Quality indicator survey versus traditional survey in New York State: a comparison of results from annual nursing home surveys.

Despite the passage of OBRA'87 for nursing home reform, concerns about care in facilities continue. The Centers for Medicare and Medicaid developed new regulations and the Traditional Survey (TS) process for annual nursing home survey. The survey is conducted by state regional offices to determine facility compliance with federal regulations. Despite the regulations and new survey process, the TS inconsistently identified problems. A computerized process called the Quality Indicator Survey (QIS) was subsequently developed. This study was designed to compare results from TS and QIS on overall deficiencies, select quality indicators, high-severity deficiencies, and severity differences of seven quality indicators in New York State over a 6-year period from 2010 through 2015. Results of t-tests determined a significant difference in the overall mean number of deficiencies (p < .001), and on four indicators: choices (p < .001), nursing staff (p < .001), dental (p < .001), and dignity (p < .05). Facilities using the TS showed a higher mean number of harm level or higher deficiencies (p < .001). Chi-square tests for severity levels showed significantly more higher severity deficiencies on two quality indicators: nutrition (p < 0.001) and hydration (p < 0.05). Thus, the QIS produced a greater mean number of deficiencies, while TS produced more higher severity deficiencies in New York State.

Evaluation of Hospital-Based Palliative Care Programs.

This study evaluated current hospital-based palliative care programs using recommendations from the Center to Advance Palliative Care (CAPC) as a framework. Seven hospitals located in Buffalo, New York were included based on the existence of a hospital-based palliative care program. Data was collected from August through October of 2013 by means of key informant interviews with nine staff members from these hospitals using a guide comprised of questions based on CAPC's recommendations. A gap analysis was conducted to analyze the current state of each hospital's program based upon CAPC's definition of a quality palliative care program. The findings identify challenges facing both existing/evolving palliative care programs, and establish a foundation for strategies to attain best practices not yet implemented. This study affirms the growing availability of palliative care services among these selected hospitals along with opportunities to improve the scope of services in line with national recommendations.

The association between acanthosis nigricans and dysglycemia in an ethnically diverse group of eighth grade students.

OBJECTIVE: The purpose of this study was to describe the prevalence of acanthosis nigricans (AN) and to quantify its association with dysglycemia in an ethnically diverse group of eighth-grade students. DESIGN AND METHODS: Data were collected in 2003 from a cross-sectional study of students from 12 middle schools in three US states. Sex, race/ethnicity, and pubertal status were self-reported. Anthropometric measures were recorded. Trained staff identified the presence and severity of AN by inspection of the back of the neck. Fasting and 2 h blood samples were analyzed for impaired fasting glucose (IFG), impaired glucose tolerance (IGT), and high-risk glycated hemoglobin (A1C), respectively, defined as ≥100 mg/dl, ≥140 mg/dl, and ≥ 5.7-6.4%. RESULTS: Overall, 25.0%, 58.2%, and 16.8% were Black, Hispanic, and White, respectively. AN was present among 406/1,438 (28.2%) of students: 39% among Black, 30% among Hispanic, and 5.4% among White. IGT and high-risk A1C were present among 2.1%, and 12.4%, respectively. In multivariate logistic modeling after adjusting for gender, family history of diabetes, BMI percentile, and pubertal staging, the presence (vs. absence) of AN was associated with a 59% increased likelihood of high-risk A1C: (P = 0.04), twice the likelihood of IGT (P = 0.06), and 47% greater likelihood of IGT/IFG combined (P < 0.0001). Adjustment for insulin attenuated the ORs by 25-70%. CONCLUSION: In a racially/ethnically diverse sample of US adolescents, AN was common, occurring in 28% of the sample. AN was associated with a 50-100% increased likelihood of dysglycemia even after consideration of established diabetes risk factors.

Screening obese students for acanthosis nigricans and other diabetes risk factors in the urban school-based health center.

OBJECTIVE: To determine the prevalence of acanthosis nigricans (AN) and other diabetes risk factors in urban school health clinics. METHODS: During the period 2006-2009 nurse practitioners (NPs) screened students who had a BMI ≥ 95th percentile and 1 additional diabetes risk factor. Blood glucose (BG) was measured by finger stick. NPs were trained on how to ascertain the presence of AN on the neck area. RESULTS: NPs screened 854 students (mean age 11.4 years, 60.5% female, and 73.3% black). AN and elevated BG were found among 26% and 6.4% of students, respectively. Females and minorities were respectively 50% and 4 times more likely to have AN. Youth with AN were twice as likely to have elevated glucose. CONCLUSION: AN can be easily identified by trained health care professionals even in busy school-based clinic settings. Checking for AN and appropriate education and counseling should become a routine part of electronic documentation in overweight youth.

