Barcey T. Levy

An Assessment of Attitudes, Behaviors, and Outcomes of Patients with Type 2 Diabetes

Objectives: Patient self-care behaviors, including taking medication, following a meal plan, exercising regularly, and testing blood glucose, influence diabetes control. The purpose of this research was to identify (1) which barriers to diabetes management are associated with problem behaviors and (2) which patient behaviors and barriers are associated with diabetes control. Methods: This was a cross-sectional study of linked medical record and self-reported information from patients with type 2 diabetes. A randomly selected sample of 800 clinic patients was mailed an investigator-developed survey. The study sample consisted of 253 (55%) individuals who had measured glycosylated hemoglobin (HbA1c) within 3 months of the survey date. Results: The barriers to each diabetes self-care behavior differed. Cost was the most common barrier to the 4 self-care behaviors. In a multivariable regression model, the belief that type 2 diabetes is a serious problem and depression were strongly associated with higher HbA1c levels. Lower HbA1c levels were significantly associated with being married and greater self-reported adherence-satisfaction with taking medication and testing blood glucose. Conclusion: This study expanded earlier research by focusing on 4 specific self-care behaviors, their barriers, and their association with HbA1c. Barriers that were significantly associated with HbA1c were specific to the behavior and varied across behaviors.

Effect of a patient's psychiatric history on physicians' estimation of probability of disease

A questionnaire was mailed to 300 Iowa family physicians to determine the influence of a prior psychiatric history on decision making. The response rate was 77%. Respondents were less likely to believe that a patient had serious illness when presenting with a severe headache or abdominal pain if the patient had a prior history of depression (P<.05) or prior history of somatic complaints (P<.05), compared with a patient with no past history. Respondents were less likely to report that they would order testing for a patient with headache or abdominal pain if the patient had a history of depression (P<.05, P=.08, respectively) or somatic complaints (P<.01). Differences in likelihood of ordering tests were not significant after adjusting for differences in estimated probability of disease. We conclude that physicians respond differently to patients with psychiatric illness because of their estimation of pretest probability of disease rather than bias. We conclude that past psychiatric history influences physicians’ estimation of disease presence and willingness to order tests.

Magnitude and variability of sequential estradiol and progesterone concentrations in women using depot medroxyprogesterone acetate for contraception

OBJECTIVE To describe the magnitude and variability of sequential serum estradiol and progesterone concentrations throughout one depot medroxyprogesterone (DMPA) injection interval. DESIGN Prospective study. SETTING Family planning and womens health clinics. PATIENT(S) Thirty-one women, ages 19 to 46, using DMPA for contraception. INTERVENTION(S) Serum for estrogen and progesterone was collected weekly throughout one DMPA injection interval. MAIN OUTCOME MEASURE(S) Serum estradiol and progesterone concentrations; estradiol patterns produced from data plotted across the entire DMPA injection interval. RESULT(S) The average daily estradiol concentrations ranged from 7.9 to 69.1 pg/mL, with a mean of 18.9 +/- 12.9 and a median of 15.4 pg/mL. Average daily progesterone concentrations ranged from 0.14 to 1.1 ng/mL, with a mean of 0.40 +/- 0.19 ng/mL and a median of 0.36 ng/mL. Two general patterns of estradiol concentrations were identified. One pattern, observed in approximately one third of the participants, reflected estradiol concentrations that were extremely low (mean, 12.7 +/- 3.6 pg/mL; median, 13.4 pg/mL) and consistently flat across the DMPA injection interval. The second pattern, seen in the remaining participants, reflected estradiol concentrations that were higher (mean, 22.2 +/- 14.9 pg/mL; median, 17.3 pg/mL) and quite variable. CONCLUSION(S) This study demonstrated that estradiol concentrations were lower than the 40 to 50 pg/mL reported in most studies and, for the majority of women, varied substantially across the DMPA injection interval.

Why Hasn't This Patient Been Screened for Colon Cancer? An Iowa Research Network Study

