High rate of microbleed formation following primary intracerebral hemorrhage.

BACKGROUND: We sought to investigate the frequency of microbleed development following intracerebral hemorrhage in a predominantly African-American population and to identify predictors of new microbleed formation. AIMS AND/OR HYPOTHESIS: To investigate the frequency and predictors of new microbleeds following intracerebral hemorrhage. METHODS: The DECIPHER study was a prospective, longitudinal, magnetic resonance-based cohort study designed to evaluate racial/ethnic differences in risk factors for microbleeds and to evaluate the prognostic impact of microbleeds in this intracerebral hemorrhage population. We evaluated new microbleed formation in two time periods: from baseline to 30 days and from 30 days to year 1. RESULTS: Of 200 subjects enrolled in DECIPHER, 84 had magnetic resonance imaging at all required time points to meet criteria for this analysis. In the baseline to day 30 analysis, 11 (13·1%) had new microbleeds, compared with 25 (29·8%) in the day 30 to year 1 analysis. Logistic regression analysis demonstrated that baseline number of microbleeds [odds ratio 1·05 (95% confidence interval 1·01, 1·08), P = 0·01] was associated with new microbleed formation at 30 days. A logistic regression model predicting new microbleed at one-year included baseline number of microbleeds [odds ratio 1·05 (1·00, 1·11), P = 0·046], baseline age [odds ratio 1·05 (1·00, 1·10), P = 0·04], and white matter disease score [odds ratio 1·18 (0·96, 1·45). P = 0·115]. Overall, 28 of 84 (33·3%) intracerebral hemorrhage subjects formed new microbleeds at some point in the first year post-intracerebral hemorrhage. CONCLUSIONS: We found that one-third of intracerebral hemorrhage subjects in this cohort surviving one-year developed new microbleeds, which suggests a dynamic and rapidly progressive vasculopathy. Future studies are needed to examine the impact of new microbleed formation on patient outcomes.

Methodology for a community-based stroke preparedness intervention: the Acute Stroke Program of Interventions Addressing Racial and Ethnic Disparities Study.

BACKGROUND AND PURPOSE: Acute stroke education has focused on stroke symptom recognition. Lack of education about stroke preparedness and appropriate actions may prevent people from seeking immediate care. Few interventions have rigorously evaluated preparedness strategies in multiethnic community settings. METHODS: The Acute Stroke Program of Interventions Addressing Racial and Ethnic Disparities (ASPIRE) project is a multilevel program using a community-engaged approach to stroke preparedness targeted to underserved black communities in the District of Columbia. This intervention aimed to decrease acute stroke presentation times and increase intravenous tissue-type plasminogen activator utilization for acute ischemic stroke. RESULTS: Phase 1 included (1) enhancement of focus of emergency medical services on acute stroke; (2) hospital collaborations to implement and enrich acute stroke protocols and transition District of Columbia hospitals toward primary stroke center certification; and (3) preintervention acute stroke patient data collection in all 7 acute care District of Columbia hospitals. A community advisory committee, focus groups, and surveys identified perceptions of barriers to emergency stroke care. Phase 2 included a pilot intervention and subsequent citywide intervention rollout. A total of 531 community interventions were conducted, reaching >10,256 participants; 3289 intervention evaluations were performed, and 19,000 preparedness bracelets and 14,000 stroke warning magnets were distributed. Phase 3 included an evaluation of emergency medical services and hospital processes for acute stroke care and a year-long postintervention acute stroke data collection period to assess changes in intravenous tissue-type plasminogen utilization. CONCLUSIONS: We report the methods, feasibility, and preintervention data collection efforts of the ASPIRE intervention. CLINICAL TRIAL REGISTRATION URL: http://www.clinicaltrials.gov. Unique identifier: NCT00724555.

Poor long-term blood pressure control after intracerebral hemorrhage.

