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Alaniz-Cantú EI, Goodwin K, Smith L, Acosta E, Chávez-Iñiguez A, Evans MJ, Gaitán M, Lei F, Yousefi-Nooraie R, Fiscella KA, Rivera MP, Cupertino AP, Cartujano-Barrera F. Understanding the perceived benefits, barriers, and cues to action for lung cancer screening among Latinos: A qualitative study. Front Oncol 2024; 14:1365739. [PMID: 38571494 PMCID: PMC10987732 DOI: 10.3389/fonc.2024.1365739] [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] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/04/2024] [Accepted: 03/11/2024] [Indexed: 04/05/2024] Open
Abstract
Introduction Rates of lung cancer screening among Latinos remain low. The purpose of the study was to understand the perceived benefits, barriers, and cues to action for lung cancer screening among Latinos. Methods Participants (N=20) were recruited using community-based recruitment strategies. Eligibility criteria included: 1) self-identified as Hispanic/Latino, 2) spoke English and/or Spanish, and 3) met the USA Preventive Services Task Force eligibility criteria for lung cancer screening. Interviews were conducted in Spanish and English, audio recorded, and transcribed verbatim. Using the health belief model, a qualitative theoretical analysis was used to analyze the interviews. Results Participants' mean age was 58.3 years old (SD=5.8), half of the participants were female, 55% had completed high school or lower educational level, and 55% reported speaking more Spanish than English. All participants were currently smoking. Fourteen participants (70%) were unaware of lung cancer screening, and eighteen (90%) did not know they were eligible for lung cancer screening. Regarding lung cancer screening, participants reported multiple perceived benefits (e.g., smoking cessation, early detection of lung cancer, increased survivorship) and barriers (e.g., fear of outcomes, cost, lung cancer screening not being recommended by their clinician). Lastly, multiple cues to actions for lung cancer screening were identified (e.g., family as a cue to action for getting screened). Conclusions Most Latinos who were eligible for lung cancer screening were unaware of it and, when informed, they reported multiple perceived benefits, barriers, and cues to action. These factors provide concrete operational strategies to address lung cancer screening among Latinos.
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Affiliation(s)
- Edgar I. Alaniz-Cantú
- Department of Public Health Sciences, University of Rochester Medical Center, Rochester, NY, United States
| | - Kalese Goodwin
- Department of Public Health Sciences, University of Rochester Medical Center, Rochester, NY, United States
| | - London Smith
- Department of Public Health Sciences, University of Rochester Medical Center, Rochester, NY, United States
| | - Eliany Acosta
- Department of Public Health Sciences, University of Rochester Medical Center, Rochester, NY, United States
| | - Arlette Chávez-Iñiguez
- Department of Public Health Sciences, University of Rochester Medical Center, Rochester, NY, United States
| | - Mary Jo Evans
- Imaging Population Health Programs, University of Rochester Medical Center, Rochester, NY, United States
| | - Marcela Gaitán
- National Alliance for Hispanic Health, Washington, DC, United States
| | - Fang Lei
- School of Nursing, University of Minnesota, Minneapolis, MN, United States
| | - Reza Yousefi-Nooraie
- Department of Public Health Sciences, University of Rochester Medical Center, Rochester, NY, United States
| | - Kevin A. Fiscella
- Department of Public Health Sciences, University of Rochester Medical Center, Rochester, NY, United States
- Department of Family Medicine, University of Rochester Medical Center, Rochester, NY, United States
| | - M. Patricia Rivera
- Department of Medicine, University of Rochester Medical Center, Rochester, NY, United States
| | - Ana Paula Cupertino
- Department of Public Health Sciences, University of Rochester Medical Center, Rochester, NY, United States
- Department of Surgery, University of Rochester Medical Center, Rochester, NY, United States
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2
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Yaeger JP, Fiscella KA, Ertefaie A, Alio AP. Persistent challenges in adjusting for race in analyses and a path forward. J Hosp Med 2024; 19:239-242. [PMID: 38017671 DOI: 10.1002/jhm.13246] [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] [Received: 02/03/2023] [Revised: 11/03/2023] [Accepted: 11/09/2023] [Indexed: 11/30/2023]
Affiliation(s)
- Jeffrey P Yaeger
- Department of Pediatrics, University of Rochester School of Medicine and Dentistry, Rochester, New York, USA
- Department of Public Health Sciences, University of Rochester Medical Center, Rochester, New York, USA
| | - Kevin A Fiscella
- Department of Family Medicine, University of Rochester School of Medicine and Dentistry, Rochester, New York, USA
| | - Ashkan Ertefaie
- Department of Biostatistics and Computational Biology, University of Rochester Medical Center, Rochester, New York, USA
| | - Amina P Alio
- Department of Public Health Sciences, University of Rochester Medical Center, Rochester, New York, USA
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3
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Thirukumaran CP, Fiscella KA, Rosenthal MB, Doshi JA, Schloemann DT, Ricciardi BF. Association of race and ethnicity with opioid prescribing for Medicare beneficiaries following total joint replacements. J Am Geriatr Soc 2024; 72:102-112. [PMID: 37772461 PMCID: PMC10841259 DOI: 10.1111/jgs.18605] [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] [Subscribe] [Scholar Register] [Received: 03/02/2023] [Revised: 06/29/2023] [Accepted: 08/24/2023] [Indexed: 09/30/2023]
Abstract
BACKGROUND Profound racial and ethnic disparities exist in the use and outcomes of total hip/knee replacements (total joint replacements [TJR]). Whether similar disparities extend to post-TJR pain management remains unknown. Our objective is to examine the association of race and ethnicity with opioid fills following elective TJRs for White, Black, and Hispanic Medicare beneficiaries. METHODS We used the 2019 national Medicare data to identify beneficiaries who underwent total hip/knee replacements. Primary outcomes were at least one opioid fill in the period from discharge to 30 days post-discharge, and 31-90 days following discharge. Secondary outcomes were morphine milligram equivalent per day and number of opioid fills. Key independent variable was patient race-ethnicity (non-Hispanic White, non-Hispanic Black, Hispanic). We estimated multivariable hierarchical logistic regressions and two-part models with state-level clustering. RESULTS Among 67,550 patients, 93.36% were White, 3.69% were Black, and 2.95% were Hispanic. Compared to White patients, more Black patients and fewer Hispanic patients filled an opioid script (84.10% [Black] and 80.11% [Hispanic] vs. 80.33% [White], p < 0.001) in the 30-day period. On multivariable analysis, Black patients had 18% higher odds of filling an opioid script in the 30-day period (odds ratio [OR]: 1.18, 95% confidence interval [CI]: 1.05-1.33, p = 0.004), and 39% higher odds in the 31-90-day period (OR: 1.39, 95% CI: 1.26-1.54, p < 0.001). There were no significant differences in the endpoints between Hispanic and White patients in the 30-day period. However, Hispanic patients had 20% higher odds of filling an opioid script in the 31- to 90-day period (OR: 1.20, 95% CI: 1.07-1.34, p = 0.002). CONCLUSIONS Important race- and ethnicity-based differences exist in post-TJR pain management with opioids. The mechanisms leading to the higher use of opioids by racial/ethnic minority patients need to be carefully examined.
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Affiliation(s)
- Caroline P. Thirukumaran
- Department of Orthopaedics – University of Rochester, NY
- Department of Public Health Sciences – University of Rochester, NY
- Center for Musculoskeletal Research – University of Rochester, NY
| | - Kevin A. Fiscella
- Department of Public Health Sciences – University of Rochester, NY
- Department of Family Medicine – University of Rochester, NY
| | - Meredith B. Rosenthal
- Department of Health Policy and Management – Harvard T. H. Chan School of Public Health, MA
| | - Jalpa A. Doshi
- Division of General Internal Medicine – University of Pennsylvania Perelman School of Medicine, PA
| | - Derek T. Schloemann
- Department of Orthopaedics – University of Rochester, NY
- Center for Musculoskeletal Research – University of Rochester, NY
| | - Benjamin F. Ricciardi
- Department of Orthopaedics – University of Rochester, NY
- Center for Musculoskeletal Research – University of Rochester, NY
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Fiscella KA, Sass E, Sridhar SB, Maguire JA, Lashway K, Wong G, Thien A, Thomas M, Bisognano JD, Rosenberg T, Sanders MR, Johnson BA, Polgreen LA. Team-based home blood pressure monitoring for blood pressure equity a protocol for a stepped wedge cluster randomized trial. Contemp Clin Trials 2023; 134:107332. [PMID: 37722482 PMCID: PMC10725081 DOI: 10.1016/j.cct.2023.107332] [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] [Subscribe] [Scholar Register] [Received: 05/31/2023] [Revised: 08/29/2023] [Accepted: 09/15/2023] [Indexed: 09/20/2023]
Abstract
BACKGROUND Home Blood Pressure Monitoring (HBPM) that includes a team with a clinical pharmacist is an evidence-based intervention that improves blood pressure (BP). Yet, strategies for promoting its adoption in primary care are lacking. We developed potentially feasible and sustainable implementation strategies to improve hypertension control and BP equity. METHODS We assessed barriers and facilitators to HBPM and iteratively adapted implementation strategies through key informative interviews and guidance from a multistakeholder stakeholder team involving investigators, clinicians, and practice administration. RESULTS Strategies include: 1) pro-active outreach to patients; 2) provision of BP devices; 3) deployment of automated bidirectional texting to support patients through education messages for patients to transmit their readings to the clinical team; 3) a hypertension visit note template; 4) monthly audit and feedback reports on progress to the team; and 5) training to the patients and teams. We will use a stepped wedge randomized trial to assess RE-AIM outcomes. These are defined as follows Reach: the proportion of eligible patients who agree to participate in the BP texting; Effectiveness: the proportion of eligible patients with their last BP reading <140/90 (six months); Adoption: the proportion of patients invited to the BP texting; Implementation: patients who text their BP reading ≥10 of days per month; and Maintenance: sustained BP control post-intervention (twelve months). We will also examine RE-AIM metrics stratified by race and ethnicity. CONCLUSIONS Findings will inform the impact of strategies for the adoption of team-based HPBM and the impact of the intervention on hypertension control and equity. REGISTRATION DETAILS www. CLINICALTRIALS gov Identifier: NCT05488795.
