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Shelton SK, Rice JD, Knoepke CE, Matlock DD, Havranek EP, Daugherty SL, Perman SM. Examining the Impact of Layperson Rescuer Gender on the Receipt of Bystander CPR for Women in Cardiac Arrest. Circ Cardiovasc Qual Outcomes 2024; 17:e010249. [PMID: 38533649 DOI: 10.1161/circoutcomes.123.010249] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/25/2023] [Accepted: 01/29/2024] [Indexed: 03/28/2024]
Abstract
BACKGROUND Women who suffer a witnessed out-of-hospital cardiac arrest receive bystander cardiopulmonary resuscitation (CPR) less often than men. To understand this phenomenon, we queried whether there are differences in deterrents to providing CPR based on the rescuer's gender. METHODS Participants were surveyed using a national crowdsourcing platform. Participants ranked the following 5 previously identified themes as reasons: rescuers are afraid to injure or hurt women; rescuers might have a misconception that women do not suffer cardiac arrest; rescuers are afraid to be accused of sexual assault or sexual harassment; rescuers have a fear of touching women or that their touch might be inappropriate; and rescuers think that women are faking it or being overdramatic. Participants were adult US residents able to correctly define CPR. Participants ranked the themes if the rescuer was gender unidentified, a man, and a woman, in variable order. RESULTS In November 2018, 520 surveys were completed. The respondents identified as 42.3% women, 74.2% White, 10.4% Black, and 6.7% Hispanic. Approximately half (48.1%) of the cohort knew how to perform CPR, but only 7.9% had ever performed CPR. When the rescuer was identified as a man, survey participants ranked fear of sexual assault or sexual harassment and fear of touching women or that the touch might be inappropriate as the top reasons (36.2% and 34.0% of responses, respectively). Conversely, when the rescuer was identified as a woman, survey respondents reported fear of hurting or injuring as the top reason (41.2%). CONCLUSIONS Public perceptions as to why women receive less bystander CPR than men were different based on the gender of the rescuer. Participants reported that men rescuers would potentially be hindered by fears of accusations of sexual assault/harassment or inappropriate touch, while women rescuers would be deterred due to fears of causing physical injury.
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Affiliation(s)
- Shelby K Shelton
- Department of Emergency Medicine, Children's Hospital of Orange County, CA (S.K.S.)
| | - John D Rice
- Department of Biostatistics and Informatics, University of Colorado Anschutz Medical Campus, Aurora (J.D.R.)
- Ludeman Center for Women's Health Research (J.D.R., C.E.K., S.M.P.), University of Colorado School of Medicine, Aurora
| | - Christopher E Knoepke
- Ludeman Center for Women's Health Research (J.D.R., C.E.K., S.M.P.), University of Colorado School of Medicine, Aurora
- Division of Cardiology, Department of Medicine (C.E.K.), University of Colorado School of Medicine, Aurora
- VA Eastern Colorado Geriatric Research Education and Clinical Center, Denver (C.E.K., D.D.M.)
| | - Daniel D Matlock
- Division of Geriatrics, Department of Medicine (D.D.M.), University of Colorado School of Medicine, Aurora
- VA Eastern Colorado Geriatric Research Education and Clinical Center, Denver (C.E.K., D.D.M.)
| | - Edward P Havranek
- Department of Internal Medicine, Denver Health Hospital Authority, CO (E.P.H.)
| | - Stacie L Daugherty
- Department of Emergency Medicine, Children's Hospital of Orange County, CA (S.K.S.)
| | - Sarah M Perman
- Ludeman Center for Women's Health Research (J.D.R., C.E.K., S.M.P.), University of Colorado School of Medicine, Aurora
- Department of Emergency Medicine (S.M.P.), University of Colorado School of Medicine, Aurora
- Department of Emergency Medicine, Yale School of Medicine, New Haven, CT (S.M.P.)
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Mazhindu T, Ndlovu N, Borok MZ, Meki S, Nyamhunga A, Havranek EP, Kessler ER, Campbell TB, Flaig TW. Metabolic and cardiovascular disease risk for Zimbabwean men with prostate cancer receiving long-term androgen deprivation therapy. Res Sq 2023:rs.3.rs-3723949. [PMID: 38168443 PMCID: PMC10760221 DOI: 10.21203/rs.3.rs-3723949/v1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 01/05/2024]
Abstract
Introduction Prostate cancer is a leading cause of cancer-related mortality in the majority of sub-Saharan Africa region countries. Androgen deprivation therapy (ADT) is effective treatment, however ADT is associated with complications including metabolic syndrome and cardiovascular disease. Although cardiovascular disease is a leading cause of mortality among prostate cancer patients, there is limited information on ADT impact on metabolic syndrome and cardiovascular disease risk among Africans. An observational prospective cohort study was carried out in Harare, Zimbabwe. Prostate cancer patients due to be initiated on ADT (medical or surgical) were assessed for metabolic syndrome and a 10-year Atherosclerotic Cardiovascular Disease (ASCVD) 10-year risk probability score was done before ADT and followed up to 9 months. Results 17 black Zimbabwean men were enrolled with a median age 72 years. Most participants (59%) had stage IV disease and 75% opted for surgical castration. At enrolment 23.5% had metabolic syndrome and this increased to 33% after 9 months of ADT. Baseline ASCVD risk was in the high risk category for 68.8% of participants and remained above 50% after 9 months of ADT. In this cohort, there is a 10% absolute increase in metabolic syndrome prevalence amongst African men with prostate cancer within 9 months of ADT initiation.
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Day GL, Havranek EP, Campbell EG, Mehta AB. Applying Intersectionality to Better Characterize Healthcare Disparities for Critically Ill Adults. Am J Respir Crit Care Med 2023; 207:1639-1641. [PMID: 37074149 PMCID: PMC10273110 DOI: 10.1164/rccm.202301-0153le] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 04/20/2023] Open
Affiliation(s)
- Gwenyth L. Day
- Division of Pulmonary Medicine and Critical Care Sciences
| | - Edward P. Havranek
- Division of General Internal Medicine, University of Colorado, Aurora, Colorado; and
- Department of Medicine, Denver Health & Hospital Authority, Denver, Colorado
| | - Eric G. Campbell
- Division of General Internal Medicine, University of Colorado, Aurora, Colorado; and
| | - Anuj B. Mehta
- Division of Pulmonary Medicine and Critical Care Sciences
- Department of Medicine, Denver Health & Hospital Authority, Denver, Colorado
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Mould-Millman NK, Dixon J, Beaty BL, Suresh K, de Vries S, Bester B, Moreira F, Cunningham C, Moodley K, Cermak R, Schauer SG, Maddry JK, Bills CB, Havranek EP, Bebarta VS, Ginde AA. Improving prehospital traumatic shock care: implementation and clinical effectiveness of a pragmatic, quasi-experimental trial in a resource-constrained South African setting. BMJ Open 2023; 13:e060338. [PMID: 37185181 PMCID: PMC10151988 DOI: 10.1136/bmjopen-2021-060338] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/30/2021] [Accepted: 04/13/2023] [Indexed: 05/17/2023] Open
Abstract
OBJECTIVES This project seeks to improve providers' practices and patient outcomes from prehospital (ie, ambulance-based) trauma care in a middle-income country using a novel implementation strategy to introduce a bundled clinical intervention. DESIGN We conduct a two-arm, controlled, mixed-methods, hybrid type II study. SETTING This study was conducted in the Western Cape Government Emergency Medical Services (EMS) system of South Africa. INTERVENTIONS We pragmatically implemented a simplified prehospital bundle of trauma care (with five core elements) using a novel workplace-based, peer-to-peer, rapid training format. We assigned the intervention and control sites. OUTCOME MEASURES We assessed implementation effectiveness among EMS providers and stakeholders, using the RE-AIM framework. Clinical effectiveness was assessed at the patient level, using changes in Shock Index x Age (SIxAge). Indices and cut-offs were established a priori. We performed a difference-in-differences (D-I-D) analysis with a multivariable mixed effects model. RESULTS 198 of 240 (82.5%) EMS providers participated, 93 (47%) intervention and 105 (53%) control, with similar baseline characteristics. The overall implementation effectiveness was excellent (80.6%): reach was good (65%), effectiveness was excellent (87%), implementation fidelity was good (72%) and adoption was excellent (87%). Participants and stakeholders generally reported very high satisfaction with the implementation strategy citing that it was a strong operational fit and effective educational model for their organisation. A total of 770 patients were included: 329 (42.7%) interventions and 441 (57.3%) controls, with no baseline differences. Intervention arm patients had more improved SIxAge compared with control at 4 months, which was not statistically significant (-1.4 D-I-D; p=0.35). There was no significant difference in change of SIxAge over time between the groups for any of the other time intervals (p=0.99). CONCLUSIONS In this quasi-experimental trial of bundled care using the novel workplace rapid training approach, we found overall excellent implementation effectiveness but no overall statistically significant clinical effectiveness.
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Affiliation(s)
- Nee-Kofi Mould-Millman
- Department of Emergency Medicine, University of Colorado Denver School of Medicine, Aurora, Colorado, USA
| | - Julia Dixon
- Department of Emergency Medicine, University of Colorado Denver School of Medicine, Aurora, Colorado, USA
| | - Brenda L Beaty
- Adult and Child Consortium for Health Outcomes Research and Delivery Science, University of Colorado - Anschutz Medical Campus, Aurora, Colorado, USA
| | - Krithika Suresh
- Department of Biostatistics & Informatics, University of Colorado School of Public Health, Aurora, Colorado, USA
| | - Shaheem de Vries
- Emergency Medical Services, Western Cape Government Department of Health, City of Cape Town, South Africa
| | - Beatrix Bester
- Emergency Medical Services, Western Cape Government Department of Health, City of Cape Town, South Africa
| | - Fabio Moreira
- Emergency Medical Services, Western Cape Government Department of Health, City of Cape Town, South Africa
| | - Charmaine Cunningham
- Division of Emergency Medicine, University of Cape Town Faculty of Health Sciences, Belville, South Africa
| | - Kubendhren Moodley
- Emergency Medical Services, Western Cape Government Department of Health, City of Cape Town, South Africa
| | - Radomir Cermak
- Emergency Medical Services, Western Cape Government Department of Health, City of Cape Town, South Africa
| | - Steven G Schauer
- US Army Institute of Surgical Research, Fort Sam Houston, San Antonio, Texas, USA
| | - Joseph K Maddry
- US Army Institute of Surgical Research, Fort Sam Houston, San Antonio, Texas, USA
| | - Corey B Bills
- Department of Emergency Medicine, University of Colorado Denver School of Medicine, Aurora, Colorado, USA
| | - Edward P Havranek
- Department of Medicine, Denver Health Medical Center, Denver, Colorado, USA
| | - Vikhyat S Bebarta
- Department of Emergency Medicine, University of Colorado Denver School of Medicine, Aurora, Colorado, USA
| | - Adit A Ginde
- Department of Emergency Medicine, University of Colorado Denver School of Medicine, Aurora, Colorado, USA
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Genelin MP, Helmkamp LJ, Steiner JF, Maertens JA, Hanratty R, Vupputuri S, Havranek EP, Dickinson LM, Blair IV, Daugherty SL. Patient Pill Organization Strategies and Adherence Measured in a Cross-Sectional Study of Hypertension. Patient Prefer Adherence 2023; 17:817-826. [PMID: 36992865 PMCID: PMC10042167 DOI: 10.2147/ppa.s399693] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/15/2022] [Accepted: 03/07/2023] [Indexed: 03/31/2023] Open
Abstract
BACKGROUND The strategies patients use to organize medications (eg, pill dispenser) may be reflected in adherence measured at follow-up. We studied whether medication organization strategies patients use at home are associated with adherence measured using pharmacy-fills, self-report, and pill counts. DESIGN Secondary analysis of data from a prospective randomized clinical trial. SETTING Eleven US safety-net and community primary care clinics. PATIENTS Of the 960 enrolled self-identified non-Hispanic Black and White patients prescribed antihypertensive medications, 731 patients reported pill organization strategies and were included. VARIABLE Patients were asked if they use any of the following medication organization strategies: finish previous refills first; use a pill dispenser; combine same prescriptions; or combine dissimilar prescriptions. OUTCOMES Adherence to antihypertensive medications using pill counts (range, 0.0-1.0% of the days covered), pharmacy-fill (proportion of days covered >90%), and self-report (adherent/non-adherent). RESULTS Of the 731 participants, 38.3% were men, 51.7% were age ≥65, 52.9% self-identified as Black or African American. Of the strategies studied, 51.7% finished previous refills first, 46.5% used a pill dispenser, 38.2% combined same prescriptions and 6.0% combined dissimilar prescriptions. Median (IQR) pill count adherence was 0.65 (0.40-0.87), pharmacy-fill adherence was 75.7%, and self-reported adherence was 63.2%. Those who combined same prescriptions had significantly lower measured pill count adherence than those who did not (0.56 (0.26-0.82) vs 0.70 (0.46-0.90), p<0.01) with no significant difference in pharmacy-fill (78.1% vs 74%, p=0.22) or self-reported adherence (63.0% vs 63.3%, p=0.93). CONCLUSION Self-reported medication organization strategies were common. Combining same prescriptions was associated with lower adherence as measured using pill counts but not pharmacy-fills or self-report. Clinicians and researchers should identify the pill organization strategies used by their patients to understand how these strategies may influence measures of patient adherence. TRIAL REGISTRATION ClinicalTrials.gov NCT03028597; https://clinicaltrials.gov/ct2/show/NCT03028597 (Archived by WebCite at http://www.webcitation.org/72vcZMzAB).
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Affiliation(s)
- Matthew P Genelin
- University of Colorado School of Medicine, Aurora, CO, USA
- Correspondence: Matthew P Genelin, University of Colorado School of Medicine, 3500 Rockmont Drive, #15-209, Denver, CO, 80202, USA, Email
| | - Laura J Helmkamp
- Adult and Child Consortium for Outcomes Research and Delivery Sciences (ACCORDS), University of Colorado, Aurora, CO, USA
| | - John F Steiner
- University of Colorado School of Medicine, Aurora, CO, USA
- Institute for Health Research, Kaiser Permanente Colorado, Denver, CO, USA
| | - Julie A Maertens
- Adult and Child Consortium for Outcomes Research and Delivery Sciences (ACCORDS), University of Colorado, Aurora, CO, USA
| | - Rebecca Hanratty
- University of Colorado School of Medicine, Aurora, CO, USA
- Department of Medicine, Denver Health and Hospital Authority, Denver, CO, USA
| | - Suma Vupputuri
- Mid-Atlantic Permanente Research Institute, Kaiser Permanente Mid-Atlantic States, Rockville, MD, USA
| | - Edward P Havranek
- University of Colorado School of Medicine, Aurora, CO, USA
- Department of Medicine, Denver Health and Hospital Authority, Denver, CO, USA
- Department of Medicine, Division of Cardiology, University of Colorado School of Medicine, Aurora, CO, USA
| | - L Miriam Dickinson
- University of Colorado School of Medicine, Aurora, CO, USA
- Adult and Child Consortium for Outcomes Research and Delivery Sciences (ACCORDS), University of Colorado, Aurora, CO, USA
| | - Irene V Blair
- Department of Psychology and Neuroscience, University of Colorado Boulder, Boulder, CO, USA
| | - Stacie L Daugherty
- University of Colorado School of Medicine, Aurora, CO, USA
- Adult and Child Consortium for Outcomes Research and Delivery Sciences (ACCORDS), University of Colorado, Aurora, CO, USA
- Institute for Health Research, Kaiser Permanente Colorado, Denver, CO, USA
- Department of Medicine, Division of Cardiology, University of Colorado School of Medicine, Aurora, CO, USA
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6
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Gust CJ, Bryan AD, Havranek EP, Vupputuri S, Steiner JF, Blair IV, Hanratty R, Daugherty SL. Health Behavior Theory and Hypertension Management: Comparisons Among Black, White, and American Indian and Alaska Native Patients. Race Soc Probl 2022; 14:369-382. [PMID: 38322707 PMCID: PMC10846351 DOI: 10.1007/s12552-022-09359-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Accepted: 02/10/2022] [Indexed: 02/08/2024]
Abstract
In the United States, hypertension is more common among individuals from racial and ethnic minority groups. Hypertension control rates are also lower for minority group members compared with White Americans. However, little research has employed well-established theoretical perspectives on health behavior, such as the Theory of Planned Behavior (TPB) and the Model of Goal-Directed Behavior (MGB), to better understand racial differences in rates of hypertension control. The present study examines the psychological processes involved in efforts to control blood pressure, through the lens of the TPB augmented by the MGB, in hypertensive patients of three racial groups: American Indian/Alaska Native, Black/African American, and White. Participants completed measures of past efforts to control blood pressure, attitudes, norms, perceived behavioral control, intentions, and anticipated emotions. Analyses employed confirmatory factor analysis and cross-groups path analysis. Measurement of the theoretical constructs and core putative mediators of blood pressure control intentions were largely similar across racial groups. With regard to the patterns of relationships among the constructs, differences among the groups were most apparent in pathways from past efforts to both cognitive and affective theoretical antecedents of intentions. These findings contribute to the sparse literature on factors involved in racial differences in hypertension control rates and may inform future interventions aimed at increasing hypertension control behaviors. Trial Registration ClinicalTrials.gov, NCT03028597, registered 23 January 2017, https://clinicaltrials.gov/ct2/show/NCT03028597; ClinicalTrials.gov, NCT04414982, registered 4 June 2020 (retrospectively registered), https://www.clinicaltrials.gov/ct2/show/NCT04414982.