Fasting Blood Glucose and Depressive Mood among Patients with Mental Illness in a Medicaid Managed Care Program.

Objective. This study explores the relationship between depressive symptoms, as measured by the PHQ-9 depression screen and blood glucose levels among patients with diabetes enrolled in Gold Choice, a Medicaid managed care program for individuals with mental illness and/or substance abuse. Methods. The PHQ-9 was mailed to 454 Gold Choice members and a questionnaire was mailed to their physicians requesting current HbA1c% and fasting blood glucose (FBG) levels. The pearson product-moment correlation was used to describe the association between PHQ-9 scores and FBG levels. Results. The PHQ-9 response rate was 55% (N = 249). Laboratory results were received for 141 patients. The correlation between FBG and PHQ-9 scores was modest but statistically significant: r = 0.21 , P = 0.015. Conclusion. A statistically significant association was found between FBG and PHQ-9 depression scores. This finding supports current recommendations that physicians be alert to depressive symptoms among patients with diabetes or impaired glucose metabolism.

Short sleep duration is associated with the development of impaired fasting glucose: the Western New York Health Study.

PURPOSE: To examine whether sleep duration was associated with incident-impaired fasting glucose (IFG) over 6 years of follow-up in the Western New York Health Study. METHODS: Participants (N = 1,455, 68% response rate) who were free of type 2 diabetes and known cardiovascular disease at baseline (1996-2001) were reexamined in the period 2003-2004. A nested case-control study was conducted. Cases had fasting plasma glucose (FPG) less than 100 mg/dL at baseline and 100 to 125 mg/dL at follow-up: controls (n = 272) had FPG less than 100 mg/dL at both exams. Cases (n = 91) were individually matched to three controls (n = 272) on sex, race, and year of study enrollment. Average sleep duration was categorized as short (<6 hours), mid-range (6 to 8 hours), and long (>8 hours). RESULTS: In multivariate conditional logistic regression after adjustment for several diabetes risk factors, the odds ratio (OR) of IFG among short sleepers was 3.0 (95% confidence limit [CL]: 1.05, 8.59) compared to mid-range sleepers. There was no association between long sleep and IFG: OR 1.6 (95% CL: 0.45, 5.42). Adjustment for insulin resistance attenuated the association only among short sleepers: OR 2.5 (95% CL: 0.83, 7.46). CONCLUSIONS: Short sleep duration was associated with an elevated risk of IFG. Insulin resistance appears to mediate this association.

A population-based study of reduced sleep duration and hypertension: the strongest association may be in premenopausal women.

OBJECTIVES: Recent evidence indicates that reduced sleep duration may be associated with an increased risk of hypertension with possibly stronger effects among women than men. We therefore examined cross-sectional sex-specific associations of sleep duration with hypertension in a large population-based sample from the Western New York Health Study (1996<2001). METHODS: Participants were 3027 white men (43.5%) and women (56.5%) without prevalent cardiovascular disease (median age 56 years). Hypertension was defined as blood pressure at least 140 or at least 90&mmHg or regular use of antihypertensive medication. Multivariate logistic regression analyses were performed to estimate odds ratios (ORs) of hypertension comparing less than 6&h of sleep per night versus the reference category (&6&h) while accounting for a number of potential confounders. RESULTS: In multivariate analyses, less than 6&h of sleep was associated with a significant increased risk of hypertension compared to sleeping at least 6&h per night, only among women [OR&=&1.66 (1.09 to 2.53)]. No significant association was found among men [OR&=&0.93 (0.62 to 1.41)].In subgroup analyses by menopausal status, the effect was stronger among premenopausal women [OR&=&3.25 (1.37 to 7.76)] than among postmenopausal women [OR&=&1.49 (0.92 to 2.41)]. CONCLUSION: Reduced sleep duration, by increasing the risk of hypertension, may produce detrimental cardiovascular effects among women. The association is independent of socioeconomic status, traditional cardiovascular risk factors, and psychiatric comorbidities, and is stronger among premenopausal women. Prospective and mechanistic evidence is necessary to support causality.

