Rationale, design, and protocol for a hybrid type 1 effectiveness-implementation trial of a proactive smoking cessation electronic visit for scalable delivery via primary care: the E-STOP trial

BACKGROUND

Cigarette smoking remains the leading cause of preventable disease and death in the United States. Primary care offers an ideal setting to reach adults who smoke cigarettes and improve uptake of evidence-based cessation treatment. Although U.S. Preventive Services Task Force Guidelines recommend the 5As model (Ask, Advise, Assess, Assist, Arrange) in primary care, there are many barriers to its implementation. Automated, comprehensive, and proactive tools are needed to overcome barriers. Our team developed and preliminarily evaluated a proactive electronic visit (e-visit) delivered via the Electronic Health Record patient portal to facilitate evidence-based smoking cessation treatment uptake in primary care, with promising initial feasibility and efficacy. This paper describes the rationale, design, and protocol for an ongoing Hybrid Type I effectiveness-implementation trial that will simultaneously assess effectiveness of the e-visit intervention for smoking cessation as well as implementation potential across diverse primary care settings.

METHODS

The primary aim of this remote five-year study is to examine the effectiveness of the e-visit intervention vs. treatment as usual (TAU) for smoking cessation via a clinic-randomized clinical trial. Adults who smoke cigarettes are recruited across 18 primary care clinics. Clinics are stratified based on their number of primary care providers and randomized 2:1 to either e-visit or TAU. An initial baseline e-visit gathers information about patient smoking history and motivation to quit, and a clinical decision support algorithm determines the best evidence-based cessation treatment to prescribe. E-visit recommendations are evaluated by a patient's own provider, and a one-month follow-up e-visit assesses cessation progress. Main outcomes include: (1) cessation treatment utilization (medication, psychosocial cessation counseling), (2) reduction in cigarettes per day, and (3) biochemically verified 7-day point prevalence abstinence (PPA) at six-months. We hypothesize that patients randomized to the e-visit condition will have better cessation outcomes (vs. TAU). A secondary aim evaluates e-visit implementation potential at patient, provider, and organizational levels using a mixed-methods approach. Implementation outcomes include acceptability, adoption, fidelity, implementation cost, penetration, and sustainability.

DISCUSSION

This asynchronous, proactive e-visit intervention could provide substantial benefits for patients, providers, and primary care practices and has potential to widely improve reach of evidence-based cessation treatment.

TRIAL REGISTRATION

NCT05493254.

Behavioral Activation-Based Digital Smoking Cessation Intervention for Individuals With Depressive Symptoms: Randomized Clinical Trial

BACKGROUND

Depression is common among adults who smoke cigarettes. Existing depression-specific cessation interventions have limited reach and are unlikely to improve smoking prevalence rates among this large subgroup of smokers.

OBJECTIVE

This study aimed to determine whether a mobile app-based intervention tailored for depression paired with a mailed sample of nicotine replacement therapy (NRT) is efficacious for treating depression and promoting smoking cessation.

METHODS

A 2-arm nationwide remote randomized clinical trial was conducted in the United States. Adults (N=150) with elevated depressive symptoms (Patient Health Questionnaire-8≥10) who smoked were enrolled. The mobile app ("Goal2Quit") provided behavioral strategies for treating depression and quitting smoking based on Behavioral Activation Treatment for Depression. Goal2Quit participants also received a 2-week sample of combination NRT. Treatment as usual participants received a self-help booklet for quitting smoking that was not tailored for depression. Primary end points included Goal2Quit usability, change in depression (Beck Depression Inventory-II) across 12 weeks, and smoking cessation including reduction in cigarettes per day, incidence of 24-hour quit attempts, floating abstinence, and 7-day point prevalence abstinence (PPA).

RESULTS

In total, 150 participants were enrolled between June 25, 2020, and February 23, 2022, of which 80 were female (53.3%) and the mean age was 38.4 (SD 10.3) years. At baseline, participants on average reported moderate depressive symptoms and smoked a mean of 14.7 (SD 7.5) cigarettes per day. Goal2Quit usability was strong with a mean usability rating on the System Usability Scale of 78.5 (SD 16.9), with 70% scoring above the ≥68 cutoff for above-average usability. Retention data for app use were generally strong immediately following trial enrollment and declined in subsequent weeks. Those who received Goal2Quit and the NRT sample reported lower mean depressive symptoms over the trial duration as compared to treatment as usual (difference of mean 3.72, SE 1.37 points less; P=.01). Across time points, all cessation outcomes favored Goal2Quit. Regarding abstinence, Goal2Quit participants reported significantly higher rates of 7-day PPA at weeks 4 (11% vs 0%; P=.02), 8 (7-day PPA: 12% vs 0%; P=.02), and 12 (16% vs 2%; P=.02).

CONCLUSIONS

A mobile app intervention tailored for depression paired with a sample of NRT was effective for depression treatment and smoking cessation. Findings support the utility of this intervention approach for addressing the currently unmet public health treatment need for tailored, scalable depression-specific cessation treatments.

TRIAL REGISTRATION

ClinicalTrials.gov NCT03837379; https://clinicaltrials.gov/ct2/show/NCT03837379.

Evaluation of a telemedicine pilot program for the provision of HIV pre-exposure prophylaxis in the Southeastern United States

Pre-exposure prophylaxis (PrEP) is a daily regimen that reduces the risk of acquiring HIV by up to 97%. There is limited information on the use of telehealth to provide PrEP in a program aimed toward the primary prevention of HIV. This was a 6-month telePrEP feasibility study that assessed process measures, clinical outcomes and patient satisfaction. Descriptive statistics and Chi-square analysis were used to evaluate measures and outcomes from the start to the end of the study. Twenty patients enrolled, and 80% completed the study. Participants were cisgender males (100%) with an average age of 35.6 years, white (95%), and were college graduates or higher (55%). The majority (75%) had very high comfort with video calls before the program. Self-reported adherence to PrEP medication remained high throughout the program (60%-70%). Without this program 31.2% of participants were unlikely to have received PrEP. For obtaining PrEP 56.3% preferred telemedicine only, and 31.2% preferred a combination of telemedicine and in-person office visits. PrEP is an effective method of preventing HIV infection for those at high risk. Our program shows that telemedicine can be useful to expand access to medication for patients at high risk.

Proactive Electronic Visits for Smoking Cessation and Chronic Obstructive Pulmonary Disease Screening in Primary Care: Randomized Controlled Trial of Feasibility, Acceptability, and Efficacy

BACKGROUND

Most smokers with chronic obstructive pulmonary disease (COPD) have not yet been diagnosed, a statistic that has remained unchanged for over two decades. A dual-focused telehealth intervention that promotes smoking cessation, while also facilitating COPD screening, could help address national priorities to improve the diagnosis, prevention, treatment, and management of COPD. The purpose of this study was to preliminarily evaluate an integrated asynchronous smoking cessation and COPD screening e-visit (electronic visit) that could be delivered proactively to adult smokers at risk for COPD, who are treated within primary care.

OBJECTIVE

The aims of this study were (1) to examine e-visit feasibility and acceptability, particularly as compared to in-lab diagnostic pulmonary function testing (PFT), and (2) to examine the efficacy of smoking cessation e-visits relative to treatment as usual (TAU), all within primary care.

METHODS

In a randomized clinical trial, 125 primary care patients who smoke were randomized 2:1 to receive either proactive e-visits or TAU. Participants randomized to the e-visit condition were screened for COPD symptoms via the COPD Assessment in Primary Care to Identify Undiagnosed Respiratory Disease and Exacerbation Risk (CAPTURE). Those with scores ≥2 were invited to complete both home spirometry and in-lab PFTs, in addition to two smoking cessation e-visits. Smoking cessation e-visits assessed smoking history and motivation to quit and included completion of an algorithm to determine the best Food and Drug Administration-approved cessation medication to prescribe. Primary outcomes included measures related to (1) e-visit acceptability, feasibility, and treatment metrics; (2) smoking cessation outcomes (cessation medication use, 24-hour quit attempts, smoking reduction ≥50%, self-reported abstinence, and biochemically confirmed abstinence); and (3) COPD screening outcomes.

RESULTS

Of 85 participants assigned to the e-visits, 64 (75.3%) were invited to complete home spirometry and in-lab PFTs based on CAPTURE. Among those eligible for spirometry, 76.6% (49/64) completed home spirometry, and 35.9% (23/64) completed in-lab PFTs. At 1 month, all cessation outcomes favored the e-visit, with a significant effect for cessation medication use (odds ratio [OR]=3.22). At 3 months, all cessation outcomes except for 24-hour quit attempts favored the e-visit, with significant effects for cessation medication use (OR=3.96) and smoking reduction (OR=3.09).

