Understanding community- and system-capacity change over time: A close look at changing social capital in Evidence2Success communities.

Evidence in majority White and low-population areas suggest that community prevention systems can create social capital that is needed to support high-quality implementation and sustainability of evidence-based programs. This study expands prior work by asking the question: How does community social capital change during the implementation of a community prevention system in low-income, highly populated communities of color? Data were collected from Community Board members and Key Leaders in five communities. Linear mixed effect models analyzed data on reports of social capital over time, first as reported by Community Board members then by Key Leaders. Community Board members reported social capital improved significantly over time during the implementation of the Evidence2Success framework. Key Leader reports did not change significantly over time. These findings suggest that community prevention systems implemented in historically marginalized communities may help communities build social capital that is likely to support the dissemination and sustainability of evidence-based programs.

Translating Comparative Effectiveness Research Into Practice: Effects of Interventions on Lifestyle, Medication Adherence, and Self-care for Type 2 Diabetes, Hypertension, and Obesity Among Black, Hispanic, and Asian Residents of Chicago and Houston, 2010 to 2013.

CONTEXT: In the United States, racial/ethnic minorities account for disproportionate disease and death from type 2 diabetes, hypertension, and obesity; however, interventions with measured efficacy in comparative effectiveness research are often not adopted or used widely in those communities. OBJECTIVE: To assess implementation and effects of comparative effectiveness research-proven interventions translated for minority communities. DESIGN: Mixed-method assessment with pretest-posttest single-group evaluation design. SETTING: US Department of Health and Human Services, Office of Minority Health, research contractor, and advisory board; health centers, including a federally qualified community health center in Chicago, Illinois; and public housing facilities for seniors in Houston, Texas. PARTICIPANTS: A total of 97 black, Hispanic, and Asian participants with any combination of health care provider-diagnosed type 2 diabetes, hypertension, or obesity. INTERVENTIONS: Virtual training institutes where intervention staff learned cultural competency methods of adapting effective interventions. Health educators delivered the Health Empowerment Lifestyle Program (HELP) in Chicago; community pharmacists delivered the MyRx Medication Adherence Program in Houston. MAIN OUTCOME MEASURES: Participation rates, satisfaction with interventions during January to April 2013, and pre- to postintervention changes in knowledge, diet, and clinical outcomes were analyzed through July 2013. RESULTS: In Chicago, 38 patients experienced statistically significant reductions in hemoglobin A1c and systolic blood pressure, increased knowledge of hypertension management, and improved dietary behaviors. In Houston, 38 subsidized housing residents had statistically nonsignificant improvements in knowledge of self-management and adherence to medication for diabetes and hypertension but high levels of participation in pharmacist home visits and group education classes. CONCLUSION: Adaptation, adoption, and implementation of HELP and MyRx demonstrated important postintervention changes among racial/ethnic participants in Chicago and Houston. The communities faced similar implementation challenges across settings, targets of change, and cities. Available resources were insufficient to sustain benefits with measurable impact on racial/ethnic disparities beyond the study period. Results suggest the need for implementation studies of longer duration, greater power, and salience to policies and programs that can sustain longterm interventions on a community-wide scale.

Evaluating the effectiveness of a patient storytelling DVD intervention to encourage physician-patient communication about nonsteroidal anti-inflammatory drug (NSAID) use.

OBJECTIVE: To evaluate the effectiveness of a culturally-sensitive, patient storytelling intervention to enhance physician-patient communication about NSAID risk. METHODS: A group randomized trial of 40 medical practices in Alabama was conducted. Patients within intervention practices received a 13-minute DVD that included patient stories related to their experiences with NSAIDs, adverse effects, and importance of communication with their physicians. The proportion of patients who: (1) spoke with their physician about NSAID risk; and (2) used both prescription and over-the-counter (OTC) NSAIDS were primary outcomes. Generalized estimating equations for panel data were used for analysis. RESULTS: Intention-to-treat analyses revealed no significant differences between intervention (n=102) and control (n=106) groups for patients speaking with their physician about NSAID risk or concomitant use of prescription/OTC NSAIDs (Odds Ratio [OR]=1.11, p=0.670; OR=0.87, p=0.632, respectively). For 54% of patients who watched the DVD, per-protocol (PP) analyses trended toward increased odds of patients speaking with their physician about prescription NSAID risk compared to the control group [OR=1.37, p=0.354] and lower odds of concomitant prescription/OTC NSAIDs use [OR=0.79, p=0.486]. CONCLUSIONS: A patient storytelling intervention in DVD format alone may not increase patient-physician interaction. PRACTICE IMPLICATIONS: Strategies that facilitate use of patient educational materials delivered by DVD are needed.

Using tablet computers compared to interactive voice response to improve subject recruitment in osteoporosis pragmatic clinical trials: feasibility, satisfaction, and sample size.