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Affiliation(s)
- Charleen J. Gust
- Department of Psychology and Neuroscience, University of Colorado Boulder, Boulder, CO, USA
| | - Angela D. Bryan
- Department of Psychology and Neuroscience, University of Colorado Boulder, Boulder, CO, USA
| | - Edward P. Havranek
- Denver Health, Denver, CO, USA
- Department of Medicine, University of Colorado School of Medicine, Aurora, CO, USA
| | - Suma Vupputuri
- Kaiser Permanente Mid-Atlantic States, Mid-Atlantic Permanente Research Institute, Rockville, MD, USA
| | - John F. Steiner
- Department of Medicine, University of Colorado School of Medicine, Aurora, CO, USA
- Kaiser Permanente Colorado, Institute for Health Research, Denver, CO, USA
| | - Irene V. Blair
- Department of Psychology and Neuroscience, University of Colorado Boulder, Boulder, CO, USA
| | - Rebecca Hanratty
- Denver Health, Denver, CO, USA
- Department of Medicine, University of Colorado School of Medicine, Aurora, CO, USA
| | - Stacie L. Daugherty
- Department of Medicine, University of Colorado School of Medicine, Aurora, CO, USA
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Wagner NM, Kempe A, Barnard JG, Rinehart DJ, Havranek EP, Glasgow RE, Blum J, Morris MA. Qualitative exploration of public health vending machines in young adults who misuse opioids: A promising strategy to increase naloxone access in a high risk underserved population. Drug Alcohol Depend Rep 2022; 5:100094. [PMID: 36687307 PMCID: PMC9851265 DOI: 10.1016/j.dadr.2022.100094] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 01/26/2023]
Abstract
Background Take home naloxone (THN) programs have been shown to effectively reverse opioid overdose events with limited adverse events, yet often miss young adults who use opioids. To identify opportunities for naloxone expansion, we conducted interviews with young adults who had used opioids. We explored young adults' experience with current THN programs, and perspectives on ideal THN programs and emerging naloxone public health vending machine (PHVM) programs shown to increase access to sterile syringes in young adults. Methods We interviewed 16 young adults receiving substance treatment services within an integrated safety net healthcare system. Participants were 18-30 years of age with a history of nonmedical prescription opioid use. Interviews obtained the patient perspective of current THN, ideal THN and PHVM programs. Interviews were transcribed and coded by team-based methods. Themes were developed using an inductive-deductive iterative approach and defined through consensus. Results Treatment was often the first exposure to naloxone. Participants recommended easy to access programs for ideal naloxone distribution and had overall positive feedback on PHVMs. Three key themes were identified to improve naloxone uptake: knowledge, convenience, and privacy. Participants identified safety, lack of police presence, and low costs as important vending machine features. Conclusions Our results identified implementation opportunities to increase naloxone uptake including convenient location and hours, privacy, and using trusted sources of information to improve program awareness. PHVMs present an opportunity to maximize these opportunities and increase access to naloxone in young adults.
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Affiliation(s)
- Nicole M. Wagner
- Adult and Child Center for Health Outcomes Research and Delivery Science, University of Colorado Anschutz Medical Campus, 1890 North Revere Court, Aurora, CO 80045, U.S.A
- Division of General Internal Medicine, School of Medicine, University of Colorado Anschutz Medical Campus, 12631 E 17th Ave., Aurora, CO 80045, U.S.A
- Corresponding author.
| | - Allison Kempe
- Adult and Child Center for Health Outcomes Research and Delivery Science, University of Colorado Anschutz Medical Campus, 1890 North Revere Court, Aurora, CO 80045, U.S.A
- Department of Pediatrics, School of Medicine, University of Colorado Anschutz Medical Campus, 13123 E 16th Ave, Aurora CO 80045, U.S.A
| | - Juliana G Barnard
- Adult and Child Center for Health Outcomes Research and Delivery Science, University of Colorado Anschutz Medical Campus, 1890 North Revere Court, Aurora, CO 80045, U.S.A
- Department of Pediatrics, School of Medicine, University of Colorado Anschutz Medical Campus, 13123 E 16th Ave, Aurora CO 80045, U.S.A
| | - Deborah J. Rinehart
- Division of General Internal Medicine, School of Medicine, University of Colorado Anschutz Medical Campus, 12631 E 17th Ave., Aurora, CO 80045, U.S.A
- Center for Health Systems Research, Denver Health Hospital and Authority, 777 Bannock St., M.C 6551, Denver, CO 80204, U.S.A
| | - Edward P. Havranek
- Center for Health Systems Research, Denver Health Hospital and Authority, 777 Bannock St., M.C 6551, Denver, CO 80204, U.S.A
- Department of Medicine, Denver Health Hospital and Authority, 777 Bannock St., M.C 4000, Denver, CO 80204, U.S.A
| | - Russell E. Glasgow
- Adult and Child Center for Health Outcomes Research and Delivery Science, University of Colorado Anschutz Medical Campus, 1890 North Revere Court, Aurora, CO 80045, U.S.A
- Department of Family Medicine, School of Medicine, University of Colorado Anschutz medical Campus, 12631 East 17th Street, Aurora CO 80045, U.S.A
| | - Joshua Blum
- Division of General Internal Medicine, School of Medicine, University of Colorado Anschutz Medical Campus, 12631 E 17th Ave., Aurora, CO 80045, U.S.A
- Center for Health Systems Research, Denver Health Hospital and Authority, 777 Bannock St., M.C 6551, Denver, CO 80204, U.S.A
| | - Megan A Morris
- Adult and Child Center for Health Outcomes Research and Delivery Science, University of Colorado Anschutz Medical Campus, 1890 North Revere Court, Aurora, CO 80045, U.S.A
- Division of General Internal Medicine, School of Medicine, University of Colorado Anschutz Medical Campus, 12631 E 17th Ave., Aurora, CO 80045, U.S.A
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Henderson KH, Helmkamp LJ, Steiner JF, Havranek EP, Vupputuri SX, Hanratty R, Blair IV, Maertens JA, Dickinson M, Daugherty SL. Relationship Between Social Vulnerability Indicators and Trial Participant Attrition: Findings From the HYVALUE Trial. Circ Cardiovasc Qual Outcomes 2022; 15:e007709. [PMID: 35418247 PMCID: PMC9117483 DOI: 10.1161/circoutcomes.120.007709] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
BACKGROUND Social vulnerability indicators are associated with health care inequities and may similarly impede ongoing participation in research studies. We evaluated the association of social vulnerability indicators and research participant attrition in a trial focused on reducing health disparities. METHODS Self-identified White or Black adults enrolled in the HYVALUE trial (Hypertension and VALUEs), a randomized trial testing a values-affirmation intervention on medication adherence, from February 2017 to September 2019 were included. The self-reported measures of social vulnerability indicators included: (1) Black race; (2) female gender; (3) no health insurance; (4) unemployment; (5) a high school diploma or less; and (6) financial-resource strain. Full attrition was defined as not completing at least one 3- or 6-month follow-up study visit. Log-binomial regression models adjusted for age, gender, race, medical comorbidities, and the other social vulnerability indicators to estimate the relative risk of each social vulnerability indicator with study attrition. RESULTS Among 825 participants, the mean age was 63.3 years (±11.7 years), 60% were women, 54% were Black, and 97% reported at least one social vulnerability. Overall, 21% participants had full attrition after study enrollment. After adjustment for all other social vulnerabilities, only financial-resource strain remained consistently associated with full attrition (relative risk, 1.71 [95% CI, 1.28-2.29]). In a secondary analysis of partial attrition (completed only one follow-up visit), financial-resource strain (relative risk, 1.40 [95% CI, 1.09-1.81]) and being uninsured (relative risk, 1.54 [95% CI, 1.01-2.34]) were associated with partial attrition. CONCLUSIONS In a trial aimed at reducing disparities in medication adherence, participants who reported financial-resource strain had a higher risk of participant attrition independent of race or gender. Our findings suggest that efforts to retain diverse populations in clinical trials should extend beyond race and gender to consider other social vulnerability indicators. REGISTRATION URL: https://www. CLINICALTRIALS gov; Unique identifier: NCT03028597.
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Affiliation(s)
- Kamal H Henderson
- Rocky Mountain Regional Veteran Affairs Medical Center, Aurora, CO (K.H.H.).,Division of Cardiology (K.H.H., E.P.H., S.L.D.), University of Colorado School of Medicine, Aurora, CO
| | - Laura J Helmkamp
- Adult and Child Consortium for Health Outcomes Research and Delivery Science (L.J.H., E.P.H., J.A.M., M.D., S.L.D.), University of Colorado School of Medicine, Aurora, CO
| | - John F Steiner
- Kaiser Permanente Colorado, Institute for Health Research, Denver, CO (J.F.S.)
| | - Edward P Havranek
- Division of Cardiology (K.H.H., E.P.H., S.L.D.), University of Colorado School of Medicine, Aurora, CO.,Adult and Child Consortium for Health Outcomes Research and Delivery Science (L.J.H., E.P.H., J.A.M., M.D., S.L.D.), University of Colorado School of Medicine, Aurora, CO.,Department of Medicine, Denver Health and Hospital Authority, CO (E.P.H., R.H.)
| | - Suma X Vupputuri
- Kaiser Permanente Mid-Atlantic States, Mid-Atlantic Permanente Research Institute, Rockville, MD (S.X.V.)
| | - Rebecca Hanratty
- Department of Medicine, Denver Health and Hospital Authority, CO (E.P.H., R.H.)
| | - Irene V Blair
- Department of Psychology and Neuroscience, University of Colorado Boulder (I.V.B.)
| | - Julie A Maertens
- Adult and Child Consortium for Health Outcomes Research and Delivery Science (L.J.H., E.P.H., J.A.M., M.D., S.L.D.), University of Colorado School of Medicine, Aurora, CO
| | - Miriam Dickinson
- Adult and Child Consortium for Health Outcomes Research and Delivery Science (L.J.H., E.P.H., J.A.M., M.D., S.L.D.), University of Colorado School of Medicine, Aurora, CO
| | - Stacie L Daugherty
- Division of Cardiology (K.H.H., E.P.H., S.L.D.), University of Colorado School of Medicine, Aurora, CO.,Adult and Child Consortium for Health Outcomes Research and Delivery Science (L.J.H., E.P.H., J.A.M., M.D., S.L.D.), University of Colorado School of Medicine, Aurora, CO
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9
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Mansoori JN, Clark BJ, Havranek EP, Douglas IS. The Impact of Choice Architecture on Sepsis Fluid Resuscitation Decisions: An Exploratory Survey-Based Study. MDM Policy Pract 2022; 7:23814683221099454. [PMID: 35592271 PMCID: PMC9112319 DOI: 10.1177/23814683221099454] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/15/2021] [Accepted: 04/21/2022] [Indexed: 11/16/2022] Open
Abstract
Background Discordance with well-known sepsis resuscitation guidelines is often
attributed to rational assessments of patients at the point of care.
Conversely, we sought to explore the impact of choice architecture (i.e.,
the environment, manner, and behavioral psychology within which options are
presented and decisions are made) on decisions to prescribe
guideline-discordant fluid volumes. Design We conducted an electronic, survey-based study using a septic shock clinical
vignette. Physicians from multiple specialties and training levels at an
academic tertiary-care hospital and academic safety-net hospital were
randomized to distinct answer sets: control (6 fluid options), time
constraint (6 fluid options with a 10-s limit to answer), or choice overload
(25 fluid options). The primary outcome was discordance with Surviving
Sepsis Campaign fluid resuscitation guidelines. We also measured response
times and examined the relationship between each choice architecture
intervention group, response time, and guideline discordance. Results A total of 189 of 624 (30.3%) physicians completed the survey. Time spent
answering the vignette was reduced in time constraint (9.5 s, interquartile
range [IQR] 7.3 s to 10.0 s, P < 0.001) and increased in
choice overload (56.8 s, IQR 35.9 s to 86.7 s, P <
0.001) groups compared with control (28.3 s, IQR 20.0 s to 44.6 s). In
contrast, the relative risk of guideline discordance was higher in time
constraint (2.07, 1.33 to 3.23, P = 0.001) and lower in
choice overload (0.75, 0.60, to 0.95, P =0.02) groups.
After controlling for time spent reading the vignette, the overall odds of
choosing guideline-discordant fluid volumes were reduced for every
additional second spent answering the vignette (OR 0.98, 0.97, to 0.99,
P < 0.001). Conclusions Choice architecture may affect fluid resuscitation decisions in sepsis
regardless of patient conditions, warranting further investigation in
real-world contexts. These effects should be considered when implementing
practice guidelines. Highlights
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Affiliation(s)
- Jason N. Mansoori
- Division of Pulmonary and Critical Care Medicine, Department of Medicine, Denver Health Medical Center, Denver, CO, USA
| | - Brendan J. Clark
- Division of Pulmonary Sciences and Critical Care Medicine, Department of Medicine, University of Colorado School of Medicine, Aurora, CO, USA
| | - Edward P. Havranek
- Division of Cardiology, Department of Medicine, Denver, CO, USA
- Division of Cardiology, Department of Medicine, University of Colorado School of Medicine, Aurora, CO, USA
| | - Ivor S. Douglas
- Division of Pulmonary and Critical Care Medicine, Department of Medicine, Denver Health Medical Center, Denver, CO, USA
- Division of Pulmonary Sciences and Critical Care Medicine, Department of Medicine, University of Colorado School of Medicine, Aurora, CO, USA
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10
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Daugherty SL, Helmkamp L, Vupputuri S, Hanratty R, Steiner JF, Blair IV, Dickinson LM, Maertens JA, Havranek EP. Effect of Values Affirmation on Reducing Racial Differences in Adherence to Hypertension Medication: The HYVALUE Randomized Clinical Trial. JAMA Netw Open 2021; 4:e2139533. [PMID: 34913976 PMCID: PMC8678693 DOI: 10.1001/jamanetworkopen.2021.39533] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/17/2022] Open
Abstract
IMPORTANCE Stereotype threat, or the fear of confirming a negative stereotype about one's social group, may contribute to racial differences in adherence to medications by decreasing patient activation to manage chronic conditions. OBJECTIVE To examine whether a values affirmation writing exercise improves medication adherence and whether the effect differs by patient race. DESIGN, SETTING, AND PARTICIPANTS The Hypertension and Values trial, a patient-level, blinded randomized clinical trial, compared an intervention and a control writing exercise delivered immediately prior to a clinic appointment. Of 20 777 eligible, self-identified non-Hispanic Black and White patients with uncontrolled hypertension who were taking blood pressure (BP) medications, 3891 were approached and 960 enrolled. Block randomization by self-identified race ensured balanced randomization. Patients enrolled between February 1, 2017, and December 31, 2019, at 11 US safety-net and community primary care clinics, with outcomes assessed at 3 and 6 months. Analysis was performed on an intention-to-treat basis. INTERVENTIONS From a list of 11 values, intervention patients wrote about their most important values and control patients wrote about their least important values. MAIN OUTCOMES AND MEASURES The primary outcome of adherence to BP medications was measured using pharmacy fill data (proportion of days covered >90%) at baseline, 3 months, and 6 months. The secondary outcome was systolic and diastolic BP. Patient activation to manage their health was also measured. RESULTS Of 960 patients, 474 (286 women [60.3%]; 256 Black patients [54.0%]; mean [SD] age, 63.4 [11.9] years) were randomly assigned to the intervention group and 486 (288 women [59.3%]; 272 Black patients [56.0%]; mean [SD] age, 62.8 [12.0] years) to the control group. Baseline medication adherence was lower (318 of 482 [66.0%] vs 331 of 412 [80.3%]) and mean (SE) BP higher among Black patients compared with White patients (systolic BP, 140.6 [18.5] vs 137.3 [17.8] mm Hg; diastolic BP, 83.9 [12.6] vs 79.7 [11.3] mm Hg). Compared with baseline, pharmacy fill adherence did not differ between intervention and control groups at 3 months (odds ratio [OR], 0.91 [95% CI, 0.57-1.43]) or at 6 months (OR, 0.86 [95% CI, 0.53-1.38]). There were also no treatment effect differences in pharmacy fill adherence by patient race (Black patients at 3 months: OR, 1.08 [95% CI, 0.61-1.92]; at 6 months: OR, 1.04 [95% CI, 0.58-1.87]; White patients at 3 months: OR, 0.68 [95% CI, 0.33-1.44]; at 6 months: OR, 0.55 [95% CI, 0.24-1.27]). Immediately after the intervention, the median patient activation was higher in intervention patients than in control patients, but this difference was not statistically significant in an unadjusted comparison (75.0 [IQR, 65.5-84.8] vs 72.5 [IQR, 63.1-80.9]; P = .06). In adjusted models, the Patient Activation Measure score immediately after the intervention was significantly higher in the intervention patients than in control patients (mean difference, 2.3 [95% CI, 0.1-4.5]). CONCLUSIONS AND RELEVANCE A values affirmation intervention was associated with higher patient activation overall but did not improve adherence or blood pressure among Black and White patients with hypertension. TRIAL REGISTRATION ClinicalTrials.gov Identifier: NCT03028597.