CONCLUSIONS

A proactive, asynchronous e-visit for smoking cessation and COPD screening may offer a feasible, efficacious approach for broad interventions within primary care.

TRIAL REGISTRATION

ClinicalTrials.gov NCT04155073; https://clinicaltrials.gov/ct2/show/NCT04155073.

Preventive Care Utilization by Patients Who Use Virtual Urgent Care

Introduction: The use of direct to patient (DTP) telemedicine for common acute conditions is widespread. It provides certain advantages over in-person visits, but has led to concerns about fragmentation of care. It is unknown whether use of DTP telemedicine decreases use of primary care services in a way that leads to missed preventive screenings and immunizations. Methods: Virtual urgent care (VUC) is a DTP telemedicine service to treat common acute conditions. All VUC encounters completed at an academic health system from July 2018 to December 2019 were evaluated and analyzed in 2020. Only patients established with primary care (at least one primary care visit in the same year as VUC encounter) were included. Specific preventive screenings (breast cancer, gonorrhea/chlamydia, and cervical cancer) and immunizations (tetanus and influenza) were characterized as up to date based on national guidelines. Chi-squares and multivariate logistic regressions were used to assess receipt of screenings and immunizations. Regressions included VUC and primary care utilization and demographic factors. Results: Patients evaluated (N = 1025) were mostly 25-50 years old (69.7%), women (81.8%), and white (74.9%). More than half (56.5%) had only used VUC once. In multivariate analyses, VUC utilization was not negatively associated with any of the preventive services evaluated, whereas primary care utilization was associated with receipt of both immunizations and gonorrhea/chlamydia screening. Conclusions: Higher VUC utilization is not negatively associated with receipt of preventive services, as long as a primary care relationship is established. VUC may provide a useful method of encouraging receipt of preventive services, especially for younger patients.

Physician Attitudes and Self-reported Practices Toward Prostate Cancer Screening in Black and White Men

BACKGROUND AND OBJECTIVES

Updated 2018 prostate cancer screening guidelines recommend informed decision-making discussions, which should include education on prostate cancer's disproportionate impact on Black men. It is unknown whether academic family physicians follow these guidelines.

METHODS

Family physicians were surveyed as part of the 2020 Council of Academic Family Medicine Educational Research Alliance (CERA) survey. We used χ2 to compare physicians' knowledge and screening practices stratified by physician age, gender, and percentage of Black patients in patient panel. We calculated logistic regressions predicting shared decision-making conversations, barriers to shared decision-making, inclusion of race in prostate cancer screening approach, and prostate-specific antigen (PSA) testing adjusted for physician age, gender, and percentage of Black patients.

RESULTS

Physicians reported engaging in shared decision-making for prostate cancer screening in half of eligible men. Only 29.2% of physicians reported routinely informing Black men of their increased prostate cancer risk. In logistic regressions, physician gender (female) and fewer Black patients in panel (<25%) were associated with lower frequency of shared decision-making with Black patients. Physician age (<40 years) was associated with not discussing race during screening discussions (OR 2.24, 95% CI 1.55-3.23).

CONCLUSIONS

Most academic family physicians do not appropriately inform Black men of increased prostate cancer risk, with younger physicians less likely to discuss race than older physicians. Female physicians, and physicians who see fewer Black patients, are less likely to have shared decision-making conversations with Black patients. This suggests educational efforts for these groups are needed to address health disparities in prostate cancer.

A Telehealth Initiative to Overcome Health Care Barriers for People Experiencing Homelessness

People experiencing homelessness (PEH) encounter barriers to health care, increasing their vulnerability to illness, hospitalization, and death. Telehealth can improve access to health care, but its use in PEH has been insufficiently evaluated. Needs assessment surveys completed by clients at an urban drop-in center for PEH (n = 63) showed mental (58.7%) and physical (52.4%) health challenges were common, as was emergency department (ED) use (75.9%, n = 54). Surveys collected after in-person and telehealth clinical visits showed patient satisfaction was >90% for both visit types (n = 125, 44.0% telehealth and 56.0% in person). Without access to telehealth visits, 29.1% of patients would have gone to the ED and 38.2% would not have gotten care. Providers (n = 93, 69.6% telehealth and 30.4% in person) were more likely to agree/strongly agree they made a positive impact on patients' health through telehealth (92.2%) than in person (71.4%) (p = 0.019). Telehealth is a feasible and potentially cost-effective method to increase access to health care and reduce health outcome disparities in PEH.

Facilitators and barriers to utilization of medications for opioid use disorder in primary care in South Carolina

OBJECTIVE

Utilization of medications for opioid use disorder (MOUD) has not been widely adopted by primary care providers. This study sought to identify interprofessional barriers and facilitators for use of MOUD (specifically naltrexone and buprenorphine) among current and future primary care providers in a southeastern academic center in South Carolina.

METHOD

Faculty, residents, and students within family medicine, internal medicine, and a physician assistant program participated in focus group interviews, and completed a brief survey. Survey data were analyzed quantitatively, and focus group transcripts were analyzed using a deductive qualitative content analysis, based upon the theory of planned behavior.

RESULTS

Seven groups (N = 46) completed focus group interviews and surveys. Survey results indicated that general attitudes towards MOUD were positive and did not differ significantly among groups. Subjective norms around prescribing and controllability (i.e., beliefs about whether prescribing was up to them) differed between specialties and between level of training groups. Focus group themes highlighted attitudes about MOUD (e.g., "opens the flood gates" to patients with addiction) and perceived facilitators and barriers of using MOUD in primary care settings. Participants felt that although MOUD in primary care would improve access and reduce stigma for patients, prescribing requires improved provider education and an integrated system of care.

CONCLUSIONS

The results of this study provide an argument for tailoring education to specifically address the barriers primary care prescribers perceive. Results promote the utilization of active, hands-on learning approaches, to ultimately promote uptake of MOUD prescribing in the primary care setting in South Carolina.

Intention to Quit Vaping Among United States Adolescents

This study estimates interest in quitting and past e-cigarette quit attempts among US adolescents who vape.

A cross-sectional study of United States family medicine residency programme director burnout: implications for mitigation efforts and future research

BACKGROUND

Academic physician burnout is concerning. Too little is known about factors associated with residency programme director burnout. Continued uncertainty risks adverse outcomes including graduate medical education leadership turnover and negative impact on recruiting and retaining under-represented minority residency programme directors.

OBJECTIVE

This study assessed symptoms of burnout (emotional exhaustion, depersonalization) and depression along with evidence-based individual and environmental risk factors in a U.S. sample of family medicine residency programme directors.

METHODS

The omnibus 2018 Council of Academic Family Medicine Education Research Alliance survey was used to contact programme directors at all Accreditation Council for Graduate Medical Education accredited U.S. family medicine residency programmes via email. Descriptive data included programme director and programme characteristics, Areas of Worklife (workload, values and control), loneliness (lack companionship, feel left out and feel isolated), burnout (emotional exhaustion, depersonalization) and depressive symptoms. Chi-square tests contrasted descriptive variables with burnout and depressive symptoms. Logistic regression (LR) modelled associations between significant descriptive variables and burnout and depressive symptoms.

RESULTS

The survey response rate was 45.2% (268/590). Programme directors reported: emotional exhaustion (25.0%), depersonalization (10.3%) and depressive symptoms (25.3%). LR models found significant associations with emotional exhaustion (Workload: lacking time and other work-related resources); lack of companionship, depersonalization (North West Central residency region; Workload and lack of companionship) and depressive symptoms (Black/African American ethnicity).

CONCLUSIONS

One-quarter of U.S. programme directors report burnout or depressive symptoms. Future research should consider associated variables as possible intervention targets to reduce programme director distress and turnover.

