Validation of a Genomic Classifier for Predicting Post-Prostatectomy Recurrence in a Community Based Health Care Setting.

PURPOSE: We determined the value of Decipher®, a genomic classifier, to predict prostate cancer outcomes among patients after prostatectomy in a community health care setting. MATERIALS AND METHODS: We examined the experience of 224 men treated with radical prostatectomy from 1997 to 2009 at Kaiser Permanente Northwest, a large prepaid health plan in Portland, Oregon. Study subjects had aggressive prostate cancer with at least 1 of several criteria such as preoperative prostate specific antigen 20 ng/ml or greater, pathological Gleason score 8 or greater, stage pT3 disease or positive surgical margins at prostatectomy. The primary end point was clinical recurrence or metastasis after surgery evaluated using a time dependent c-index. Secondary end points were biochemical recurrence and salvage treatment failure. We compared the performance of Decipher alone to the widely used CAPRA-S (Cancer of the Prostate Risk Assessment Post-Surgical) score, and assessed the independent contributions of Decipher, CAPRA-S and their combination for the prediction of recurrence and treatment failure. RESULTS: Of the 224 patients treated 12 experienced clinical recurrence, 68 had biochemical recurrence and 34 experienced salvage treatment failure. At 10 years after prostatectomy the recurrence rate was 2.6% among patients with low Decipher scores but 13.6% among those with high Decipher scores (p=0.02). When CAPRA-S and Decipher scores were considered together, the discrimination accuracy of the ROC curve was increased by 0.11 compared to the CAPRA-S score alone (combined c-index 0.84 at 10 years after radical prostatectomy) for clinical recurrence. CONCLUSIONS: Decipher improves our ability to predict clinical recurrence in prostate cancer and adds precision to conventional pathological prognostic measures.

Factors affecting medication adherence trajectories for patients with heart failure.

OBJECTIVES: To examine the relationship between patient characteristics and medication adherence trajectories for patients with congestive heart failure (CHF). STUDY DESIGN: Historical prospective study. METHODS: We conducted a secondary analysis of data assembled for the Practice Variation and Care Outcomes (PRAVCO) study, which examined patterns of cardiovascular care. We used group based trajectory modeling to define medication adherence trajectories, and then modeled factors associated with belonging to a trajectory group during the 6year period from 2005 to 2010 (n = 10,986). We focused on the use of angiotensin-converting enzyme (ACE) inhibitors or angiotensin II receptor blockers (ARBs) for secondary prevention of CHF. RESULTS: Four trajectory groups were optimal in characterizing adherence level patterns: 1) low adherence group, with an initial average adherence rate of 62% that dropped to between 40% and 50%; 2) increasing adherence group, with an initial average adherence rate of 55% that increased to 90%; 3) decreasing adherence group, with an initial average adherence rate above 90% that decreased to 60%; 4) high adherence group, with an average adherence rate consistently above 90%. Age, region, education, smoking, and race were all significantly associated with the likelihood of belonging to a particular trajectory. Nonwhites were less likely to be in the high adherence group, and smoking was more common in the low adherence group (22%) than in the high group (10%); increasing body mass index and Charlson Comorbidity Index (CCI) scores were also associated with being in the low adherence group. CONCLUSIONS: Population characteristics associated with sustained low adherence might be used to target interventions and improve vulnerable patients' prospects of heart health.

The dynamic behavior of the early dental caries lesion in caries-active adults and implications.

