The Impact of Social Determinants of Health on Eye Care Utilization in a National Sample of People with Diabetes.

PURPOSE: To evaluate the association of social determinants of health (SDoH) with eye care utilization among people with diabetes mellitus using the 2013-2017 National Health Interview Survey (NHIS). DESIGN: Retrospective cross-sectional study. PARTICIPANTS: Participants ≥ 18 years of age with self-reported diabetes. METHODS: The SDoH in the following domains were used: (1) economic stability; (2) neighborhood, physical environment, and social cohesion; (3) community and social context; (4) food environment; (5) education; and (6) health care system. An aggregate SDoH score was calculated and divided into quartiles, with Q4 representing those with the highest adverse SDoH burden. Survey-weighted multivariable logistic regression models evaluated the association of SDoH quartile with eye care utilization in the preceding 12 months. A linear trend test was conducted. Domain-specific mean SDoH scores were calculated, and the performance of domain-specific models was compared using area under the curve (AUC). MAIN OUTCOME MEASURE: Eye care utilization in the preceding 12 months. RESULTS: Of 20 807 adults with diabetes, 43% had not used eye care. Greater adverse SDoH burden was associated with decrements in odds of eye care utilization (P < 0.001 for trend). Participants in the highest quartile of adverse SDoH burden (Q4) had a 58% lower odds (odds ratio [OR], 0.42; 95% confidence interval [CI], 0.37-0.47) of eye care utilization than those in Q1. The domain-specific model using economic stability had the highest performing AUC (0.63; 95% CI, 0.62-0.64). CONCLUSIONS: Among a national sample of people with diabetes, adverse SDoH were associated with decreased eye care utilization. Evaluating and intervening upon the effects of adverse SDoH may be a means by which to improve eye care utilization and prevent vision loss. FINANCIAL DISCLOSURE(S): Proprietary or commercial disclosure may be found in the Footnotes and Disclosures at the end of this article.

Does the Quality of Behavior Change Counseling in Routine HIV Care Vary According to Topic and Demand?

HIV clinicians face increasing time constraints. Our objective was to describe the prevalence and quality of behavior change counseling within routine HIV visits and to explore whether clinicians may provide lower quality counseling when facing increased counseling demands. We audio-recorded and transcribed encounters between 205 patients and 12 clinicians at an urban HIV primary care clinic. We identified and coded episodes of behavior change counseling to determine clinicians' consistency with motivational interviewing (MI) and used multi-level regression to evaluate counseling quality changes with each additional topic. Clinician counseling for at least one behavior was indicated in 92% of visits (mean 2.5/visit). Behavioral topics included antiretroviral medication adherence (80%, n = 163), appointment adherence (54%, n = 110), drug use (46%, n = 95), tobacco use (45%, n = 93), unsafe sex (43%, n = 89), weight management (39%, n = 80), and alcohol use (35%, n = 71). Clinician counseling was most MI-consistent when discussing drug and tobacco use and least consistent for medication and appointment adherence, unsafe sex, and alcohol use. In multilevel analyses, clinician counseling was significantly less MI-consistent (ß = - 0.14, 95% CI - 0.29 to - 0.001) with each additional behavior change counseling need. This suggests that HIV ambulatory care be restructured to allocate increased time for patients with greater need for behavior change.

Clinician Response to Patient Emotion: Impact on Subsequent Communication and Visit Length.

