Individual and System Contributions to Race and Sex Disparities in Thrombolysis Use for Stroke Patients in the United States

BACKGROUND AND PURPOSE

Intravenous thrombolysis (IVT) is underutilized in ethnic minorities and women. To disentangle individual and system-based factors determining disparities in IVT use, we investigated race/sex differences in IVT utilization among hospitals serving varying proportions of minority patients.

METHODS

Ischemic stroke admissions were identified from the Nationwide Inpatient Sample between 2007 and 2011. Hospitals were categorized based on the percentage of minority patients admitted with stroke (<25% minority patients [white hospitals], 25% to 50% minority patients [mixed hospitals], or >50% minority patients [minority hospitals]). Logistic regression was used to evaluate the association between race/sex and IVT use within and between the different hospital strata.

RESULTS

Among 337 201 stroke admissions, white men had the highest odds of IVT among all race/sex groups in any hospital strata, and the odds of IVT for white men did not differ by hospital strata. For white women and minority men, the odds of IVT were significantly lower in minority hospitals compared with white hospitals (odds ratio, 0.83; 95% confidence interval, 0.71-0.97, for white women; and odds ratio, 0.82; 95% confidence interval, 0.69-0.99, for minority men). Race disparities in IVT use among women were observed in white hospitals (odds ratio, 0.88; 95% confidence interval, 0.78-0.99, in minority compared with white women), but not in minority hospitals (odds ratio, 0.94, 95% confidence interval, 0.82-1.09). Sex disparities in IVT use were observed among whites but not among minorities.

CONCLUSIONS

Minority men and white women have significantly lower odds of IVT in minority hospitals compared with white hospitals. IVT use in white men does not differ by hospital strata.

Residents' Attitude, Knowledge, and Perceived Preparedness Toward Caring for Patients from Diverse Sociocultural Backgrounds

Purpose: Training residents to deliver care to increasingly diverse patients in the United States is an important strategy to help alleviate racial and ethnic disparities in health outcomes. Cross-cultural care training of residents continues to present challenges. This study sought to explore the associations among residents' cross-cultural attitudes, preparedness, and knowledge about disparities to better elucidate possible training needs. Methods: This cross-sectional study used web-based questionnaires from 2013 to 2014. Eighty-four internal medicine residency programs with 954 residents across the United States participated. The main outcome was perceived preparedness to care for sociocultural diverse patients. Key Results: Regression analysis showed attitude toward cross-cultural care (beta coefficient [β]=0.57, 95% confidence interval [CI]: 0.49-0.64, p<0.001) and report of serving a large number of racial/ethnic minorities (β=0.90, 95% CI: 0.56-1.24, p<0.001), and low-socioeconomic status patients (β=0.74, 95% CI: 0.37-1.10, p<0.001) were positively associated with preparedness. Knowledge of disparities was poor and did not differ significantly across postgraduate year (PGY)-1, PGY-2, and PGY-3 residents (mean scores: 56%, 58%, and 55%, respectively; p=0.08). Conclusion: Residents' knowledge of health and healthcare disparities is poor and does not improve during training. Residents' preparedness to provide cross-cultural care is directly associated with their attitude toward cross-cultural care and their level of exposure to patients from diverse sociocultural backgrounds. Future studies should examine the role of residents' cross-cultural care-related attitudes on their ability to care for diverse patients.

Family presence and participation during medical visits of heart failure patients: An analysis of survey and audiotaped communication data

OBJECTIVE

To describe the frequency, roles, and utility of family companion involvement in the care of patients with Heart Failure (HF) care and to examine the association between audiotaped patient, companion, and provider communication behaviors.

METHODS

We collected survey data and audiotaped a single medical visit for 93 HF patients (36 brought a companion into the examination room) and their cardiology provider. Communication data was analyzed using the Roter Interaction Analysis System.

RESULTS

There were 32% more positive rapport-building statements (p<0.01) and almost three times as many social rapport-building statements (p<0.01) from patients and companions in accompanied visits versus unaccompanied patient visits. There were less psychosocial information giving statements in accompanied visits compared to unaccompanied patient visits (p<0.01.) Providers made 25% more biomedical information giving statements (p=0.04) and almost three times more social rapport-building statements (p<0.01) in accompanied visits. Providers asked fewer biomedical and psychosocial questions in accompanied versus unaccompanied visits. Providers made 16% fewer partnership-building statements in accompanied versus unaccompanied visits (p=0.01).