OBJECTIVE: To describe the full range of behavior of the visible, noncavitated, early caries lesion in caries-active adults with substantial fluoride exposure, and to consider implications. METHODS: The data were from the Xylitol for Adult Caries Trial (X-ACT) collected annually for 33 months using condensed ICDAS caries threshold criteria. Individual tooth surfaces having a noncavitated caries lesion were included, and the patterns of transition to each subsequent annual clinical examination to sound, noncavitated or cavitated, filled or crowned were determined. The resulting sets of patterns for an individual tooth surface, looking forward from its first appearance as a noncavitated lesion, were combined into one of four behavior profiles classified as reversing, stable, oscillating, or continuously progressing, or were excluded if not part of the caries continuum. The distributions of profile types were assessed using the Rao-Scott chi-square test, which adjusts for clustering of tooth surfaces within teeth. RESULTS: Inter- and intra-examiner kappa scores demonstrated acceptable calibration at baseline and annually. 8084 tooth surfaces from 543 subjects were included. The distribution of profile types differed significantly between coronal and root surfaces. Overall, two-thirds of all coronal noncavitated lesions were first seen at baseline, half reversed, over a fifth were stable, 15% oscillated, and only 8.3% progressed to cavitation, filled, or crowned in 33 months or less (6.3% consistently Progressed plus 2.0% inconsistently, a subset of oscillating, which oscillated before progressing to cavitation). Approximal, smooth, and occlusal coronal surfaces each were significantly different in their individual distributions of profile types. Xylitol showed no significant and consistent effect on this distribution by tooth surface type. This was in keeping with the X-ACT's lack of effect of xylitol at the noncavitated plus cavitated lesion thresholds combined. CONCLUSIONS: This study demonstrated the full dynamic range of early caries lesion behavior. The great majority were not progressive, and few (8.3%) became cavitated over 33 months in caries-active adults using fluorides. Important caries management implications favoring recorded longitudinal monitoring, prevention of active risks, and minimal restoration only after direct visual determination of cavitation are discussed.

Visual scoring of non cavitated caries lesions and clinical trial efficiency, testing xylitol in caries-active adults.

OBJECTIVES: To better understand the effectiveness of xylitol in caries prevention in adults and to attempt improved clinical trial efficiency. METHODS: As part of the Xylitol for Adult Caries Trial (X-ACT), non cavitated and cavitated caries lesions were assessed in subjects who were experiencing the disease. The trial was a test of the effectiveness of 5 g/day of xylitol, consumed by dissolving in the mouth five 1 g lozenges spaced across each day, compared with a sucralose placebo. For this analysis, seeking trial efficiency, 538 subjects aged 21-80, with complete data for four dental examinations, were selected from the 691 randomized into the 3-year trial, conducted at three sites. Acceptable inter- and intra-examiner reliability before and during the trial was quantified using the kappa statistic. RESULTS: The mean annualized noncavitated plus cavitated lesion transition scores in coronal and root surfaces, from sound to carious favoured xylitol over placebo, during the three cumulative periods of 12, 24, and 33 months, but these clinically and statistically nonsignificant differences declined in magnitude over time. Restricting the present assessment to those subjects with a higher baseline lifetime caries experience showed possible but inconsistent benefit. CONCLUSIONS: There was no clear and clinically relevant preventive effect of xylitol on caries in adults with adequate fluoride exposure when non cavitated plus cavitated lesions were assessed. This conformed to the X-ACT trial result assessing cavitated lesions. Including non cavitated lesion assessment in this full-scale, placebo-controlled, multisite, randomized, double-blinded clinical trial in adults experiencing dental caries did not achieve added trial efficiency or demonstrate practical benefit of xylitol. TRIAL REGISTRATION: ClinicalTrials.Gov NCT00393055.

Personal health record use and association with immunizations and well-child care visits recommendations.

OBJECTIVE: To determine the association of parental use of integrated personal health records (PHRs) with children's adherence to immunization and well-child care (WCC) visit recommendations. STUDY DESIGN: For the immunization and WCC visit measures, we retrospectively analyzed, respectively, 766 and 639 matched pairs at Kaiser Permanente (KP) Hawaii and 2795 and 2448 pairs at KP Northwest who were ≤ 31 days old at enrollment and continuously enrolled for 2 years between January 2007 and July 2011. The independent variable (≥ 1 PHR feature used vs none) was matched using propensity scores on parental and children characteristics. The dependent variables were 2 measures from the 2010 Healthcare Effectiveness Data and Information Set: combination 2 immunization (all immunizations vs .05; KP Northwest OR 1.2, 95% CI 1.0-1.3, P < .05). PHR use was associated with better adherence to WCC visit recommendations for both KP Hawaii (OR 1.9, 95% CI 1.3-2.9, P < .001) and KP Northwest (OR 2.5, 95% CI 2.1-2.9, P < .001). CONCLUSIONS: Young children whose parents used a PHR were more likely to adhere to the recommended WCC visits in both regions but immunizations in only 1 region.