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Affiliation(s)
- Kevin A Fiscella
- Department of Family Medicine Research, Highland Hospital, University of Rochester Medical Center, 1381 South Ave, Rochester, NY 14620, United States of America.
| | - Emma Sass
- Department of Family Medicine Research, Highland Hospital, University of Rochester Medical Center, 1381 South Ave, Rochester, NY 14620, United States of America
| | - Soumya B Sridhar
- Department of Family Medicine, Highland Hospital, University of Rochester Medical Center, 777 S. Clinton Ave, Rochester, NY 14620, United States of America
| | - Jennifer A Maguire
- Department of Family Medicine, Highland Hospital, University of Rochester Medical Center, 777 S. Clinton Ave, Rochester, NY 14620, United States of America
| | - Katie Lashway
- Department of Family Medicine, Highland Hospital, University of Rochester Medical Center, 777 S. Clinton Ave, Rochester, NY 14620, United States of America
| | - Geoff Wong
- Nuffield Department of Primary Care, Medical Sciences Division, University of Oxford, United Kingdom
| | - Amy Thien
- Department of Family Medicine, Highland Hospital, University of Rochester Medical Center, 777 S. Clinton Ave, Rochester, NY 14620, United States of America
| | - Marie Thomas
- Department of Family Medicine Research, Highland Hospital, University of Rochester Medical Center, 1381 South Ave, Rochester, NY 14620, United States of America
| | - John D Bisognano
- Department of Medicine, Cardiology Division, University of Michigan, 24 Frank Lloyd Wright Dr. Ste 1300, Lobby A, Ann Arbor, MI 48106, United States of America
| | - Tziporah Rosenberg
- Department of Family Medicine, Highland Hospital, University of Rochester Medical Center, 777 S. Clinton Ave, Rochester, NY 14620, United States of America
| | - Mechelle R Sanders
- Department of Family Medicine Research, Highland Hospital, University of Rochester Medical Center, 1381 South Ave, Rochester, NY 14620, United States of America
| | - Brent A Johnson
- Department of Biostatistics and Computational Biology, University of Rochester Medical Center, 265 Crittenden Blvd, Rochester, NY 14642, United States of America
| | - Linnea A Polgreen
- College of Pharmacy, Iowa University, 340 College of Pharmacy Building, 180 S Grand Ave, Iowa City, IA 5224, United States of America
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Saeed F, Eneanya A, Allen RJ, Tamura MK, Fiscella KA. Addressing Racial Injustice, Developing Cultural Humility, and Fostering Rapport-Building Communication Skills to Improve Disparities in End-of-Life Planning. J Pain Symptom Manage 2023; 66:e451-e453. [PMID: 37355055 DOI: 10.1016/j.jpainsymman.2023.05.019] [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] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/25/2023] [Accepted: 05/30/2023] [Indexed: 06/26/2023]
Affiliation(s)
- Fahad Saeed
- Departments of medicine and Public Health, Divisions of Nephrology and Palliative Care (F.S.), University of Rochester Medical Center, Rochester, New York, USA.
| | - Amaka Eneanya
- Fresenius Medical Care, Global Medical Office (A.E.), Philadelphia, Pennsylvania, USA
| | - Rebecca J Allen
- School of Behavior and Natural Science (R.J. A.), Mount St. Joseph University, Cincinnati, Ohio, USA
| | - Manjula K Tamura
- Division of Nephrology (M.K.T.), Stanford University and Geriatric Research and Education Clinical Center Veterans Affairs Palo Alto, Palo Alto, California, USA
| | - Kevin A Fiscella
- Department of Family Medicine and Center for Center for Communication and Disparities Research (K.A.F.), University of Rochester School of Medicine and Dentistry, Rochester, New York, USA
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Saeed F, Dahl S, Horowitz RK, Duberstein PR, Epstein RM, Fiscella KA, Allen RJ. Development and Acceptability of a Kidney Therapy Decision Aid for Patients Aged 75 Years and Older: A Design-Based Research Involving Patients, Caregivers, and a Multidisciplinary Team. Kidney Med 2023; 5:100671. [PMID: 37492114 PMCID: PMC10363565 DOI: 10.1016/j.xkme.2023.100671] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 07/27/2023] Open
Abstract
Rationale & Objective Many older adults prefer quality of life over longevity, and some prefer conservative kidney management (CKM) over dialysis. There is a lack of patient-decision aids for adults aged 75 years or older facing kidney therapy decisions, which not only include information on dialysis and CKM but also encourage end-of-life planning. We iteratively developed a paper-based patient-decision aid for older people with low literacy and conducted surveys to assess its acceptability. Study Design Design-based research. Setting and Participants Informed by design-based research principles and theory of behavioral activation, a multidisciplinary team of experts created a first version of the patient-decision aid containing 2 components: (1) educational material about kidney therapy options such as CKM, and (2) a question prompt list relevant to kidney therapy and end-of-life decision making. On the basis of the acceptability input of patients and caregivers, separate qualitative interviews of 35 people receiving maintenance dialysis, and with the independent feedback of educated layperson, we further modified the patient-decision aid to create a second version. Analytical Approach We used descriptive statistics to present the results of acceptability surveys and thematic content analyses for patients' qualitative interviews. Results The mean age of patients (n=21) who tested the patient-decision aid was 80 years and the mean age of caregivers (n=9) was 70 years. All respondents held positive views about the educational component and would recommend the educational component to others (100% patients and caregivers). Most of the patients reported that the question prompt list helped them put concerns into words (80% patients and 88% caregivers) and would recommend the question prompt list to others (95% patients and 100% caregivers). Limitations Single-center study. Conclusions Both components of the patient-decision aid received high acceptability ratings. We plan to launch a larger effectiveness study to test the outcomes of a decision-supporting intervention combining the patient-decision aid with palliative care-based decision coaching.
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Affiliation(s)
- Fahad Saeed
- Department of Medicine, Division of Nephrology, University of Rochester School of Medicine and Dentistry, Rochester, NY
- Department of Medicine, Division of Palliative Care, University of Rochester School of Medicine and Dentistry, Rochester, NY
| | - Spencer Dahl
- University of Rochester School of Medicine and Dentistry, Rochester, NY
| | - Robert K. Horowitz
- Department of Medicine, Division of Palliative Care, University of Rochester School of Medicine and Dentistry, Rochester, NY
| | - Paul R. Duberstein
- Department of Health Behavior, Society, and Policy, Rutgers School of Public Health, Piscataway, NJ
| | - Ronald M. Epstein
- Department of Medicine, Division of Palliative Care, University of Rochester School of Medicine and Dentistry, Rochester, NY
- Department of Family Medicine and Center for Center for Communication and Disparities Research, University of Rochester School of Medicine and Dentistry, Rochester, NY
| | - Kevin A. Fiscella
- Department of Family Medicine and Center for Center for Communication and Disparities Research, University of Rochester School of Medicine and Dentistry, Rochester, NY
| | - Rebecca J. Allen
- Mount St. Joseph University, School of Behavioral and Natural Sciences, Cincinnati, OH
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Kazi BS, Duberstein PR, Kluger BM, Epstein RM, Fiscella KA, Kazi ZS, Dahl SK, Allen RJ, Saeed F. Prevalence and Correlates of Preference-Concordant Care Among Hospitalized People Receiving Maintenance Dialysis. Kidney360 2023; 4:e751-e758. [PMID: 37143194 PMCID: PMC10371368 DOI: 10.34067/kid.0000000000000131] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 09/09/2022] [Accepted: 03/30/2023] [Indexed: 05/06/2023]
Abstract
Key Points A large proportion of hospitalized patients receiving dialysis report not receiving preference-concordant care. Hospitalized patients on dialysis desiring a comfort-oriented medical plan were likely to report receiving preference-concordant care. Background Preference-concordant care is a cornerstone of high-quality medical decision-making, yet the prevalence and correlates of preference-concordant care have not been well-studied in patients receiving dialysis. We surveyed hospitalized people receiving maintenance dialysis to estimate the prevalence and correlates of preference-concordant care among this population. Methods We assessed preference concordance by asking participants (223/380, 59% response rate), “How strongly do you agree or disagree that your current treatment plan meets your preference?” We assessed treatment plan preference by asking whether patients preferred a plan that focused on (1 ) extending life or (2 ) relieving pain and discomfort. We assessed shared dialysis decision-making using the 9-item Shared Decision-Making Questionnaire. We examined the differences between those reporting lack of preference-concordant care and those reporting receipt of preference-concordant care using chi-squared analyses. We also studied whether patients' treatment plan preferences or shared dialysis decision-making scores were correlated with their likelihood of receiving preference-concordant care. Results Of the 213 respondents who provided data on preference concordance, 90 (42.3%) reported that they were not receiving preference-concordant care. Patients who preferred pain and discomfort relief over life extension were less likely (odds ratio, 0.15 [95% confidence interval, 0.08 to 0.28] P = <0.0001) to report receiving preference-concordant care; patients with higher shared decision-making scores were more likely (odds ratio, 1.02 [95% confidence interval, 1.01 to 1.03], P = 0.02) to report preference-concordant care. Conclusions A substantial proportion of this sample of hospitalized people receiving maintenance dialysis reported not receiving preference-concordant care. Efforts to improve symptom management and enhance patient engagement in dialysis decision-making may improve the patients' perceptions of receiving preference-concordant care.
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Affiliation(s)
- Basil S Kazi
- Department of Internal Medicine, University of Illinois at Chicago, Chicago, Illinois
- School of Medicine and Dentistry, University of Rochester, Rochester, New York
| | - Paul R Duberstein
- Department of Health Behavior, Society and Policy, Rutgers School of Public Health, Piscataway, New Jersey
| | - Benzi M Kluger
- Department of Palliative Care, University of Rochester Medical Center, Rochester, New York
- Department of Neurology, University of Rochester Medical Center, Rochester, New York
| | - Ronald M Epstein
- Department of Palliative Care, University of Rochester Medical Center, Rochester, New York
- Department of Family Medicine, University of Rochester Medical Center, Rochester, New York
| | - Kevin A Fiscella
- Department of Family Medicine, University of Rochester Medical Center, Rochester, New York
- Department of Public Health Sciences, University of Rochester Medical Center, Rochester, New York
| | - Zain S Kazi
- Institute of Advanced Analytics, North Carolina State University, Raleigh, North Carolina
| | - Spencer K Dahl
- School of Medicine and Dentistry, University of Rochester, Rochester, New York
| | - Rebecca J Allen
- School of Behavioral and Natural Sciences, Mount St. Joseph University, Cincinnati, Ohio
| | - Fahad Saeed
- Department of Public Health Sciences, University of Rochester Medical Center, Rochester, New York
- Department of Nephrology, University of Rochester Medical Center, Rochester, New York
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Saeed F, Ladwig S, Allen RJ, Eneanya ND, Tamura MK, Fiscella KA. Racial Disparities in Health Beliefs and Advance Care Planning Among Patients Receiving Maintenance Dialysis. J Pain Symptom Manage 2023; 65:318-325. [PMID: 36521766 PMCID: PMC10103744 DOI: 10.1016/j.jpainsymman.2022.12.002] [Citation(s) in RCA: 6] [Impact Index Per Article: 6.0] [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: 06/07/2022] [Revised: 11/30/2022] [Accepted: 12/02/2022] [Indexed: 12/14/2022]
Abstract
CONTEXT Among people receiving maintenance dialysis, little is known about racial disparities in the occurrence of prognostic discussions, beliefs about future health, and completion of advance care planning (ACP) documents. OBJECTIVES We examined whether Black patients receiving maintenance dialysis differ from White patients in prognostic discussions, beliefs about future health, and completion of ACP-related documents. METHODS We surveyed adult patients receiving maintenance dialysis from seven dialysis units in Cleveland, Ohio, and hospitalized patients at a tertiary care hospital in Cleveland. Of the 450 patients who were asked to participate in the study, 423 (94%) agreed. We restricted the current secondary analyses to include only Black (n=285) and White (n=114) patients. The survey assessed patients' knowledge of their kidney disease, attitudes toward chronic kidney disease (CKD) treatment, preferences for end-of-life (EoL) care, the patient-reported occurrence of prognostic discussions, experiences with kidney therapy decision making, sentiments of dialysis regret, beliefs about health over the next 12 months, and advance care planning. We used stepwise logistic regression to determine if race was associated with the occurrence of prognostic discussions, beliefs about future health, and completion of an ACP-related document, while controlling for potential confounders. RESULTS We found no significant difference in the frequency of prognostic discussions between Black (11.9%) versus White patients (7%) (P=0.15). However, Black patients (19%) had lower odds of believing that their health would worsen over the next 12 months (OR 0.22, CI 0.12, 0.44) and reporting completion of any ACP-related document (OR 0.5, CI 0.32, 0.81) compared to White patients CONCLUSION: Racial differences exist in beliefs about future health and completion of ACP-related documents. Systemic efforts to investigate differences in health beliefs and address racial disparities in the completion of ACP-related documents are needed.