Background: Less than half of eligible Americans have been screened for colorectal cancer (CRC). The objective of this study was to describe physicians’ reasons for screening or not screening specific patients for CRC and their approach to CRC testing discussions. Methods: This study used mixed-methods. Physicians described their reasons for screening or not screening 6 randomly chosen patients who were eligible for CRC screening (3 screened and 3 not screened) whose CRC testing status was ascertained by medical record review. Verbatim transcripts from physicians responding to structured interview questions were used to identify themes. Specific elements of discussion were examined for their association with each physicians screening rate. Fifteen randomly chosen Iowa family physicians from the Iowa Research Network stratified by privileges to perform colonoscopy, flexible sigmoidoscopy, or neither procedure dictated the reasons why 43 patients were screened and 40 patients were not screened. Results: Reasons patients were not up to date fell into 2 major categories: (1) no discussion by physician (50%) and (2) patient refusal (43%). Reasons for no discussion included lack of opportunity, assessment that cost would be prohibitive, distraction by other life issues/health problems, physician forgetfulness, and expected patient refusal. Patients declined because of cost, lack of interest, autonomy, other life issues, fear of screening, and lack of symptoms. Patients who were up to date received (1) diagnostic testing (for previous colon pathology or symptoms; 56%) or (2) asymptomatic screening (44%). Physicians who were more adamant about screening had higher screening rates (P < .05; Wilcoxon rank sum). Physicians framed their recommendations differently (“I recommend” vs “They recommend”), with lower screening rates among physicians who used “they recommend” (P = .05; Wilcoxon rank sum). Conclusions: Reasons many patients remain unscreened for CRC include (1) factors related to the health care system, patient, and physician that impede or prevent discussion; (2) patient refusal; and (3) the focus on diagnostic testing. Strategies to improve screening might include patient and physician education about the rationale for screening, universal coverage for health maintenance exams, and development of effective tracking and reminder systems. The words physicians choose to frame their recommendations are important and should be explored further.

Mailed Fecal Immunochemical Tests Plus Educational Materials to Improve Colon Cancer Screening Rates in Iowa Research Network (IRENE) Practices

Introduction: Only about half of all eligible Americans have been screened for colorectal cancer (CRC). The objective of this study was to test whether mailed educational materials and a fecal immunochemical test (FIT), with or without a scripted telephone reminder, led to FIT testing. In addition, we compared changes in attitudes toward, readiness for, and barriers to screening from baseline to follow-up after education about screening. Methods: Subjects due for CRC screening were recruited from 16 Iowa Research Network family physician offices. Half of the subjects were randomized to receive mailed written and DVD educational materials, along with a FIT, either with or without a telephone call designed to encourage screening and address barriers. Subjects completed surveys regarding their attitudes and readiness for CRC screening at baseline and after education about screening. The main outcome was whether the subject completed FIT testing. Results: A total of 373 individuals received educational materials (including a FIT) and 231 (62%) returned a posteducation survey. The mean age was 61.2 years; 52% were women, 99% were white, 39% had a high school education or less, 39% had a total family income of less than

Predictors of neonatal resuscitation, low Apgar scores, and umbilical artery pH among growth-restricted neonates.

40,000, and 7% had no insurance. The written materials were read by 82%, understood by 91% (of those who read them), and 82% felt their knowledge was increased. The DVD was viewed by 67%, understood by 94% of those who viewed it, and 86% felt the DVD increased their knowledge. Compared with baseline, individuals reported being significantly more likely to bring up CRC screening at their next doctors visit (P < .0001) and being more likely to be tested for CRC in the next 6 months (P < .0001). Comparing baseline with follow-up, summary attitude scores improved (P < .0001), readiness scores improved (P < .0001), and there were fewer barriers (P = .034, Wilcoxon signed rank). The FIT return rate increased from 0% to 45.2% in the education alone group and from 0% to 48.7% for the group receiving education plus the telephone call (P < .0001 for each group individually and overall when compared with Medicare beneficiaries in Iowa). Conclusions: Mailing FIT kits with easy-to-understand educational materials improved attitudes toward screening and dramatically increased CRC screening rates among patients who were due for screening in a practice-based research network. A telephone call addressing barriers to screening did not result in increased FIT testing compared with mailed education alone.

Personal health records: a randomized trial of effects on elder medication safety

Objective To identify risk factors associated with poorer immediate neonatal outcomes among growth-restricted neonates. Methods Records of all 530 growth-restricted neonates born between January 1989 and February 1995 were reviewed. Outcomes included resuscitation measures, Apgar scores, and umbilical blood gas values. Neonates were assigned to one of six anesthetic groups, and outcomes were compared. Predictors of poorer outcomes were examined using logistic and linear regression. Results Neonates exposed to general anesthesia were more likely to be intubated (37.9% versus 4.1%, P < .001, Pearson χ2) and had lower mean 1- (4.0 versus 7.0) and 5-minute (6.5 versus 8.4) Apgar scores (P < .01, Scheffé) than those in all other anesthetic groups. They also had significantly lower umbilical artery (UA) pH values than neonates who received nalbuphine, epidural, or no anesthesia (7.21 versus 7.28, 7.26, 7.29, respectively; P < .01, Scheffé). Factors that significantly and independently predicted intubation among all neonates included exposure to general anesthesia (odds ratio [OR] 4.1; 95% confidence interval [CI] 1.9, 8.9) and lower infant weight (OR 10.1 per kg decrease; CI 5.1, 20). Factors predicting UA pH at most 7.15 included preeclampsia (OR 3.0; CI 1.5, 5.9) and older maternal age (OR 1.3 per 5 years; CI 1.02, 1.64); vertex delivery (OR 0.5; CI 0.2, 0.9) was protective. Factors predicting a 5-minute Apgar less than 7 were meconium (OR 1.5 per category going from none to terminal to light to heavy; CI 1.04, 2.3), general anesthesia (OR 6.9; CI 2.6, 18.2), lower infant weight (OR 16.5 per kg decrease; CI 7.8, 34.5), and vaginal breech delivery (OR 7.0; CI 1.8, 28.6); cesarean delivery (OR 0.2; CI 0.08, 0.66) was protective. Spontaneous vertex delivery raised the UA pH, and preeclampsia, amnioinfusion, breech delivery, and general anesthesia significantly and independently lowered the UA pH among all neonates. For infants delivered by cesarean, “fetal distress,” preeclampsia, previous spontaneous abortion, failed forceps use, and nalbuphine significantly and independently predicted lower UA pH. Conclusion Risk factors for poorer immediate neonatal outcomes among growth-restricted neonates include preeclampsia, fetal distress, breech delivery, forceps use, nalbuphine during labor, lower infant weight, and general anesthesia.