Immunohistochemical expression of ERG in the molecular epidemiology of fatal prostate cancer study.

BACKGROUND: Gene fusions between the ERG transcription factor and the androgen-regulated gene TMPRSS2 occur in a subset of prostate cancers and contribute to transformation of prostatic epithelial cells. Prior reports have used fluorescence in situ hybridization (FISH) or quantitative PCR (QPCR) to determine the presence of TMPRSS2-ERG fusions or ERG expression, respectively. Recently, several groups have reported on immunohistochemistry (IHC) to measure ERG expression, which is much more readily performed in clinical practice. However, the prior studies examining ERG expression by IHC had small sample sizes or they failed to clarify the association of ERG protein expression with important clinico-pathological features or prostate cancer-specific mortality. METHODS: To address these deficits, we evaluated ERG expression by IHC in 208 radical prostatectomy samples from the Kaiser Permanente Molecular Epidemiology of Fatal Prostate Cancer (MEFPC) study, a case-control study of prostate cancer-specific mortality. RESULTS: Nuclear ERG expression was seen in neoplastic prostate epithelia in 49 of the samples (23.7%). ERG expression in tumor cells was associated with higher tumor stage (OR = 2.0, 95% confidence interval 1.0-4.0, P value = 0.04). ERG immunoreactivity was positively associated with prostate cancer-specific mortality, although the confidence interval was wide (OR = 1.9, 95% confidence interval 0.88-4.0, P value = 0.10). CONCLUSIONS: Our results demonstrate that ERG protein expression is readily quantifiable with an existing commercial antibody. Evaluating ERG protein expression may improve our ability to identify the subset of more aggressive, invasive prostate cancers.

Glycemic index and glycemic load are associated with some cardiovascular risk factors among the PREMIER study participants.

BACKGROUND: The clinical significance of glycemic index (GI) and glycemic load (GL) is inconclusive. OBJECTIVE: This study was conducted to examine the association of GI and GL with clinical cardiovascular disease (CVD) risk factors including body weight, blood pressure (BP), serum lipids, fasting glucose, insulin and homocysteine over time among the PREMIER participants. DESIGN: PREMIER was an 18-month randomized lifestyle intervention trial, conducted from 2000 to 2002, designed to help participants reduce BP by following the Dietary Approaches to Stop Hypertension (DASH) dietary pattern, losing weight, reducing sodium and increasing physical activity. GI and GL were estimated from 24 h diet recall data at baseline, 6 and 18 months after intervention. PROC MIXED model was used to examine the association of changes in GI or GL with changes in CVD risk factors. RESULTS: A total of 756 randomized participants, 62% females and 34% African Americans and who averaged 50.0±0.3 years old and 95.3±0.7 kg, were included in this report. Neither GI nor GL changes was associated with changes in any risk factors at 6 months. At 18 months, however, the GI change was significantly and positively associated with total cholesterol (TC) change only (p<0.05, ß=23.80±12.11 mg/dL or 0.62±0.31 mmol/L) with a significant age interaction. The GL change was significantly associated with TC (p=0.02, ß=0.28±0.15 mg/dL or 0.01±0.00 mmol/L) positively and with low density lipoprotein cholesterol (LDL-C) changes negatively (p=0.03, ß=-0.01±0.00 mg/dL or -0.00±0.00 mmol/L), and significant age interactions were observed for both. CONCLUSIONS: GI and GL was associated with TC and LDL-C after controlling for energy, fat and fiber intake and other potential confounders and the associations were modified by age. Further investigation into this relationship is important because of its potential clinical impact.

US acculturation is associated with health behaviors and obesity, but not their change, with a hotel-based intervention among Asian-Pacific Islanders.

