Brandon Koretz

History of socioeconomic disadvantage and allostatic load in later life.

There is a growing interest in understanding how the experience of socioeconomic status (SES) adversity across the life course may accumulate to negatively affect the functioning of biological regulatory systems important to functioning and health in later adulthood. The goal of the present analyses was to examine whether greater life course SES adversity experience would be associated with higher scores on a multi-system allostatic load (AL) index of physiological function in adulthood. Data for these analyses are from 1008 participants (92.2% White) from the Biomarker Substudy of the Study of Midlife in the US (MIDUS). Multiple indicators of SES adversity in childhood (parent educational attainment, welfare status, financial situation) and two points in adulthood (educational attainment, household income, difficulty paying bills, availability of money to meet basic needs, current financial situation) were used to construct SES adversity measures for each life course phase. An AL score was constructed using information on 24 biomarkers from 7 different physiological systems (sympathetic and parasympathetic nervous systems, hypothalamic-pituitary-adrenal axis, cardiovascular, lipid metabolism, glucose metabolism, inflammatory immune activity). Analyses indicate higher AL as a function of greater SES adversity at each phase of, and cumulatively across, the life course. Associations were only moderately attenuated when accounting for a wide array of health status, behavioral and psychosocial factors. Findings suggest that SES adversity experience may cumulate across the life course to have a negative impact on multiple biological systems in adulthood. An important aim of future research is the replication of current findings in this predominantly White sample in more ethnically diverse populations.

Early life adversity and adult biological risk profiles.

Objectives To determine whether there is a relationship between early life adversity (ELA) and biological parameters known to predict health risks and to examine the extent to which circumstances in midlife mediate this relationship. Methods We analyzed data on 1180 respondents from the biomarker subsample of the second wave of the National Survey of Midlife Development in the United States. ELA assessments were based on childhood socioeconomic disadvantage (i.e., on welfare, perceived low income, and less educated parents) and other stressors (e.g., parental death, parental divorce, and parental physical abuse). The outcome variable was cumulative allostatic load (AL), a marker of biological risk. We also incorporate information on adult circumstances, including than following: education, social relationships, and health behaviors. Results Childhood socioeconomic adversity and physical abuse were associated with increased AL (B = 0.094, standard error = 0.041, and B = 0.263, standard error = 0.091 respectively), with nonsignificant associations for parental divorce and death with AL. Adult education mediated the relationship between socioeconomic ELA and cumulative AL to the point of nonsignificance, with this factor alone explaining nearly 40% of the relationship. The association between childhood physical abuse and AL remained even after adjusting for adult educational attainments, social relationships, and health behaviors. These associations were most pronounced for secondary stress systems, including inflammation, cardiovascular function, and lipid metabolism. Conclusions The physiological consequences of early life socioeconomic adversity are attenuated by achieving high levels of schooling later on. The adverse consequences of childhood physical abuse, on the other hand, persist in multivariable-adjusted analysis.

Social Relationships and Allostatic Load in the MIDUS Study

OBJECTIVE This study examines how the social environment is related to allostatic load (AL), a multisystem index of biological risk. METHOD A national sample of adults (N = 949) aged 34-84 rated their relationships with spouse, family, and friends at 2 time points 10 years apart. At the second time point, participants completed a biological protocol in which indices of autonomic, hypothalamic-pituitary-adrenal axis, cardiovascular, inflammatory, and metabolic function were obtained and used to create an AL summary score. Generalized estimating equations were used to examine the associations among 3 aspects of social relationships-social support, social negativity, and frequency of social contact-and AL. RESULTS Higher levels of spouse negativity, family negativity, friend contact, and network level contact were each associated with higher AL, and higher levels of spouse support were associated with lower AL, independent of age, sociodemographic factors, and health covariates. Tests for age interactions suggested that friend support and network support were each associated with higher AL among older adults, but at younger ages there appeared to be no association between friend support and AL and a negative association between network support and AL. For network negativity, there was a marginal interaction such that network negativity was associated with higher AL among younger adults but there was no association among older adults. CONCLUSIONS These findings demonstrate that structural and functional aspects of the social environment are associated with AL, and extend previous work by demonstrating that these associations vary based on the type of relationship assessed and by age.

