Utilization of Direct Oral Anticoagulants in People Living with Human Immunodeficiency Virus: Observational Data from the District of Columbia Cohort.

BACKGROUND: Direct oral anticoagulants (DOACs) have become first-line treatment for venous thrombotic events. DOAC prescribing trends among people living with human immunodeficiency virus (PWH) are not well described. The coadministration of DOACs with the antiretroviral (ARV) pharmacokinetic boosters ritonavir (RTV) or cobicistat (COBI) may be complicated by pharmacokinetic interactions. METHODS: A longitudinal cohort study was conducted using the D.C. Cohort Database in Washington, D.C., from January 2011 to March 2017, to describe oral anticoagulant prescribing among PWH ≥ 18 years old and the prevalence of DOAC use with RTV or COBI. Data collection included demographic and clinical characteristics, ARV and anticoagulant prescriptions, and International Classification of Diseases Ninth and Tenth Edition diagnosis codes. RESULTS: Among 8315 PWH, there were 236 anticoagulant prescriptions (96 DOAC, 140 warfarin) for 206 persons. PWH prescribed anticoagulants were predominantly Black (82%) and male (82%), with a mean age at anticoagulant initiation of 56 years. DOAC use increased from 3% of total anticoagulant prescribing in 2011 to 43% in 2016, accounting for 64% of all newly recorded anticoagulant prescriptions by 2016. There were 19 bleeding events recorded among 16 individuals. Despite the Food and Drug Administration label recommendation to avoid rivaroxaban with boosted ARVs, 41% remained on boosted ARVs after rivaroxaban initiation. CONCLUSIONS: DOAC use increased substantially in PWH by 2016. Although rivaroxaban is not recommended with RTV or COBI, concomitant use was recorded in 41% of rivaroxaban recipients in this cohort. As DOAC usage increases, clinicians need to be aware of potential DOAC/ARV interactions in order to select the most appropriate oral anticoagulant and monitoring plan for PWH.

Despite early Medicaid expansion, decreased durable virologic suppression among publicly insured people with HIV in Washington, DC: a retrospective analysis.

BACKGROUND: Despite widely available access to HIV care in Washington, DC, inequities in HIV outcomes persist. We hypothesized that laboratory monitoring and virologic outcomes would not differ significantly based on insurance type. METHODS: We compared HIV monitoring with outcomes among people with HIV (PWH) with private (commercial payer) versus public (Medicare, Medicaid) insurance receiving care at community and hospital clinics. The DC Cohort follows over 8000 PWH from 14 clinics. We included those ≥18 years old enrolled between 2011 and 2015 with stable insurance. Outcomes included frequency of CD4 count and HIV RNA monitoring (> 2 lab measures/year, > 30 days apart) and durable viral suppression (VS; HIV RNA < 50 copies/mL at last visit and receiving antiretroviral therapy (ART) for ≥12 months). Multivariable logistic regression models examined impact of demographic and clinical factors. RESULTS: Among 3908 PWH, 67.9% were publicly-insured and 58.9% attended community clinics. Compared with privately insured participants, a higher proportion of publicly insured participants had the following characteristics: female sex, Black race, heterosexual, unemployed, and attending community clinics. Despite less lab monitoring, privately-insured PWH had greater durable VS than publicly-insured PWH (ART-naïve: private 70.0% vs public 53.1%, p = 0.03; ART-experienced: private 80.2% vs public 69.4%, p < 0.0001). Privately-insured PWH had greater durable VS than publicly-insured PWH at hospital clinics (AOR = 1.59, 95% CI: 1.20, 2.12; p = 0.001). CONCLUSIONS: Paradoxical differences between HIV monitoring and durable VS exist among publicly and privately-insured PWH in Washington, DC. Programs serving PWH must improve efforts to address barriers creating inequity in HIV outcomes.

Emerging from the shadows: Trends in HIV ambulatory care, viral load testing, and viral suppression in a U.S. HIV cohort, 2019-2022: Impact of COVID-19 pandemic.