Evaluation of a Proactive Smoking Cessation Electronic Visit to Extend the Reach of Evidence-Based Cessation Treatment via Primary Care

Background: Best practice guidelines for smoking cessation treatment through primary care advise the 5As model. However, compliance with these guidelines is poor, leaving many smokers untreated. The purpose of this study was to develop and preliminarily evaluate an asynchronous smoking cessation electronic visit (e-visit) that could be delivered proactively through the electronic health record (EHR) to adult smokers treated within primary care. The goal of the e-visit is to automate 5As delivery to ensure that all smokers receive evidence-based cessation treatment. As such, the aims of this study were twofold: (1) to examine acceptability, feasibility, and treatment metrics associated with e-visit utilization and (2) to preliminarily examine efficacy relative to treatment as usual (TAU) within primary care. Methods: Participants (n = 51) were recruited from primary care practices between November 2018 and October 2019 and randomized 2:1 to receive either the smoking cessation e-visit or TAU. Participants completed assessments of cessation outcomes 1-month and 3-months postenrollment and e-visit analytics data were gathered from the EHR. Results: Self-report feedback from e-visit participants indicated satisfaction with the intervention and interest in using e-visits again in the future. Nearly all e-visits resulted in prescription of a U.S. Food and Drug Administration (FDA)-approved smoking cessation medication. In general, smoking cessation outcomes favored the e-visit condition at both 1 (odds ratios [ORs]: 2.10-5.39) and 3 months (ORs: 1.31-4.67). Conclusions: These results preliminarily indicate the feasibility, acceptability, and efficacy of this smoking cessation e-visit within primary care. Future studies should focus on larger scale examination of effectiveness and implementation across settings. The clinicaltrials.gov registration number for this trial is NCT04316260.

Direct-to-Patient Telehealth: Opportunities and Challenges

Provision of healthcare services through telehealth continues to increase. This rise is driven by the several factors, such as improved access, decreased cost, patient convenience and positive patient satisfaction. Direct-to-patient (DTP) care delivery is the most popular form of telehealth. However, barriers exist to its widespread use in practice, such as lack of reimbursement, concern that the convenience of these services may raise utilization to the point that spending increases without increasing quality of care, concern about quality of care provided and low uptake by underrepresented or at risk populations. DTP offers opportunities to improve population health and provide value-based care within integrated health systems, but requires thoughtful implementation strategies that address patient and provider barriers to its use.

Identifying and Remediating Quality Issues at Clinical Teaching Sites: A CERA Clerkship Directors Survey

Background and Objectives: Family medicine clerkship directors must secure an adequate number of teaching sites while maintaining or improving the quality of teaching. This survey details how family medicine clerkship directors identify community-based clinical sites with performance challenges, types of challenges, and whether a remediation option exists for struggling clinical sites or preceptors. This study also investigates the relationship between clerkship structure and problems with maintaining high-quality teaching sites. Methods: Data were gathered and analyzed as part of the 2018 Council of Academic Family Medicine’s (CAFM) Educational Research Alliance (CERA) survey of family medicine clerkship directors. Results: There was a significant relationship between ease/difficulty of identifying clinical sites and paying preceptors (P=.032). A lower proportion of sites where a system is in place for remediation reported it being difficult to identify clinical sites (70.0% vs 92.2%, respectively, P=.011). Having a remediation system in place was also associated with less removal of sites (2.5% removed three or more sites vs 25% removed three or more sites, respectively, P=.005). Conclusions: Medical education leaders can explore payment to incentivize community-based preceptors in schools where identifying clinical sites is a challenge. Offering centralized preceptor development activities from medical schools, geared toward the importance of evaluations, balancing learners and opportunities for student engagement, may overcome some of the identified challenges. Medical schools may also consider providing additional time and support for clerkship directors to assist with tracking teaching quality at sites, and to assist struggling preceptors prior to removing them from teaching.

Pilot Randomized Trial of a Self-Help Behavioral Activation Mobile App for Utilization in Primary Care

Mobile technologies can be leveraged to meet the need for evidence-based psychological depression treatment via primary care. The purpose of the present study was to preliminarily examine the feasibility and efficacy of a self-help brief behavioral activation mobile application (app; "Moodivate") for depressive symptoms among adults treated via primary care. Participants (N = 52) were recruited from primary care practices between January and December 2017 and were randomized 2:2:1 to receive (a) Moodivate, (b) an active control cognitive-behavioral therapy-based mobile app ("MoodKit"), or (c) treatment as usual (TAU; no app). Participants completed assessments of depressive symptoms weekly for 8 weeks. App analytics data were captured to examine Moodivate feasibility (analytics unavailable for control app). Moodivate participants on average had 46.76 (SD = 30.10) app sessions throughout the trial duration, spent 3.50 (2.76) minutes using the app per session, and spent 120.76 (101.02) minutes using the app in total throughout the trial. Nearly 70% of Moodivate participants continued to use the app 1 month after trial enrollment and 50% at the end of the 8-week follow-up period. A generalized estimating equation model examining change in depressive symptoms over time by treatment condition indicated a significant interaction between time and treatment condition (χ2 = 42.21, df = 14, p < .001). As compared to TAU, participants in both app conditions evidenced significant decreases in depressive symptoms over time, and these treatment gains were sustained across the trial period. These results preliminarily indicate feasibility of Moodivate as well as efficacy of both Moodivate and MoodKit for the treatment of depression among adults recruited via primary care. Future studies should focus on larger-scale examinations of treatment efficacy and effectiveness across primary care settings.

¡Aptívate!: A Spanish-language behavioral activation mobile application for delivery via primary care

Treatment for depression is a core health disparity for Latino/as in the United States. U.S. Latino/as are most likely to report depressive symptoms to primary care physicians, who often have limited resources for providing evidence-based psychological depression treatment. This limited treatment accessibility is further compounded by additional treatment barriers, including stigma related to seeking mental health treatment and limited English proficiency. Mobile technologies, including smartphones and mobile applications (apps) delivered via smartphone, are promising for addressing this treatment need. Herein, we discuss the development of a Spanish-language brief behavioral activation mobile application, ¡Aptívate!, that was developed to disseminate depression-based psychological treatment via primary care to Spanish-speaking Latino/as. This article focuses on the description of (a) rationale for ¡Aptívate! treatment development, (b) treatment components, and (c) a clinical case example describing potential implementation in primary care. (PsycINFO Database Record (c) 2019 APA, all rights reserved).

Pilot randomized controlled trial of a Spanish-language Behavioral Activation mobile app (¡Aptívate!) for the treatment of depressive symptoms among united states Latinx adults with limited English proficiency

BACKGROUND

To address the need for disseminable, evidence-based depression treatment options for Latinx adults with limited English proficiency (LEP), our team developed ¡Aptívate!, a Spanish-language Behavioral Activation self-help mobile application. Primary aims of this study were to: 1) examine feasibility and uptake of ¡Aptívate! among depressed Latinx adults with LEP and 2) preliminarily examine ¡Aptívate! efficacy for depression treatment.

METHODS

Participants (N = 42) with elevated depressive symptoms were randomized 2:1:1 to: 1) ¡Aptívate! (n = 22), 2) an active control Spanish-language app ("iCouch CBT"; n = 9), or 3) Treatment As Usual (i.e., no app; n = 11). Feasibility was assessed via self-reported app utilization and app analytics data. Depressive symptoms were assessed weekly for eight weeks via self report.

RESULTS

All ¡Aptívate! participants used the app at least once, 81.8% of participants used the app ≥8 times, and 36.4% of participants used the app ≥56 times. Weekly retention was strong: 72.7% and 50% of participants continued to use the app at one- and two-months post-enrollment, respectively. Generalized Estimating Equation models indicated a significant interaction between time and treatment, such that ¡Aptívate! participants reported significantly lower depressive symptoms over time than TAU. Depressive symptoms did not differ on average across time between the iCouch and TAU conditions, nor between iCouch and ¡Aptívate!.

LIMITATIONS

Limitations include small sample size, limited follow-up, and lack of analytics data for the active control condition.

CONCLUSIONS

With further research, ¡Aptívate! may offer a feasible, efficacious approach to extend the reach of evidence-based depression treatment for Latinx adults with LEP.

Body mass index is negatively associated with telomere length: a collaborative cross-sectional meta-analysis of 87 observational studies

Background

Even before the onset of age-related diseases, obesity might be a contributing factor to the cumulative burden of oxidative stress and chronic inflammation throughout the life course. Obesity may therefore contribute to accelerated shortening of telomeres. Consequently, obese persons are more likely to have shorter telomeres, but the association between body mass index (BMI) and leukocyte telomere length (TL) might differ across the life span and between ethnicities and sexes.

Objective

A collaborative cross-sectional meta-analysis of observational studies was conducted to investigate the associations between BMI and TL across the life span.

Design

Eighty-seven distinct study samples were included in the meta-analysis capturing data from 146,114 individuals. Study-specific age- and sex-adjusted regression coefficients were combined by using a random-effects model in which absolute [base pairs (bp)] and relative telomere to single-copy gene ratio (T/S ratio) TLs were regressed against BMI. Stratified analysis was performed by 3 age categories ("young": 18-60 y; "middle": 61-75 y; and "old": >75 y), sex, and ethnicity.

