Alexander Quarshie

Presence of a Community Health Center and Uninsured Emergency Department Visit Rates in Rural Counties

CONTEXT Community health centers (CHCs) provide essential access to a primary care medical home for the uninsured, especially in rural communities with no other primary care safety net. CHCs could potentially reduce uninsured emergency department (ED) visits in rural communities. PURPOSE We compared uninsured ED visit rates between rural counties in Georgia that have a CHC clinic site and counties without a CHC presence. METHODS We analyzed data from 100% of ED visits occurring in 117 rural (non-metropolitan statistical area [MSA]) counties in Georgia from 2003 to 2005. The counties were classified as having a CHC presence if a federally funded (Section 330) CHC had a primary care delivery site in that county throughout the study period. The main outcome measure was uninsured ED visit rates among the uninsured (all-cause ED visits and visits for ambulatory care sensitive conditions). Poisson regression models were used to examine the relationship between ED rates and the presence of a CHC. To ensure that the effects were unique to the uninsured population, we ran similar analyses on insured ED visits. FINDINGS Counties without a CHC primary care clinic site had 33% higher rates of uninsured all-cause ED visits per 10,000 uninsured population compared with non-CHC counties (rate ratio [RR] 1.33, 95% confidence interval [CI] 1.11-1.59). Higher ED visit rates remained significant (RR 1.21, 95% CI 1.02-1.42) after adjustment for percentage of population below poverty level, percentage of black population, and number of hospitals. Uninsured ED visit rates were also higher for various categories of diagnoses, but remained statistically significant on multivariate analysis only for ambulatory care sensitive conditions (adjusted RR = 1.22, 95% CI 1.01-1.47). No such relationship was found for ED visit rates of insured patients (RR 1.06, 95% CI 0.92-1.22). CONCLUSIONS The absence of a CHC is associated with a substantial excess in uninsured ED visits in rural counties, an excess not seen for ED visit rates among the insured.

Scalable Collaborative Infrastructure for a Learning Healthcare System (SCILHS): architecture.

We describe the architecture of the Patient Centered Outcomes Research Institute (PCORI) funded Scalable Collaborative Infrastructure for a Learning Healthcare System (SCILHS, http://www.SCILHS.org) clinical data research network, which leverages the

The Impact of Health Literacy on Self-Monitoring of Blood Glucose in Patients With Diabetes Receiving Care in an Inner-City Hospital

48 billion dollar federal investment in health information technology (IT) to enable a queryable semantic data model across 10 health systems covering more than 8 million patients, plugging universally into the point of care, generating evidence and discovery, and thereby enabling clinician and patient participation in research during the patient encounter. Central to the success of SCILHS is development of innovative ‘apps’ to improve PCOR research methods and capacitate point of care functions such as consent, enrollment, randomization, and outreach for patient-reported outcomes. SCILHS adapts and extends an existing national research network formed on an advanced IT infrastructure built with open source, free, modular components.

Erythropoiesis and myocardial energy requirements contribute to the hypermetabolism of childhood sickle cell anemia.

BACKGROUND Self-monitoring of blood glucose (SMBG) is considered to be 1 of the cornerstones of diabetes self-management. It is unclear whether inadequate health literacy affects SMBG. OBJECTIVE The objective of this study was to examine the relationship between health literacy and SMBG. METHODS This was a cross-sectional survey of 189 patients with diabetes, aged 18 to 65 years, receiving care in a large urban, public health care setting. We measured health literacy using the shortened version of the Test of Functional Health Literacy in Adults. The diabetes care profile was used to determine the use of self-monitoring of blood glucose. RESULTS Most (60.9%) of the survey participants were assessed as functionally health literate. The majority (90.9%) of the study participants reported testing their blood sugar at least once daily. Although adequate health literacy was associated with recording of blood sugar testing (p = .049), we found no statistically significant relationship between health literacy and the frequency of SMBG. Persons self-reporting having diabetes for more than 10 years were less likely to self-monitor blood glucose (odds ratio, 0.33; 95% CI, 0.11-0.99). CONCLUSIONS SMBG frequency is not independently associated with health literacy, but SMBG result recording is noted among patients with inadequate literacy.