BACKGROUND: Immigration to the United States has been associated with obesity, yet the relationship of acculturation to obesity and energy balance (ie, physical activity/dietary intake) in adults is a complex issue. Limited longitudinal data are available on immigrant Asians and Pacific Islanders. DESIGN: Analyses were conducted on baseline data and change data from baseline to 24 months in the hotel-based cluster-randomized Work, Weight and Wellness trial involving 15 control and 15 intervention hotels on the island of Oahu, Hawaii. SAMPLE: Participants were adult employees of predominantly Asian and Pacific Islander ancestry who were assessed one or more times over the course of 24 months. The full sample consisted of 4,236 hotel workers (about 40% of hotel workforce) at baseline, 3,502 hotel workers at Year 1 and 2,963 hotel workers at the 24-month follow up. One thousand one hundred fifteen hotel workers had at least two measurements, and were included in the analysis. INTERVENTION: The Work, Weight, and Wellness trial was designed to promote weight loss via motivation and support for increases in physical activity and increased access to and consumption of healthy low-fat/low-energy foods. The measure of acculturation consisted of a score that was a compilation of a participant's age when he or she immigrated to the United States, country of birth, language spoken at home, and years of education. STATISTICAL ANALYSES: We used mixed effect regression models for cross-sectional baseline models and longitudinal multilevel regression analysis of change in diet and physical activity behaviors and obesity over time using a random intercept. Estimates of the intervention effect are expressed as an annual rate of change for all study outcomes. RESULTS: At baseline acculturation was positively associated with body mass index; physical activity level; and fruit, meat, and sweetened drink intake level. In analyses of change across 24 months, acculturation did not significantly influence change in dietary intake or indexes of obesity (ie, body mass index or waist-to-height ratio). However physical activity increased significantly more in the intervention group during the course of the intervention compared with the control group, which decreased activity, when sociodemographic factors (including acculturation) and food intake behavior were controlled for.

Procedures used to standardize data collected by RT3 triaxial accelerometers in a large-scale weight-loss trial.

BACKGROUND: Accelerometers measure intensity, frequency, and duration of physical activity. However, the scarcity of reports on data reduction makes comparing accelerometer results across studies difficult. METHODS: Participants were asked to wear a triaxial accelerometer (RT3) for ?10 hours for at least 4 days, including one weekend day. We summarize our data-cleaning procedures and assess the impact of defining a usable day of measurements as at least 6, 8, or 10 hours of wear time, and of standardizing data to a 12-hour day. RESULTS: Eighty-two percent of participants met wear time requirements; 93% met requirements when we defined a day as 8-or-more hours of wear time. Normalization of data to a 12-hour day had little impact on estimates of daily moderate-to-vigorous physical activity (MVPA; 16.9 vs. 17.1 minutes); restricting MVPA to activities occurring in bouts of 10 minutes or longer had greater impact (16.9 vs. 6.3 minutes per day). CONCLUSION: Our account of accelerometry quality-control and data-cleaning procedures documents the small impact of variations in daily wear time requirements on MVPA estimates, and the larger impact of evaluating total MVPA vs. MVPA occurring in extended bouts. This paper should allow other researchers to duplicate or revise our methods as needed.

Patterns of physical activity among overweight and obese adults.

INTRODUCTION: Little is known about patterns of physical activity in overweight and obese adults, although they are at high risk for chronic disease and can benefit from physical activity. We describe patterns of moderate-to-vigorous physical activity (MVPA) and MVPA in bouts of 10 minutes or longer in overweight and obese adults. METHODS: Overweight and obese participants (n = 1,648) who were screened for the multicenter Weight Loss Maintenance Trial wore RT3 accelerometers for at least 3 weekdays and 1 weekend day. We determined minutes spent in moderate physical activity, vigorous physical activity, and MVPA overall, by weekday vs weekend, and by time of day. We also measured bouts of at least 10 minutes of sustained MVPA. RESULTS: Participants were active for an average of 15.8 minutes per day. Among those who engaged in bouts of MVPA, the average bout was 33.3 minutes long. Participants who were younger than 50 years, male, non-African American, or overweight were more active than were those who were older than 50, female, African American, or obese. Participants were more active on weekends than on weekdays and in the morning than in the afternoon or evening. Only 2% of participants were active for 60 or more minutes per day. CONCLUSION: We found differences in physical activity patterns by demographic characteristics, day, and time of day. Weekend mornings may be an opportune time to promote additional physical activity.