BACKGROUND AND PURPOSE: Hypertension is the most important risk factor associated with intracerebral hemorrhage. We explored racial differences in blood pressure (BP) control after intracerebral hemorrhage and assessed predictors of BP control at presentation, 30 days, and 1 year in a prospective cohort study. METHODS: Subjects with spontaneous intracerebral hemorrhage were identified from the DiffErenCes in the Imaging of Primary Hemorrhage based on Ethnicity or Race (DECIPHER) Project. BP was compared by race at each time point. Multivariable linear regression was used to determine predictors of presenting mean arterial pressure, and longitudinal linear regression was used to assess predictors of mean arterial pressure at follow-up. RESULTS: A total of 162 patients were included (mean age, 59 years; 53% male; 77% black). Mean arterial pressure at presentation was 9.6 mm Hg higher in blacks than whites despite adjustment for confounders (P=0.065). Fewer than 20% of patients had normal BP (<120/80 mm Hg) at 30 days or 1 year. Although there was no difference at 30 days (P=0.331), blacks were more likely than whites to have Stage I/II hypertension at 1 year (P=0.036). Factors associated with lower mean arterial pressure at follow-up in multivariable analysis were being married at baseline (P=0.032) and living in a facility (versus personal residence) at the time of BP measurement (P=0.023). CONCLUSIONS: Long-term BP control is inadequate in patients after intracerebral hemorrhage, particularly in blacks. Further studies are needed to understand the role of social support and barriers to control to identify optimal approaches to improve BP in this high-risk population.

Exploring the potential of Web 2.0 to address health disparities.

This article addresses use of the Internet and Web 2.0 technologies by racial and ethnic minorities and explores the potential opportunities and challenges in leveraging Web 2.0 approaches to impact health disparities. These opportunities and challenges include developing approaches and methods to (a) identify strategies for integrating social media into health promotion interventions focused on major health-related issues that affect members of medically underserved groups; (b) amalgamate techniques to leverage and connect social-media technologies to other evidence-informed online resources; (c) integrate health communication best practices, including addressing health literacy issues; (d) capitalize on social networking to enhance access and communication with health care providers; and (e) advance current efforts and ongoing expansion of research participation by individuals from underserved communities.

Racial disparities in tissue plasminogen activator treatment rate for stroke: a population-based study.

BACKGROUND AND PURPOSE: Some prior studies have shown that racial disparities exist in intravenous tissue plasminogen activator (tPA) use for acute ischemic stroke. We sought to determine whether race was associated with tPA treatment for stroke in a predominantly black urban population. METHODS: Systematic chart abstraction was performed on consecutive hospitalized patients with ischemic stroke from all 7 acute care hospitals in the District of Columbia from February 1, 2008, to January 31, 2009. RESULTS: Of 1044 patients with ischemic stroke, 74% were black, 19% non-Hispanic white, and 5% received intravenous tPA. Blacks were one third less likely than whites to receive intravenous tPA (3% versus 10%, P<0.001). However, blacks were also less likely than whites to present within 3 hours of symptom onset (13% versus 21%, P=0.004) and also less likely to be tPA-eligible (5% versus 13%, P<0.001). Of those who presented within 3 hours, blacks were almost half as likely to be treated with intravenous tPA than whites (27% versus 46%, P=0.023). The treatment rate for tPA-eligible patients was similar for blacks and whites (70% versus 76%, P=0.62). CONCLUSIONS: In this predominantly black urban population hospitalized for acute ischemic stroke, blacks were significantly less likely to be treated with intravenous tPA due to contraindications to treatment, delayed presentation, and stroke severity. Effective interventions designed to increase treatment in this population need to focus on culturally relevant education programs designed to address barriers specific to this population.

Understanding reasons for delay in seeking acute stroke care in an underserved urban population.

