A Mixed-Methods Study to Understand Community Health Worker Integration With Health Care Teams.

Two models employed to integrate community health workers (CHWs) in health care settings are community-clinical linkages and employment within health care. Our objective was to understand the variability in how these models are implemented. We conducted a mixed-methods study across a large health system that included CHW focus groups and electronic health record data on patients referred to the teams. We identified three primary themes in the four focus groups (N = 29) and found differences in the demographics and health care use of the 1,097 patients. Both community- and clinically embedded CHWs reported addressing diverse patient needs; yet, challenges persist in integrating both models.

Blood Pressure Control in a Diverse Population of Hypertensive Patients With Heart Failure.

Hypertensive patients with heart failure (HF), with reduced or preserved ejection fraction, belong to a vulnerable subset with high mortality risks. In HF patients, the current clinical guideline recommends attaining a systolic blood pressure (BP) <130 mm Hg. However, levels of BP control and their correlates in this subgroup are not well understood. Our study aimed at establishing levels of BP control and its associated factors in a geographically, racially diverse population of hypertensive patients with HF. Our study involved 10,802 patients within a large health system in the Charlotte metropolitan area in 2019. We documented a high prevalence of systolic BP ≥130 mm Hg, 48.1% (95% confidence interval 47.4% to 48.8%), and of BP ≥130/80 mm Hg, 57.6% (57.0% to 58.3%). From a multivariate logistic regression model, systolic BP ≥130 mm Hg was associated with race-ethnicity (p <0.0001), gender (p = 0.0001), insurance (p <0.0001), attribution with a primary care physician (p = 0.0001). Non-Hispanic Blacks (vs non-Hispanic Whites odds ratio [OR] 1.38, 1.28 to 1.48), women (OR 1.12, 1.06 to 1.19), and uninsured patients (vs privately insured OR 1.43, 1.20 to 1.72) had a higher risk of systolic BP ≥130 mm Hg; patients with primary care physician attribution had a lower risk of systolic BP ≥130 mm Hg (OR 0.87, 0.81 to 0.94). Similar results were found with the outcome BP ≥130/80 mm Hg. Overall, further efforts are needed to optimize treatment in hypertensive patients with HF and improve health equity across patient communities.

Prevalence and Correlates of Uncontrolled Hypertension, Persistently Uncontrolled Hypertension, and Hypertensive Crisis at a Healthcare System.

BACKGROUND: Uncontrolled hypertension significantly increases risk of cardiovascular disease and death. This study examined the prevalence of uncontrolled hypertension, persistently uncontrolled hypertension, and hypertensive crisis and factors associated with these outcomes in a real-world patient cohort. METHODS: Electronic medical records from a large healthcare system in North Carolina were used to identify adults with uncontrolled hypertension (last ambulatory blood pressure [BP] measurement ≥140/90); persistently uncontrolled hypertension (≥2 ambulatory BP measurements with all readings ≥140/90); and hypertensive crisis (any BP reading ≥180/120) in 2019. Generalized linear mixed models tested the association between patient and provider characteristics and each outcome. RESULTS: The study cohort included 213,836 patients (mean age 63.1 (±14.0) years, 55.5% female, 70.8% white). Of these, 29.7% and 13.1% had uncontrolled hypertension and hypertensive crisis, respectively. Among those experiencing hypertensive crisis, >50% did not have uncontrolled hypertension. Of the 171,061 patients with ≥2 BP measurements, 5.9% had persistently uncontrolled hypertension. The likelihood of uncontrolled hypertension, persistently uncontrolled hypertension, and hypertensive crisis was higher in patients with black race (vs. white), self-pay (vs. private), prior emergency room visit, and no attributed primary care provider. Readings taken in the evening (vs. morning) and at specialty (vs. primary care) practices were more likely to meet thresholds for uncontrolled hypertension and hypertensive crisis. CONCLUSIONS: Hypertension control remains a significant challenge in healthcare. Health systems may benefit from segmenting their patient population based on factors such as race, prior healthcare use, and timing of BP measurement to prioritize outreach and intervention.

The Association Between Metabolic Syndrome and Non-Alcoholic Fatty Liver Disease Diagnosis Varies by Race.