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Affiliation(s)
- Stacie L. Daugherty
- Division of Cardiology, Department of Medicine, University of Colorado School of Medicine, Aurora
- Adult and Children Center for Outcomes Research and Delivery Sciences, University of Colorado, Aurora
- Colorado Cardiovascular Outcomes Research Group, University of Colorado, Aurora, Denver
| | - Laura Helmkamp
- Adult and Children Center for Outcomes Research and Delivery Sciences, University of Colorado, Aurora
| | - Suma Vupputuri
- Mid-Atlantic Permanente Research Institute, Kaiser Permanente Mid-Atlantic States, Rockville, Maryland
| | - Rebecca Hanratty
- Department of Medicine, Denver Health and Hospital Authority, Denver, Colorado
| | - John F. Steiner
- Institute for Health Research, Kaiser Permanente Colorado, Denver
| | - Irene V. Blair
- Department of Psychology and Neuroscience, University of Colorado Boulder, Boulder
| | - L. Miriam Dickinson
- Adult and Children Center for Outcomes Research and Delivery Sciences, University of Colorado, Aurora
- Department of Family Medicine, University of Colorado School of Medicine, Aurora
| | - Julie A. Maertens
- Adult and Children Center for Outcomes Research and Delivery Sciences, University of Colorado, Aurora
| | - Edward P. Havranek
- Division of Cardiology, Department of Medicine, University of Colorado School of Medicine, Aurora
- Adult and Children Center for Outcomes Research and Delivery Sciences, University of Colorado, Aurora
- Colorado Cardiovascular Outcomes Research Group, University of Colorado, Aurora, Denver
- Department of Medicine, Denver Health and Hospital Authority, Denver, Colorado
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11
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Trent SA, George N, Havranek EP, Ginde AA, Haukoos JS. Established evidence-based treatment guidelines help mitigate disparities in quality of emergency care. Acad Emerg Med 2021; 28:1051-1060. [PMID: 33599040 DOI: 10.1111/acem.14235] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/10/2020] [Revised: 02/11/2021] [Accepted: 02/16/2021] [Indexed: 12/20/2022]
Abstract
BACKGROUND Evidence-based guidelines are often cited as a means of ensuring high-quality care for all patients. Our objective was to assess whether emergency department (ED) adherence to core evidence-based guidelines differed by patient sex and race/ethnicity and to assess the effect of ED guideline adherence on patient outcomes by sex and race/ethnicity. METHODS We conducted a preplanned secondary analysis of data from a multicenter retrospective observational study evaluating variation in ED adherence to five core evidence-based treatment guidelines including aspirin for acute coronary syndrome, door-to-balloon time for acute ST-elevation myocardial infarction, systemic thrombolysis for acute ischemic stroke, antibiotic selection for inpatient pneumonia, and early management of severe sepsis/septic shock. This study was performed at six hospitals in Colorado with heterogeneous and diverse practice environments. Hierarchical generalized linear modeling was used to estimate adjusted associations between ED adherence and patient sex and race/ethnicity while controlling for other patient, physician, and environmental factors that could confound this association. RESULTS A total of 1,880 patients were included in the study with a median (IQR) age of 62 (51-74) years. Males and non-Hispanic whites comprised 59% and 71% of the cohort, respectively. While unadjusted differences were identified, our adjusted analyses found no significant association between ED guideline adherence and sex or race/ethnicity. Patients who did not receive guideline adherent care in the ED were significantly more likely to die while in the hospital (odds ratio = 2.0, 95% confidence interval = 1.3 to 3.2). CONCLUSIONS Longstanding, nationally reported evidence-based guidelines can help eliminate sex and race/ethnicity disparities in quality of care. When providers know their care is being monitored and reported, their implicit biases may be less likely to impact care.
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Affiliation(s)
- Stacy A. Trent
- Department of Emergency Medicine Denver Health Medical Center Denver Colorado USA
- Department of Emergency Medicine University of Colorado School of Medicine Aurora Colorado USA
| | - Nigel George
- Department of Emergency Medicine Piedmont Athens Regional Medical Center Athens Georgia USA
| | - Edward P. Havranek
- Department of Medicine Denver Health Medical Center Denver Colorado USA
- Division of Cardiology University of Colorado School of Medicine Aurora Colorado USA
| | - Adit A. Ginde
- Department of Emergency Medicine University of Colorado School of Medicine Aurora Colorado USA
| | - Jason S. Haukoos
- Department of Emergency Medicine Denver Health Medical Center Denver Colorado USA
- Department of Emergency Medicine University of Colorado School of Medicine Aurora Colorado USA
- Department of Epidemiology Colorado School of Public Health Aurora Colorado USA
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12
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Maw AM, Ho PM, Morris MA, Glasgow RE, Huebschmann AG, Barnard JG, Metter R, Tierney DM, Mathews BK, Havranek EP, Kissler M, Fleshner M, Burian BK, Platz E, Soni NJ. Hospitalist Perceptions of Barriers to Lung Ultrasound Adoption in Diverse Hospital Environments. Diagnostics (Basel) 2021; 11:diagnostics11081451. [PMID: 34441385 PMCID: PMC8391960 DOI: 10.3390/diagnostics11081451] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/30/2021] [Revised: 08/05/2021] [Accepted: 08/06/2021] [Indexed: 01/16/2023] Open
Abstract
Despite the many advantages of lung ultrasound (LUS) in the diagnosis and management of patients with dyspnea, its adoption among hospitalists has been slow. We performed semi-structured interviews of hospitals from four diverse health systems in the United States to understand determinants of adoption within a range of clinical settings. We used the diffusion of innovation theory to guide a framework analysis of the data. Of the 27 hospitalists invited, we performed 22 interviews from four hospitals of diverse types. Median years post-residency of interviewees was 10.5 [IQR:5-15]. Four main themes emerged: (1) There are important clinical advantages to LUS despite operator dependence, (2) LUS enhances patient and clinician experience, (3) Investment of clinician time to learn and perform LUS is a barrier to adoption but yields improved efficiency for the health system and (4) Mandated training and use may be necessary to achieve broad adoption as monetary incentives are less effective. Despite the perceived benefits of LUS for patients, clinicians and health systems, a significant barrier to broad LUS adoption is the experience of time scarcity by hospitalists. Future implementation strategies should focus on changes to the clinical environment that address clinician barriers to learning and adoption of new skills.
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Affiliation(s)
- Anna M. Maw
- Division of Hospital Medicine, University of Colorado School of Medicine, Aurora, CO 80045, USA; (R.M.); (M.K.); (M.F.)
- Correspondence:
| | - P. Michael Ho
- Division of Cardiology, University of Colorado School of Medicine, Aurora, CO 80045, USA;
| | - Megan A. Morris
- Adult and Child Consortium for Health Outcomes Research and Delivery Science (ACCORDS), University of Colorado School of Medicine, Aurora, CO 80045, USA; (M.A.M.); (R.E.G.); (J.G.B.)
| | - Russell E. Glasgow
- Adult and Child Consortium for Health Outcomes Research and Delivery Science (ACCORDS), University of Colorado School of Medicine, Aurora, CO 80045, USA; (M.A.M.); (R.E.G.); (J.G.B.)
| | - Amy G. Huebschmann
- Division of General Internal Medicine, University of Colorado School of Medicine, Aurora, CO 80045, USA;
| | - Juliana G. Barnard
- Adult and Child Consortium for Health Outcomes Research and Delivery Science (ACCORDS), University of Colorado School of Medicine, Aurora, CO 80045, USA; (M.A.M.); (R.E.G.); (J.G.B.)
| | - Robert Metter
- Division of Hospital Medicine, University of Colorado School of Medicine, Aurora, CO 80045, USA; (R.M.); (M.K.); (M.F.)
| | - David M. Tierney
- Medical Education Department, Abbott Northwestern Hospital, Minneapolis, MN 55407, USA;
| | - Benji K. Mathews
- Department of Hospital Medicine, HealthPartners, Bloomington, MI 55420, USA;
| | | | - Mark Kissler
- Division of Hospital Medicine, University of Colorado School of Medicine, Aurora, CO 80045, USA; (R.M.); (M.K.); (M.F.)
| | - Michelle Fleshner
- Division of Hospital Medicine, University of Colorado School of Medicine, Aurora, CO 80045, USA; (R.M.); (M.K.); (M.F.)
| | - Barbara K. Burian
- Human Systems Integration Division NASA Ames Research Center, Mountain View, CA 94043, USA;
| | - Elke Platz
- Cardiovascular Division, Brigham and Women’s Hospital, Harvard Medical School, Boston, MA 02115, USA;
| | - Nilam J. Soni
- Division of Pulmonary and Critical Care Medicine and Division of General & Hospital Medicine, University of Texas Health San Antonio, San Antonio, TX 78229, USA;
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13
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Affiliation(s)
- Edward P Havranek
- Division of Cardiology, Department of Medicine, Denver Health Medical Center, University of Colorado School of Medicine, Denver
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14
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Vogel JA, Burnham RI, McVaney K, Havranek EP, Edwards D, Hulac S, Sasson C. The Importance of Neighborhood in 9-1-1 Ambulance Contacts: A Geospatial Analysis of Medical and Trauma Emergencies in Denver. PREHOSP EMERG CARE 2021; 26:233-245. [DOI: 10.1080/10903127.2020.1868634] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/22/2022]
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15
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Rinehart DJ, Leslie SE, Kuka K, Doyle R, Stowell M, Thomas-Gale T, Shlay JC, Havranek EP, Albright K. Adolescent Female Perspectives in an Urban Safety Net: Developing an Intervention Focusing on Sexual Health and Text-Messaging. J Health Care Poor Underserved 2021; 31:1379-1398. [PMID: 33416701 DOI: 10.1353/hpu.2020.0101] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
Abstract
Our goal was to develop a patient-centered text-message intervention for adolescent females in an urban safety-net health system. We conducted interviews with adolescent females to explore sexual health knowledge and inform the development of a text-messaging intervention. Focused group discussions (FGDs) verified or challenged interview themes and elicited preferences for intervention design. Forty-two females participated, including 15 interviewees and 27 FGD participants. Over half (67%) were Hispanic/Latina, 19% Black, 10% White and 5% Asian. The average age was 16 (±1.5) and 55% reported ever having sex. Participants felt susceptible to and were more concerned with preventing unintended pregnancies than sexually transmitted infections, and described more barriers to condom use than other contraceptive methods. Their input informed the development of a text-messaging intervention, which is described. This study supports the acceptability of a patient-centered texting intervention for promoting and normalizing healthy sexual behaviors among adolescent females in an urban safety-net setting.
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16
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Rinehart DJ, Leslie S, Durfee MJ, Stowell M, Cox-Martin M, Thomas-Gale T, Shlay JC, Havranek EP. Acceptability and Efficacy of a Sexual Health Texting Intervention Designed to Support Adolescent Females. Acad Pediatr 2020; 20:475-484. [PMID: 31560971 DOI: 10.1016/j.acap.2019.09.004] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/14/2019] [Revised: 09/11/2019] [Accepted: 09/14/2019] [Indexed: 11/26/2022]
Abstract
OBJECTIVE To evaluate the feasibility, acceptability, and initial efficacy of a pilot texting intervention ("t4she") in primary care designed to increase sexual health knowledge and promote dual protection strategies to reduce unintended pregnancies and sexually transmitted infections among adolescent females. METHODS Participants were recruited from 2 federally qualified health centers. Eligibility included: being 13 to 18 years of age; assigned female at birth; English-speaking; not currently pregnant and/or intending to become pregnant; and having texting capabilities. A randomized controlled trial assessed between-group differences at 3 and 6 months on knowledge, Health Belief Model constructs, and sexual behaviors. Input on intervention acceptability was obtained at 3 months. RESULTS Among 244 participants enrolled and randomized, the average age was 16 (±1.6), 80% were Hispanic/Latina, 53% had ever had vaginal sex, and 50% had used prescription birth control with 24% currently using a long-acting reversible method. Among those sexually active, 29% reported consistent condom use and 24% reported engaging in dual protection behaviors at last sex. Among participants with all follow-up data (N = 136), intervention participants had significant increases in sexual health knowledge and reported more prescription birth control use at follow-up than control participants. No significant outcome differences were found for condom use or dual protection behaviors. Intervention participants reported receiving messages, being introduced to new information, and reading and sharing the messages. CONCLUSIONS The pilot t4she sexual health intervention significantly improved knowledge and use of short-acting prescription birth control among young females in primary care and was acceptable by youth and feasible to implement.
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Affiliation(s)
- Deborah J Rinehart
- Center for Health Systems Research, Office of Research, Denver Health and Hospital Authority (DJ Rinehart, S Leslie, MJ Durfee, M Stowell, and EP Havranek), Denver, Colo; Department of Medicine, University of Colorado, School of Medicine (DJ Rinehart, EP Havranek, and M Cox-Martin), Aurora, Colo.
| | - Sarah Leslie
- Center for Health Systems Research, Office of Research, Denver Health and Hospital Authority (DJ Rinehart, S Leslie, MJ Durfee, M Stowell, and EP Havranek), Denver, Colo
| | - M Joshua Durfee
- Center for Health Systems Research, Office of Research, Denver Health and Hospital Authority (DJ Rinehart, S Leslie, MJ Durfee, M Stowell, and EP Havranek), Denver, Colo
| | - Melanie Stowell
- Center for Health Systems Research, Office of Research, Denver Health and Hospital Authority (DJ Rinehart, S Leslie, MJ Durfee, M Stowell, and EP Havranek), Denver, Colo
| | - Matthew Cox-Martin
- Department of Medicine, University of Colorado, School of Medicine (DJ Rinehart, EP Havranek, and M Cox-Martin), Aurora, Colo
| | - Tara Thomas-Gale
- Ambulatory Care Services, Denver Health and Hospital Authority (T Thomas-Gale), Denver, Colo
| | - Judith C Shlay
- Denver Public Health, Denver Health and Hospital Authority (JC Shlay), Denver, Colo; Department of Family Medicine, School of Medicine, University of Colorado Anschutz Medical Campus (JC Shlay), Aurora, Colo
| | - Edward P Havranek
- Center for Health Systems Research, Office of Research, Denver Health and Hospital Authority (DJ Rinehart, S Leslie, MJ Durfee, M Stowell, and EP Havranek), Denver, Colo; Department of Medicine, University of Colorado, School of Medicine (DJ Rinehart, EP Havranek, and M Cox-Martin), Aurora, Colo
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17
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Perman SM, Beaty BL, Daugherty SL, Havranek EP, Haukoos JS, Juarez-Colunga E, Bradley SM, Fendler TJ, Chan PS. Do Sex Differences Exist in the Establishment of "Do Not Attempt Resuscitation" Orders and Survival in Patients Successfully Resuscitated From In-Hospital Cardiac Arrest? J Am Heart Assoc 2020; 9:e014200. [PMID: 32063126 PMCID: PMC7070220 DOI: 10.1161/jaha.119.014200] [Citation(s) in RCA: 12] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/21/2022]
Abstract
Background Women have higher utilization of “do not attempt resuscitation” (DNAR) orders during treatment for critical illness. Occurrence of sex differences in the establishment of DNAR orders after resuscitation from in‐hospital cardiac arrest is unknown. Whether differences in DNAR use by sex lead to disparities in survival remains unclear. Methods and Results We identified 71 820 patients with return of spontaneous circulation (ROSC) after in‐hospital cardiac arrest from the Get With The Guidelines–Resuscitation registry. Multivariable models evaluated the association between de novo DNAR (anytime after ROSC, within 12 hours of ROSC, or within 72 hours of ROSC) by sex and the association between sex and survival to discharge accounting for DNAR. All models accounted for clustering of patients within hospital and adjusted for demographic and cardiac arrest characteristics. The cohort included 30 454 (42.4%) women, who were slightly more likely than male participants to establish DNAR orders anytime after ROSC (45.0% versus 43.5%; adjusted relative risk: 1.15 [95% CI, 1.10–1.20]; P<0.0001). Of those with DNAR orders, women were more likely to be DNAR status within the first 12 hours (51.8% versus 46.5%; adjusted relative risk: 1.40 [95% CI, 1.30–1.52]; P<0.0001) and within 72 hours after ROSC (75.9% versus 70.9%; adjusted relative risk: 1.35 [95% CI, 1.26–1.45]; P<0.0001). However, no difference in survival to hospital discharge between women and men (34.5% versus 36.7%; adjusted relative risk: 1.00 [95% CI, 0.99–1.02]; P=0.74) was appreciated. Conclusions In patients successfully resuscitated from in‐hospital cardiac arrest, there was no survival difference between men and women while accounting for DNAR. However, women had a higher rate of DNAR status early after resuscitation (<12 and <72 hours) in comparison to men.