Reliability of RT3 accelerometers among overweight and obese adults.

PURPOSE: Accurate and reliable measurement of physical activity plays an important role in assessing effective lifestyle interventions for obesity. This study examined reliability of accelerometer-based estimates of physical activity levels of overweight and obese adults before and after a lifestyle weight loss program. METHODS: Participants were overweight and obese (body mass index = 25-45 kg x m) members (n = 1592; 67% female, 42% African American) of the multicenter weight loss maintenance trial. They wore RT3 accelerometers during waking hours for 7 d at baseline and after a 6-month weight loss intervention that included diet and physical activity recommendations. Moderate-to-vigorous physical activity (MVPA) and MVPA occurring in bouts >or=10 min (bout MVPA) were assessed. RESULTS: At baseline, wear time minimums of 10 and 6 h.d resulted in similar average minutes per day of MVPA (18.3 and 18.0 min) and MVPA bout minutes per day (6.9 and 6.7 min). Similar wear times occurred after the weight loss intervention for MVPA (27.0 and 26.8 min) and bout MVPA (15.1 and 15.0 min). Reliability measurements by intraclass correlation (ICC) were larger for 4 versus 2 d x wk minimum wear time for both MVPA and bout MVPA (4-d ICC = 0.27-0.44 and 2-d ICC = 0.19-0.38), but there was little increase in ICC comparing 4 (ICC = 0.27-0.44) and 7 d x wk (ICC = 0.30-0.46). CONCLUSIONS: Longer wear time requirements did not result in significant increases in reliability. Using 4 d of data with >or=6 h x d of wear time optimized the balance between ICC and participant burden in overweight and obese adults before and after a weight loss intervention. Future investigations using accelerometers to estimate MVPA in overweight and obese samples can consider requiring less monitor wear time.

Biobank Recruitment: Motivations for Nonparticipation.

Molecular data, essential for genomics research, can be captured more efficiently in large-scale, population-based biobanks of genetic material rather than by individual studies. Biobanks also offer improved quality and reliability of genetic samples and access through automated sample retrieval. However, it is challenging to adequately inform participants of the broad nature of the research and participation risks and benefits. In addition, recent studies suggest concerns about data sharing and return of research results, or future research topics (eg, stereotypical or potentially stigmatizing traits). We evaluated the interest in participating in a biobank and reasons for nonparticipation.

Performance of the U.S. Office of Management and Budget's Revised Race and Ethnicity Categories in Asian Populations*

OBJECTIVES: The U.S. Office of Management and Budget (OMB) guidelines for collecting and reporting race and ethnicity information recently divided the "Asian or Pacific Islander" category into "Asian" and "Native Hawaiian or Other Pacific Islander". The OMB's decision to disaggregate the "Asian or Pacific Islander" category was the first step toward providing these communities with information to better serve their needs. However, whether individuals who formerly made up the combined group categorize themselves as the new guidelines intend is a question analyzed in this report. METHODS: A subset of adults participating in the Hemochromatosis and Iron Overload Screening Study completed both the OMB-minimum and the expanded race and ethnicity measure used in the National Health Interview Survey. We compared responses on the expanded measure contained within the OMB "Asian" definition (Filipino, Korean, Vietnamese, Japanese, Asian Indian, Chinese, and/or Other Asian) to "Asian" responses on the OMB-minimum measure. RESULTS: Mixed heritage Asians less often marked "Asian". Among mixed heritage Japanese, Chinese, and Filipinos, 27%, 49%, and 52% did not mark "Asian" on the OMB measure, respectively. Eleven percent of single-heritage Filipinos did not mark "Asian." CONCLUSIONS: Many individuals formerly making up the combined "Asian or Pacific Islander" group do not categorize themselves as the revised OMB guidelines intend. This is particularly evident among Filipinos and among Asians of mixed heritage. This research illuminates the reliability and utility of the broad "Asian" category and points to possible consequences of collapsing groups into a single category, i.e., missed information and/or erroneous generalization.

