Peer training of community health workers to improve heart health among African American women.

INTRODUCTION: Training community health workers (CHWs) builds a workforce that is essential to addressing the chronic disease crisis. This article describes a highly replicable CHW training program that targets heart disease risk among African American women. BACKGROUND: African American women suffer disproportionately from heart disease mortality and morbidity. Well-trained CHWs are uniquely positioned to close this disparity gap. Method. We used a Learning Circle approach to train CHWs in heart health education. The curriculum blended web-based, self-directed learning and in-person peer coaching. CHWs learned through (a) peer-to-peer sharing, (b) problem solving and brainstorming, and (c) leadership and experiential activities. Training evaluation measures were CHWs' (a) self-confidence, (b) heart health knowledge, (c) satisfaction with training, (d) training retention, and (e) replication of training within 90 days after training. RESULTS: This training resulted in appreciable effects on four of five outcome measures. Heart health knowledge increased significantly among experienced CHWs (p = .011). CHWs were satisfied with training and retention was 100%. CHWs initiated and subsequently delivered 122 person hours of community heart health education and CHW training in their communities. DISCUSSION/CONCLUSION: CHW heart health training using Learning Circles is a practical and replicable method of training CHWs and holds significant potential for building capacity in resource-poor community organizations.

A High Level of Patient Activation Is Observed But Unrelated to Glycemic Control Among Adults With Type 2 Diabetes.

OBJECTIVE: To measure patient activation and its relationship to glycemic control among adults with type 2 diabetes who had not participated in a formal diabetes self-management education program as a baseline assessment for tailoring diabetes education in a primary care setting. RESEARCH DESIGN AND METHODS: Patient activation was assessed in a stratified, cross-sectional study of adults with controlled (n = 21) and uncontrolled (n = 27) type 2 diabetes, who were receiving primary care at a unique family practice center of Baylor Health Care System in Dallas, Tex. RESULTS: The mean patient activation was 66.0 (95% confidence interval [CI] 60.8-71.2) among patients with uncontrolled diabetes and 63.7 (55.9-71.5) among those with controlled diabetes (P = 0.607). A significant association was observed between the self-management behavior score and activation among patients whose glycemia was under control (ρ = 0.73, P = 0.01) as well as among patients with uncontrolled glycemia (ρ = 0.48, P < 0.001). CONCLUSIONS: Although activation is correlated with self-management and may be important in tailored patient-centered approaches to improving diabetes care outcomes, the highest stage of activation may be necessary to achieve glycemic control. These findings reinforce the importance of conducting prerequisite needs assessments so diabetes educators are able to tailor their educational interventions to individual patients' needs and readiness to take action.

The impact of health literacy on self-monitoring of blood glucose in patients with diabetes receiving care in an inner-city hospital.

BACKGROUND: Self-monitoring of blood glucose (SMBG) is considered to be 1 of the cornerstones of diabetes self-management. It is unclear whether inadequate health literacy affects SMBG. OBJECTIVE: The objective of this study was to examine the relationship between health literacy and SMBG. METHODS: This was a cross-sectional survey of 189 patients with diabetes, aged 18 to 65 years, receiving care in a large urban, public health care setting. We measured health literacy using the shortened version of the Test of Functional Health Literacy in Adults. The diabetes care profile was used to determine the use of self-monitoring of blood glucose. RESULTS: Most (60.9%) of the survey participants were assessed as functionally health literate. The majority (90.9%) of the study participants reported testing their blood sugar at least once daily. Although adequate health literacy was associated with recording of blood sugar testing (p = .049), we found no statistically significant relationship between health literacy and the frequency of SMBG. Persons self-reporting having diabetes for more than 10 years were less likely to self-monitor blood glucose (odds ratio, 0.33; 95% CI, 0.11-0.99). CONCLUSIONS: SMBG frequency is not independently associated with health literacy, but SMBG result recording is noted among patients with inadequate literacy.

Explaining Poor Medication Adherence among Adults with Type 2 Diabetes in an Urban Community Health Center.