This article aimed at analyzing the acute impact and the longer-term recovery of COVID-19 pandemic effects on clinical encounter types, HIV viral load (VL) testing, and suppression (HIV VL < 200 copies/mL). This study was a longitudinal cohort study of participants seen during 2019-2022 at nine HIV Outpatient Study (HOPS) sites. Generalized linear mixed models (GLMMs) estimated monthly rates of all encounters, office and telemedicine visits, and HIV VL tests using 2010-2022 data. We examined factors associated with nonsuppressed VL (VL ≥ 200 copies/mL) and not having ambulatory care visits during the pandemic using GLMM for logistic regression with 2017-2022 and 2019-2022 data, respectively. Of 2351 active participants, 76.0% were male, 57.6% aged ≥ 50 years, 40.7% non-Hispanic White, 38.2% non-Hispanic Black, 17.3% Hispanic/Latino, and 51.0% publicly insured. The monthly rates of in-person and telemedicine visits varied during 2020 through mid-year 2022. Multivariable logistic regression showed that persons with no encounters were more likely to be male or have VL ≥ 200 copies/mL. For participants with ≥1 VL test, the prevalence rate of HIV VL ≥ 200 copies/mL during 2020 was close to the rates from 2014 to 2019. The change in probability of viral suppression was not associated with participant's age, sex, race/ethnicity, or insurance type. In the HOPS, overall patient encounters declined over 2 years during the pandemic with variations in telemedicine and in-person events, with relative maintenance of viral suppression. Ongoing recovery from the impact of COVID-19 on ambulatory care will require continued efforts to improve retention and patient access to medical services.

Weight Gain and Metabolic Effects in Persons With HIV Who Switch to ART Regimens Containing Integrase Inhibitors or Tenofovir Alafenamide.

BACKGROUND: The timing and magnitude of antiretroviral therapy-associated weight change attributions are unclear. SETTING: HIV Outpatient Study participants. METHODS: We analyzed 2007-2018 records of virally suppressed (VS) persons without integrase inhibitor (INSTI) experience who switched to either INSTI-based or another non-INSTI-based ART, and remained VS. We analyzed BMI changes using linear mixed models, INSTI- and tenofovir alafenamide (TAF) contributions to BMI change by linear mixed models-estimated slopes, and BMI inflection points. RESULTS: Among 736 participants (5316 person-years), 441 (60%) switched to INSTI-based ART; the remainder to non-INSTI-based ART. The mean follow-up was 7.15 years for INSTI recipients and 7.35 years for non-INSTI. Preswitch, INSTI and non-INSTI groups had similar median BMI (26.3 versus 25.9 kg/m 2 , P = 0.41). INSTI regimens included raltegravir (178), elvitegravir (112), and dolutegravir (143). Monthly BMI increases postswitch were greater with INSTI than non-INSTI (0.0525 versus 0.006, P < 0.001). A BMI inflection point occurred 8 months after switch among INSTI users; slopes were similar regardless of TAF use immediately postswitch. Among INSTI + TAF users, during 8 months postswitch, 87% of BMI slope change was associated with INSTI use, 13% with TAF use; after 8 months, estimated contributions were 27% and 73%, respectively. For non-INSTI+TAF, 84% of BMI gain was TAF-associated consistently postswitch. Persons switching from TDF to TAF had greater BMI increases than others ( P < 0.001). CONCLUSION: Among VS persons who switched ART, INSTI and TAF use were independently associated with BMI increases. During 8 months postswitch, BMI changes were greatest and most associated with INSTI use; afterward, gradual BMI gain was largely TAF-associated.

Incidence of Hyperlipidemia among Adults Initiating Antiretroviral Therapy in the HIV Outpatient Study (HOPS), USA, 2007-2021.