BACKGROUND AND PURPOSE: Few patients arrive early enough at hospitals to be eligible for emergent stroke treatment. There may be barriers specific to underserved, urban populations that need to be identified before effective educational interventions to reduce delay times can be developed. METHODS: A survey of respondents' likely action in a hypothetical stroke situation was given to 253 community volunteers in the catchment areas of a large urban community hospital. Concurrently, 100 structured interviews were conducted in the same hospital with patients with acute stroke or a proxy. RESULTS: In this predominantly urban, black population, if faced with a hypothetical stroke, 89% of community volunteers surveyed said they would call 911 first, and few felt any of the suggested potential barriers applied to them. However, only 12% of patients with stroke interviewed actually called 911 first (OR, 63.9; 95% CI, 29.5 to 138.2). Instead, 75% called a relative/friend. Eighty-nine percent of patients with stroke reported significant delay in seeking medical attention, and almost half said the reason for the delay was thinking the symptoms were not serious and/or they would self-resolve. For those arriving by ambulance, only 25% did so because they thought it would be faster, whereas 35% cited having no other transportation options. CONCLUSIONS: In this predominantly black urban population, although 89% of community volunteers report the intent of calling 911 during a stroke, only 12% of actual patients with stroke did so. Further research is needed to determine and conquer the barriers between behavioral intent and actual behavior to call 911 for witnessed stroke.

Exploring the link between populomics and knowledge management: patient-oriented case exemplars.

The challenge of population-level health problems, such as healthcare disparities, encompasses socio-behavioural, community and biologic factors and advances in information and communication technologies (ICTs). These elements are reflected in the key ethos of contemporary knowledge management (KM), as knowledge emerges from the confluence of people, process and technology. This paper illustrates how knowledge-based health case studies can be used as effective exemplars to illuminate understanding and explore possible connections between populomics and KM.

A systematic approach: optimization of healthcare operations with knowledge management.

Effective decision making is vital in all healthcare activities. While this decision making is typically complex and unstructured, it requires the decision maker to gather multispectral data and information in order to make an effective choice when faced with numerous options. Unstructured decision making in dynamic and complex environments is challenging and in almost every situation the decision maker is undoubtedly faced with information inferiority. The need for germane knowledge, pertinent information and relevant data are critical and hence the value of harnessing knowledge and embracing the tools, techniques, technologies and tactics of knowledge management are essential to ensuring efficiency and efficacy in the decision making process. The systematic approach and application of knowledge management (KM) principles and tools can provide the necessary foundation for improving the decision making processes in healthcare. A combination of Boyd's OODA Loop (Observe, Orient, Decide, Act) and the Intelligence Continuum provide an integrated, systematic and dynamic model for ensuring that the healthcare decision maker is always provided with the appropriate and necessary knowledge elements that will help to ensure that healthcare decision making process outcomes are optimized for maximal patient benefit. The example of orthopaedic operating room processes will illustrate the application of the integrated model to support effective decision making in the clinical environment.

Realising the knowledge spiral in healthcare: the role of data mining and knowledge management.

Knowledge Management (KM) is an emerging business approach aimed at solving current problems such as competitiveness and the need to innovate which are faced by businesses today. The premise for the need for KM is based on a paradigm shift in the business environment where knowledge is central to organizational performance . Organizations trying to embrace KM have many tools, techniques and strategies at their disposal. A vital technique in KM is data mining which enables critical knowledge to be gained from the analysis of large amounts of data and information. The healthcare industry is a very information rich industry. The collecting of data and information permeate most, if not all areas of this industry; however, the healthcare industry has yet to fully embrace KM, let alone the new evolving techniques of data mining. In this paper, we demonstrate the ubiquitous benefits of data mining and KM to healthcare by highlighting their potential to enable and facilitate superior clinical practice and administrative management to ensue. Specifically, we show how data mining can realize the knowledge spiral by effecting the four key transformations identified by Nonaka of turning: (1) existing explicit knowledge to new explicit knowledge, (2) existing explicit knowledge to new tacit knowledge, (3) existing tacit knowledge to new explicit knowledge and (4) existing tacit knowledge to new tacit knowledge. This is done through the establishment of theoretical models that respectively identify the function of the knowledge spiral and the powers of data mining, both exploratory and predictive, in the knowledge discovery process. Our models are then applied to a healthcare data set to demonstrate the potential of this approach as well as the implications of such an approach to the clinical and administrative aspects of healthcare. Further, we demonstrate how these techniques can facilitate hospitals to address the six healthcare quality dimensions identified by the Committee for Quality Healthcare.