Objectives: This study investigated how the association between metabolic syndrome (MetS) and nonalcoholic fatty liver disease (NAFLD) diagnosis varies between non-Hispanic African American and white patients. Methods: A retrospective cohort study was performed using electronic medical records from an integrated health care system (2010-2018). Adults with records for all MetS measurements (body mass index, lipids, blood pressure, and blood glucose) in 2011, who did not have a NAFLD diagnosis before their last MetS measurement, were included. Results: The study cohort consisted of 139,336 patients (age 56.1 ± 15.2 years, 57.9% female, 79.4% non-Hispanic white). The rate of NAFLD diagnosis was higher in MetS patients compared with non-MetS patients [adjusted hazards ratio (AHR) = 1.99, 95% CI = 1.91-2.09] with a significant interaction by race (AHR = 2.05, 95% CI = 1.95-2.15 in non-Hispanic whites vs. AHR = 1.76, 95% CI = 1.58-1.96 non-Hispanic African Americans, P = 0.017). Secondary analyses revealed that the relative NAFLD diagnosis rate was higher in non-Hispanic whites with MetS compared with non-Hispanic African Americans with MetS among females and patients 18-39 years of age and 40-59 years, but not among males and those ≥60 years of age. Conclusions: Non-Hispanic white patients with MetS, particularly females and those <60 years of age, may be at increased risk of NAFLD compared with non-Hispanic African American MetS patients and may benefit from extra attention regarding NAFLD screening.

Characteristics and Healthcare Burden of Patients with Schizophrenia Treated in a US Integrated Healthcare System.

BACKGROUND: Schizophrenia is one of 15 major causes of disability worldwide and is responsible for more than USD 150 billion in annual healthcare costs in the United States. Although the burden of schizophrenia as measured by healthcare resource utilization (HRU) is known to be considerable, data generally come from claims databases or healthcare systems/payors representing only a subset of patients, such as Medicare/Medicaid recipients. A broader understanding of HRU across the schizophrenia patient population would help identify underserved groups and inform strategies for improving healthcare delivery. AIMS OF THE STUDY: This observational study examined overall HRU and the influence of sociodemographic factors in adult patients with schizophrenia receiving care in a US integrated healthcare system. METHODS: A retrospective cohort study was conducted using data from electronic medical records (EMRs). Patients were required to have at least two diagnostic codes for schizophrenia recorded in the EMR within a 12-month period from January 2009 to June 2018, and to have received active care (≥ 1 in-system healthcare visit every six months) for at least 12 months before and after the index date (the earlier of the schizophrenia diagnosis dates). Patients were followed until no longer receiving active care or the end of the study. Patient characteristics were assessed during the 12-month pre-index period, and inpatient, readmission, emergency room (ER), and outpatient visits and antipsychotic prescriptions were described during follow-up. Findings were reported overall and in subgroups by race/ethnicity, age, and sex. RESULTS: The study cohort included 2,941 patients (mean age, 48.3 years; 54.5% male, 51.8% black, 45.8% with Medicare). During the follow-up period (mean, 4.6 years), inpatient hospital stays were common, with at least one all-cause, mental health-related, or schizophrenia-related inpatient visit occurring for 48.7%, 47.3%, and 38.8% of patients, respectively. Hospital readmissions within 30 days of an all-cause inpatient visit occurred in 20.4% of patients, with 14.5% of patients readmitted within 30 days of a schizophrenia-related inpatient visit. More than two-thirds of patients had ER visits, and 40.7% had schizophrenia-related ER visits. Only 46.7% of patients with a schizophrenia-related inpatient visit and 58.5% of patients with a mental health-related inpatient visit had a 30-day outpatient follow-up visit. Subgroup analyses revealed that a larger proportion of non-Hispanic black vs non-Hispanic white patients had 30-day outpatient follow-up visits, ER visits, mental health specialist visits, and antipsychotic prescriptions. Moreover, older age was associated with fewer ER and mental health specialist visits and less use of injectable and second-generation antipsychotics, and women were less likely than men to receive antipsychotic therapy, particularly injectable medications. DISCUSSION: Patients with schizophrenia receiving care in a US integrated healthcare system had considerable acute HRU and suboptimal rates of routine and follow-up care. Inequities in schizophrenia burden and care were observed in demographic subgroups. IMPLICATIONS FOR HEALTH POLICIES: Population health management strategies focusing on efficient resource allocation and improving healthcare quality are needed to reduce the burden of schizophrenia. Differential findings by race/ethnicity, age, and sex indicate the need for optimizing approaches to care in these subgroups.

