Sharina D. Person

Relation of race and sex to the use of reperfusion therapy in Medicare beneficiaries with acute myocardial infarction.

BACKGROUND There are few reports describing the combined influence of the race and sex of a patient on the use of reperfusion therapy for acute myocardial infarction. METHODS To determine the relation of race and sex to the receipt of reperfusion therapy for myocardial infarction in the United States, we reviewed the medical records of 234,769 Medicare patients with myocardial infarction. From these records we identified 26,575 white or black patients who met strict eligibility criteria for reperfusion therapy. We then performed bivariate and multivariate analyses of prevalence ratios to determine predictors of the use of reperfusion therapy in four subgroups of patients categorized according to race and sex: white men, white women, black men, and black women. RESULTS Among eligible patients, white men received reperfusion therapy with the highest frequency (59 percent), followed by white women (56 percent), black men (50 percent), and black women (44 percent). After adjustment for differences in demographic and clinical characteristics, white women were as likely as white men to receive reperfusion therapy (prevalence ratio, 1.00; 95 percent confidence interval, 0.98 to 1.03). Likewise, black women were as likely as black men to receive reperfusion therapy (prevalence ratio, 1.00; 95 percent confidence interval, 0.89 to 1.13). However, black women were significantly less likely to receive reperfusion therapy than white men (prevalence ratio, 0.90; 95 percent confidence interval, 0.82 to 0.98), as were black men (prevalence ratio, 0.85; 95 percent confidence interval, 0.78 to 0.93). CONCLUSIONS After adjustment for differences in clinical and demographic characteristics and clinical presentation, differences according to sex in the use of reperfusion therapy are minimal. However, blacks, regardless of sex, are significantly less likely than whites to receive this potentially lifesaving therapy.

Active and passive smoking and development of glucose intolerance among young adults in a prospective cohort: CARDIA study

Abstract Objective To assess whether active and passive smokers are more likely than non-smokers to develop clinically relevant glucose intolerance or diabetes. Design Coronary artery risk development in young adults (CARDIA) is a prospective cohort study begun in 1985-6 with 15 years of follow-up. Setting Participants recruited from Birmingham, Alabama; Chicago, Illinois; Minneapolis, Minnesota; and Oakland, California, USA. Participants Black and white men and women aged 18-30 years with no glucose intolerance at baseline, including 1386 current smokers, 621 previous smokers, 1452 never smokers with reported exposure to secondhand smoke (validated by serum cotinine concentrations 1-15 ng/ml), and 1113 never smokers with no exposure to secondhand smoke. Main outcome measure Time to development of glucose intolerance (glucose ≥ 100 mg/dl or taking antidiabetic drugs) during 15 years of follow-up. Results Median age at baseline was 25, 55% of participants were women, and 50% were African-American. During follow-up, 16.7% of participants developed glucose intolerance. A graded association existed between smoking exposure and the development of glucose intolerance. The 15 year incidence of glucose intolerance was highest among smokers (21.8%), followed by never smokers with passive smoke exposure (17.2%), and then previous smokers (14.4%); it was lowest for never smokers with no passive smoke exposure (11.5%). Current smokers (hazard ratio 1.65, 95% confidence interval 1.27 to 2.13) and never smokers with passive smoke exposure (1.35, 1.06 to 1.71) remained at higher risk than never smokers without passive smoke exposure after adjustment for multiple baseline sociodemographic, biological, and behavioural factors, but risk in previous smokers was similar to that in never smokers without passive smoke exposure. Conclusion These findings support a role of both active and passive smoking in the development of glucose intolerance in young adulthood.