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Affiliation(s)
- Fahad Saeed
- Department of Medicine, Division of Nephrology (F.S.), University of Rochester School of Medicine and Dentistry, Rochester, New York, USA; Division of Palliative Care (F.S., S.L.), University of Rochester School of Medicine and Dentistry, Rochester, New York, USA.
| | - Susan Ladwig
- Division of Palliative Care (F.S., S.L.), University of Rochester School of Medicine and Dentistry, Rochester, New York, USA
| | - Rebecca Jane Allen
- Mount St. Joseph University, School of Behavior and Natural Science (R.J.A.), Cincinnati, Ohio, USA
| | - Nwamaka D Eneanya
- Fresenius Medical Care, Global Medical Office, Philadelphia, Pennsylvania, USA
| | - Manjula Kurella Tamura
- Division of Nephrology (MKT), Stanford University and Geriatric Research and Education Clinical Center Veterans Affairs Palo Alto, Palo Alto, California, USA
| | - Kevin A Fiscella
- Department of Family Medicine and Center for Center for Communication and Disparities Research (K.A.F.), University of Rochester School of Medicine and Dentistry, Rochester, New York, USA
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Yaeger JP, Richfield C, Schiller E, Oh Y, Pereira BMC, Shabangu T, Fiscella KA. Performance of AAP Clinical Practice Guideline for Febrile Infants at One Pediatric Hospital. Hosp Pediatr 2023; 13:e47-e50. [PMID: 36727277 PMCID: PMC9986852 DOI: 10.1542/hpeds.2022-006820] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/03/2023]
Abstract
BACKGROUND In the absence of procalcitonin, the American Academy of Pediatrics' clinical practice guideline (CPG) for evaluating and managing febrile infants recommends using previously untested combinations of inflammatory marker thresholds. Thus, CPG performance in detecting invasive bacterial infections (IBIs; bacteremia, bacterial meningitis) is poorly understood. OBJECTIVE To evaluate CPG performance without procalcitonin in detecting IBIs in well-appearing febrile infants 8 to 60 days old. METHODS For this cross-sectional, single-site study, we manually abstracted data for febrile infants using electronic health records from 2011 to 2018. We used CPG inclusion/exclusion criteria to identify eligible infants and stratified IBI risk with CPG inflammatory marker thresholds for temperature, absolute neutrophil count, and C-reactive protein. Because the CPG permits a wide array of interpretations, we performed 3 sensitivity analyses, modifying age and inflammatory marker thresholds. For each approach, we calculated area-under-the-receiver operating characteristic curve, sensitivity, and specificity in detecting IBIs. RESULTS For this study, 507 infants met the inclusion criteria. For the main analysis, we observed an area-under-the-receiver operating characteristic curve of 0.673 (95% confidence interval 0.652-0.694), sensitivity of 100% (66.4%-100%), and specificity of 34.5% (30.4%-38.9%). For the sensitivity analyses, sensitivities were all 100% and specificities ranged from 9% to 38%. CONCLUSION Findings suggest that the CPG is highly sensitive, minimizing missed IBIs, but specificity may be lower than previously reported. Future studies should prospectively investigate CPG performance in larger, multisite samples.
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Affiliation(s)
- Jeffrey P. Yaeger
- Departments of Pediatrics
- University of Rochester Medical Center, Department of Public Health Sciences, Rochester, New York
| | | | - Emily Schiller
- New York University Long Island School of Medicine, Long Island, New York
| | | | | | | | - Kevin A. Fiscella
- Family Medicine, University of RochesterSchool of Medicine and Dentistry, Rochester, New York
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10
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Eckert C, Sanders M, Bharadwaj R, Fiscella KA. Accessibility of State and Territory Public Health Department Website Information on COVID-19 Outpatient Treatments in the US. JAMA Netw Open 2023; 6:e230186. [PMID: 36809472 PMCID: PMC9945065 DOI: 10.1001/jamanetworkopen.2023.0186] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/16/2022] [Accepted: 01/04/2023] [Indexed: 02/23/2023] Open
Abstract
This cross-sectional study assesses the reading level and accessibility of information on COVID-19 treatments posted on US public health websites for states, territories, and Washington, DC.
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Affiliation(s)
- Cody Eckert
- University of Rochester Medical Center, Rochester, New York
| | | | - Rhea Bharadwaj
- University of Rochester Medical Center, Rochester, New York
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11
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Yaeger JP, Jones J, Ertefaie A, Caserta MT, Fiscella KA. Derivation of a clinical-based model to detect invasive bacterial infections in febrile infants. J Hosp Med 2022; 17:893-900. [PMID: 36036211 PMCID: PMC9633417 DOI: 10.1002/jhm.12956] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/10/2022] [Revised: 07/28/2022] [Accepted: 08/15/2022] [Indexed: 11/10/2022]
Abstract
BACKGROUND Febrile infants are at risk for invasive bacterial infections (IBIs) (i.e., bacteremia and bacterial meningitis), which, when undiagnosed, may have devastating consequences. Current IBI predictive models rely on serum biomarkers, which may not provide timely results and may be difficult to obtain in low-resource settings. OBJECTIVE The aim of this study was to derive a clinical-based IBI predictive model for febrile infants. DESIGNS, SETTING, AND PARTICIPANTS This is a cross-sectional study of infants brought to two pediatric emergency departments from January 2011 to December 2018. Inclusion criteria were age 0-90 days, temperature ≥38°C, and documented gestational age, fever duration, and illness duration. MAIN OUTCOME AND MEASURES To detect IBIs, we used regression and ensemble machine learning models and evidence-based predictors (i.e., sex, age, chronic medical condition, gestational age, appearance, maximum temperature, fever duration, illness duration, cough status, and urinary tract inflammation). We up-weighted infants with IBIs 8-fold and used 10-fold cross-validation to avoid overfitting. We calculated the area under the receiver operating characteristic curve (AUC), prioritizing a high sensitivity to identify the optimal cut-point to estimate sensitivity and specificity. RESULTS Of 2311 febrile infants, 39 had an IBI (1.7%); the median age was 54 days (interquartile range: 35-71). The AUC was 0.819 (95% confidence interval: 0.762, 0.868). The predictive model achieved a sensitivity of 0.974 (0.800, 1.00) and a specificity of 0.530 (0.484, 0.575). Findings suggest that a clinical-based model can detect IBIs in febrile infants, performing similarly to serum biomarker-based models. This model may improve health equity by enabling clinicians to estimate IBI risk in any setting. Future studies should prospectively validate findings across multiple sites and investigate performance by age.
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Affiliation(s)
- Jeffrey P Yaeger
- Department of Pediatrics, University of Rochester School of Medicine and Dentistry, Rochester, New York, USA
- Department of Public Health Sciences, University of Rochester Medical Center, Rochester, New York, USA
| | - Jeremiah Jones
- Department of Biostatistics and Computational Biology, University of Rochester Medical Center, Rochester, New York, USA
| | - Ashkan Ertefaie
- Department of Biostatistics and Computational Biology, University of Rochester Medical Center, Rochester, New York, USA
| | - Mary T Caserta
- Department of Pediatrics, University of Rochester School of Medicine and Dentistry, Rochester, New York, USA
| | - Kevin A Fiscella
- Department of Family Medicine, University of Rochester School of Medicine and Dentistry, Rochester, New York, USA
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Saeed F, Moss AH, Duberstein PR, Fiscella KA. Enabling Patient Choice: The "Deciding Not to Decide" Option for Older Adults Facing Dialysis Decisions. J Am Soc Nephrol 2022; 33:880-882. [PMID: 35169067 PMCID: PMC9063883 DOI: 10.1681/asn.2021081143] [Citation(s) in RCA: 7] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/03/2022] Open
Affiliation(s)
- Fahad Saeed
- Departments of Medicine and Public Health, Divisions of Nephrology and Palliative Care, University of Rochester School of Medicine and Dentistry, Rochester, New York
| | - Alvin H Moss
- Sections of Nephrology, Geriatrics, and Palliative Medicine, West Virginia University School of Medicine, Morgantown, West Virginia
| | - Paul R Duberstein
- Department of Health Behavior, Society, and Policy, Rutgers School of Public Health, Piscataway, New Jersey
| | - Kevin A Fiscella
- Department of Family Medicine and Center for Communication and Disparities Research, University of Rochester School of Medicine and Dentistry, Rochester, New York
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13
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Saeed F, Murad HF, Wing RE, Li J, Schold JD, Fiscella KA. Outcomes Following In-Hospital Cardiopulmonary Resuscitation in People Receiving Maintenance Dialysis. Kidney Med 2022; 4:100380. [PMID: 35072044 PMCID: PMC8767126 DOI: 10.1016/j.xkme.2021.08.014] [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] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/10/2023] Open
Abstract
Rationale & Objective Previous studies showing poor cardiopulmonary resuscitation (CPR) outcomes in the dialysis population have largely been derived from claims data and are somewhat limited by a lack of detailed characterization of CPR events. We aimed to analyze CPR-related outcomes in individuals receiving maintenance dialysis. Study Design Retrospective chart review. Setting & Participants Using electronic medical records from a single academic health care system, we identified all hospitalized adult patients receiving maintenance dialysis who had undergone in-hospital CPR between 2006 and 2014. Exposure Initial in-hospital CPR. Outcomes Overall survival, predictors of unsuccessful CPR, predictors of death during the same hospitalization among initial survivors, predictors of discharge-to-home status. Analytical Approach We provide descriptive statistics for the study variables and used t tests, χ2 tests, or Fisher exact tests to compare differences between the groups. We built multivariable logistic regression models to examine the CPR-related outcomes. Results A total of 184 patients received in-hospital CPR: 51 (28%) did not survive the initial CPR event, and 77 CPR survivors died (additional 42%) later during the same hospitalization (overall mortality 70%). Only 18 (10%) were discharged home, with the remaining 32 (17%) discharged to a rehabilitation facility or a nursing home. In the multivariable model, the only predictor of unsuccessful CPR was CPR duration (OR, 1.41; 95% CI, 1.24-1.61; P < 0.001). Predictors of death during the same hospitalization after surviving the initial CPR event were CPR duration (OR, 1.15; 95% CI 1.04-1.27; P = 0.007) and older age (OR, 1.64; 95% CI, 1.23-2.2; P < 0.001). Older people also had lower odds of discharge-to-home status (OR, 0.25; 95% CI, 0.11-0.54; P < 0.001). Limitations Retrospective study design, single-center study, no information on functional status. Conclusions Patients receiving maintenance dialysis experience high mortality following in-hospital CPR and only 10% are discharged home. These data may help clinicians provide useful prognostic information while engaging in goals of care conversations.