PURPOSE: It is widely cited-based on limited evidence-that attending to a patient's emotions results in shorter visits because patients are less likely to repeat themselves if they feel understood. We evaluated the association of clinician responses to patient emotions with subsequent communication and visit length. METHODS: We audio-recorded 41 clinicians with 342 unique patients and used the Verona Coding Definitions of Emotional Sequences (VR-CoDES) to time stamp patient emotional expressions and categorize clinician responses. We used random-intercept multilevel-regression models to evaluate the associations of clinician responses with timing of the expressed emotion, patient repetition, and subsequent length of visit. RESULTS: The mean visit length was 30.4 minutes, with 1,028 emotional expressions total. The majority of clinician responses provided space for the patient to elaborate on the emotion (81%) and were nonexplicit (56%). As each minute passed, clinicians had lower odds of providing space (odds ratio [OR] = 0.96; 95% CI, 0.95-0.98) and higher odds of being explicit (OR = 1.02; 95% CI, 1.00-1.03). Emotions were more likely to be repeated when clinicians provided space (OR = 2.33; 95% CI, 1.66-3.27), and less likely to be repeated when clinicians were explicit (OR = 0.61; 95% CI, 0.47-0.80). Visits were shorter (ß = -0.98 minutes; 95% CI, -2.19 to 0.23) when clinicians' responses explicitly focused on patient affect. CONCLUSION: If saving time is a goal, clinicians should consider responses that explicitly address a patient's emotion. Arguments for providing space for patients to discuss emotional issues should focus on other benefits, including patients' well-being.

Psychosocial and Clinical Risk Factors Associated with Substance Use in Observational Cohort of Patients with Sickle Cell Disease.

BACKGROUND: Patients with sickle cell disease (SCD) experience high rates of chronic pain, and have a high burden of mental health comorbidities shown to negatively influence health. There is limited research on substance use among individuals with SCD. Objective: The aim of this study is to measure the prevalence of substance use in patients with SCD and determine whether psychosocial or clinical risk factors are associated with substance use. Methods: This study was conducted as part of an observational study of patients with SCD at two academic medical centers. We asked participants (ages 15 and older) about the lifetime use of heroin, cocaine, amphetamines, and marijuana/cannabis. We measured stigma, depression, urban life stress, pain catastrophizing, and asked about a brief pain inventory. Results: Of 258 participants, 24.9% (n = 71) reported substance use. Marijuana was the most common substance used (22.5%; n = 65). The mean depressive score met criteria for positive screen amongst individuals who reported a history of substance use (mean 10.7(5.76)). Adjusting for age, sex, yearly family income, and education level, odds of substance use increased with higher levels of internalized stigma (aOR: 1.38; 95% CI: 1.07, 1.77; p = 0.012); higher urban life stress scores (aOR 1.06; 95% CI: 1.01, 1.12; p = 0.017) and higher pain catastrophizing scores (aOR: 1.03; 95% CI: 1.01, 1.06; p = 0.008). Conclusions: Among individuals with SCD who endorse substance use, there was markedly more stress and distress with higher rates of depression and poorer quality of life. Interventions focusing on improving distress tolerance and coping to not only pain, but also social stressors, might reduce substance use.

Emotional Communication in HIV Care: An Observational Study of Patients' Expressed Emotions and Clinician Response.

Emotional support is essential to good communication, yet clinicians often miss opportunities to provide empathy to patients. Our study explores the nature of emotional expressions found among patients new to HIV care, how HIV clinicians respond to these expressions, and predictors of clinician responses. Patient-provider encounters were audio-recorded, transcribed, and coded using the VR-CoDES. We categorized patient emotional expressions by intensity (subtle 'cues' vs. more explicit 'concerns'), timing (initial vs. subsequent), and content (medical vs. non-medical). Emotional communication was present in 65 of 91 encounters. Clinicians were more likely to focus specifically on patient emotion for concerns versus cues (OR 4.55; 95% CI 1.36, 15.20). Clinicians were less likely to provide space when emotional expressions were repeated (OR 0.32; 95% CI 0.14, 0.77), medically-related (OR 0.36; 95% CI 0.17, 0.77), and from African American patients (OR 0.42; 95% CI 0.21, 0.84). Potential areas for quality improvement include raising clinician awareness of subtle emotional expressions, the emotional content of medically-related issues, and racial differences in clinician response.

Sociodemographic and Kidney Disease Correlates of Nutrient Intakes Among Urban African Americans With Uncontrolled Hypertension.