Current U.S. guidelines recommend integrase strand transfer inhibitor (INSTI)-based antiretroviral therapy (ART) as initial treatment for people with HIV (PWH). We assessed long-term effects of INSTI use on lipid profiles in routine HIV care. We analyzed medical record data from the HIV Outpatient Study's participants in care from 2007 to 2021. Hyperlipidemia was defined based on clinical diagnoses, treatments, and laboratory results. We calculated hyperlipidemia incidence rates and rate ratios (RRs) during initial ART and assessed predictors of incident hyperlipidemia by using Poisson regression. Among 349 eligible ART-naïve PWH, 168 were prescribed INSTI-based ART (36 raltegravir (RAL), 51 dolutegravir (DTG), and 81 INSTI-others (elvitegravir and bictegravir)) and 181 non-INSTI-based ART, including 68 protease inhibitor (PI)-based ART. During a median follow-up of 1.4 years, hyperlipidemia rates were 12.8, 22.3, 22.7, 17.4, and 12.6 per 100 person years for RAL-, DTG-, INSTI-others-, non-INSTI-PI-, and non-INSTI-non-PI-based ART, respectively. In multivariable analysis, compared with the RAL group, hyperlipidemia rates were higher in INSTI-others (RR = 2.25; 95% confidence interval (CI): 1.29-3.93) and non-INSTI-PI groups (RR = 1.89; CI: 1.12-3.19) but not statistically higher for the DTG (RR = 1.73; CI: 0.95-3.17) and non-INSTI-non-PI groups (RR = 1.55; CI: 0.92-2.62). Other factors independently associated with hyperlipidemia included older age, non-Hispanic White race/ethnicity, and ART without tenofovir disoproxil fumarate. PWH using RAL-based regimens had lower rates of incident hyperlipidemia than PWH receiving non-INSTI-PI-based ART but had similar rates as those receiving DTG-based ART, supporting federal recommendations for using DTG-based regimens as the initial therapy for ART-naïve PWH.

The prevalence of and factors associated with chronic atrial fibrillation in Medicare/Medicaid-eligible dialysis patients.

Atrial fibrillation is an important comorbidity with substantial therapeutic implications in dialysis patients but its prevalence varies in different studies. We used a database that includes patients in the United States on hemodialysis who were eligible for government assistance with prescription drugs. We then used ICD-9 codes from billing claims in this database to identify patients with chronic atrial fibrillation. Multivariable logistic regression was used to determine adjusted prevalence odds ratios for associated factors. Of 63,884 individuals, the prevalence of chronic atrial fibrillation was 7%. The factors of age over 60 years, male, Caucasian, body mass index over 25 kg/m(2), coronary artery disease, and heart failure were all significantly associated with chronic atrial fibrillation. Prevalence rates, particularly in younger patients, were far higher than those reported in an age group-matched nondialysis population. Thus, given its clinical impact, future efforts are needed to examine risk factors for adverse outcomes in chronic atrial fibrillation, and to identify appropriate management strategies for this disorder, as well as opportunities for quality improvement in this vulnerable population.

Geographic variation in HMG-CoA reductase inhibitor use in dialysis patients.

BACKGROUND: Despite uncertainty about their effectiveness in chronic dialysis patients, statin use has increased in recent years. Little is known about the demographic, clinical, and geographic factors associated with statin exposure in end-stage renal disease (ESRD) patients. OBJECTIVE: To analyze the demographic, clinical, and geographic factors associated with use of statins among chronic dialysis patients. DESIGN: Cross-sectional analysis. SETTING: Prevalent dialysis patients across the U.S. PARTICIPANTS: 55,573 chronic dialysis patients who were dually eligible for Medicaid and Medicare services during the last four months of 2005. METHODS: Using Medicaid prescription drug claims and United States Renal Data System core data, we examined demographics, comorbid conditions, and state of residence using hierarchical logistic regression models to determine their associations with statin use. INTERVENTION: Prescription for a statin. OUTCOME MEASURES: Factors associated with a prescription for a statin. RESULTS: Statin exposure was significantly associated with older age, female sex, Caucasian (versus African-American) race, body mass index, use of self-care dialysis, diabetes, and comorbidity burden. Moreover, there was substantial state-by-state variation in statin use, with a greater than 2.3-fold difference in adjusted odds ratios between the highest- and lowest-prescribing states. CONCLUSIONS: Among publicly insured chronic dialysis patients, there were marked differences between states in the use of HMG-CoA reductase inhibitors above and beyond patient characteristics. This suggests substantial clinical uncertainty about the utility of these medications. Understanding how such regional variations impact patient care in this high-risk population is an important focus for future work.

Association of race with cumulative exposure to statins in dialysis.