The Impact of Once-Monthly Paliperidone Palmitate on Healthcare Utilization Among Patients With Schizophrenia Treated in an Integrated Healthcare System: A Retrospective Mirror-Image Study.

INTRODUCTION: Previous evidence demonstrated that patients with schizophrenia consumed substantial healthcare resources in an integrated healthcare system. This study evaluated the impact of initiating once-monthly paliperidone palmitate (PP1M) on healthcare resource utilization (HRU) among patients with schizophrenia treated in a US integrated healthcare system. METHODS: This retrospective study used electronic medical records from Atrium Health. Adults with at least two diagnoses of schizophrenia who received an initial PP1M dose between September 2009 and April 2019 (the corresponding date defined the index date) and at least one subsequent dose within 90 days were included. Additionally, patients were required to have received active care (at least one healthcare visit every 6 months) during 12-month pre- and post-index periods and at least one oral antipsychotic prescription during the 12-month pre-index period. Inpatient, emergency room (ER), and outpatient visits were compared over 12-month pre- versus post-index periods within the same cohort using McNemar's and Wilcoxon signed rank tests. Findings were reported for all patients and separately in patients with at least one schizophrenia relapse (schizophrenia-related inpatient or ER visit) during the 12-month pre-index period. RESULTS: The study cohort included 210 patients (mean age 34.2 years, 69.5% male, 39.1% had Medicaid). From the 12-month pre- to post-index period, the proportion of patients with visits and mean number of visits reduced for all-cause inpatient (67.6% to 22.4%, 1.2 to 0.4), 30-day readmission (12.4% to 2.4%, 0.2 to 0.1), and ER (68.6% to 45.7%, 2.3 to 1.2) visits, whereas the mean number of outpatient visits increased (8.7 to 11.6) (all P < 0.05). Similar trends were observed for mental health- and schizophrenia-related HRU. The trends in HRU in patients with prior relapse were similar with a higher extent of reduction in inpatient and ER use compared to the overall cohort. CONCLUSION: Initiation of PP1M was associated with reduced acute HRU in patients with schizophrenia, indicating potential clinical and economic benefits, especially in patients with prior relapse.

Metformin dosage patterns in type 2 diabetes patients in a real-world setting in the United States.

AIM: To examine metformin dosage patterns among adults with type 2 diabetes in an integrated healthcare system in the US. METHODS: Using electronic medical records, the proportions of patients receiving different initial metformin doses were reported. Proportion of patients receiving ≥1500 mg metformin daily at initiation or within six months after initiation and the associated sociodemographic and clincal factors were examined. RESULTS: The cohort included 715 patients (52.6% female, 64.1% white, and mean age = 57.0 ± 12.7 years). Of these, 31.3% received an initial daily metformin dose of <850 mg, 46.9% received 850-1499 mg, and 21.8% received ≥1500 mg and 244 (34.1%) patients received ≥1500 mg metformin daily at initiation or within six months after initiation. Patients aged 65-79 years (vs. those aged <50 years) and blacks (vs. whites) were less likely and Hispanics (vs. whites) and patients with higher HbA1c before metformin initiation were more likely to receive ≥1500 mg metformin daily at initiation or within six months after initiation. CONCLUSIONS: Study findings suggest a need for efforts to maximize the proportion of eligible patients receiving a recommended metformin dose. Factors impacting metformin dosage identified in the study could be a useful guidance.

Comparative Effectiveness of Metformin Dosage Uptitration Versus Adding Another Antihyperglycemic Medication on Glycemic Control in Type 2 Diabetes Patients Failing Initial Metformin Monotherapy: A Retrospective Cohort Study.