OBJECTIVE: The objective of this study was to determine the association between sociodemographic factors and intakes of 4 nutrients and associations between intakes and markers of kidney disease to identify opportunities to improve outcomes among clinically high-risk African Americans. DESIGN AND METHODS: We conducted a cross-sectional study of baseline data from the Achieving Blood Pressure Control Together study, a randomized controlled trial of 159 African Americans (117 females) with uncontrolled hypertension in Baltimore MD. To determine the association between sociodemographic factors and nutrient intakes, we constructed linear and logistic regression models. Using logistic regression, we determined the association between below-median nutrient intakes and kidney disease. Our outcomes of interest were daily intakes of vitamin C, magnesium, dietary fiber, and potassium as estimated by the Block Fruit-Vegetable-Fiber Screener and kidney disease defined as estimated glomerular filtration rate <60 mL/min per 1.73 m2 or urinary albumin-to-creatinine ratio >=30 mg/g. SETTING AND SUBJECTS: Baseline data from the Achieving Blood Pressure Control Together study, a randomized controlled trial of 159 African Americans (117 females) with uncontrolled hypertension, were obtained. METHODS: To determine the association between sociodemographic factors and nutrient intakes, we constructed linear and logistic regression models. Using logistic regression, we determined the association between below-median nutrient intakes and kidney disease. MAIN OUTCOME MEASURES: Our outcomes of interest were daily intakes of vitamin C, magnesium, dietary fiber, and potassium as estimated by the Block Fruit-Vegetable-Fiber Screener and kidney disease defined as estimated glomerular filtration rate <60 mL/min per 1.73 m2 or urinary albumin-to-creatinine ratio ≥30 mg/g. RESULTS: Overall, compared to Institute of Medicine recommendations, participants had lower intakes of magnesium, fiber, and potassium but higher vitamin C intakes. For females, sociodemographic factors that significantly associated with lower intake of the 4 nutrients were older age, obesity, lower health numeracy, and lesser educational attainment. For males, none of the sociodemographic factors were significantly associated with nutrient intakes. Below-median intake was significantly associated with albumin-to-creatinine ratio ≥30 (adjusted odds ratio [95% confidence interval]: 3.4 [1.5, 7.8] for vitamin C; 3.6 [1.6, 8.4] for magnesium; 2.9 [1.3, 6.5] for fiber; 3.6 [1.6, 8.4] for potassium), but not with estimated glomerular filtration rate <60. CONCLUSION: African Americans with uncontrolled hypertension may have low intakes of important nutrients, which could increase their risk of chronic kidney disease. Tailored dietary interventions for African Americans at high risk for chronic kidney disease may be warranted.

Risk Factors for New-Onset Depression After First-Time Traumatic Brain Injury.

BACKGROUND: Major depression after traumatic brain injury (TBI) has devastating consequences as it increases the risk of suicide, impairs overall quality of life, and affects interpersonal, occupational, and social functioning. Although the literature has reported factors associated with depression after TBI, very few studies have examined the prevalence and correlates focused on the development of new-onset depression (NOD) after first-time TBI. Our study aimed to identify TBI- and non-TBI-related factors associated with the development of NOD in the first year after TBI. METHODS: A total of 103 subjects with first-time TBI were seen within 12 months postinjury and evaluated for the development of NOD at 3, 6, and 12 months. RESULTS: Frontal lobe functioning, frontal lesions, and pre-TBI/early post-TBI social impairment were not found to be predictors of development of NOD within the first year after injury. Decreased post-TBI social functioning as perceived by the subject at 3, 6, and 12 months was found to be associated with NOD at each of these time points, respectively. CONCLUSION: The study findings highlight the importance of psychotherapeutic interventions to address the individuals' overall perception of their social impairment in the early-TBI period. This may help decrease the progression of major depression within the first year after injury.

Correlates and Prevalence of Aggression at Six Months and One Year After First-Time Traumatic Brain Injury.

Few studies have examined clinical correlates of aggression after first-time traumatic brain injury (TBI) within the first year after injury. The authors aimed to identify the rates of aggression at 6 and 12 months post-TBI and establish clinical and demographic correlates. A total of 103 subjects with first-time TBI were seen within 12 months postinjury and evaluated for aggression. Post-TBI social functioning and new-onset depression (within 3 months of the TBI) may serve as particularly important predictors for aggression within the first year of TBI, as these factors may afford intervention and subsequent decreased risk of aggression.