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Affiliation(s)
- Sarah M Perman
- Department of Emergency Medicine University of Colorado, School of Medicine Aurora CO
| | - Brenda L Beaty
- Adult and Child Consortium for Health Outcomes Research and Delivery Science University of Colorado, School of Medicine Aurora CO
| | - Stacie L Daugherty
- Adult and Child Consortium for Health Outcomes Research and Delivery Science University of Colorado, School of Medicine Aurora CO.,Division of Cardiology University of Colorado School of Medicine Aurora CO
| | | | - Jason S Haukoos
- Department of Emergency Medicine University of Colorado, School of Medicine Aurora CO.,Department of Emergency Medicine Denver Health Medical Center Denver CO.,Department of Epidemiology Colorado School of Public Health Aurora CO
| | - Elizabeth Juarez-Colunga
- Adult and Child Consortium for Health Outcomes Research and Delivery Science University of Colorado, School of Medicine Aurora CO
| | - Steven M Bradley
- Minneapolis Heart Institute and Minneapolis Heart Institute Foundation Minneapolis MN
| | | | - Paul S Chan
- Department of Cardiology Mid America Heart Institute Kansas City MO
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18
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Mansoori JN, Linde-Zwirble W, Hou PC, Havranek EP, Douglas IS. Variability in usual care fluid resuscitation and risk-adjusted outcomes for mechanically ventilated patients in shock. Crit Care 2020; 24:25. [PMID: 31992351 PMCID: PMC6986034 DOI: 10.1186/s13054-020-2734-9] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 10/04/2019] [Accepted: 01/10/2020] [Indexed: 01/20/2023]
Abstract
RATIONALE There remains significant controversy regarding the optimal approach to fluid resuscitation for patients in shock. The magnitude of care variability in shock resuscitation, the confounding effects of disease severity and comorbidity, and the relative impact on sepsis survival are poorly understood. OBJECTIVE To evaluate usual care variability and determine the differential effect of observed and predicted fluid resuscitation volumes on risk-adjusted hospital mortality for mechanically ventilated patients in shock. METHODS We performed a retrospective outcome analysis of mechanically ventilated patients admitted to intensive care units using the 2013 Premier Hospital Database (Premier, Inc.). Observed and predicted hospital mortality were evaluated by observed and predicted day 1 fluid administration, using the difference in predicted and observed outcomes to adjust for disease severity between groups. Both predictive models were validated using a second large administrative database (Truven Health Analytics Inc.). Secondary outcomes included duration of mechanical ventilation, hospital and ICU length of stay, and cost. RESULTS Among 33,831 patients, observed hospital mortality was incrementally higher than predicted for each additional liter of day 1 fluid beginning at 7 L (40.9% vs. 37.2%, p = 0.008). Compared to patients that received expected (± 1.5 L predicted) day 1 fluid volumes, greater-than-expected fluid resuscitation was associated with increased risk-adjusted hospital mortality (52.3% vs. 45.0%, p < 0.0001) among all patients with shock and among a subgroup of shock patients with comorbid conditions predictive of lower fluid volume administration (47.1% vs. 41.5%, p < 0.0001). However, in patients with shock but without such conditions, both greater-than-expected (57.5% vs. 49.2%, p < 0.0001) and less-than-expected (52.1% vs. 49.2%, p = 0.037) day 1 fluid resuscitation were associated with increased risk-adjusted hospital mortality. CONCLUSIONS Highly variable day 1 fluid resuscitation was associated with a non-uniform impact on risk-adjusted hospital mortality among distinct subgroups of mechanically ventilated patients with shock. These findings support closer evaluation of fluid resuscitation strategies that include broadly applied fluid volume targets in the early phase of shock resuscitation.
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Affiliation(s)
- Jason N Mansoori
- Division of Pulmonary, Critical Care and Sleep Medicine, Department of Medicine, Denver Health Medical Center, 601 Broadway, MC 4000, Denver, CO, 80203, USA. .,Division of Pulmonary Sciences and Critical Care Medicine, Department of Medicine, University of Colorado School of Medicine, Aurora, USA.
| | | | - Peter C Hou
- Division of Emergency Care Medicine, Department of Emergency Medicine, Brigham and Women's Hospital, Harvard Medical School, Boston, USA
| | - Edward P Havranek
- Division of Cardiology, Department of Medicine, Denver Health Medical Center, Denver, USA.,Division of Cardiology, Department of Medicine, University of Colorado School of Medicine, Aurora, USA
| | - Ivor S Douglas
- Division of Pulmonary, Critical Care and Sleep Medicine, Department of Medicine, Denver Health Medical Center, 601 Broadway, MC 4000, Denver, CO, 80203, USA.,Division of Pulmonary Sciences and Critical Care Medicine, Department of Medicine, University of Colorado School of Medicine, Aurora, USA
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19
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Mould-Millman NK, Dixon J, Lamp A, de Vries S, Beaty B, Finck L, Colborn K, Moodley K, Skenadore A, Glasgow RE, Havranek EP, Bebarta VS, Ginde AA. A single-site pilot implementation of a novel trauma training program for prehospital providers in a resource-limited setting. Pilot Feasibility Stud 2019; 5:143. [PMID: 31844551 PMCID: PMC6896719 DOI: 10.1186/s40814-019-0536-0] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/04/2019] [Accepted: 11/27/2019] [Indexed: 12/17/2022] Open
Abstract
Background Prehospital (ambulance) care can reduce morbidity and mortality from trauma. Yet, there is a dearth of effective evidence-based interventions and implementation strategies. Emergency Medical Services Traumatic Shock Care (EMS-TruShoC) is a novel bundle of five core evidence-based trauma care interventions. High-Efficiency EMS Training (HEET) is an innovative training and sensitization program conducted during clinical shifts in ambulances. We assess the feasibility of implementing EMS-TruShoC using the HEET strategy, and feasibility of assessing implementation and clinical outcomes. Findings will inform a main trial. Methods We conducted a single-site, prospective cohort, multi-methods pilot implementation study in Western Cape EMS system of South Africa. Of the 120 providers at the study site, 12 were trainers and the remaining were eligible learners. Feasibility of implementation was guided by the RE-AIM (reach, effectiveness, adoption, implementation, and maintenance) framework. Feasibility of assessing clinical outcomes was assessed using shock indices and clinical quality of care scores, collected via abstraction of patients' prehospital trauma charts. Thresholds for progression to a main trial were developed a priori. Results The average of all implementation indices was 83% (standard deviation = 10.3). Reach of the HEET program was high, with 84% learners completing at least 75% of training modules. Comparing the proportion of learners attaining perfect scores in post- versus pre-implementation assessments, there was an 8-fold (52% vs. 6%) improvement in knowledge, 3-fold (39% vs. 12%) improvement in skills, and 2-fold (42% vs. 21%) increase in self-efficacy. Clinical outcomes data were successfully calculated-there were clinically significant improvements in shock indices and quality of prehospital trauma care in the post- versus pre-implementation phases. Adoption of HEET was good, evidenced by 83% of facilitator participation in trainings, and 100% of surveyed stakeholders indicating good programmatic fit for their organization. Stakeholders responded that HEET was a sustainable educational solution that aligned well with their organization. Implementation fidelity was very high; 90% of the HEET intervention and 77% of the implementation strategy were delivered as originally planned. Participants provided very positive feedback, and explained that on-the-job timing enhanced their participation. Maintenance was not relevant to assess in this pilot study. Conclusions We successfully implemented the EMS-TruShoC educational intervention using the HEET training strategy in a single-site pilot study conducted in a low-resource international setting. All clinical outcomes were successfully calculated. Overall, this pilot study suggests high feasibility of our future, planned experimental trial.
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Affiliation(s)
- Nee-Kofi Mould-Millman
- 1University of Colorado, School of Medicine, Aurora, CO USA.,2Department of Emergency Medicine, University of Colorado, School of Medicine, 12401 E. 17th Ave, B215, Aurora, CO 80045 USA
| | - Julia Dixon
- 1University of Colorado, School of Medicine, Aurora, CO USA.,2Department of Emergency Medicine, University of Colorado, School of Medicine, 12401 E. 17th Ave, B215, Aurora, CO 80045 USA
| | - Andrew Lamp
- 1University of Colorado, School of Medicine, Aurora, CO USA
| | - Shaheem de Vries
- Western Cape Government Health, Emergency Medical Services, Bellville, Cape Town, South Africa
| | - Brenda Beaty
- 4Adult and Child Consortium for Health Outcomes Research and Delivery Science, University of Colorado, Aurora, CO USA
| | - Lani Finck
- 1University of Colorado, School of Medicine, Aurora, CO USA.,2Department of Emergency Medicine, University of Colorado, School of Medicine, 12401 E. 17th Ave, B215, Aurora, CO 80045 USA
| | - Kathryn Colborn
- 5Department of Biostatistics and Informatics, Colorado School of Public Health, University of Colorado, Aurora, CO USA
| | - Kubendhren Moodley
- College of Emergency Care, Western Cape Government, Bellville, Western Cape South Africa
| | - Amanda Skenadore
- 4Adult and Child Consortium for Health Outcomes Research and Delivery Science, University of Colorado, Aurora, CO USA
| | - Russell E Glasgow
- 4Adult and Child Consortium for Health Outcomes Research and Delivery Science, University of Colorado, Aurora, CO USA
| | - Edward P Havranek
- 1University of Colorado, School of Medicine, Aurora, CO USA.,4Adult and Child Consortium for Health Outcomes Research and Delivery Science, University of Colorado, Aurora, CO USA.,7Department of Medicine, Denver Health Medical Center, Denver, CO USA
| | - Vikhyat S Bebarta
- 1University of Colorado, School of Medicine, Aurora, CO USA.,2Department of Emergency Medicine, University of Colorado, School of Medicine, 12401 E. 17th Ave, B215, Aurora, CO 80045 USA.,8Office of the Chief Scientist, 59th Medical Wing, Joint Base San Antonio-Lackland, San Antonio, TX USA
| | - Adit A Ginde
- 1University of Colorado, School of Medicine, Aurora, CO USA.,2Department of Emergency Medicine, University of Colorado, School of Medicine, 12401 E. 17th Ave, B215, Aurora, CO 80045 USA
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Perman SM, Shelton SK, Knoepke C, Rappaport K, Matlock DD, Adelgais K, Havranek EP, Daugherty SL. Public Perceptions on Why Women Receive Less Bystander Cardiopulmonary Resuscitation Than Men in Out-of-Hospital Cardiac Arrest. Circulation 2019; 139:1060-1068. [PMID: 30779655 DOI: 10.1161/circulationaha.118.037692] [Citation(s) in RCA: 55] [Impact Index Per Article: 11.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
BACKGROUND Women who suffer an out-of-hospital cardiac arrest receive bystander cardiopulmonary resuscitation (CPR) less often than men. Understanding public perceptions of why this occurs is a necessary first step toward equitable application of this potentially life-saving intervention. METHODS We conducted a national survey of members of the public using Mechanical Turk, Amazon's crowdsourcing platform, to determine reasons why women might receive bystander CPR less often than men. Eligible participants were adults (≥18 years) located in the United States. Responses were excluded if the participant was not able to define CPR correctly. Participants were asked to answer the following free-text question: "Do you have any ideas on why women may be less likely to receive CPR than men when they collapse in public?" Descriptive statistics were used to define the cohort. The free-text response was coded using open coding, and major themes were identified via classical content analysis. RESULTS In total, 548 subjects were surveyed. Mean age was 38.8 years, and 49.8% were female. Participants were geographically distributed as follows: 18.5% West, 9.2% Southwest, 22.0% Midwest, 27.5% Southeast, and 22.9% Northeast. After analysis, 3 major themes were detected for why the public perceives that women receive less bystander CPR. They include the following: (1) sexualization of women's bodies; (2) women are weak and frail and therefore prone to injury; and (3) misperceptions about women in acute medical distress. Overall, 41.9% (227) were trained in CPR while 4.4% reported having provided CPR in a medical emergency. CONCLUSIONS Members of the general public perceive fears about inappropriate touching, accusations of sexual assault, and fear of causing injury as inhibiting bystander CPR for women. Educational and policy efforts to address these perceptions may reduce the sex differences in the application of bystander CPR.
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Affiliation(s)
- Sarah M Perman
- Department of Emergency Medicine (S.M.P., S.K.S.), Department of Medicine, University of Colorado School of Medicine, Aurora.,Center for Women's Health Research (S.M.P., C.K., S.L.D.), Department of Medicine, University of Colorado School of Medicine, Aurora.,Colorado Cardiovascular Outcomes Research Group, Denver (S.M.P., C.K., D.D.M., E.P.H., S.L.D.)
| | - Shelby K Shelton
- Department of Emergency Medicine (S.M.P., S.K.S.), Department of Medicine, University of Colorado School of Medicine, Aurora
| | - Christopher Knoepke
- Center for Women's Health Research (S.M.P., C.K., S.L.D.), Department of Medicine, University of Colorado School of Medicine, Aurora.,Division of Cardiology (C.K., S.L.D.), Department of Medicine, University of Colorado School of Medicine, Aurora.,Colorado Cardiovascular Outcomes Research Group, Denver (S.M.P., C.K., D.D.M., E.P.H., S.L.D.).,Adult and Child Consortium for Outcomes Research and Delivery Science, Aurora, CO (C.K., D.D.M., S.L.D.)
| | - Kathryn Rappaport
- Section of Emergency Medicine, Children's Hospital of Colorado, Aurora (K.R., K.A.)
| | - Daniel D Matlock
- Division of Geriatric Medicine (D.D.M.), Department of Medicine, University of Colorado School of Medicine, Aurora.,Colorado Cardiovascular Outcomes Research Group, Denver (S.M.P., C.K., D.D.M., E.P.H., S.L.D.).,Adult and Child Consortium for Outcomes Research and Delivery Science, Aurora, CO (C.K., D.D.M., S.L.D.).,VA Eastern Colorado Geriatric Research Education and Clinical Center, Aurora, CO (D.D.M.)
| | - Kathleen Adelgais
- Section of Emergency Medicine, Children's Hospital of Colorado, Aurora (K.R., K.A.)
| | - Edward P Havranek
- Colorado Cardiovascular Outcomes Research Group, Denver (S.M.P., C.K., D.D.M., E.P.H., S.L.D.).,Department of Medicine, Denver Health Medical Center, CO (E.P.H.)
| | - Stacie L Daugherty
- Center for Women's Health Research (S.M.P., C.K., S.L.D.), Department of Medicine, University of Colorado School of Medicine, Aurora.,Division of Cardiology (C.K., S.L.D.), Department of Medicine, University of Colorado School of Medicine, Aurora.,Colorado Cardiovascular Outcomes Research Group, Denver (S.M.P., C.K., D.D.M., E.P.H., S.L.D.)