Results

Each unit increase in BMI corresponded to a -3.99 bp (95% CI: -5.17, -2.81 bp) difference in TL in the total pooled sample; among young adults, each unit increase in BMI corresponded to a -7.67 bp (95% CI: -10.03, -5.31 bp) difference. Each unit increase in BMI corresponded to a -1.58 × 10(-3) unit T/S ratio (0.16% decrease; 95% CI: -2.14 × 10(-3), -1.01 × 10(-3)) difference in age- and sex-adjusted relative TL in the total pooled sample; among young adults, each unit increase in BMI corresponded to a -2.58 × 10(-3) unit T/S ratio (0.26% decrease; 95% CI: -3.92 × 10(-3), -1.25 × 10(-3)). The associations were predominantly for the white pooled population. No sex differences were observed.

Conclusions

A higher BMI is associated with shorter telomeres, especially in younger individuals. The presently observed difference is not negligible. Meta-analyses of longitudinal studies evaluating change in body weight alongside change in TL are warranted.

Diabetes management in the USA and England: comparative analysis of national surveys

Objectives

To compare diabetes management in adults between England and the United States, particularly focusing on the impact of a universal access health insurance system.

Design

Analysis of the nationally-representative surveys Health Survey of England, 2003 (unweighted n=14 057) and the National Health and Nutrition Examination Survey, 2001–2002 (unweighted n=5411).

Setting and Participants

Adults 20–64 years of age; individuals >65.

Main Outcome Measures

Glycaemic, lipid and blood pressure control and medication use among individuals with previously diagnosed diabetes.

Results

Among those aged 20–64 the prevalence of diagnosed diabetes was lower in England (2.7%) than in the USA (5.0%). The proportion with diabetes receiving treatment was similar for the two countries. However, the mean HbA1c in England was 7.6%: in the USA it was 7.5% for those with insurance and 8.6% for those without insurance. The proportion of individuals on ACE inhibitors in England was 39%: in USA it was 39% for those with insurance, and 14% for those without.

Conclusions

Individuals in a healthcare system providing universal access have better managed diabetes than those in a market based system once one accounts for insurance.

Moodivate: A self-help behavioral activation mobile app for utilization in primary care-Development and clinical considerations

Depressive symptoms are highly prevalent and are associated with considerable functional impairment, significant public health costs, and heightened mortality risk. Individuals experiencing impairment due to depressive symptomatology are most likely to report their symptoms to a primary care provider. As such, national guidelines highlight the need to assess and effectively treat depression via primary care. Despite these guidelines, the dissemination of evidence-based psychotherapy via primary care is limited, likely due to both provider- and patient-level treatment barriers. Mobile health (mHealth) technologies are promising for addressing these barriers and for promoting uptake of evidence-based depression treatment. Among evidence-based psychotherapies for depression, brief Behavioral Activation Treatment for Depression (BATD) has shown great promise and is particularly amenable to mHealth delivery. Herein, we discuss the development of a BATD mobile application, Moodivate, that was developed in order to disseminate BATD via primary care. This paper focuses on description of (1) rationale for Moodivate treatment development, (2) Moodivate treatment components, (3) ongoing clinical trial evaluation of Moodivate, and (4) clinical considerations for incorporating Moodivate into clinical practice.

Comparison of Alcohol Use Disorder Screens During College Athlete Pre-Participation Evaluations

BACKGROUND AND OBJECTIVES

The US Preventive Services Task Force (USPSTF) recommends screening adults for alcohol misuse, a challenge among young adults who may not have regular primary care. The pre-participation evaluation (PPE) provides an opportunity for screening, but traditional screening tools require extra time in an already busy visit. The objective of this study was to compare the 10-item Alcohol Use Disorders Identification Test (AUDIT) with a single-question alcohol misuse screen in a population of college-aged athletes.

METHODS

This cross-sectional study was performed during an athletic PPE clinic at a college in the Southeastern United States among athletes ages 18 years and older. Written AUDIT and single-question screen "How many times in the past year have you had X or more drinks in a day?" (five for men, four for women) asked orally were administered to each participant. Sensitivity, specificity, and positive and negative predictive values for the single-question screen were compared to AUDIT.

RESULTS

A total of 225 athletes were screened; 60% were female; 29% screened positive by AUDIT; 59% positive by single-question instrument. Males were more likely to screen positive by both methods. Compared to the AUDIT, the brief single-question screen had 92% sensitivity for alcohol misuse and 55% specificity. The negative predictive value of the single-question screen was 95% compared to AUDIT.

CONCLUSIONS

A single-question screen for alcohol misuse in college-aged athletes had a high sensitivity and negative predictive value compared to the more extensive AUDIT screen. Ease of administration of this screening tool is ideal for use within the pre-participation physical among college-aged athletes who may not seek regular medical care.

Cost and Utilization: Hospitalized Patients on a Family Medicine Service

OBJECTIVES

The cost of hospitalizations contributes to the rising expense of medical care in the United States. Providing health insurance to uninsured Americans is a strategy to reduce these costs, but only if costs for uninsured patients are disproportionately high. This study examined hospitalization use patterns for uninsured patients compared with those with Medicaid and commercial insurance.

METHODS

We performed a retrospective chart review to analyze inpatient admissions to a family medicine teaching service in a 290-bed, for-profit community hospital during a 2-year period based on insurance status of the patient. Outcome variables investigated were length of stay, emergency department visits, and readmission rates to the hospital and/or emergency department. Secondary outcome variables were mean charges.

RESULTS

A total of 1102 admissions to a family medicine teaching service were evaluated. Length of stay, readmission rates to the hospital and the emergency department after hospital discharge, and average length of stay compared with diagnosis-related groups were significantly higher in the Medicaid population than for insured and uninsured individuals. Variable costs also were significantly higher.

CONCLUSIONS

Insurance status was found to be a significant factor in hospital charges and utilization data, with Medicaid patients having the highest costs. This suggests that moving uninsured patients to Medicaid may not significantly reduce hospitalization costs.

Use of a Tablet-Based Risk Assessment Program to Improve Health Counseling and Patient-Provider Relationships in a Federally Qualified Health Center

This study evaluates the impact of an interactive, tablet-based lifestyle behavior questionnaire prior to a patient's primary care visit on counseling for health behaviors and patient-provider relationships. Using a quasi-experimental design at 2 federally qualified health centers, adults aged 18 to 35 years were asked to complete a tablet-based assessment about nutrition, physical activity, weight, smoking status, and alcohol use to identify unhealthy behaviors and their desire to discuss them with their provider. In the intervention group, participants were more likely to trust their providers (83% vs 71%, P = .0427) and feel that their provider cared about their health (80% vs 68%, P = .0468). Overweight/obese individuals were more likely to discuss weight loss with their doctor (59% vs 33%, P = .0088). Integrating information technology into primary care to encourage providers to discuss lifestyle issues and promote a positive patient-provider relationship may help improve the health promotion in primary care practices.

Balint groups in family medicine residency programs: a follow-up study from 1990--2010

BACKGROUND AND OBJECTIVES

Balint groups have been part of residency education for decades. This study updates our understanding of the organization, purpose, and leadership of Balint groups within US family medicine residency programs.

METHODS

Accreditation Council for Graduate Medical Education (ACGME)-approved family medicine residency training programs (n=453) were contacted to complete a questionnaire, similar to ones performed in 1990 and 2000. This survey included questions regarding Balint groups, including their composition, management, and goals.

RESULTS

More than half (54%) of respondent programs (n=159) have at least one Balint group, compared to 19% in 1990 and 60% in 2000. Of programs without Balint, 24% would like to have a Balint group, and 6% plan to initiate one within the following year. The proportion of groups meeting weekly decreased over time (80.9% in 1990 versus 40.4% in 2000 versus 11.7% in 2010). The proportion of peer only groups decreased (45.2% versus 53.6% versus 35.1%) while the proportion of groups with > 11 members increased (11.1% versus 15.8% versus 27.2%). Less than half of Balint group leaders reported going to formal training at the American Balint Society Leader's Intensive Workshop (41%). "Understanding the patient as a person" was seen as the main objective of Balint groups.

CONCLUSIONS

Balint groups are still commonly occurring, but their implementation is changing. Groups are meeting less frequently and are more likely to be larger and heterogeneous. This trend and lack of formally trained/certified leaders may be decreasing the benefit to residents involved in Balint groups.

Stressors and coping mechanisms associated with perceived stress in Latinos

OBJECTIVE

To evaluate the relationship between causes of perceived stress and the coping mechanisms used by Latino adults with perceived stress.

DESIGN, SETTING, PARTICIPANTS

This cross-sectional survey was conducted on a convenience sample of 200 Latino adults (aged ≥18 years). They were recruited from clinics, migrant camps, community events, and churches located in Charleston, S.C. This survey included questions regarding causes of perceived stress, perceived stress (Perceived Stress Scale 10), coping mechanisms (Brief COPE), and depression (Perceived Health Questionnaire 9).