Nonadherence to diabetes medication is a common and costly problem, significantly precluding the evidence-based benefits of diabetes care. Nonadherence is also a poorly understood multifactorial behavior, particularly among African Americans with type 2 diabetes receiving care in under-resourced primary care settings. We investigated several known or suspected individual-level factors influencing diabetes medication adherence among a predominantly African American group of adults with diabetes at a local community health center. Overall diabetes medication adherence was observed to be surprisingly low at 23% (95% confidence interval (CI) = 19%-26%) and did not differ by medication type (p=.435). Common sociodemographic factors were poor predictors of adherence. However, self-perceived health and presence of comorbid conditions were significant. The strongest independent predictors of diabetes medication adherence in this population were a heart attack and having maintained a desired level of glycemic control, indicating the importance of specific comorbidities and motivation for self-care in tailoring interventions to improve adherence.

Diabetes retinopathy and related health management in Asians versus whites using BRFSS 2005-2017 data.

PURPOSE: Asian Americans had high rate of type 2 diabetes and less risk for diabetes complications compared to white. The purpose of this study was to examine diabetic retinopathy and related healthcare management among Asian American adults with diabetes. MATERIALS AND METHOD: Asian and white type 2 diabetes participants from 2005-2017 Behavioral Risk Factor Surveillance System (BRFSS) data were used to perform the analysis. SAS 9.4 survey procedures were used to conduct the statistical test. Health care management variables (self-blood sugar check, eye check and HbA1C check with doctors, health care professional visit) were analyzed and compared between Asian and white. RESULTS: During 2005-2017, diabetic retinopathy (DR) rate among Asian Americans was 10% higher than white, and Asian Americans was more than 100% more likely to develop DR compared to white. Asian Americans was less likely to check their blood sugar once a day (P<0.05 for all years except 2005 and 2007) and more likely to see the health care professional and perform eye and HbA1C check even the relationship was not statistically significant. After adjusting all the demo-social factors and health care management factors, Asian still had higher rate of DR compared to white. CONCLUSION: Asian Americans had higher rate of DR rate compared to white. Asian and white all had low rate of selfcare of blood sugar. Interventions for DR need to apply among Asian population.

Development of Zinc Chelating Resin Polymer Beads for the Removal of Cell-Free Hemoglobin.

Red blood cell (RBC) hemolysis is one of the most common storage lesions in packed RBCs (pRBC). Older units of pRBCs, especially those > 21 days old, have increasing levels of hemolysis leading to increased oxidative stress and premature platelet activation. This effect can mostly be attributed to the increase of cell-free hemoglobin (Hb). Therefore, removal of cell-free Hb from pRBCs prior to transfusion could mitigate these deleterious effects. We propose a new method for the removal of Hb from pRBCs using zinc beads. Prepared Hb solutions and pRBCs were treated with zinc beads using two different protocols. UV-Vis spectrophotometry was used to determine Hb concentrations, before and after treatment. Experiments were run in triplicate and paired t tests were used to determine significant differences between groups. Zinc beads removed on average 94% of cell-free Hb within 15 min and 78% Hb from pRBCs (p < 0.0001), demonstrating a maximum binding capacity ~ 66.2 ± 0.7 mg Hb/mL beads. No differences in RBC morphology or deformability were observed after treatment. This study demonstrates the feasibility of using zinc beads for the rapid and targeted removal of Hb from pRBC units. Further investigation is needed to scale this method for large volume removal.

Point of care testing to improve glycemic control.

