Martin R. Frankel

The Care of HIV-Infected Adults in the United States

BACKGROUND AND METHODSnIn order to elucidate the medical care of patients with human immunodeficiency virus (HIV) infection in the United States, we randomly sampled HIV-infected adults receiving medical care in the contiguous United States at a facility other than military, prison, or emergency department facility during the first two months of 1996. We interviewed 76 percent of 4042 patients selected from among the patients receiving care from 145 providers in 28 metropolitan areas and 51 providers in 25 rural areas.nnnRESULTSnDuring the first two months of 1996, an estimated 231,400 HIV-infected adults (95 percent confidence interval, 162,800 to 300,000) received care. Fifty-nine percent had the acquired immunodeficiency syndrome according to the case definition of the Centers for Disease Control and Prevention, and 91 percent had CD4+ cell counts of less than 500 per cubic millimeter. Eleven percent were 50 years of age or older, 23 percent were women, 33 percent were black, and 49 percent were men who had had sex with men. Forty-six percent had incomes of less than

Improving Adherence to Dementia Guidelines through Education and Opinion Leaders: A Randomized, Controlled Trial

10,000 per year, 68 percent had public health insurance or no insurance, and 30 percent received care at teaching institutions. The estimated annual direct expenditures for the care of the patients seen during the first two months of 1996 were

A Probability Sample for Monitoring the HIV-infected Population in Care in the U.S. and in Selected States

5.1 billion; the expenditures for the estimated 335,000 HIV-infected adults seen at least as often as every six months were

The Care of HIV-infected Adults in Rural Areas of the United States

6.7 billion, which is about

Rationale, design and respondent characteristics of the 2013–2014 New York City Health and Nutrition Examination Survey (NYC HANES 2013–2014)

20,000 per patient per year.nnnCONCLUSIONSnIn this national survey we found that most HIV-infected adults who were receiving medical care had advanced disease. The patient population was disproportionately male, black, and poor. Many Americans with diagnosed or undiagnosed HIV infection are not receiving medical care at least as often as every six months. The total cost of medical care for HIV-infected Americans accounts for less than 1 percent of all direct personal health expenditures in the United States.

Relationship of child loss to psychiatric and functional impairment in resettled Cambodian refugees.

