Verna L. Welch

Methodologies for Improving Response Rates in Surveys of Physicians: A Systematic Review

Although physician surveys are an important tool in health services and policy research, they are often characterized by low response rates. The authors conducted a systematic review of 66 published reports of efforts to improve response rates to physician surveys. Two general strategies were explored in this literature: incentive and design-based approaches. Even small financial incentives were found to be effective in improving physician response. Token nonmonetary incentives were much less effective. In terms of design strategies, postal and telephone strategies have generally been more successful than have fax or Web-based approaches, with evidence also supporting use of mixed-mode surveys in this population. In addition, use of first-class stamps on return envelopes and questionnaires designed to be brief, personalized, and endorsed by legitimizing professional associations were also more likely to be successful. Researchers should continue to implement design strategies that have been documented to improve the survey response of physicians.

Interaction of sleep quality and psychosocial stress on obesity in African Americans: the Cardiovascular Health Epidemiology Study (CHES)

BackgroundCompared with whites, sleep disturbance and sleep deprivation appear more prevalent in African Americans (AA). Long-term sleep deprivation may increase the risk of obesity through multiple metabolic and endocrine alterations. Previous studies have reported contradictory results on the association between habitual sleep duration and obesity. Accordingly, we aimed to assess whether sleep quality and duration are inversely associated with body mass index (BMI) and obesity and test whether these associations are modified by psychosocial stress, known to influence sleep quality.MethodsA sample of 1,515 AA residents of metropolitan Atlanta, aged 30-65 years, was recruited by a random-digit-dialing method in 2007-08. The outcome obesity was defined by BMI (kg/m2) continuously and categorically (BMI ≥ 30 versus BMI < 30). Global sleep quality (GSQ) score was computed as the sum of response values for the seven components of the Pittsburgh Sleep Quality Index (PSQI) scale. GSQ score was defined as a continuous variable (range 0-21) and as tertiles. The general perceived stress (GPS), derived from the validated Cohen scale, was categorized into tertiles to test the interaction. Chi-square tests, correlation coefficients and weighted multiple linear and logistic regression were used to assess the associations of GSQ, GPS and obesity.ResultsThe mean (standard deviation) age was 47.5 (17.0) years, and 1,096 (72%) were women. GSQ score categorized into tertiles was associated with BMI. Among women, after multivariable adjustment that included age, gender, physical activity, smoking status, education, total family income, financial stress and history of hypertension, hypercholesterolemia, diabetes and myocardial infarction, obesity was associated with sleep quality as assessed by GSQ continuous score, [odds ratio, OR (95% C.I.): 1.08 (1.03 - 1.12)], and with a worse sleep disturbance subcomponent score [OR (95% C.I.): 1.48 (1.16 - 1.89)]. Among all participants, stress modified the association between obesity and sleep quality; there was an increased likelihood of obesity in the medium stress category, OR (95% C.I.): 1.09 (1.02 - 1.17).ConclusionSleep quality was associated with obesity in women. The association of sleep quality with obesity was modified by perceived stress. Our results indicate the need for simultaneous assessment of sleep and stress.

Vital Exhaustion as a Risk Factor for Adverse Cardiac Events (from the Atherosclerosis Risk In Communities [ARIC] Study)

Vital exhaustion, defined as excessive fatigue, feelings of demoralization, and increased irritability, has been identified as a risk factor for incident and recurrent cardiac events, but there are no population-based prospective studies of this association in US samples. We examined the predictive value of vital exhaustion for incident myocardial infarction or fatal coronary heart disease in middle-aged men and women in 4 US communities. Participants were 12,895 black or white men and women enrolled in the Atherosclerosis Risk In Communities (ARIC) study cohort and followed for the occurrence of cardiac morbidity and mortality from 1990 through 2002 (maximum follow-up 13.0 years). Vital exhaustion was assessed using the 21-item Maastricht Questionnaire and scores were partitioned into approximate quartiles for statistical analyses. High vital exhaustion (fourth quartile) predicted adverse cardiac events in age-, gender-, and race-center-adjusted analyses (1.69, 95% confidence interval 1.40 to 2.05) and in analyses further adjusted for educational level, body mass index, plasma low-density lipoprotein and high-density lipoprotein cholesterol levels, systolic and diastolic blood pressure levels, diabetes mellitus, cigarette smoking status, and pack-years of cigarette smoking (1.46, 95% confidence interval 1.20 to 1.79). Risk for adverse cardiac events increased monotonically from the first through the fourth quartile of vital exhaustion. Probabilities of adverse cardiac events over time were significantly higher in people with high vital exhaustion compared to those with low exhaustion (p = 0.002). In conclusion, vital exhaustion predicts long-term risk for adverse cardiac events in men and women, independent of established biomedical risk factors.