CONCLUSIONS

Our findings are mixed regarding the benefits of accompaniment for facilitating patient-provider communication based on survey and audiotaped data.

PRACTICE IMPLICATIONS

Strategies to enhance engagement during visits, such as pre-visit question prompt lists, may be beneficial.

Effect of DECIDE (Decision-making Education for Choices In Diabetes Everyday) Program Delivery Modalities on Clinical and Behavioral Outcomes in Urban African Americans With Type 2 Diabetes: A Randomized Trial

OBJECTIVE

To compare the effectiveness of three delivery modalities of Decision-making Education for Choices In Diabetes Everyday (DECIDE), a nine-module, literacy-adapted diabetes and cardiovascular disease (CVD) education and problem-solving training, compared with an enhanced usual care (UC), on clinical and behavioral outcomes among urban African Americans with type 2 diabetes.

RESEARCH DESIGN AND METHODS

Eligible participants (n = 182) had a suboptimal CVD risk factor profile (A1C, blood pressure, and/or lipids). Participants were randomized to DECIDE Self-Study (n = 46), DECIDE Individual (n = 45), DECIDE Group (n = 46), or Enhanced UC (n = 45). Intervention duration was 18-20 weeks. Outcomes were A1C, blood pressure, lipids, problem-solving, disease knowledge, and self-care activities, all measured at baseline, 1 week, and 6 months after completion of the intervention.

RESULTS

DECIDE modalities and Enhanced UC did not significantly differ in clinical outcomes at 6 months postintervention. In participants with A1C ≥7.5% (58 mmol/mol) at baseline, A1C declined in each DECIDE modality at 1 week postintervention (P < 0.05) and only in Self-Study at 6 months postintervention (b = -0.24, P < 0.05). There was significant reduction in systolic blood pressure in Self-Study (b = -4.04) and Group (b = -3.59) at 6 months postintervention. Self-Study, Individual, and Enhanced UC had significant declines in LDL and Self-Study had an increase in HDL (b = 1.76, P < 0.05) at 6 months postintervention. Self-Study and Individual had a higher increase in knowledge than Enhanced UC (P < 0.05), and all arms improved in problem-solving (P < 0.01) at 6 months postintervention.

CONCLUSIONS

DECIDE modalities showed benefits after intervention. Self-Study demonstrated robust improvements across clinical and behavioral outcomes, suggesting program suitability for broader dissemination to populations with similar educational and literacy levels.

A Qualitative Study of Problem Solving and Diabetes Control in Type 2 Diabetes Self-Management

PURPOSE

The purpose of this study was to explore and compare diabetes-related problem solving in urban African Americans in good and poor diabetes control.

METHODS

Two focus groups were conducted, one with participants in good diabetes control and one with participants in poor control. Based on a theoretical model, focus group interview questions were designed to elicit responses about 3 aspects of diabetes-related problem solving: (1) problem-solving orientation, (2) problem-solving process, and (3) transfer of past experience. Transcripts were analyzed using a qualitative data analysis software program, and expert panel members independently reviewed responses and coding.

RESULTS

The primary types of problems with diabetes self-management were similar in the good control and poor control groups. Predominant problem-solving themes in the good control group reflected a positive orientation toward diabetes self-management and problem solving, a rational problem-solving process, and a positive transfer of past experience. In contrast, predominant themes in the poor control group revealed a negative orientation, careless and avoidant problem-solving processes, and negative transfer of past learning to new situations.

CONCLUSIONS

The problem-solving model may help identify ineffective problem-solving patterns in persons with poor diabetes control. Empirical studies testing the model are warranted.

The Role of Care Management as a Population Health Intervention to Address Disparities and Control Hypertension: A Quasi-Experimental Observational Study

OBJECTIVE

We studied whether care management is a pragmatic solution for improving population blood pressure (BP) control and addressing BP disparities between Blacks and Whites in routine clinical environments.