MEASURES

High perceived stress (PSS ≥15) was the primary outcome measure. Coping mechanisms and stressors were secondary outcomes.

RESULTS

Most (92%) of the sample was born outside the United States, and 66% reported high perceived stress. Stressors associated with high perceived stress included discrimination (P=.0010), lack of insurance (P=.0193), health problems (P=.0058), and lack of money (P=.0015). The most frequently utilized coping mechanisms were self-distraction (54.77%), active coping (69.85%), positive reframing (56.78%), planning (63.82%), acceptance (57.87%), and religion (57.79%). Latinos with higher perceived stress were more likely to report discrimination (OR: 3.401; 95%CI 1.285-9.004) and health problems (OR: 2.782; 95%CI 1.088-7.111) as stressors, and to use denial as a coping mechanism (OR: 2.904; 95%CI 1.280-6.589).

CONCLUSION

An increased prevalence of perceived stress among the Latinos evaluated in this study was associated with using denial as a coping mechanism, and encountering discrimination and health problems as sources of perceived stress. Most individuals responded to stressors by utilizing a variety of both adaptive and maladaptive coping mechanisms.

Discrepancies in cardiovascular disease risk calculation affect aspirin use recommendations in patients with diabetes

OBJECTIVES

Aspirin is recommended for cardiovascular disease (CVD) prevention in patients who are at high risk for CVD. The objective of this study was to compare agreement between two American Diabetes Association-endorsed CVD risk calculators in identifying candidates for aspirin therapy.

METHODS

Adult patients with diabetes mellitus (n = 238) were studied for 1 year in a family medicine clinic. Risk scores were calculated based on the United Kingdom Prospective Diabetes Study Risk Engine and the Atherosclerosis Risk in Communities Coronary Heart Disease Risk Calculator. Analyses included χ(2), κ scores, and logistic regressions.

RESULTS

The Atherosclerosis Risk in Communities Coronary Heart Disease Risk Calculator identified 50.4% of patients as high risk versus 23.5% by the United Kingdom Prospective Diabetes Study Risk Engine. κ score for agreement identifying high-risk status was 0.3642. Among patients at high risk, African Americans (odds ratio [OR] 0.45, 95% confidence interval [CI] 0.24-0.86) and those with uncontrolled diabetes (OR 0.30, 95% CI 0.16-0.56) had lower odds of disagreement, whereas nonsmokers had higher odds (OR 2.98, 95% CI 1.57-5.69). Among patients at low risk, women (OR 3.83, 95% CI 1.64-8.91), African Americans (OR 5.96, 95% CI 3.07-11.59), and those with high high-density lipoprotein (OR 2.82, 95% CI 1.48-5.37) showed greater odds of disagreement.

CONCLUSIONS

Improved risk assessment methods are needed to identify patients with diabetes mellitus who benefit from aspirin for the primary prevention of CVD. Prospective trials are needed to provide additional evidence for aspirin use in this population.

Elevated transferrin saturation, health-related quality of life and telomere length

We sought to examine the relationship between elevated transferrin saturation (TS) and measures of health status (telomere length and patient-reported health-related quality of life) to assess whether elevated TS is associated with negative patient outcomes beyond increased risk for morbidity and mortality, using a cross-sectional analysis of the Hemochromatosis and Iron Overload Screening Study supplemented with assays for leukocyte telomere length in adults ≥25 years old (n = 669). Among individuals with elevated TS (≥45 % for women and ≥50 % for men), who also had a usual source of care, only 5.2 % reported ever being told by a doctor that they had an elevated iron condition. In a fully adjusted general linear regression model controlling for demographic characteristics as well as health conditions associated with iron overload, elevated TS versus non-elevated TS was associated with worse general health status (60.4 vs. 63.8, P < 0.05), mental health status (76.5 vs. 82.2, P < 0.0001) and shorter telomere length (241.4 vs. 261.3, P < 0.05). Increased surveillance of elevated TS may be in order as elevated TS is associated with decreased health status and very few patients with elevated TS are aware of their condition.

Satisfaction, early removal, and side effects associated with long-acting reversible contraception

BACKGROUND AND OBJECTIVES

Although intrauterine devices (IUDs) and subdermal implants (SDI) are recommended as first-line contraception for the majority of women by the American College of Obstetrics and Gynecology, these methods of long-acting reversible contraception (LARC) are underutilized. Some concerns regarding their use include cost of placement, side effects, and perception of frequent early removal. This study evaluated satisfaction with LARC, frequency, and reasons behind early removal in a family medicine setting.

METHODS

Women > 18 years seen for placement of removal of an IUD or SDI were identified from billing data and surveyed via telephone to determine satisfaction and side effects with LARC. Additional demographic information was extracted from the electronic health record.

RESULTS

Of the 132 respondents (response rate 61.4%), 58.3% had IUDs and 41.7% had SDIs placed. Early removal occurred in 24.2% of women, and 72.7% were satisfied with their contraceptive choice. Younger and nulliparous women were more likely to have an SDI placed, whereas older and multiparous women chose the IUD. Younger nulliparous women were less likely to have LARC removed early. Pain (more commonly reported with the IUD) and increased frequency in bleeding (more commonly reported with the SDI) were associated with early removal rates.

CONCLUSIONS

Most women who received LARC were satisfied with their contraceptive choice, and only one in four had the LARC removed early. This is significantly better than continuation rates with other contraceptive methods. Younger, nulliparous women were good candidates for LARC, continuing their use more than older, multiparous women. Improved counseling regarding pain and changes in menstrual bleeding patterns may impact early removal of IUDs and SDIs, respectively.

Racial differences in attitudes toward personalized medicine

BACKGROUND/AIMS

Patient concerns regarding personalized medicine may limit its use. This study assesses racial differences in attitudes toward personalized medicine, evaluating variables that may influence these attitudes.

METHODS

A convenience sample of 190 adults (≥18 years) from an academic primary care practice was surveyed regarding awareness and acceptance of personalized medicine, plus concerns and benefits regarding its use. Logistic regressions predicting awareness, acceptance and concerns were performed, controlling for race, gender, marital status, education, children, internet use, and self-reported discrimination.

RESULTS

The sample was 35% non-Hispanic white (NHW) and 34.7% male. More NHW participants expressed acceptance of personalized medicine than non-Hispanic black (NHB) participants (94.4 vs. 81.9%, p = 0.0190). More NHBs were concerned about the use of genes without consent (57.3 vs. 20.6%, p < 0.0001), sharing genetic information without consent (65.0 vs. 35.6%, p < 0.0001), discrimination based on genes (62.4 vs. 34.3%, p = 0.0002), and lack of access due to cost (75.0 vs. 48.0%, p = 0.0002). In logistic regressions, NHBs (OR = 7.46, 95% CI = 3.04-18.32) and those self-reporting discrimination (OR = 2.87, 95% CI = 1.22-6.78) had more concerns about the misuse of genes and costs associated with personalized medicine.

CONCLUSION

Racial differences exist in attitudes toward personalized medicine and may be influenced by self-reported discrimination. Further study to understand factors influencing the acceptance of personalized medicine could help encourage its use.

Telomere length and elevated iron: the influence of phenotype and HFE genotype

Elevated body iron stores are associated with morbidity and mortality due to oxidative stress. Hereditary hemochromatosis, a common condition caused by HFE gene mutations, can lead to excess iron storage and disease but clinical penetrance of HFE gene mutations is low and many people with elevated iron stores lack HFE mutations. We analyzed data from the Hemochromatosis and Iron Overload Screening Study to assess the relationship among HFE genotype (individuals with either homozygous or compound heterozygous status for C282Y and/or H63D HFE mutations were defined as genotype positive, or G+), elevated iron phenotype (individuals exceeding gender-specific transferrin saturation and serum ferritin threshold levels were considered phenotype positive, or P+), and leukocyte telomere length, a marker of biological aging and cumulative oxidative stress. In unadjusted analyses in comparison to individuals who were G-P-, G+P- were not significantly different (OR 0.74; 95% CI 0.26-2.04), while the G+P+ (OR 2.03; 95% CI 1.15-3.56), and G-P+ (OR 2.24; 95% CI 1.5-3.29) had increased risk of short telomeres (<=25th percentile) rather than long telomeres (>=75th percentile). In analyses adjusting for age, gender, and race/ethnicity, the effect of individuals with elevated iron phenotypes having short telomeres persisted with G+P+ individuals (OR 1.94; 95% CI 1.02-3.72), and G-P+ individuals (OR 2.17; 95% CI 1.39-3.39) being significantly different from the G-P- group. In conclusion, elevated iron phenotype, but not HFE genotype, was associated with shortened telomeres. Further studies will be needed to determine whether telomere length provides a marker for morbidities specifically associated with iron overload.