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Hurst R, Liljenquist K, Lowry SJ, Szilagyi PG, Fiscella KA, Weaver MR, Porras-Javier L, Ortiz J, Sotelo Guerra LJ, Coker TR. A Parent Coach-Led Model of Well-Child Care for Young Children in Low-Income Communities: Protocol for a Cluster Randomized Controlled Trial. JMIR Res Protoc 2021; 10:e27054. [PMID: 34842563 PMCID: PMC8663704 DOI: 10.2196/27054] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [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: 02/09/2021] [Revised: 09/22/2021] [Accepted: 09/27/2021] [Indexed: 11/26/2022] Open
Abstract
Background The Parent-focused Redesign for Encounters, Newborns to Toddlers (PARENT) intervention was created as a team-based approach to well-child care (WCC) that relies on a health educator (Parent Coach) to provide the bulk of WCC services, address specific needs faced by families in low-income communities, and decrease reliance on the clinician as the primary provider of WCC services. Objective This study aims to evaluate the impact of PARENT using a cluster randomized controlled trial. Methods This study tested the effectiveness of PARENT at 10 clinical sites in 2 federally qualified health centers in Tacoma, Washington, and Los Angeles, California. We conducted a cluster randomized controlled trial that included 916 families with children aged ≤12 months at the time of the baseline survey. Parents will be followed up at 6 and 12 months after enrollment. The Parent Coach, the main element of PARENT, provides anticipatory guidance, psychosocial screening and referral, developmental and behavioral surveillance, screening, and guidance at each WCC visit. The coach is supported by parent-focused previsit screening and visit prioritization, a brief, problem-focused clinician encounter for a physical examination and any concerns that require a clinician’s attention, and an automated text message parent reminder and education service for periodic, age-specific messages to reinforce key health-related information recommended by Bright Futures national guidelines. We will examine parent-reported quality of care (receipt of nationally recommended WCC services, family-centeredness of care, and parental experiences of care), and health care use (WCC, urgent care, emergency department, and hospitalizations), conduct a cost analysis, and conduct a separate time-motion study of clinician time allocation to assess efficiency. We will also collect data on exploratory measures of parent-and parenting-focused outcomes. Our primary outcomes were receipt of anticipatory guidance and emergency department use. Results Participant recruitment began in March 2019. After recruitment, 6- and 12-month follow-up surveys will be completed. As of August 30, 2021, we enrolled a total of 916 participants. Conclusions This large pragmatic trial of PARENT in partnership with federally qualified health centers will assess its utility as an evidence-based and financially sustainable model for the delivery of preventive care services to children in low-income communities. Trial Registration ClinicalTrials.gov: NCT03797898; https://clinicaltrials.gov/ct2/show/NCT03797898 International Registered Report Identifier (IRRID) DERR1-10.2196/27054
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Affiliation(s)
- Rachel Hurst
- School of Public Health, New York University, New York, NY, United States
| | - Kendra Liljenquist
- Seattle Children's Research Institute, Seattle, WA, United States.,Department of Pediatrics, University of Washington School of Medicine, Seattle, WA, United States
| | - Sarah J Lowry
- Seattle Children's Research Institute, Seattle, WA, United States
| | - Peter G Szilagyi
- Department of Pediatrics, University of California, Los Angeles, Los Angeles, CA, United States
| | - Kevin A Fiscella
- Department of Family Medicine, University of Rochester Medical Center, Rochester, NY, United States
| | - Marcia R Weaver
- Department of Health Metrics Sciences, School of Medicine, University of Washington, Seattle, WA, United States.,Institute for Health Metrics and Evaluation, School of Medicine, University of Washington, Seattle, WA, United States
| | - Lorena Porras-Javier
- Department of Pediatrics, University of California, Los Angeles, Los Angeles, CA, United States
| | - Janette Ortiz
- Department of Pediatrics, University of California, Los Angeles, Los Angeles, CA, United States
| | | | - Tumaini R Coker
- Seattle Children's Research Institute, Seattle, WA, United States.,Department of Pediatrics, University of Washington School of Medicine, Seattle, WA, United States
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15
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Wu TT, Xiao J, Sohn MB, Fiscella KA, Gilbert C, Grier A, Gill AL, Gill SR. Machine Learning Approach Identified Multi-Platform Factors for Caries Prediction in Child-Mother Dyads. Front Cell Infect Microbiol 2021; 11:727630. [PMID: 34490147 PMCID: PMC8417465 DOI: 10.3389/fcimb.2021.727630] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [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: 06/19/2021] [Accepted: 07/09/2021] [Indexed: 12/19/2022] Open
Abstract
Untreated tooth decays affect nearly one third of the world and is the most prevalent disease burden among children. The disease progression of tooth decay is multifactorial and involves a prolonged decrease in pH, resulting in the demineralization of tooth surfaces. Bacterial species that are capable of fermenting carbohydrates contribute to the demineralization process by the production of organic acids. The combined use of machine learning and 16s rRNA sequencing offers the potential to predict tooth decay by identifying the bacterial community that is present in an individual’s oral cavity. A few recent studies have demonstrated machine learning predictive modeling using 16s rRNA sequencing of oral samples, but they lack consideration of the multifactorial nature of tooth decay, as well as the role of fungal species within their models. Here, the oral microbiome of mother–child dyads (both healthy and caries-active) was used in combination with demographic–environmental factors and relevant fungal information to create a multifactorial machine learning model based on the LASSO-penalized logistic regression. For the children, not only were several bacterial species found to be caries-associated (Prevotella histicola, Streptococcus mutans, and Rothia muciloginosa) but also Candida detection and lower toothbrushing frequency were also caries-associated. Mothers enrolled in this study had a higher detection of S. mutans and Candida and a higher plaque index. This proof-of-concept study demonstrates the significant impact machine learning could have in prevention and diagnostic advancements for tooth decay, as well as the importance of considering fungal and demographic–environmental factors.
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Affiliation(s)
- Tong Tong Wu
- Department of Biostatistics and Computational Biology, University of Rochester Medical Center, Rochester, NY, United States
| | - Jin Xiao
- Eastman Institute for Oral Health, University of Rochester Medical Center, Rochester, NY, United States
| | - Michael B Sohn
- Department of Biostatistics and Computational Biology, University of Rochester Medical Center, Rochester, NY, United States
| | - Kevin A Fiscella
- Department of Family Medicine, University of Rochester Medical Center, Rochester, NY, United States
| | - Christie Gilbert
- Microbiology and Immunology, University of Rochester Medical Center, Rochester, NY, United States
| | - Alex Grier
- Microbiology and Immunology, University of Rochester Medical Center, Rochester, NY, United States
| | - Ann L Gill
- Microbiology and Immunology, University of Rochester Medical Center, Rochester, NY, United States
| | - Steve R Gill
- Microbiology and Immunology, University of Rochester Medical Center, Rochester, NY, United States
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16
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Saeed F, Shah AY, Allen RJ, Epstein RM, Fiscella KA. Communication principles and practices for making shared decisions about renal replacement therapy: a review of the literature. Curr Opin Nephrol Hypertens 2021; 30:507-515. [PMID: 34148978 PMCID: PMC8373782 DOI: 10.1097/mnh.0000000000000731] [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] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
PURPOSE OF REVIEW To provide an overview of the skill set required for communication and person-centered decision making for renal replacement therapy (RRT) choices, especially conservative kidney management (CKM). RECENT FINDINGS Research on communication and decision-making skills for shared RRT decision making is still in infancy. We adapt literature from other fields such as primary care and oncology for effective RRT decision making. SUMMARY We review seven key skills: (1) Announcing the need for decision making (2) Agenda Setting (3) Educating patients about RRT options (4) Discussing prognoses (5) Eliciting patient preferences (6) Responding to emotions and showing empathy, and (7) Investing in the end. We also provide example sentences to frame the conversations around RRT choices including CKM.