Prevalence and persistence of human papillomavirus in postmenopausal age women

PURPOSE To examine the impact of a personal health record (PHR) on medication-use safety among older adults. BACKGROUND Online PHRs have potential as tools to manage health information. We know little about how to make PHRs accessible for older adults and what effects this will have. METHODS A PHR was designed and pretested with older adults and tested in a 6-month randomized controlled trial. After completing mailed baseline questionnaires, eligible computer users aged 65 and over were randomized 3:1 to be given access to a PHR (n=802) or serve as a standard care control group (n=273). Follow-up questionnaires measured change from baseline medication use, medication reconciliation behaviors, and medication management problems. RESULTS Older adults were interested in keeping track of their health and medication information. A majority (55.2%) logged into the PHR and used it, but only 16.1% used it frequently. At follow-up, those randomized to the PHR group were significantly less likely to use multiple non-steroidal anti-inflammatory drugs-the most common warning generated by the system (viewed by 23% of participants). Compared with low/non-users, high users reported significantly more changes in medication use and improved medication reconciliation behaviors, and recognized significantly more side effects, but there was no difference in use of inappropriate medications or adherence measures. CONCLUSIONS PHRs can engage older adults for better medication self-management; however, features that motivate continued use will be needed. Longer-term studies of continued users will be required to evaluate the impact of these changes in behavior on patient health outcomes.

A Randomized Controlled Trial to Improve Colon Cancer Screening in Rural Family Medicine: An Iowa Research Network (IRENE) Study

Little is known about the prevalence and persistence of human papillomavirus (HPV) in older women, or about the association between hormone replacement therapy (HRT) use and HPV detection. Like oral contraceptives, HRT hormones may upregulate viral expression and subsequent risk of genital cancer. Postmenopausal women seeking routine gynecologic care were evaluated for HPV infection, testing cervical/vaginal cytology by PCR/DNA sequencing. The prevalence of HPV was 14%; 6% had oncogenic types and 5.8% had persistent infection. Although risk of HPV detection was non-significantly elevated after adjustment for age and HPV-related risk factors among current (adjusted odds ratio (OR)=2.3) and past (adjusted OR=3.2) hormone users compared to never users, past users had a significantly higher risk using combination HRT regimens with increasing duration (adjusted OR=1.8 per year; 95% confidence interval (CI)=1.1-3.1). These findings suggest that a significant percentage of older women are infected with HPV. This may put them at increased risk of genital cancers with longer use of HRTs. Additional studies are needed.

Test Characteristics of Faecal Immunochemical Tests (FIT) Compared with Optical Colonoscopy

Background: Many adults have not been screened for colon cancer, a potentially preventable cause of death. Methods: This was a randomized controlled trial conducted between December 2008 and April 2011 to improve CRC screening in 16 rural family physician offices. Subjects due for CRC screening were randomized within each practice to 1 of 4 groups: (1) usual care; (2) physician chart reminder; (3) physician chart reminder, mailed education, CRC reminder magnet, and fecal immunochemical test (FIT) (mailed education/FIT); or (4) all the preceding plus a structured telephone call to the patient from project staff to provide education, assess interest in screening, explain the screening tests, and address barriers (mailed education/FIT plus phone call). The main outcome was completion of any CRC screening. Results: This study enrolled 743 patients. CRC screening was completed by 17.8% in the usual care group, 20.5% in the chart reminder group, 56.5% in the mailed education/FIT group, and 57.2% in the mailed education/FIT plus phone call group. We found no effect from the chart reminder compared with usual care (odds ratio [OR], 1.2; 95% confidence interval [CI], 0.7–2.0); and a beneficial effect from the mailed education/FIT (OR, 6.0; 95% CI, 3.7–9.6) and the mailed education/FIT plus phone call (OR, 6.2; 95% CI, 3.8–9.9). Both FIT and colonoscopy rates increased significantly in both mailed education groups. Conclusion: CRC screening rates increased significantly among patients who were overdue for screening after they received mailed educational materials and a FIT. The addition of a phone call did not further increase screening rates.