Neeraja B. Peterson

Faculty Self-reported Experience with Racial and Ethnic Discrimination in Academic Medicine

ABCKGROUND: Despite the need to recruit and retain minority faculty in academic medicine, little is known about the experiences of minority faculty, in particular their self-reported experience of racial and ethnic discrimination at their institutions.OBJECTIVE: To determine the frequency of self-reported experience of racial/ethnic discrimination among faculty of U.S. medical schools, as well as associations with outcomes, such as career satisfaction, academic rank, and number of peer-reviewed publications.DESIGN: A 177-item self-administered mailed survey of U.S. medical school faculty.SETTING: Twenty-four randomly selected medical schools in the contiguous United States.PARTICIPANTS: A random sample of 1,979 full-time faculty, stratified by medical school, specialty, graduation cohort, and gender.MEASUREMENTS: Frequency of self-reported experiences of racial/ethnic bias and discrimination.RESULTS: The response rate was 60%. Of 1,833 faculty eligible, 82% were non-Hispanic white, 10% underrepresented minority (URM), and 8% nonunderrepresented minority (NURM). URM and NURM faculty were substantially more likely than majority faculty to perceive racial/ethnic bias in their academic environment (odds ratio [OR], 5.4; P<.01 and OR, 2.6; P<.01, respectively). Nearly half (48%) of URM and 26% of NURM reported experiencing racial/ethnic discrimination by a superior or colleague. Faculty with such reported experiences had lower career satisfaction scores than other faculty (P<.01). However, they received comparable salaries, published comparable numbers of papers, and were similarly likely to have attained senior rank (full or associate professor).CONCLUSIONS: Many minority faculty report experiencing racial/ethnic bias in academic medicine and have lower career satisfaction than other faculty. Despite this, minority faculty who reported experiencing racial/ethnic discrimination achieved academic productivity similar to that of other faculty.

Validating drug repurposing signals using electronic health records: a case study of metformin associated with reduced cancer mortality

Objectives Drug repurposing, which finds new indications for existing drugs, has received great attention recently. The goal of our work is to assess the feasibility of using electronic health records (EHRs) and automated informatics methods to efficiently validate a recent drug repurposing association of metformin with reduced cancer mortality. Methods By linking two large EHRs from Vanderbilt University Medical Center and Mayo Clinic to their tumor registries, we constructed a cohort including 32 415 adults with a cancer diagnosis at Vanderbilt and 79 258 cancer patients at Mayo from 1995 to 2010. Using automated informatics methods, we further identified type 2 diabetes patients within the cancer cohort and determined their drug exposure information, as well as other covariates such as smoking status. We then estimated HRs for all-cause mortality and their associated 95% CIs using stratified Cox proportional hazard models. HRs were estimated according to metformin exposure, adjusted for age at diagnosis, sex, race, body mass index, tobacco use, insulin use, cancer type, and non-cancer Charlson comorbidity index. Results Among all Vanderbilt cancer patients, metformin was associated with a 22% decrease in overall mortality compared to other oral hypoglycemic medications (HR 0.78; 95% CI 0.69 to 0.88) and with a 39% decrease compared to type 2 diabetes patients on insulin only (HR 0.61; 95% CI 0.50 to 0.73). Diabetic patients on metformin also had a 23% improved survival compared with non-diabetic patients (HR 0.77; 95% CI 0.71 to 0.85). These associations were replicated using the Mayo Clinic EHR data. Many site-specific cancers including breast, colorectal, lung, and prostate demonstrated reduced mortality with metformin use in at least one EHR. Conclusions EHR data suggested that the use of metformin was associated with decreased mortality after a cancer diagnosis compared with diabetic and non-diabetic cancer patients not on metformin, indicating its potential as a chemotherapeutic regimen. This study serves as a model for robust and inexpensive validation studies for drug repurposing signals using EHR data.