Vitality and recurrent event risk in acute myocardial infarction survivors.

BACKGROUND: Low vitality, characterized by fatigue and lack of energy, is common among survivors of acute myocardial infarction (AMI) and has been shown to be associated with increased risk of primary and secondary cardiac events. The goal of this study was to determine whether an association between vitality and recurrent cardiac events (nonfatal MI, cardiac death) among acute MI survivors persists after controlling for possible physiological and psychological confounders. DESIGN AND METHODS: Incident AMI survivors (n = 1328) from Erie and Niagara (New York) county hospitals were enrolled and followed up to 9 years. Vitality was measured by the Short Form-36 on a 0-100 scale approximately 4 months post-AMI. Cox proportional hazards models were developed to assess the vitality-recurrent event association controlling for traditional cardiovascular disease risk factors, index MI severity, and psychological correlates of vitality. RESULTS: Low-vitality individuals at baseline were more likely females, of higher BMI, smoking, diabetic, less physically active, and to have worse depression scores. Vitality was not strongly associated with MI severity markers. Lower vitality scores were associated with increased risk of recurrent cardiac events: adjusted hazard ratios (95% CI) for vitality scores 51-79, 21-50, and < or =20 (compared with > or =80) were 1.2 (0.8, 1.8), 1.4 (0.9, 2.2), and 2.9 (1.5, 5.4), respectively (Ptrend = 0.005). CONCLUSION: Low vitality was associated with increased risk of recurrent cardiac events among AMI survivors after controlling for physiological and psychological confounders. Mechanistic links with vitality should be sought as interventional targets.

Cigarette smoking is associated with conversion from normoglycemia to impaired fasting glucose: the Western New York Health Study.

PURPOSE: To determine whether cigarette smoking is associated with the conversion from normoglycemia to impaired fasting glucose (IFG). METHODS: During the years 2003 and 2004, 1,455 participants (mean age, 56.5 years; range, 35-79 years) from the Western New York Health Study who were free of type 2 diabetes and known cardiovascular disease at baseline (1996-2001) were reexamined (68% response rate). Incident IFG was defined as a subject whose baseline fasting plasma glucose was <100mg/dL (normoglycemic) and between 100 and 125 mg/dL at follow-up. Prevalent IFG (n=528) was excluded. Baseline smoking status was categorized as never, former, or current. RESULTS: Of the 1,455 participants, 924 were normoglycemic at baseline: 101/924 converted to IFG over 6 years. Compared with those who remained normoglycemic, converters to IFG were at baseline older, had a larger body mass index, more likely to be hypertensive, currently smoke, and have a family history of type 2 diabetes mellitus (all p<0.05). Multivariate logistic regression demonstrated that compared with subjects who remained normoglycemic, the odds ratio of incident IFG among former and current smokers (vs. never) was 1.68 (95% confidence interval: 0.99-2.80) and 2.35 (95% confidence interval: 1.17-4.72) (p trend=0.008), respectively. CONCLUSION: Smoking was positively associated with incident IFG after accounting for several putative risk factors.

Additional contribution of emerging risk factors to the prediction of the risk of type 2 diabetes: evidence from the Western New York Study.

OBJECTIVE: To examine whether several biomarkers of endothelial function and inflammation improve prediction of type 2 diabetes over 5.9 years of follow-up, independent of traditional risk factors. METHODS AND PROCEDURES: A total of 1,455 participants from the Western New York Study, free of type 2 diabetes at baseline, were selected. Incident type 2 diabetes was defined as fasting glucose exceeding 125 mg/dl or on antidiabetic medication at the follow-up visit. Sixty-one people who met the case definition (8/1,000 person years) were identified and individually matched with up to three controls on gender, race, year of study enrollment, and baseline fasting glucose (<110 or 110-125 mg/dl). Biomarkers were measured from frozen baseline samples. RESULTS: In conditional logistic regression analyses accounting for traditional risk factors (age, family history of diabetes, smoking, drinking status, and BMI), E-selectin was positively related (3rd vs. 1st tertile: odds ratio 2.77, 95% confidence interval (CI) 1.13-6.79, P for linear trend = 0.023) and serum albumin was inversely related (3rd vs. 1st tertile: odds ratio 0.36, 95% CI 0.14-0.93, P for linear trend = 0.032) to type 2 diabetes incidence. The addition of E-selectin, serum albumin, and leukocyte count to a basic risk factor model including only traditional risk factors significantly increased the area under the receiver operating characteristic curve (AUC) (from 0.646 to 0.726, P value = 0.04). DISCUSSION: These results support the role of endothelial dysfunction and subclinical inflammation as important mechanisms in the etiopathogenesis of type 2 diabetes; moreover, they indicate that novel biomarkers may improve the prediction of type 2 diabetes beyond the use of traditional risk factors alone.

