Deepa Bhat

Effectiveness of a Barber-Based Intervention for Improving Hypertension Control in Black Men: The BARBER-1 Study: A Cluster Randomized Trial

BACKGROUND Barbershop-based hypertension (HTN) outreach programs for black men are becoming increasingly common, but whether they are an effective approach for improving HTN control remains uncertain. METHODS To evaluate whether a continuous high blood pressure (BP) monitoring and referral program conducted by barbers motivates male patrons with elevated BP to pursue physician follow-up, leading to improved HTN control, a cluster randomized trial (BARBER-1) of HTN control was conducted among black male patrons of 17 black-owned barbershops in Dallas County, Texas (March 2006-December 2008). Participants underwent 10-week baseline BP screening, and then study sites were randomized to a comparison group that received standard BP pamphlets (8 shops, 77 hypertensive patrons per shop) or an intervention group in which barbers continually offered BP checks with haircuts and promoted physician follow-up with sex-specific peer-based health messaging (9 shops, 75 hypertensive patrons per shop). After 10 months, follow-up data were obtained. The primary outcome measure was change in HTN control rate for each barbershop. RESULTS The HTN control rate increased more in intervention barbershops than in comparison barbershops (absolute group difference, 8.8% [95% confidence interval (CI), 0.8%-16.9%]) (P = .04); the intervention effect persisted after adjustment for covariates (P = .03). A marginal intervention effect was found for systolic BP change (absolute group difference, -2.5 mm Hg [95% CI, -5.3 to 0.3 mm Hg]) (P = .08). CONCLUSIONS The effect of BP screening on HTN control among black male barbershop patrons was improved when barbers were enabled to become health educators, monitor BP, and promote physician follow-up. Further research is warranted. TRIAL REGISTRATION clinicaltrials.gov Identifier: NCT00325533.

Reduction in Hospital Admission Rates Due to Post-Prostate Biopsy Infections After Augmenting Standard Antibiotic Prophylaxis

PURPOSE We evaluated the incidence of infectious complications requiring hospitalization after transrectal ultrasound guided prostate biopsy, comparing an augmented regimen of antibiotic prophylaxis to the standard regimen, and established cost-effectiveness at our center. MATERIALS AND METHODS Our standard antibiotic prophylaxis regimen consisted of 3 days of ciprofloxacin or Bactrim™ DS in the perioperative period. An increase in hospital admissions related to infection after transrectal ultrasound guided biopsy from January 2010 through December 2010 led us to initiate an augmented regimen of 3 days of ciprofloxacin or Bactrim DS in addition to 1 dose of intramuscular gentamicin before biopsy from January 2011 to December 2011. Urine and blood cultures along with bacterial susceptibilities were obtained at admission and compared between the 2 groups. Cost analysis was done to determine the cost-effectiveness of standard and augmented regimens. RESULTS The rate of hospitalization due to post-biopsy infections was 3.8% (11 patients among 290 biopsies) in 2010, which decreased to 0.6% (2 patients among 310 biopsies) in 2011 (p <0.001). Of the admitted patients who received standard prophylaxis, 73% had fluoroquinolone resistant Escherichia coli urinary infection and/or bacteremia and only 9% had strains resistant to gentamicin. Multivariate analysis showed that the standard regimen was significantly associated with hospital admission due to post-biopsy infection (HR 2.078 ± 0.84, p = 0.013). The augmented regimen resulted in a cost savings of

Factors Associated With Hypertension Awareness, Treatment, and Control in Dallas County, Texas

15,700 per 100 patients compared to the standard regimen. CONCLUSIONS The addition of gentamicin to current prophylactic regimens significantly reduced the rate of hospitalization for post-biopsy infectious complications and was shown to be cost-effective.