Culturally appropriate storytelling to improve blood pressure: a randomized trial

BACKGROUND Storytelling is emerging as a powerful tool for health promotion in vulnerable populations. However, these interventions remain largely untested in rigorous studies. OBJECTIVE To test an interactive storytelling intervention involving DVDs. DESIGN Randomized, controlled trial in which comparison patients received an attention control DVD. Separate random assignments were performed for patients with controlled or uncontrolled hypertension. (ClinicalTrials.gov registration number: NCT00875225) SETTING An inner-city safety-net clinic in the southern United States. PATIENTS 230 African Americans with hypertension. INTERVENTION 3 DVDs that contained patient stories. Storytellers were drawn from the patient population. MEASUREMENTS The outcomes were differential change in blood pressure for patients in the intervention versus the comparison group at baseline, 3 months, and 6 to 9 months. RESULTS 299 African American patients were randomly assigned between December 2007 and May 2008 and 76.9% were retained throughout the study. Most patients (71.4%) were women, and the mean age was 53.7 years. Baseline mean systolic and diastolic pressures were similar in both groups. Among patients with baseline uncontrolled hypertension, reduction favored the intervention group at 3 months for both systolic (11.21 mm Hg [95% CI, 2.51 to 19.9 mm Hg]; P = 0.012) and diastolic (6.43 mm Hg [CI, 1.49 to 11.45 mm Hg]; P = 0.012) blood pressures. Patients with baseline controlled hypertension did not significantly differ over time between study groups. Blood pressure subsequently increased for both groups, but between-group differences remained relatively constant. LIMITATION This was a single-site study with 23% loss to follow-up and only 6 months of follow-up. CONCLUSION The storytelling intervention produced substantial and significant improvements in blood pressure for patients with baseline uncontrolled hypertension. PRIMARY FUNDING SOURCE Finding Answers: Disparities Research for Change, a national program of the Robert Wood Johnson Foundation.

Patient Smoking Cessation Advice by Health Care Providers: The Role of Ethnicity, Socioeconomic Status, and Health

OBJECTIVES We assessed differences by ethnicity in ever receiving advice from providers to quit smoking. We evaluated whether socioeconomic status and health status were moderators of the association. METHODS We used 2000 Behavioral Risk Factor Surveillance Survey data, a population-based cross-sectional survey. RESULTS After adjusting for complex survey design, 69% of the 14089 current smokers reported ever being advised to quit by a provider. Hispanics (50%) and African Americans (61%) reported receiving smoking counseling less frequently compared with Whites (72%, P<.01 for each). Ethnic minority status, lower education, and poorer health status remained significantly associated with lower rates of advice to quit after adjustment for number of cigarettes, time from last provider visit, income, comorbidities, health insurance, gender, and age. Smoking counseling differences between African Americans and Whites were greater among those with lower income and those without health insurance. Compared with Whites, differences for both Hispanics and African Americans were also greater among those with lower education. CONCLUSION We found lower rates of smoking cessation advice among ethnic minorities. However, we also found complex interactions of ethnicity with socioeconomic factors.

Nurse staffing and mortality for Medicare patients with acute myocardial infarction

ContextRecent hospital reductions in registered nurses (RNs) for hospital care raise concerns about patient outcomes. ObjectiveAssess the association of nurse staffing with in-hospital mortality for patients with acute myocardial infarction (AMI). Design, Setting, and Patients.Medical record review data from the 1994–1995 Cooperative Cardiovascular Project were linked with American Hospital Association data for 118,940 fee-for-service Medicare patients hospitalized with AMI. Staffing levels were represented as nurse to patient ratios categorized into quartiles for RNs and for licensed practical nurses (LPNs). Main Outcome Measures.In-hospital mortality. ResultsFrom highest to lowest quartile of RN staffing, in-hospital mortality was 17.8%, 17.4%, 18.5%, and 20.1%, respectively (P < 0.001 for trend). However, from highest to lowest quartile of LPN staffing, mortality was 20.1%, 18.7%, 17.9%, and 17.2%, respectively P < 0.001). After adjustment for patient demographic and clinical characteristics, treatment, and for hospital volume, technology index, and teaching and urban status, patients treated in environments with higher RN staffing were less likely to die in-hospital; odds ratios (95% confidence intervals) of quartiles 4, 3, and 2 versus quartile 1 were 0.91 (0.86–0.97), 0.94 (0.88–1.00), and 0.96 (0.90–1.02), respectively. Conversely, after adjustment, patients treated in environments with higher LPN staffing were more likely to die in-hospital; odds ratios (95% confidence intervals) of quartiles 4, 3, and 2 versus quartile 1 were 1.07 (1.00–1.15), 1.02 (0.96–1.09), and 1.00 (0.94–1.07), respectively. ConclusionsEven after extensive adjustment, higher RN staffing levels were associated with lower mortality. Our findings suggest an important effect of nurse staffing on in-hospital mortality.