Continuous Abstinence During Early Alcohol Treatment is Significantly Associated with Positive Treatment Outcomes, Independent of Duration of Abstinence.

AIMS: Neither the predictive value of early continuous abstinence in alcohol use disorder (AUD) or the point at which this effect may emerge has been evaluated. This analysis of the Combined Pharmacotherapies and Behavioral Interventions (COMBINE) clinical trial evaluated whether abstinence early in treatment was a predictor of longer term abstinence. METHODS: Participants who stated a goal of total abstinence (N = 954) were dichotomized into Early Abstainer vs. Nonabstainers and were compared on a variety of drinking outcome measures that are frequently used in clinical trial evaluations of alcohol treatment strategies, as a function of duration of early continuous abstinence. RESULTS: Significant differences existed for every outcome. Early Abstinence was significantly associated with fewer drinks per drinking day, number of drinking and number of heavy drinking days, and longer time to first drinking and first heavy drinking day. Effects were evident within the first week. The magnitude of all effects increased as the duration of early abstinence (1-4 weeks) increased, though the size of increase varied across the outcomes. CONCLUSIONS: These data provide evidence that drinking at the beginning of alcohol treatment is significantly and robustly associated with drinking throughout and at the end of a clinical trial treatment for AUD. Early drinking may be a useful early index to identify whether patients are responding positively to a treatment strategy, and provides a useful method for tailoring treatment to patients that is consistent with a personalized medicine approach.

Clinicopathological correlates of depression in early Alzheimer's disease in the NACC.

OBJECTIVE: Depression may be a prodrome to Alzheimer's disease (AD). We assessed whether AD neuropathology is associated with depression in mild cognitive impairment (MCI) and mild dementia (dAD). METHODS: All clinical and neuropathological data for this study came from the National Alzheimer's Coordinating Center (NACC). Healthy control (HC, n = 120), MCI (n = 77), and mild dAD (n = 93) patients who underwent brain autopsy were included. In regression models with Geriatric Depression Scale (GDS) as the outcome, neuritic plaque (NP) score or Braak Stages of neurofibrillary (NF) pathology were covariates. RESULTS: GDS was not associated with cognitive status, NP score, Braak Stages, or their interaction. In both models, a history of TIAs, depression within the last 2 years, current benzodiazepine use, and greater severity of neuropsychiatric symptoms were associated with greater depression. In the Braak Stages model, less education was another significant predictor. CONCLUSIONS: Depression in early AD appears to be independent of NP and NF pathology. Studies are needed to investigate other mechanisms that may be responsible for depression in MCI and dAD.

Pathological Laughter and Crying and Psychiatric Comorbidity After Traumatic Brain Injury.

There are limited data regarding the incidence of pathological laughter and crying (PLC) after traumatic brain injury (TBI). This study aimed to identify the occurrence of PLC in the first year after TBI and to determine whether there is a relationship between PLC and other clinical features or demographics. Subjects who sustained a first-time TBI were recruited from acute trauma units and were assessed at 3, 6, and 12 months after TBI. Rates of PLC at 3, 6, and 12 months after TBI were 21.4%, 17.5%, and 15.5%, respectively. Patients with PLC had higher percentages of psychiatric diagnoses, including personality changes, depressive disorders, and mood disorders secondary to a general medical condition, as well as higher rates of posttraumatic stress disorder. Univariate logistic and linear regression analyses indicated a significant association between PLC and scores on the Clinical Anxiety Scale 3 months after TBI and on the Hamilton Depression Rating Scale 12 months after TBI. Individuals who have PLC during the first year after TBI are more likely to have any psychiatric diagnosis as well as higher rates of mood and anxiety symptoms. In addition, PLC in the early TBI period may serve as a predictor of depression and anxiety symptoms at 12 months after TBI.

Does acute TBI-related sleep disturbance predict subsequent neuropsychiatric disturbances?

