Educational Outcomes of a 4-Year MD-MPH Dual-Degree Program: High Completion Rates and Higher Likelihood of Primary Care Residency.

PURPOSE: In 2007, University of Texas Health Science Center Houston School of Public Health at San Antonio (UTHealth SPH) and UT Health San Antonio Long School of Medicine (LSOM) designed and implemented a 4-year dual MD and Master of Public Health (MPH) program. Dual MD-MPH programs wherein students can receive both degrees within 4 years are unique, and programmatic evaluation may have generalizable implications for accredited MD-MPH programs. METHOD: Demographic information was collected from UTHealth SPH and LSOM student data. The primary outcome variable was MD-MPH program completion in 4 years. Comprehensive Basic Science Examination (CBSE) scores, United States Medical Licensing Examination Step 1 and Step 2 scores, and successful primary care residency match data were compared between MD-MPH and MD-only students. Family medicine, internal medicine, obstetrics-gynecology, and pediatrics were considered primary care residencies, and an analysis excluding obstetrics-gynecology was also conducted. RESULTS: Of 241 MD-MPH students enrolled 2007-2017, 66% were women, 22% Hispanic, and 10% African American. Four-year MD-MPH program completion occurred for 202 (93% of eligible) students; 9 (4.1%) received MD only, 3 (1.4%) received MPH only; and 4 (1.8%) received neither. MD-MPH students' median CBSE score was 2 points lower than for MD-only students (P = .035), but Step 1 and 2 scores did not differ. Primary care residency match was more likely compared with MD-only students, both including and excluding obstetrics-gynecology (odds ratio [OR]: 1.75; 95% confidence interval [CI]: 1.31, 2.33; and OR: 1.36; 95% CI: 1.02, 1.82, respectively). CONCLUSIONS: The 4-year MD-MPH program retains and graduates a socioeconomically and racial/ethnically diverse group of students with a 93% success rate. MD-MPH graduates were more likely to pursue primary care residency than non-dual-degree students, which may have implications for addressing population health disparities.

Development of an E-Cigarettes Education and Cessation Program: A South Texas Oral Health Network Study.

Electronic cigarette (e-cigarette) use, or vaping, among youth and young adults has become a major public health concern. The prevalence of vaping has grown an astounding 900% among high school students from 2011 to 2015, and e-cigarette use among high school students has increased by 78% from 2017 to 2018, largely due to the rise in popularity of the high-dose nicotine product, JUUL. To date, there are few evidence-based e-cigarette cessation programs. To address this need, the South Texas Oral Health Network collaborated with dental practitioners and community members to conduct focus groups assessing knowledge and awareness of e-cigarette use. Based on this feedback, we developed a dental practitioner-based e-cigarette cessation program. The next step will be to utilize this program in a practice-based research network, a "real-world" practice setting that has the potential to increase the number of dental practitioners who counsel their patients about ecigarettes.

Low Adherence to Post Emergency Department Follow-Up Among Hypertensive Patients With Medical Insurance.

BACKGROUND: Improvement in hypertension control in the insured, adult population could improve morbidity and mortality associated with hypertension in the United States. The emergency department (ED) is a potential site of intervention, where individuals are diagnosed with asymptomatic hypertension and referred to primary care. OBJECTIVE: To inform intervention strategies, we identified risk factors of nonadherence to primary care follow-up among individuals aged 18-60 years with a primary discharge diagnosis of asymptomatic hypertension in the ED. METHODS: Data were obtained from a commercial claims database for January 2012-September 2015. A total of 84,929 individuals were included. Rate of nonadherence to primary care follow-up was determined for individuals billed for a primary discharge diagnosis of essential hypertension. Multivariate logistic regression was used to calculate adjusted odds ratios. The relationships between demographic and clinical variables with nonadherence to follow-up were assessed. RESULTS: Two-thirds of the study population did not adhere to follow-up within 30 days of ED discharge. Risk factors for nonadherence included no history of recent visit with primary care (odds ratio [OR] 1.87; 95% confidence interval [CI] 1.81-1.93) and multiple prior ED visits (OR 1.65; 95% CI 1.57-1.73). Protective characteristics included history of filling antihypertensive prescriptions in the last year (OR 0.42; 95% CI 0.40-0.43); or history of filling a 30-day antihypertensive prescription on day of diagnosis (OR 0.83; 95% CI 0.80-0.87). CONCLUSIONS: Individuals without a recent primary care visit or who visit the ED frequently are at higher risk of nonadherence to follow-up for hypertension, despite medical insurance. Insurance status may not overcome individual level barriers to follow-up.