Elevated cystatin C concentration and progression to pre-diabetes: the Western New York study.

OBJECTIVE: We conducted a nested case-control investigation to examine whether elevated baseline concentrations of cystatin C predicted progression from normoglycemia to pre-diabetes over 6 years of follow-up from the Western New York Health Study. RESEARCH DESIGN AND METHODS: In 2002-2004, 1,455 participants from the Western New York Health Study, who were free of type 2 diabetes and known cardiovascular disease at baseline (1996-2001), were reexamined. An incident case of pre-diabetes was defined as an individual with fasting glucose < 100 mg/dl at the baseline examination and > or = 100 and < or = 125 mg/dl at the follow-up examination, thereby eliminating individuals with prevalent pre-diabetics. All case patients (n = 91) were matched 1:3 to control participants based on sex, race/ethnicity, and year of study enrollment. All control subjects had fasting glucose levels < 100 mg/dl at both baseline and follow-up examinations. Cystatin C concentrations and the urinary albumin-to-creatinine ratio were measured from frozen (-196 degrees C) baseline blood and urine samples. Serum creatinine concentrations were available from the baseline examination only. RESULTS: Multivariate conditional logistic regression analyses adjusted for age, baseline glucose level, homeostasis model assessment of insulin resistance, BMI, hypertension, estimated glomerular filtration rate, cigarette smoking, and alcohol use revealed a significantly increased risk of progression to pre-diabetes among those with elevated baseline concentrations of cystatin C (odds ratio 3.28 [95% CI 1.43-7.54]) (upper quintile versus the remainder). Results of secondary analyses that considered high-sensitivity C-reactive protein, interleukin-6, E-selectin, or soluble intercellular adhesion molecule-1 did not alter these results. CONCLUSIONS: These results suggest that cystatin C was associated with a threefold excess risk of progression to pre-diabetes in this population.

Sex differences in endothelial function markers before conversion to pre-diabetes: does the clock start ticking earlier among women? The Western New York Study.

OBJECTIVE: We examined whether biomarkers of endothelial function, fibrinolysis/thrombosis and adiponectin, predict the progression from normal to pre-diabetes more strongly among women than men over 6 years of follow-up from the Western New York Health Study. RESEARCH DESIGN AND METHODS: In 2002-2004, 1,455 participants from the Western New York Health Study, who were free of type 2 diabetes and cardiovascular disease at baseline (1996-2001), were selected for reexamination. An incident case of pre-diabetes was defined as fasting glucose <100 mg/dl at the baseline examination and > or =100 and <126 mg/dl at the follow-up examination. Biomarkers of endothelial function (E-selectin and soluble intracellular adhesion molecule-1 [sICAM-1]), fibrinolysis/thrombosis (plasminogen activator inhibitor-1 [PAI-1]), and fasting insulin, adiponectin, and inflammation (high-sensitivity C-reactive protein) were measured in frozen (-190 degrees C) baseline samples. RESULTS: Multivariate analyses revealed higher adjusted mean values of biomarkers of endothelial dysfunction (E-selectin and sICAM-1) and fibrinolysis (PAI-1) and lower mean values of adiponectin only among women who developed pre-diabetes compared with control subjects. Formal tests for interaction between sex and case/control status were statistically significant for E-selectin (P = 0.042), PAI-1 (P = 0.001), sICAM-1 (P = 0.011), and frequency of hypertension (P < 0.001). CONCLUSIONS: These results support the concept that women who progressed from normoglycemia to pre-diabetes have greater endothelial dysfunction than men as well as more hypertension and a greater degree of fibrinolysis/thrombosis. Whether this relates to the higher risk of heart disease among diabetic women awaits further study.