Metformin is recommended as first-line treatment for type 2 diabetes (T2D). A disadvantage of metformin is the possibility of gastrointestinal adverse effects in some patients. Many T2D patients are not able to achieve/maintain glycemic control from initial metformin treatment and receive treatment intensification by means of metformin dosage uptitration or addition of a T2D drug. This retrospective study evaluated the comparative effectiveness of these 2 treatment intensification strategies. The study cohort included T2D patients at a US integrated health care system who: were initiated on metformin monotherapy (MM) during January 2009 - September 2013; had an uncontrolled HbA1c (≥7%) after at least 90 days of MM; and received metformin dosage uptitration or an additional T2D medication within 6 months of the uncontrolled HbA1c reading. Statistical techniques included Kaplan-Meier curves and Cox proportional hazards regression. The study cohort included 1167 patients, 52.4% male and 65.1% white, with a mean age of 55.3 (±11.9) years. Of these, 49.1% received metformin dosage uptitration and 50.9% received an additional T2D medication. Metformin dosage uptitration was as effective as adding another T2D medication with the probability of not achieving glycemic control (P = 0.599) and rate of glycemic control (adjusted hazard ratio = 1.28, 95% confidence interval = 0.98-1.68) within 6 months of intensification not significantly different between the 2 groups. Metformin dosage uptitration could be a preferable initial intensification strategy in patients failing initial MM unless there is a concern for gastrointestinal adverse effects, in which case adding a T2D medication might be preferable.

Racial/ethnic differences in healthcare use among patients with uncontrolled and controlled diabetes.

OBJECTIVES: To examine racial/ethnic differences in healthcare use among patients classified as having controlled and uncontrolled diabetes. DESIGN: Data from the Carolinas HealthCare System electronic data warehouse were used. Glycemic control was defined as glycosylated hemoglobin (HbA1c) < 8% (64 mmol/mol) in 2012 (n = 9996). Patients with HbA1c ≥ 8% (64 mmol/mol) in 2012 were classified as uncontrolled (n = 2576). Race and ethnicity were jointly classified as non-Hispanic Black, non-Hispanic White or Other. Separate mixed effects negative binomial models estimated the independent effect of race/ethnicity on the number of emergency department (ED) visits, hospitalizations and physician office visits in 2013, in each patient group, adjusting for significant confounding variables. RESULTS: Rates of diabetes-related ED visits were two to three times higher for non-Hispanic Blacks compared to non-Hispanic Whites (uncontrolled rate ratio [RR]: 3.41 95% CI: 1.41-8.22; controlled RR: 2.95; 95% CI: 1.78-4.91). Similar differences were observed for all-cause ED visits (uncontrolled RR: 1.83, 95% CI: 1.50-2.24; controlled RR: 2.45, 95% CI: 2.17-2.77). Non-Hispanic Blacks with controlled and uncontrolled diabetes also had lower rates of all-cause physician office visits when compared to non-Hispanic Whites (uncontrolled RR: 0.84, 95% CI: 0.77-0.91; controlled RR: 0.81, 95% CI: 0.78-0.84). CONCLUSION: Notable racial/ethnic disparities exist in the use of emergency services and physician offices for diabetes care. Strategies such as patient education and care delivery changes that address healthcare access issues in racial/ethnic minorities should be considered to offer better diabetes management and address diabetes disparities.

Shared decision making and time to exacerbation in children with asthma.

Objective: Although shared decision making (SDM) is a promising approach for improving outcomes for patients with chronic diseases, no evidence currently supports the use of SDM to delay asthma exacerbations. We evaluated the impact of an SDM intervention implemented by providers in a real-world setting on time to exacerbation in children with asthma. Methods: This study used a prospective cohort observed between 2011 and 2013 at five primary care practices that serve vulnerable populations (e.g., Medicaid and uninsured patients) in Charlotte, NC. Patients aged 2 to 17 receiving SDM were matched to those receiving usual care using propensity scores. Time to asthma exacerbation (asthma hospitalization, emergency department visit or oral steroid prescription in the outpatient setting) was compared between groups using Kaplan-Meier curves and conditional Cox proportional hazards models. Results: The cohort included 746 children, 60.5% male and 54.2% African American, with a mean age of 8.6 years. Of these, 625 received usual care and 121 received SDM. The final analysis included 100 matched pairs of children. Kaplan-Meier curves showed longer exacerbation-free time for patients in the SDM intervention compared to those in usual care (p = 0.005). The difference in risk of experiencing an exacerbation was marginally significant between the two groups (HR = 0.56, 95% C.I. = 0.29-1.08, p = 0.08). Conclusions: SDM was found to delay exacerbations among children with asthma. Clinicians should consider incorporating patient preferences in treatment decisions through SDM as a means for longer exacerbation-free time among children with poor asthma control.

