Anthony M. Roman

The MOBILIZE Boston Study: Design and methods of a prospective cohort study of novel risk factors for falls in an older population

BackgroundFalls are the sixth leading cause of death in elderly people in the U.S. Despite progress in understanding risk factors for falls, many suspected risk factors have not been adequately studied. Putative risk factors for falls such as pain, reductions in cerebral blood flow, somatosensory deficits, and foot disorders are poorly understood, in part because they pose measurement challenges, particularly for large observational studies.MethodsThe MOBILIZE Boston Study (MBS), an NIA-funded Program Project, is a prospective cohort study of a unique set of risk factors for falls in seniors in the Boston area. Using a door-to-door population-based recruitment, we have enrolled 765 persons aged 70 and older. The baseline assessment was conducted in 2 segments: a 3-hour home interview followed within 4 weeks by a 3-hour clinic examination. Measures included pain, cerebral hemodynamics, and foot disorders as well as established fall risk factors. For the falls follow-up, participants return fall calendar postcards to the research center at the end of each month. Reports of falls are followed-up with a telephone interview to assess circumstances and consequences of each fall. A second assessment is performed 18 months following baseline.ResultsOf the 2382 who met all eligibility criteria at the door, 1616 (67.8%) agreed to participate and were referred to the research center for further screening. The primary reason for ineligibility was inability to communicate in English. Results from the first 600 participants showed that participants are largely representative of seniors in the Boston area in terms of age, sex, race and Hispanic ethnicity. The average age of study participants was 77.9 years (s.d. 5.5) and nearly two-thirds were women. The study cohort was 78% white and 17% black. Many participants (39%) reported having fallen at least once in the year before baseline.ConclusionOur results demonstrate the feasibility of conducting comprehensive assessments, including rigorous physiologic measurements, in a diverse population of older adults to study non-traditional risk factors for falls and disability. The MBS will provide an important new data resource for examining novel risk factors for falls and mobility problems in the older population.

Issues in Conducting Epidemiologic Research Among Elders: Lessons From The MOBILIZE Boston Study

Conducting research in elderly populations is important, but challenging. In this paper, the authors describe specific challenges that have arisen and solutions that have been used in carrying out The MOBILIZE Boston Study, a community-based, prospective cohort study in Massachusetts focusing on falls among 765 participants aged 70 years or older enrolled during 2005-2007. To recruit older individuals, face-to-face interactions are more effective than less personal approaches. Use of a board of community leaders facilitated community acceptance of the research. Establishing eligibility for potential participants required several interactions, so resources must be anticipated in advance. Assuring a safe and warm environment for elderly participants and offering a positive experience are a vital priority. Adequate funding, planning, and monitoring are required to provide transportation and a fully accessible environment in which to conduct study procedures as well as to select personnel highly skilled in interacting with elders. It is hoped that this paper will encourage and inform future epidemiologic research in this important segment of the population.

T-ACASI reduces bias in STD measurements: The National STD and Behavior Measurement Experiment:

Background: Although telephone surveys provide an economical method for assessing patterns of diagnosed sexually transmitted diseases (STDs) and STD-related behaviors in populations, the requirement that respondents report such information to human telephone interviewers introduces an opportunity for substantial reporting bias. Telephone computer-assisted self-interviewing (T-ACASI) surveys substitute a computer for human interviewers when asking sensitive questions. Methods: A randomized experiment was embedded in a telephone survey that drew probability samples of the populations of the United States (N = 1543) and Baltimore city (N = 744). Respondents were randomly assigned to have sensitive questions asked either by a T-ACASI computer or by a human telephone interviewer. Results: Respondents interviewed by a T-ACASI computer were more likely to report STD symptoms [dysuria, genital sores, genital discharge, and genital warts; adjusted odds ratios (ORs) = 1.5–2.8] and a diagnosis of gonococcal or chlamydial infection during the past year (adjusted ORs = 3.6 and 6.1). T-ACASI respondents with a main sex partner in the past year were more likely to report that their partner has had an STD (adjusted OR = 2.4). For some measurements, the impact of T-ACASI was strongest among younger and less-educated respondents. When sampling weights were applied to project National STD and Behavior Measurement Experiment results to the populations of the United States and Baltimore, we found that reliance on data obtained by human interviewers would underestimate the annual incidence of chlamydial and gonococcal infections in these populations by factors of 2.4 to 9.7. Conclusions: Compared with human telephone interviewers, T-ACASI surveys obtain increased reporting of STD symptoms, infections, and STD-related behaviors.