INTRODUCTION: Pragmatic clinical trials (PCTs) provide large sample sizes and enhanced generalizability to assess therapeutic effectiveness, but efficient patient enrollment procedures are a challenge, especially for community physicians. Advances in technology may improve methods of patient recruitment and screening in PCTs. Our study looked at a tablet computer versus an integrated voice response system (IVRS) for patient recruitment and screening for an osteoporosis PCT in community physician offices. MATERIALS AND METHODS: We recruited women ≥ 65 years of age from community physician offices to answer screening questions for a hypothetical osteoporosis active comparator PCT using a tablet computer or IVRS. We assessed the feasibility of these technologies for patient recruitment as well as for patient, physician, and office staff satisfaction with the process. We also evaluated the implications of these novel recruitment processes in determining the number of primary care practices and screened patients needed to conduct the proposed trial. RESULTS: A total of 160 women (80% of those approached) agreed to complete the osteoporosis screening questions in ten family physicians' offices. Women using the tablet computer were able to complete all screening questions consistently and showed a nonsignificant trend towards greater ease of use and willingness to spend more time in their physician's office compared to those using IVRS. Using the proportion of women found to be eligible in this study (almost 20%) and other eligibility scenarios, we determined that between 240 and 670 community physician offices would be needed to recruit ample patients for our hypothetical study. CONCLUSION: We found good satisfaction and feasibility with a tablet computer interface for the recruitment and screening of patients for a hypothetical osteoporosis PCT in community office settings. In addition, we used this experience to estimate the number of research sites needed for such a study.

Predictors of moderate-to-vigorous physical activity (MVPA) in African American young adolescents.

BACKGROUND: African American adolescents residing in the South are at increased risk for obesity and physical inactivity, yet our understanding of potential influences is limited. PURPOSE: Using an ecological framework, this study explored multilevel predictors (individual, family, home, and neighborhood environment) of moderate-to-vigorous physical activity (MVPA) among 116 African American adolescents (ages 12-16). METHODS: Adolescents and their parents completed self-report surveys for hypothesized predictors. Youth physical activity was measured using accelerometry. RESULTS: In multiple regression models, decreased daily MVPA was associated with female sex (ß = -24.27, p < 0.0001). Family social support (ß = 1.07, p = 0.004) and adolescent self efficacy for PA (ß = 6.89, p = 0.054) were positively associated with daily MVPA. CONCLUSIONS: Adolescent demographics along with family social support and self-efficacy influence younger African American adolescent physical activity. Further exploration of the complex interaction of multiple levels of influence is needed to develop appropriate interventions for this vulnerable group.

Improving the efficiency and effectiveness of pragmatic clinical trials in older adults in the United States.

Pragmatic clinical trials (PCTs) seek to improve the generalizability and increase the statistical power of traditional explanatory trials. They are a major tenet of comparative effectiveness research. While a powerful study design, PCTs have been limited by high cost, modest efficiency, and limited ability to fill relevant evidence gaps. Based on an American Reinvestment and Recovery Act (ARRA) supported meeting of national stakeholders, we propose several innovations and future research that could improve the efficiency and effectiveness of such studies focused in the U.S. Innovations discussed include optimizing the use of community based practices through partnership with Practice Based Research Networks (PBRNs), using information technology to simplify PCT subject recruitment, consent and randomization processes, and utilizing linkages to large administrative databases, such as Medicare, as a mechanism to capture outcomes and other important PCT variables with lower subject and research team burden. Testing and adaptation of such innovations to PCT are anticipated to improve the public health value of these increasingly important studies.

Health information seeking and use outside of the medical encounter: is it associated with race and ethnicity?

Increasing numbers of adults in the United States of America (USA) are seeking and using health information within their medical encounters. The theory of uncertainty management suggests that patients reduce health care uncertainty by increasing their understanding of disease etiology or treatment options, improving patient-doctor communication, and enhancing knowledge of disease self-management through health information seeking. However, research shows racial and ethnic minorities are less likely than Whites to seek health information and use it in their physician visits. How racial and ethnic minorities use health information outside of their medical encounters is unknown. In this study we used data from the 2007 USA Health Tracking Household survey, a nationally-representative survey of civilian, non-institutionalized Americans (n = 12,549). Using logistic regression we found African Americans were no different from Whites in seeking health information and using it when they talked with their doctors. Latinos were significantly less likely than Whites to seek health information and less likely to use it when they talked with their doctors. But, among those who sought health information, African Americans and Latinos were significantly more likely than Whites to use health information to change their approach to maintaining their health and better understand how to treat illnesses. Also, education significantly moderated the relationship between race/ethnicity and health information seeking. However, results were mixed for education as a moderator in the relationship between race/ethnicity and health information use. Future research should focus on interventions to improve how African Americans and Latinos interface with providers and ensure that health information sought and used outside of their medical encounters augments treatment protocols.