Impact of Timely Treatment Intensification on Glycemic Goal Achievement in Patients With Type 2 Diabetes Failing Metformin Monotherapy.

Purpose The purpose of the study was to examine the association between timely treatment intensification (TTI) and glycemic goal achievement in patients with type 2 diabetes (T2D) failing metformin monotherapy (MM). Methods This study was set at a large integrated health care system in the United States. The study cohort included T2D patients aged 18 to 85 years who were on MM between January 2009 and September 2013 and had an uncontrolled glycated hemoglobin (A1C) reading (≥8%) after at least 3 months of MM (corresponding date was index date). Secondary analyses were performed using A1C <7% as T2D control. TTI was defined as receipt of an add-on therapy within 180 days after the index date. Impact of TTI on glycemic goal achievement was determined using multivariate Cox proportional hazards regression. Patients were censored at their last A1C reading or health care visit during 2 years after the index date. Results The study cohort consisted of 996 patients, ~58% male and ~59% Caucasian, with a mean age of ~54 (±12) years. TTI was observed in 50.2% of the patients. The rate of glycemic goal achievement was higher in patients with TTI compared with patients without TTI (hazards ratio = 1.632, 95% confidence interval = 1.328-2.006). The results for the secondary analyses were largely consistent with the primary findings. Conclusions TTI positively affected glycemic goal achievement among T2D patients failing MM and could be a useful strategy to increase the currently low proportion of patients with their T2D controlled in the United States.

Patient and Provider Factors Affecting Clinical Inertia in Patients With Type 2 Diabetes on Metformin Monotherapy.

PURPOSE: Our aim was to determine the extent of clinical inertia and the associated patient and provider factors in patients with type 2 diabetes on metformin monotherapy (MM) at a large integrated health care system in the United States. METHODS: The study cohort included patients with type 2 diabetes aged 18 to 85 years, on MM between January 2009 and September 2013, who experienced MM failure (had an uncontrolled glycosylated hemoglobin [HbA1c] reading (≥8.0% [64 mmol/mol]) after at least 90 days of MM). Clinical inertia was defined as absence of treatment intensification with an add-on therapy within 180 days after the MM failure (index date). The impact of patient and provider factors on clinical inertia was determined using generalized estimating equations. FINDINGS: The study cohort consisted of 996 patients; 58% were men and 59% were white, with a mean age of 53 (11.8) years. Of these, 49.8% experienced clinical inertia. Lower HbA1c at index date, absence of liver diseases, absence of renal diseases, and greater provider age were associated with clinical inertia. The clinical inertia rate in a secondary analysis considering HbA1c <7.0% (53 mmol/mol) as glycemic control was 67.9%. Greater patient age, lower HbA1c at index date, greater provider age, and being a primary care physician were associated with clinical inertia. IMPLICATIONS: Considerable clinical inertia rates were observed in our real-world patient population, suggesting the need of interventions to reduce clinical inertia in clinical practice. Information about patient and provider factors affecting clinical inertia provided by this study could help healthcare policymakers plan and implement such interventions.

Retrospective Analysis of Catheter-Acquired Urinary Tract Infection: Relationship to Stroke Diagnosis.