Relation of School Environment and Policy to Adolescent Physical Activity

BACKGROUND Physical activity (PA) declines as children and adolescents age. The purpose of this study was to examine how specific school factors relate to youth PA, TV viewing, and body mass index (BMI). METHODS A sample of 12- to 18-year-old adolescents in 3 cities (N = 165, 53% females, mean age 14.6 +/- 1.7 years, 44% nonwhite) completed surveys assessing days of physical education (PE) class per week, school equipment accessibility, after-school supervised PA, and after-school field access. Regression analyses were conducted to examine relationships between these school factors and PA at school facilities open to the public (never active vs active), overall PA level (days per week physically active for 60 minutes), BMI z score, and TV watching (hours per week). RESULTS Adjusting for demographics, days of PE per week and access to school fields after school were correlated with overall PA (beta= 0.286, p = .002, semipartial correlation .236 and beta= 0.801, p = .016, semipartial correlation .186, respectively). The association between after-school field access and overall PA was mediated by use of publicly accessible school facilities for PA. After-school supervised PA and school PA equipment were not associated with overall PA. In adjusted regression analyses including all school factors, days of PE remained correlated to overall PA independent of other school factors (beta= 0.264, p = .007, semipartial correlation = .136). There were no associations between school factors and BMI or TV watching. CONCLUSIONS Based on these study findings, PE is a promising intervention to address improving overall adolescent PA within the school setting.

Validity of self-reported sexually transmitted diseases among African American female adolescents participating in an HIV/STD prevention intervention trial.

Background Studies assessing the validity attributed to self-reported measures of sexually transmitted diseases (STDs) clearly are needed, particularly those used for high-risk populations such as female adolescents, in whom STD prevention is a priority. Goal To determine the accuracy of self-reported STD test results in female adolescents over a relatively brief period (≈28 days). Study Design A prospective, randomized, controlled clinical trial of STD/HIV prevention for African American females, ages 14 to 18, was conducted. Study participants were recruited from medical clinics and school health classes in low-income neighborhoods of Birmingham, Alabama, that had high rates of unemployment, substance abuse, violence, STDs, and teenage pregnancy. Results Of the 522 adolescents enrolled in the trial, 92% (n = 479) completed baseline STD testing and follow-up surveys. At baseline, 28% had positive test results for at least one disease: 4.8% for Neisseria gonorrhoeae, 17.1% for Chlamydia trachomatis, and 12.3% for Trichomonas vaginalis. Of the adolescents with negative STD test results, 98.8% were accurate in their self-report of STD status, as compared with 68.7% of the adolescents with positive results. Underreporting varied by type of STD. Adolescents who accurately reported their positive STD status were significantly more likely to report their receipt of treatment accurately (P < 0.001). Conclusions The substantial underreporting of STD incidence in this study suggests that reliance on self-reports of STD history may introduce misclassification bias, potentially leading to false conclusions regarding the efficacy of prevention interventions. This observation highlights the importance of using biologic indicators as outcome measures.

Methods, Results, and Lessons Learned from Process Evaluation of the High 5 School-Based Nutrition Intervention:

This article describes the process evaluation of High 5, a school-based intervention targeting fruit and vegetable consumption among fourth graders and their families. The outcome evaluation involved 28 schools randomized to intervention or control conditions. The intervention included classroom, family, and cafeteria components. Process evaluation was completed on each of these components by using observations, self-report checklists, surveys, and other measures. Results indicated high implementation rates on the classroom activities. Moderate family involvement was attained, perhaps diminishing intervention effects on parent consumption. Cafeterias provided environmental cues, and fruit and vegetable offerings as directed by the program. A lower dose of the intervention was delivered to schools with larger African American enrollments and lower-income families. This article provides insights into the effective elements of a school-based dietary intervention and provides suggestions for process evaluation in similar studies.