BACKGROUND: Patients on dialysis have high rates of cardiovascular disease and are frequently treated with HMG-CoA reductase inhibitors. Given that these patients have insurance coverage for medications as well as regular contact with health care providers, differences by race in exposure to statins over time should be minimal among patients who are candidates for the drug. METHODS: We created a cohort of incident dialysis patients who were dually eligible for Medicare and Medicaid services. We determined the proportion of days covered (or PDC, a marker of cumulative medication exposure) by a statin prescription over a mean of 2.0 ± 1.4 years. Ordinary least squares regression was used to determine the factors associated with cumulative drug exposure. RESULTS: Of the 18,727 patients who filled at least one prescription for a statin, mean PDC was 0.57 ± 0.32. The unadjusted PDC was higher for Caucasians (0.63 ± 0.31) than for African-Americans (0.51 ± 0.32), Hispanics (0.54 ± 0.31), and individuals of other race/ethnicity (0.58 ± 0.32). In multivariable modeling, Caucasian race was independently associated with greater exposure to statins. Relative to Caucasians, the adjusted odds ratios for the PDC for African-Americans was 0.47 (95% confidence interval, CI, 0.43-0.50), for Hispanics 0.52 (0.48-0.56) and for others, 0.72 (0.64-0.81). CONCLUSIONS: Despite insurance coverage, regular contact with health care providers, and at least one prescription for a statin, there are large differences by race in statin exposure over time. The provider- and patient-associated factors related to this phenomenon should be further examined.

Gastric electrical stimulation improves outcomes of patients with gastroparesis for up to 10 years.

BACKGROUND & AIMS: We assessed the long-term clinical outcomes of gastric electrical stimulation (GES) therapy with Enterra (Enterra Therapy System; Medtronic, Minneapolis, MN) in a large cohort of patients with severe gastroparesis. METHODS: Gastroparesis patients (n=221; 142 diabetic, 48 idiopathic, and 31 postsurgical) treated with Enterra (Medtronic) for 1-11 years were retrospectively assessed; 188 had follow-up visits and data were collected for at least 1 year (mean 56 months, range 12-131 months). Total symptom scores (TSSs), gastric emptying, nutritional status, weight, hospitalizations, use of prokinetic and/or antiemetic medications, levels of HbA1c levels (in diabetic patients), and adverse events were evaluated at the beginning of the study (baseline) and during the follow-up period. RESULTS: TSS, hospitalization days, and use of medications were significantly reduced among all patients (P<.05). More patients with diabetic (58%) and postsurgical gastroparesis (53%) had a greater than 50% reduction in TSS than those with idiopathic disease (48%; P=.32). Weight significantly increased among all groups, and 89% of J-tubes could be removed. At end of the follow-up period, all etiological groups had similar, abnormal delays in mean gastric retention. Thirteen patients (7%) had their devices removed because of infection at the pulse generator site. CONCLUSIONS: GES therapy significantly improved subjective and objective parameters in patients with severe gastroparesis; efficacy was sustained for up to 10 years and was accompanied by good safety and tolerance profiles. Patients with diabetic or postsurgical gastroparesis benefited more than those with idiopathic disease.

Geographic variation in cardioprotective antihypertensive medication usage in dialysis patients.

BACKGROUND: Despite their high risk of adverse cardiac outcomes, persons on long-term dialysis therapy have had lower use of antihypertensive medications with cardioprotective properties, such as angiotensin-converting enzyme (ACE) inhibitors/angiotensin receptor blockers (ARBs), ß-blockers, and calcium channel blockers, than might be expected. We constructed a novel database that permits detailed exploration into the demographic, clinical, and geographic factors associated with the use of these agents in hypertensive long-term dialysis patients. STUDY DESIGN: National cross-sectional retrospective analysis linking Medicaid prescription drug claims with US Renal Data System core data. SETTING & PARTICIPANTS: 48,882 hypertensive long-term dialysis patients who were dually eligible for Medicaid and Medicare services in 2005. FACTORS: Demographics, comorbid conditions, functional status, and state of residence. OUTCOMES: Prevalence of cardioprotective antihypertensive agents in Medicaid pharmacy claims and state-specific observed to expected ORs of medication exposure. MEASUREMENTS: Factors associated with medication use were modeled using multilevel logistic regression models. RESULTS: In multivariable analyses, cardioprotective antihypertensive medication exposure was associated significantly with younger age, female sex, nonwhite race, intact functional status, and use of in-center hemodialysis. Diabetes was associated with a statistically significant 28% higher odds of ACE-inhibitor/ARB use, but congestive heart failure was associated with only a 9% increase in the odds of ß-blocker use and no increase in ACE-inhibitor/ARB use. There was substantial state-by-state variation in the use of all classes of agents, with a greater than 2.9-fold difference in adjusted-rate ORs between the highest and lowest prescribing states for ACE inhibitors/ARBs and a 3.6-fold difference for ß-blockers. LIMITATIONS: Limited generalizability beyond study population. CONCLUSIONS: In publicly insured long-term dialysis patients with hypertension, there were marked differences in use rates by state, potentially due in part to differences in Medicaid benefits. However, geographic characteristics also were associated with exposure, suggesting clinical uncertainty about the utility of these medications.