PURPOSE: The purpose of this paper is to pilot-test the feasibility and impact of protocol-driven point-of-care HbAlc testing on levels of glycemic control and on rates of diabetic regimen intensification in an urban community health center serving low-income patients. DESIGN/METHODOLOGY/APPROACH: The paper suggests a primary care process re-design, using point of care finger-stick HbA1c testing under a standing order protocol that provided test results to the provider at patient visit. FINDINGS: The paper finds that the protocol was well received by both nurses and physicians. HbA1c testing rates increased from 73.6 percent to 86.8 percent (p = 0.40, n = 106). For the 69 patients who had both pre- and post-intervention results, HbAlc levels decreased significantly from 8.55 to 7.84 (p = 0.004, n = 69). At baseline, the health center as a system was relatively ineffective in responding to elevated HbA1c levels. An opportunity to intensify, i.e. a face-to-face visit with lab results available, occurred for only 68.6 percent of elevated HbAlc levels before the intervention, vs. 100 percent post-intervention (p < 0.001). Only 28.6 percent of patients with HbAlc levels >8.0 had their regimens intensified in the pre-intervention phase, compared with 53.8 percent in the post-intervention phase (p = 0.03). RESEARCH LIMITATIONS/IMPLICATIONS: This was a pilot-study in one urban health center. Larger group-randomized controlled trials are needed. PRACTICAL IMPLICATIONS: The health center's performance as a system, improved significantly as a way of intensifying diabetic regimens thereby achieving improved glycemic control. ORIGINALITY/VALUE: This intervention is feasible, replicable and scalable and does not rely on changing physician behaviors to improve primary care diabetic outcomes.

Improving quality and reducing inequities: a challenge in achieving best care.

The health care quality chasm is better described as a gulf for certain segments of the population, such as racial and ethnic minority groups, given the gap between actual care received and ideal or best care quality. The landmark Institute of Medicine report Crossing the Quality Chasm: A New Health System for the 21st Century challenges all health care organizations to pursue six major aims of health care improvement: safety, timeliness, effectiveness, efficiency, equity, and patient-centeredness. "Equity" aims to ensure that quality care is available to all and that the quality of care provided does not differ by race, ethnicity, or other personal characteristics unrelated to a patient's reason for seeking care. Baylor Health Care System is in the unique position of being able to examine the current state of equity in a typical health care delivery system and to lead the way in health equity research. Its organizational vision, "culture of quality," and involved leadership bode well for achieving equitable best care. However, inequities in access, use, and outcomes of health care must be scrutinized; the moral, ethical, and economic issues they raise and the critical injustice they create must be remedied if this goal is to be achieved. Eliminating any observed inequities in health care must be synergistically integrated with quality improvement. Quality performance indicators currently collected and evaluated indicate that Baylor Health Care System often performs better than the national average. However, there are significant variations in care by age, gender, race/ethnicity, and socioeconomic status that indicate the many remaining challenges in achieving "best care" for all.

Risk of Skin and Soft Tissue Infections among Children Found to be Staphylococcus aureus MRSA USA300 Carriers.

INTRODUCTION: The purpose of this study was to examine community-associated methicillin resistant Staphylococcus aureus (CA-MRSA) carriage and infections and determine risk factors associated specifically with MRSA USA300. METHODS: We conducted a case control study in a pediatric emergency department. Nasal and axillary swabs were collected, and participants were interviewed for risk factors. The primary outcome was the proportion of S. aureus carriers among those presenting with and without a skin and soft tissue infection (SSTI). We further categorized S. aureus carriers into MRSA USA300 carriers or non-MRSA USA300 carriers. RESULTS: We found the MRSA USA300 carriage rate was higher in children less than two years of age, those with an SSTI, children with recent antibiotic use, and those with a family history of SSTI. MRSA USA300 carriers were also more likely to have lower income compared to non-MRSA USA300 carriers and no S. aureus carriers. Rates of Panton-Valentine leukocidin (PVL) genes were higher in MRSA carriage isolates with an SSTI, compared to MRSA carriage isolates of patients without an SSTI. There was an association between MRSA USA300 carriage and presence of PVL in those diagnosed with an abscess. CONCLUSION: Children younger than two years were at highest risk for MRSA USA300 carriage. Lower income, recent antibiotic use, and previous or family history of SSTI were risk factors for MRSA USA300 carriage. There is a high association between MRSA USA300 nasal/axillary carriage and presence of PVL in those with abscesses.