AIMS: The objective of this study was to determine if a diagnosis of stroke was associated with a higher incidence of catheter-associated urinary tract infections (CAUTIs). Secondary aims included examining the effect of healthcare-related variables including antibiotic and steroid use, length of stay before catheter insertion, and duration of catheter use on the incidence of CAUTI in stroke patients. DESIGN: This was a retrospective chart review analysis set in a large teaching hospital in the Southeastern United States. METHODS: A total of 300 patients with indwelling urinary catheter use who also had a stroke diagnosis were randomly selected and matched (on age, gender, race, and admission date) to 300 randomly selected patients with indwelling urinary catheter use and without stroke. Bivariate statistical tests included Wilcoxon signed-rank test and McNemar's test, whereas the multivariate test consisted of generalized estimating equations. RESULTS: The incidence of CAUTIs in stroke patients was significantly higher than that in nonstroke patients (6.0% vs 1.7%, P = .005). In the multivariable generalized estimating equations analysis, stroke patients were found to be approximately 3.5 times more likely to experience CAUTI compared with nonstroke patients (odds ratio = 3.53; 95% confidence interval, 1.24-10.03; P = .018). The proportion of patients who used steroids was greater among stroke patients who experienced CAUTI compared with those who did not experience CAUTI (55.6% vs 24.5%, P = .004). CONCLUSION: Stroke patients were more likely to develop CAUTI compared with nonstroke patients. These patients should be considered as key targets when implementing interventions aimed at reducing CAUTIs. Use of steroids may be associated with a higher likelihood of CAUTI in stroke patients. IMPLICATIONS: Clinical nurse specialists are directly influential in preventing CAUTIs. This study provides evidence regarding the association between stroke and CAUTI to clinical nurse specialists to help them plan CAUTI prevention initiatives.

Results from a pragmatic prospective cohort study: Shared decision making improves outcomes for children with asthma.

OBJECTIVE: Patient/provider shared decision making (SDM) improves asthma control in a pragmatic clinical trial setting. This study evaluated the impact of an evidence-based SDM toolkit on outcomes for patients with asthma implemented by providers in a real world setting. We hypothesized that these patients with asthma would demonstrate improved outcomes such as reduced emergency department (ED) visits, hospitalizations, and oral steroid use in the 12 months following a SDM visit compared to those who did not receive the intervention. METHODS: Patients with asthma were identified within six primary care practices that serve vulnerable populations in Charlotte, NC (746 children; 718 adult patients). Propensity scores were used to match 200 children and 206 adults for analysis. The primary outcome variable was asthma exacerbation defined as an ED visit or hospitalization for asthma or outpatient prescription of an oral steroid. Patients were monitored at 3, 6, and 12 months after the intervention date. The outcome variables of ED visits, hospitalizations, and oral steroids were compared between intervention and matched control patients. RESULTS: The proportion of pediatric patients with one or more exacerbations was significantly lower in the SDM intervention group compared to controls during 12 months after exposure to the intervention (33% vs. 47%, p = 0.023). For adults, there was not a strong association between use of the SDM intervention and outcomes improvement. CONCLUSIONS: The evidence-based SDM intervention implemented in this study was associated with improved asthma outcomes for pediatric patients but not adult patients in a real world clinical setting.

Prevalence of Metabolic Syndrome in a Large Integrated Health Care System in North Carolina.

BACKGROUND: Metabolic syndrome (MetS) is a cluster of conditions--including abdominal obesity, dyslipidemia, hypertension, and hyperglycemia--that are associated with a significantly increased risk of developing diabetes and cardiovascular diseases. No information currently exists regarding the prevalence of MetS in North Carolina. This study determined the prevalence of MetS among adults receiving care in a large integrated health care system in North Carolina. METHODS: This study used data from the Carolinas HealthCare System's electronic medical record system and included adults receiving care during 2014. The association between patient demographic characteristics and MetS was determined using multivariable logistic regression. RESULTS: The prevalence of MetS was approximately 22.5%. Individuals aged 18-29 years were less likely to have MetS compared with those aged 80 years and older (odds ratio [OR], 0.61; 95% confidence interval [CI], 0.56-0.67). Groups that were more likely to have MetS included women (OR, 1.07; 95% CI, 1.05-1.10), Hispanics (OR, 1.14; 95% CI, 1.05-1.23), individuals with Medicare (OR, 1.38; 95% CI, 1.33-1.42), and those with Medicaid (OR, 1.68; 95% CI, 1.58-1.78) compared with men, whites, and those with commercial insurance, respectively. LIMITATIONS: We excluded individuals with missing data for any of the conditions that define MetS, which may underestimate the actual prevalence of this condition. CONCLUSIONS: The considerable prevalence of MetS in our North Carolina sample suggests that interventions are needed to achieve the state's population health goals.