The Box-Cox power transformation on nursing sensitive indicators: does it matter if structural effects are omitted during the estimation of the transformation parameter?

BACKGROUND: Many nursing and health related research studies have continuous outcome measures that are inherently non-normal in distribution. The Box-Cox transformation provides a powerful tool for developing a parsimonious model for data representation and interpretation when the distribution of the dependent variable, or outcome measure, of interest deviates from the normal distribution. The objectives of this study was to contrast the effect of obtaining the Box-Cox power transformation parameter and subsequent analysis of variance with or without a priori knowledge of predictor variables under the classic linear or linear mixed model settings. METHODS: Simulation data from a 3 × 4 factorial treatments design, along with the Patient Falls and Patient Injury Falls from the National Database of Nursing Quality Indicators (NDNQI® for the 3rd quarter of 2007 from a convenience sample of over one thousand US hospitals were analyzed. The effect of the nonlinear monotonic transformation was contrasted in two ways: a) estimating the transformation parameter along with factors with potential structural effects, and b) estimating the transformation parameter first and then conducting analysis of variance for the structural effect. RESULTS: Linear model ANOVA with Monte Carlo simulation and mixed models with correlated error terms with NDNQI examples showed no substantial differences on statistical tests for structural effects if the factors with structural effects were omitted during the estimation of the transformation parameter. CONCLUSIONS: The Box-Cox power transformation can still be an effective tool for validating statistical inferences with large observational, cross-sectional, and hierarchical or repeated measure studies under the linear or the mixed model settings without prior knowledge of all the factors with potential structural effects.

Optimizing the diagnostic power with gastric emptying scintigraphy at multiple time points.

BACKGROUND: Gastric Emptying Scintigraphy (GES) at intervals over 4 hours after a standardized radio-labeled meal is commonly regarded as the gold standard for diagnosing gastroparesis. The objectives of this study were: 1) to investigate the best time point and the best combination of multiple time points for diagnosing gastroparesis with repeated GES measures, and 2) to contrast and cross-validate Fisher's Linear Discriminant Analysis (LDA), a rank based Distribution Free (DF) approach, and the Classification And Regression Tree (CART) model. METHODS: A total of 320 patients with GES measures at 1, 2, 3, and 4 hour (h) after a standard meal using a standardized method were retrospectively collected. Area under the Receiver Operating Characteristic (ROC) curve and the rate of false classification through jackknife cross-validation were used for model comparison. RESULTS: Due to strong correlation and an abnormality in data distribution, no substantial improvement in diagnostic power was found with the best linear combination by LDA approach even with data transformation. With DF method, the linear combination of 4-h and 3-h increased the Area Under the Curve (AUC) and decreased the number of false classifications (0.87; 15.0%) over individual time points (0.83, 0.82; 15.6%, 25.3%, for 4-h and 3-h, respectively) at a higher sensitivity level (sensitivity=0.9). The CART model using 4 hourly GES measurements along with patient's age was the most accurate diagnostic tool (AUC=0.88, false classification=13.8%). Patients having a 4-h gastric retention value>10% were 5 times more likely to have gastroparesis (179/207=86.5%) than those with ≤10% (18/113=15.9%). CONCLUSIONS: With a mixed group of patients either referred with suspected gastroparesis or investigated for other reasons, the CART model is more robust than the LDA and DF approaches, capable of accommodating covariate effects and can be generalized for cross institutional applications, but could be unstable if sample size is limited.

A spatial model approach for assessing windbreak growth and carbon stocks.