Biological correlates of adult cognition: midlife in the United States (MIDUS).

Multiple biological processes are related to cognitive impairment in older adults, but their combined impact on cognition in midlife is not known. Using an array of measurements across key regulatory physiological systems and a state-of-the-art cognition battery that is sensitive to early changes, in a large, national sample of middle-aged and older adults, we examined the associations of individual biological systems and a combined, multi-system index, allostatic load, with cognitive performance. Allostatic load was strongly inversely associated with performance in both episodic memory and executive function. Of 7 biological systems, only the cardiovascular system was associated inversely with both; inflammation was associated inversely with episodic memory only, and glucose metabolism with executive function only. The associations of allostatic load with cognition were not different by age, suggesting that the implications of high allostatic load on cognitive functioning are not restricted to older adults. Findings suggest that a multi-system score, like allostatic load, may assist in the early identification of adults at increased risk for cognitive impairment.

Social status and biological dysregulation: The “status syndrome” and allostatic load

Data from a national sample of 1255 adults who were part of the MIDUS (Mid-life in the U.S.) follow-up study and agreed to participate in a clinic-based in-depth assessment of their health status were used to test the hypothesis that, quite part from income or educational status, perceptions of lower achieved rank relative to others and of relative inequality in key life domains would be associated with greater evidence of biological health risks (i.e., higher allostatic load). Results indicate that over a variety of status indices (including, for example, the persons sense of control, placement in the community rank hierarchy, perception of inequality in the workplace) a syndrome of perceived relative deprivation is associated with higher levels of biological dysregulation. The evidence is interpreted in light of the well-established associations between lower socio-economic status and various clinically identified health morbidities. The present evidence serves, in effect, both as a part of the explanation of how socio-economic disparities produce downstream morbidity, and as an early warning system regarding the ultimate health effects of currently increasing status inequalities.

The Effect of a Physician Partner Program on Physician Efficiency and Patient Satisfaction

Despite the advantages of electronic health records, concerns have been raised about the amount of computer time spent documenting care1 and its adverse effects on the physician-patient relationship. Using scribes to reduce physician documentation time has resulted in improved satisfaction among urologists2 and increased productivity among Emergency Department physicians3 and cardiologists4. Although scribes have been used in primary care,5 their effects have received little formal evaluation. We created a new position, a Physician Partner (P2), to facilitate patient care during the office visit and tested this in two practices at an academic medical center to determine its effect upon physician efficiency and patient satisfaction.

Frontline Account: Physician Partners: An Antidote to the Electronic Health Record

The modern medical record was originally developed in the 1920s as a way for physicians to briefly document patients’ medical conditions and plans for treating them. It was a means of jogging the memory so that solo practitioners could care for thousands of patients and quickly get up to speed on the major issues affecting each. Records were handwritten, lacked a consistent method of organization, and were often illegible to others. As medicine became more complicated and physician groups were formed, it became increasingly important for others to be able to view records, and the structure of the medical note became more standardized. Over time, the medical record began to be used for other purposes, such as for insurers who required documentation to justify reimbursement rates. With the advent of the electronic health record (EHR), the reasons for use have expanded dramatically, including documenting and improving quality of care, scheduling, billing, research, rapid communication within the health system and between patients and physicians, and tracking when and how long physicians are working. In short, the EHR has taken control of physicians’ professional lives. In response, many physicians have become stressed and feel overburdened in practice. To cope with the additional work of documentation, physicians have changed how they interact with the patient, sitting at the keyboard, frequently with eyes on the screen rather than on the patient. They talk less and multitask more, searching for needed information in real time, further eroding the doctor–patient relationship. Some physicians have retired early rather than practice in the new EHR world. Others have off-loaded documentation and other administrative tasks to less highly trained personnel, such as scribes. In 2012, we first heard of these approaches and thought that they might be able to help relieve physician stress locally resulting from a push to see more patients and impending deployment of a new EHR. Accordingly, we built upon existing scribe programs to create the UCLA Physicians Partner program, with the intent of making the physician’s work easier, improving the quality of time spent with patients, and increasing efficiency.