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Affiliation(s)
- Fahad Saeed
- Departments of Medicine and Public Health, Division of Nephrology
- Division of Palliative Care
- University of Rochester School of Medicine, National University of Medical Sciences
| | - Amna Yousaf Shah
- Rawalpindi, Pakistan; CITE Center, Department of Behavioral and Natural Sciences
| | | | - Ronald M Epstein
- Division of Palliative Care
- Department of Family Medicine and Center for Center for Communication and Disparities Research, University of Rochester School of Medicine and Dentistry, Rochester, New York, USA
| | - Kevin A Fiscella
- Department of Family Medicine and Center for Center for Communication and Disparities Research, University of Rochester School of Medicine and Dentistry, Rochester, New York, USA
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17
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Xiao J, Fiscella KA, Meyerowitz C. mDentistry: A powerful tool to improve oral health of a broad population in the digital era. J Am Dent Assoc 2021; 152:713-716. [PMID: 34454644 DOI: 10.1016/j.adaj.2021.06.004] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/02/2021] [Revised: 05/09/2021] [Accepted: 06/01/2021] [Indexed: 12/19/2022]
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18
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Thirukumaran CP, Kim Y, Cai X, Ricciardi BF, Li Y, Fiscella KA, Mesfin A, Glance LG. Association of the Comprehensive Care for Joint Replacement Model With Disparities in the Use of Total Hip and Total Knee Replacement. JAMA Netw Open 2021; 4:e2111858. [PMID: 34047790 PMCID: PMC8164097 DOI: 10.1001/jamanetworkopen.2021.11858] [Citation(s) in RCA: 26] [Impact Index Per Article: 8.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/19/2022] Open
Abstract
IMPORTANCE The Comprehensive Care for Joint Replacement (CJR) model is Medicare's mandatory bundled payment reform to improve quality and spending for beneficiaries who need total hip replacement (THR) or total knee replacement (TKR), yet it does not account for sociodemographic risk factors such as race/ethnicity and income. Results of this study could be the basis for a Medicare payment reform that addresses inequities in joint replacement care. OBJECTIVE To examine the association of the CJR model with racial/ethnic and socioeconomic disparities in the use of elective THR and TKR among older Medicare beneficiaries after accounting for the population of patients who were at risk or eligible for these surgical procedures. DESIGN, SETTING, AND PARTICIPANTS This cohort study used the 2013 to 2017 national Medicare data and multivariable logistic regressions with triple-differences estimation. Medicare beneficiaries who were aged 65 to 99 years, entitled to Medicare, alive at the end of the calendar year, and residing either in the 67 metropolitan statistical areas (MSAs) mandated to participate in the CJR model or in the 104 control MSAs were identified. A subset of Medicare beneficiaries with a diagnosis of arthritis underwent THR or TKR. Data were analyzed from March to December 2020. EXPOSURES Implementation of the CJR model in 2016. MAIN OUTCOMES AND MEASURES Outcomes were separate binary indicators for whether a beneficiary underwent THR or TKR. Key independent variables were MSA treatment status, pre- or post-CJR model implementation phase, combination of race/ethnicity (non-Hispanic White, non-Hispanic Black, and Hispanic beneficiaries) and dual eligibility, and their interactions. Logistic regression models were used to control for patient characteristics, MSA fixed effects, and time trends. RESULTS The 2013 cohort included 4 447 205 Medicare beneficiaries, of which 2 025 357 (45.5%) resided in MSAs with the CJR model. The cohort's mean (SD) age was 77.18 (7.95) years, and it was composed of 2 951 140 female (66.4%), 3 928 432 non-Hispanic White (88.3%), and 657 073 dually eligible (14.8%) beneficiaries. Before the CJR model implementation, rates were highest among non-Hispanic White non-dual-eligible beneficiaries at 1.25% (95% CI, 1.24%-1.26%) for THR use and 2.28% (95% CI, 2.26%-2.29%) for TKR use in MSAs with CJR model. Compared with MSAs without the CJR model and the analogous race/ethnicity and dual-eligibility group, the CJR model was associated with a 0.10 (95% CI, 0.05-0.15; P < .001) percentage-point increase in TKR use for non-Hispanic White non-dual-eligible beneficiaries, a 0.11 (95% CI, 0.004-0.21; P = .04) percentage-point increase for non-Hispanic White dual-eligible beneficiaries, a 0.15 (95% CI, -0.29 to -0.01; P = .04) percentage-point decrease for non-Hispanic Black non-dual-eligible beneficiaries, and a 0.18 (95% CI, -0.34 to -0.01; P = .03) percentage-point decrease for non-Hispanic Black dual-eligible beneficiaries. These CJR model-associated changes in TKR use were 0.25 (95% CI, -0.40 to -0.10; P = .001) percentage points lower for non-Hispanic Black non-dual-eligible beneficiaries and 0.27 (95% CI, -0.45 to -0.10; P = .002) percentage points lower for non-Hispanic Black dual-eligible beneficiaries compared with the model-associated changes for non-Hispanic White non-dual-eligible beneficiaries. No association was found between the CJR model and a widening of the THR use gap among race/ethnicity and dual eligibility groups. CONCLUSIONS AND RELEVANCE Results of this study indicate that the CJR model was associated with a modest increase in the already substantial difference in TKR use among non-Hispanic Black vs non-Hispanic White beneficiaries; no difference was found for THR. These findings support the widespread concern that payment reform has the potential to exacerbate disparities in access to joint replacement care.
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MESH Headings
- Aged
- Aged, 80 and over
- Arthroplasty, Replacement, Hip/economics
- Arthroplasty, Replacement, Hip/standards
- Arthroplasty, Replacement, Hip/statistics & numerical data
- Arthroplasty, Replacement, Knee/economics
- Arthroplasty, Replacement, Knee/standards
- Arthroplasty, Replacement, Knee/statistics & numerical data
- Cohort Studies
- Elective Surgical Procedures/economics
- Elective Surgical Procedures/standards
- Elective Surgical Procedures/statistics & numerical data
- Eligibility Determination/standards
- Eligibility Determination/statistics & numerical data
- Female
- Healthcare Disparities/economics
- Healthcare Disparities/standards
- Healthcare Disparities/statistics & numerical data
- Humans
- Male
- Medicare/economics
- Medicare/standards
- Medicare/statistics & numerical data
- Race Factors
- Reimbursement Mechanisms
- Socioeconomic Factors
- United States
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Affiliation(s)
- Caroline P. Thirukumaran
- Department of Orthopaedics, University of Rochester, Rochester, New York
- Department of Public Health Sciences, University of Rochester, Rochester, New York
- Center for Musculoskeletal Research, University of Rochester, Rochester, New York
| | - Yeunkyung Kim
- Department of Public Health Sciences, University of Rochester, Rochester, New York
| | - Xueya Cai
- Department of Biostatistics and Computational Biology, University of Rochester, Rochester, New York
| | - Benjamin F. Ricciardi
- Department of Orthopaedics, University of Rochester, Rochester, New York
- Center for Musculoskeletal Research, University of Rochester, Rochester, New York
| | - Yue Li
- Department of Public Health Sciences, University of Rochester, Rochester, New York
| | - Kevin A. Fiscella
- Department of Public Health Sciences, University of Rochester, Rochester, New York
- Department of Family Medicine, University of Rochester, Rochester, New York
- Center for Community Health and Prevention, University of Rochester, Rochester, New York
| | - Addisu Mesfin
- Department of Orthopaedics, University of Rochester, Rochester, New York
- Center for Musculoskeletal Research, University of Rochester, Rochester, New York
| | - Laurent G. Glance
- Department of Public Health Sciences, University of Rochester, Rochester, New York
- Department of Anesthesiology and Perioperative Medicine, University of Rochester, Rochester, New York
- RAND Health, RAND, Boston, Massachusetts
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Thirukumaran CP, Cai X, Glance LG, Kim Y, Ricciardi BF, Fiscella KA, Li Y. Geographic Variation and Disparities in Total Joint Replacement Use for Medicare Beneficiaries: 2009 to 2017. J Bone Joint Surg Am 2020; 102:2120-2128. [PMID: 33079898 PMCID: PMC8190867 DOI: 10.2106/jbjs.20.00246] [Citation(s) in RCA: 35] [Impact Index Per Article: 8.8] [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: 02/01/2023]
Abstract
BACKGROUND Little is known about how the geographic variation and disparities in use of elective primary total hip and knee replacements for Medicare beneficiaries have evolved in recent years. The study objectives are to determine these variations and disparities, whether Black Medicare beneficiaries have continued to undergo fewer total hip replacements and total knee replacements across regions, and whether disparities affected all Black beneficiaries or mainly affected socioeconomically disadvantaged Black beneficiaries. METHODS We used 2009 to 2017 Medicare enrollment and claims data to examine Hospital Referral Region (HRR)-level variation and disparities by race (non-Hispanic White and Black) and socioeconomic status (Medicare-only and dual eligibility for both Medicare and Medicaid). The outcomes were HRR-level age and sex-standardized total hip replacement and total knee replacement utilization rates for White Medicare-only beneficiaries, White dual-eligible beneficiaries, Black Medicare-only beneficiaries, and Black dual-eligible beneficiaries, and the differences in rates between these groups as a representation of disparities. The key exposure variables were race-socioeconomic group and year. We constructed multilevel mixed-effects linear regression models to estimate trends in total hip replacement and total knee replacement rates and to examine whether rates were lower in HRRs with high percentages of Black beneficiaries or dual-eligible beneficiaries. RESULTS The study included 924,844 total hip replacements and 2,075,968 total knee replacements. In 2017, the mean HRR-level total hip replacement rate was 4.64 surgical procedures per 1,000 beneficiaries, and the mean HRR-level total knee replacement rate was 9.66 surgical procedures per 1,000 beneficiaries, with a threefold variation across HRRs. In 2017, the total hip replacement rate was 32% higher for White Medicare-only beneficiaries and 48% higher for Black Medicare-only beneficiaries than in 2009 (p < 0.001). However, because the surgical rates for White and Black dual-eligible beneficiaries remained unchanged over the study period, the 2017 Medicare-only and dual-eligible disparity for White beneficiaries increased by 0.75 surgical procedures per 1,000 from 2009 (40.98% increase; p = 0.03), and the disparity for Black beneficiaries by 1.13 surgical procedures per 1,000 beneficiaries (297.37% increase; p < 0.001). The total knee replacement disparities remained unchanged. Notably, the rates for White dual-eligible beneficiaries were significantly lower than those for Black Medicare-only beneficiaries (p < 0.001 for both total hip replacements and total knee replacements), and fewer surgical procedures were conducted in HRRs with a higher density of Black or dual-eligible beneficiaries. CONCLUSIONS Although the total hip replacement use for Medicare-only beneficiaries of both races increased, disparities for White and Black dual-eligible beneficiaries (compared with their Medicare-only counterparts) are increasing. Efforts to improve equity must identify and address both racial and socioeconomic barriers and focus on regions with high concentrations of disadvantaged beneficiaries. CLINICAL RELEVANCE Although total hip replacements and total knee replacements are highly successful surgical procedures for end-stage osteoarthritis, our findings show that, as recently as 2017, Black beneficiaries and those dual eligible for Medicaid (a proxy for socioeconomic status) are less likely to undergo these surgical procedures and that there is profound geographic variation in the use of these surgical procedures. This evidence is essential for the design and implementation of disparity-reduction strategies focused on patients, providers, and geographic areas that can potentially improve the equity in joint replacement care.