Patients' Perceptions of Screening for Health Literacy: Reactions to the Newest Vital Sign

Difficulties in caring for patients with limited health literacy have prompted interest in health literacy screening. Several prior studies, however, have suggested that health literacy testing can lead to feelings of shame and stigmatization. In this study, we examine patient reaction to the Newest Vital Sign (NVS), a screening instrument developed specifically for use in primary care. Data were collected in 2008 in the Morehouse School of Medicine, Department of Family Medicine Primary Care Clinics, where health literacy screening was implemented as part of routine intake procedures. Following the visit, patients completed a series of questions assessing their screening experiences. A total of 179 patients completed both the NVS and the reaction survey. Nearly all (> 99%) patients reported that the screening did not cause them to feel shameful. There were also no differences in the reported prevalence of shame (p ≤ .33) by literacy level. Finally, when asked if they would recommend clinical screening, 97% of patients answered in the affirmative. These results suggest that screening for limited health literacy in primary care may not automatically elicit feelings of shame. Even patients with the lowest levels of literacy were both comfortable with and strongly supportive of clinical screening.

Time, Costs, and Clinical Utilization of Screening for Health Literacy: A Case Study Using the Newest Vital Sign (NVS) Instrument

Purpose: Difficulties in identifying and caring for patients with limited health literacy have prompted interest in clinical screening to assess health literacy. Little agreement exists, however, on the utility of such screening. In this case study we explore the business and clinical cases for screening for health literacy using the Newest Vital Sign (NVS), a brief instrument specifically developed for use in primary care settings. Methods: Data were collected in 2008 in the Morehouse School of Medicine Department of Family Medicine Primary Care Clinic, where health literacy screening was implemented as part of routine intake procedures within an ongoing quality improvement effort to improve cardiovascular disease and diabetes outcomes. Specifically, we monitored time requirements, administrative and training costs, and clinician utilization associated with the NVS. Results: Results identified only small time and cost constraints associated with implementing NVS screening. Clinical utility was more problematic, however, because refresher trainings were needed to ensure continued staff and clinician buy-in, use of the NVS data, and implementation of best practices to communicate with at-risk patients. Conclusions: Though the time and cost constraints associated with screening for health literacy were small, clinician utilization of this data in decision making and care processes may require further training and/or support.

Treatment and Control of BP and Lipids in Patients with Hypertension and Additional Risk Factors