PRIMARY OBJECTIVE: To determine whether sleep disturbance in the acute post-traumatic brain injury (TBI) period predicts symptoms of depression, anxiety or apathy measured 6 and 12 months after TBI. RESEARCH DESIGN: Longitudinal, observational study. METHODS AND PROCEDURES: First time closed-head injury patients (n = 101) were recruited and evaluated within 3 months of injury and followed longitudinally, with psychiatric evaluations at 6 and 12 months post-injury. Pre- and post-injury sleep disturbances were measured via the Medical Outcome Scale (MOS) for Sleep. Subjects were also assessed for anxiety, depression, apathy, medical comorbidity and severity of TBI. MAIN OUTCOMES AND RESULTS: Sleep disturbance in the acute TBI period was associated with increased symptoms of depression, anxiety and apathy 12 months post-injury. CONCLUSIONS: Sleep disturbances experienced soon after trauma (i.e. <3 months after injury) predicted neuropsychiatric symptoms 1 year after injury, raising two important clinical questions: (1) Is sleep disturbance soon after trauma a prognostic marker of subsequent neuropsychiatric symptoms? and (2) Can early treatment of sleep disturbance during the post-TBI period reduce subsequent development of neuropsychiatric symptoms? Future studies with larger sample sizes and appropriate control groups could help to answer these questions, using evidence-based methods for evaluating and treating sleep disturbances.

Which clinician responses to emotion are associated with more positive patient experiences of communication?

OBJECTIVES: To identify communication strategies that may improve clinician-patient interactions, we assessed the association between clinician response to emotion and patient ratings of communication. METHODS: From a cohort of 1817 clinician-patient encounters, we designed a retrospective case-control study by identifying 69 patients who rated their interpersonal care as low-quality and 69 patients who rated their care as high-quality. We used the Verona Coding Definitions of Emotional Sequences (VR-CoDES) to identify patient emotional expressions and clinician responses. Using mixed-effects logistic regression, we evaluated the association between clinician responses to patients' emotions and patient ratings of their interpersonal care. RESULTS: In adjusted analyses, explicit responses that reduced space for further emotional communication were associated with high ratings of care (OR 1.94, 95% CI 1.25, 2.99); non-explicit responses providing additional space were associated with low ratings (OR 0.54, 95% CI 0.36-0.82). In terms of specific response types, neutral/passive responses were associated with low ratings (OR 0.59, 95% CI 0.39-0.90), whereas giving information/advice was associated with high ratings (OR, 95% 1.91 CI 1.17-3.1). CONCLUSIONS: Patients may prefer responses to their expressed emotions that demonstrate clinician engagement, with or without expressions of empathy. PRACTICE IMPLICATIONS: These findings may inform educational interventions to improve clinician-patient communication.

Association of Neighborhood Socioeconomic Disadvantage with Proliferative Diabetic Retinopathy.

OBJECTIVE OR PURPOSE: To evaluate the association between neighborhood socioeconomic deprivation, distance from ophthalmology clinics, and diagnosis of proliferative diabetic retinopathy (PDR). DESIGN: Retrospective cohort study. SUBJECTS, PARTICIPANTS, AND/OR CONTROLS: Adult patients (≥18 years) with diabetes mellitus at Johns Hopkins Hospital and University of Wisconsin-Madison. METHODS, INTERVENTION, OR TESTING: Patient addresses were geocoded and the block group was linked to the 2021 national Area Deprivation Index (ADI). ADI was divided into quartiles, with higher quartiles indicating greater socioeconomic disadvantage. The distance between patient's residence and ophthalmology clinics was calculated. Multivariable logistic regression models were used to analyze the association between ADI quartile, distance from clinic, and PDR, adjusted for demographics and insurance status. The interaction between ADI and distance was tested. MAIN OUTCOME MEASURES: Diagnosis of PDR. RESULTS: 73,618 patients were included. A significant interaction was observed between ADI quartile and distance from ophthalmology clinics (P < .001). Among patients residing within 8 miles of clinics, those in higher ADI quartiles had increased odds of PDR compared to those in ADI Q1 (Q2: OR 1.36, 95% CI 1.12-1.65; Q3: OR 1.79, 95% CI 1.46-2.19; Q4: OR 2.60, 95% CI 2.09-3.25; P<.001 for trend). Conversely, for patients living more than 8 miles from clinics, the odds of PDR were similar across ADI quartiles (Q1: OR 0.85, 95% CI 0.73-0.98; Q2: OR 1.02, 95% CI 0.87-1.12; Q3: OR 1.08, 95% CI 0.90-1.30). However, patients in all ADI quartiles more than 8 miles had greater odds of PDR compared to those in the same ADI quartile within 8 miles (OR 3.15, 95% CI 2.61-3.80, OR 1.97, 95% CI 1.71-2.27, OR 1.79, 95% CI 1.51-2.12, and OR 1.31, 95% CI 1.07-1.61 in ADI Q1 to Q4 respectively). CONCLUSIONS: Patients living in neighborhoods with greater socioeconomic disadvantage and further from ophthalmology clinics have greater odds of PDR. These findings suggest the potential utility of targeted interventions in socioeconomically deprived and distant areas to reduce PDR-related blindness.