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21
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Havranek EP. The Influence of Social and Economic Factors on Heart Disease. JAMA Cardiol 2019; 4:1212-1213. [PMID: 31596424 DOI: 10.1001/jamacardio.2019.3802] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/14/2022]
Affiliation(s)
- Edward P Havranek
- Department of Medicine, Denver Health, Denver, Colorado.,Division of Cardiology, Department of Medicine, University of Colorado School of Medicine
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22
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Vogel JA, Rising KL, Jones J, Bowden ML, Ginde AA, Havranek EP. Reasons Patients Choose the Emergency Department over Primary Care: a Qualitative Metasynthesis. J Gen Intern Med 2019; 34:2610-2619. [PMID: 31428988 PMCID: PMC6848423 DOI: 10.1007/s11606-019-05128-x] [Citation(s) in RCA: 22] [Impact Index Per Article: 4.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/25/2019] [Revised: 04/18/2019] [Accepted: 05/24/2019] [Indexed: 11/30/2022]
Abstract
BACKGROUND To enhance the acute care delivery system, a comprehensive understanding of the patient's perspectives for seeking care in the emergency department (ED) versus primary care (PC) is necessary. METHODS We conducted a qualitative metasynthesis on reasons patients seek care in the ED instead of PC. A comprehensive literature search in PubMed, CINAHL, Psych Info, and Web of Science was completed to identify qualitative studies relevant to the research question. Articles were critically appraised using the McMaster University Critical Review Form for Qualitative Studies. We excluded pediatric articles and nonqualitative and mixed-methods studies. The metasynthesis was completed with an interpretive approach using reciprocal translation analyses. RESULTS Nine articles met criteria for inclusion. Eleven themes under four domains were identified. The first domain was acuity of condition that led to the ED visit. In this domain, themes included pain: "it's urgent because it hurts," and concern for severe illness. The second domain was barriers associated with PC, which included difficulty accessing PC when ill: "my doctor said he was booked up and he instructed me to go to the ED." The third domain was related to multiple advantages associated with ED care: "my doctor cannot do X-rays and laboratory tests, while the ED has all the technical support." In this domain, patients also identified 24/7 accessibility of the ED and no need for an immediate copay at the ED as advantageous. The fourth domain included fulfillment of medical needs. Themes in this domain included the alleviation of pain and the perceived expertise of the ED healthcare providers. CONCLUSIONS In this qualitative metasynthesis, reasons patients visit the ED over primary care included (1) urgency of the medical condition, (2) barriers to accessing primary care, (3) advantages of the ED, and (4) fulfillment of medical needs and quality of care in the ED.
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Affiliation(s)
- Jody A Vogel
- Department of Emergency Medicine, Denver Health Medical Center, Denver, CO, USA. .,Department of Emergency Medicine, University of Colorado School of Medicine, Aurora, CO, USA. .,Center for Health Systems Research, Denver Health Medical Center, Denver, CO, USA.
| | - Kristin L Rising
- Department of Emergency Medicine, Thomas Jefferson University, Philadelphia, PA, USA
| | | | | | - Adit A Ginde
- Department of Emergency Medicine, Denver Health Medical Center, Denver, CO, USA.,Department of Emergency Medicine, University of Colorado School of Medicine, Aurora, CO, USA
| | - Edward P Havranek
- Center for Health Systems Research, Denver Health Medical Center, Denver, CO, USA.,University of Colorado School of Medicine, Aurora, CO, USA.,Department of Medicine, Denver Health Medical Center, Denver, CO, USA
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23
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Perman SM, Shelton SK, Knoepke C, Rappaport K, Matlock DD, Adelgais K, Havranek EP, Daugherty SL. Response by Perman et al to Letter Regarding Article, "Public Perceptions on Why Women Receive Less Bystander Cardiopulmonary Resuscitation Than Men in Out-of-Hospital Cardiac Arrest". Circulation 2019; 140:e511-e512. [PMID: 31449454 DOI: 10.1161/circulationaha.119.041484] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Affiliation(s)
- Sarah M Perman
- Department of Emergency Medicine (S.M.P, S.K.S.), University of Colorado School of Medicine, Aurora.,Center for Women's Health Research (S.M.P, C.K., S.L.D.), University of Colorado School of Medicine, Aurora.,Colorado Cardiovascular Outcomes Research Group, Denver (S.M.P., C.K., D.D.M., E.P.H., S.L.D.)
| | - Shelby K Shelton
- Department of Emergency Medicine (S.M.P, S.K.S.), University of Colorado School of Medicine, Aurora
| | - Christopher Knoepke
- Center for Women's Health Research (S.M.P, C.K., S.L.D.), University of Colorado School of Medicine, Aurora.,Division of Cardiology, Department of Medicine (C.K., S.L.D.), University of Colorado School of Medicine, Aurora.,Colorado Cardiovascular Outcomes Research Group, Denver (S.M.P., C.K., D.D.M., E.P.H., S.L.D.).,Adult and Child Consortium for Outcomes Research and Delivery Science, Aurora, CO (C.K., D.D.M., S.L.D.)
| | - Kathryn Rappaport
- Section of Emergency Medicine, Children's Hospital of Colorado, Aurora (K.R., K.A.)
| | - Daniel D Matlock
- Division of Geriatric Medicine, Department of Medicine (D.D.M.), University of Colorado School of Medicine, Aurora.,Colorado Cardiovascular Outcomes Research Group, Denver (S.M.P., C.K., D.D.M., E.P.H., S.L.D.).,Adult and Child Consortium for Outcomes Research and Delivery Science, Aurora, CO (C.K., D.D.M., S.L.D.).,VA Eastern Colorado Geriatric Research Education and Clinical Center, Aurora (D.D.M.)
| | - Kathleen Adelgais
- Section of Emergency Medicine, Children's Hospital of Colorado, Aurora (K.R., K.A.)
| | - Edward P Havranek
- Colorado Cardiovascular Outcomes Research Group, Denver (S.M.P., C.K., D.D.M., E.P.H., S.L.D.).,Department of Medicine, Denver Health Medical Center, CO (E.P.H.)
| | - Stacie L Daugherty
- Center for Women's Health Research (S.M.P, C.K., S.L.D.), University of Colorado School of Medicine, Aurora.,Division of Cardiology, Department of Medicine (C.K., S.L.D.), University of Colorado School of Medicine, Aurora.,Colorado Cardiovascular Outcomes Research Group, Denver (S.M.P., C.K., D.D.M., E.P.H., S.L.D.).,Adult and Child Consortium for Outcomes Research and Delivery Science, Aurora, CO (C.K., D.D.M., S.L.D.)
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24
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Trent SA, Jarou ZJ, Havranek EP, Ginde AA, Haukoos JS. Variation in Emergency Department Adherence to Treatment Guidelines for Inpatient Pneumonia and Sepsis: A Retrospective Cohort Study. Acad Emerg Med 2019; 26:908-920. [PMID: 30343515 DOI: 10.1111/acem.13639] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/23/2018] [Revised: 10/12/2018] [Accepted: 10/17/2018] [Indexed: 11/26/2022]
Abstract
OBJECTIVES Evidence-based clinical practice guidelines (CPGs) for the treatment of pneumonia and sepsis have existed for many years with multiple studies suggesting improved patient outcomes. Despite their importance, little is known about variation in emergency department (ED) adherence to these CPGs. Our objectives were to estimate variation in ED adherence across CPGs for pneumonia and sepsis and identify patient, provider, and environmental factors associated with adherence. METHODS This was a multicenter retrospective study using standard medical record review methods. The population consisted of consecutive adults hospitalized for pneumonia or sepsis (identified by discharge ICD-9 codes) at five Colorado hospitals (two academic, three community) who were admitted to the hospital from the ED and for whom the ED diagnosed or initiated treatment. The outcome measured was ED adherence to the CPG (primary) and in-hospital mortality (secondary). Hierarchical generalized linear models were used for analysis. RESULTS Among 827 patients, ED care was 57% adherence to CPGs with significant variation in adherence across CPGs (sepsis 50%, pneumonia 64%, p < 0.001). Patients were less likely to receive adherent care if they presented with chief complaints that were associated but not typical of the diagnosis (odds ratio [OR] = 0.6, 95% confidence interval [CI] = 0.4-0.8), received an ED diagnosis that was not specific to the CPG (associated diagnosis OR = 0.3 [95% CI = 0.2-0.5]; unrelated diagnosis OR = 0.4 [95% CI = 0.2-0.6]) or presented to a community hospital (OR = 0.6, 95% CI = 0.4-0.9). ED CPG nonadherence was associated with higher in-hospital mortality (OR = 2.4, 95% CI = 1.2-4.8). CONCLUSION Adherence to ED infectious CPGs for pneumonia and sepsis varies significantly across diseases and types of institutions with significant room for improvement, especially in light of a significant association with in-hospital mortality.
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Affiliation(s)
- Stacy A. Trent
- Department of Emergency Medicine Denver Health Medical Center Denver CO
- Department of Emergency Medicine University of Colorado School of Medicine Aurora CO
| | - Zachary J. Jarou
- Department of Emergency Medicine Denver Health Medical Center Denver CO
- Department of Emergency Medicine University of Chicago School of Medicine Chicago IL
| | - Edward P. Havranek
- Department of Medicine Denver Health Medical Center Denver CO
- Division of Cardiology University of Colorado School of Medicine Aurora CO
| | - Adit A. Ginde
- Department of Emergency Medicine University of Colorado School of Medicine Aurora CO
| | - Jason S. Haukoos
- Department of Emergency Medicine Denver Health Medical Center Denver CO
- Department of Emergency Medicine University of Colorado School of Medicine Aurora CO
- Department of Epidemiology Colorado School of Public Health Aurora CO
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Havranek EP. Epidemiology of heart disease: The influence of socioeconomic position. Trends Cardiovasc Med 2019; 29:298-303. [DOI: 10.1016/j.tcm.2018.09.007] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/11/2017] [Revised: 08/31/2018] [Accepted: 09/10/2018] [Indexed: 10/28/2022]
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26
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Perman SM, Siry BJ, Ginde AA, Grossestreuer AV, Abella BS, Daugherty SL, Havranek EP. Sex Differences in "Do Not Attempt Resuscitation" Orders After Out-of-Hospital Cardiac Arrest and the Relationship to Critical Hospital Interventions. Clin Ther 2019; 41:1029-1037. [PMID: 31047712 DOI: 10.1016/j.clinthera.2019.03.017] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/13/2018] [Revised: 03/19/2019] [Accepted: 03/29/2019] [Indexed: 12/21/2022]
Abstract
PURPOSE Women who experience out-of-hospital cardiac arrest have similar rates of survival to hospital admission as men; however, women are less likely to survive to hospital discharge. We hypothesized that women would have higher rates of "do not attempt resuscitation" (DNAR) orders and that this order would be associated with lower use of aggressive interventions. METHODS We identified adult hospital admissions with a diagnosis of cardiac arrest (ICD-9 427.5) from the 2010 California State Inpatient Dataset. Multivariable logistic regression was used to test the association between patient sex and a DNAR order within the first 24 h of admission, adjusting for patient demographic characteristics and comorbid medical conditions. In secondary analysis, procedures performed after establishment of DNAR order and survival to hospital discharge were compared by sex. FINDINGS We analyzed 6562 patients (44% women, 56% men) who experienced out-of-hospital cardiac arrest and survived to hospital admission. In unadjusted analysis, more women than men had establishment of a DNAR order during the first 24 h of admission (23.4% versus 19.3%; P < 0.01). After adjusting for age, race, and comorbid conditions, women remained significantly more likely to have a DNAR order established during the first 24 h of their hospital admission after cardiac arrest compared with men (odds ratio = 1.23; 95% CI, 1.09-1.40). No sex difference was found in procedures used after DNAR order was established. IMPLICATIONS Female survivors of cardiac arrest are significantly more likely than men to have a DNAR order established within the first 24 h of in-hospital treatment. The establishment of a DNAR order is associated with patients undergoing fewer procedures than individuals who do not have a DNAR order established. Given that patients who have a DNAR order receive less-aggressive intervention after arrest, it is possible that an early DNAR order may contribute to sex differences in survival to hospital discharge.
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Affiliation(s)
- Sarah M Perman
- Department of Emergency Medicine, University of Colorado School of Medicine, Aurora, CO, USA.
| | - Bonnie J Siry
- Department of Emergency Medicine, University of Colorado School of Medicine, Aurora, CO, USA
| | - Adit A Ginde
- Department of Emergency Medicine, University of Colorado School of Medicine, Aurora, CO, USA
| | - Anne V Grossestreuer
- Department of Emergency Medicine, Beth Israel Deaconess Medical Center, Boston, MA, USA
| | - Benjamin S Abella
- Department of Emergency Medicine, University of Pennsylvania Perelman School of Medicine, Philadelphia, PA, USA
| | - Stacie L Daugherty
- Division of Cardiology, University of Colorado School of Medicine, Aurora, CO, USA
| | - Edward P Havranek
- Department of Medicine, Denver Health Medical Center, Denver, CO, USA
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Ritchie ND, Carroll JK, Holtrop JS, Havranek EP. Effects of physical activity goal attainment on engagement and outcomes in the National Diabetes Prevention Program. Transl Behav Med 2019; 8:932-937. [PMID: 29669050 DOI: 10.1093/tbm/ibx021] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Abstract
The National Diabetes Prevention Program (NDPP) is the most widely available behavioral intervention to prevent diabetes, but attrition is a concern and strategies are needed to make the program more engaging. Previous evidence suggests that the 150-min weekly physical activity goal in NDPP is hard for many to achieve. Further study of the impact of this protocol recommendation may improve understanding for NDPP reach and effectiveness in reducing diabetes risk. We conducted an observational study of relationships between physical activity goal attainment and retention and weight loss among 391 NDPP participants between March 2013 and May 2016. Average percent of self-reported weekly physical activity goal attainment was 52.7% (SD = 35.1). Goal attainment was related to percent of sessions attended, β = 0.21 (p < .01) and program completion (OR 0.47; p < .05; 95% CI 0.24-0.90). Each occurrence of goal failure was associated with a 25% lower likelihood of attending the next session (OR 0.75; p < .001; 95% CI 0.64-0.87). Goal attainment was also related to total percent weight loss, β = -0.14 (p < .05) and achieving ≥5% weight loss (OR 0.39; p < .01; 95% CI 0.19-0.76), but there was no effect of goal attainment on weight change per session attended. Failing to attain physical activity goals may deter retention in the NDPP. Yet, goal attainment did not affect the rate of weight loss per session attended. It may be important to encourage continued engagement among individuals who struggle to achieve physical activity goals. Moreover, it may be necessary to modify physical activity recommendations to meet individual needs.