Barriers to prenatal care among Black women of low socioeconomic status.

OBJECTIVE: To qualitatively identify attitudinal and psychosocial determinants of early prenatal care among Black women of low socioeconomic status (SES). METHODS: Focus group discussions were conducted among Black women who attended community clinics for prenatal care. RESULTS: Early initiators of prenatal care, compared with late initiators, had positive attitudes toward pregnancy, were knowledgeable about pregnancy signs/symptoms, and thought prenatal care was important. All participants indicated strong social support during pregnancy. Late initiators, particularly multiparous women, perceived clinic staff to be insensitive. CONCLUSIONS: Findings provide valuable insight into overcoming barriers to early initiation of prenatal care among low SES Black women.

A Self-assessment Tool for Screening Young Adults at Risk of Type 2 Diabetes Using Strong Heart Family Study Data.

PURPOSE: The purpose of this study is to characterize risk factors associated with type 2 diabetes in young adults aged 18 to 29 years to develop a noninvasive risk assessment tool for use with younger American populations. METHODS: The self-assessment tool was developed with the Strong Heart Family Study data. A total of 590 young American Indian adults (242 men) who had normoglycemia and were not receiving diabetes treatment were included. Risk factors recommended by the American Diabetes Association were used to assess diabetes risk in these young adults. A logistic regression model was developed to calculate the predicted probability. The area under the receiver operating characteristic curve was used to evaluate the model. RESULTS: The final model showed that parental history of diabetes, obesity level, alcohol consumption, and high fasting glucose, even within normal range, were significantly associated with onset of prediabetes/diabetes in 5 years. The area under the receiver operating characteristic curve value was 0.68 with original and validated data, indicating that the risk assessment tool had reasonably good discrimination ability. CONCLUSIONS: This new noninvasive screening tool, based on data from American Indian young adults, has potential to screen young adults' early-onset diabetes risk. Future studies are warranted to test this risk assessment tool in other racial/ethnic young adults.

Morehouse Community Physicians Network (CPN) hypertension registry: patterns of care and opportunities for targeted medical education.

BACKGROUND: Provider-focused strategies for improving outcomes in hypertension have produced mixed results. Studies suggest that the effectiveness of a chosen strategy increases when it is tailored to the specific situation. The hypertension registry includes data on African-American hypertensives who receive care in community-based primary care settings. We examined the registry to identify patterns of care and opportunities for provider-focused interventions to improve patient outcomes. METHODS AND RESULTS: The registry will include all records of hypertensive patients from 50 community-based primary care practices at full enrollment. Data from nine practices were manually abstracted into an electronic database and analyzed. Seven hundred and ten records were included in this report. Approximately 70% are female, average age 47 +/- 13 years, 5.3% are uninsured, and more than 60% have at least a high school education. Registry patients have multiple co-morbid conditions: 28% are diabetic, 8% have left ventricular hypertrophy, 5% have congestive heart failure, 6.5% have renal insufficiency, 5% have cerebrovascular disease, 3.5% have previous myocardial infarction and 2% have peripheral vascular disease. Among those with diabetes, mean glycosylated hemoglobin was 7.4 +/- 2. Pattern of antihypertensive use showed 43% on diuretics, 28% on calcium channel blockers, 24% on angiotensin converting enzyme inhibitors, 20% on beta blockers and 16% on angiotensin receptor blockers. Overall, 37% were at goal blood pressure and among those with diabetes, only 16% reached goal blood pressure. CONCLUSION: We conclude that the blood pressure control rates of African Americans in the registry trail those of the general population. This provides a unique opportunity to study the underlying factors and design tailored interventions to address this disparity in health outcome.

The Community Physicians' Network (CPN): an academic-community partnership to eliminate healthcare disparities.