Do local opinion leaders augment hospital quality improvement efforts? A randomized trial to promote adherence to unstable angina guidelines

Background. The influence of an opinion leader intervention on adherence to Unstable Angina (UA) guidelines compared with a traditional quality improvement model was investigated. Research Design. A group-randomized controlled trial with 2210 patients from 21 hospitals was designed. There were three intervention arms: (1) no intervention (NI); (2) a traditional Health Care Quality Improvement Program (HCQIP); and (3) a physician opinion leader in addition to the HCQIP model (OL). Quality indicators included: electrocardiogram within 20 minutes, antiplatelet therapy within 24 hours and at discharge, and heparin and &bgr;-blockers during hospitalization. Hospitals could determine the specific indicators they wished to target. Potential cases of UA were identified from Medicare claims data. UA confirmation was determined by a clinical algorithm based on data abstracted from medical records. Data analyses included both hospital level analysis (analysis of variance) and patient level analysis (generalized linear models). Results. The only statistically significant postintervention difference in percentage compliant was greater improvement for the OL group in the use of antiplatelet therapy at 24 hours in both hospital level (P = 0.01) and patient level analyses (P <0.05) compared with the HCQIP and NI groups. When analyses were confined to hospitals that targeted specific indicators, compared with the HCQIP hospitals, the OL hospitals showed significantly greater change in percentage compliant postintervention in both antiplatelet therapy during the first 24 hours (20.2% vs. −3.9%, P = 0.02) and heparin (31.0% vs.9.1%, P = 0.05). Conclusions. The influence of physician opinion leaders was unequivocally positive for only one of five quality indicators. To maximize adherence to best practices through physician opinion leaders, more research on how these physicians influence health care delivery in their organizations will be required.

Association of consultation between generalists and cardiologists with quality and outcomes of heart failure care

BACKGROUND The appropriate roles for generalists and cardiologists in the care of patients with heart failure (HF) are unknown. The objective of this retrospective cohort study was to determine whether consultation between generalists and cardiologists was associated with better quality and outcomes of HF care. METHODS We studied left ventricular function evaluation (LVFE) and angiotensin-converting enzyme inhibitor (ACEI) use and 90-day readmission and 90-day mortality rates in patients with HF who were hospitalized. Patient care was categorized into cardiologist (solo), generalist (solo), or consultative cares. The processes and outcomes of care were compared by care category using logistic regression analyses fit with generalized linear mixed models to adjust for hospital-related clustering. RESULTS Of the 1075 patients studied, 13% received cardiologist care, 55% received generalist care, and 32% received consultative care. More patients who received consultative care (75%) received LVFE than patients who received generalist care (36%) and cardiologist care (53%; P <.001). Fewer patients who received solo care (54% each) received ACEI compared with 71% of patients who received consultative care (P <.001). After multivariable adjustment, consultative care was associated with higher odds of LVFE than generalist care (adjusted odds ratio [OR], 6.06; 95% CI, 3.97-9.26) or cardiologist care (adjusted OR, 2.96; 95% CI, 1.70-5.13) care. Consultation was also associated with higher odds of ACEI use compared with generalist (adjusted OR, 2.42; 95% CI, 1.42-4.12) or cardiologist (adjusted OR, 2.32; 95% CI, 1.14-4.72) care. Compared with patients who received generalist care, patients who received consultative care had lower odds of 90-day readmission (adjusted OR, 0.54; 95% CI, 0.34-0.86). CONCLUSION Collaboration between generalists and cardiologists, rather than solo care by either, was associated with better HF processes and outcomes of care.