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Affiliation(s)
- Natalie D Ritchie
- Denver Health and Hospital Authority, Denver, CO, USA.,University of Colorado School of Medicine, Aurora, CO, USA
| | | | | | - Edward P Havranek
- Denver Health and Hospital Authority, Denver, CO, USA.,University of Colorado School of Medicine, Aurora, CO, USA
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Daugherty SL, Vupputuri S, Hanratty R, Steiner JF, Maertens JA, Blair IV, Dickinson LM, Helmkamp L, Havranek EP. Using Values Affirmation to Reduce the Effects of Stereotype Threat on Hypertension Disparities: Protocol for the Multicenter Randomized Hypertension and Values (HYVALUE) Trial. JMIR Res Protoc 2019; 8:e12498. [PMID: 30907744 PMCID: PMC6452278 DOI: 10.2196/12498] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/12/2018] [Revised: 12/26/2018] [Accepted: 01/03/2019] [Indexed: 01/22/2023] Open
Abstract
Background Medication nonadherence is a significant, modifiable contributor to uncontrolled hypertension. Stereotype threat may contribute to racial disparities in adherence by hindering a patient’s ability to actively engage during a clinical encounter, resulting in reduced activation to adhere to prescribed therapies. Objective The Hypertension and Values (HYVALUE) trial aims to examine whether a values-affirmation intervention improves medication adherence (primary outcome) by targeting racial stereotype threat. Methods The HYVALUE trial is a patient-level, blinded randomized controlled trial comparing a brief values-affirmation writing exercise with a control writing exercise among black and white patients with uncontrolled hypertension. We are recruiting patients from 3 large health systems in the United States. The primary outcome is patients’ adherence to antihypertensive medications, with secondary outcomes of systolic and diastolic blood pressure over time, time for which blood pressure is under control, and treatment intensification. We are comparing the effects of the intervention among blacks and whites, exploring possible moderators (ie, patients’ prior experiences of discrimination and clinician racial bias) and mediators (ie, patient activation) of intervention effects on outcomes. Results This study was funded by the National Heart, Lung, and Blood Institute. Enrollment and follow-up are ongoing and data analysis is expected to begin in late 2020. Planned enrollment is 1130 patients. On the basis of evidence supporting the effectiveness of values affirmation in educational settings and our pilot work demonstrating improved patient-clinician communication, we hypothesize that values affirmation disrupts the negative effects of stereotype threat on the clinical interaction and can reduce racial disparities in medication adherence and subsequent health outcomes. Conclusions The HYVALUE study moves beyond documentation of race-based health disparities toward testing an intervention. We focus on a medical condition—hypertension, which is arguably the greatest contributor to mortality disparities for black patients. If successful, this study will be the first to provide evidence for a low-resource intervention that has the potential to substantially reduce health care disparities across a wide range of health care conditions and populations. Trial Registration ClinicalTrials.gov NCT03028597; https://clinicaltrials.gov/ct2/show/NCT03028597 (Archived by WebCite at http://www.webcitation.org/72vcZMzAB). International Registered Report Identifier (IRRID) DERR1-10.2196/12498
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Affiliation(s)
- Stacie L Daugherty
- University of Colorado Denver, School of Medicine, Department of Medicine, Division of Cardiology, Adult and Child Consortium for Health Outcomes Research and Delivery Science, Aurora, CO, United States
| | - Suma Vupputuri
- Kaiser Permanente Mid-Atlantic States, Mid-Atlantic Permanente Research Institute, Rockville, MD, United States
| | - Rebecca Hanratty
- Denver Health and Hospital Authority, Department of Medicine, Denver, CO, United States
| | - John F Steiner
- Kaiser Permanente Colorado, Institute for Health Research, Denver, CO, United States
| | - Julie A Maertens
- University of Colorado Denver, Adult and Child Consortium for Health Outcomes Research and Delivery Science, Aurora, CO, United States
| | - Irene V Blair
- University of Colorado Boulder, Department of Psychology and Neuroscience, Boulder, CO, United States
| | - L Miriam Dickinson
- University of Colorado Denver, Adult and Child Consortium for Health Outcomes Research and Delivery Science, Aurora, CO, United States
| | - Laura Helmkamp
- University of Colorado Denver, Adult and Child Consortium for Health Outcomes Research and Delivery Science, Aurora, CO, United States
| | - Edward P Havranek
- University of Colorado School of Medicine, Adult and Child Consortium for Health Outcomes Research and Delivery Science, Denver Health and Hospital Authority, Department of Medicine, Denver, CO, United States
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Trent SA, Morse EA, Ginde AA, Havranek EP, Haukoos JS. Barriers to Prompt Presentation to Emergency Departments in Colorado after Onset of Stroke Symptoms. West J Emerg Med 2018; 20:237-243. [PMID: 30881542 PMCID: PMC6404721 DOI: 10.5811/westjem.2018.10.38731] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/21/2018] [Revised: 08/01/2018] [Accepted: 10/10/2018] [Indexed: 01/01/2023] Open
Abstract
Introduction Despite significant morbidity and mortality from stroke, patient delays to emergency department (ED) presentation following the onset of stroke symptoms are one of the main contraindications to treatment for acute ischemic stroke (AIS). Our objective was to identify patient and environmental factors associated with delayed presentations to the ED after onset of stroke symptoms. Methods This was a pre-planned secondary analysis of data from a multicenter, retrospective observational study at three hospitals in Colorado. We included consecutive adult patients if they were admitted to the hospital from the ED, and the ED diagnosed or initiated treatment for AIS. Patients were excluded if they were transferred from another hospital. Primary outcome was delayed presentation to the ED (> 3.5 hours) following onset stroke symptoms. Results Among 351 patients, 63% presented to the ED more than 3.5 hours after onset of stroke symptoms. Adjusted results show that patients who presented in the evening hours (odds ratio [OR] [0.45], 95% confidence interval [CI] [0.3–0.8]), as compared to daytime, were significantly less likely to have a delayed presentation. Speaking a language other than English (Spanish [OR 3.3, 95% CI 1.2–8.9] and “other” [OR 9.1, 95% CI 1.2–71.0]), having known cerebrovascular risk factors (>2 risk factors [OR 2.4, 95% CI 1.05–5.4] and 1–2 risk factors [OR 2.3, 95% CI 1.03–5.1], compared to zero risk factors), and presenting to a rural hospital (OR 2.2, 95% CI 1.2–4.2), compared to urban, were significantly associated with delayed presentation. Conclusion Important patient and environmental factors are significantly associated with delayed ED presentations following the onset of stroke symptoms. Identifying how best to educate patients on stroke risk and recognition remains critically important.
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Affiliation(s)
- Stacy A Trent
- Denver Health Medical Center, Department of Emergency Medicine, Denver, Colorado.,University of Colorado School of Medicine, Department of Emergency Medicine, Aurora, Colorado
| | - Erica A Morse
- St. Joseph's Hospital, Department of Emergency Medicine, Denver, Colorado
| | - Adit A Ginde
- University of Colorado School of Medicine, Department of Emergency Medicine, Aurora, Colorado.,Colorado School of Public Health, Department of Epidemiology, Aurora, Colorado
| | - Edward P Havranek
- Denver Health Medical Center, Department of Medicine, Denver, Colorado.,University of Colorado School of Medicine, Division of Cardiology, Aurora, Colorado
| | - Jason S Haukoos
- Denver Health Medical Center, Department of Emergency Medicine, Denver, Colorado.,University of Colorado School of Medicine, Department of Emergency Medicine, Aurora, Colorado.,Colorado School of Public Health, Department of Epidemiology, Aurora, Colorado
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Trent SA, Havranek EP, Ginde AA, Haukoos JS. Effect of Audit and Feedback on Physician Adherence to Clinical Practice Guidelines for Pneumonia and Sepsis. Am J Med Qual 2018; 34:217-225. [PMID: 30205697 DOI: 10.1177/1062860618796947] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/21/2023]
Abstract
The objective was to estimate the effect of feedback with blinded peer comparison on emergency physician adherence to guidelines for appropriate antibiotic administration for inpatient pneumonia and completion of the 3-hour Surviving Sepsis Bundle for severe sepsis. The authors performed a quasi-experiment using a stepped wedge design at a single urban safety net hospital. Attending emergency physicians were randomized into 6 clusters. Once a cluster crossed into the intervention group, physicians in that cluster began receiving detailed feedback with blinded peer comparison on their adherence to guidelines for pneumonia and sepsis. Feedback with blinded peer comparison significantly improved guideline adherence from 52% without feedback to 65% with feedback (difference = 13%, 95% confidence interval = 4% to 22%). In adjusted analyses, the odds of providing guideline adherent care were 1.8 (95% confidence interval = 1.01-3.2) after the introduction of feedback with blinded peer comparison. Feedback with blinded peer comparison significantly improved emergency physician guideline adherence.
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Affiliation(s)
- Stacy A Trent
- 1 Denver Health Medical Center, Denver, CO.,2 University of Colorado, Aurora, CO
| | - Edward P Havranek
- 1 Denver Health Medical Center, Denver, CO.,2 University of Colorado, Aurora, CO
| | - Adit A Ginde
- 2 University of Colorado, Aurora, CO.,3 Colorado School of Public Health, Aurora, CO
| | - Jason S Haukoos
- 1 Denver Health Medical Center, Denver, CO.,2 University of Colorado, Aurora, CO.,3 Colorado School of Public Health, Aurora, CO
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31
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Doyle R, Albright K, Hurley LP, Chávez C, Stowell M, Dircksen S, Havranek EP, Anderson M. Patient Perspectives on a Text Messaging Program to Support Asthma Management: A Qualitative Study. Health Promot Pract 2018; 20:585-592. [PMID: 29732922 DOI: 10.1177/1524839918770209] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
Introduction. This study investigated participants' acceptance of a short messaging service (SMS) intervention designed to support asthma management, including suggestions regarding program delivery and message content. Methods. Individual and group interviews were conducted with patients from a safety-net health care system in Denver, Colorado. Eligible participants were English or Spanish speakers between the ages of 13 and 40 years, with diagnosed persistent asthma. All individual and group interviews were digitally recorded, transcribed, translated from Spanish to English (where applicable), and analyzed for thematic content by experienced analysts using established qualitative content techniques. The qualitative software package ATLAS.ti was used for data analysis and management. Results. This study included a total of 43 participants. In general, participants were receptive toward the SMS program and supported the use of tailored and interactive messages. Adolescents supported the idea of enhancing care by sending messages to a support person, such as a parent or guardian. However, adults were less receptive toward this idea. Participants also preferred directive educational messages and cues to action, while general messages reminding them of their asthma diagnosis were viewed less favorably. Implications. The results from this study will inform a randomized control trial evaluating the efficacy of the SMS intervention.
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Affiliation(s)
- Reina Doyle
- 1 Denver Health and Hospital Authority, Denver, CO, USA
| | - Karen Albright
- 2 University of Denver, Denver, CO, USA.,3 University of Colorado Anschutz Medical Campus, Aurora, CO, USA
| | - Laura P Hurley
- 1 Denver Health and Hospital Authority, Denver, CO, USA.,2 University of Denver, Denver, CO, USA
| | - Catia Chávez
- 3 University of Colorado Anschutz Medical Campus, Aurora, CO, USA
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32
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Bekelman DB, Allen LA, McBryde CF, Hattler B, Fairclough DL, Havranek EP, Turvey C, Meek PM. Effect of a Collaborative Care Intervention vs Usual Care on Health Status of Patients With Chronic Heart Failure: The CASA Randomized Clinical Trial. JAMA Intern Med 2018; 178:511-519. [PMID: 29482218 PMCID: PMC5876807 DOI: 10.1001/jamainternmed.2017.8667] [Citation(s) in RCA: 111] [Impact Index Per Article: 18.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/20/2023]
Abstract
IMPORTANCE Many patients with chronic heart failure experience reduced health status despite receiving conventional therapy. OBJECTIVE To determine whether a symptom and psychosocial collaborative care intervention improves heart failure-specific health status, depression, and symptom burden in patients with heart failure. DESIGN, SETTING, AND PARTICIPANTS A single-blind, 2-arm, multisite randomized clinical trial was conducted at Veterans Affairs, academic, and safety-net health systems in Colorado among outpatients with symptomatic heart failure and reduced health status recruited between August 2012 and April 2015. Data from all participants were included regardless of level of participation, using an intent-to-treat approach. INTERVENTIONS Patients were randomized 1:1 to receive the Collaborative Care to Alleviate Symptoms and Adjust to Illness (CASA) intervention or usual care. The CASA intervention included collaborative symptom care provided by a nurse and psychosocial care provided by a social worker, both of whom worked with the patients' primary care clinicians and were supervised by a study primary care clinician, cardiologist, and palliative care physician. MAIN OUTCOMES AND MEASURES The primary outcome was patient-reported heart failure-specific health status, measured by difference in change scores on the Kansas City Cardiomyopathy Questionnaire (range, 0-100) at 6 months. Secondary outcomes included depression (measured by the 9-item Patient Health Questionnaire), anxiety (measured by the 7-item Generalized Anxiety Disorder Questionnaire), overall symptom distress (measured by the General Symptom Distress Scale), specific symptoms (pain, fatigue, and shortness of breath), number of hospitalizations, and mortality. RESULTS Of 314 patients randomized (157 to intervention arm and 157 to control arm), there were 67 women and 247 men, mean (SD) age was 65.5 (11.4) years, and 178 (56.7%) had reduced ejection fraction. At 6 months, the mean Kansas City Cardiomyopathy Questionnaire score improved 5.5 points in the intervention arm and 2.9 points in the control arm (difference, 2.6; 95% CI, -1.3 to 6.6; P = .19). Among secondary outcomes, depressive symptoms and fatigue improved at 6 months with CASA (effect size of -0.29 [95% CI, -0.53 to -0.04] for depressive symptoms and -0.30 [95% CI, -0.55 to -0.06] for fatigue; P = .02 for both). There were no significant changes in overall symptom distress, pain, shortness of breath, or number of hospitalizations. Mortality at 12 months was similar in both arms (10 patients died receiving CASA, and 13 patients died receiving usual care; P = .52). CONCLUSIONS AND RELEVANCE This multisite randomized clinical trial of the CASA intervention did not demonstrate improved heart failure-specific health status. Secondary outcomes of depression and fatigue, both difficult symptoms to treat in heart failure, improved. TRIAL REGISTRATION clinicaltrials.gov Identifier: NCT01739686.
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Affiliation(s)
- David B Bekelman
- Department of Medicine, Department of Veterans Affairs, Eastern Colorado Health Care System, Denver.,Division of General Internal Medicine, Department of Medicine, University of Colorado School of Medicine, Anschutz Medical Campus, Aurora
| | - Larry A Allen
- Division of Cardiology, Department of Medicine, University of Colorado School of Medicine, Anschutz Medical Campus, Aurora
| | - Connor F McBryde
- Department of Medicine, Department of Veterans Affairs, Eastern Colorado Health Care System, Denver.,Division of General Internal Medicine, Department of Medicine, University of Colorado School of Medicine, Anschutz Medical Campus, Aurora
| | - Brack Hattler
- Department of Medicine, Department of Veterans Affairs, Eastern Colorado Health Care System, Denver.,Division of Cardiology, Department of Medicine, University of Colorado School of Medicine, Anschutz Medical Campus, Aurora
| | - Diane L Fairclough
- Department of Biostatistics and Informatics, University of Colorado School of Public Health, Anschutz Medical Campus, Aurora, Colorado
| | - Edward P Havranek
- Division of Cardiology, Department of Medicine, University of Colorado School of Medicine, Anschutz Medical Campus, Aurora.,Department of Medicine, Denver Health, Denver, Colorado
| | | | - Paula M Meek
- College of Nursing, University of Colorado, Anschutz Medical Campus, Aurora
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Daugherty SL, Blair IV, Havranek EP, Furniss A, Dickinson LM, Karimkhani E, Main DS, Masoudi FA. Implicit Gender Bias and the Use of Cardiovascular Tests Among Cardiologists. J Am Heart Assoc 2017; 6:JAHA.117.006872. [PMID: 29187391 PMCID: PMC5779009 DOI: 10.1161/jaha.117.006872] [Citation(s) in RCA: 67] [Impact Index Per Article: 9.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Abstract
Background Physicians' gender bias may contribute to gender disparities in cardiovascular testing. We used the Implicit Association Test to examine the association of implicit gender biases with decisions to use cardiovascular tests. Methods and Results In 2014, cardiologists completed Implicit Association Tests and a clinical vignette with patient gender randomly assigned. The Implicit Association Tests measured implicit gender bias for the characteristics of strength and risk taking. The vignette represented an intermediate likelihood of coronary artery disease regardless of patient gender: chest pain (part 1) followed by an abnormal exercise treadmill test (part 2). Cardiologists rated the likelihood of coronary artery disease and the usefulness of stress testing and angiography for the assigned patient. Of the 503 respondents (9.3% of eligible; 87% male, median age of 45 years, 58% in private practice), the majority associated strength or risk taking implicitly with male more than female patients. The estimated likelihood of coronary artery disease for both parts of the vignette was similar by patient gender. The utility of secondary stress testing after an abnormal exercise treadmill test was rated as “high” more often for female than male patients (32.8% versus 24.3%, P=0.04); this difference did not vary with implicit bias. Angiography was more consistently rated as having “high” utility for male versus female patients (part 1: 19.7% versus 9.8%; part 2: 73.7% versus 64.3%; P<0.05 for both); this difference was larger for cardiologists with higher implicit gender bias on risk taking (P=0.01). Conclusions Cardiologists have varying degrees of implicit gender bias. This bias explained some, but not all, of the gender variability in simulated clinical decision‐making for suspected coronary artery disease.
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Affiliation(s)
- Stacie L Daugherty
- Division of Cardiology, Department of Medicine, University of Colorado School of Medicine, Aurora, CO .,Adult and Children Center for Outcomes Research and Delivery Sciences (ACCORDS), University of Colorado, Aurora, CO.,Colorado Cardiovascular Outcomes Research Group, Denver, CO
| | - Irene V Blair
- Department of Psychology and Neuroscience, University of Colorado Boulder, Boulder, CO
| | - Edward P Havranek
- Division of Cardiology, Department of Medicine, University of Colorado School of Medicine, Aurora, CO.,Adult and Children Center for Outcomes Research and Delivery Sciences (ACCORDS), University of Colorado, Aurora, CO.,Colorado Cardiovascular Outcomes Research Group, Denver, CO.,Division of Cardiology, Denver Health and Hospital Authority, Denver, CO
| | - Anna Furniss
- Adult and Children Center for Outcomes Research and Delivery Sciences (ACCORDS), University of Colorado, Aurora, CO
| | - L Miriam Dickinson
- Adult and Children Center for Outcomes Research and Delivery Sciences (ACCORDS), University of Colorado, Aurora, CO
| | - Elhum Karimkhani
- Division of Cardiology, Department of Medicine, University of Colorado School of Medicine, Aurora, CO
| | - Deborah S Main
- Department of Health and Behavioral Sciences, University of Colorado Denver, Denver, CO
| | - Frederick A Masoudi
- Division of Cardiology, Department of Medicine, University of Colorado School of Medicine, Aurora, CO.,Adult and Children Center for Outcomes Research and Delivery Sciences (ACCORDS), University of Colorado, Aurora, CO.,Colorado Cardiovascular Outcomes Research Group, Denver, CO
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Affiliation(s)
- Edward P Havranek
- From the Department of Medicine, Denver Health Medical Center, CO (E.P.H.); and Division of Cardiology, Department of Medicine, University of Colorado School of Medicine, Aurora (E.P.H., S.L.D.).
| | - Stacie L Daugherty
- From the Department of Medicine, Denver Health Medical Center, CO (E.P.H.); and Division of Cardiology, Department of Medicine, University of Colorado School of Medicine, Aurora (E.P.H., S.L.D.)