Factors affecting HPV vaccine use among recent family medicine residency graduates

BACKGROUND AND OBJECTIVES

Many adolescents seek care by family physicians for well visits and have the opportunity for HPV vaccination during these visits. Limited information is available regarding what affects physicians in offering the vaccine. The purpose of this study was to examine factors that affect family physician administration of the HPV vaccine.

METHODS

We used a mail survey of recent graduates from family medicine residencies affiliated with the South Carolina Area Health Education Consortium.

RESULTS

The response rate was 51.3%. Almost 79% offer the HPV vaccine at least most of the time to their adolescent female patients in their practice. Approximately 83% of respondents reported supporting the use of the HPV vaccine in males, but less than 8% reported having actually offered the vaccine to males. Those physicians who are female (OR=8.95, 95% CI=1.56--51.3), practice full time in an office setting (OR=9.08, 95% CI=1.71--48.3), are involved in teaching (OR=8.86, 95% CI=1.75--44.9), and practice in a family medicine setting (OR=8.20, 95% CI=1.69-39.8) had greater odds of offering the vaccine. Those who currently practiced in the southeastern United States were less likely to offer the vaccine (OR=0.04, 95% CI=0.002--0.59).

CONCLUSIONS

Recent graduates of family medicine training programs frequently offer the HPV vaccine to adolescent females. Multiple practice factors affected the odds of offering the vaccine. Though most respondents agree with using the vaccine in males, most do not offer it to males.

Unequal burden of disease, unequal participation in clinical trials: solutions from African American and Latino community members

African Americans and Latinos are underrepresented in clinical trials. The purpose of this study was to elicit solutions to participation barriers from African Americans and Latinos. Fifty-seven adults (32 African Americans, 25 Latinos) ages 50 years and older participated. The Institute of Medicine's Unequal Treatment conceptual framework was used. Six racially/ ethnically homogenous focus groups were conducted at five sites in three counties. Themes within groups and cross-cutting themes were identified. The NVIVO program was used for data classification. The data were reviewed for final coding and consensus. Shared solutions included addressing costs, recruiting in community contexts, conducting community and individualized patient education, and sharing patient safety information. Participants were unanimously in favor of clinical trials navigation recruitment interventions. Solutions specific to African Americans included diversifying research teams, recognizing past research abuses, and increasing community trust. Solutions specific to Latinos included providing low-literacy materials, providing Spanish-speaking clinicians and advocates, and clarifying that immigration status would neither be documented nor prevent participation. Solutions from African Americans and Latinos reflect their cultural backgrounds and historical experiences. The results suggest the importance of developing a tailored, barriers-focused navigation intervention to improve participation among diverse racial and ethnic populations.

Chlamydia pneumoniae and progression of subclinical atherosclerosis

BACKGROUND

Cross-sectional investigation between presence of antibodies and coronary artery calcification (CAC) in past studies has shown no relationship, but progression over time has not been investigated. The objective of this study was to determine the relationship between presence of Chlamydia pneumoniae antibodies and progression of CAC and ankle-brachial index (ABI).

DESIGN

The Multiethnic Study of Atherosclerosis (MESA) is a prospective population-based cohort of racially and ethnically diverse male and female participants recruited from six communities in the USA, age 45-84 years, free of clinical cardiovascular disease at baseline.

METHODS

The main outcomes were progression of mean CAC and ABI between exams 1 (2000-02) and 3 (2004-05) (median follow-up of 3.13 years) by C. pneumoniae antibody. Multivariate models adjusting for demographics, obesity, smoking, alcohol use, and physical activity were computed.

RESULTS

Of 2223 subjects analysed, 76% were positive for C. pneumoniae antibodies. Progression of CAC was significantly higher in the antibody-positive group (93.8 vs. 78.2 agatston units, p = 0.02) and in antibody-positive subjects with CAC ≥10 at baseline (216.5 vs. 178.6, p = 0.02) than antibody-negative group. Smoking and body mass index ≥30 kg/m(2) both had interactions with presence of C. pneumoniae yielding significantly greater CAC progression. Progression of ABI did not significantly differ by C. pneumoniae antibody status in models adjusted for covariates.

CONCLUSIONS

C. pneumoniae antibodies are related to progression of CAC, particularly in individuals with CAC present at baseline. This provides evidence that certain groups are at higher risk of atherosclerotic progression and may be useful for risk stratification and treatment.

Transferrin saturation and hospital length of stay and mortality in Medicare beneficiaries

OBJECTIVES

To evaluate in a large, nationally representative cohort the association between high serum transferrin saturation (TS) and hospital length of stay and mortality in older adults.

DESIGN

Prospective cohort.

SETTING

Longitudinal analyses of the Third National Health and Nutrition Examination Survey linked to Medicare claims from 1991 through 2006.

PARTICIPANTS

Medicare beneficiaries aged 65 and older at baseline.

MEASUREMENTS

Transferrin saturation collected on each participant at baseline was characterized as <20.0%, 20.0% to 54.9%, and 55.0% and greater. Length of stay in the hospital and death in the hospital were primary outcomes. Analyses were adjusted for age, sex, race and ethnicity, education, and severity of illness.

RESULTS

Individuals hospitalized during the study period (79.4%) with high (odds ratio (OR) = 2.54, 95% confidence interval (CI) = 1.05-6.12) or low (OR = 1.31, 95% CI = 1.07-1.62) TS had a significantly greater risk of death than those with moderate TS. Individuals with high TS had longer average length of stay per hospitalization (11.1 days, (standard error, SE 1.7 days), P = .01) than those with moderate TS (8.4 (0.3) days). Individuals with high TS also had more hospital days per year (8.6 (2.0) days, P = .04) than those with moderate TS (6.7 (0.5) days).

CONCLUSION

High TS is associated with longer length of stay and death in the hospital (unweighted N = 3,847, weighted N = 28,395,464).

A randomized recruitment intervention trial in Parkinson's disease to increase participant diversity: early stopping for lack of efficacy

BACKGROUND

Failure to include participants of diverse race and ethnicity (i.e. those other than European Caucasian, non-Hispanic) in clinical trials impedes the safe development of new therapies given the potential for racial/ethnicity-related variations in treatment response. Increasing diversity is problematic for low prevalence diseases, where most community-based approaches do not reach those with the disease.

PURPOSE

Increase racial/ethnic diversity of participants in a Parkinson's disease therapeutic trial.

METHODS

We incorporated a randomized Ancillary Trial into the multisite National Institute of Neurologic Disorders and Stroke Exploratory Trials in Parkinson's Disease Long-Term Study 1. Movement disorders clinics already participating in long-term trial 1 were eligible and were the unit of randomization and analysis. At least 14% of adult residents over age 55 and living within 30 miles of the eligible site were from a diverse population, or there was a near-by zip code with a highly diverse population. Eligible sites also agreed to be randomized. The intervention was designed to increase community physicians' trust in long-term trial 1 investigators and address recruitment barriers in diverse populations. Primary outcomes included percentage of participants from diverse racial/ethnic groups enrolled in long-term trial 1, and qualitative findings from key informant interviews of the Ancillary Trial investigators and coordinators at the end of the trial.

RESULTS

The Ancillary Trial stopped early for lack of efficacy, conditional power less than 1%. The 17 intervention sites had 12.6% diverse participants compared to 15.6% in 15 control clinics; odds ratio 0.82 (95% confidence interval = 0.32-2.16). In key informant interviews, high enrollers of diverse participants reported more use of existing physician relationships, untargeted community outreach, and extensive efforts to overcome participants' barriers. Low enrollers reported more use of patients in their practices and placed more responsibility for low enrollment on prospective participants.

LIMITATIONS

The Ancillary Trial included only those with Parkinson's disease. Whether our findings generalize to trials in other low prevalence diseases is unknown.

CONCLUSIONS

Increasing diversity in Parkinson's disease clinical trials requires new paradigms for trial investigator and coordinator interactions with community physicians and prospective trial participants.

Impact of quality improvement training during residency on current practice

BACKGROUND AND OBJECTIVES

Quality improvement (QI) has become an integral aspect of family medicine residency training. This study examines whether QI training during residency is associated with the integration of QI activities into practice following graduation.