A Barber-Based Intervention for Hypertension in African American Men: Design of a Group Randomized Trial

BACKGROUND Hypertension (HTN) control rates in the United States remain lower in black than white persons, particularly before 65 years of age. Potential sociocultural factors have not been sufficiently addressed. METHODS We analyzed data from structured interviews and blood pressure measurements in a population-based sample of 1514 hypertensive (1194 non-Hispanic black and 320 non-Hispanic white) subjects aged 18 to 64 years in Dallas County, Texas, from 2000 to 2002 to identify sociocultural factors associated with low rates of HTN control. We calculated adjusted odds ratios (aORs) and 95% confidence intervals (CIs) using multivariate logistic regression. RESULTS Awareness, treatment, and control of HTN were negatively associated with a common perception of good health, with aORs (95% CIs) of 0.37 (0.27-0.50) for awareness, 0.47 (0.36-0.62) for treatment, and 0.66 (0.51-0.86) for control. They were positively associated with having a regular physician, with aORs (95% CIs) of 3.81 (2.86-5.07) for awareness, 8.36 (5.95-11.74) for treatment, and 5.23 (3.30-8.29) for control. Among untreated hypertensive subjects, lack of perceived need for a regular physician was associated with perceived good health (aOR [95% CI], 2.2 [1.2-4.0]), male gender (aOR [95% CI], 2.4 [1.4-4.1]), and black race/ethnicity (aOR [95% CI], 2.1 [1.0-4.4]). The HTN outcomes were unrelated to perceived racism or lay beliefs about the causes, consequences, and treatment of HTN. CONCLUSIONS Among young to middle-aged hypertensive subjects, a perception of good health and the lack of perceived need for a regular physician remain major factors associated with untreated and uncontrolled HTN at the community level-particularly among black men. These factors merit greater emphasis in professional education and public health programs on HTN.

What is evaluation of hematuria by primary care physicians? Use of electronic medical records to assess practice patterns with intermediate follow-up

BACKGROUND Barbershops constitute potential sites for community health promotion programs targeting hypertension (HTN) in African American men but such programs previously have not been formally evaluated. METHODS A randomized trial (ClinicalTrials.gov no. NCT00325533) will test whether a continuous HTN detection and medical referral program conducted by influential peers (barbers) in a receptive community setting (barbershops) can promote treatment-seeking behavior and thus lower blood pressure (BP) among the regular customers with HTN. Barbers will offer a BP check with each haircut and encourage appropriate medical referral using real stories of other customers modeling the desired behaviors. A cohort of 16 barbershops will go through a pretest/posttest group-randomization protocol. Serial cross-sectional data collection periods (10 weeks each) will be conducted by interviewers to obtain accurate snapshots of HTN control in each barbershop before and after 10 months of either barber-based intervention or no active intervention. The primary outcome is BP control: BP <135/85 mm Hg (nondiabetic subjects) and <130/80 mm Hg (diabetic subjects) measured in the barbershop during the 2 data collection periods. The multilevel analysis plan uses hierarchical models to assess the effect of covariates on HTN control and secondary outcomes while accounting for clustering of observations within barbershops. CONCLUSIONS By linking community health promotion to the health care system, this program could serve as a new model for HTN control and cardiovascular risk reduction in African American men on a nationwide scale.

Testing and referral patterns in the years surrounding the US Preventive Services Task Force recommendation against prostate-specific antigen screening.