DESIGN

Quasi-experimental, observational study.

SETTING AND PARTICIPANTS

3,964 uncontrolled hypertensive patients receiving primary care within the last year from one of six Baltimore clinics were identified as eligible.

INTERVENTION

Three in-person sessions over three months with registered dietitians and pharmacists who addressed medication titration, patient adherence to healthy behaviors and medication, and disparities-related barriers.

MAIN MEASURES

We assessed the population impact of care management using the RE-AIM framework. To evaluate effectiveness in improving BP, we used unadjusted, adjusted, and propensity-score matched differences-in-differences models to compare those who completed all sessions with partial completers and non-participants.

RESULTS

Of all eligible patients, 5% participated in care management. Of 629 patients who entered care management, 245 (39%) completed all three sessions. Those completing all sessions on average reached BP control (mean BP 137/78) and experienced 9 mm Hg systolic blood pressure (P<.001) and 4 mm Hg DBP (P=.004) greater improvement than non-participants; findings did not vary in adjusted or propensity-score matched models. Disparities in systolic and diastolic BP between Blacks and Whites were not detectable at completion.

CONCLUSIONS

It may be possible to achieve BP control among both Black and White patients who participate in a few sessions of care management. However, the very limited reach and patient challenges with program completion should raise significant caution with relying on care management alone to improve population BP control and eliminate related disparities.

Reaching for Health Equity and Social Justice in Baltimore: The Evolution of an Academic-Community Partnership and Conceptual Framework to Address Hypertension Disparities

Cardiovascular health disparities persist despite decades of recognition and the availability of evidence-based clinical and public health interventions. Racial and ethnic minorities and adults in urban and low-income communities are high-risk groups for uncontrolled hypertension (HTN), a major contributor to cardiovascular health disparities, in part due to inequitable social structures and economic systems that negatively impact daily environments and risk behaviors. This commentary presents the Johns Hopkins Center to Eliminate Cardiovascular Health Disparities as a case study for highlighting the evolution of an academic-community partnership to overcome HTN disparities. Key elements of the iterative development process of a Community Advisory Board (CAB) are summarized, and major CAB activities and engagement with the Baltimore community are highlighted. Using a conceptual framework adapted from O'Mara-Eves and colleagues, the authors discuss how different population groups and needs, motivations, types and intensity of community participation, contextual factors, and actions have shaped the Center's approach to stakeholder engagement in research and community outreach efforts to achieve health equity.

Structural Representations of Objects: Invariance over a Shape-Distorting Transformation

Object perception seems robust over changes in properties such as rotation, reflection, and size. Such changes, however, are shape preserving. To investigate the effect of changes that disrupt overall shape yet keep the global relations among the parts intact, a set of objects was scaled by 50% along just the x-axis. Compression or expansion along a single axis markedly affects the overall shape of an object but leaves the global relations among the parts intact. In an initial encoding phase, subjects viewed images of symmetric and asymmetric three-dimensional nonsense objects and determined whether each faced principally to the left or right. We have previously found that such judgments require subjects to process the objects as global three-dimensional forms. In a subsequent test phase, subjects judged whether a set of both studied and novel objects were symmetric or asymmetric. Half of the studied items were either compressed or expanded along the x-axis in the test presentation. The magnitude of priming was equivalent for the transformed and the untransformed objects. In a second experiment, subjects performed the same initial left/right encoding task followed by a recognition test that assessed explicit memory for the previously presented objects. Although subjects were instructed to disregard changes in scale, recognition performance was reliably better for the untransformed objects. These results support the role of a structural representation system that captures the global relations among the parts and the principal axis of an object and an episodic system which also encodes features of shape.

Sex Differences in Cardiovascular Disease Risk of Ghanaian- and Nigerian-Born West African Immigrants in the United States: The Afro-Cardiac Study

BACKGROUND

The number of African immigrants in the United States grew 40-fold between 1960 and 2007, from 35 355 to 1.4 million, with a large majority from West Africa. This study sought to examine the prevalence of cardiovascular disease (CVD) risk factors and global CVD risk and to identify independent predictors of increased CVD risk among West African immigrants in the United States.