Patient Numeracy, Perceptions of Provider Communication, and Colorectal Cancer Screening Utilization

Patients with poor numeracy skills may have difficulty participating in shared-decision making, affecting their utilization of colorectal cancer (CRC) screening. We explored the relationship between numeracy, provider communication, and CRC screening. Data were from the 2007 National Cancer Institute Health Information Trends Survey. Individuals age 50 years or older responded via mail or phone to items measuring numeracy, perceptions of provider communication quality, and CRC screening. After accounting for national sampling weights, multivariate logistic regression models examined the association between these factors. A total of 1,436 subjects responded to an objective numeracy item via mail, and 3,286 responded to a subjective numeracy item via mail or phone; 22.6% had low objective numeracy, and 39.4% had low subjective numeracy. Low subjective numeracy was associated with a lower likelihood of perceiving high quality provider communication (OR 0.63–0.73), but for low objective numeracy, the opposite was observed (OR 1.51–1.64). Low objective or subjective numeracy was associated with less CRC screening. There was significant interaction between subjective numeracy, perceptions of provider communication, and CRC screening. Patient numeracy is associated with perceptions of provider communication quality. For individuals with low subjective numeracy, perceiving high quality communication offset the association between low numeracy and underutilization of CRC screening.

Natural language processing improves identification of colorectal cancer testing in the electronic medical record.

Background. Difficulty identifying patients in need of colorectal cancer (CRC) screening contributes to low screening rates. Objective. To use Electronic Health Record (EHR) data to identify patients with prior CRC testing. Design. A clinical natural language processing (NLP) system was modified to identify 4 CRC tests (colonoscopy, flexible sigmoidoscopy, fecal occult blood testing, and double contrast barium enema) within electronic clinical documentation. Text phrases in clinical notes referencing CRC tests were interpreted by the system to determine whether testing was planned or completed and to estimate the date of completed tests. Setting. Large academic medical center. Patients. 200 patients ≥50 years old who had completed ≥2 non-acute primary care visits within a 1-year period. Measures. Recall and precision of the NLP system, billing records, and human chart review were compared to a reference standard of human review of all available information sources. Results. For identification of all CRC tests, recall and precision were as follows: NLP system (recall 93%, precision 94%), chart review (74%, 98%), and billing records review (44%, 83%). Recall and precision for identification of patients in need of screening were: NLP system (recall 95%, precision 88%), chart review (99%, 82%), and billing records (99%, 67%). Limitations. Small sample size and requirement for a robust EHR. Conclusions. Applying NLP to EHR records detected more CRC tests than either manual chart review or billing records review alone. NLP had better precision but marginally lower recall to identify patients who were due for CRC screening than billing record review.

Adverse Drug Events during AKI and Its Recovery

BACKGROUND AND OBJECTIVES The impact of AKI on adverse drug events and therapeutic failures and the medication errors leading to these events have not been well described. DESIGN, SETTING, PARTICIPANTS, & MEASUREMENTS A single-center observational study of 396 hospitalized patients with a minimum 0.5 mg/dl change in serum creatinine who were prescribed a nephrotoxic or renally eliminated medication was conducted. The population was stratified into two groups by the direction of their initial serum creatinine change: AKI and AKI recovery. Adverse drug events, potential adverse drug events, therapeutic failures, and potential therapeutic failures for 148 drugs and 46 outcomes were retrospectively measured. Events were classified for preventability and severity by expert adjudication. Multivariable analysis identified medication classes predisposing AKI patients to adverse drug events. RESULTS Forty-three percent of patients experienced a potential adverse drug event, adverse drug event, therapeutic failure, or potential therapeutic failure; 66% of study events were preventable. Failure to adjust for kidney function (63%) and use of nephrotoxic medications during AKI (28%) were the most common potential adverse drug events. Worsening AKI and hypotension were the most common preventable adverse drug events. Most adverse drug events were considered serious (63%) or life-threatening (31%), with one fatal adverse drug event. Among AKI patients, administration of angiotensin-converting enzyme inhibitors/angiotensin receptor blockers, antibiotics, and antithrombotics was most strongly associated with the development of an adverse drug event or potential adverse drug event. CONCLUSIONS Adverse drug events and potential therapeutic failures are common and frequently severe in patients with AKI exposed to nephrotoxic or renally eliminated medications.

