Robert L. Rhyne

Alcohol intake in the healthy elderly. Changes with age in a cross-sectional and longitudinal study.

Several cross‐sectional studies have shown a decline in alcohol intake with increasing age. Longitudinal studies have failed to confirm this trend, which suggests that cohort effects may account for the reported decline. To address this, both cross‐sectional and longitudinal analyses of alcohol use in 270 healthy elderly persons over a seven‐year period (1980–1987) were performed. Alcohol consumption was assessed by three‐day diet records. One hundred sixty‐five subjects (61.1%) remained in the study until 1987; 143 (53%) completed diet records for every year. Longitudinal analysis showed a statistically significant decline in the percent of subjects consuming any alcohol over time (slope = −2% per year; 95% confidence interval −2.8, −1.1%). A cross‐sectional analysis of the 1980 data revealed a similar decline in percent drinkers with increasing age (slope = −2.7% per year; 95% confidence interval −4.4, −1.1%). Mean alcohol intake for those who continued to drink did not change over time except among heavy drinkers (consumption of >30 g per day in 1980), who did show a significant decline in mean alcohol intake (P = .02). Thus, in our population the decline in percent of drinkers with age found by a cross‐sectional analysis was confirmed in longitudinal analyses, suggesting that this represents a true age‐related decline rather than a cohort effect.

Combining Web-Based and Mail Surveys Improves Response Rates: A PBRN Study From PRIME Net

PURPOSE The advent of Web-based survey tools has provided the investigator with an alternative to paper-based survey methods that in many instances may be less expensive to implement than traditional paper-based surveys. Newer technology, however, does not diminish the importance of obtaining an adequate response rate. METHODS We analyzed response rate data obtained from a survey implemented across 3 practice-based research networks (PBRNs) in which the survey was first implemented electronically with 5 rounds of electronic solicitation for an Internet-based questionnaire and then by 2 rounds of a paper-based version mailed only to nonresponders. RESULTS Overall, 24% of the total survey responses received were in the paper mode despite intense promotion of the survey in the electronic phase. CONCLUSIONS Our results suggest there is still an important role for the use of paper-based methods in PBRN survey research. Both hard copy and electronic survey collection methods may be required to enhance clinician response rates in PBRNs.

Acanthosis Nigricans and Diabetes Risk Factors: Prevalence in Young Persons Seen in Southwestern US Primary Care Practices

PURPOSE Evidence shows acanthosis nigricans is often associated with hyperinsulinemia and may indicate increased risk of type 2 diabetes mellitus. The purpose of this study was to determine the association of acanthosis nigricans with type 2 diabetes risk factors and disease in young persons. METHODS We conducted a cross-sectional study in the Research in Outpatient Settings Network, a practice-based research network in southwestern US communities. Participating clinicians (N = 96) collected data on children and young adults aged 7 to 39 years seen during a 2-week sampling period. The main outcomes were the prevalence of acanthosis nigricans, type 2 diabetes risk factors (ethnicity, family history of type 2 diabetes, hypertension, overweight/obesity), type 2 diabetes, and the relationships among these. RESULTS Among 1,133 patients sampled, risk factors for type 2 diabetes were common: 69% had a family history of the disease; 3% of children (aged 7 to 19 years) and 12% of adults had hypertension; 43% of children and 73% of adults were overweight or obese; and 80% were members of ethnic minorities. Acanthosis nigricans was found in 17% of children and 21% of adults. Among children and adults alike, the more type 2 diabetes risk factors that were present, the higher the prevalence of acanthosis nigricans (P <.001). The prevalence ratio for type 2 diabetes in patients with acanthosis nigricans was 1.97 (95% confidence interval, 1.18–3.27; P = .01) after controlling for age, body mass index, and the number of type 2 diabetes risk factors. Clinicians reported that the identification of acanthosis nigricans frequently led to discussions about lifestyle modification for decreasing the risk of type 2 diabetes. CONCLUSIONS Patients with acanthosis nigricans are likely to have multiple risk factors for type 2 diabetes. Acanthosis nigricans may be an independent risk factor for this disease. Detection of acanthosis nigricans may help clinicians more rapidly identify high-risk individuals for diabetes counseling.

Expressions of Machismo in Colorectal Cancer Screening Among New Mexico Hispanic Subpopulations

Although national colorectal cancer (CRC) incidence rates have steadily decreased, the rate for New Mexico Hispanics has been increasing, and screening rates are low. We conducted an exploratory qualitative study to determine barriers to CRC screening for New Mexico Hispanics. We found that machismo served as a dynamic influence on men’s health-seeking behaviors; however, it was conceptualized differently by two distinct Hispanic subpopulations, and therefore appeared to play a different role in shaping their screening attitudes and behaviors. Machismo emerged as more of an influence for Mexican men, who expressed concern over colonoscopies being potentially transformative and/or stigmatizing, but was not as salient for Hispanos, who viewed the colonoscopy as “strictly medical,” and were more concerned with discomfort and pain. Findings from the study highlight the importance of identifying varying characteristics among subpopulations to better understand screening barriers and provide optimal CRC screening counseling in primary care settings.

Longitudinal prescribing patterns in a nursing home population.