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Ritchie ND, Havranek EP, Moore SL, Pereira RI. Proposed Medicare Coverage for Diabetes Prevention: Strengths, Limitations, and Recommendations for Improvement. Am J Prev Med 2017; 53:260-263. [PMID: 28336351 DOI: 10.1016/j.amepre.2017.02.005] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/09/2016] [Revised: 01/10/2017] [Accepted: 02/01/2017] [Indexed: 12/01/2022]
Affiliation(s)
- Natalie D Ritchie
- Ambulatory Care Services, Denver Health and Hospital Authority, Denver, Colorado; Department of Psychiatry, University of Colorado School of Medicine, Aurora, Colorado.
| | - Edward P Havranek
- Department of Medicine, Denver Health and Hospital Authority, Denver, Colorado; Department of Medicine, University of Colorado School of Medicine, Aurora, Colorado
| | - Susan L Moore
- Department of Medicine, University of Colorado School of Medicine, Aurora, Colorado; Department of Patient Safety and Quality, Denver Health and Hospital Authority, Denver, Colorado
| | - Rocio I Pereira
- Department of Medicine, Denver Health and Hospital Authority, Denver, Colorado; Department of Endocrinology, University of Colorado School of Medicine, Aurora, Colorado
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36
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Ritchie ND, Christoe-Frazier L, McFann KK, Havranek EP, Pereira RI. Effect of the National Diabetes Prevention Program on Weight Loss for English- and Spanish-Speaking Latinos. Am J Health Promot 2017; 32:812-815. [PMID: 28320212 DOI: 10.1177/0890117117698623] [Citation(s) in RCA: 35] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/15/2023]
Abstract
PURPOSE To study the effect of the National Diabetes Prevention Program (NDPP) on weight loss in Latinos. DESIGN No-control, cohort study comparing Latino and non-Hispanic white (NHW) participants. SETTING A health-care system. PARTICIPANTS Five hundred sixty-seven Latino and 175 NHW patients who enrolled in the NDPP. A total of 45.2% of Latinos selected the Spanish-language NDPP. INTERVENTION The NDPP is a nationwide translation of a clinical trial and seeks to prevent diabetes through weight loss in a yearlong group program. MEASURES Independent variables included ethnicity, class language, and number of sessions attended. Main outcomes were initial attendance, number of sessions attended, and weight loss. ANALYSIS Multivariate logistic regression and analysis of covariance were used to determine differences in NDPP outcomes by ethnicity, language, and number of sessions attended. RESULTS Mean attendance was 8.60 of 22 sessions. Each session was associated with 0.30% (±0.02; P < .001) body weight loss. Latinos were half as likely to attend as NHWs, odds ratio 0.52 ( P < .001). Latino attendees came to 2.67 ± 0.63 ( P < .001) fewer sessions than NHWs. There were no weight loss differences by ethnicity after controlling for attendance. Outcomes did not differ among Latinos in the English- and Spanish-language NDPP. CONCLUSION Latinos appeared to benefit less from the NDPP compared to NHWs, likely due to lower attendance rates. Further efforts are needed to support their participation.
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Affiliation(s)
- Natalie D Ritchie
- 1 Ambulatory Care Services, Denver Health and Hospital Authority, Denver, CO, USA.,2 Department of Psychiatry, University of Colorado School of Medicine, Aurora, CO, USA
| | | | - Kim K McFann
- 4 Colorado School of Public Health, University of Colorado, Aurora, CO, USA
| | - Edward P Havranek
- 5 Department of Medicine, Denver Health and Hospital Authority, Denver, CO, USA.,6 Department of Medicine, University of Colorado School of Medicine, Aurora, CO, USA
| | - Rocio I Pereira
- 5 Department of Medicine, Denver Health and Hospital Authority, Denver, CO, USA.,7 Department of Endocrinology, University of Colorado School of Medicine, Aurora, CO, USA
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37
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Bekelman DB, Allen LA, Peterson J, Hattler B, Havranek EP, Fairclough DL, McBryde CF, Meek PM. Rationale and study design of a patient-centered intervention to improve health status in chronic heart failure: The Collaborative Care to Alleviate Symptoms and Adjust to Illness (CASA) randomized trial. Contemp Clin Trials 2016; 51:1-7. [DOI: 10.1016/j.cct.2016.09.002] [Citation(s) in RCA: 21] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/02/2016] [Revised: 09/06/2016] [Accepted: 09/11/2016] [Indexed: 02/02/2023]
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Fischer HH, Pereira RI, Moore SL, Durfee MJ, Rozwadowski JM, Havranek EP. Response to Comment on Fischer et al. Text Message Support for Weight Loss in Patients With Prediabetes: A Randomized Clinical Trial. Diabetes Care 2016;39:1364-1370. Diabetes Care 2016; 39:e207-e208. [PMID: 27926904 DOI: 10.2337/dci16-0024] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/03/2023]
Affiliation(s)
| | - Rocio I Pereira
- Denver Health and Hospital Authority, Denver, CO.,University of Colorado School of Medicine, Aurora, CO
| | | | | | | | - Edward P Havranek
- Denver Health and Hospital Authority, Denver, CO.,University of Colorado School of Medicine, Aurora, CO
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39
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Fischer HH, Fischer IP, Pereira RI, Furniss AL, Rozwadowski JM, Moore SL, Durfee MJ, Raghunath SG, Tsai AG, Havranek EP. Text Message Support for Weight Loss in Patients With Prediabetes: A Randomized Clinical Trial. Diabetes Care 2016; 39:1364-70. [PMID: 26861922 DOI: 10.2337/dc15-2137] [Citation(s) in RCA: 51] [Impact Index Per Article: 6.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/29/2015] [Accepted: 01/07/2016] [Indexed: 02/03/2023]
Abstract
OBJECTIVE Although the benefits of in-person Diabetes Prevention Program (DPP) classes for diabetes prevention have been demonstrated in trials, effectiveness in clinical practice is limited by low participation rates. This study explores whether text message support enhances weight loss in patients offered DPP classes. RESEARCH DESIGN AND METHODS English- and Spanish-speaking patients with prediabetes (n = 163) were randomized to the control group, which only received an invitation to DPP classes as defined by the Centers for Disease Control and Prevention, or to the text message-augmented intervention group, which also received text messages adapted from the DPP curriculum for 12 months. RESULTS Mean weight decreased 0.6 pounds (95% CI -2.7 to 1.6) in the control group and 2.6 pounds (95% CI -5.5 to 0.2) in the intervention group (P value 0.05). Three percent weight loss was achieved by 21.5% of participants in the control group (95% CI 12.5-30.6), compared with 38.5% in the intervention group (95% CI 27.7-49.3) (absolute difference 17.0%; P value 0.02). Mean glycated hemoglobin (HbA1c) increased by 0.19% or 2.1 mmol/mol (95% CI -0.1 to 0.5%) and decreased by 0.09% or 1.0 mmol/mol (95% CI -0.2 to 0.0%) in the control group and intervention participants, respectively (absolute difference 0.28%; P value 0.07). Stratification by language demonstrated a significant treatment effect in Spanish speakers but not in English speakers. CONCLUSIONS Text message support can lead to clinically significant weight loss in patients with prediabetes. Further study assessing effect by primary language and in an operational setting is warranted.
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Affiliation(s)
| | | | - Rocio I Pereira
- Denver Health and Hospital Authority, Denver, CO University of Colorado School of Medicine, Aurora, CO
| | | | | | | | | | | | - Adam G Tsai
- University of Colorado School of Medicine, Aurora, CO Kaiser Permanente, Denver, CO
| | - Edward P Havranek
- Denver Health and Hospital Authority, Denver, CO University of Colorado School of Medicine, Aurora, CO
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40
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Pflederer MC, Long CS, Beaty B, Havranek EP, Mehler PS, Keniston A, Krantz MJ. Longitudinal Changes in Vascular Risk Markers and Mortality Rates among a Latino Population with Hypertension. Tex Heart Inst J 2016; 43:131-6. [PMID: 27127427 DOI: 10.14503/thij-15-5053] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/24/2022]
Abstract
Vascular markers such as pulse-wave velocity and carotid intima-media thickness (CIMT) might improve the prediction of incident cardiovascular disease beyond traditional risk factors. These vascular markers have not been well characterized in minority populations and might be more useful than inflammatory biomarkers. We conducted a prospective, longitudinal cohort study among hypertensive patients in an urban safety-net hospital. We evaluated inflammatory biomarkers, arterial pulse-wave velocity, and carotid intima-media thickness at baseline, 1 year, and 2 years. The primary outcome variable was CIMT. Generalized linear mixed-effects models were used to evaluate associations between CIMT and predictive variables accounting for the correlation of multiple measurements within subjects over time. For our secondary outcome, we used administrative and National Death Index data to determine all-cause death, and univariate relationships were evaluated. Among 175 subjects, 117 were Latino (67%) and 117 were female (67%). Pulse-wave velocity and CIMT regressed over time (both P <0.001) and were highly correlated (P <0.001). Only pulse-wave velocity (P=0.002) and total cholesterol (P=0.03) were associated with CIMT in time-varying covariate analysis. At a median follow-up period of 80 months, 17 of 175 subjects had died (10%). Higher baseline CIMT and pulse-wave velocity were associated with increased mortality rates (both P <0.01). No serum inflammatory marker was significantly correlated with longitudinal changes in CIMT or death. In conclusion, both arterial stiffness and preclinical carotid atherosclerosis were associated with increased mortality rates and might be useful risk-stratification markers among this minority population.
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Pereira RI, Low Wang CC, Wolfe P, Havranek EP, Long CS, Bessesen DH. Associations of Adiponectin with Adiposity, Insulin Sensitivity, and Diet in Young, Healthy, Mexican Americans and Non-Latino White Adults. Int J Environ Res Public Health 2015; 13:ijerph13010054. [PMID: 26703682 PMCID: PMC4730445 DOI: 10.3390/ijerph13010054] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 08/15/2015] [Revised: 10/22/2015] [Accepted: 12/01/2015] [Indexed: 12/24/2022]
Abstract
Low circulating adiponectin levels may contribute to higher diabetes risk among Mexican Americans (MA) compared to non-Latino whites (NLW). Our objective was to determine if among young healthy adult MAs have lower adiponectin than NLWs, independent of differences in adiposity. In addition, we explored associations between adiponectin and diet. This was an observational, cross-sectional study of healthy MA and NLW adults living in Colorado (U.S.A.). We measured plasma total adiponectin, adiposity (BMI, and visceral adipose tissue), insulin sensitivity (IVGTT), and self-reported dietary intake in 43 MA and NLW adults. Mean adiponectin levels were 40% lower among MA than NLW (5.8 ± 3.3 vs. 10.7 ± 4.2 µg/mL, p = 0.0003), and this difference persisted after controlling for age, sex, BMI, and visceral adiposity. Lower adiponectin in MA was associated with lower insulin sensitivity (R2 = 0.42, p < 0.01). Lower adiponectin was also associated with higher dietary glycemic index, lower intake of vegetables, higher intake of trans fat, and higher intake of grains. Our findings confirm that ethnic differences in adiponectin reflect differences in insulin sensitivity, but suggest that these are not due to differences in adiposity. Observed associations between adiponectin and diet support the need for future studies exploring the regulation of adiponectin by diet and other environmental factors.
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Affiliation(s)
- Rocio I Pereira
- Anschutz Medical Campus, University of Colorado, Aurora, CO 80045, USA.
- Denver Health Medical Center, Denver, CO 80204, USA.
| | | | - Pamela Wolfe
- Anschutz Medical Campus, University of Colorado, Aurora, CO 80045, USA.
| | | | - Carlin S Long
- Denver Health Medical Center, Denver, CO 80204, USA.
| | - Daniel H Bessesen
- Anschutz Medical Campus, University of Colorado, Aurora, CO 80045, USA.
- Denver Health Medical Center, Denver, CO 80204, USA.
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Abstract
OBJECTIVE To summarize research relating to health services research translation in the safety net through analysis of the literature and case study of a safety net system. DATA SOURCES/STUDY SETTING Literature review and key informant interviews at an integrated safety net hospital. STUDY DESIGN This paper describes the results of a comprehensive literature review of translational science literature as applied to health care paired with qualitative analysis of five key informant interviews conducted with senior-level management at Denver Health and Hospital Authority. PRINCIPAL FINDINGS Results from the literature suggest that implementing innovation may be more difficult in the safety net due to multiple factors, including financial and organizational constraints. Results from key informant interviews confirmed the reality of financial barriers to innovation implementation but also implied that factors, including institutional respect for data, organizational attitudes, and leadership support, could compensate for disadvantages. CONCLUSIONS Translating research into practice is of critical importance to safety net providers, which are under increased pressure to improve patient care and satisfaction. Results suggest that translational research done in the safety net can better illuminate the special challenges of this setting; more such research is needed.
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Affiliation(s)
- Susan L Moore
- Denver Health and Hospital Authority, Center for Health Systems Research, Denver, CO.,Adult and Child Center for Outcomes Research and Delivery Science (ACCORDS), Department of Medicine, University of Colorado Denver School of Medicine, Aurora, CO
| | - Ilana Fischer
- Denver Health and Hospital Authority, Center for Health Systems Research, Denver, CO
| | - Edward P Havranek
- Denver Health and Hospital Authority, Center for Health Systems Research, Denver, CO.,Adult and Child Center for Outcomes Research and Delivery Science (ACCORDS), Department of Medicine, University of Colorado Denver School of Medicine, Aurora, CO
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Krantz MJ, Havranek EP, Pereira RI, Beaty B, Mehler PS, Long CS. Effects of omega-3 fatty acids on arterial stiffness in patients with hypertension: a randomized pilot study. J Negat Results Biomed 2015; 14:21. [PMID: 26631058 PMCID: PMC4668614 DOI: 10.1186/s12952-015-0040-x] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/17/2015] [Accepted: 11/24/2015] [Indexed: 11/18/2022] Open
Abstract
Background Omega–3 fatty acids prevent cardiovascular disease (CVD) events in patients with myocardial infarction or heart failure. Benefits in patients without overt CVD have not been demonstrated, though most studies did not use treatment doses (3.36 g) of omega-3 fatty acids. Arterial stiffness measured by pulse wave velocity (PWV) predicts CVD events independent of standard risk factors. However, no therapy has been shown to reduce PWV in a blood pressure-independent manner. We assessed the effects of esterified omega–3 fatty acids on PWV and serum markers of inflammation among patients with hypertension. Design and methods We performed a prospective, randomized; double-blinded pilot study of omega-3 fatty acids among 62 patients in an urban, safety net hospital. Patients received 3.36 g of omega–3 fatty acids vs. matched placebo daily for 3-months. The principal outcome measure was change in brachial-ankle PWV. Serum inflammatory markers associated with CVD risk were also assessed. Results The majority (71 %) were of Latino ethnicity. After 3-months, mean change in arterial PWV among omega-3 and placebo groups was −97 cm/s vs. −33 cm/s respectively (p = 0.36 for difference, after multivariate adjustment for baseline age, systolic blood pressure, and serum adiponectin). Non-significant reductions in lipoprotein-associated phospholipase A2 (LpPLA2) mass and high sensitivity C-reactive protein (hsCRP) relative to placebo were also observed (p = 0.08, and 0.21, respectively). Conclusion High-dose omega-3 fatty acids did not reduce arterial PWV or markers of inflammation among patients within a Latino-predominant population with hypertension. Clinical trial registration NCT00935766, registered July 8 2009.
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Affiliation(s)
- Mori J Krantz
- Cardiology Division, Denver Health Medical Center, 777 Bannock St., MC0960, Denver, CO, 80204, USA. .,Department of Medicine, University of Colorado School of Medicine, 13001 E 17th Pl., Aurora, CO, 80045, USA.
| | - Edward P Havranek
- Cardiology Division, Denver Health Medical Center, 777 Bannock St., MC0960, Denver, CO, 80204, USA. .,Department of Medicine, University of Colorado School of Medicine, 13001 E 17th Pl., Aurora, CO, 80045, USA.
| | - Rocio I Pereira
- Department of Medicine, University of Colorado School of Medicine, 13001 E 17th Pl., Aurora, CO, 80045, USA.
| | - Brenda Beaty
- Colorado Health Outcomes Program, University of Colorado School of Medicine, 13199 E. Montview Blvd. Suite 300, Aurora, CO, 80045, USA.
| | - Philip S Mehler
- Department of Medicine, University of Colorado School of Medicine, 13001 E 17th Pl., Aurora, CO, 80045, USA.
| | - Carlin S Long
- Cardiology Division, Denver Health Medical Center, 777 Bannock St., MC0960, Denver, CO, 80204, USA. .,Department of Medicine, University of Colorado School of Medicine, 13001 E 17th Pl., Aurora, CO, 80045, USA.