Polymorphisms in tissue inhibitors of metalloproteinases-2 and -3 and breast cancer susceptibility and survival.

Tissue inhibitors of metalloproteinases (TIMPs) are endogenous inhibitors of matrix metalloproteinases which are involved in normal cellular processes and also in cancer development and progression. The purpose of this study was to evaluate polymorphisms in the TIMP‐2 and TIMP‐3 genes for their associations with breast cancer susceptibility and survival. Using data from the Shanghai Breast Cancer Study, 19 SNPs for each gene were evaluated for associations with breast cancer risk among 1,062 cases and 1,069 controls; associations with disease‐free and overall survival were evaluated among the cases. For TIMP‐2, women with the rs7501477 TT genotype were 3 times more likely to be breast cancer cases than women with the CC genotype (OR: 2.9, 95% CI: 1.2–7.0). For TIMP‐3, women with the rs9609643 AA genotype were 60% less likely to be breast cancer cases than women with the GG genotype (OR: 0.4, 95% CI: 0.2–1.0), whereas women with the rs8136803 TT genotype were 5 times more likely to be cases than women with the GG genotype (OR: 5.1, 95% CI: 1.1–24.3). Further, breast cancer cases with rs8136803 TT were almost 4 times more likely to have decreased disease‐free survival (HR: 3.9, 95% CI: 1.4–10.6) and had a trend toward decreased overall survival (HR: 1.9, 95% CI: 0.6–6.1). An important study limitation was that these 3 SNPs (rs7501477, rs9609643, rs8136803) had low minor allele frequencies which resulted in small numbers of homozygote individuals. Genetic variation in the TIMP‐2 and TIMP‐3 genes may contribute to individual differences in breast cancer susceptibility and survival.

Colonoscopy Screening in African Americans and Whites With Affected First-Degree Relatives

BACKGROUND Family history is a risk factor for colon cancer, and guidelines recommend initiating screening at age 40 years in individuals with affected relatives. Racial differences in colon cancer mortality could be related to variations in screening of increased-risk individuals. METHODS Baseline data from 41 830 participants in the Southern Community Cohort Study were analyzed to determine the proportion of colonoscopy procedures in individuals with strong family histories of colon cancer, and whether differences existed based on race. RESULTS In participants with multiple affected first-degree relatives (FDRs) or relatives diagnosed before age 50 years, 27.3% (95% confidence interval [CI], 23.5%-31.1%) of African Americans reported having a colonoscopy within the past 5 years compared with 43.1% (95% CI, 37.0%-49.2%) of white participants (P<.001). African Americans in this group had an odds ratio of 0.51 (95% CI, 0.38-0.68) of having undergone recommended screening procedures compared with white participants after adjusting for age, sex, educational status, annual income, insurance status, total number of affected and unaffected FDRs, and time since last medical visit. African Americans with multiple affected FDRs or relatives diagnosed before age 50 years and who had ever undergone endoscopy were less likely to report a personal history of colon polyps (odds ratio, 0.29; 95% CI, 0.20-0.42) when compared with whites with similar family histories. CONCLUSIONS African Americans who have FDRs with colon cancer are less likely to undergo colonoscopy screening compared with whites who have affected relatives. Increased efforts need to be directed at identifying and managing underserved populations at increased risk for colon cancer based on their family histories.