METHODS

A confidential survey was delivered to South Carolina Area Health Education Consortium (SC AHEC)-associated family medicine residency program graduates from 2005--2009. The survey evaluated QI training during residency, as well as the following QI activities in current practice: periodic patient care data review, patient care registries, specific QI projects, disease-specific QI activities, National Committee on Quality Assurance (NCQA) Recognition, having staff QI leaders, and participation in a Practice-based Research Network (PBRN). Proportions were compared using chi-square tests. Stepwise logistic regressions were performed to identify variables predictive of specific QI activities in practice.

RESULTS

The response rate was 51.3% (n=136). Most participants received QI training (75.8%) and currently participated in at least one QI activity (87.1%). PBRN involvement and having staff QI leaders was associated with involvement in all other QI activities. QI training was associated with periodic patient care data review (odds ratio (OR)=3.32; 95% confidence interval (CI)=1.26--8.78) and performing specific QI projects (OR=3.17; 95% CI=1.09--9.23).

CONCLUSIONS

QI training during residency is associated with involvement in specific QI activities following graduation. Further, participation in a PBRN or having staff QI leaders is also associated with involvement in QI activities. Further evaluation of residency QI curricula is warranted to identify effective strategies that positively impact future practice.

Identification and treatment of depression in minority populations

Depression is a common condition, representing close to 6% of visits to primary care providers. Although minorities are more likely to have chronic depression, they are more likely to be incorrectly diagnosed and less likely to receive treatment when compared to the mainstream population. Screening and appropriate treatment within primary care is recommended in clinical practices that have systems in place to assure accurate diagnosis, effective treatment, and follow-up. This recommendation is especially relevant for treatment of minority populations, as they are more likely to seek care for mental health problems from primary care providers rather than specialists. A number of self-report screening tools that simplify screening are available. Treatment modalities that are supported by evidence are psychotherapy, prescription medications, and electroconvulsive therapy for severe depression. Selective serotonin reuptake inhibitors (SSRIs) have become the cornerstone of therapy for depression since the Food and Drug Administration (FDA) approval of fluoxetine in 1987. No substantial differences in efficacy of SSRIs have been found, although data suggest differences with respect to onset of action and adverse effects that may be relevant in the choice of one medicine over another. Common side effects of serotonin reuptake inhibitors include nausea, diarrhea, insomnia, somnolence and dizziness, akathisia, and sexual dysfunction. While most of these symptoms tend to subside within several weeks of use, sexual dysfunction appears to be a long-term side effect that typically reverses within a few days after discontinuation of the causative medication. Selective norepinephrine reuptake inhibitors (SNRIs), bupropion, mirtazapine, and tricyclic antidepressants (TCAs) are other commonly used medications. Complementary and alternative treatments, such as St. John's wort (Hypericum perforatum), exercise, acupuncture, music therapy, and relaxation, have limited data supporting their efficacy.

Cardiovascular and diabetes risk perception in a Hispanic community sample

PURPOSE

We examined perceptions of 10-year coronary heart disease (CHD) risk or likelihood of having undiagnosed diabetes or impaired fasting glucose (IFG) with actual risk in a community sample of Hispanic adults.

METHODS

We conducted a survey of 183 Hispanic adults (> or =18 years) recruited at community events around Charleston, SC. Likelihood of having undiagnosed diabetes/IFG as well as 10-year CHD risk were calculated. Perceived risk was assessed with questions based on the Risk Perception Survey-Diabetes Mellitus.

RESULTS

Over half of respondents (54.8%) underestimated their likelihood of undiagnosed diabetes/IFG and 14.8% underestimated their 10-year CHD risk. Older and overweight respondents were more likely to underestimate their likelihood of undiagnosed diabetes/IFG. Respondents with family history of diabetes were the least likely to underestimate their likelihood of current undiagnosed diabetes/IFG. Respondents with diagnosed hypertension, diabetes, high cholesterol or a family history of heart attack were more likely to underestimate their 10-year CHD risk. Men were more likely to underestimate their risk for diabetes/IFG and CHD risk.

CONCLUSIONS

Health education to improve accurate risk perception could improve health promotion for this population.

Association between vitamin D and diabetic neuropathy in a nationally representative sample: results from 2001-2004 NHANES

AIMS

To evaluate the association between vitamin D insufficiency and peripheral neuropathy in a nationally representative sample of adults with diagnosed diabetes.

METHODS

Vitamin D concentrations, medical examination variables and questionnaire results from the 2001-2004 National Health and Nutrition Examination Survey were analysed for adults ≥ 40 years old with diagnosed diabetes (unweighted n = 591, weighted n = 8.82 million). Neuropathy was defined as self report of peripheral neuropathy symptoms of painful sensation, tingling, numbness or loss of feeling in hands or feet. Additionally, Semmes-Weinstein monofilament test results were used as an indicator of neuropathy. Insufficient vitamin D was characterized as < 30 ng/ml.

RESULTS

In the weighted population, 81% of adults with diabetes had vitamin D insufficiency. Vitamin D insufficiency was more common among Hispanics (92%) and non-Hispanic black people (98%) than among non-Hispanic white people (76%). Within the 3 months preceding the questionnaire, 50% reported experiencing pain or numbness (paresthesia) in their hands or feet; 37% reported pain or tingling in hands or feet; and 38% reported numbness or loss of feeling in hands or feet. Eight per cent had 4-6 insensate areas on their feet as determined by the Semmes-Weinstein monofilament test. Logistic regressions demonstrate vitamin D insufficiency is associated with the adjusted composite paresthesia measure (odds ratio 2.12; 95% CI 1.17-3.85) and the adjusted numbness measure (odds ratio 2.04; 95% CI 1.18-3.52).

CONCLUSIONS

Vitamin D insufficiency is associated with self-reported peripheral neuropathy symptoms even after adjusting for demographic factors, obesity, co-morbidities, use of medications for neuropathy and diabetes duration and control.

Impact of insurance and hospital ownership on hospital length of stay among patients with ambulatory care-sensitive conditions

PURPOSE Some studies suggest proprietary (for-profit) hospitals are maximizing financial margins from patient care by limiting therapies or decreasing length of stay for uninsured patients. This study examines the role of insurance related to length of stay once the patient is in the hospital and risk for mortality, particularly in a for-profit environment. METHODS We undertook an analysis of hospitalizations in the National Hospital Discharge Survey (NHDS) of the 5-year period of 2003 to 2007 for patients aged 18 to 64 years (unweighted n = 849,866; weighted n = 90 million). The analysis included those who were hospitalized with both ambulatory care-sensitive conditions (ACSCs), hospitalizations considered to be preventable, and non-ACSCs. We analyzed the transformed mean length of stay between individuals who had Medicaid or all other insurance types while hospitalized and those who were hospitalized without insurance. This analysis was stratified by hospital ownership. We also examined the relationship between in-hospital mortality and insurance status. RESULTS After controlling for comorbidities; age, sex, and race/ethnicity; and hospitalizations with either an ACSC or non-ACSC diagnosis, patients without insurance tended to have a significantly shorter length of stay. Across all hospital types, the mean length of stay for ACSCs was significantly shorter for individuals without insurance (2.77 days) than for those with either private insurance (2.89 days, P = .04) or Medicaid (3.19, P <.01). Among hospitalizations for ACSCs, in-hospital mortality rate for individuals with either private insurance or Medicaid was not significantly different from the mortality rate for those without insurance. CONCLUSIONS Patients without insurance have shorter lengths of stay for both ACSCs and non-ACSCs. Future research should examine whether patients without insurance are being discharged prematurely.

IRon Overload screeNing tool (IRON): development of a tool to guide screening in primary care

Iron overload is associated with significant morbidity and mortality yet is easily treated. The objective of this study was to create a tool that could be easily adapted to clinical practice that indicates the likelihood of a patient having undetected iron overload. We used the National Health and Nutrition Examination Survey (NHANES) 1999-2002 for US adults aged 20 years and older to build a model (unweighted n=8,779). We chose potential variables for inclusion that could be gathered by self-report or measured without laboratory data and were suggested by past literature on hemochromatosis and iron overload. We computed logistic regressions to create the scores by initially evaluating the variables' relationship with elevated ferritin and elevated transferrin saturation and then using odds ratios to correspond to scores. The resulting score on the IRon Overload ScreeNing Tool (IRON) was then validated with data on 13,844 adults in the NHANES III, 1988-94. Predictors in the final tool were age, gender, previous diagnoses of liver condition, osteoporosis or thyroid disease. The IRON score yielded an area under the curve (AUC) in the NHANES 1999-02 of 0.720 and an AUC of 0.685 in the NHANES III validation sample. The IRON score is a tool to assist in identification of patients with iron overload that has several qualities that make it attractive for use in clinical practice with an undifferentiated patient population including brevity, easily collected information and predictive ability comparable to other tools that help in directing screening.

