Roberto B. Vargas

Characteristics of the original patient navigation programs to reduce disparities in the diagnosis and treatment of breast cancer

Patient navigation is an intervention developed to reduce disparities in cancer care that is being widely replicated and receiving considerable support for demonstration projects and research to test its effectiveness. In the current study, the authors present an in‐depth descriptive analysis of the original patient navigation programs to inform current and future program development.

Can a Chronic Care Model Collaborative Reduce Heart Disease Risk in Patients with Diabetes

BackgroundThere is a need to identify effective practical interventions to decrease cardiovascular disease risk in patients with diabetes.ObjectiveWe examine the impact of participation in a collaborative implementing the chronic care model (CCM) on the reduction of cardiovascular disease risk in patients with diabetes.DesignControlled pre- and postintervention study.Patients/ParticipantsPersons with diabetes receiving care at 13 health care organizations exposed to the CCM collaborative and controls receiving care in nonexposed sites.Measurements and Main ResultsTen-year risk of cardiovascular disease; determined using a modified United Kingdom Prospective Diabetes Study risk engine score. A total number of 613 patients from CCM intervention sites and 557 patients from usual care control sites met the inclusion criteria. The baseline mean 10-year risk of cardiovascular disease was 31% for both the intervention group and the control group. Participants in both groups had improved blood pressure, lipid levels, and HbA1c levels during the observation period. Random intercept hierarchical regression models showed that the intervention group had a 2.1% (95% CI −3.7%, −0.5%) greater reduction in predicted risk for future cardiovascular events when compared to the control group. This would result in a reduced risk of one cardiovascular disease event for every 48 patients exposed to the intervention.ConclusionsOver a 1-year interval, this collaborative intervention using the CCM lowered the cardiovascular disease risk factors of patients with diabetes who were cared for in the participating organization’s settings. Further work could enhance the impact of this promising multifactorial intervention on cardiovascular disease risk reduction.

Patient education integrated with acupuncture for relief of cancer-related fatigue randomized controlled feasibility study.

BackgroundCancer-related fatigue (CRF) is a prominent clinical problem. There are calls for multi-modal interventions.MethodsWe assessed the feasibility of delivering patient education integrated with acupuncture for relief of CRF in a pilot randomized controlled trial (RCT) with breast cancer survivors using usual care as control. Social cognitive and integrative medicine theories guided integration of patient education with acupuncture into a coherent treatment protocol. The intervention consisted of two parts. First, patients were taught to improve self-care by optimizing exercise routines, improving nutrition, implementing some additional evidence-based cognitive behavioral techniques such as stress management in four weekly 50-minute sessions. Second, patients received eight weekly 50-minute acupuncture sessions. The pre-specified primary outcome, CRF, was assessed with the Brief Fatigue Inventory (BFI). Secondary outcomes included three dimensions of cognitive impairment assessed with the FACT-COGv2.ResultsDue to difficulties in recruitment, we tried several methods that led to the development of a tailored recruitment strategy: we enlisted oncologists into the core research team and recruited patients completing treatment from oncology waiting rooms. Compared to usual care control, the intervention was associated with a 2.38-point decline in fatigue as measured by the BFI (90% Confidence Interval from 0.586 to 5.014; p <0.10). Outcomes associated with cognitive dysfunction were not statistically significant.ConclusionsPatient education integrated with acupuncture had a very promising effect that warrants conducting a larger RCT to confirm findings. An effective recruitment strategy will be essential for the successful execution of a larger-scale trial.Trial registrationNCT00646633

Strategies to Build Trust and Recruit African American and Latino Community Residents for Health Research: A Cohort Study

This study used Community Partnered Participatory Research (CPPR) to address low participation of racial and ethnic minorities in medical research and the lack of trust between underrepresented communities and researchers.

Community-Partnered Approaches to Enhance Chronic Kidney Disease Awareness, Prevention, and Early Intervention

There is a need to increase community involvement in addressing the growing burden of chronic kidney disease (CKD). Community-partnered participatory research (CPPR) is a collaborative approach that equitably involves academic, community, and professional partners in research, and the development of shared goals and of interventional programs to attain these goals. We present a case study of the processes, strategies, and activities concerning the interface of World Kidney Day goals and community-academic partnerships using a CPPR model focused on CKD. We show that CPPR methods can be used to (1) bring together community and academic leaders around goal sharing and research agenda development, (2) convene a community/professional conference aimed at knowledge transfer and data collection among partners, and (3) develop workgroups from a diverse group of participants to collaborate in community partnered strategies to reduce the burden of CKD. Participants included health care professionals, patients, faith-based professionals, government employees and officials, academics, caregivers, and community members. Follow-up workgroups developed action plans to address shared concerns. Using CPPR practices and principles, we were able to incorporate World Kidney Day objectives with community-derived goals to develop a community-partnered infrastructure, shared objectives, and workgroups to reduce the burden of chronic kidney disease.

Kidney Disease Progression and Screening Cost-Effectiveness among African Americans

Where is the wisdom we have lost in knowledge? Where is the knowledge we have lost in information?—T.S. Eliot The tragedy in the continuing disparities in the progression of CKD to ESRD and cardiovascular events for poor and disadvantaged (often minority) patients has not been so much that

Racial and ethnic differences in utilization of health services in patients with diabetes enrolled in medicaid.