Many medical specialty societies devote substantial resources to the development and dissemination of practice guidelines. Studies suggest that passive dissemination (such as publication or mailing of guidelines) is ineffective in increasing adoption of recommendations into clinical practice (1-5). Educational efforts to increase physicians adoption of guidelines are more likely to be effective when they are local, are multifaceted, and incorporate strategies that use a social influence model of change (1, 2, 4, 6-9). In particular, opinion leadersrespected authorities within a medical communityhave been shown to influence the adoption of guidelines (1, 7, 10, 11). However, despite the widespread development and endorsement of guidelines by specialty societies, little research has been done on the effectiveness of guideline implementation efforts (3-5, 12). We conducted a randomized, controlled trial to evaluate a multifaceted, evidence-based educational program to enhance the adoption of practice recommendations for the care of patients with dementia that were endorsed by the American Academy of Neurology (AAN) and local opinion leaders. We hypothesized that more neurologists who received the educational intervention would adhere more to the guideline recommendations than would neurologists who did not receive this intervention. Methods Our methods have been described in detail elsewhere (13) and are summarized here. The University of Rochester institutional review board approved the study. Study Sample We identified neurologists from six major urban regions in New York State (Albany, Buffalo, the Upper East Side of Manhattan, Queens, Rochester, and Syracuse) by using both the AAN membership database (n=407) and, for neurologists not in the AAN database, the New York State physician master file (n=10) (13). Neurologists were eligible to participate if they were board eligible or board certified in neurology or currently in a neurology residency or fellowship. We excluded neurologists whose primary specialty was child neurology, neuropathology, ophthalmology, nuclear medicine, or pediatrics and those who provided no patient care. Study Group Assignment We randomly assigned neurologists to the baseline group, control group, or intervention group (Figure 1). Only neurologists in the intervention group received the educational intervention. We assessed the primary study outcomes in the baseline group 3 months before the intervention and in the control and intervention groups 6 months after the intervention. Neurologists in the same practice could be randomly assigned to different study groups. Comparison of baseline and control group results enabled assessment of possible temporal effects and potential information transfer between control and intervention groups (14). Figure 1. Participant flow and follow-up. n n n P CME Selection of Practice Recommendations We reviewed all available clinical practice guidelines on dementia care that were developed and endorsed by the AAN (15, 16), as well as other published dementia guidelines (17-26). We selected six recommendations because they were developed or endorsed by a specialty society and because the literature suggested performance gaps and practice variations for the clinical care issues outlined in the recommendations (27-30). These recommendations included two about the indications for neuroimaging and electroencephalography in patients with dementia, from a previously published, AAN-developed practice parameter on dementia (15); one on the use of apolipoprotein E genotype testing, from a position paper that had been officially endorsed by the AAN and other specialty society organizations (16); and one on detection and treatment of depression, from guidelines developed by a national panel of experts (19, 20). In addition, we developed two recommendations specifically for the project on referring patients and their families to the Alzheimers Association and to the Alzheimers Association Safe Return Program, a national program designed to reduce the potential of adverse consequences of wandering. An AAN Advisory Panelcomposed of four dementia experts nominated by the AAN, neurology opinion leaders from each study region, and persons from the local Alzheimers associations representing the study regionsendorsed all six recommendations (see the Appendix for the wording of each guideline). Opinion Leader Selection To identify local opinion leaders, we mailed a survey (31) to a random sample of half of all eligible persons in each region except Albany and Syracuse, where all eligible persons received the survey. This survey was completed before neurologists were randomly assigned to study groups, and it guided the identification and recruitment of 12 opinion leaders: 1 in Albany; 2 each in Buffalo, Manhattan, Rochester, and Syracuse; and 3 in Queens (13). Educational Intervention The intervention was an evidence-based educational program consisting of a mailed AAN continuing medical education (CME) course (32), a resource manual with tools to help implement guidelines, an invitation to an AAN-sponsored evidence-based seminar, and five reminder mailings. The AAN, the local opinion leaders, and other advisory panel members endorsed the program. The individual components of the program were administered in the fall of 1997 to the intervention group only. The mailed CME course was designed so that readers could quickly review each recommendation and then analyze the rationale and evidence supporting it in more depth (32). The course begins with an executive summary highlighting all six practice recommendations, along with a short rationale formatted as a bulleted list. The course continues with four similarly formatted sections. Each section presents one or two recommendations in outline format, along with the endorsing organizations, followed by the rationale and supporting data, a clinical algorithm and a clinical case vignette illustrating and reinforcing each recommendation, and an in-depth discussion that elaborates on the recommendations. We included a list of physician resources and patient education and information handouts in two appendices. The resource manual consisted of a three-ring binder containing tools designed to help neurologists incorporate these recommendations into their practice, including the Cornell Scale for Depression in Dementia (33), a fact sheet for patients and caregivers about their local branch of the Alzheimers Association (with the Associations telephone number), and a Safe Return Program application (13). All tools were also included in the CME course. We invited all neurologists in the intervention group to attend an AAN-sponsored local seminar on dementia care. The seminars occurred on a weeknight, included dinner, and lasted 3 hours. The local opinion leaders, a representative from the local Alzheimers Association, and a study investigator served as faculty. The seminars followed a standard format. The study investigator presented each practice recommendation, along with the rationale and supporting evidence. After formal presentation of each recommendation, the opinion leaders endorsed the recommendation and led a 10- to 15-minute interactive discussion with attendees about practical issues of incorporating the recommendation in routine clinical practice. The Alzheimers Association representative also actively participated in the discussion. Tools that applied to the recommendations were presented and were distributed to each attendee. Six weeks after the seminar, we sent five mailings (each approximately 2 to 3 weeks apart) with cover letters signed by the opinion leaders to all intervention neurologists. The first four mailings highlighted one or two recommendations. The final mailing included a copy of the executive summary of all six recommendations, a business card for the local branch of the Alzheimers Association, and a Safe Return Program application. The AAN was the primary sponsoring body for the practice recommendations and evidence-based seminars. We also used the AANs continuing education program, CONTINUUM (34), as the primary vehicle to disseminate the recommendations in the CME course. In addition, AAN leadership signed introductory letters that accompanied study mailings. Outcome Measures We assessed adherence to the six practice recommendations by evaluating neurologists written responses to three clinical scenarios, each depicting a typical patient with dementia presenting for an initial evaluation. After each scenario, participants were asked to provide information on the same four items: 1) Write in the most likely diagnosis; 2) from a list of 12 common diagnostic tests, indicate which you would order; 3) write in any additional diagnostic tests you would order; and 4) write in any treatment or management recommendations you would make. The scenarios and questions were developed by study investigators, reviewed by dementia experts on the Advisory Panel, and pilot tested with seven neurologists. Scenarios 1 and 3 depicted patients who presented with features typical of Alzheimers disease and who did not meet any of the recommended criteria for ordering either a neuroimaging study or electroencephalography. Scenario 2 depicted a patient with established Alzheimers disease who had symptoms consistent with a diagnosis of major depression. Three physician investigators who were masked to the neurologists group assignments reviewed all written responses to each scenario and determined whether each response adhered to each practice recommendation. Neurologists who did not order a neuroimaging study (magnetic resonance imaging or computed tomography) were considered adherent to the neuroimaging recommendation. We analyzed responses to scenarios 1 and 3 separately because the patient in scenario 1 had no previous neuroimaging studies, whereas in scenario 3, the patient had a normal noncontrast computed tomogr