Colorectal cancer screening: Understanding the health literacy needs of hispanic rural residents.

PURPOSE: Hispanics residing in rural areas are among those who are least likely to be screened for colorectal cancer (CRC) and more likely to present with late stage CRC than other racial or ethnic groups. We conducted a pilot study utilizing a mixed-method approach to explore perceptions of CRC and CRC screening among Hispanic adults residing in South Texas rural communities and to identify health literacy needs associated with CRC screening uptake. METHODS: A convenience sample of 58 participants, aged 35-65, were recruited to complete questionnaires and participate in focus groups, ranging in size from 4 to 13 participants. Six focus groups were conducted across 3 adjacent rural counties. A semi-structured moderator's guide was designed to elicit discussion about participants' experiences, knowledge, and perceptions of CRC and CRC screening. FINDINGS: Lack of knowledge of CRC and CRC screening as cancer prevention was a common theme across focus groups. A majority, 59%, reported never been screened. Thirty-nine percent reported they had been screened for colon cancer and 5% reported they did not know if they had been screened. Participants with lower educational levels perceived themselves at high risk for developing CRC polyps, would not want to know if they had CRC, and if they did have CRC, would not want to know until the very end. Limited information about CRC and CRC screening, a lack of specialized providers, limited transportation assistance, and compromised personal privacy in small-town medical facilities were perceived to be barriers to CRC screening. CONCLUSIONS: Low screening rates persist among rural Hispanics. Improving CRC screening literacy and addressing factors unique to rural Hispanics may be a beneficial strategy for reducing screening disparities in this at-risk population.

Development of an Implementation Intervention Using Intervention Mapping to Increase Mammography Among Low Income Women.

Background: Although much work has begun to elucidate contextual factors influencing implementation, the specific processes that facilitate and hinder adoption, implementation, and maintenance of evidence-based interventions (EBIs) in clinical settings remains poorly understood. Intervention Mapping (IM) is a systematic process that facilitates planning and design for dissemination, implementation and maintenance of EBIs in practice. IM has been used to guide the design of many health interventions, focusing on program implementation. Less studied is its use to adapt and scale screening interventions within the healthcare clinic setting. This paper describes the development of an implementation intervention using IM to facilitate the adoption, implementation, and maintenance of an EBI designed to increase mammography adherence in healthcare clinics, the adapted Peace of Mind Program (PMP). Methods: IM framework, Step 5, was used to guide the implementation intervention planning. IM guided identification of specific adoption, implementation, and maintenance performance objectives. We formed an implementation intervention planning group consisting of members of the academic team, our community partner and community health workers (CHWs) with substantial experience working on mammography screening programs in federally qualified health centers (FQHCs) and charity clinics. Results: Results are presented by Intervention Mapping task for Step 5 (Program Implementation Plan). We describe how the consolidated framework for implementation research (CFIR) informed the selection of performance objectives, determinants, methods, and practical applications in the final implementation intervention. Conclusions: This paper provides an example of the use of Intervention Mapping Step 5 and CFIR to create an implementation intervention to support EBI scale up of an evidence-based mammography intervention within a specific setting. Clinical trials registration number: NCT02296177.

Exploring the links between groundwater quality and bacterial communities near oil and gas extraction activities.