This study documents the patient characteristics associated with prescribed medications on entry to a nursing home and the change in prescribing patterns after 3 months.

Changes in anthropometric indices of body composition with age in a healthy elderly population

Changes in body composition are known to occur with old age, but there is limited knowledge of the normal values rates of change in anthropometric indices of body composition or the distribution of these changes in the elderly. In the present study, 98 elderly white men and 122 elderly white women were followed prospectively for 6 years. These participants were divided into 5‐years cohorts on the basis of age at the start of the study in 1980. Separate linear regressions of triceps skinfold thickness, midarm circumference, midarm muscle area, and weight divided by stature squared on age were computed for each participant. The mean annual changes or slopes for these indices were small for each sex. A loss of subcutaneous adipose tissue was indicated with age, but the effects of compression or measurement error may hamper the detection of changes in indices of body composition in the elderly.

Acanthosis Nigricans: High Prevalence and Association with Diabetes in a Practice-based Research Network Consortium—A PRImary care Multi-Ethnic Network (PRIME Net) Study

Background: Previous work has established a surprisingly high prevalence of acanthosis nigricans (AN) and its association with increased risk of type 2 diabetes in a Southwestern practice-based research network (PBRN). Our objective was to establish whether this high prevalence of AN would be present in other areas. Methods: We examined the prevalence of type 2 diabetes and its risk factors and the prevalence of AN among patients aged 7 to 65 years who had been seen by one of 86 participating clinicians in a national PBRN consortium during a 1-week data collection period. In a subsample of nondiabetic matched pairs who had or did not have AN, we compared fasting glucose, insulin, and lipid levels. Results: AN was present in 19.4% of 1730 patients from among all age ranges studied. AN was most prevalent among persons with more risk factors for diabetes. Patients with AN were twice as likely as those without AN to have type 2 diabetes (35.4% vs 17.6%; P < .001). In multivariable analysis, the prevalence ratio for diabetes was 2.1 (95% CI, 1.3–3.5) among non-Hispanic whites with AN and 1.4 (95% CI, 1.1–1.7) among minority patients with AN. In a subsample of 11 matched pairs, those with AN had higher levels of insulin and insulin resistance. Conclusions: We found high rates of AN among patients in primary care practices across the country. Patients with AN likely have multiple diabetes risk factors and are more likely to have diabetes.

Attitudes and Beliefs of Primary Care Providers in New Mexico About Lung Cancer Screening Using Low-Dose Computed Tomography.

Introduction On the basis of results from the National Lung Screening Trial (NLST), national guidelines now recommend using low-dose computed tomography (LDCT) to screen high-risk smokers for lung cancer. Our study objective was to characterize the knowledge, attitudes, and beliefs of primary care providers about implementing LDCT screening. Methods We conducted semistructured interviews with primary care providers practicing in New Mexico clinics for underserved minority populations. The interviews, conducted from February through September 2014, focused on providers’ tobacco cessation efforts, lung cancer screening practices, perceptions of NLST and screening guidelines, and attitudes about informed decision making for cancer screening. Investigators iteratively reviewed transcripts to create a coding structure. Results We reached thematic saturation after interviewing 10 providers practicing in 6 urban and 4 rural settings; 8 practiced at federally qualified health centers. All 10 providers promoted smoking cessation, some screened with chest x-rays, and none screened with LDCT. Not all were aware of NLST results or current guideline recommendations. Providers viewed study results skeptically, particularly that 95% of abnormal LDCT results were false positives, the need to screen 320 patients to prevent 1 lung cancer death, and the small proportion of minority participants. Providers were uncertain whether New Mexico had the necessary infrastructure to support high-quality screening, and worried about access barriers and financial burdens for rural, underinsured populations. Providers noted the complexity of discussing benefits and harms of screening and surveillance with their patient population. Conclusion Providers have several concerns about the feasibility and appropriateness of implementing LDCT screening. Effective lung cancer screening programs will need to educate providers and patients to support informed decision making and to ensure that high-quality screening can be efficiently delivered in community practice.

Clinical chemistry reference intervals for healthy elderly subjects

In 1979, 304 healthy elderly individuals in New Mexico were recruited for a longitudinal study of nutrition and aging. Repeat measurements on a yearly basis of commonly requested clinical chemistry analytes allowed the calculation of reference intervals, between and within-subject variance components, and percentiles for change in concentration between two yearly measurements. The latter was further divided into analytical and biological variance components. The upper 95th percentile for the difference between two yearly measurements, expressed as a percent of the population mean, ranged from 4% for Na+ to approximately 20% for total cholesterol and to greater than 90% for ferritin. Year-to-year differences attributable to the biological component ranged from a low of 2% of the population mean for Na+ to 70% for gamma-glutamyltransferase.

No Longer Simply a Practice-based Research Network (PBRN): Health Improvement Networks

While primary care Practice-based Research Networks are best known for their original, research purpose, evidence accumulating over the last several years is demonstrating broader values of these collaborations. Studies have demonstrated their role in quality improvement and practice change, in continuing professional education, in clinician retention in medically underserved areas, and in facilitating transition of primary care organization. A role in informing and facilitating health policy development is also suggested. Taking into account this more robust potential, we propose a new title, the Health Improvement Network, and a new vision for Practice-based Research Networks.