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Martin SS, Faridi KF, Joshi PH, Blaha MJ, Kulkarni KR, Khokhar AA, Maddox TM, Havranek EP, Toth PP, Tang F, Spertus JA, Jones SR. Remnant Lipoprotein Cholesterol and Mortality After Acute Myocardial Infarction: Further Evidence for a Hypercholesterolemia Paradox From the TRIUMPH Registry. Clin Cardiol 2015; 38:660-7. [PMID: 26459191 DOI: 10.1002/clc.22470] [Citation(s) in RCA: 21] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/10/2015] [Revised: 08/22/2015] [Indexed: 12/22/2022] Open
Abstract
BACKGROUND Remnants are partially hydrolyzed, triglyceride-rich lipoproteins that, like other apolipoprotein B-containing lipoproteins, are atherogenic. Prior observational studies suggest paradoxically better outcomes in hypercholesterolemic patients who sustain an acute myocardial infarction (AMI), one of several known recurrent risk paradoxes. To date, the association of directly measured remnant lipoprotein cholesterol (RLP-C) with survival after an AMI has not been examined. HYPOTHESIS Higher RLP-C levels may be paradoxically associated with lower mortality. METHODS We examined 2465 AMI survivors in a prospective, 24-center US study of AMI outcomes. Lipoprotein cholesterol subfractions were directly measured by ultracentrifugation. RLP-C was defined as intermediate-density lipoprotein cholesterol (IDL-C) + very-low-density lipoprotein cholesterol subfraction 3 (VLDL3 -C). Given a linear relationship between RLP-C and mortality, we examined RLP-C by tertiles and continuously. Cox regression hazard ratios (HRs) were adjusted for the Global Registry of Acute Coronary Events (GRACE) score and 23 other covariates. RESULTS Participants were age 58 ± 12 years (mean ± SD), and 68% were men. After 2 years of follow-up, 226 (9%) participants died. The mortality proportion was 12.4% in the lowest tertile of RLP-C (0-15 mg/dL), 8.5% in the middle tertile (16-23 mg/dL), and 6.8% in the highest tertile (24-120 mg/dL; P < 0.001). A 1-SD increase in RLP-C (11 mg/dL) predicted a 24% lower adjusted risk of 2-year mortality (HR: 0.76, 95% confidence interval [CI]: 0.64-0.91). Similar results were found for a 1-SD increase in IDL-C (HR per 8 mg/dL: 0.80, 95% CI: 0.67-0.96), VLDL3 -C (HR per 4 mg/dL: 0.74, 95% CI: 0.61-0.89), and very-low-density lipoprotein cholesterol (VLDL-C; HR per 8 mg/dL: 0.69, 95% CI: 0.55-0.85). CONCLUSIONS Higher RLP-C levels were associated with lower mortality 2 years after AMI despite rigorous adjustment for known confounders. Unknown protective factors or a lead-time bias likely explains the paradox.
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Affiliation(s)
- Seth S Martin
- Johns Hopkins Ciccarone Center for the Prevention of Heart Disease, Baltimore, Maryland
| | - Kamil F Faridi
- Johns Hopkins Ciccarone Center for the Prevention of Heart Disease, Baltimore, Maryland
| | - Parag H Joshi
- Johns Hopkins Ciccarone Center for the Prevention of Heart Disease, Baltimore, Maryland
| | - Michael J Blaha
- Johns Hopkins Ciccarone Center for the Prevention of Heart Disease, Baltimore, Maryland
| | | | - Arif A Khokhar
- Northwest London Hospitals NHS Trust, London, United Kingdom
| | - Thomas M Maddox
- VA Eastern Colorado Health Care System, Denver, Colorado.,University of Colorado School of Medicine, Aurora, Colorado
| | | | - Peter P Toth
- Johns Hopkins Ciccarone Center for the Prevention of Heart Disease, Baltimore, Maryland.,Department of Preventive Cardiology, CGH Medical Center, Sterling, Illinois.,University of Illinois School of Medicine, Peoria, Illinois
| | - Fengming Tang
- Saint Luke's Mid America Heart Institute, University of Missouri-Kansas City, Kansas City, Missouri
| | - John A Spertus
- Saint Luke's Mid America Heart Institute, University of Missouri-Kansas City, Kansas City, Missouri
| | - Steven R Jones
- Johns Hopkins Ciccarone Center for the Prevention of Heart Disease, Baltimore, Maryland
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Havranek EP, Mujahid MS, Barr DA, Blair IV, Cohen MS, Cruz-Flores S, Davey-Smith G, Dennison-Himmelfarb CR, Lauer MS, Lockwood DW, Rosal M, Yancy CW. Social Determinants of Risk and Outcomes for Cardiovascular Disease. Circulation 2015; 132:873-98. [DOI: 10.1161/cir.0000000000000228] [Citation(s) in RCA: 738] [Impact Index Per Article: 82.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/19/2022]
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Affiliation(s)
- Edward P. Havranek
- From the Division of Cardiology, Department of Medicine, Denver Health Medical Center, University of Colorado School of Medicine
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Thompson LE, Furniss A, Masoudi FA, Peterson PN, Havranek EP, Dickinson LM, Main D, Karimkhani E, Daugherty SL. Abstract 180: Variation in the Use of Angiography Between Procedural and Non-procedural Cardiologists. Circ Cardiovasc Qual Outcomes 2015. [DOI: 10.1161/circoutcomes.8.suppl_2.180] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Background:
Physician specialty is associated with adherence to practice guidelines; clinical activities may influence management approaches when guidelines create equipoise. In a scenario in which either a non-invasive stress test or invasive angiography is appropriate, we hypothesized that cardiologists who perform cardiac procedures would be more likely to recommend an invasive approach compared to non-procedural cardiologists.
Methods:
We developed a web-based, email survey with a 2-part standardized patient case. The first part described a patient with symptoms suggestive of obstructive coronary artery disease (CAD) the second part described an abnormal exercise treadmill test (ETT) result in that patient. In both parts, the scenario was designed to represent an intermediate likelihood of obstructive CAD. Providers were asked to rate the likelihood of obstructive CAD and choose between angiography and stress testing for that patient; both a secondary stress and angiography would be consistent with guidelines. Cardiologists were classified based on self-report to non-procedural (general, non-invasive, heart failure/transplant, congenital) or procedural (invasive, interventional, electrophysiology and cardiothoracic surgery) practice. Multivariable models were used to determine the association between procedural practice and referral for angiography controlling for provider factors (age, gender, years in practice, practice setting) and estimated likelihood of CAD for that patient.
Results:
Of the 500 cardiologists who responded, 41.8% were procedural cardiologists. Procedural cardiologists similarly rated the patient as having a high likelihood for CAD (part 1: 38.8% vs 40.9%, p= 0.63; part 2: 81.8% vs 81.1%, p = 0.84) compared to non-procedural cardiologists. Although for a patient with intermediate risk of CAD by symptoms, more procedural cardiologists recommended direct angiography referral (12% vs 5.6%, p <0.01) than non-procedural cardiologists. In multivariable models, procedural practice remained associated with higher direct angiography referral (OR 2.67; 95% CI 1.30, 5.49, p= 0.008). After an intermediate risk ETT result, both groups recommended angiography more often (70.5% vs 68.2% p=0.58) than secondary stress testing.
Conclusions:
Procedural cardiologists more often referred a patient with symptoms concerning for CAD directly for angiography compared to non-procedural cardiologists. When presented an abnormal stress test, both groups were equally likely to recommend angiography over additional stress testing. Therefore, clinical activities may influence management approaches; procedural cardiologists pursued an invasive approach earlier in the diagnostic pathway. Efforts to understand variation in invasive procedure use should take physician clinical activities into account.
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Lambert-Kerzner A, Havranek EP, Plomondon ME, Fagan KM, McCreight MS, Fehling KB, Williams DJ, Hamilton AB, Albright K, Blatchford PJ, Mihalko-Corbitt R, Bryson CL, Bosworth HB, Kirshner MA, Giacco EJD, Ho PM. Perspectives of patients on factors relating to adherence to post-acute coronary syndrome medical regimens. Patient Prefer Adherence 2015; 9:1053-9. [PMID: 26244013 PMCID: PMC4521673 DOI: 10.2147/ppa.s84546] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/01/2023] Open
Abstract
PURPOSE Poor adherence to cardioprotective medications after acute coronary syndrome (ACS) hospitalization is associated with increased risk of rehospitalization and mortality. Clinical trials of multifaceted interventions have improved medication adherence with varying results. Patients' perspectives on interventions could help researchers interpret inconsistent outcomes. Identifying factors that patients believe would improve adherence might inform the design of future interventions and make them more parsimonious and sustainable. The objective of this study was to obtain patients' perspectives on adherence to medical regimens after experiencing an ACS event and their participation in a medication adherence randomized control trial following their hospitalization. PATIENTS AND METHODS Sixty-four in-depth interviews were conducted with ACS patients who participated in an efficacious, multifaceted, medication adherence randomized control trial. Interview transcripts were analyzed using the constant comparative approach. RESULTS Participants described their post-ACS event experiences and how they affected their adherence behaviors. Patients reported that adherence decisions were facilitated by mutually respectful and collaborative provider-patient treatment planning. Frequent interactions with providers and medication refill reminder calls supported improved adherence. Additional facilitators included having social support, adherence routines, and positive attitudes toward an ACS event. The majority of patients expressed that being active participants in health care decision-making contributed to their health. CONCLUSION Our findings demonstrate that respectful collaborative communication can contribute to medication adherence after ACS hospitalization. These results suggest a potential role for training health-care providers, including pharmacists, social workers, registered nurses, etc, to elicit and acknowledge the patients' views regarding medication treatment in order to improve adherence. Future research is needed with providers to understand how they elicit and acknowledge patients' views, particularly in the face of nonadherence, and with patients to understand how to empower them to share their opinions with their providers.
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Affiliation(s)
- Anne Lambert-Kerzner
- Department of Crdiology, Veterans Health Administration (VA) Eastern Colorado Health Care System, Denver, CO, USA
- School of Public Health or School of Medicine, University of Colorado, Anschutz Medical Campus, Aurora, CO, USA
- Correspondence: Anne Lambert-Kerzner, Veterans Health Administration (VA) Eastern Colorado Health Care System, 1055 Clermont St, Denver, CO 80220, USA, Tel +1 720 857 5129, Email
| | - Edward P Havranek
- School of Public Health or School of Medicine, University of Colorado, Anschutz Medical Campus, Aurora, CO, USA
- Cardiology, Denver Health Medical Center, Denver, CO, USA
| | - Mary E Plomondon
- Department of Crdiology, Veterans Health Administration (VA) Eastern Colorado Health Care System, Denver, CO, USA
- School of Public Health or School of Medicine, University of Colorado, Anschutz Medical Campus, Aurora, CO, USA
| | - Katherine M Fagan
- Department of Crdiology, Veterans Health Administration (VA) Eastern Colorado Health Care System, Denver, CO, USA
| | - Marina S McCreight
- Department of Crdiology, Veterans Health Administration (VA) Eastern Colorado Health Care System, Denver, CO, USA
| | - Kelty B Fehling
- Department of Crdiology, Veterans Health Administration (VA) Eastern Colorado Health Care System, Denver, CO, USA
| | - David J Williams
- School of Public Health or School of Medicine, University of Colorado, Anschutz Medical Campus, Aurora, CO, USA
| | - Alison B Hamilton
- Health Services Research, Veterans Health Administration (VA) Greater Los Angeles Healthcare System, Los Angeles, CA, USA
| | - Karen Albright
- School of Public Health or School of Medicine, University of Colorado, Anschutz Medical Campus, Aurora, CO, USA
| | - Patrick J Blatchford
- School of Public Health or School of Medicine, University of Colorado, Anschutz Medical Campus, Aurora, CO, USA
| | - Renee Mihalko-Corbitt
- Internal Medicine, John L. McClellan Memorial Veterans Hospital, Little Rock, AR, USA
| | - Chris L Bryson
- Health Services Research, Veterans Health Administration (VA) Puget Sound Health Care System, Seattle, WA, USA
| | - Hayden B Bosworth
- Health Services Research, Durham Veterans Affairs Medical Center, Durham, NC, USA
| | - Miriam A Kirshner
- Health Services Research, Durham Veterans Affairs Medical Center, Durham, NC, USA
| | - Eric J Del Giacco
- Internal Medicine, John L. McClellan Memorial Veterans Hospital, Little Rock, AR, USA
| | - P Michael Ho
- Department of Crdiology, Veterans Health Administration (VA) Eastern Colorado Health Care System, Denver, CO, USA
- School of Public Health or School of Medicine, University of Colorado, Anschutz Medical Campus, Aurora, CO, USA
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Daugherty SL, Havranek EP, Blair IV, Dickinson M, Bronsert M, Karimkhani E, Main D, Masoudi FA. Abstract 108: Differences in Cardiologists’ Interpretation and Management of Chest Pain Symptoms and Abnormal Stress Tests in Women and Men. Circ Cardiovasc Qual Outcomes 2014. [DOI: 10.1161/circoutcomes.7.suppl_1.108] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Background:
Gender differences in evaluation of coronary artery disease (CAD) have been suggested in observational cohorts. Whether gender differences in care exist under standardized conditions is not well known.
Methods:
We developed a web-based survey that randomly varied a case vignette by patient gender alone. The first part described a patient presenting with symptoms suggestive of CAD and the second described the results of an abnormal ETT (exercise treadmill test) in that patient. For both parts, the scenario was designed to represent an intermediate likelihood of obstructive CAD regardless of patient gender. Providers were asked to rate the likelihood of obstructive CAD and to choose the best treatment option. The survey was emailed to all physician members of a state cardiology association. A total of 3 reminder emails were sent.
Results:
Of the 317 cardiologists with valid addresses, 71 (22.4%) completed the survey. Participants were mostly men (82.4%) and non-invasive cardiologists (63%). For both parts of the vignette, cardiologists tended to estimate the likelihood of obstructive CAD as “high” more often when the patient was a man (Table). Respondents were equally likely to recommend cardiac testing based on symptoms suggestive of CAD regardless of patient gender; however, after an abnormal ETT, cardiologists were more likely to recommend angiography for male patients and more likely to recommend a second stress test with imaging for female patients (Table).
Conclusions:
Using a standardized case patient at intermediate risk for CAD, cardiologists tended to estimate the likelihood of CAD as higher and were more likely to recommend cardiac angiography after an abnormal ETT in male patients and more likely to recommend stress testing with imaging for women. Our findings suggest differences in how cardiologists evaluate symptoms and manage abnormal stress test results according to patient gender.
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Daugherty SL, Blair IV, Havranek EP, Main D, Dickinson M, Bronsert M, Karimkhani E, Masoudi FA. Abstract 206: Gender Bias among Cardiology Physicians. Circ Cardiovasc Qual Outcomes 2014. [DOI: 10.1161/circoutcomes.7.suppl_1.206] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Background:
Physician bias is a likely contributor to gender disparities in the use of cardiac procedures. The Implicit Association Test (IAT) is a validated tool to measure implicit (unconscious) attitudes but has not been used to study gender disparities in health care. We measured attitudes around patient gender among cardiology physicians using the IAT.
Methods:
We developed two web-based IATs focused on gender attitudes applicable to cardiology procedures. The IAT measures implicit biases by comparing the speed with which concepts can be sorted, when paired in different combinations (i.e. women=strength and men=weakness vs. men=strength and women=weakness). The Strong-IAT measured gender associations with “strength versus weakness” and the Risk-IAT measured gender associations with “risk-taker versus risk-averse”. The IAT is scored from –2.0 to +2.0 with negative scores suggesting a pro-female bias (e.g. women are stronger than men), a positive score suggesting a pro-male bias (e.g. men are stronger than women) and “0” meaning no bias. We emailed a web-based survey including the IATs to all physician members of a state cardiology association. Potential participants received three weekly reminders and, for validation purposes, a subset re-took the survey after 30-days.
Results:
Of the 317 cardiology physicians with valid email addresses, 52 (16.4%) completed the survey. Participants’ mean age was 48.2 (+/- 12.1), 81% were male, and 77% were white. Most (63%) were non-invasive cardiologists (22% interventional cardiologists and 16% electrophysiologists) and 67% practiced in an academic setting. The mean Strong-IAT score was 0.60 (SD = 0 .42) and Risk-IAT score was 0.45 (SD = 0.54) revealing a significant pro-male bias. Over 38% had a high degree of pro-male bias for both IATs (Figure). Among the 11 participants who retook the survey, test-retest reliability was high (Strong-IAT r=0.68; Risk-IAT r=0.79).
Conclusions:
On average, cardiology physicians exhibited implicit gender bias suggesting they are more likely to view men as being stronger and more likely to take risks than women. These attitudes appeared to be relatively stable over time. Future work is needed to understand whether these attitudes influence treatment decisions and contribute to gender disparities in cardiology care.
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