Lessons learned from community-based participatory research: establishing a partnership to support lesbian, gay, bisexual and transgender ageing in place.

Background: Due to a history of oppression and lack of culturally competent services, lesbian, gay, bisexual and transgender (LGBT) seniors experience barriers to accessing social services. Tailoring an evidence-based ageing in place intervention to address the unique needs of LGBT seniors may decrease the isolation often faced by this population. Objective: To describe practices used in the formation of a community-based participatory research (CBPR), partnership involving social workers, health services providers, researchers and community members who engaged to establish a LGBT ageing in place model called Seniors Using Supports To Age In Neighborhoods (SUSTAIN). Methods: A case study approach was employed to describe the partnership development process by reflecting on past meeting minutes, progress reports and interviews with SUSTAIN's partners. Results: Key partnering practices utilized by SUSTAIN included (i) development of a shared commitment and vision; (ii) identifying partners with intersecting spheres of influence in multiple communities of identity (ageing services, LGBT, health research); (iii) attending to power dynamics (e.g. equitable sharing of funds); and (iv) building community capacity through reciprocal learning. Although the partnership dissolved after 4 years, it served as a successful catalyst to establish community programming to support ageing in place for LGBT seniors. Conclusion: Multi-sector stakeholder involvement with capacity to connect communities and use frameworks that formalize equity was key to establishing a high-trust CBPR partnership. However, lack of focus on external forces impacting each partner (e.g. individual organizational strategic planning, community funding agency perspectives) ultimately led to dissolution of the SUSTAIN partnership even though implementation of community programming was realized.

Assessing capacity for providing culturally competent services to LGBT older adults.

This qualitative, interview-based study assessed the cultural competence of health and social service providers to meet the needs of LGBT older adults in an urban neighborhood in Denver, Colorado, known to have a large LGBT community. Only 4 of the agencies were categorized as "high competency"; 12 were felt to be "seeking improvement" and 8 were considered "not aware." These results indicate significant gaps in cultural competency for the majority of service providers. Social workers are well-suited to lead efforts directed at improving service provision and care competencies for the older LGBT community.

Clinicians' implicit ethnic/racial bias and perceptions of care among Black and Latino patients.

PURPOSE: We investigated whether clinicians' explicit and implicit ethnic/racial bias is related to black and Latino patients' perceptions of their care in established clinical relationships. METHODS: We administered a telephone survey to 2,908 patients, stratified by ethnicity/race, and randomly selected from the patient panels of 134 clinicians who had previously completed tests of explicit and implicit ethnic/racial bias. Patients completed the Primary Care Assessment Survey, which addressed their clinicians' interpersonal treatment, communication, trust, and contextual knowledge. We created a composite measure of patient-centered care from the 4 subscales. RESULTS: Levels of explicit bias were low among clinicians and unrelated to patients' perceptions. Levels of implicit bias varied among clinicians, and those with greater implicit bias were rated lower in patient-centered care by their black patients as compared with a reference group of white patients (P = .04). Latino patients gave the clinicians lower ratings than did other groups (P <.0001), and this did not depend on the clinicians' implicit bias (P = .98). CONCLUSIONS: This is among the first studies to investigate clinicians' implicit bias and communication processes in ongoing clinical relationships. Our findings suggest that clinicians' implicit bias may jeopardize their clinical relationships with black patients, which could have negative effects on other care processes. As such, this finding supports the Institute of Medicine's suggestion that clinician bias may contribute to health disparities. Latinos' overall greater concerns about their clinicians appear to be based on aspects of care other than clinician bias.

The positive predictive value of a hyperkalemia diagnosis in automated health care data.

PURPOSE: Our objectives were to determine performance of coded hyperkalemia diagnosis at identifying (1) clinically evident hyperkalemia and (2) serum potassium>6 mmol/L. METHODS: This retrospective observational study included 8722 patients with diabetes within an integrated healthcare system who newly initiated an angiotensin converting enzyme inhibitor, angiotensin receptor blocker, or spironolactone. The primary outcome was first hyperkalemia-associated event (hospitalization, emergency department visit or death within 24 hours of coded diagnosis and/or potassium≥6 mmol/L) during the first year of therapy. Medical records were reviewed. RESULTS: Among a random sample of 99 patients not coded as having hyperkalemia, none had hyperkalemia upon record review. Among all 64 patients identified as having hyperkalemia, all had hospitalization or emergency department visit associated with coded diagnosis or elevated potassium. Of 55 with coded diagnosis, 42 (PPV 76%) had clinically evident hyperkalemia; 32 (PPV 58%) had potassium≥6. Of 9 identified using only potassium≥6, 7 (PPV 78%) had clinically evident hyperkalemia. CONCLUSIONS: Nearly one-fourth of patients with coded diagnosis do not have clinically evident hyperkalemia and nearly one-half do not have potassium≥6. Because both false positives and negatives occur with coded diagnoses, medical record validation of hyperkalemia-associated outcomes is necessary.

Increasingly restrictive definitions of hyperkalemia outcomes in a database study: effect on incidence estimates.