Bacterial communities in groundwater are very important as they maintain a balanced biogeochemical environment. When subjected to stressful environments, for example, due to anthropogenic contamination, bacterial communities and their dynamics change. Studying the responses of the groundwater microbiome in the face of environmental changes can add to our growing knowledge of microbial ecology, which can be utilized for the development of novel bioremediation strategies. High-throughput and simpler techniques that allow the real-time study of different microbiomes and their dynamics are necessary, especially when examining larger data sets. Matrix-assisted laser desorption-ionization (MALDI) time-of-flight mass spectrometry (TOF-MS) is a workhorse for the high-throughput identification of bacteria. In this work, groundwater samples were collected from a rural area in southern Texas, where agricultural activities and unconventional oil and gas development are the most prevalent anthropogenic activities. Bacterial communities were assessed using MALDI-TOF MS, with bacterial diversity and abundance being analyzed with the contexts of numerous organic and inorganic groundwater constituents. Mainly denitrifying and heterotrophic bacteria from the Phylum Proteobacteria were isolated. These microorganisms are able to either transform nitrate into gaseous forms of nitrogen or degrade organic compounds such as hydrocarbons. Overall, the bacterial communities varied significantly with respect to the compositional differences that were observed from the collected groundwater samples. Collectively, these data provide a baseline measurement of bacterial diversity in groundwater located near anthropogenic surface and subsurface activities.

Ethnic differences in patients' perceptions towards isolated orthopedic injuries: a pilot study.

BACKGROUND: Patients' perceptions of their healthcare have been reported to influence clinical outcomes following orthopedic trauma. Findings across clinical outcomes have demonstrated significant differences in perceptions towards healthcare between Hispanics and non-Hispanic whites. However, ethnic disparities in perceptions towards orthopedic injuries have not been examined in the literature. AIM OF STUDY: The aim of this pilot study is to explore whether Hispanic patients with isolated orthopedic injuries will demonstrate different perceptions towards their injury as compared to non-Hispanic white patients. The pilot data will be used to inform a subsequent larger clinical investigation and interventional study. METHODS: A total of 43 patients (31 Hispanics and 12 non-Hispanic whites) with isolated orthopedic injuries requiring surgical treatment were enrolled in this cross-sectional observational pilot study. Outcome measures included the Questionnaire of Perceived Injustice (QPI), Short-Form 36 Health Survey (SF-36v2), Pain Catastrophizing Scale, and Consumer Assessment of Healthcare Providers and Systems (CAHPS) Cultural Competence (CC) item set. RESULTS: The CAHPS was completed by 34 patients, and the remaining scoring systems were completed by all 43 subjects enrolled in this study. Hispanic patients trended towards higher QPI scores indicating poorer outcomes than non-Hispanic whites (mean difference [MD] 5.4, 95%; confidence interval [CI] - 4.4, 15.2). The mental component summary score of the SF-36 trended lower in Hispanics as compared to non-Hispanic white (MD - 6.8, 95%; CI - 15.0, 1.4). Hispanic patients also expressed less trust in their doctor on a scale from 0 to 10 (MD - 1.0, 95%; CI - 1.9, - 0.1). CONCLUSIONS: Our study suggests ethnic differences in patients' perceptions towards isolated orthopedic injuries. These results must be interpreted cautiously given the limited number of subjects in this pilot examination. We collected sufficient data to allow a sample size calculation for a subsequent larger clinical investigation. Future clinical investigations may determine the influence of ethnic differences in patients' perceptions towards orthopedic injuries, identify their impact on the functional outcomes, and establish intervention strategies.

Less Exercise and More Drugs: How a Low-Income Population Manages Chronic Pain.

OBJECTIVES: To evaluate chronic pain management in a multistate, low-income Hispanic population, and to examine predictors of exercising and prescription pain medication (PPM) use. DESIGN: Online survey administered to a representative sample of Hispanic adults in June 2015. SETTING: Five southwestern states. PARTICIPANTS: Among all online panel members who were Hispanic (N=1007), aged 35 to 75 years from 5 states, representing 11,016,135 persons, the survey was completed by 516 members (51%). Among these, 102 participants were identified with chronic noncancer pain representing 1,140,170 persons. INTERVENTIONS: Not applicable. MAIN OUTCOME MEASURES: Exercising or using PPM for chronic pain in past year. RESULTS: Most participants reported using PPM (58%) and exercise (54%) to manage pain. Compared with annual household incomes >$75,000, adjusted odds ratios [AORs] for exercising were .20 for <$10,000 (P=.12); .40 for $10,000 to $34,999 (P=.22); and .15 for $35,000 to $74,999 (P=.015). Conversely, AORs for PPM were over 4-fold higher for lower-income groups as follows: 14.2, 4.79, and 4.85, respectively (all P<.065). PPM users rated the importance of accessing a gym to manage pain lower (P=.01), while exercisers rated the feasibility of gym access to manage pain higher (P=.001). CONCLUSIONS: In a Hispanic population-based sample with chronic pain, lower-income groups tended to exercise less but use PPM more. Barriers to gym access and use may play a role in these disparities.