Snus use and rejection in the USA

Objective To determine whether snus might become a strategy for reducing the harm associated with cigarette smoking in the USA as appears to be the case in Sweden, we examined receptivity to snus use in two cities with the greatest exposure to the major brands. Methods A dual frame, telephone survey and a brief mail survey were conducted in 2011 and 2012 in Indianapolis, Indiana and Dallas/Fort Worth Texas. Over 5000 adults completed surveys. Trial, ever use, current use and reasons for using or quitting snus after trial were measured. Results Among male smokers, 29.9% had ever tried snus (CI 22.7 to 38.1) and 4.2% were current users (CI 1.6 to 10.7). Among female smokers, 8.5% ever tried snus (CI 4.4 to 15.7) and current use was unknown. Current use was virtually absent among former smokers and never smokers. A major predictor of any level of snus use was current use of conventional smokeless tobacco. Those who tried and gave up snus cited curiosity (41.3%) and the fact that it was available at low or no cost (30%) as reasons for trial; reasons for not continuing included preferring another form of tobacco (75.1%) and disliking the mouth feel (34.6%). Almost all current snus users indicated that they were trying to cut down on cigarettes, but few (3.9%) were using it to quit smoking entirely. Conclusions The low rate of adoption of snus suggests that neither the hopes nor the fears surrounding this new product are likely to be realised in the USA with the current marketing patterns.

Chlamydia trachomatis infection among 15- to 35-year-olds in Baltimore, MD.

Background: Chlamydia trachomatis (Ct) is the most frequently reported infectious disease in the United States. This article reports population and subpopulation prevalence estimates of Ct and correlates of infection among 15- to 35-year-olds in Baltimore, MD. Methods: The Monitoring STIs Survey Program (MSSP) monitored sexually transmitted infection (STI) prevalence among probability samples of residents of Baltimore, a city with high STI rates. MSSP respondents completed telephone audio computer-assisted self-interviews and provided biospecimens for STI testing. Results: Among 2120 Baltimore residents aged 15 to 35 years, the estimated prevalence of chlamydia was 3.9% (95% confidence interval [CI]: 2.8, 5.0). Prevalence was 5.8% (95% CI: 4.1, 7.6) among black MSSP respondents versus 0.7% (95% CI: 0.0, 1.4) among nonblack respondents; all but 4 infections detected were among black respondents. Sexual behaviors and other factors associated with infection were far more prevalent among black than nonblack Baltimore residents. Racial disparities persisted after adjustment for sociodemographic, behavioral, and health factors. Conclusion: The MSSP highlights a higher Ct prevalence among young people in Baltimore than in the United States overall, with notable racial disparities in infection and associated risk behaviors. Public health efforts are needed to improve the diagnosis and treatment of asymptomatic infections in this population.

Epidemiology of Undiagnosed Trichomoniasis in a Probability Sample of Urban Young Adults

T. vaginalis infection (trichomoniasis) is the most common curable sexually transmitted infection (STI) in the U.S. It is associated with increased HIV risk and adverse pregnancy outcomes. Trichomoniasis surveillance data do not exist for either national or local populations. The Monitoring STIs Survey Program (MSSP) collected survey data and specimens which were tested using nucleic acid amplification tests to monitor trichomoniasis and other STIs in 2006–09 among a probability sample of young adults (N = 2,936) in Baltimore, Maryland — an urban area with high rates of reported STIs. The estimated prevalence of trichomoniasis was 7.5% (95% CI 6.3, 9.1) in the overall population and 16.1% (95% CI 13.0, 19.8) among Black women. The overwhelming majority of infected men (98.5%) and women (73.3%) were asymptomatic. Infections were more common in both women (OR = 3.6, 95% CI 1.6, 8.2) and men (OR = 9.0, 95% CI 1.8, 44.3) with concurrent chlamydial infection. Trichomoniasis did not vary significantly by age for either men or women. Women with two or more partners in the past year and women with a history of personal or partner incarceration were more likely to have an infection. Overall, these results suggest that routine T vaginalis screening in populations at elevated risk of infection should be considered.