Social Risk Groups in Patients With Diabetes With Differing Eye Care Utilization and Vision Outcomes.

Purpose: To evaluate whether latent class analysis on social determinants of health (SDoH) data can identify social risk groups that differ by adverse SDoH and vision outcomes in patients with diabetes. Methods: This was a prospective cohort study of adults ≥18 years with diabetes who completed a SDoH survey. Latent class analysis was used to cluster patients into social risk groups. The association of social risk group and severity of diabetic retinopathy, history of lapses in diabetic retinopathy care, and visual acuity was evaluated. Results: A total of 1006 participants were included. The three social risk groups differed by sociodemographic characteristics. The average age was 65, 60, and 54 in Groups 1, 2, and 3 respectively. Most (51%) patients in group 1 were non-Hispanic White, 66% in group 2 were non-Hispanic Black, and 80% in group 3 were Hispanic. Group 1 had the lowest burden of adverse SDoH per person (average 3.6), group 2 had 8.2, and group 3 had 10.5. In general, group 1 lacked diabetic retinopathy knowledge, group 2 had financial insecurity and difficulties with transportation, and group 3 had financial insecurity and did not have health insurance. Social risk group was associated with a history of lapses in diabetic retinopathy care, and presenting with worse vision. Conclusions and Translational Relevance: We identified distinct social risk groups among patients seeking care for diabetic retinopathy that differed by social needs, eye care utilization, and vision. Identifying these groups and their specific needs can help guide interventions to effectively address adverse SDoH and improve eye care utilization and vision outcomes among patients with diabetes.

Bleomycin-induced mutagen sensitivity, passive smoking, and risk of breast cancer in Chinese women: a case-control study.

BACKGROUND: It is well recognized that genetic variation as well as environmental factors modulates breast cancer risk. Deficiencies in DNA repair capacity are thought to associate with breast cancer risk. The main aim of this study was to use the mutagen sensitivity assay as an indirect measure of DNA repair capacity to assess breast cancer risk and the relationship between passive smoking and breast cancer risk among women in China. METHODS: We carried out a case-control study, involving 196 Chinese patients with breast cancer and 211 controls without the disease and with no history of cancer. We investigated the association between mutagen sensitivity and breast cancer risk using bleomycin as the mutagen. Mutagen sensitivity was measured by quantifying the chromatid breaks induced by mutagens in short-term cultures of peripheral blood lymphocytes. Nonparametric tests and the Fisher's exact test were used to determine the statistical significance of the crude case-control comparisons, followed by logistic regression to adjust for important covariates. RESULTS: The mean number of bleomycin-induced breaks per cell was 0.81 for cases compared with 0.73 for the controls (p = 0.016). A greater number of bleomycin-induced chromosomal breaks per cell was associated with an increased risk of breast cancer (adjusted odds ratio of 1.82, p trend <0.01). The association between bleomycin sensitivity and breast cancer risk was greater for women who were exposed to tobacco smoke (passive smokers). The combination of bleomycin sensitivity and exposure to tobacco smoke increased risk further; women passive smokers with high sensitivity to bleomycin had a 2.77-fold increased risk of breast cancer. CONCLUSIONS: Our data indicate that increased bleomycin-induced mutagen sensitivity is significantly associated with an increased risk of breast cancer among Chinese women. Exposure to passive smoke is also associated with increased breast cancer risk, and the correlation is even greater for women with both longer passive exposure to tobacco smoke and high sensitivity to bleomycin.