The PREMIER intervention helps participants follow the Dietary Approaches to Stop Hypertension dietary pattern and the current Dietary Reference Intakes recommendations.

OBJECTIVE: To examine the influence of the PREMIER study lifestyle interventions on dietary intakes and adherence to the Dietary Approaches to Stop Hypertension (DASH) dietary pattern and the Dietary Reference Intakes (DRI). DESIGN: An 18-month multicenter, randomized controlled trial comparing two multicomponent lifestyle intervention programs to an advice only control group. SUBJECTS/SETTING: A total of 810 participants were recruited from local communities and randomized into the study. Individuals were eligible if they were aged 25 years or older, had body mass index between 18.5 and 45.0, not taking antihypertensive medication, and had prehypertension or stage 1 hypertension (systolic blood pressure 120 to 159 mm Hg and diastolic blood pressure 80 to 95 mm Hg). INTERVENTION: The two active intervention programs were a behavioral lifestyle intervention that implements established recommendations, and an established intervention plus the DASH dietary pattern. Both interventions consisted of intensive group and individual counseling sessions. The control group received a brief advice session after randomization and again after 6 months of data collection. Dietary intakes were collected by two random 24-hour recalls at baseline, 6 months, and 18 months. MAIN OUTCOME MEASURES: The primary outcome of the PREMIER study was change in systolic blood pressure at 6 months. The main outcomes examined here include dietary variables collected by 24-hour recall at each time point. STATISTICAL ANALYSES: Nutrient intakes were calculated and compared among the time points and the three intervention groups using mixed models with repeated measures at 6 and 18 months. Proportion of participants who met or achieved the original DASH nutrient intake levels and the DRIs were calculated and compared among the three intervention groups. P<0.01 was considered statistically significant. RESULTS: Participants in both the established intervention and established intervention plus DASH dietary pattern groups substantially reduced energy, total fat, saturated fat, and sodium intake and these reductions persisted throughout the study. Established intervention plus DASH dietary pattern group participants increased intakes of fruits, vegetables, dairy, and many vitamins and minerals; these increases were significantly greater than that of the control and established intervention groups. A majority of established intervention plus DASH dietary pattern group participants achieved at least two thirds of the DRI recommendations for most nutrients at 6 months, despite their reduction in total energy intake. Some but relatively small recidivism occurred at 18 months. CONCLUSIONS: Both the established intervention and established intervention plus DASH dietary pattern group intervention were effective in helping participants follow established recommendations to control blood pressure. The advice-only control group also made some behavior changes, mainly decreasing energy and sodium intake. Only the established intervention plus DASH dietary pattern group significantly increased intakes of DASH-specific food groups, including fruits, vegetables, and dairy products, and nutrients, including protein, fiber, calcium, potassium, and magnesium. Most of the increases did not reach the levels consumed in the original DASH feeding studies. Whereas the established intervention plus DASH dietary pattern group intervention provides a useful platform to achieve the DASH dietary pattern and current DRI recommendations, intervention enhancements, including a greater emphasis on nutrient-dense foods, would likely improve this intervention.

Using an asthma control questionnaire and administrative data to predict health-care utilization.

OBJECTIVE: To examine the merits of the Asthma Therapy Assessment Questionnaire (ATAQ) control index together with prior asthma health-care utilization from administrative data in predicting future acute asthma health-care utilization. DESIGN: Prospective cohort study. POPULATION: A total of 4,788 adult asthma patients aged 17 to 93 years who completed a baseline evaluation and had at least 6 months of follow-up data. STATISTICAL METHODS: Classification and regression tree methodology to predict future risk of acute health-care utilization events. RESULTS: These results show that the ATAQ control index and administrative data are jointly useful for predicting future health-care utilization. The utility of the ATAQ control index in the presence of information about prior health-care utilization is to further stratify risk among the subset of younger individuals who did not have any prior acute health-care utilization. While administrative health-care utilization data served as the strongest predictor of future health-care utilization, the ATAQ control index helped to identify 1% of individuals without recent acute care that had approximately a sixfold elevated risk (95% confidence interval, 4.2 to 8.4) of future acute health-care utilization. This is an important result since only a small fraction of individuals with acute events in a given year will have had acute events in the previous year. CONCLUSION: These findings should assist the practicing clinician and organizations interested in population-based asthma disease management.