PURPOSE: To determine the incidence of hyperkalemia-associated adverse outcomes among ambulatory patients with diabetes newly initiating renin-angiotensin-aldosterone system (RAAS) inhibitor therapy and to examine to what extent increasingly restrictive definitions of hyperkalemia-associated outcomes influenced incidence estimates. METHODS: Retrospective cohort study of 27 355 individuals with diabetes who were new users of RAAS inhibitors at three integrated healthcare systems. RESULTS: Using the least restrictive definition of hyperkalemia-associated outcome, an ambulatory visit (AV), inpatient hospitalization (IP), or emergency department (ED) visit co-occurring within 7 days of coded hyperkalemia diagnosis and/or potassium concentration of > or =5.5 mmol/L, the incidence rate of hyperkalemia was 30.1 per 1000 person-years (p-y). Restricting to only IP or ED visits co-occurring within 24 hours of coded diagnosis and/or potassium > or =6 mmol/L, the incidence rate was 10.2 per 1000 p-y. When this latter definition was further restricted by removing available potassium laboratory values, the incidence rate declined to 9.5 per 1000 p-y. CONCLUSIONS: Modifying the definition of hyperkalemia-associated outcome resulted in up to threefold differences in incidence rate estimates. Our results demonstrate the value of including potassium laboratory results and AVs in identifying hyperkalemia from electronic data. Comparing incidence estimates across published studies requires consideration of differences in outcome definitions.

Perspectives of LGBTQ Older Adults on Aging in Place: A Qualitative Investigation.

This qualitative study conducted by a community-research partnership used multiple types of data collection to examine variables relevant for LGBTQ older adults who wished to age in place in their urban Denver neighborhood. Focus groups, interviews, and a town hall meeting were used to identify barriers and supports to aging in place. Participants (N = 73) identified primarily as lesbian or gay, aged 50-69, and lived with a partner. Ageism, heterosexism, and cisgenderism emerged as cross-cutting themes that negatively impact access to health care, housing, social support, home assistance, and legal services. Resilience from weathering a lifetime of discrimination was identified as a strength to handle aging challenges. Recommendations for establishing an aging in place model included establishing welcoming communities and resource centers and increasing cultural competence of service providers. This study provides a unique contribution to understanding the psychosocial, medical, and legal barriers for successfully aging in place.

Pharmaceuticals from development to practice: learnings from an online curriculum.

OBJECTIVE: To report outcomes of a pilot online curriculum educating clinicians about off-label prescribing, finding unbiased sources of pharmaceutical information, and responding to patient inquiries about direct-to-consumer advertised medications. STUDY DESIGN: Case study. METHODS: We developed 3 case-oriented Internet modules to educate healthcare professionals about off-label prescribing, accessing and appraising unbiased drug information, and talking with patients about direct-to-consumer advertising. Modules included reflective questions and opportunities to asynchronously ask questions of faculty. Pilot testing occurred among 52 Kaiser Permanente Colorado prescribing clinicians from May 2007 through September 2007. We assessed self-reported changes in knowledge, intent-to-change practice, and barriers to practice change. We also examined curriculum participant pre-post changes in prescribing of selected highly advertised medications. RESULTS: Most participants reported changes in knowledge after curriculum completion, many made intent-to-change practice statements at curriculum completion, and several reported changes in practice 3 to 6 months after curriculum completion. Six categories of barriers to practice change were noted. Prescribing of targeted medications rose by 0.8 prescription per month in the intervention group and by 6.3 prescriptions per month in the control group, but this difference was not significant (P = .17). CONCLUSIONS: Targeted curricula on aspects of the pharmaceutical development, approval, and marketing process can lead to subjective changes in clinician knowledge and can facilitate intent-to-change practice. Larger studies are needed to assess the effect of such interventions on prescribing patterns.

Prescribers' and Organizational Leaders' Preferences for Education about Heavily Marketed Drugs.

OBJECTIVE: We conducted a study to assess the educational needs and interests of medication prescribers and organizational needs regarding heavily marketed drugs. STUDY DESIGN: We used an Internet and paper-based educational needs assessment survey to gather data. METHODS: Approximately 1000 Denver-area Kaiser Permanente Colorado (KPCO) physicians, nurse practitioners, and physician assistants ("health maintenance organization [HMO] prescribers"); 780 Colorado Springs KPCO network (preferred provider organization [PPO] prescribers); and 36 Denver-area KPCO pharmacy leaders were surveyed. Prescribers were asked about interest in pharmaceutical development, approval, and marketing processes and interest in learning about accessing and using drug information in practice. They were also asked to identify areas in which they would like to improve prescribing practices. Organizational leaders were asked about areas in which curricula could assist current cost-effective prescribing efforts. HMO prescriber and leader surveys were conducted via the Internet. PPO learner surveys were conducted by mail. RESULTS: Responses were collected from 127 (13%) HMO and 70 (9%) PPO prescribers. Top interest areas in both groups were accessing unbiased drug information, comparing evidence about drugs within class, critical appraisal of drug information, off-label drug use, and addressing patient medication inquiries. Pharmaceutical industry marketing practices, roles and responsibilities of the US Food and Drug Administration, and the US drug development and approval process were rated lowest. HMO prescribers most wanted to improve prescribing for bacterial infections, depression, and diabetes; PPO prescribers also wanted to improve prescribing for migraine headaches. Highest organizational priority drug classes were those for depression and asthma. CONCLUSIONS: Prescribers are interested in areas of pharmaceutical development and marketing that relate closely to providing patient care, especially in commonly seen clinical conditions. They are less interested in regulatory or policy aspects of the process.