Predictors of retention of African American women in a walking program.

OBJECTIVE: To predict retention of African American women 6 months after initiating a community walking program. METHODS: Demographics, health status, cancer-related health behaviors, and network membership data from baseline wellness questionnaires of 1322 African American women participating in the walking program were analyzed using multivariate logistic regression models. RESULTS: Seventy-eight percent (n = 1032) of African American women were retained at 6 months. Network membership was the primary predictor of retention. CONCLUSIONS: Women affiliated with our comprehensive network, which provides ongoing cancer awareness, screening, and prevention programs to reduce cancer health disparities, were more likely to accomplish the first major milestone of the program.

Which fractures are most attributable to osteoporosis?

BACKGROUND: Determining anatomic sites and circumstances under which a fracture may be a consequence of osteoporosis is a topic of ongoing debate and controversy that is important to both clinicians and researchers. METHODS: We conducted a systematic literature review and generated an evidence report on fracture risk based on specific anatomic bone sites and fracture diagnosis codes. Using the Research and Development/University of California at Los Angeles appropriateness process, we convened a multidisciplinary panel of 11 experts who rated fractures according to their likelihood of being because of osteoporosis based on the evidence report. Fracture sites (as determined by International Classification of Diseases Clinical Modification codes) were stratified by four clinical risk factor categories based on age, sex, race/ethnicity (African American and Caucasian), and presence or absence of trauma. RESULTS: Consistent with current clinical experience, the fractures rated most likely because of osteoporosis were the femoral neck, pathologic fractures of the vertebrae, and lumbar and thoracic vertebral fractures. The fractures rated least likely because of osteoporosis were open proximal humerus fractures, skull, and facial bones. The expert panel rated open fractures of the arm (except proximal humerus) and fractures of the tibia/fibula, patella, ribs, and sacrum as being highly likely because of osteoporosis in older Caucasian women but a lower likelihood in younger African American men. CONCLUSION: Osteoporosis attribution scores for all fracture sites were determined by a multidisciplinary expert panel to provide an evidence-based continuum of the likelihood of a fracture being associated with osteoporosis.

Health information technology and physician career satisfaction.

PURPOSE: Health information technology (HIT) and physician career satisfaction are associated with higher-quality medical care. However, the link between HIT and physician career satisfaction, which could potentially reduce provider burnout and attrition, has not been fully examined. This study uses a nationally representative survey to assess the association between key forms of HIT and career satisfaction among primary care physicians (PCPs) and specialty physicians. METHODS: We performed a retrospective, cross-sectional analysis of physician career satisfaction using the Community Tracking Study Physician Survey, 2004-2005. Nine specific types of HIT as well as the overall adoption of HIT in the practice were examined using multivariate logistic regression. RESULTS: Physicians who used five to six (odds ratio [OR] = 1.46) or seven to nine (OR = 1.47) types of HIT were more likely than physicians who used zero to two types of HIT to be "very satisfied" with their careers. Information technology usages for communicating with other physicians (OR = 1.31) and e-mailing patients (OR = 1.35) were positively associated with career satisfaction. PCPs who used technology to write prescriptions were less likely to report career satisfaction (OR = 0.67), while specialists who wrote notes using technology were less likely to report career satisfaction (OR = 0.75). CONCLUSIONS: Using more information technology was the strongest positive predictor of physicians being very satisfied with their careers. Toward that end, healthcare organizations working in conjunction with providers should consider exploring ways to integrate various forms of HIT into practice.

Health services utilization after fractures: evidence from Medicare.

BACKGROUND: Osteoporosis-related fractures impose a large and growing societal burden, including adverse health effects and direct medical costs. Postfracture utilization of health care services represents an alternative measure of the resource costs associated with these fractures. METHODS: We use a 5% random sample of Medicare claims data to construct annual cohorts (2000-2004) of beneficiaries diagnosed with incident fractures at one of seven sites--clinical vertebral, hip pelvis, femur, tibia/fibula, humerus, and distal radius/ulna. We use person-specific changes in health services utilization (eg, inpatient acute/postacute days, home health visits, physical, and occupational therapy) before/after fractures and probabilities of entry into (long-term) nursing home residency to estimate the utilization burden associated with fractures. RESULTS: Relative to the prior 6-month period, rates of acute hospitalization are between 19.5 (distal radius/ulna) and 72.4 (hip) percentage points higher in the 6 months after fractures. Average acute inpatient days are 1.9 (distal radius/ulna) to 8.7 (hip) higher in the postfracture period. Fractures are associated with large increases in all forms of postacute care, including postacute hospitalizations (13.1-71.5 percentage points), postacute inpatient days (6.1-31.4), home health care hours (3.4-8.4), and hours of physical (5.2-23.6) and occupational (4.3-14.0) therapy. Among patients who were community dwelling at the time of the initial fracture, 0.9%-1.1% (2.4%-4.0%) were living in a nursing home 6 months (1 year) after the fracture. CONCLUSIONS: Fractures are associated with significant increases in health services utilization relative to prefracture levels. Additional research is needed to assess the determinants and effectiveness of alternative forms of fracture care.