Barriers to recruiting underrepresented populations to cancer clinical trials: a systematic review.

Racial and ethnic minorities, older adults, rural residents, and individuals of low socioeconomic status are underrepresented among participants in cancer-related trials. The authors conducted a systematic review to determine the barriers to participation of underrepresented populations in cancer-related trials. Their search included English-language publications that reported original data on the recruitment of underrepresented groups to cancer treatment or prevention trials between 1966 and December 2005 in multiple electronic databases. They also hand-searched titles in 34 journals from January 2003 to December 2005 and they examined reference lists for eligible articles. Titles and abstracts were reviewed to identify relevant studies. Data on barriers to participation were synthesized both qualitatively and based on statistically significant associations with trial enrollment. Of 5257 studies that were cited, 65 studies were eligible for inclusion in the current analysis, including 46 studies on recruitment into cancer therapeutic trials, 15 studies on recruitment into prevention trials, and 4 studies on recruitment into both prevention and treatment trials. Numerous factors were reported as barriers to participation in cancer-related trials. However, only 20 of the studies reported statistically significant associations between hypothesized barriers and enrollment. The available evidence had limitations in quality regarding representativeness, justification of study methods, the reliability and validity of data-collection methods, potential for bias, and data analysis. The results indicated that underrepresented populations face numerous barriers to participation in cancer-related trials. The current systematic review highlighting the literature on recruitment of underrepresented populations to cancer trials and may be used as the evidence base toward developing an agenda for etiologic and intervention research to reduce the disparities in participation in cancer-related trials.

Provider roles in the recruitment of underrepresented populations to cancer clinical trials.

BACKGROUND: Providers play a vital role in the successful recruitment of underrepresented patients to cancer clinical trials because they often introduce the opportunity of clinical trials. The purpose of the current systematic review was to describe provider-related factors influencing recruitment of underrepresented populations to cancer clinical trials. METHODS: To find original studies on the recruitment of underrepresented populations to cancer clinical trials, electronic databases from January 1966 to December 2005 were searched; hand-searched titles in 34 journals from January 2003 to January 2006; and reference lists were examined of eligible articles. Title and abstract reviews were conducted to identify relevant studies. Potential articles were then abstracted using a structured instrument and a serial review process by 2 investigators. RESULTS: Eighteen studies were eligible for review: 13 targeted healthcare providers, 3 targeted patients/participants, and 2 targeted both providers and patients. The study designs included randomized controlled trial, concurrent controlled trial, case-control, descriptive, and qualitative. A lack of available protocols and/or a lack of provider awareness about clinical trials prevented providers from discussing the opportunity of clinical trials in 2 studies. In 14 studies, patient accrual was affected by provider attitudinal barriers relating to patient adherence to the study protocol, patient mistrust of research, patient costs, data collection costs, and/or patient eligibility. Providers' communication methods were barriers in 5 studies and promoters in 1 study. CONCLUSIONS: A heterogeneous body of evidence suggests that several provider-related factors influence recruitment of underrepresented groups to clinical trials. Future recruitment efforts should address these factors.

The sociobiologic integrative model (SBIM): enhancing the integration of sociobehavioral, environmental, and biomolecular knowledge in urban health and disparities research.

Disentangling the myriad determinants of disease, within the context of urban health or health disparities, requires a transdisciplinary approach. Transdisciplinary approaches draw on concepts from multiple scientific disciplines to develop a novel, integrated perspective from which to conduct scientific investigation. Most historic and contemporary conceptual models of health were derived either from the sociobehavioral sciences or the biomolecular sciences. Those models deriving from the sociobehavioral sciences generally lack detail on involved biological mechanisms whereas those derived from the biomolecular sciences largely do not consider socioenvironmental determinants. As such, advances in transdisciplinary characterizations of health in complex systems like the urban environment or health disparities may be impeded. This paper suggests a sociobiologic organizing model that encourages a multilevel, integrative perspective in the study of urban health and health disparities.