METHODS AND RESULTS

This cross-sectional study assessed West African (Ghanaian and Nigerian) immigrants aged 35-74 years in the Baltimore-Washington metropolitan area. The mean age of participants was 49.5±9.2 years, and 58% were female. The majority (95%) had ≥1 of the 6 CVD risk factors. Smoking was least prevalent, and overweight or obesity was most prevalent, with 88% having a body mass index (in kg/m(2)) ≥25; 16% had a prior diagnosis of diabetes or had fasting blood glucose levels ≥126 mg/dL. In addition, 44% were physically inactive. Among women, employment and health insurance were associated with odds of 0.09 (95% CI 0.033-0.29) and 0.25 (95% CI 0.09-0.67), respectively, of having a Pooled Cohort Equations estimate ≥7.5% in the multivariable logistic regression analysis. Among men, higher social support was associated with 0.90 (95% CI 0.83-0.98) lower odds of having ≥3 CVD risk factors but not with having a Pooled Cohort Equations estimate ≥7.5%.

CONCLUSIONS

The prevalence of CVD risk factors among West African immigrants was particularly high. Being employed and having health insurance were associated with lower CVD risk in women, but only higher social support was associated with lower CVD risk in men.

Reduced Racial Disparity in Kidney Transplant Outcomes in the United States from 1990 to 2012

Earlier studies reported inferior outcomes among black compared with white kidney transplant (KT) recipients. We examined whether this disparity improved in recent decades. Using the Scientific Registry of Transplant Recipients and Cox regression models, we compared all-cause graft loss among 63,910 black and 145,482 white adults who received a first-time live donor KT (LDKT) or deceased donor KT (DDKT) in 1990-2012. Over this period, 5-year graft loss after DDKT improved from 51.4% to 30.6% for blacks and from 37.3% to 25.0% for whites; 5-year graft loss after LDKT improved from 37.4% to 22.2% for blacks and from 20.8% to 13.9% for whites. Among DDKT recipients in the earliest cohort, blacks were 39% more likely than whites to experience 5-year graft loss (adjusted hazard ratio [aHR], 1.39; 95% confidence interval [95% CI], 1.32 to 1.47; P<0.001), but this disparity narrowed in the most recent cohort (aHR, 1.10; 95% CI, 1.03 to 1.18; P=0.01). Among LDKT recipients in the earliest cohort, blacks were 53% more likely than whites to experience 5-year graft loss (aHR, 1.53; 95% CI, 1.27 to 1.83; P<0.001), but this disparity also narrowed in the most recent cohort (aHR, 1.37; 95% CI, 1.17 to 1.61; P<0.001). Analyses revealed no statistically significant differences in 1-year or 3-year graft loss after LDKT or DDKT in the most recent cohorts. Our findings of reduced disparities over the last 22 years driven by more markedly improved outcomes for blacks may encourage nephrologists and patients to aggressively promote access to transplantation in the black community.

A Dietary Intervention in Urban African Americans: Results of the "Five Plus Nuts and Beans" Randomized Trial

INTRODUCTION

Unhealthy diets, often low in potassium, likely contribute to racial disparities in blood pressure. We tested the effectiveness of providing weekly dietary advice, assistance with selection of higher potassium grocery items, and a $30 per week food allowance on blood pressure and other outcomes in African American adults with hypertension.

DESIGN

We conducted an 8-week RCT with two parallel arms between May 2012 and November 2013.

SETTING/PARTICIPANTS

We randomized 123 African Americans with controlled hypertension from an urban primary care clinic in Baltimore, Maryland, and implemented the trial in partnership with a community supermarket and the Baltimore City Health Department. Mean (SD) age was 58.6 (9.5) years; 71% were female; blood pressure was 131.3 (14.7)/77.2 (10.5) mmHg; BMI was 34.5 (8.2); and 28% had diabetes.

INTERVENTION

Participants randomized to the active intervention group (Dietary Approaches to Stop Hypertension [DASH]-Plus) received coach-directed dietary advice and assistance with weekly online ordering and purchasing of high-potassium foods ($30/week) delivered by a community supermarket to a neighborhood library. Participants in the control group received a printed DASH diet brochure along with a debit account of equivalent value to that of the DASH-Plus group.