Electronic medical record reminder improves osteoporosis management after a fracture: a randomized, controlled trial.

OBJECTIVES: Osteoporosis treatment rates after a fracture are low. This study evaluated methods to increase guideline-recommended osteoporosis care postfracture. DESIGN: Participants were randomly assigned to usual care or one of two interventions. Analysis of primary outcomes used electronic data and linear regression. SETTING: A Pacific Northwest nonprofit health maintenance organization. PARTICIPANTS: Female patients aged 50 to 89 who suffered a fracture in 1999 and had not received bone mineral density (BMD) measurement or medication for osteoporosis (n=311) and their primary care providers (n=159). INTERVENTION: Patient-specific clinical guideline advice to the primary care provider delivered by electronic medical record (EMR) message or electronic reminder to the provider plus an educational letter mailed to the patient. MEASUREMENTS: BMD measurement and osteoporosis medication. RESULTS: At 6 months, provider reminder resulted in 51.5% of patients receiving BMD measurement or osteoporosis medication, provider reminder plus patient education resulted in 43.1%, and usual care resulted in 5.9% (P<.001). The effect of provider advice combined with patient education was not significantly different from provider advice alone (P=.88). Patients aged 60 to 69 were 18% (95% confidence interval=3-34) more likely to receive BMD measurement or an osteoporosis medication than those aged 80 to 89. CONCLUSION: Patient-specific postfracture advice to the provider through an EMR message significantly increased BMD measurement and osteoporosis medication. As EMRs become more widespread, this intervention could improve osteoporosis management for many postfracture patients. Future research should identify barriers to and facilitators of care for older, high-risk patients.

Informing cancer prevention strategies for African Americans: the relationship of African American acculturation to fruit, vegetable, and fat intake.

Acculturation has been associated with health-related behaviors in African Americans. We sought to determine if there is a relationship between acculturation and dietary intake in African Americans. African Americans in the PREMIER trial completed the African American Acculturation Scale (AAAS) and 2 nonconsecutive 24-h dietary recalls (n = 238). Analysis of variance (ANOVA) and canonical correlation were used to assess relationships between acculturation and dietary intakes. Canonical correlation (p = 0.05) showed that traditional African Americans had lower intakes of fruits/vegetables and milk/dairy with higher intakes of fats, meat, and nuts. This pattern was supported by differences in the ANOVA. African American acculturation is related to dietary intake. These findings have implications for the design of cancer-related public health messages targeted to African Americans.

Screening rarely screened women: time-to-service and 24-month outcomes of tailored interventions.

BACKGROUND: Managed care organizations and others reaching out to underscreened women seek strategies to encourage mammogram and Pap screening. METHODS: Female HMO members aged 50-69 years and overdue for a mammogram and a Pap test (n = 501) were followed for 24 months after interventions began. An Outreach intervention (tailored letters and motivational telephone interviews), an Inreach intervention (motivational interview delivered in clinics), and a Combined Inreach/Outreach intervention were compared to Usual Care at 24 months. Logistic regression and Cox hazard models examined predictors of obtaining screening services and time-to-service, respectively. RESULTS: Compared with Usual Care, the odds of Outreach women aged 50-64 obtaining a mammogram (OR = 2.06; 95% CI = 1.59-5.29), a Pap test (OR = 1.97; 95% CI = 1.12-3.53), or both (OR = 2.53; 95% CI = 1.40-4.63) remained significantly increased at 24 months. The average time-to-service for Outreach women was reduced by 4 months. Outreach effects persisted despite intensive, ongoing health plan efforts to improve screening of all women. CONCLUSIONS: This brief, tailored outreach intervention was an effective strategy for encouraging cervical and breast cancer screening among women overdue for both screening services. It also shortened time-to-service, an important benefit for early detection and treatment. Alternative strategies are needed for women who remain unscreened.