Time to first annual HIV care visit and associated factors for patients in care for HIV infection in 10 US cities

Epidemiologic and clinical changes in the HIV epidemic over time have presented a challenge to public health surveillance to monitor behavioral and clinical factors that affect disease progression and HIV transmission. The Medical Monitoring Project (MMP) is a supplemental surveillance project designed to provide representative, population-based data on clinical status, care, outcomes, and behaviors of HIV-infected persons receiving care at the national level. We describe a three-stage probability sampling method that provides both nationally and state-level representative estimates. In stage-I, 20 states, which included 6 separately funded cities/counties, were selected using probability proportional to size (PPS) sampling. PPS sampling was also used in stage-II to select facilities for participation in each of the 26 funded areas. In stage-III, patients were randomly selected from sampled facilities in a manner that maximized the possibility of having overall equal selection probabilities for every patient in the state or city/county. The sampling methods for MMP could be adapted to other research projects at national or sub-national levels to monitor populations of interest or evaluate outcomes and care for a range of specific diseases or conditions.

A Randomized Trial to Implement Practice Recommendations: Design and Methods of the Dementia Care Study

Objective: This study describes the population of HIV‐infected adults receiving care in rural areas of the United States and compares HIV care received in rural and urban areas. Methods: Interviews were conducted with a nationally representative sample of 367 HIV‐infected adults receiving health care in rural areas and 2806 HIV‐infected adults receiving health care in urban areas of the contiguous United States. Results: We estimate that 4800 HIV‐infected persons received medical care in rural areas during the first half of 1996. Patients in rural HIV care were more likely than patients in urban HIV care to receive care from providers seeing few (<10) HIV‐infected patients (38% vs. 3%; p < .001). Rural care patients were less likely than urban care patients to have taken highly active antiretroviral agents (57% vs. 73%; p < .001) or Pneumocystis carinii pneumonia prophylactic medication when indicated (60% vs. 75%; p = .006). Conclusions: Few American adults received HIV care in rural areas of the United States. Our findings suggest ongoing disparities between urban and rural areas in access to high‐quality HIV care.

Predictors of dentists' level of knowledge regarding the recommended prophylactic regimen for patients with rheumatic heart disease

Purpose Capacity to monitor non-communicable diseases (NCDs) at state or local levels is limited. Emerging approaches include using biomeasures and electronic health record (EHR) data. In 2004, New York City (NYC) performed a population-based health study on adult residents using biomeasures (NYC Health and Nutrition Examination Study, or NYC HANES), modeled after NHANES. A second NYC HANES was launched in 2013 to examine change over time, evaluate municipal policies, and validate a proposed EHR-based surveillance system. We describe the rationale and methods of NYC HANES 2013–2014. Methods NYC HANES was a population-based, cross-sectional survey of NYC adults using three-stage cluster sampling. Between August 2013 and June 2014, selected participants completed a health interview and physical exam (blood pressure, body mass index, and waist circumference). Fasting biomeasures included diabetes, lipid profiles, kidney function, environmental biomarkers, and select infectious diseases. Results Of the 3065 households approached, 2742 were eligible and 1827 were successfully screened (67%). A total of 1524 of eligible participants completed the survey (54%), for an overall response rate of 36%. Conclusion Completing a second NYC HANES a decade after the first study affords an opportunity to understand changes in prevalence, awareness and control of NCDs and evaluate municipal efforts to manage them.

Confidence limits for small proportions in complex samples

One hundred sixty eight respondents, recruited from a community of resettled Cambodian refugees in Massachusetts, were interviewed for a study of trauma, physical and emotional health, and functioning. Of the 161 respondents who have ever had any children, 70 parents (43%) reported the death of between one and six of their children. Child loss was positively associated with health-related concerns, a variety of somatic symptoms, and culture-bound conditions of emotional distress. No relationship was found with conventional psychiatric symptoms of depression and posttraumatic stress disorder. Parents whose children died were performing most routine daily activities and participating in social activities to a similar and even greater extent than were parents who did not lose children. Nevertheless, child loss was strongly associated with a perception of health-related limitation in both physical functioning and social activities. Further research on the prevalence of child loss and its impact on long-term adjustment in survivors of mass trauma is indicated.