Agroforestry, the deliberate integration of trees into agricultural operations, sequesters carbon (C) while providing valuable services on agricultural lands. However, methods to quantify present and projected C stocks in these open-grown woody systems are limited. As an initial step to address C accounting in agroforestry systems, a spatial Markov random field model for predicting the natural logarithm (log) of the mean aboveground volume of green ash ( Marsh.) within a shelterbelt, referred to as the log of aboveground volume, was developed using data from an earlier study and web-available soil and climate information. Windbreak characteristics, site, and climate variables were used to model the large-scale trend of the log of aboveground volume. The residuals from this initial model were correlated among sites up to 24 km from a point of interest. Therefore, a spatial dependence parameter was used to incorporate information from sites within 24 km into the prediction of the log of the aboveground volume. Age is an important windbreak characteristic in the model. Thus, the log of aboveground volume can be predicted for a given windbreak age and for values of other explanatory variables associated with a site of interest. Such predictions can be exponentiated to obtain predictions of aboveground volume for windbreaks without repeated inventory. With the capability of quantifying uncertainty, the model has the potential for large regional planning efforts and C stock assessments for many deciduous tree species used in windbreaks and riparian buffers once it is calibrated.

The impact of race and ethnicity on outcomes in 19,584 adults hospitalized with COVID-19.

INTRODUCTION: At the population level, Black and Hispanic adults in the United States have increased risk of dying from COVID-19, yet whether race and ethnicity impact on risk of mortality among those hospitalized for COVID-19 is unclear. METHODS: Retrospective cohort study using data on adults hospitalized with COVID-19 from the electronic health record from 52 health systems across the United States contributing data to Cerner Real World DataTM. In-hospital mortality was evaluated by race first in unadjusted analysis then sequentially adjusting for demographics and clinical characteristics using logistic regression. RESULTS: Through August 2020, 19,584 patients with median age 52 years were hospitalized with COVID-19, including n = 4,215 (21.5%) Black and n = 5,761 (29.4%) Hispanic patients. Relative to white patients, crude mortality was slightly higher in Black adults [22.7% vs 20.8%, unadjusted OR 1.12 (95% CI 1.02-1.22)]. Mortality remained higher among Black adults after adjusting for demographic factors including age, sex, date, region, and insurance status (OR 1.13, 95% CI 1.01-1.27), but not after including comorbidities and body mass index (OR 1.07, 95% CI 0.93-1.23). Compared with non-Hispanic patients, Hispanic patients had lower mortality both in unadjusted and adjusted models [mortality 12.7 vs 25.0%, unadjusted OR 0.44(95% CI 0.40-0.48), fully adjusted OR 0.71 (95% CI 0.59-0.86)]. DISCUSSION: In this large, multicenter, EHR-based analysis, Black adults hospitalized with COVID-19 had higher observed mortality than white patients due to a higher burden of comorbidities in Black adults. In contrast, Hispanic ethnicity was associated with lower mortality, even in fully adjusted models.

Disparities in Treatment with Direct-Acting Hepatitis C Virus Antivirals Persist Among Adults Coinfected with HIV and Hepatitis C Virus in US Clinics, 2010-2018.

Human immunodeficiency virus (HIV) and hepatitis C virus (HCV) coinfection carries substantial risk for all-cause mortality and liver-related morbidity and mortality, yet many persons coinfected with HIV/HCV remain untreated for HCV. We explored demographic, clinical, and sociodemographic factors among participants in routine HIV care associated with prescription of direct-acting antivirals (DAAs). The HIV Outpatient Study (HOPS) is an ongoing longitudinal cohort study of persons with HIV in care at participating clinics since 1993. There are currently eight study sites in six US cities. We analyzed medical records data of HOPS participants diagnosed with HCV since June 2010. Sustained virological response (SVR) was documented with first undetectable HCV viral load (VL). We assessed factors associated with being prescribed DAAs by multi-variable logistic regression and described the cumulative rate of SVR. Among 306 eligible participants, 131 (43%) were prescribed DAA therapy. Factors associated with greater odds of being prescribed DAA were older age, private health insurance, higher CD4 cell count, being a person who injects drugs, and receiving care at publicly funded sites (p < 0.05). Of 127 (97%) participants with at least 1 follow-up HCV VL, 110 (87%) achieved SVR at 12 weeks. Of the total 131 participants, 123 (94%) eventually achieved SVR. Less than half of HIV/HCV coinfected patients in HOPS have been prescribed DAAs. Interventions are needed to address deficits in DAA prescription, including among patients with public or no health insurance, younger age, and lower CD4 cell count.

Colorectal cancer screening, perceived discrimination, and low-income and trust in doctors: a survey of minority patients.