MAIN OUTCOME MEASURES

The primary outcome was blood pressure change. Analyses were conducted in January to October 2014.

RESULTS

Compared with the control group, the DASH-Plus group increased self-reported consumption of fruits and vegetables (mean=1.4, 95% CI=0.7, 2.1 servings/day); estimated intake of potassium (mean=0.4, 95% CI=0.1, 0.7 grams/day); and urine potassium excretion (mean=19%, 95% CI=1%, 38%). There was no significant effect on blood pressure.

CONCLUSIONS

A program providing dietary advice, assistance with grocery ordering, and $30/week of high-potassium foods in African American patients with controlled hypertension in a community-based clinic did not reduce BP. However, the intervention increased consumption of fruits, vegetables, and urinary excretion of potassium.

The Contribution of Age and Weight to Blood Pressure Levels Among Blacks and Whites Receiving Care in Community-Based Primary Care Practices

We examined whether race and age, risk factors for obesity and hypertension, affect the association of obesity with elevated blood pressure (BP). Using electronic medical record data, we conducted a cross-sectional study of adult patients seen at 6 Maryland primary care clinics from September 2011 through June 2012. The risk for higher BP among patients younger than 65 years and in an elevated weight category was greater for both races but was higher for whites than blacks. For patients aged 65 years or older, weight had little impact on systolic BP, suggesting that approaches involving weight loss to address elevated BP should focus on populations younger than 65.

Unconscious race and social class bias among acute care surgical clinicians and clinical treatment decisions

IMPORTANCE

Significant health inequities persist among minority and socially disadvantaged patients. Better understanding of how unconscious biases affect clinical decision making may help to illuminate clinicians' roles in propagating disparities.

OBJECTIVE

To determine whether clinicians' unconscious race and/or social class biases correlate with patient management decisions.

DESIGN, SETTING, AND PARTICIPANTS

We conducted a web-based survey among 230 physicians from surgery and related specialties at an academic, level I trauma center from December 1, 2011, through January 31, 2012.

INTERVENTIONS

We administered clinical vignettes, each with 3 management questions. Eight vignettes assessed the relationship between unconscious bias and clinical decision making. We performed ordered logistic regression analysis on the Implicit Association Test (IAT) scores and used multivariable analysis to determine whether implicit bias was associated with the vignette responses.

MAIN OUTCOMES AND MEASURES

Differential response times (D scores) on the IAT as a surrogate for unconscious bias. Patient management vignettes varied by patient race or social class. Resulting D scores were calculated for each management decision.

RESULTS

In total, 215 clinicians were included and consisted of 74 attending surgeons, 32 fellows, 86 residents, 19 interns, and 4 physicians with an undetermined level of education. Specialties included surgery (32.1%), anesthesia (18.1%), emergency medicine (18.1%), orthopedics (7.9%), otolaryngology (7.0%), neurosurgery (7.0%), critical care (6.0%), and urology (2.8%); 1.9% did not report a departmental affiliation. Implicit race and social class biases were present in most respondents. Among all clinicians, mean IAT D scores for race and social class were 0.42 (95% CI, 0.37-0.48) and 0.71 (95% CI, 0.65-0.78), respectively. Race and class scores were similar across departments (general surgery, orthopedics, urology, etc), race, or age. Women demonstrated less bias concerning race (mean IAT D score, 0.39 [95% CI, 0.29-0.49]) and social class (mean IAT D score, 0.66 [95% CI, 0.57-0.75]) relative to men (mean IAT D scores, 0.44 [95% CI, 0.37-0.52] and 0.82 [95% CI, 0.75-0.89], respectively). In univariate analyses, we found an association between race/social class bias and 3 of 27 possible patient-care decisions. Multivariable analyses revealed no association between the IAT D scores and vignette-based clinical assessments.

CONCLUSIONS AND RELEVANCE

Unconscious social class and race biases were not significantly associated with clinical decision making among acute care surgical clinicians. Further studies involving real physician-patient interactions may be warranted.