Psychometric Properties of the Mini Pediatric Asthma Quality of Life Questionnaire in a US Sample.

The 13-item Mini Pediatric Asthma Quality of Life Questionnaire (MiniPAQLQ) was developed to measure asthma-specific quality of life in children. However, no validation studies have been conducted in the United States. This study aimed at determining the psychometric properties of the MiniPAQLQ in a US sample. Children aged 7-17 years and with an asthma diagnosis (n = 193) were identified from primary care clinics within an integrated healthcare system in the Southeastern United States. Participants completed surveys consisting of the MiniPAQLQ and the control module of the Asthma Therapy Assessment Questionnaire (ATAQ). Convergent validity was determined based on association between the MiniPAQLQ and ATAQ scores. Internal consistency reliability was determined from Cronbach's alpha coefficients for the MiniPAQLQ subscales (symptoms, emotions, and activities). Item-convergent validity was examined based on corrected item-total correlations. Item-discriminant validity was determined by comparing corrected item-total correlations and item-to-other-scale correlations. Floor and ceiling effects were examined based on the percentage of respondents having the lowest and highest scores on the MiniPAQLQ. A negative association was observed between quality of life scores from the MiniPAQLQ and asthma control as determined from the ATAQ, providing evidence of convergent validity. Internal consistency reliability was good with Cronbach's alpha values of above 0.8 for the MiniPAQLQ subscales. Item-convergent validity was confirmed, whereas item-discriminant validity was not confirmed. Floor effects were absent, whereas ceiling effects were present. The MiniPAQLQ possesses moderately good psychometric properties among children and adolescents in the United States and could be a useful tool for asthma management in clinical practice.

Impact of Preexisting Mental Illnesses on Receipt of Guideline-Consistent Breast Cancer Treatment and Health Care Utilization.

This study determined the impact of preexisting mental illnesses on guideline-consistent breast cancer treatment and breast cancer-related health care utilization. This was a retrospective, longitudinal, cohort study conducted using data from the 2006-2008 Medicaid Analytic Extract files. The target population for the study consisted of female Medicaid enrollees who were aged 18-64 years and were newly diagnosed with breast cancer in 2007. Guideline-consistent breast cancer treatment was defined according to established guidelines. Breast cancer-related health care use was reported in the form of inpatient, outpatient, and emergency room visits. Statistical analyses consisted of multivariable hierarchical regression models. A total of 2142 newly diagnosed cases of breast cancer were identified. Approximately 38% of these had a preexisting mental illness. Individuals with any preexisting mental illness were less likely to receive guideline-consistent breast cancer treatment compared to those without any preexisting mental illness (adjusted odds ratio: 0.793, 95% confidence interval [CI]: 0.646-0.973). A negative association was observed between preexisting mental illness and breast cancer-related outpatient (adjusted incident rate ratio (AIRR): 0.917, 95% CI: 0.892-0.942) and emergency room utilization (AIRR: 0.842, 95% CI: 0.709-0.999). The association between preexisting mental illnesses and breast cancer-related inpatient utilization was statistically insignificant (AIRR: 0.993, 95% CI: 0.851-1.159). The findings of this study indicate that breast cancer patients with preexisting mental illnesses experience disparities in terms of receipt of guideline-consistent breast cancer treatment and health care utilization. The results of this study highlight the need for more focused care for patients with preexisting mental illness.

Pharmacists' perspectives on the Patient Protection and Affordable Care Act.