BACKGROUND: Completion of colorectal cancer (CRC) screening testing is lower among low-income and minority groups than the population as a whole. Given the multiple cancer screening health disparities known to exist within the U.S., this study investigated the relationship between perceived discrimination, trust in most doctors, and completion of Fecal Occult Blood Testing (FOBT) among a low-income, minority primary care population in an urban setting. METHODS: We recruited a convenience sample of adults over age 40 (n = 282) from a federally qualified community health center (70% African American). Participants completed a survey which included measures of trust in most doctors, perceived discrimination, demographics and report of cancer screening. RESULTS: Participants reported high levels of trust in most doctors, regardless of sex, race, education or income. High trust was associated with low perceived discrimination (p < 0.01). The trend was for older participants to express more trust (p = 0.09) and less perceived discrimination (p < 0.01). Neither trust nor discrimination was associated with race or education. Trust was higher among participants over 50 who were up-to-date on FOBT screening vs. those who were not (31 vs. 29 (median), p < 0.05 by T-test). Among those over 50, up-to-date FOBT screening was nearly associated with high trust (p < 0.06; 95% CI 0.99, 1.28) and low perceived discrimination (p < 0.01; 95% CI 0.76, 0.96). Nevertheless, in multivariate-modeling, age and income explained FOBT completion better than race, trust and discrimination. CONCLUSION: Perceived discrimination was related to income, but not race, suggesting that discrimination is not unique to minorities, but common to those in poverty. Since trust in most doctors trended toward being related to age, FOBT screening could be negatively influenced by low trust and perceived discrimination in health care settings. A failure to address these issues in middle-aged, low income individuals could exacerbate future disparities in CRC screening.

Validation of the support provided measure among spouses of smokers receiving a clinical smoking cessation intervention.

Studies indicate a positive association between social support and smoking cessation. However, clinic-based interventions designed to increase social support have had limited success. Most studies have relied on only the smoker's perceptions of support received while few have assessed the support provider's report of support delivered. Understanding supportive interactions between support providers and recipients may assist in developing effective support interventions for cessation. The current investigation examined the perceptions of smoking-specific support provided by the spouse of a partner who smokes and was seen for a nicotine dependence consultation. Specifically, we examined spouse reported willingness to help their spouse quit, interest in learning ways to help their spouse quit, and characteristics associated with the provision of smoking-specific supportive behaviors (as assessed via the Support Provided Measure, SPM), in the 2-weeks prior to the consultation. The current investigation also examined the concurrent validity of the SPM with a validated measure of support provided to a smoker, the Partner Interaction Questionnaire (PIQ), accounting for social desirability bias and smoker readiness to change. The sample comprised 84 adult cigarette smokers seen for a clinical smoking cessation intervention and their spouses (N = 84). Results indicate that a high percentage of spouses are willing to help their partner who smokes and interested in learning way to help. As expected, spouses who were females and had never smoked had higher scores on the SPM than males or current smokers. The SPM was significantly correlated with the PIQ positive (r = 0.50, p < 0.01) and negative (r = 0.44, p <0.01) item scales overall and for spouses whose partners reported higher levels of readiness to quit smoking (r = 0.54, p < 0.01; r = 0.50, p < 0.01, respectively). Suggestions for future research are offered.

Incidence and Risk Factors for Renal Disease in an Outpatient Cohort of HIV-Infected Patients on Antiretroviral Therapy.

INTRODUCTION: Prior studies found renal disease was common among HIV-infected outpatients. We updated incident renal disease estimates in this population, comparing those with and without tenofovir exposure. METHODS: We conducted a retrospective analysis of the DC Cohort, a longitudinal study of HIV patients in Washington, DC, from 2011 to 2015. We included adults prescribed antiretroviral therapy (ART) with baseline glomerular filtration rate (GFR) ≥15 ml/min per 1.73 m2. We defined renal disease as 50% decrease in GFR or doubled serum creatinine (Cr) within 3 months. We defined cumulative viral load as area under the curve (AUC) of log10 transformed longitudinal HIV RNA viral load (VL). Correlates of time to incident renal disease were identified using Cox proportional hazard regression models, adjusted for demographics and known risk factors for kidney disease. RESULTS: Among 6068 adults, 77% were Black and median age was 48 years. Incident renal disease rate was 0.77 per 100 person-years (95% confidence interval [CI]: 0.65-0.9). Factors associated with renal disease were age (adjusted hazard ratio [aHR]: 1.4; CI 1.1-1.7 per 10 years), public non-Medicaid, non-Medicare insurance (aHR: 3.4; CI: 1.9-6.4), AUC VL (aHR: 1.1; CI: 1.1-1.2), diabetes mellitus (aHR: 1.6; CI: 1.0-2.4), and mildly reduced GFR (60-89 ml/min per 1.73 m2) (aHR: 1.5; CI: 1.0-2.3); recent tenofovir exposure was not associated with renal disease (aHR: 0.7; CI: 0.5-1.1). CONCLUSION: Our study revealed a substantial burden of renal disease among HIV patients. Cumulative VL was associated with renal disease, suggesting that early VL suppression may decrease its incidence.