INTRODUCTION: Disparities in health care are maintained by three primary factors: 1) patient factors which include multiple risk factors and comorbidities; 2) healthcare practitioner factors comprising inconsistent application of practice guidelines due to a limited database of clinical trials of effective therapies in African Americans and other underrepresented minorities; and 3) barriers in the healthcare delivery system resulting in poor access to care. The Morehouse School of Medicine Community Physicians' Network (CPN) was established to address disparities in health care by focusing on provider-specific strategies. OBJECTIVES: To: 1) use disease-specific registries to identify treatment gaps and facilitate quality improvement processes among CPN practices; 2) develop practice-specific and guideline-based educational messages to promote quality care; 3) engage and train CPN-physicians for participation in approved NIH, other government, and industry-supported clinical protocols; and 4) develop a data repository of all CPN-sponsored clinical trials that include significant numbers of African Americans and other underrepresented minorities. METHODS: The disease-specific outpatient registries will have the following features: 1) data structures and data elements will use standard database codes and a data dictionary; 2) HIPPA-compliant data abstraction and data transfer tool; 3) baseline chart review to establish practice patterns and provide practice-specific feedback; 4) annual update of registry; 5) data registry and repository maintained on Morehouse School of Medicine's secure servers; 6) registry publications will include only aggregate data, without identification of contributing practices; 7) an electronic medical records platform will be encouraged as the ultimate data management tool for CPN practices. In addition, up to three continuing medical education (CME) programs each year will feature national speakers and promote evidence-based practice guidelines. RESULTS: Eighty-five primary care and subspecialty practices are actively enrolled in CPN with a total of 385,000 annual outpatient visits. The makeup of insurance status is: HMO/PPO (45%); Medicare only (19%); Medicare HMO (11%); Medicare plus (8%); Medicaid (6%); Uninsured (11%). CONCLUSIONS: The Community Physicians' Network will address specific gaps in the health care of African-American and other minority patients by promoting quality care among its members and by facilitating participation in approved clinical trial protocols. The unique academic community partnership is consistent with the NIH roadmap goal of eliminating healthcare disparities.

The prevalence of cognitive impairment among African-American patients with congestive heart failure.

This cross-sectional study sought to determine the prevalence of cognitive impairment among African-American patients with congestive heart failure (CHF). We studied 100 African-American CHF patients (aged 55-87 years) in New York Heart Association classes II-IV, who are enrolled in an ongoing, randomized, controlled trial, evaluating the effectiveness of a telemonitoring intervention to improve access to ambulatory care for heart failure patients. These CHF patients were recruited from an inner-city practice, rural physician practices and an urban physician practice in Atlanta. The Mini-Mental Status Examination (MMSE) was used to measure cognition. Cognitive impairment was defined as a MMSE score of less than 24. The crude prevalence of cognitive impairment was 10% in this population of African Americans with CHF. The results of multivariate logistic regression analysis indicated an increase in odds of cognitive impairment with increasing age [odds ratio (OR) = 1.10 and 95% confidence interval, 1.00-1.20; p=0.042]. There was no significant relationship between cognitive impairment and gender, education status, depression and severity of CHF. This study indicates that cognitive impairment is relatively prevalent among African Americans with CHF, but lower than previously reported among Caucasians with CHF.

Determinants of glycemic status monitoring in Black and White Medicaid beneficiaries with diabetes mellitus.

Routine monitoring of glycemic status during regularly scheduled physician office visits is not performed according to recommended guidelines for most people with diabetes. We conducted this investigation to identify the determinants of glycemic status monitoring during primary care office visits among Black and White adult Medicaid beneficiaries diagnosed with type 2 diabetes in 1996 and 1997 and followed for a 12-month period through year 1997 and year 1998, respectively (N=3,321). Multivariate logistic regression analyses indicated that the likelihood of receiving the American Diabetes Association (ADA) recommended 2 or more HbA1c tests was more than 2 times greater for persons with diabetes who had 10 or more visits than for those with only one visit in the one-year period since initial diagnosis (relative risk (RR) = 2.31, 95% confidence interval (CI) = 1.51-3.51). Quality improvement efforts that emphasize the patient-primary provider relationship and better coordination of care will improve adherence to diabetes care standards.