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Affiliation(s)
- Caroline P. Thirukumaran
- Departments of Orthopaedics, Public Health Sciences, Biostatistics and Computational Biology, Anesthesiology and Perioperative Medicine, and Family Medicine, University of Rochester, Rochester, New York,Center for Musculoskeletal Research, University of Rochester, Rochester, New York
| | - Xueya Cai
- Departments of Orthopaedics, Public Health Sciences, Biostatistics and Computational Biology, Anesthesiology and Perioperative Medicine, and Family Medicine, University of Rochester, Rochester, New York
| | - Laurent G. Glance
- Departments of Orthopaedics, Public Health Sciences, Biostatistics and Computational Biology, Anesthesiology and Perioperative Medicine, and Family Medicine, University of Rochester, Rochester, New York
| | - Yeunkyung Kim
- Departments of Orthopaedics, Public Health Sciences, Biostatistics and Computational Biology, Anesthesiology and Perioperative Medicine, and Family Medicine, University of Rochester, Rochester, New York
| | - Benjamin F. Ricciardi
- Departments of Orthopaedics, Public Health Sciences, Biostatistics and Computational Biology, Anesthesiology and Perioperative Medicine, and Family Medicine, University of Rochester, Rochester, New York,Center for Musculoskeletal Research, University of Rochester, Rochester, New York
| | - Kevin A. Fiscella
- Departments of Orthopaedics, Public Health Sciences, Biostatistics and Computational Biology, Anesthesiology and Perioperative Medicine, and Family Medicine, University of Rochester, Rochester, New York,Center for Community Health and Prevention, University of Rochester, Rochester, New York
| | - Yue Li
- Departments of Orthopaedics, Public Health Sciences, Biostatistics and Computational Biology, Anesthesiology and Perioperative Medicine, and Family Medicine, University of Rochester, Rochester, New York
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20
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Wang L, Ren J, Fiscella KA, Bullock S, Sanders MR, Loomis EL, Eliav E, Mendoza M, Cacciato R, Thomas M, Kopycka-Kedzierawski DT, Billings RJ, Xiao J. Interprofessional collaboration and smartphone use as promising strategies to improve prenatal oral health care utilization among US underserved women: results from a qualitative study. BMC Oral Health 2020; 20:333. [PMID: 33228617 PMCID: PMC7685586 DOI: 10.1186/s12903-020-01327-9] [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] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/31/2020] [Accepted: 11/12/2020] [Indexed: 12/12/2022] Open
Abstract
Background Data on barriers and facilitators to prenatal oral health care among low-income US women are lacking. The objective of this study was to understand barriers/facilitators and patient-centered mitigation strategies related to the use of prenatal oral health care among underserved US women.
Methods We used community-based participatory research to conduct two focus groups with eight pregnant/parenting women; ten individual in-depth interviews with medical providers, dental providers and community/social workers; and one community engagement studio with five representative community stakeholders in 2018–2019. Using an interpretive description research design, we conducted semi-structured interviews and focus groups which were audio-recorded, transcribed, and analyzed for thematic content. Results We identified individual and systemic barriers/facilitators to the utilization of prenatal oral health care by underserved US women. Strategies reported to improve utilization included healthcare system-wide changes to promote inter-professional collaborations, innovative educational programs to improve dissemination and implementation of prenatal oral health care guidelines, and specialized dental facilities providing prenatal oral health care to underserved women. Moreover, smartphones have the potential to be an innovative entry point to promote utilization of prenatal oral care at the individual level. Conclusions Low-income women face multiple, addressable barriers to obtaining oral health care during pregnancy. Inter-professional collaboration holds strong promise for improving prenatal oral health care utilization.
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Affiliation(s)
- Lin Wang
- Eastman Institute for Oral Health, University of Rochester Medical Center, Rochester, NY, USA.,Peking University School of Stomatology, Beijing, China
| | - Johana Ren
- University of Rochester River Campus, Rochester, NY, USA
| | - Kevin A Fiscella
- Department of Family Medicine, University of Rochester Medical Center, Rochester, NY, USA
| | | | - Mechelle R Sanders
- Department of Family Medicine, University of Rochester Medical Center, Rochester, NY, USA
| | - Elizabeth L Loomis
- Department of Family Medicine, University of Rochester Medical Center, Rochester, NY, USA
| | - Eli Eliav
- Eastman Institute for Oral Health, University of Rochester Medical Center, Rochester, NY, USA
| | - Michael Mendoza
- Department of Family Medicine, University of Rochester Medical Center, Rochester, NY, USA.,Monroe County Department of Public Health, Rochester, NY, USA
| | - Rita Cacciato
- Eastman Institute for Oral Health, University of Rochester Medical Center, Rochester, NY, USA
| | - Marie Thomas
- University of Rochester River Campus, Rochester, NY, USA
| | | | - Ronald J Billings
- Eastman Institute for Oral Health, University of Rochester Medical Center, Rochester, NY, USA
| | - Jin Xiao
- Eastman Institute for Oral Health, University of Rochester Medical Center, Rochester, NY, USA.
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21
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Saeed F, Sardar M, Rasheed K, Naseer R, Epstein RM, Davison SN, Mujtaba M, Fiscella KA. Dialysis Decision Making and Preferences for End-of-Life Care: Perspectives of Pakistani Patients Receiving Maintenance Dialysis. J Pain Symptom Manage 2020; 60:336-345. [PMID: 32201311 PMCID: PMC7375006 DOI: 10.1016/j.jpainsymman.2020.03.009] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/16/2020] [Revised: 03/11/2020] [Accepted: 03/12/2020] [Indexed: 02/06/2023]
Abstract
CONTEXT Previous studies from the U.S. and Canada report deficiencies in informed decision making and a need to improve end-of-life (EoL) care in patients undergoing dialysis. However, there is a paucity of literature on these issues in Pakistani dialysis patients, who differ from Western patients in culture, religion, and available health care services. OBJECTIVES To study informed dialysis decision-making and EoL attitudes and beliefs in Pakistani patients receiving dialysis. METHODS We used convenience sampling to collect 522 surveys (90% response rate) from patients in seven different dialysis units in Pakistan. We used an existing dialysis survey tool, translated into Urdu, and backtranslated to English. A facilitator distributed the survey, explained questions, and orally administered it to patients unable to read. RESULTS Less than one-fourth of the respondents (23%) felt informed about their medical condition, and 45% were hopeful that their condition would improve in the future. More than half (54%) wished to know their prognosis, and 80% reported having no prognostic discussion. Almost 63% deemed EoL planning important, but only 5% recalled discussing EoL decisions with a doctor during the last 12 months. Nearly 62% of the patients regretted their decision to start dialysis. Patients' self-reported knowledge of hospice (5%) and palliative care (7.9%) services was very limited, yet 46% preferred a treatment plan focused on comfort and symptom management rather than life extension. CONCLUSION Pakistani patients reported a need for better informed dialysis decision making and EoL care and better access to palliative care services. These findings underscore the need for palliative care training of Pakistani physicians and in other developing countries to help address communication and EoL needs of their dialysis patients.
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Affiliation(s)
- Fahad Saeed
- Division of Nephrology, Department of Medicine, University of Rochester School of Medicine and Dentistry, Rochester, New York, USA; Division of Palliative Care, University of Rochester School of Medicine and Dentistry, Rochester, New York, USA.
| | - Muhammad Sardar
- Department of Medicine, University of Arizona, Tuscan, Arizona, USA
| | - Khalid Rasheed
- Department of Medicine, Shifa medical Center, Islamabad, Pakistan
| | - Raza Naseer
- The Wright Center for Community Health, Scranton, Pennsylvania, USA
| | - Ronald M Epstein
- Division of Palliative Care, University of Rochester School of Medicine and Dentistry, Rochester, New York, USA; Department of Psychiatry, University of Rochester School of Medicine and Dentistry, Rochester, New York, USA; Department of Family Medicine and Center for Communication and Disparities Research, University of Rochester School of Medicine and Dentistry, Rochester, New York, USA
| | - Sara N Davison
- Division of Nephrology & Immunology, University of Alberta, Edmonton, Alberta, Canada
| | - Muhammad Mujtaba
- Division of Nephrology, Department of Medicine, University of Texas Medical Branch, Galveston, Texas, USA
| | - Kevin A Fiscella
- Department of Family Medicine and Center for Communication and Disparities Research, University of Rochester School of Medicine and Dentistry, Rochester, New York, USA
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22
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Gamble-George JC, Longenecker CT, Webel AR, Au DH, Brown AF, Bosworth H, Crothers K, Cunningham WE, Fiscella KA, Hamilton AB, Helfrich CD, Ladapo JA, Luque A, Tobin JN, Wyatt GE. ImPlementation REsearCh to DEvelop Interventions for People Living with HIV (the PRECluDE consortium): Combatting chronic disease comorbidities in HIV populations through implementation research. Prog Cardiovasc Dis 2020; 63:79-91. [PMID: 32199901 PMCID: PMC7237329 DOI: 10.1016/j.pcad.2020.03.006] [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: 03/11/2020] [Accepted: 03/11/2020] [Indexed: 02/08/2023]
Abstract
Antiretroviral therapy (ART) prevented premature mortality and improved the quality of life among people living with the human immunodeficiency virus (PLWH), such that now more than half of PLWH in the United States are 50 years of age and older. Increased longevity among PLWH has resulted in a significant rise in chronic, comorbid diseases. However, the implementation of guideline-based interventions for preventing, treating, and managing such age-related, chronic conditions among the HIV population is lacking. The PRECluDE consortium supported by the Center for Translation Research and Implementation Science at the National Heart, Lung, and Blood Institute catalyzes implementation research on proven-effective interventions for co-occurring heart, lung, blood, and sleep diseases and conditions among PLWH. These collaborative research studies use novel implementation frameworks with HIV, mental health, cardiovascular, and pulmonary care to advance comprehensive HIV and chronic disease healthcare in a variety of settings and among diverse populations.
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Affiliation(s)
- Joyonna Carrie Gamble-George
- Health Scientist Administrator and AAAS Science and Technology Policy Fellow, Implementation Science Branch (ISB), Center for Translation Research and Implementation Science (CTRIS), National Heart, Lung, and Blood Institute (NHLBI), National Institutes of Health (NIH), U.S. Department of Health and Human Services, Bethesda, MD 20892, United States of America; Office of Science Policy (OSP), Office of the Director (OD), National Institutes of Health, U.S. Department of Health and Human Services, Bethesda, MD 20892, United States of America.