Obesity induced a leptin-Notch signaling axis in breast cancer

Objectives: We hypothesized that an elevated hemoglobin synthesis rate (SynHb) and myocardial oxygen consumption (MVO2) contribute to the excess protein and energy metabolism reported in children with sickle cell anemia. Patients and Methods: Twelve children (6–12 years old) with asymptomatic sickle cell and 9 healthy children matched for age and sex were studied. Measurements were whole-body protein turnover by [1-13C]leucine, SynHb by [15N]glycine, resting energy expenditure by indirect calorimetry and the systolic blood pressure–heart rate product used as an index of MVO2. Protein energy cost was calculated from protein turnover. Statistical analysis included Spearman correlations and partial correlation analyses. Results: Although body mass index was significantly lower for sickle cell versus controls (P < 0.02), children with asymptomatic sickle cell had 52% higher protein turnover (P < 0.0005). Proportional reticulocyte count, SynHb, MVO2 and resting energy expenditure were also significantly higher in children with sickle cell (P < 0.01). Protein turnover correlated significantly with both SynHb (r = 0.63, P < 0.01) and reticulocyte percentage (r = 0.83, P < 0.0001). Partial correlation of these 3 variables showed reticulocyte percentage as the only variable to be significantly associated with protein turnover, even after adjusting for sickle cell anemia (P = 0.03). Partial correlation of log resting energy expenditure on MVO2 was significant, controlling for protein energy cost, sex and age (P = 0.03). Conclusion: These results indicate that metabolic demands of increased erythropoiesis and cardiac energy consumption account for much of the excess protein and energy metabolism in children with sickle cell anemia.

Disease Management to Promote Blood Pressure Control Among African Americans

To investigate whether obesity induces a leptin‐Notch signaling axis in breast cancer (BC), leptin‐induced Notch was determined in human MCF‐7 and MDA‐MB231 and mouse E0771 cells and in E0771‐BC hosted by syngeneic lean and diet‐induced obesity (DIO) C57BL/6J female mice. Lean and DIO mice were treated for 3 weeks with leptin inhibitor (PEG‐LPrA2) 1 week after the inoculation of E0771 cells. Leptin induced Notch1, 3 and 4 in BC cells, but Notch2 expression showed opposite pattern in MCF‐7 compared to MDA‐MB231 cells. Notch loss‐of‐function (DAPT and dominant negative [R218H] RBP‐Jk [CSL/CBF1]) showed that a functional leptin‐Notch signaling axis was involved in the proliferation and migration of E0771 cells. E0771‐BC onset was affected by obesity (lean mice7/10 [70%] vs. DIO mice: 11/12 [92%]; Pearson χ2: p = 0.06]). PEG‐LPrA2 significantly reduced BC growth (untreated: 19/42; [45%] vs. treated: 8/42 [19%]; Pearson χ2: p = 0.008). PEG‐LPrA2 did not influence the caloric intake of mice but increased carcass and/or body weights of lean and DIO mice inoculated with E0771 cells, which could be related to the improvement of health conditions (less aggressive disease). Importantly, BC from obese mice had higher levels of Notch3, JAG1 and survivin than lean mice. Inhibition of leptin signaling reduced protein levels of Notch (NICD1, NICD4, Notch3, JAG1 and survivin) and significantly decreased mRNA expression of Notch receptors, ligands and targets. PEG‐LPrAs effects were more prominent in DIO mice. Present data suggest that leptin induces Notch, which could be involved in the reported higher incidence and aggressiveness and, poor prognosis of BC in obese patients.

Plasma interleukin-1β concentration is associated with stroke in sickle cell disease

