSIONS

Although chlamydia screening rates are alarmingly low overall, there is substantial variation across offices. Understanding predictors of better office performance may lead to effective interventions to promote screening.