Genetic counselors' implicit racial attitudes and their relationship to communication

OBJECTIVE

Implicit racial attitudes are thought to shape interpersonal interactions and may contribute to health-care disparities. This study explored the relationship between genetic counselors' implicit racial attitudes and their communication during simulated genetic counseling sessions.

METHOD

A nationally representative sample of genetic counselors completed a web-based survey that included the Race Implicit Association Test (IAT; Greenwald, McGhee, & Schwartz, 1998; Cooper et al., 2012). A subset of these counselors (n = 67) had participated in an earlier study in which they were video recorded counseling Black, Hispanic, and non-Hispanic White SCs about their prenatal or cancer risks. The counselors' IAT scores were related to their session communications through robust regression modeling.

RESULTS

Genetic counselors showed a moderate to strong pro-White bias on the Race IAT (M = 0.41, SD = 0.35). Counselors with stronger pro-White bias were rated as displaying lower levels of positive affect (p < .05) and tended to use less emotionally responsive communication (p < .10) when counseling minority SCs. When counseling White SCs, pro-White bias was associated with lower levels of verbal dominance during sessions (p < .10). Stronger pro-White bias was also associated with more positive ratings of counselors' nonverbal effectiveness by White SCs.

CONCLUSION

Implicit racial bias is associated with negative markers of communication in minority client sessions and may contribute to racial disparities in processes of care related to genetic services.

Reducing racial and ethnic disparities in hypertension prevention and control: what will it take to translate research into practice and policy?

INTRODUCTION

Despite available, effective therapies, racial and ethnic disparities in care and outcomes of hypertension persist. Several interventions have been tested to reduce disparities; however, their translation into practice and policy is hampered by knowledge gaps and limited collaboration among stakeholders.

METHODS

We characterized factors influencing disparities in blood pressure (BP) control by levels of an ecological model. We then conducted a literature search using PubMed, Scopus, and CINAHL databases to identify interventions targeted toward reducing disparities in BP control, categorized them by the levels of the model at which they were primarily targeted, and summarized the evidence regarding their effectiveness.

RESULTS

We identified 39 interventions and several state and national policy initiatives targeted toward reducing racial and ethnic disparities in BP control, 5 of which are ongoing. Most had patient populations that were majority African-American. Of completed interventions, 27 demonstrated some improvement in BP control or related process measures, and 7 did not; of the 6 studies examining disparities, 3 reduced, 2 increased, and 1 had no effect on disparities.

CONCLUSIONS

Several effective interventions exist to improve BP in racial and ethnic minorities; however, evidence that they reduce disparities is limited, and many groups are understudied. To strengthen the evidence and translate it into practice and policy, we recommend rigorous evaluation of pragmatic, sustainable, multilevel interventions; institutional support for training implementation researchers and creating broad partnerships among payers, patients, providers, researchers, policymakers, and community-based organizations; and balance and alignment in the priorities and incentives of each stakeholder group.

The severity of disparity: increasing injury intensity accentuates disparate outcomes following trauma

OBJECTIVE

Studies have shown disparities in mortality among racial groups and among those with differing insurance coverage. Our goal was to determine if injury severity affects these disparities.

METHODS

We classified patients from the 2003-2008 National Trauma Data Banks suffering moderate to severe injuries into six groups based on race/ethnicity and insurance, stratifying by injury severity. Logistic regression compared odds of death between races-ethnicities/insurance groups within these strata. We adjusted for age, gender, Injury Severity Score, Glasgow Coma Scale motor component, hypotension, and mechanism of injury.

RESULTS

Patients meeting inclusion criteria numbered 760,598. Disparities between races-ethnicities/insurance groups increased as injury severity worsened. Odds of death for uninsured Black patients compared with insured Whites increased from 1.82 among moderately injured patients to 3.14 among severely injured, hypotensive patients. A similar pattern was seen among uninsured Hispanic patients.

CONCLUSIONS

Disparities in trauma mortality suffered by minority and uninsured patients, when compared with non-minority and insured patients, worsen with increasing injury.

U.S. health professionals' views on obesity care, training, and self-efficacy

BACKGROUND

Despite emphasis of recent guidelines on multidisciplinary teams for collaborative weight management, little is known about non-physician health professionals' perspectives on obesity, their weight management training, and self-efficacy for obesity care.