Health inequalities and emerging themes in compunetics.

Inequalities in health have been documented for hundreds of years. The causes of these inequalities are complex and related to social, medical, environmental, class, healthcare system and behavioral determinants. Currently governments and healthcare systems are struggling to effectively reduce these differences. In addition, the number of individuals with chronic diseases is rapidly growing, particularly in developed nations. Most of the care needed for effective management of these chronic diseases is performed outside of the hospital setting by non-physicians. However the world's healthcare systems are primarily oriented toward acute, hospital based emergency care and therefore currently largely unable to effectively and consistently provide high quality care to every person. Recent developments in the computer industry have led to major advances in scientific research capabilities and in like manner will, in the future, likely enable significant advances in the field of compunetics. By enabling the instantaneous capture and utilization of large amounts of diverse data, IT will facilitate a population level orientation in compunetics in addition to the current focus on individual patient applications. Similarly the development of behavioral compunetics or a focus innovative uses of technology to influence health behaviors of patients and physicians are on the verge of occurring. In so doing, these and other advances in compunetincs may significantly increase our ability to provide high quality community oriented care, improve the health of individuals and populations and thereby help reduce health inequalities.

Effectiveness of strategies to recruit underrepresented populations into cancer clinical trials.

BACKGROUND: Certain populations, including racial and ethnic minorities and older persons, have had a history of low participation in cancer-related trials, yet there has been little information reported on recruitment strategies tailored to improve their enrollment. METHODS: We conducted a systematic literature review to examine the methods used to study recruitment of underrepresented populations into cancer prevention and treatment trials and examined the studies that compared the efficacy and/or effectiveness of different recruitment strategies. We performed an electronic search through multiple databases including PubMed and a hand search of 34 journals. Potential studies were pulled and underwent title, abstract, and article review by at least two investigators. RESULTS: Fourteen articles examined recruitment of underrepresented populations into cancer trials and, of these, five compared efficacy or effectiveness of different strategies for recruitment of underrepresented populations into randomized or concurrent controlled trials. These five studies used various strategies but only three reported that specific recruitment strategies, such as media campaigns and church-based project sessions, resulted in improvement in accrual to cancer trials. CONCLUSION: There is limited evidence for efficacious or effective strategies to recruit underrepresented populations in cancer-related trials. The available evidence cannot be generalized to these heterogeneous groups. Further study is needed on efficacious strategies for recruitment of underrepresented populations into cancer-related trials.

The Johns Hopkins Urban Health Institute: A collaborative response to urban health issues.

The authors provide background on the poor health and economic status of the residents of East Baltimore, Maryland--the neighborhood surrounding a significant part of Johns Hopkins University, including the School of Medicine, the School of Nursing, the Bloomberg School of Public Health, and the Johns Hopkins Hospital. The president of the Johns Hopkins University established a council on urban health, consisting of a broad array of individuals from across the university and the community to develop a recommended course of action to help deal with these conditions. Based on the recommendations of the council, the Johns Hopkins Urban Health Institute was established with the mission to marshall the resources of the university and external groups to improve the health and well-being of the residents of East Baltimore and to promote evidence-based interventions to solve urban health problems nationwide. After becoming fully operational in 2001, the institute established three major goals: (1) strengthen research and learning, (2) reduce disparities in health and health care for East Baltimore residents, and (3) promote economic growth in East Baltimore. The article describes the institute's major activities, including community-based participatory research projects, the Journal of Community-Based Participatory Research, and programs for research fellows to promote research and learning; HIV/AIDS counseling and testing centers and a primary care clinic for the uninsured to reduce health disparities; and a technology resource center providing training and job opportunities to promote economic growth. The authors conclude by outlining the next steps planned for the institute.