African Americans have a higher prevalence of hypertension and poorer cardiovascular and renal outcomes than white Americans. The objective of this study was to determine whether a telephonic nurse disease management (DM) program designed for African Americans is more effective than a home monitoring program alone to increase blood pressure (BP) control among African Americans enrolled in a national health plan. A prospective randomized controlled study (March 2006-December 2007) was conducted, with 12 months of follow-up on each subject. A total of 5932 health plan members were randomly selected from the population of self-identified African Americans, age 23 and older, in health maintenance organization plans, with hypertension; 954 accepted, 638 completed initial assessment, and 485 completed follow-up assessment. The intervention consisted of telephonic nurse DM (intervention group) including educational materials, lifestyle and diet counseling, and home BP monitor vs. home BP monitor alone (control group). Measurements included proportion with BP < 120/80, mean systolic BP, mean diastolic BP, and frequency of BP self-monitoring. Results revealed that systolic BP was lower in the intervention group (adjusted means 123.6 vs. 126.7 mm Hg, P = 0.03); there was no difference for diastolic BP. The intervention group was 50% more likely to have BP in control (odds ratio [OR] = 1.50, 95% confidence interval [CI] 0.997-2.27, P = 0.052) and 46% more likely to monitor BP at least weekly (OR 1.46, 95% CI 1.07-2.00, P = 0.02) than the control group. A nurse DM program tailored for African Americans was effective at decreasing systolic BP and increasing the frequency of self-monitoring of BP to a greater extent than home monitoring alone. Recruitment and program completion rates could be improved for maximal impact.

Translation Squared: Improving Asthma Care for High-Disparity Populations Through a Safety Net Practice-Based Research Network

The pathogenesis of sickle cell disease (HbSS), which has numerous complications including stroke, involves inflammation resulting in alteration of plasma inflammatory protein concentration. We investigated HbSS children with abnormal cerebral blood flow detected by trans-cranial Doppler ultrasound (TCD) who participated in the multi-center stroke prevention (STOP) study, to determine if plasma inflammatory protein concentration is associated with the outcome of stroke. Thirty-nine plasma samples from HbSS participants with elevated TCD who had no stroke, HbSS-NS (n=13) or had stroke, HbSS-S (n=13), HbSS steady-state controls (n=7) and controls with normal hemoglobin, HbAA (n=6), were analyzed simultaneously for 27 circulating inflammatory proteins. Logistic regression and receiver operating characteristics curve analysis of stroke on plasma inflammatory mediator concentration, adjusted for age and gender, demonstrated that interleukin-1beta (IL-1beta) was protective against stroke development (HbSS-NS=19, 17-23, HbSS-S=17, 16-19 pg/mL, median and 25th-75th percentile; odds ratio=0.59, C.I.=0.36-0.96) and was a good predictor of stroke (area under curve=0.852). This result demonstrates a strong association of systemic inflammation with stroke development in HbSS via moderately increased plasma IL-1beta concentration, which is furthermore associated with a decreased likelihood of stroke in HbSS.

A comprehensive examination of the health knowledge, attitudes and behaviors of students attending historically black colleges and universities.

To assess the effectiveness of an intervention designed to increase compliance with national asthma care guidelines in primary care safety net health centers serving high-disparity patient populations, we conducted a group-randomized controlled trial (seven intervention sites and nine control sites) in federally funded community health centers in eight southeastern states. There were three components involved in the intervention: resources (asthma kits including peak flow meter, MDI spacer device, plus educational materials), training of all health center staff in asthma care guidelines, and tools or templates for practice-level systems change (asthma flow sheets and standing orders). Control group sites received only copies of the national asthma guidelines. Chart reviews were performed to determine practitioners compliance with national guidelines for asthma care. Clinicians practicing in intervention health centers showed significantly (p < 0.01) greater improvement on some measures than did the control health centers, although postintervention compliance with guidelines was still suboptimal. Disseminating national guidelines is not enough. Providing training and guideline-specific resources, in combination with tools for practice change, improved care significantly even in safety net health centers serving high-disparity patient populations.

Dialysis “No-Shows” on Saturdays: Implications of the Weekly Hemodialysis Schedules on Nonadherence and Outcomes

There is limited information about African American students attending Historically Black Colleges and Universities (HBCUs) in the areas of health behavior, health knowledge, and attitudes. To fill this gap, a comprehensive examination of first-year students was undertaken at a consortium of HBCUs. A non-random sample of 1,115 freshmen were administered a survey that assessed several domains including: (1) demographics, (2) general health, (3) smoking habits, (4) disease risk, (5) weight perception, (6) physical activity, (7) perceived stress, (8) eating habits, (9) social support, (10) personal/family medical history, (11) leadership, (12) domestic violence, (13) substance use, and (14) sexual behavior. In general, most students knew about health behaviors and disease risk. Areas that warrant further exploration include physical activity, sexual behavior, and drug use. The analyses provide key information for health education and prevention.