BACKGROUND To determine whether patients found to have hematuria by their primary care physicians are evaluated according to best practice policy. MATERIALS AND METHODS The University of Texas Southwestern Medical Center maintains institutional outpatient electronic medical records (EMR) that are used by all providers in all specialties. We conducted an Institutional Review Board approved observational study of patients found to have more than 5 red blood cells/high power field between March 2009 and February 2010. RESULTS There were 449 patients of whom the majority were female (82%), Caucasian (39%), with microscopic hematuria (MH) (85%). Almost 58% of patients were initially symptomatic with urinary symptoms or pain. Evaluation for the source of hematuria was limited and included imaging (35.6%), cystoscopy (9%, and cytology (7.3%). Only 36% of men and 8% of women were referred to a urologist. No abnormality was found in 32% and 51% of patients with gross hematuria and MH, respectively (P = 0.004). There were 4 bladder tumors and 1 renal mass detected. Male gender, ethnicity and gross (vs. microscopic) hematuria were associated with higher rate of urological referral. Advanced age, smoking, provider practice type, and the presence of urinary symptoms were not associated with an increase rate of urological referral. No additional cancers were diagnosed with 29-month follow-up. CONCLUSIONS While urinalysis remains a common diagnostic tool, most cases of both microscopic and gross hematuria are not fully evaluated according to guidelines. Use of cystoscopy, cytology, and upper tract imaging is limited. Further studies will be needed to determine the extent of the problem and impact on morbidity and survival.

Use of electronic medical records to identify patients at risk for prostate cancer in an academic institution

Since the US Preventive Services Task Force (USPSTF) recommended against prostate‐specific antigen (PSA) screening, there have been conflicting reports regarding the impact on the behavior of providers. This study analyzed real‐world data on PSA ordering and referral practices in the years surrounding the recommendation.

Improving Performance on Preventive Health Quality Measures Using Clinical Decision Support to Capture Care Done Elsewhere and Patient Exceptions

One purported advantage of electronic medical records (EMRs) is to improve patient care. This study uses a search of EMR to identify patients at risk for prostate cancer who were not evaluated by an urologist. The University of Texas Southwestern Medical Center (UTSW) has an institutional outpatient EMR that is used by all providers in all specialties. Since March 2009, all PSA tests were reported with specific interpretative comments including a recommendation for referral to urology for a PSA >2.5 ng ml−1. All PSA tests were performed on campus since institution of these recommendations were analyzed, and charts reviewed for all patients not seen in urology with a serum PSA >2.5 ng ml−1. Of the 2884 non-urology patients that had a serum PSA drawn between March 2009 and February 2010 at UTSW, 293 patients had a serum PSA >2.5 ng ml−1. Of these, 39 patients had known prostate cancer and were seeing an oncologist. There were 59 patients seeing urologists outside the institution. A total of 195 patients were not seen by an urologist and only 11 patients were recommended to see one but did not make an appointment. There were 151 patients with more than one PSA in the system, and of these 103 had a rise in PSA with a median rise of 0.53 ng ml−1 per year. EMR allows identification of patients at increased risk of prostate cancer who are not evaluated. Prospective studies are needed to identify ways to improve appropriate evaluation and detection of prostate cancer.

How Common Are Pulmonary and Hepatic Adverse Effects in Older Adults Prescribed Nitrofurantoin

Preventive services required for performance measurement often are completed in outside health systems and not captured in electronic medical records (EMRs). A before–after study was conducted to examine the ability of clinical decision support (CDS) to improve performance on preventive quality measures, capture clinician-reported services completed elsewhere, and patient/medical exceptions and to describe their impact on quality measurement. CDS improved performance on colorectal cancer screening, osteoporosis screening, and pneumococcal vaccination measures (P < .05) but not breast or cervical cancer screening. CDS captured clinician-reported services completed elsewhere (2% to 10%) and patient/medical exceptions (<3%). Compared to measures using only within-system data, including services completed elsewhere in the numerator improved performance: pneumococcal vaccine (73% vs 82%); breast (69% vs 75%), colorectal (58% vs 70%), and cervical cancer (53% vs 62%); and osteoporosis (72% vs 75%) screening (P < .05). Visit-based CDS can capture clinician-reported preventive services, and accounting for services completed elsewhere improves performance on quality measures.

Patient, Provider, and System Factors Associated With Failure to Follow-Up Elevated Glucose Results in Patients Without Diagnosed Diabetes

To determine the frequency of serious pulmonary and hepatic adverse events (AEs) in persons aged 65 and older prescribed nitrofurantoin.