Mina Silberberg

Teaching Population Health: A Competency Map Approach to Education

A 2012 Institute of Medicine report is the latest in the growing number of calls to incorporate a population health approach in health professionals’ training. Over the last decade, Duke University, particularly its Department of Community and Family Medicine, has been heavily involved with community partners in Durham, North Carolina, to improve the local community’s health. On the basis of these initiatives, a group of interprofessional faculty began tackling the need to fill the curriculum gap to train future health professionals in public health practice, community engagement, critical thinking, and team skills to improve population health effectively in Durham and elsewhere. The Department of Community and Family Medicine has spent years in care delivery redesign and curriculum experimentation, design, and evaluation to distinguish the skills trainees and faculty need for population health improvement and to integrate them into educational programs. These clinical and educational experiences have led to a set of competencies that form an organizational framework for curricular planning and training. This framework delineates which learning objectives are appropriate and necessary for each learning level, from novice through expert, across multiple disciplines and domains. The resulting competency map has guided Duke’s efforts to develop, implement, and assess training in population health for learners and faculty. In this article, the authors describe the competency map development process as well as examples of its application and evaluation at Duke and limitations to its use with the hope that other institutions will apply it in different settings.

Perceived Discrimination and Use of Health Care Services in a North Carolina Population of Latino Immigrants

ealth care utilization among Latinos in the United States is low. Nationwide, only 55% had seen a physician in the past year, compared with 73% of non-Latino whites ( Ezzati-Rice, Kasjijara, & Machlin, 2004 ). Thus, identifying and removing barriers to care in this population is essential. Barriers that Latinos face to health care access include culture and language differences, immigration status, and inadequate insurance

Stroke-Related Knowledge among Uninsured Latino Immigrants in Durham County, North Carolina

BACKGROUND Knowledge of stroke risk factors and symptoms is a necessary prerequisite for improving prevention and reducing treatment delays. Little is known about stroke-related knowledge among the US immigrant Latino population. METHODS A previously published stroke knowledge survey was translated into Spanish and administered orally to a convenience sample of 76 Latino Spanish-speaking clients of a community-based health care management program for uninsured residents of Durham County, North Carolina, between January and March 2007. RESULTS Of respondents, 81% could not correctly name a single stroke risk factor, 57% could not correctly identify a stroke symptom, and only 45% said they would telephone emergency services (dial 9-1-1), call an ambulance, or go to a hospital if they or a family member were having a stroke. However, 80% of respondents knew that a stroke could be prevented, and 86% knew that a stroke could be treated. CONCLUSION Stroke-related knowledge may be particularly poor in the uninsured Latino immigrant population. Novel approaches will be needed to improve awareness and prevention in this high-risk group.

Education, glucose control, and mortality risks among U.S. older adults with diabetes

AIMS Studies have shown that diabetes mellitus disproportionately afflicts persons of low socioeconomic status and that the burden of disease is greatest among the disadvantaged. However, our understanding of educational differences in the control of diabetes and its impact on survival is limited. This study investigated the associations among education, hemoglobin A1c (HbA1c), and subsequent mortality in adults with diabetes. METHODS Prospective cohort data from the 2006, 2008, and 2010 Health and Retirement Study were linked with biomarker data for U.S. older adults with diabetes (n=3312). Weighted distributions were estimated for all subjects at baseline and by the American Diabetes Associations general guidelines for HbA1c control (<7.0% [53 mmol/mol] vs. ≥7.0% [53 mmol/mol]). Proportional hazard models were used to estimate educational differences in all-cause mortality by HbA1c level with sequential adjustments for contributing risk factors. RESULTS Mortality risks associated with HbA1c≥7.0% [53 mmol/mol] were significantly greater in lower-educated adults than higher-educated adults (P<0.001). We found that the hazard ratios (HR) associated with HbA1c ≥7.0% [53 mmol/mol] were highest among low-educated adults (HR=2.18, 95% CI: 1.62, 2.94) and that a combination of socioeconomic, psychosocial, and behavioral factors accounted for most, but not all, of the associations. CONCLUSIONS Educational differences in HbA1c control have significant implications for mortality and efforts to reduce these disparities should involve more vigilant screening and monitoring of lower-educated adults with diabetes.

Balancing Autonomy and Dependence for Community and Nongovernmental Organizations

Prior studies have emphasized the dangers of dependence when community organizations seek nongovernmental organization (NGO) support. This article emphasizes that community group autonomy can undermine the effectiveness of assistance. Furthermore, and contrary to expectations, community group autonomy can contribute to suspicion of NGOs, weaken grassroots influence over them, and move NGOs away from serving grassroots needs.