We evaluated racial and ethnic differences in use of medical care between patients with diabetes enrolled in Medicaid and explored whether differences varied by state Medicaid program. Using data from 137,006 patients we created a multivariable Poisson regression model to examine the effect of race on ambulatory care visits, emergency ward visits, and hospitalization rates for patients with diabetes mellitus enrolled in three state Medicaid programs. We found significant differences in service use between groups, which varied depending on state. For example, black patients compared with whites had significantly fewer outpatient visits but more hospitalizations in New Jersey; by contrast, blacks had higher outpatient visit rates and lower hospitalization rates in Georgia. Racial and ethnic differences in health service use among Medicaid enrollees were not consistent across states, suggesting that local factors, including varied Medicaid policies, may affect racial and ethnic differences in use of health care services.

Church attendance, allostatic load and mortality in middle aged adults

Importance Religiosity has been associated with positive health outcomes. Hypothesized pathways for this association include religious practices, such as church attendance, that result in reduced stress. Objective The objective of this study was to examine the relationship between religiosity (church attendance), allostatic load (AL) (a physiologic measure of stress) and all-cause mortality in middle-aged adults. Design, setting and participants Data for this study are from NHANES III (1988–1994). The analytic sample (n = 5449) was restricted to adult participants, who were between 40–65 years of age at the time of interview, had values for at least 9 out of 10 clinical/biologic markers used to derive AL, and had complete information on church attendance. Main outcomes and measures The primary outcomes were AL and mortality. AL was derived from values for metabolic, cardiovascular, and nutritional/inflammatory clinical/biologic markers. Mortality was derived from a probabilistic algorithm matching the NHANES III Linked Mortality File to the National Death Index through December 31, 2006, providing up to 18 years follow-up. The primary predictor variable was baseline report of church attendance over the past 12 months. Cox proportional hazard logistic regression models contained key covariates including socioeconomic status, self-rated health, co-morbid medical conditions, social support, healthy eating, physical activity, and alcohol intake. Results Churchgoers (at least once a year) comprised 64.0% of the study cohort (n = 3782). Non-churchgoers had significantly higher overall mean AL scores and higher prevalence of high-risk values for 3 of the 10 markers of AL than did churchgoers. In bivariate analyses non-churchgoers, compared to churchgoers, had higher odds of an AL score 2–3 (OR 1.24; 95% CI 1.01, 1.50) or ≥4 (OR 1.38; 95% CI 1.11, 1.71) compared to AL score of 0–1. More frequent churchgoers (more than once a week) had a 55% reduction of all-cause mortality risk compared with non-churchgoers. (HR 0.45, CI 0.24–0.85) in the fully adjusted model that included AL. Conclusions and relevance We found a significant association between church attendance and mortality among middle-aged adults after full adjustments. AL, a measure of stress, only partially explained differences in mortality between church and non-church attendees. These findings suggest a potential independent effect of church attendance on mortality.

Catalyzing Implementation of Evidence-Based Interventions in Safety Net Settings: A Clinical–Community Partnership in South Los Angeles

This study is a process evaluation of a clinical–community partnership that implemented evidence-based interventions in clinical safety net settings. Adoption and implementation of evidence-based interventions in these settings can help reduce health disparities by improving the quality of clinical preventive services in health care settings with underserved populations. A clinical–community partnership model is a possible avenue to catalyze adoption and implementation of interventions amid organizational barriers to change. Three Federally Qualified Health Centers in South Los Angeles participated in a partnership led by a local community-based organization (CBO) to implement hypertension interventions. Qualitative research methods were used to evaluate intervention selection and implementation processes between January 2014 and June 2015. Data collection tools included a key participant interview guide, health care provider interview guide, and protocol for taking meeting minutes. This case study demonstrates how a CBO acted as an external facilitator and employed a collaborative partnership model to catalyze implementation of evidence-based interventions in safety net settings. The study phases observed included initiation, planning, and implementation. Three emergent categories of organizational facilitators and barriers were identified (personnel capacity, professional development capacity, and technological capacity). Key participants and health care providers expressed a high level of satisfaction with the collaborative and the interventions, respectively. The CBO’s role as a facilitator and catalyst is a replicable model to promote intervention adoption and implementation in safety net settings. Key lessons learned are provided for researchers and practitioners interested in partnering with Federally Qualified Health Centers to implement health promotion interventions.

A Community Partnered-Participatory Research Approach to Reduce Cancer Disparities in South Los Angeles

Background: Community–academic partnerships may offer opportunities to improve population health in communities that suffer from cancer-related health disparities.Objectives: This project describes a community partnered effort to promote cancer research and reduce local cancer-related disparities.Methods: We used a community-partnered participatory research (CPPR) model and modified Delphi method approach to bring together community and academic stakeholders from South Los Angeles around reducing cancer disparities.Results: The 36-member Community–Academic Council consisted of cancer survivors, academics, and representatives of local community-based organizations and churches. Forty-nine unique cancer-related community priorities were collaboratively used to develop shared products. Early CPPR products included convening of a community conference, a collaboratively developed survey instrument, and new partnerships resulting in externally funded projects.Conclusions: Our approach demonstrates the feasibility of the use of a replicable model of community and academic engagement that has resulted in products developed through collaborative efforts.