Gaps in the Public's Knowledge About Chronic Pain: Representative Sample of Hispanic Residents From 5 States.

Educating the general public about chronic pain and its care is a national health priority. We evaluated knowledge, attitudes, and beliefs (KAB) of a 5-state, population-based sample of Hispanic individuals aged 35 to 75 years without chronic pain, representing more than 8.8 million persons. A Web-based survey assessed KAB using an adapted version of the Survey of Pain Attitudes-Brief and self-reported knowledge about chronic pain (nothing, a little, a lot). In unweighted analyses of participants (N = 349), the mean age was 52.0 (±10.6) years, 54% were women, 53% preferred Spanish, and 39% did not graduate from high school. More participants reported knowing nothing about chronic pain (24%) than a lot (12%). In weighted logistic models with knowing nothing as the reference, knowing a lot was associated with greater KAB for chronic pain-related emotions, functioning, and cure (all P < .01) but poorer KAB about pain medications (P < .001). Associations were similar for those knowing a little. Men and women preferring Spanish had poorer KAB about pain medications than men preferring English (both P < .001). In view of Hispanic individuals' disparities in chronic pain care, these data underscore the need for effective public educational campaigns about chronic pain. PERSPECTIVE: In this 5-state representative sample of Hispanic individuals without chronic pain, one-quarter reported knowing nothing about chronic pain and had poorer KAB about multiple aspects of this disease. This study reinforces the need to evaluate and address gaps in the general public's knowledge about chronic pain.

Comparing two sampling methods to engage hard-to-reach communities in research priority setting.

BACKGROUND: Effective community-partnered and patient-centered outcomes research needs to address community priorities. However, optimal sampling methods to engage stakeholders from hard-to-reach, vulnerable communities to generate research priorities have not been identified. METHODS: In two similar rural, largely Hispanic communities, a community advisory board guided recruitment of stakeholders affected by chronic pain using a different method in each community: 1) snowball sampling, a chain- referral method or 2) purposive sampling to recruit diverse stakeholders. In both communities, three groups of stakeholders attended a series of three facilitated meetings to orient, brainstorm, and prioritize ideas (9 meetings/community). Using mixed methods analysis, we compared stakeholder recruitment and retention as well as priorities from both communities' stakeholders on mean ratings of their ideas based on importance and feasibility for implementation in their community. RESULTS: Of 65 eligible stakeholders in one community recruited by snowball sampling, 55 (85 %) consented, 52 (95 %) attended the first meeting, and 36 (65 %) attended all 3 meetings. In the second community, the purposive sampling method was supplemented by convenience sampling to increase recruitment. Of 69 stakeholders recruited by this combined strategy, 62 (90 %) consented, 36 (58 %) attended the first meeting, and 26 (42 %) attended all 3 meetings. Snowball sampling recruited more Hispanics and disabled persons (all P < 0.05). Despite differing recruitment strategies, stakeholders from the two communities identified largely similar ideas for research, focusing on non-pharmacologic interventions for management of chronic pain. Ratings on importance and feasibility for community implementation differed only on the importance of massage services (P = 0.045) which was higher for the purposive/convenience sampling group and for city improvements/transportation services (P = 0.004) which was higher for the snowball sampling group. CONCLUSIONS: In each of the two similar hard-to-reach communities, a community advisory board partnered with researchers to implement a different sampling method to recruit stakeholders. The snowball sampling method achieved greater participation with more Hispanics but also more individuals with disabilities than a purposive-convenience sampling method. However, priorities for research on chronic pain from both stakeholder groups were similar. Although utilizing a snowball sampling method appears to be superior, further research is needed on implementation costs and resources.