The Relationship of Socioeconomic and Behavioral Risk Factors With Trends of Overweight in Korea

Objectives: Previous studies have shown that overweight (including obesity) has increased significantly in Korea in recent decades. However, it remains unclear whether this change has been uniform among all Koreans and to what extent socioeconomic and behavioral factors have contributed to this increase. Methods: Changes in overweight were estimated using data from the 1998, 2001, 2005, 2007-2009, and 2010-2012 Korea National Health and Nutrition Examination Survey (n=55 761). Results: Overweight increased significantly among men but not among women between 1998 and 2012. Changes in socioeconomic and behavioral factors over the time period were not associated with overall trends for both men and women. However, we found significant differences in the prevalence of overweight relative to key risk factors. For men, overweight increased at a significantly greater rate among the non-exercising (predicted probability [PP] from 0.23 to 0.32] and high-calorie (PP from 0.18 to 0.37) groups compared to their active and lower-calorie counterparts, respectively. For women, overweight increased only among the non-exercising (PP from 0.27 to 0.28) and low-income (PP from 0.31 to 0.36) groups during this period. Conclusions: These findings suggest that programs aimed at reducing overweight should target Korean men and women in specific socioeconomic and behavioral risk groups differentially.

Dynamics of patient targeting for care management in Medicaid: a case study of the Durham Community Health Network.

Targeting appropriate patients for care management is crucial to maximizing quality of care and cost-effectiveness in Medicaid care management programs. This study examined patient characteristics predicting selection for care management pre- and postmanagement changes at the Durham Community Health Network (DHCN), one of North Carolina’s Medicaid primary care management networks. From the beginning, care managers were directed to target asthmatics, diabetics, and high-volume utilizers of health care, using an array of markers to identify patients who needed management. In 2003, the state reinforced its focus on chronic disease and high utilizers, and new management at DCHN began emphasizing the use of protocols for patient targeting. This study examined the relative effects of patient demographics, diagnoses, PCP group, and health care utilization as predictors of patient selection before and after these changes.

Increasing Stroke Knowledge and Decreasing Stroke Risk in a Latino Immigrant Population

Stroke knowledge is poor and stroke risk is growing for the U.S. Latino immigrant population. We present results of an evaluation of a tailored, community-based intervention in Durham, North Carolina. The intervention included integration of stroke knowledge into classes and workshops at a community-based organization. Knowledge surveys were administered to participants immediately before and after stroke education, and at multiple points over the following year. For both low-risk participants receiving classroom-based education and individually care managed participants with risk factors, stroke knowledge improved dramatically and remained high among those who could be reached for follow-up. Evidence of behavior change and change in clinical status was weak. These findings from an observational study conducted in a real-world context complement the results of previously reported efficacy studies, indicating potential gains from health education for Latino immigrants, even from classroom-based education for low-risk individuals.

Evaluating the Effectiveness of Community and Hospital Medical Record Integration on Management of Behavioral Health in the Emergency Department

This study evaluated the correlation of an emergency department embedded care coordinator with access to community and medical records in decreasing hospital and emergency department use in patients with behavioral health issues. This retrospective cohort study presents a 6-month pre-post analysis on patients seen by the care coordinator (n=524). Looking at all-cause healthcare utilization, care coordination was associated with a significant median decrease of one emergency department visit per patient (p < 0.001) and a decrease of 9.5 h in emergency department length of stay per average visit per patient (p<0.001). There was no significant effect on the number of hospitalizations or hospital length of stay. This intervention demonstrated a correlation with reducing emergency department use in patients with behavioral health issues, but no correlation with reducing hospital utilization. This under-researched approach of integrating medical records at point-of-care could serve as a model for better emergency department management of behavioral health patients.

Use of the 5 As for Teen Alcohol Use

Clinical guidelines recommend addressing adolescent alcohol use in primary care; the 5 As (Ask, Advise, Assess, Assist, Arrange) may be a useful model for intervention. We audio-recorded 540 visits with 49 physicians and adolescents, compared alcohol disclosure rates in the encounter with those in a survey, and analyzed conversations for use of the 5 As and their relation to adolescent reports of drinking 3 months after the encounter. When physicians asked clear, nonleading questions, drinkers were more likely to disclose alcohol use (P = .004). In 64% of visits in which alcohol was discussed, physicians used one or more of the 5 As, most frequently “Ask.” No physician used all 5 As. Among drinkers, there was no association between physicians’ partial use of the 5 As and adolescent alcohol consumption at 3 months. Physicians can learn more effective ways to “Ask” about alcohol use to increase disclosure of drinking and to be more comprehensive in their counseling.