Discussing weight with obese primary care patients: physician and patient perceptions.

OBJECTIVE: To evaluate patient-provider agreement on whether weight and related behaviors were discussed during routine visits. DESIGN: Post-visit survey assessments of patients and providers. PARTICIPANTS: Obese patients make up the majority of all patients seen in primary care (PC). The patients and physicians were recruited at the time of PC visits. MEASUREMENTS AND MAIN RESULTS: Percent patient-physician agreement and patient, provider and practice characteristics associated with agreement. Patients (456) and physicians (30) agreed about whether or not they discussed weight, physical activity (PA), and diet for 61% of office visits. There was disagreement on one of the items (weight, PA, or diet) for 23% of office visits, and for 2 or more of the items for 16% of the visits. Agreement was relatively greater for discussing weight than for discussing diet or physical activity. Physicians reported discussing weight issues more often than did patients. Overall patient-physician agreement was 0.51-0.59 (weighted Kappa statistic). In a multivariate analyses of factors associated with patient-physician agreement, health insurance (odds ratio [OR]=3.67, p value = 0.002), physician description of patient weight status (OR = 2.27, p value = 0.002), patient report of how weight relates to health (OR = 1.70, p value = 0.04), and female patient gender (OR = 1.62, p = value = 0.02) were significantly related to agreement. CONCLUSIONS: Patients and providers disagreed about whether or not weight issues were discussed in a large number of primary care encounters in this study. Physicians may be able to improve care for their obese patients by focusing discussions on specific details of diet and physical activity behaviors, and by clarifying that patients perceive weight-related information has been shared.

Candidemia and invasive candidiasis among hospitalized neonates and pediatric patients.

OBJECTIVE: To investigate the epidemiology, treatment, length of stay (LOS) and costs for neonatal and pediatric inpatients with invasive candidiasis (IC). METHODS: The Cerner Health Facts Database was used to assess inpatients (2005-2014) identified by positive blood or cerebrospinal fluid (CSF) Candida cultures. Log-transformed LOS and cost were examined in candidemia-only patients (n = 191) using multivariable linear regression. RESULTS: A total of 202 patients had a positive culture (blood: n = 192; CSF: n = 10; both: n = 2). The most prevalent species were C. parapsilosis (n = 70, 34.7%), and C. albicans (n = 66, 32.7%). Mean (SD) age was 5 (5.5) years; 30 (14.9%) patients were <4 months. Comorbidities included sepsis (n = 85, 42.1%), coagulation disorders (n = 57, 28.2%), cancer (n = 64, 31.7%), and low birthweight (n = 26, 12.9%). Antifungals (AFs) included azoles (57.4%), polyenes (28.7%), and echinocandins (35.1%); 20.8% of patients received no AF during their encounter. The mean (SD) cost per encounter was $97,392 ($149,253), with a mean (SD) LOS of 45.6 (59.5) days and 9.9% mortality at discharge. Results were similar across Candida species. In regression analysis, intensive care unit (ICU) exposure, central catheter, sepsis, AF >48 hours prior to index culture, and age <4 months were associated with increased LOS; treatment at a non-teaching hospital was associated with reduced LOS (p < .05). AF use >48 hours before index, in-hospital mortality, Midwest region and ventricular shunt were associated with increased cost (p ≤ .05). CONCLUSIONS: This analysis confirms the association between pediatric candidemia and increased resource utilization and LOS. Given high observed rates of potential under-treatment, an opportunity may exist to improve AF therapy in this population.