Examining health literacy among urban African-American adolescents with asthma.

OBJECTIVE: This exploratory study assessed health literacy among urban African-American high school students to improve understanding of the association between adolescent health literacy and asthma. METHODS: We conducted a secondary data analysis of the control group (n = 181) of the Puff City randomized controlled trial (2006-2010), a web-based intervention to promote asthma management among students, grades 9 through 12. A validated self-report 3-item health literacy screening instrument was completed at final online follow-up survey. Logistic regression was used to explore the association between health literacy, demographic characteristics, quality of life, asthma management, and health care utilization. RESULTS: Multivariate analysis revealed that an overall inadequate health literacy score was associated with students who were more likely to be younger (OR 0.61; 95% CI 0.44-0.84), not on Medicaid (OR 0.36; 95% CI 0.17-0.76), have at least one hospitalization (OR 1.29; 95% CI 1.07-1.56); and a lower overall quality of life (OR 0.75; 95% CI 0.59-0.95). Those lacking confidence in filling out medical forms, needing help reading hospital materials, and having difficulty understanding written information were more likely to not have a rescue inhaler (OR 0.49; 95% CI 0.25-0.94), have one or more emergency visits (OR 1.21 95% CI 1.02-1.43), and one or more hospitalizations (OR 1.19; 95% CI 1.01-1.41), respectively. CONCLUSIONS: The findings indicate a significant association between inadequate health literary and suboptimal asthma management. It is important to advance understanding of adolescent health literacy, especially those at-risk, as they assume asthma self-management tasks and move toward independent adult self-care.

National Survey of Medical Spanish Curriculum in U.S. Medical Schools.

BACKGROUND: Patients with limited English proficiency (LEP) may be at risk for medical errors and worse health outcomes. Language concordance between patient and provider has been shown to improve health outcomes for Spanish-speaking patients. Nearly 40 % of Hispanics, a growing population in the United States, are categorized as having limited English proficiency. Many medical schools have incorporated a medical Spanish curriculum to prepare students for clinical encounters with LEP patients. OBJECTIVE: To describe the current state of medical Spanish curricula at United States medical schools. METHODS: The Latino Medical Student Association distributed an e-mail survey comprising 39 items to deans from each U.S. medical school from July 2012 through July 2014. This study was IRB-exempt. RESULTS: Eighty-three percent (110/132) of the U.S. medical schools completed the survey. Sixty-six percent (73/110) of these schools reported offering a medical Spanish curriculum. In addition, of schools with no curriculum, 32 % (12/37) planned to incorporate the curriculum within the next two years. Most existing curricula were elective, not eligible for course credit, and taught by faculty or students. Teaching modalities included didactic instruction, role play, and immersion activities. Schools with the curriculum reported that the diverse patient populations in their respective service areas and/or student interest drove course development. Barriers to implementing the curriculum included lack of time in students' schedules, overly heterogeneous student language skill levels, and a lack of financial resources. Few schools reported the use of validated instruments to measure language proficiency after completion of the curriculum. CONCLUSIONS: Growing LEP patient populations and medical student interest have driven the implementation of medical Spanish curricula at U.S. medical schools, and more schools have plans to incorporate this curriculum in the near future. Studies are needed to reveal best practices for developing and evaluating the curriculum.

Health literacy measurement: an inventory and descriptive summary of 51 instruments.