PURPOSE

To evaluate differences in health professionals' perspectives on (1) the causes of obesity; (2) training in weight management; and (3) self-efficacy for providing obesity care.

METHODS

Data were obtained from a cross-sectional Internet-based survey of 500 U.S. health professionals from nutrition, nursing, behavioral/mental health, exercise, and pharmacy (collected from January 20 through February 5, 2014). Inferences were derived using logistic regression adjusting for age and education (analyzed in 2014).

RESULTS

Nearly all non-physician health professionals, regardless of specialty, cited individual-level factors, such as overconsumption of food (97%), as important causes of obesity. Nutrition professionals were significantly more likely to report high-quality training in weight management (78%) than the other professionals (nursing, 53%; behavioral/mental health, 32%; exercise, 50%; pharmacy, 47%; p<0.05). Nutrition professionals were significantly more likely to report high confidence in helping obese patients achieve clinically significant weight loss (88%) than the other professionals (nursing, 61%; behavioral/mental health, 51%; exercise, 52%; pharmacy, 61%; p<0.05), and more likely to perceive success in helping patients with obesity achieve clinically significant weight loss (nutrition, 81%; nursing, behavioral/mental health, exercise, and pharmacy, all <50%; p<0.05).

CONCLUSIONS

Nursing, behavioral/mental health, exercise, and pharmacy professionals may need additional training in weight management and obesity care to effectively participate in collaborative weight management models.

Provider perspectives on essential functions for care management in the collaborative treatment of hypertension: the P.A.R.T.N.E.R. framework

BACKGROUND

Care management has become a widespread strategy for improving chronic illness care. However, primary care provider (PCP) participation in programs has been poor. Because the success of care management relies on provider engagement, understanding provider perspectives is necessary.

OBJECTIVE

Our goal was to identify care management functions most valuable to PCPs in hypertension treatment.

DESIGN

Six focus groups were conducted to discuss current challenges in hypertension care and identify specific functions of care management that would improve care.

PARTICIPANTS

The study included 39 PCPs (participation rate: 83 %) representing six clinics, two of which care for large African American populations and four that are in underserved locations, in the greater Baltimore metropolitan area.

APPROACH

This was a qualitative analysis of focus groups, using grounded theory and iterative coding.

KEY RESULTS

Providers desired achieving blood pressure control more rapidly. Collaborating with care managers who obtain ongoing patient data would allow treatment plans to be tailored to the changing life conditions of patients. The P.A.R.T.N.E.R. framework summarizes the care management functions that providers reported were necessary for effective collaboration: Partner with patients, providers, and the community; Arrange follow-up care; Resolve barriers to adherence; Track treatment response and progress; Navigate the health care system with patients; Educate patients & Engage patients in self-management; Relay information between patients and/or provider(s).

CONCLUSIONS

The P.A.R.T.N.E.R. framework is the first to offer a checklist of care management functions that may promote successful collaboration with PCPs. Future research should examine the validity of this framework in various settings and for diverse patient populations affected by chronic diseases.

Unconscious Race and Class Biases among Registered Nurses: Vignette-Based Study Using Implicit Association Testing

BACKGROUND

Implicit bias is an unconscious preference for a specific social group that can have adverse consequences for patient care. Acute care clinical vignettes were used to examine whether implicit race or class biases among registered nurses (RNs) impacted patient-management decisions.

STUDY DESIGN

In a prospective study conducted among surgical RNs at the Johns Hopkins Hospital, participants were presented 8 multi-stage clinical vignettes in which patients' race or social class were randomly altered. Registered nurses were administered implicit association tests (IATs) for social class and race. Ordered logistic regression was then used to examine associations among treatment differences, race, or social class, and RN's IAT scores. Spearman's rank coefficients comparing RN's implicit (IAT) and explicit (stated) preferences were also investigated.