| | - Christopher T Longenecker
- Department of Medicine, Case Western Reserve University School of Medicine, University Hospitals Harrington Heart and Vascular Institute, Cleveland, OH 44106, United States of America
| | - Allison R Webel
- Frances Payne Bolton School of Nursing, Case Western Reserve University, Cleveland, OH 44106, United States of America
| | - David H Au
- Division of Pulmonary, Critical Care and Sleep Medicine, University of Washington School of Medicine, Seattle, WA 98195, United States of America; Seattle-Denver Center of Innovation (COIN) for Veteran-Centered and Value-Driven Care, Veterans Affairs (VA) Puget Sound Health Care System, Seattle, WA 98108, United States of America
| | - Arleen F Brown
- Department of Medicine, Division of General Internal Medicine and Health Services Research (GIM and HSR), David Geffen School of Medicine, University of California, Los Angeles (UCLA), Los Angeles, CA 90095, United States of America; GIM and HSR, Olive View-UCLA Medical Center Sylmar, Los Angeles, CA 90095, United States of America; Community Engagement and Research Program, UCLA Clinical and Translational Science Institute, Los Angeles, CA 90095, United States of America
| | - Hayden Bosworth
- Department of Medicine, Duke University School of Medicine, Durham, NC 27701, United States of America; Department of Population Health Sciences, Duke University School of Medicine, Durham, NC 27701, United States of America; Department of Psychiatry and Behavioral Sciences, Duke University School of Medicine, Durham, NC 27701, United States of America
| | - Kristina Crothers
- Division of Pulmonary, Critical Care and Sleep Medicine, University of Washington School of Medicine, Seattle, WA 98195, United States of America; Pulmonary and Critical Care Section, VA Puget Sound Health Care System, Seattle, WA 98108, United States of America
| | - William E Cunningham
- Department of Medicine, GIM and HSR, David Geffen School of Medicine, UCLA, Los Angeles, CA 90095, United States of America; Department of Health Policy and Management, UCLA Fielding School of Public Health, Los Angeles, CA 90095, United States of America
| | - Kevin A Fiscella
- Department of Family Medicine, University of Rochester Medical Center, Rochester, NY 14620, United States of America; Department of Public Health Sciences, University of Rochester Medical Center, Rochester, NY 14620, United States of America; Center for Community Health and Prevention, University of Rochester Medical Center, Rochester, NY 14620, United States of America; Center for Communication and Disparities Research, University of Rochester Medical Center, Rochester, NY 14620, United States of America; Greater Rochester Practice-Based Research Network, Clinical and Translational Science Institute (CTSI), University of Rochester Medical Center, Rochester, NY 14642, United States of America
| | - Alison B Hamilton
- Department of Psychiatry and Biobehavioral Sciences, David Geffen School of Medicine, UCLA Jane and Terry Semel Institute for Neuroscience and Human Behavior, Los Angeles, CA 90095, United States of America; VA Health Services Research and Development (HSR&D) Service, Center for the Study of Healthcare Innovation, Implementation, and Policy (CSHIIP), VA Greater Los Angeles Healthcare System, North Hills, CA 91343, United States of America
| | - Christian D Helfrich
- Department of Health Services, School of Public Health, University of Washington, Seattle, WA 98101, United States of America; Health Services Research and Development, Seattle-Denver Center of Innovation for Veteran-Centered and Value-Driven Care, Veterans Administration (VA) Puget Sound Health Care System, Seattle, WA 98108, United States of America
| | - Joseph A Ladapo
- Department of Medicine, GIM and HSR, David Geffen School of Medicine, UCLA, Los Angeles, CA 90095, United States of America; Department of Population Health, New York University (NYU) Grossman School of Medicine, New York, NY 10016, United States of America
| | - Amneris Luque
- HIV Clinical Services, Parkland Health and Hospital System, Dallas, TX 75235, United States of America; Department of Internal Medicine, University of Texas (UT) Southwestern Medical Center, Dallas, TX 75390, United States of America
| | - Jonathan N Tobin
- Clinical Directors Network, Inc. (CDN), New York, NY 10018; Community-Engaged Research, The Rockefeller University Center for Clinical and Translational Science, New York, NY 10065, United States of America
| | - Gail E Wyatt
- Department of Psychiatry and Biobehavioral Sciences, David Geffen School of Medicine, UCLA Jane and Terry Semel Institute for Neuroscience and Human Behavior, Los Angeles, CA 90095, United States of America; Sexual Health Programs, UCLA Jane and Terry Semel Institute for Neuroscience and Human Behavior, Los Angeles, CA 90095, United States of America; The Center for Culture, Trauma, and Mental Health Disparities, UCLA Jane and Terry Semel Institute for Neuroscience and Human Behavior, Los Angeles, CA 90024, United States of America; University of Cape Town, Rondebosch, Cape Town 7701, South Africa
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23
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Saeed F, Xing G, Tancredi DJ, Epstein RM, Fiscella KA, Norton SA, Duberstein PR. Is Annual Income a Predictor of Completion of Advance Directives (ADs) in Patients With Cancer. Am J Hosp Palliat Care 2018; 36:402-407. [PMID: 30477311 DOI: 10.1177/1049909118813973] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.8] [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: 01/10/2023] Open
Abstract
CONTEXT: Completion of advance directives (ADs) enhances the likelihood of receiving goal-concordant treatments near the end of life. Previous research on community samples have shown that completion of ADs is less common in lower socioeconomic status demographic group; there is a paucity of such research in patients with cancer. OBJECTIVES: To study the effect of income and education on the completion of ADs. HYPOTHESIS: Patients with cancer having lower incomes and education levels would be less likely to report completing ADs. METHODS: We conducted cross-sectional analyses of data provided by patients (n = 265) enrolled in the Values and Options in Cancer Care clinical trial. Patients with advanced cancer reported whether they had (1) completed a living will or (2) designated a health-care proxy. Response options for both questions were yes (scored 1), no (scored 0), and unsure (scored 0). We studied the association of lower household income (≤US$20 000) and education level (never attended college) with AD scores. RESULTS: Patients with lower annual incomes had lower AD scores (estimate -0.44; confidence intervals [CI]: -0.71 to -0.16, P = .001); the association between higher educational attainment (some college or more) and completion of ADs was not statistically significant (estimate 0.04, CI: -0.16 to 0.24, P = .70). CONCLUSION: Interventions to promote completion of ADs among lower income patients with serious illnesses are needed.
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Affiliation(s)
- Fahad Saeed
- 1 Division of Nephrology, Department of Medicine, University of Rochester School of Medicine and Dentistry, Rochester, NY, USA.,2 Division of Palliative Care, University of Rochester School of Medicine and Dentistry, Rochester, NY, USA.,3 Department of Public Health Sciences, University of Rochester School of Medicine and Dentistry, Rochester, NY, USA
| | - Guibo Xing
- 4 Center for Healthcare Policy and Research, University of California, Davis, CA, USA
| | - Daniel J Tancredi
- 5 Department of Pediatrics, University of California, Davis, CA, USA
| | - Ronald M Epstein
- 2 Division of Palliative Care, University of Rochester School of Medicine and Dentistry, Rochester, NY, USA.,6 Department of Psychiatry, University of Rochester School of Medicine and Dentistry, Rochester, NY, USA.,7 Department of Family Medicine and Center for Center for Communication and Disparities Research, University of Rochester School of Medicine and Dentistry, Rochester, NY, USA
| | - Kevin A Fiscella
- 3 Department of Public Health Sciences, University of Rochester School of Medicine and Dentistry, Rochester, NY, USA.,7 Department of Family Medicine and Center for Center for Communication and Disparities Research, University of Rochester School of Medicine and Dentistry, Rochester, NY, USA
| | - Sally A Norton
- 8 University of Rochester School of Nursing, University of Rochester School of Medicine and Dentistry, Rochester, NY, USA
| | - Paul R Duberstein
- 6 Department of Psychiatry, University of Rochester School of Medicine and Dentistry, Rochester, NY, USA.,9 Department of Health Behavior, Disparities, and Policy, Rutgers School of Public Health, Rochester, NY, USA
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24
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Egan BM, Li J, Davis RA, Fiscella KA, Tobin JN, Jones DW, Sinopoli A. Differences in primary cardiovascular disease prevention between the 2013 and 2016 cholesterol guidelines and impact of the 2017 hypertension guideline in the United States. J Clin Hypertens (Greenwich) 2018; 20:991-1000. [PMID: 29774988 DOI: 10.1111/jch.13314] [Citation(s) in RCA: 3] [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] [Subscribe] [Scholar Register] [Received: 02/06/2018] [Revised: 04/04/2018] [Accepted: 04/20/2018] [Indexed: 01/08/2023]
Abstract
The US Preventive Services Task Force cholesterol guideline recommended statins for fewer adults than the 2013 American College of Cardiology/American Heart Association (ACC/AHA) guideline by setting a higher 10-year atherosclerotic cardiovascular disease threshold (≥10.0% vs ≥7.5%) and requiring concomitant diabetes mellitus, hypertension, dyslipidemia, or cigarette smoking. The 2017 ACC/AHA hypertension guideline lowered the hypertension threshold, increasing 2016 guideline statin-eligible adults. Cross-sectional data on US adults aged 40 to 75 years enabled estimated numbers for the 2013 guideline and 2016 guideline with hypertension thresholds of ≥140/≥90 mm Hg and ≥130/80 mm Hg, respectively, on: (1) untreated, statin-eligible adults for primary atherosclerotic cardiovascular disease prevention (25.40, 14.72, 15.35 million); (2) atherosclerotic cardiovascular disease events prevented annually (124 000, 70 852, 73 199); (3) number needed to treat (21, 21, 21); and (4) number needed to harm (38, 143, 143) per 1000 patient-years for incident diabetes mellitus (42 800, 6700, 7100 cases per year). Despite the lower hypertension threshold, the 2013 cholesterol guideline qualifies approximately 10 million more adults for statins and prevents approximately 50 600 more primary atherosclerotic cardiovascular disease events but induces approximately 35 700 more diabetes mellitus cases annually than the 2016 guideline.
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Affiliation(s)
- Brent M Egan
- Care Coordination Institute, Greenville, SC, USA.,Department of Medicine, University of South Carolina School of Medicine, Greenville, SC, USA
| | - Jiexiang Li
- Care Coordination Institute, Greenville, SC, USA.,Department of Mathematics, College of Charleston, Charleston, SC, USA
| | - Robert A Davis
- Care Coordination Institute, Greenville, SC, USA.,Department of Medicine, University of South Carolina School of Medicine, Greenville, SC, USA
| | - Kevin A Fiscella
- Department of Family Medicine, University of Rochester Medical Center, Rochester, NY, USA
| | - Jonathan N Tobin
- Clinical Directors Network (CDN), New York, NY, USA.,Center for Clinical and Translational Science, The Rockefeller University, New York, NY, USA.,Department of Epidemiology and Population Health, Albert Einstein College of Medicine/Montefiore Medical Center, Bronx, NY, USA
| | - Daniel W Jones
- Department of Medicine, University of Mississippi Medical Center, Jackson, MS, USA.,Department of Physiology & Biophysics, University of Mississippi Medical Center, Jackson, MS, USA
| | - Angelo Sinopoli
- Care Coordination Institute, Greenville, SC, USA.,Department of Medicine, University of South Carolina School of Medicine, Greenville, SC, USA
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25
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Egan BM, Li J, Sarasua SM, Davis RA, Fiscella KA, Tobin JN, Jones DW, Sinopoli A. Cholesterol Control Among Uninsured Adults Did Not Improve From 2001-2004 to 2009-2012 as Disparities With Both Publicly and Privately Insured Adults Doubled. J Am Heart Assoc 2017; 6:e006105. [PMID: 29097386 PMCID: PMC5721738 DOI: 10.1161/jaha.117.006105] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.3] [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] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/15/2017] [Accepted: 08/23/2017] [Indexed: 11/16/2022]
Abstract
BACKGROUND Low-density lipoprotein cholesterol (LDL-C) control is higher among insured than uninsured adults, but data on time trends and contributing factors are incomplete and important for improving health equity. METHODS AND RESULTS Awareness, treatment, and control of elevated LDL-C were compared among insured versus uninsured and publicly versus privately insured adults, aged 21 to 64 years, in National Health and Nutrition Examination Surveys from 2001 to 2004, 2005 to 2008, and 2009 to 2012 using Adult Treatment Panel-3 criteria. Compared with insured adults, uninsured adults were younger; were more often minority; reported lower incomes, less education, and fewer healthcare encounters; and had lower awareness and treatment of elevated LDL-C (P<0.0001). LDL-C control was higher among insured than uninsured adults in 2001 to 2004 (mean±SEM, 21.4±1.6% versus 10.5±2.6%; P<0.01), and the gap widened by 2009 to 2012 (35.1±1.9% versus 11.3±2.2%; P<0.0001). Despite more minorities (P<0.01), greater poverty, and less education (P<0.001), publicly insured adults had more healthcare visits/year than privately insured adults (P<0.001) and similar awareness, treatment, and control of LDL-C from 2001 to 2012. In multivariable logistic regression, significant positive predictors of cholesterol awareness, treatment, and control included more frequent health care (strongest), increasing age, private healthcare insurance versus uninsured, and hypertension. Public insurance (versus uninsured) was a significant positive predictor of LDL-C control, whereas income <200% versus ≥200% of federal poverty was a significant negative predictor. CONCLUSIONS LDL-C control improved similarly over time in publicly and privately insured adults but was stagnant among the uninsured. Healthcare insurance largely addresses socioeconomic barriers to effective LDL-C management, yet poverty retains an independent adverse effect.