This article aimed to provide a descriptive review of the psychometric properties and conceptual dimensions of published health literacy measurement tools. PsycINFO and PubMed search from 1999 through 2013, review of the grey literature, and an environmental scan was conducted to identify health literacy measurement tools. For each tool, we evaluated the conceptual dimensions assessed, test parameters, and psychometric properties. Of the 51 tools identified, 26 measured general health literacy, and 15 were disease or content specific, and 10 aimed at specific populations. Most tools are performance based, require in-person administration, and are exclusively available in a pencil and paper testing mode. The tools assess 0 (proxy measure) to 9 of the 11 defined dimensions of health literacy. Reported administration times vary, from less than 1 to 60 minutes. Validation procedures for most of the tools are limited by inadequate power to ensure reliability across subgroups (i.e., race, age, ethnicity, and gender). The health literacy measurement tools currently available generally represent a narrow set of conceptual dimensions with limited modes of administration. Most of the tools lack information on key psychometric properties. Significant work is needed to establish important aspects of the construct, convergent, and predictive validity for many tools. As researchers develop new measures, inclusion of a full range of conceptual dimensions of health literacy, more representative sampling for testing, and additional modes of administration will allow a more refined and flexible approach to research in this field.

Health literacy among insulin-taking African Americans: a need for tailored intervention in clinical practice.

AIMS: To determine the levels of functional health literacy (FHL) among insulin-taking African Americans with diabetes from an urban medical practice and to determine if associations exist between FHL levels and glycemic control. METHODS: Seventy insulin-taking African Americans seen for diabetes management comprised the analysis cohort. Patients were 18 years or older, African American, had diabetes, and currently using insulin via syringe, pen, or insulin pump. All participants completed a one-time assessment of FHL levels, using the Newest Vital Sign (NVS). Scores ranged from 0 to 6 (0-1 = high likelihood of limited FHL; 2-3 = possibility of limited FHL; 4-6 = adequate FHL). A combination of t tests, Pearson's chi-square tests, and multivariate logistic regression models were used to determine associations between glycemic control and FHL. RESULTS: Average age was 58.7, 59.1% were female, 90.8% with type 2 diabetes, and 15.1% using an insulin pump. Glycemic control was: A1C < 7%: 22.9%, A1C < 8%: 47.1%. Of participants, 47.1% had adequate FHL, 31.4% had possible limited FHL, and 21.4% had a high likelihood of limited FHL. Also, 67.7% of participants with A1C ≥ 8% had a high likelihood of limited FHL. After adjusting for age and gender, participants with a high likelihood of limited FHL were 6.2 times (95% confidence interval [CI], 1.4-28.3) more likely to have A1C ≥ 8%. CONCLUSIONS: Insulin-taking African Americans with a high likelihood of limited FHL are approximately 6 times more likely to have an A1C ≥ 8% compared to patients with a possibility of limited FHL, or adequate FHL, demonstrating the need for focused interventions tailored to FHL needs.

Everyday discrimination, diabetes-related distress, and depressive symptoms among African Americans and Latinos with diabetes.

It is not known how discrimination might affect diabetes-related distress (DRD), an important correlate of diabetes outcomes. We examined correlates of discrimination and the influence of discrimination on DRD and depressive symptoms (DS) for African Americans and Latinos with type 2 diabetes. We analyzed survey data (n = 157) collected at enrollment into a diabetes management intervention. Using multiple linear regression, we examined correlates of discrimination and the association between discrimination and DRD and DS. Discrimination was significantly associated with higher DRD for Latinos (b 1.58, 95% CI 1.08, 2.31, p < 0.05), but not significant for African Americans (b 0.96, 95% CI 0.59, 1.57). Discrimination was marginally significantly associated with more DS for Latinos (b 1.43, 95% CI 0.97, 2.12, p < 0.10), but not significant for African Americans (b 1.21, 95% CI 0.87, 1.70). These findings suggest the need to address stressors unique to racial/ethnic minorities to improve diabetes-related outcomes.

A conceptual model of verbal exchange health literacy.

OBJECTIVE: To address a gap in understanding of verbal exchange (oral and aural) health literacy by describing the systematic development of a verbal exchange health literacy (VEHL) definition and model which hypothesizes the role of VEHL in health outcomes. METHODS: Current health literacy and communication literature was systematically reviewed and combined with qualitative patient and provider data that were analyzed using a grounded theory approach. RESULTS: Analyses of current literature and formative data indicated the importance of verbal exchange in the clinical setting and revealed various factors associated with the patient-provider relationship and their characteristics that influence decision making and health behaviors. VEHL is defined as the ability to speak and listen that facilitates exchanging, understanding, and interpreting of health information for health-decision making, disease management and navigation of the healthcare system. A model depiction of mediating and influenced factors is presented. CONCLUSION: A definition and model of VEHL is a step toward addressing a gap in health literacy knowledge and provides a foundation for examining the influence of VEHL on health outcomes. PRACTICE IMPLICATIONS: VEHL is an extension of current descriptions of health literacy and has implications for patient-provider communication and health decision making.