Value of a small control group for estimating intervention effectiveness: results from simulations of immunization effectiveness studies.

AIM: To improve evidence for public health practice, the conduct of effectiveness studies by practitioners is needed and may be stimulated if knowledge that smaller than usual samples may provide the same reliability of intervention effect size as larger samples. MATERIALS & METHODS: We examined reliability of intervention effect using computerized simulations of 2000 hypothetical immunization effectiveness studies from an actual study population and by small (30 and 60) and larger (100 and 200) control groups compared with an intervention group of 200 participants. RESULTS & CONCLUSION: Across simulated studies, the mean intervention effect (14%) and effect sizes were equivalent regardless of control group size and equal to the actual study effect. These results are relevant for similarly designed and executed studies and indicate that studies with smaller control groups can generate valid and accurate evidence for effective public health practice in communities.

Breast cancer knowledge, beliefs, and screening behaviors among low-income, elderly black women.

This cross-sectional study explored whether there are age-specific differences in breast cancer-related knowledge, beliefs, and screening behaviors among low-income, elderly black women. Data were collected at senior citizen facilities from 214 black women aged 65 and older. Differences in knowledge, beliefs, and screening practices across three age groups were assessed by chi-square tests. Logistic regression modeling was used to determine the effect of these factors on compliance with American Cancer Society (ACS) screening guidelines. Age was inversely associated with knowledge and screening practices. The youngest group (65-74) was about twice as likely as the oldest group (85 and over) to correctly recognize breast cancer risk factors. About 50% of the oldest women compared to about 20% of the youngest women believed their risk for breast cancer was nil. The oldest group was also least likely to have had a mammogram or clinical breast examination within the past year, as recommended by the ACS. Our results suggest that educating elderly women, especially those 85 and over, about breast cancer and screening may lead to higher compliance with ACS recommendations.

Incorporating translational research with clinical research to increase effectiveness in healthcare for better health.

BACKGROUND: The transfer of new scientific discoveries into healthcare interventions requires that basic and clinical researchers work together with health care providers to generate team science. These innovative models require translational teams, and need to extend beyond the academic environment. The future of translational science requires partnerships with the healthcare community as well as the broader, general community. This new integrated model of effective translational teams holds promise for addressing thorny and persistent health disparities, is consistent with the nation's strategic priority of eliminating health disparities, and bodes well for increasing healthcare effectiveness aimed at better health for all. DISCUSSION: As part of the 13th Research Centers in Minority Institutions (RCMI) International Symposium on Health Disparities, several senior academic leaders joined efforts to hold a workshop to discuss a model that considers the incorporation of two translational research strategies in research career development programs: Comparative effectiveness research (CER) and community-based participatory research (CBPR) for increasing healthcare effectiveness and eliminating healthcare disparities. Discussion included what issues may be most germane to the concept of a unified model for research workforce development through formal training and career development leading to increased effectiveness in healthcare for better health. SUMMARY: We believe that there is a gap in knowledge and skills in formal research career development programs that will enable physicians, other clinicians, and basic scientists to actively participate in these two translational research strategies. The purpose of this paper is to share the outcomes of these discussions, and encourage further discussion and possible innovation in the formulation of a new model for translational research workforce development.

A Study of Effects of MultiCollinearity in the Multivariable Analysis.

A multivariable analysis is the most popular approach when investigating associations between risk factors and disease. However, efficiency of multivariable analysis highly depends on correlation structure among predictive variables. When the covariates in the model are not independent one another, collinearity/multicollinearity problems arise in the analysis, which leads to biased estimation. This work aims to perform a simulation study with various scenarios of different collinearity structures to investigate the effects of collinearity under various correlation structures amongst predictive and explanatory variables and to compare these results with existing guidelines to decide harmful collinearity. Three correlation scenarios among predictor variables are considered: (1) bivariate collinear structure as the most simple collinearity case, (2) multivariate collinear structure where an explanatory variable is correlated with two other covariates, (3) a more realistic scenario when an independent variable can be expressed by various functions including the other variables.