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Affiliation(s)
- Brent M Egan
- Care Coordination Institute, Greenville, SC
- Department of Medicine, University of South Carolina School of Medicine, Greenville, SC
| | - Jiexiang Li
- Care Coordination Institute, Greenville, SC
- Department of Mathematics, College of Charleston, Charleston, SC
| | - Sara M Sarasua
- Care Coordination Institute, Greenville, SC
- Clemson University School of Nursing, Clemson, SC
| | - Robert A Davis
- Care Coordination Institute, Greenville, SC
- Department of Medicine, University of South Carolina School of Medicine, Greenville, SC
| | - Kevin A Fiscella
- Department of Family Medicine, University of Rochester Medical Center, Rochester, NY
| | - Jonathan N Tobin
- Clinical Directors Network, New York, NY
- Center for Clinical and Translational Science, The Rockefeller University, New York, NY
- Department of Epidemiology and Population Health, Albert Einstein College of Medicine/Montefiore Medical Center, Bronx, NY
| | - Daniel W Jones
- Department of Medicine and Department of Physiology and Biophysics, University of Mississippi Medical Center, Jackson, MS
| | - Angelo Sinopoli
- Care Coordination Institute, Greenville, SC
- Department of Medicine, University of South Carolina School of Medicine, Greenville, SC
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26
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Sarasua SM, Li J, Hernandez GT, Ferdinand KC, Tobin JN, Fiscella KA, Jones DW, Sinopoli A, Egan BM. Opportunities for improving cardiovascular health outcomes in adults younger than 65 years with guideline-recommended statin therapy. J Clin Hypertens (Greenwich) 2017; 19:850-860. [PMID: 28480530 DOI: 10.1111/jch.13004] [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] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/09/2016] [Revised: 02/01/2017] [Accepted: 02/13/2017] [Indexed: 10/19/2022]
Abstract
The impact of age, race/ethnicity, healthcare insurance, and selected clinical variables on statin-preventable ASCVD were quantified in adults aged 21 to 79 years from National Health and Nutrition Examination Surveys 2007-2012 using the 2013 American College of Cardiology/American Heart Association guideline on the treatment of cholesterol. Among ≈42.4 million statin-eligible, untreated adults, 52.6% were hypertensive and 71% were younger than 65 years. Of ≈232 000 statin-preventable ASCVD events annually, most occur in individuals younger than 65 years, with higher proportions in blacks and Hispanics than whites (73.0% and 69.2% vs 56.9%, respectively; P<.01). Among adults younger than 65 years, the ratio of statin-eligible but untreated to statin-treated adults was higher in blacks and Hispanics than whites (3.0 and 2.9 vs 1.3, respectively; P<.01), and blacks, men, hypertensives, and cigarette smokers were more likely to be statin eligible than their statin-ineligible counterparts by multivariable logistic regression. Two thirds of untreated statin-eligible adults had two or more healthcare visits per year. Identifying and treating more statin-eligible adults in the healthcare system could improve cardiovascular health equity.
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Affiliation(s)
- Sara M Sarasua
- Care Coordination Institute, Greenville, SC, USA.,Clemson University, School of Nursing, Clemson, SC, USA
| | - Jiexiang Li
- Department of Mathematics, College of Charleston, Charleston, SC, USA
| | - German T Hernandez
- Department of Internal Medicine, Texas Tech University Health Sciences Center, El Paso, TX, USA
| | - Keith C Ferdinand
- Department of Medicine, Tulane University School of Medicine, New Orleans, LA, USA
| | - Jonathan N Tobin
- Clinical Directors Network (CDN), New York, NY, USA.,Center for Clinical and Translational Science, The Rockefeller University, New York, NY, USA.,Department of Epidemiology and Population Health, Albert Einstein College of Medicine/Montefiore Medical Center, Bronx, NY, USA
| | - Kevin A Fiscella
- Department of Family Medicine, University of Rochester Medical Center, Rochester, NY, USA
| | - Daniel W Jones
- Departments of Medicine and Physiology and Biophysics, University of Mississippi Medical Center, Jackson, MS, USA
| | - Angelo Sinopoli
- Care Coordination Institute, Greenville, SC, USA.,University of South Carolina School of Medicine-Greenville, Greenville, SC, USA
| | - Brent M Egan
- Care Coordination Institute, Greenville, SC, USA.,University of South Carolina School of Medicine-Greenville, Greenville, SC, USA
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27
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Edwardsen EA, Horwitz SH, Pless NA, le Roux HD, Fiscella KA. Improving identification and management of partner violence: examining the process of academic detailing: a qualitative study. BMC Med Educ 2011; 11:36. [PMID: 21679450 PMCID: PMC3130715 DOI: 10.1186/1472-6920-11-36] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 12/02/2010] [Accepted: 06/16/2011] [Indexed: 05/30/2023]
Abstract
BACKGROUND Many physicians do not routinely inquire about intimate partner violence. PURPOSE This qualitative study explores the process of academic detailing as an intervention to change physician behavior with regard to intimate partner violence (IPV) identification and documentation. METHOD A non-physician academic detailer provided a seven-session modular curriculum over a two-and-a-half month period. The detailer noted written details of each training session. Audiotapes of training sessions and semi-structured exit interviews with each physician were recorded and transcribed. Transcriptions were qualitatively and thematically coded and analyzed using Atlas ti®. RESULTS All three study physicians reported increased clarity with regard to the scope of their responsibility to their patients experiencing IPV. They also reported increased levels of comfort in the effective identification and appropriate documentation of IPV and the provision of ongoing support to the patient, including referrals to specialized community services. CONCLUSION Academic detailing, if presented by a supportive and knowledgeable academic detailer, shows promise to improve physician attitudes and practices with regards to patients in violent relationships.
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Affiliation(s)
| | - Susan H Horwitz
- University of Rochester School of Medicine and Dentistry, Rochester, NY, 14642, USA
| | - Naomi A Pless
- University of Rochester School of Medicine and Dentistry, Rochester, NY, 14642, USA
| | - Helena D le Roux
- University of Rochester School of Medicine and Dentistry, Rochester, NY, 14642, USA
| | - Kevin A Fiscella
- University of Rochester School of Medicine and Dentistry, Rochester, NY, 14642, USA
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28
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Franks P, Winters PC, Tancredi DJ, Fiscella KA. Do changes in traditional coronary heart disease risk factors over time explain the association between socio-economic status and coronary heart disease? BMC Cardiovasc Disord 2011; 11:28. [PMID: 21639906 PMCID: PMC3130693 DOI: 10.1186/1471-2261-11-28] [Citation(s) in RCA: 56] [Impact Index Per Article: 4.3] [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: 11/16/2010] [Accepted: 06/03/2011] [Indexed: 01/28/2023] Open
Abstract
Background Socioeconomic status (SES) predicts coronary heart disease independently of the traditional risk factors included in the Framingham risk score. However, it is unknown whether changes in Framingham risk score variables over time explain the association between SES and coronary heart disease. We examined this question given its relevance to risk assessment in clinical decision making. Methods The Atherosclerosis Risk in Communities study data (initiated in 1987 with 10-years follow-up of 15,495 adults aged 45-64 years in four Southern and Mid-Western communities) were used. SES was assessed at baseline, dichotomized as low SES (defined as low education and/or low income) or not. The time dependent variables - smoking, total and high density lipoprotein cholesterol, systolic blood pressure and use of blood pressure lowering medication - were assessed every three years. Ten-year incidence of coronary heart disease was based on EKG and cardiac enzyme criteria, or adjudicated death certificate data. Cox survival analyses examined the contribution of SES to heart disease risk independent of baseline Framingham risk score, without and with further adjustment for the time dependent variables. Results Adjusting for baseline Framingham risk score, low SES was associated with an increased coronary heart disease risk (hazard ratio [HR] = 1.53; 95% Confidence Interval [CI], 1.27 to1.85). After further adjustment for the time dependent variables, the SES effect remained significant (HR = 1.44; 95% CI, 1.19 to1.74). Conclusion Using Framingham Risk Score alone under estimated the coronary heart disease risk in low SES persons. This bias was not eliminated by subsequent changes in Framingham risk score variables.
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Affiliation(s)
- Peter Franks
- Center for Healthcare Policy and Research, University of California at Davis, University of California, Davis, 4860 Y Street, Suite 2300, Sacramento, California 95817, USA.
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Abstract
BACKGROUND To assess the impact of a multimodal educational outreach on physician screening and documentation of intimate partner violence (IPV) in primary care. METHODS Pre- and post-intervention assessment of physician screening and chart documentation of IPV. Physician screening was assessed by post-visit survey of patients and documentation was assessed by medical record review. SETTING Three medical offices in an urban community of approximately 1 million. PARTICIPANTS Three primary care physicians (one internist, one obstetrician, and one family physician) and 100 patients from each of these practices. INTERVENTIONS Multimodal educational outreach to physicians and their office staff regarding appropriate screening and management of IPV. A trained IPV educator made periodic office visits in 2002 to educate the physician and office staff regarding appropriate screening and management of IPV. RESULTS Before the intervention, 36/150 (24%) of sample patients reported having been previously asked about IPV and 24/150 (16%) reported being asked in a written format. After the intervention, 100/149 (67%) and 41/108(28%) reported being asked verbally or in writing, respectively. CONCLUSIONS This pilot study of three physicians suggests educational outreach represents a promising and feasible means of improving physician screening and documentation of IPV in primary care.
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Affiliation(s)
- Elizabeth A Edwardsen
- Department of Emergency Medicine, University of Rochester, Rochester, NY 14642, USA.
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