Health care expenditures associated with skeletal fractures among Medicare beneficiaries, 1999-2005.

Fractures impose substantial burdens, in terms of both costs and health, on individuals and health care systems. This is particularly true for older Americans and the Medicare system. The objective of this study was to estimate the costs of care associated with selected fractures among Medicare beneficiaries. This was a retrospective, person-level, pre/postfracture analysis using administrative data. The study used Medicare claims data from 1999 through 2005 for a 5% sample of Medicare beneficiaries. The subjects included Medicare beneficiaries, >or=65 yr of age, who had at least 13 mo of both Parts A and B coverage and not enrolled in Medicare Advantage and who experienced a closed fracture of the hip, femur, pelvis, tibia/fibula, ankle, distal forearm, nondistal radius/ulna, humerus, clavicle, spine, or wrist, or any fracture of the distal forearm or ankle during the years 2000 through 2005. The main outcome measures were incremental (greater than baseline) and attributable (directly associated) payments for Medicare-covered services for the first 6 mo after incident fractures. Incremental payments ranged from $7788 (95% CI, $7550-$8025) for distal forearm fractures to $31,310 (95% CI, $31,073-$31,547) for open hip fractures; the attributable payments for distal forearm and hip fractures were $1856 and $18,734, respectively. Fractures are associated with substantial increases in health services utilization and costs among Medicare beneficiaries, but significant proportions of those costs are not directly attributable to fracture treatment. Further research is needed to ascertain other health conditions that are driving costs for Medicare beneficiaries after fractures.

Regional variation in the denial of reimbursement for bone mineral density testing among US Medicare beneficiaries.

Although the Bone Mass Measurement Act outlines the indications for central dual-energy X-ray absorptiometry (DXA) testing for US Medicare beneficiaries, the specifics regarding the appropriate ICD-9 codes to use for covered indications have not been specified by Medicare and are sometimes ambiguous. We describe the extent to which DXA reimbursement was denied by gender and age of beneficiary, ICD-9 code submitted, time since previous DXA, whether the scan was performed in the physician's office and local Medicare carrier. Using Medicare administrative claims data from 1999 to 2005, we studied a 5% national sample of beneficiaries age > or =65 yr with part A+B coverage who were not health maintenance organization enrollees. We identified central DXA claims and evaluated the relationship between the factors listed above and reimbursement for central DXA (CPT code 76075). Multivariable logistic regression was used to evaluate the independent relationship between DXA reimbursement, ICD-9 diagnosis code, and Medicare carrier. For persons who had no DXA in 1999 or 2000 and who had 1 in 2001 or 2002, the proportion of DXA claims denied was 5.3% for women and 9.1% for men. For repeat DXAs performed within 23 mo, the proportion denied was approximately 19% and did not differ by sex. Reimbursement varied by more than 6-fold according to the ICD-9 diagnosis code submitted. For repeat DXAs performed at <23 mo, the proportion of claims denied ranged from 2% to 43%, depending on Medicare carrier. Denial of Medicare reimbursement for DXA varies significantly by sex, time since previous DXA, ICD-9 diagnosis code submitted, place of service (office vs facility), and local Medicare carrier. Greater guidance and transparency in coding policies are needed to ensure that DXA as a covered service is reimbursed for Medicare beneficiaries with the appropriate indications.

Do needs drive services use in young children?

OBJECTIVE: To determine whether different factors predicted parental recognition of mental health problems in children and use of services for those problems and to determine whether mental health problems elicit service use in the same way as physical health or developmental problems. METHODS: Survey of the parents of an age- and sex-stratified random sample of children who were born in 1 Connecticut hospital selected from state birth records. RESULTS: Logistic regression results demonstrate that a number of child and family factors are related to problem recognition, defined as thinking about seeking services and/or talking to a professional about a problem. However, factors related to the third outcome of interest-service use-are more limited and include only physical health and developmental problems, parental worry about language, and family conflict. Furthermore, mental health problems were not discussed with professionals, and they were not associated with receipt of services at the same rates as physical health or developmental problems. CONCLUSIONS: The correlates of problem recognition (defined as thinking about seeking services or actually speaking to a professional about a problem) differ from those of service use, and, whereas mental health, physical health, and developmental problems all affect problem recognition, mental health problems do not result in service use. Furthermore, rates of service use vary dramatically across the 3 categories. These results suggest that needs alone do not drive service use. Rather, other factors may influence which needs are met.