A risk score for identifying overweight adolescents with dysglycemia in primary care settings.

OBJECTIVE: To develop a clinical risk scoring system for identifying adolescents with dysglycemia (prediabetes or diabetes) who need further confirmatory testing and to determine whether the addition of non-fasting tests would improve the prediction of dysglycemia. STUDY DESIGN: A sample of 176 overweight and obese adolescents (10-17 years) had a history/physical exam, a 2-h oral glucose tolerance test, and non-fasting tests [hemoglobin A1c, 1-h glucose challenge test (GCT), and random glucose test] performed. Given the low number of children with diabetes, we created several risk scoring systems combining the clinical characteristics with non-fasting tests for identifying adolescents with dysglycemia and compared the test performance. RESULTS: Sixty percent of participants were white and 32% were black; 39.2% had prediabetes and 1.1% had diabetes. A basic model including demographics, body mass index percentile, family history of diabetes, and acanthosis nigricans had reasonable test performance [area under the curve (AUC), 0.75; 95% confidence interval (95% CI), 0.68-0.82]. The addition of random glucose (AUC, 0.81; 95% CI, 0.75-0.87) or 1-h GCT (AUC, 0.82; 95% CI, 0.75-0.88) to the basic model significantly improved the predictive capacity, but the addition of hemoglobin A1c did not (AUC, 0.76; 95% CI, 0.68-0.83). The clinical score thresholds to consider for the basic plus random glucose model are total score cutoffs of 60 or 65 (sensitivity 86% and 65% and specificity 60% and 78%, respectively) and for the basic plus 1-h GCT model are total score cutoffs of 50 or 55 (sensitivity 87% and 73% and specificity 59% and 76%, respectively). CONCLUSIONS: Pending a validation in additional populations, a risk score combining the clinical characteristics with non-fasting test results may be a useful tool for identifying children with dysglycemia in the primary care setting.

Long-term effects of negotiated treatment plans on self-management behaviors and satisfaction with care among women with asthma.

OBJECTIVE: To examine characteristics of women with negotiated treatment plans, factors that contribute to newly forming a treatment plan, and the impact of plans on asthma management, and their satisfaction with care over 2 years. METHODS: Data came from telephone interviews with 324 women with asthma at baseline, 12 and 24 months. The effect of having a negotiated treatment plan on medication adherence, asking the physician questions about asthma, asthma management self-efficacy, and satisfaction with care was assessed over 24 months. Data were analyzed using mixed models. Analyses controlled for patient characteristics. RESULTS: Thirty-eight percent of participants reported having a negotiated treatment plan at three time points. Seeing an asthma specialist (χ(2)(1) = 24.07, p < .001), was associated with having a plan. Women who did not have a negotiated treatment plan at baseline, but acquired one at 12 or 24 months, were more likely to report greater urgent office visits for asthma (odds ratio (OR) = 1.37, 95% confidence interval (CI) = 1.07-1.61). No associations were observed between having a plan and urgent healthcare use or symptom frequency. When adjusting for household income, level of asthma control, and specialty of the caregiving provider, women who did not have a negotiated treatment plan (OR = 0.28, 95% CI = 0.09-0.79) and those with a plan at fewer than three time points (OR = 0.30, 95% CI = 0.11-0.83) were less likely to report medication adherence and satisfaction with their care (regression coefficient (standard error) = -0.65 (0.17), p < .001). No differences in asthma management self-efficacy or asking the doctor questions about asthma were observed. CONCLUSION: Women with asthma who had a negotiated treatment plan were more likely to see an asthma specialist. In the long-term, not having a treatment plan that is developed in partnership with a clinician may have an adverse impact on medication use and patient views of clinical services.