BACKGROUND: Passed in 2010, the Patient Protection and Affordable Care Act (PPACA) resulted in significant changes to the health care system in the United States (US). Though general population surveys reveal the fractious political debate surrounding the law, insights on pharmacists' perspectives on the PPACA are lacking in the literature. OBJECTIVES: The objectives of this study were to determine pharmacists' perspectives on the PPACA and determine whether pharmacists' demographic and practice-related characteristics and political beliefs influence their perspectives on the PPACA. METHODS: This study was conducted using a descriptive, cross-sectional design. Study data were collected with a self-administered online questionnaire distributed to 21,769 registered pharmacists in five states. RESULTS: A total of 1127 completed surveys were received (5.6% response rate). Roughly 37% of pharmacists reported that they understood the major provisions of the PPACA although most (89%) respondents agreed that understanding such policies is important for practicing pharmacy. Just over half (50.6%) of respondents did not support the PPACA while 47.7% supported the legislation. Political orientation, age, gender, and race were found to be significantly related to pharmacists' perspectives on the PPACA. CONCLUSION: Respondent pharmacists' perceptions of the PPACA appear to be related to political orientation and demographic characteristics. Given that pharmacists will be impacted by the implementation of the PPACA and are so accessible to the public, additional information on health care policy and PPACA should be provided to pharmacists.

Association between health-related quality of life and colorectal cancer screening.

Conflicting information currently exists about the role played by health-related quality of life (HRQOL) in influencing colorectal cancer screening. The current study aimed to determine the relationship between HRQOL and colorectal cancer screening, using nationally representative public data from the Behavioral Risk Factor Surveillance System (BRFSS). The 2010 BRFSS data were used for this study. Individuals younger than age 50 years were excluded from the study. Missing data were imputed using the multiple imputation technique. Multiple multivariate logistic regression models were fitted to the data to determine the association between different components of HRQOL (physical HRQOL, mental HRQOL, activity limitation caused by poor mental or physical HRQOL, and general health status) and receipt of colorectal cancer screening tests (fecal occult blood testing [FOBT] in the past year, sigmoidoscopy in the past 5 years, and colonoscopy in the past 10 years). The study sample comprised 301,488 individuals. Approximately 12% of the respondents had received FOBT in the past year, 62.6% had received sigmoidoscopy in the past 5 years, or colonoscopy in the past 10 years, and 65.4% had received either of the screening tests within appropriate time frames. After controlling for demographic and health-related covariates, an inverse relationship was observed between HRQOL and colorectal cancer screening with the exception of mental HRQOL and FOBT. The relationship between mental HRQOL and FOBT was found to be nonsignificant. Policy makers should consider including HRQOL as an important parameter when designing interventions aimed at improving colorectal cancer screening rates.

Risk of adverse cardiovascular outcomes and all-cause mortality associated with concomitant use of clopidogrel and proton pump inhibitors in elderly patients.

OBJECTIVE: To examine the effect of concomitant use of clopidogrel and PPIs in a national sample of elderly Medicare beneficiaries (age ≥65 years). METHODS: A nested case-control design was employed. A cohort of Medicare beneficiaries who initiated clopidogrel and did not have any gap of ≥30 days between clopidogrel fills between July 1, 2006 and December 31, 2008 was identified from a 5% national sample of Medicare claims data. Within this cohort, cases (beneficiaries who experienced any major cardiovascular event [MCE] [acute myocardial infarction, stroke, coronary artery bypass graft, or percutaneous coronary intervention] or all-cause mortality) and controls (beneficiaries who did not experience any MCE or all-cause mortality) were identified from inpatient and outpatient claims. Cases and controls were matched on age and the time to first clopidogrel fill. Conditional logistic regression was performed on the matched sample to evaluate the association between concomitant use of clopidogrel and PPIs and adverse health outcomes (MCEs and all-cause mortality). RESULTS: A total of 43,159 clopidogrel users were identified. Among them, 15,415 (35.7%) received clopidogrel and a PPI concomitantly at any time during the study period, 3502 (8.1%) experienced a MCE, 7306 (17.1%) died, and a total of 9908 (22.8%) experienced the primary composite outcome (any MCE or all-cause mortality) during follow-up. The odds ratio (OR) for the primary composite outcome was 1.26 (95% confidence interval [CI]: 1.18-1.35). Secondary analyses indicated that elderly patients using clopidogrel and a PPI concomitantly were more likely to experience all-cause mortality (OR: 1.40; 95% CI: 1.29-1.53) as compared to those receiving clopidogrel only, but not MCEs (OR: 1.06; 95% CI: 0.95-1.18). CONCLUSIONS: Concomitant use of clopidogrel and PPIs was associated with a slightly increased risk of all-cause mortality but not MCEs.