Surveying Multiple Health Professional Team Members within Institutional Settings: An Example from the Nursing Home Industry

Quality improvement and cost containment initiatives in health care increasingly involve interdisciplinary teams of providers. To understand organizational functioning, information is often needed from multiple members of a leadership team since no one person may have sufficient knowledge of all aspects of the organization. To minimize survey burden, it is ideal to ask unique questions of each member of the leadership team in areas of their expertise. However, this risks substantial missing data if all eligible members of the organization do not respond to the survey. Nursing home administrators (NHA) and directors of nursing (DoN) play important roles in the leadership of long-term care facilities. Surveys were administered to NHAs and DoNs from a random, nationally representative sample of U.S. nursing homes about the impact of state policies, market forces, and organizational factors that impact provider performance and residents’ outcomes. Responses were obtained from a total of 2,686 facilities (response rate [RR] = 66.6%) in which at least one individual completed the questionnaire and 1,693 facilities (RR = 42.0%) in which both providers participated. No evidence of nonresponse bias was detected. A high-quality representative sample of two providers in a long-term care facility can be obtained. It is possible to optimize data collection by obtaining unique information about the organization from each provider while minimizing the number of items asked of each individual. However, sufficient resources must be available for follow-up to nonresponders with particular attention paid to lower resourced, lower quality facilities caring for higher acuity residents in highly competitive nursing home markets.

The Patient-Doctor Relationship and Online Social Networks: Results of a National Survey

To the Editors: —We write to express our concern regarding the article entitled “The Patient Doctor Relationship and On-line Social Networks: Results of a National Survey.”1 We believe this study has serious methodological errors that render the data uninterpretable and the conclusions inappropriate. The most obvious concern is the 16% response rate. With such a poor response rate and with no knowledge of how respondents differed from non-respondents, it is impossible to have confidence in the population estimates for behaviors such as participation in online social networking (OSN). For example, suppose the 84% of the sample who did not respond to the survey are different from the 16% of the people who did respond, perhaps because use of OSNs is correlated with the decision to respond. For practicing physicians, the survey reports that about 40% use OSNs. If the rate of use among the 84% of the sample who did not respond to the survey were really 20%, then the overall population estimate for use among practicing physicians would be 23.2%. This would be about half of the reported 40% and could lead to a totally different perspective on the results. Second, the data are not weighted to adjust for differences in response rates and the different probabilities of selection within the sample. Development and application of the survey weights are essential to appropriately develop strata level and population estimates. Failing to conduct weighted analyses that adjust for both non-response and survey design effects calls into question all of the population-level estimates presented in this paper. Third, the study significantly over-represents female physicians. This over-representation is problematic since female gender is also strongly associated with choice of specialty, both personal age and professional age—factors that could be related to participation in OSN and other forms of social behaviors. Generally, fatal flaws of this nature are easily detectable upon peer-review. We are surprised that such a paper was accepted for publication in a journal of JGIM’s quality. It is our opinion that any basic survey text or any survey professional could have helped the authors to take up this interesting research question and provide data to inform it.

Exploring Determinants of Surrogate Decision-Maker Confidence An Example From the ICU

This article is an exploratory data analysis of the determinants of confidence in a surrogate decision maker who has been asked to permit an intensive care unit (ICU) patient’s participation in genetic research. We pursue the difference between surrogates’ and patients’ confidence that the surrogate can accurately represent the patient’s wishes. The article also explores whether greater confidence leads to greater agreement between patients and surrogates. Our data come from a survey conducted in three hospital ICUs. We interviewed 445 surrogates and 214 patients. The only thing that influences patients’ confidence in their surrogate’s decision is whether they had prior discussions with him or her; however, there are more influences operating on the surrogate’s self-confidence. More confident surrogates are more likely to match their patients’ wishes. Patients are more likely to agree to research participation than their surrogates would allow. The surrogates whose response did not match as closely were less trusting of the hospital staff, were less likely to allow patient participation if there were no direct benefits to the patient, had given less thought about the way genetic research is conducted, and were much less likely to have a person in their life who they would trust to make decisions for them if they were incapacitated.