BackgroundNCEP ATP III (National Cholesterol Education Program Adult Treatment Panel III) guidelines recommend that for patients at high risk for cardiovascular disease (CVD), lipid-lowering therapy should be considered even at relatively low cholesterol levels (low-density lipoprotein-cholesterol ↓100 mg/dL). Furthermore, the ASCOT-LLA (Anglo-Scandinavian Cardiac Outcomes Trial-Lipid-Lowering Arm) has demonstrated the importance of statin therapy in the primary prevention of major cardiovascular events in people with hypertension and ↓3 cardiovascular risk factors with total cholesterol levels of ↑250 mg/dL (↑6.5 mmol/L).ObjectiveTo analyze the utilization of antihypertensive and lipid-lowering medications, and associated rates of BP and cholesterol goal attainment, in the primary prevention of CVD among patients with hypertension.Study designRetrospective cross-sectional analysis of data from outpatient medical records (including BP, co-morbidities, and medications) abstracted for visits between 1 October 2001 and 30 September 2003 to the Atlanta Veterans Affairs Medical Center (VAMC). Patients were tracked for at least 1 year.PatientsVeterans newly diagnosed with hypertension, with lipid levels ↑240 mg/dL (↑6.2 mmol/L) and no prior coronary heart disease, and who were seeking care at the VAMC were included in the analysis. Patients were grouped by the presence of <3 or ↓3 cardiovascular risk factors in addition to hypertension.Main outcome measuresThe frequency of utilizing antihypertensive and lipid-lowering medications, and attainment of BP targets were assessed based on the Seventh Report of the Joint National Committee on Prevention, Detection, Evaluation, and Treatment of High Blood Pressure (JNC 7) guidelines (<140/90mm Hg, or <130/80mm Hg for patients with diabetes mellitus or chronic kidney disease) and a ratio of total cholesterol/ high-density lipoprotein-cholesterol (HDL-C) <6.ResultsA total of 7839 veterans were included. Mean age was 58.7 ±13.2 years, and 93.8% were men. Among patients with ↓3 cardiovascular risk factors, 81.9% received any antihypertensive medication and 60.4% were prescribed multiple antihypertensive agents compared with 69.7% and 44.3% of patients, respectively, in the group with <3 cardiovascular risk factors. Lipid-lowering medications were prescribed to 55.3% of patients with ↓3 cardiovascular risk factors, and to 33.8% of those with <3 cardiovascular risk factors. Overall, 14.3% of patients met both BP and lipid targets (8.1% and 17.4% of patients with ↓3 and <3 cardiovascular risk factors, respectively [p <0.0001]). JNC 7 goals were attained in 27.9% of patients with ↓3 cardiovascular risk factors and 41.7% of those with <3 cardiovascular risk factors (p <0.001). Total cholesterol/HDL-C ratio <6 was achieved by 32.3% of patients with ↓3 cardiovascular risk factors and 52.1% of those with <3 cardiovascular risk factors (p <0.001).ConclusionVeterans with ↓3 risk factors for CVD were treated more intensively, but levels of goal attainment were lower compared with patients with <3 cardiovascular risk factors. Our results suggest that the therapeutic strategies used by physicians in the Atlanta VAMC need to be adapted in order to improve lipid goal attainment among patients with hypertension, and thereby further reduce the risk of cardiovascular events.

Impact of a Diabetes Disease Management Program by Race and Ethnicity

BackgroundIn the US, diabetes mellitus affects people in all racial and ethnic groups, but the prevalence and risk of complications are considerably higher among African Americans, Hispanics, American Indians, and Alaskan Natives. This study aimed to evaluate the impact of enrollment for at least 1 calendar year in a diabetes disease management program (DDMP) in a large, commercially insured, managed care population. We assessed changes in utilization of preventive services and adoption of diabetes self-management behaviors by race and ethnicity.MethodsParticipants were aged >17 years and had type 1 or 2 diabetes. They were enrolled in a targeted, high-risk level DDMP between January 2003 and September 2003 and were enrolled in the managed care organization (MCO) for a 2-year period beginning 1 year prior to their enrollment in the DDMP. At baseline, 19 483 MCO enrollees who were participating in the targeted high-risk level DDMP were mailed a 40-item, self-administered baseline survey, which took between 10 and 15 minutes to complete. Baseline results are reported elsewhere. One year later, in June 2004, 5174 of the baseline responders were mailed a slightly modified version of the 40-item survey. The survey measured use of eight preventive services (cholesterol test, dental examination, dilated eye examination, urinalysis, foot examination, influenza vaccination, pneumococcal vaccination, and glycated hemoglobin testing) and engagement in four self-management behaviors (blood glucose tests, diet monitoring, exercise, and smoking avoidance).ResultsOf the 5174 follow-up surveys mailed, 1961 (37.9%) were eligible for comparative analysis. Blacks and Hispanics reported more annual healthcare visits (average of 6.2 and 6.5, respectively) compared with Whites (average of 5.0, p < 0.0001). However, at follow-up, both Blacks and Hispanics had lower utilization rates than Whites for six of the eight preventive services that were measured. At follow-up, both Blacks and Whites were more likely than at baseline to report up-to-date status of influenza and pneumococcal vaccination (p ≤ 0.0001). At follow-up, the racial/ethnic gap in self-management behaviors that was observed at baseline had reduced and in fact had reversed direction for glucose tests, as Blacks were more likely than Whites to routinely test their blood glucose.ConclusionsThese data indicate that DDMP enrollment for at least 1 calendar year had a mixed impact on overall diabetes behaviors and on racial/ethnic disparities in preventive services utilization and self-management behaviors. Further studies are needed to give a clearer understanding of why some diabetic MCO enrollees are less likely to use preventive services, and why disparities remain even in settings where healthcare services are universally available.