Addressing the Scholarly Activity Requirements for Residents: One Program's Solution

BACKGROUND

Scholarly activity as a component of residency education is becoming increasingly emphasized by the Accreditation Council for Graduate Medical Education. "Limited or no evidence of resident or faculty scholarly activity" is a common citation given to family medicine residency programs by the Review Committee for Family Medicine.

OBJECTIVE

The objective was to provide a model scholarly activity curriculum that has been successful in improving the quality of graduate medical education in a family medicine residency program, as evidenced by a record of resident academic presentations and publications.

METHODS

We provide a description of the Clinical Scholars Program that has been implemented into the curriculum of the Trident/Medical University of South Carolina Family Medicine Residency Program.

RESULTS

During the most recent 10-year academic period (2000-2010), a total of 111 residents completed training and participated in the Clinical Scholars Program. This program has produced more than 24 presentations during national and international meetings of medical societies and 15 publications in peer-reviewed medical journals. In addition, many of the projects have been presented during meetings of state and regional medical organizations.

CONCLUSIONS

This paper presents a model curriculum for teaching about scholarship to family medicine residents. The success of this program is evidenced by the numerous presentations and publications by participating residents.

Trends in hospitalizations with antibiotic-resistant infections: U.S., 1997-2006

OBJECTIVES

Antibiotic resistance is a significant global problem, but the trends in prevalence and impact of antibiotic resistance in hospitalizations in the United States are unclear. We evaluated the trends in hospitalizations associated with antibiotic-resistant infections in U.S. hospitals from 1997 to 2006.

METHODS

We analyzed the National Hospital Discharge Survey (NHDS) during 1997-2006 (unweighted n = 3.3 million hospitalizations; weighted n = 370.3 million hospitalizations) and examined trends in prevalence of hospitalizations with antibiotic-resistant infections, length of stay, and discharge status.

RESULTS

The number of infection-related hospitalizations with antibiotic resistance increased 359% during the 10-year period, from 37,005 in 1997 to 169,985 in 2006. The steepest rise was seen among individuals < 18 years of age. The mean age of individuals with infection-related hospitalizations that had antibiotic-resistant infections decreased substantially, from 65.7 years (standard error [SE] = 2.01) in 1997 to 44.2 years (SE = 1.47) in 2006. As the proportion of patients with antibiotic-resistant infections who did not have insurance increased, the length of stay for those hospitalizations had a corresponding decrease (r = 0.91, p < 0.01).

CONCLUSIONS

Antibiotic-resistant infections are becoming increasingly commonplace in hospitalizations in the U.S., with a steady upward trend between 1997 and 2006. Antibiotic-resistant infections are increasingly being seen in younger patients and those without health insurance.

Clinician knowledge about use of intrauterine devices in adolescents in South Carolina AHEC

BACKGROUND AND OBJECTIVES

Intrauterine devices (IUDs) are recommended as first-line choices for both nulliparous and parous adolescents by the American College of Obstetrics and Gynecology (ACOG). This study describes use of IUDs and knowledge regarding IUD use in adolescents in South Carolina family medicine residency programs.

METHODS

Faculty and residents in South Carolina Area Health Education Consortium (SC AHEC) Family Medicine Residency Programs received an anonymous survey including questions about current use of IUDs and scenarios where they were asked whether they would recommend an IUD. Proportions were compared using chi-square or Fisher's Exact Test. Modified Wald method was utilized to calculate 95% confidence intervals.

RESULTS

The survey response rate was 53.8% (n=133). Most respondents (78%) prescribed IUDs and 42% inserted them, but ≥ 90% reported only prescribing or inserting ≤ 10 yearly. In scenarios where IUD recommendation was appropriate, only 27% (95% CI: 20.2-35.2) recommended IUDs for a sexually active adolescent, whereas 60% (95% CI: 51.7-68.1) recommended use for a postpartum adolescent. For similar scenarios in non-adolescents, a statistically significant higher proportion recommended IUDs, with 50% (95% CI: 42.0-58.7) recommending use in a 21-year-old nulliparous woman and 77% (95% CI: 68.8-83.1) in a breast-feeding mother. Women were more likely to recommend IUD use than men in non-adolescents, but not adolescents. There was no difference in recommendations by level of training.

CONCLUSIONS

Knowledge regarding IUD use in nulliparous women and adolescents is limited in this sample of family physicians. Increasing appropriate IUD recommendations may increase IUD use and improve contraceptive counseling for adolescents.

Ethnic differences in the relationship of prediabetes with the presence of target-organ disease

BACKGROUND

Cardiovascular risk is associated with prediabetes states. Ethnic differences in risks related to prediabetes have not been well studied. The purpose of this study was to examine the relationship between prediabetes and the presence of target-organ disease in terms of ethnic differences.

METHODS

Cross-sectional analysis of the Multi-Ethnic Study of Atherosclerosis (MESA) involved a prospective cohort of 6814 participants aged 45-84 years in the US, including Black, white and hispanic subjects from an initial examination in 2000 with no known history of heart attack, stroke or diabetes. Main outcomes were comparisons of markers for coronary artery calcification (CAC), carotid stenosis more than 25%, Ankle-Brachial Index (ABI) less than 1.0 and presence of protein in urine (>30 mg/g) between participants with normal fasting glucose (NFG) and impaired fasting glucose (IFG), and between ethnic groups with prediabetes/IFG.

RESULTS

There were 2457 white, 1548 black and 1229 Hispanic participants. After adjustments, there were no differences for each outcome between normal and prediabetes black and Hispanic subjects, whereas white participants with prediabetes had significantly higher odds of carotid stenosis (OR: 1.50), low ABI (OR: 1.77) and albuminuria (OR: 1.66) compared with whites with NFG. When comparing those with IFG/prediabetes by ethnicity, blacks and Hispanics had less CAC and carotid stenosis. In addition, Hispanics had lower reduced ABIs (OR: 0.35, 95% CI 0.19-0.65) compared with whites with IFG.

CONCLUSION

Prediabetes is related to the presence of several indicators of end-organ damage in white subjects, but not in blacks or Hispanics. Further longitudinal investigations into disease risks related to prediabetes in different ethnic groups are also needed.

Leukocyte telomere length and marital status among middle-aged adults

BACKGROUND

being unmarried is associated with worse health and increased mortality risk. Telomere length has emerged as a marker for biological ageing but it is unclear how telomere length relates to marital status.

OBJECTIVE

to examine the relationship between telomere length and marital status in a sample of middle-aged adults.

DESIGN AND SUBJECTS

cross-sectional analysis among 321 adults aged 40-64 years.

METHODS

telomere length was measured by PCR (T/S ratio). Participants provided information on healthy lifestyle activities including smoking, alcohol use, diet, exercise, obesity as well as social support.

RESULTS

participants married or living with a partner had a mean T/S ratio of 1.70 and those widowed, divorced, separated or never married had a mean T/S ratio of 1.58 in a model adjusted for age, gender and race/ethnicity (P < 0.001). When the analysis was further adjusted for diet, alcohol consumption, exercise, smoking, social support, poverty and obesity, persons married or living with a partner had a higher mean T/S ratio of 1.69 than their unmarried counterparts (1.59) (P = 0.004).

CONCLUSIONS

these results indicate that unmarried individuals have shorter telomeres. This relationship between marital status and telomere length is independent of presumed benefits of marriage such as social support and a healthier lifestyle.

Life stress and atherosclerosis: a pathway through unhealthy lifestyle

OBJECTIVE

To examine the relationship between a general measure of chronic life stress and atherosclerosis among middle aged adults without clinical cardiovascular disease via pathways through unhealthy lifestyle characteristics.

METHODS

We conducted an analysis of The Multi-Ethnic Study of Atherosclerosis (MESA). The MESA collected in 2000 includes 5,773 participants, aged 45-84. We computed standard regression techniques to examine the relationship between life stress and atherosclerosis as well as path analysis with hypothesized paths from stress to atherosclerosis through unhealthy lifestyle. Our outcome was sub-clinical atherosclerosis measured as presence of coronary artery calcification (CAC).

RESULTS

A logistic regression adjusted for potential confounding variables along with the unhealthy lifestyle characteristics of smoking, excessive alcohol use, high caloric intake, sedentary lifestyle, and obesity yielded no significant relationship between chronic life stress (OR 0.93, 95% CI 0.80-1.08) and CAC. However, significant indirect pathways between chronic life stress and CAC through smoking (p = .007), and sedentary lifestyle (p = .03) and caloric intake (.002) through obesity were found.

CONCLUSIONS

These results suggest that life stress is related to atherosclerosis once paths of unhealthy coping behaviors are considered.