RESULTS

Two hundred and forty-five RNs participated. The majority were female (n=217 [88.5%]) and white (n=203 [82.9%]). Most reported that they had no explicit race or class preferences (n=174 [71.0%] and n=108 [44.1%], respectively). However, only 36 nurses (14.7%) demonstrated no implicit race preference as measured by race IAT, and only 16 nurses (6.53%) displayed no implicit class preference on the class IAT. Implicit association tests scores did not statistically correlate with vignette-based clinical decision making. Spearman's rank coefficients comparing implicit (IAT) and explicit preferences also demonstrated no statistically significant correlation (r=-0.06; p=0.340 and r=-0.06; p=0.342, respectively).

CONCLUSIONS

The majority of RNs displayed implicit preferences toward white race and upper social class patients on IAT assessment. However, unlike published data on physicians, implicit biases among RNs did not correlate with clinical decision making.

Enhancing the role of nutrition professionals in weight management: A cross-sectional survey

OBJECTIVE

(1) To determine the nonphysician health profession perceived as best qualified to provide weight management. (2) To examine nutrition professionals' current practice characteristics and perceived challenges and solutions for obesity care. (3) To examine the association between nutrition professionals' quality of training and self-efficacy in weight management.

METHODS

A 2014 national cross-sectional online survey of 500 U.S. nonphysician health professionals (100 from each: nutrition, nursing, behavioral/mental health, exercise, pharmacy) was analyzed.

RESULTS

Nutrition professionals most commonly self-identified as the most qualified group to help patients lose weight (92%), sentiments supported by other health professionals (57%). The most often cited challenge was lack of patient adherence (87%). Among nutrition professionals, 77% reported receiving high-quality training in weight loss counseling. Nutrition professionals who reported high-quality training were significantly more likely to report confidence (95% vs. 48%) and success (74 vs. 50%) in helping obese patients lose weight (P<0.05) than those reporting lower-quality training.

CONCLUSIONS

Across all nonphysician health professionals, nutrition professionals were identified as best suited to provide routine weight management counseling to obese patients. Yet nutrition professionals' receipt of high-quality weight management training appears critical to their success in helping patients lose weight.

Recruitment and enrollment of African Americans and Caucasians in a health promotion trial for persons with serious mental illness

African Americans with serious mental illness (SMI) continue to experience inadequate representation in clinical trials. Persons with SMI, regardless of race, have an increased burden of all cardiovascular disease (CVD) risk factors including obesity, hypertension, diabetes mellitus, dyslipidemia, metabolic syndrome and tobacco smoking. Having SMI and being African American, however, is each associated with an increased risk of CVD mortality compared to the general population. There is a critical need, therefore, to adapt health promotion interventions for African Americans with SMI. We sought to examine overall recruitment into a randomized clinical trial of CVD prevention among persons with SMI, and to examine racial differences in interest, enrollment, and potential barriers to participation. Although similar levels of interest in participation were seen between African Americans and Caucasians in signing screening consent, 9.6% fewer African Americans enrolled due to inability to complete initial data collection. Further work is needed to better understand the nature of the barriers encountered by African Americans with SMI who otherwise may be interested in participating within clinical trials.

Impact of non-physician health professionals' BMI on obesity care and beliefs

OBJECTIVE

Examine the impact of non-physician health professional body mass index (BMI) on obesity care, self-efficacy, and perceptions of patient trust in weight loss advice.

METHODS

A national cross-sectional Internet-based survey of 500 US non-physician health professionals specializing in nutrition, nursing, behavioral/mental health, exercise, and pharmacy collected between January 20 and February 5, 2014 was analyzed.

RESULTS

Normal-BMI professionals were more likely than overweight/obese professionals to report success in helping patients achieve clinically significant weight loss (52% vs. 29%, P = 0.01). No differences by health professional BMI about the appropriate patient body weight for weight-related care (initiate weight loss discussions and success in helping patients lose weight), confidence in ability to help patients lose weight, or in perceived patient trust in their advice were observed. Most health professionals (71%) do not feel successful in helping patients lose weight until they are morbidly obese, regardless of BMI.

CONCLUSIONS

Normal-BMI non-physician health professionals report being more successful than overweight and obese health professionals at helping obese patients lose weight. More research is needed to understand how to improve self-efficacy for delivering obesity care, particularly among overweight and class I obese patients.