Alcohol consumption and ovarian cancer risk in a population‐based case–control study

Alcohol consumption has been investigated as a possible risk factor for ovarian cancer in several epidemiological studies, with inconsistent findings. Recent studies have suggested that the association between alcohol consumption and ovarian cancer may vary according to histologic subtype of ovarian cancer and type of alcohol consumed (e.g., wine, beer, or liquor). We examined these associations in a population‐based case‐control study comprised of 762 incident cases of epithelial ovarian cancer and 6,271 population controls from Massachusetts and Wisconsin aged 40–79 years. Women reported their usual alcohol consumption as young adults (20–30 years of age) and in the recent past. Odds ratios (ORs) and 95% confidence intervals (CIs) were calculated. There was no significant association of ovarian cancer with increasing alcohol consumption either during ages 20–30 years (p trend 0.42) or in the recent past (p trend 0.83). Regular drinking of beer (1 drink/day or more) during ages 20–30 (OR 1.55, 95% CI 1.07–2.26), though not liquor (OR 1.35, 95% CI 0.86–2.11) or wine (OR 0.99, 95% CI 0.49–2.00), was associated with a statistically significant increase in risk of invasive tumors, whereas no significant relationships were observed for recent drinking, regardless of alcohol type. The elevated risk for early adult regular drinking was confined to serous invasive tumors (OR 1.52, 95% CI 1.01–2.30), though results for other subtypes were based on sparse data and results were imprecise. In this study, neither total alcohol consumption as a young adult nor recently was associated with an increase in the risk of ovarian cancer.

Real-time pharmacy surveillance and clinical decision support to reduce adverse drug events in acute kidney injury: a randomized, controlled trial.

OBJECTIVES: Clinical decision support (CDS), such as computerized alerts, improves prescribing in the setting of acute kidney injury (AKI), but considerable opportunity remains to improve patient safety. The authors sought to determine whether pharmacy surveillance of AKI patients could detect and prevent medication errors that are not corrected by automated interventions. METHODS: The authors conducted a randomized clinical trial among 396 patients admitted to an academic, tertiary care hospital between June 1, 2010 and August 31, 2010 with an acute 0.5 mg/dl change in serum creatinine over 48 hours and a nephrotoxic or renally cleared medication order. Patients randomly assigned to the intervention group received surveillance from a clinical pharmacist using a web-based surveillance tool to monitor drug prescribing and kidney function trends. CDS alerting and standard pharmacy services were active in both study arms. Outcome measures included blinded adjudication of potential adverse drug events (pADEs), adverse drug events (ADEs) and time to provider modification or discontinuation of targeted nephrotoxic or renally cleared medications. RESULTS: Potential ADEs or ADEs occurred for 104 (8.0%) of control and 99 (7.1%) of intervention patient-medication pairs (p=0.4). Additionally, the time to provider modification or discontinuation of targeted nephrotoxic or renally cleared medications did not differ between control and intervention patients (33.4 hrs vs. 30.3 hrs, p=0.3). CONCLUSIONS: Pharmacy surveillance had no incremental benefit over previously implemented CDS alerts.

Papanicolaou testing among women in the southern United States.

BACKGROUND Cervical cancer is largely preventable with screening using Papanicolaou (Pap) testing. We examined Pap testing among southern women, mostly of low income and educational status, to determine if rates were similar to those reported nationally and to examine which factors were related to receipt of Pap tests. METHODS Baseline interview data from 19,046 women aged 40-79 enrolled at community health centers into the Southern Community Cohort were analyzed. The percentages of women reporting a recent Pap test (within the past 3 years) were compared according to sociodemographic, healthcare access, and health-related behavior variables. Logistic regression analyses were employed to compute odds ratios (ORs) and corresponding 95% confidence intervals (95% CI). RESULTS Overall, 88% of the women reported having received a recent Pap test. Screening rates were high among all racial/ethnic groups, but highest for African American women. Not having a Pap test was significantly associated with lower education (OR declining to 0.73, 95% CI 0.64-0.85, among those with less than a high school education), lower income (OR declining to 0.61, 95% CI 0.43-0.87, among those with annual household incomes <