Taxonomy and effectiveness of clinician agenda-setting questions in routine ambulatory encounters: A mixed method study.

OBJECTIVES: Despite decades of communication training, studies repeatedly demonstrate that clinicians fail to elicit patients' agendas. Our goal was to provide clinicians with actionable guidance about the effectiveness of agenda-soliciting questions. METHODS: We coded clinician agenda-soliciting questions and patient responses in audio-recorded ambulatory encounters at an urban academic hospital. To evaluate the association between question type and odds of the patient raising a concern, we performed mixed-effects logistic regression. RESULTS: We identified 346 agenda-soliciting questions within 138 visits (mean 2.51/visit; range 0-9). Agenda-soliciting questions were categorized as personal state inquiries (37%, "How are you?"), feeling-focused (5% "How're you feeling?"), problem-focused (12%; "Are you having any problems"), direct solicitations (3%; "Anything you want to discuss today?"), "what else" (3%), "anything else" (14%), leading (16%; "Nothing else today?"), and space-reducing (11% "Anything else? Smoking?"). Patients raised a concern in response to 107 clinician questions (27%). Patients were more likely to raise a concern to direct solicitation (OR 22.95, 95% CI 2.62-200.70) or "what else" (OR 4.68, 95% CI 1.05-20.77) questions. CONCLUSIONS: The most effective agenda-soliciting questions are used least frequently by clinicians. PRACTICE IMPLICATIONS: Clinicians should elicit patient agendas by using direct language, and solicit additional concerns using "what else" vs. "anything else" questions.

Health Literacy, Numeracy, and Dietary Approaches to Stop Hypertension Accordance Among Hypertensive Adults.

BACKGROUND: Health literacy (HL) and health numeracy (HN), the ability to interpret and act on quantitative health information, are important for hypertension self-management such as limiting sodium intake. We examined associations of HL, HN, and Dietary Approaches to Stop Hypertension (DASH) diet accordance. PARTICIPANTS: Among 1,073 hypertensive adults enrolled in a Baltimore, Maryland-based cohort study, we performed a cross-sectional analysis. Rapid Estimate of Adult Literacy in Medicine (REALM) measured HL and Test of Functional Health Literacy in Adults (TOFHLA) numeracy score measured HN. METHOD: DASH accordance was based on nine key nutrients. Linear regression models estimated associations of HL and HN with DASH total and sodium score, inclusive of dietary supplement data. RESULTS: In our sample, 39% of participants were male, 66% were Black, 40.2% lived in poverty, and 29.5% reported food insecurity. Fully, 32.5% had limited HL and 14.5% had limited HN. Mean DASH score overall was 2 (range = 0-7.5); only 6.9% were DASH accordant (score ≥4.5). In age and sex adjusted models, higher REALM was associated with a higher DASH score in the overall sample; the relationship of HN with DASH was statistically significant among White but not Black participants. Educational attainment appeared to explain both findings. There were no significant associations between HL or HN and DASH sodium scores. CONCLUSION: Differences in educational attainment explained the relation of higher HL and greater accordance to the DASH diet in a population of hypertensive adults. Understanding these factors is vital to reducing disparities in hypertension and its sequelae.

Effects of general medical health on Alzheimer's progression: the Cache County Dementia Progression Study.

BACKGROUND: Several observational studies have suggested a link between health status and rate of decline among individuals with Alzheimer's disease (AD). We sought to quantify the relationship in a population-based study of incident AD, and to compare global comorbidity ratings to counts of comorbid conditions and medications as predictors of AD progression. METHODS: This was a case-only cohort study arising from a population-based longitudinal study of memory and aging, in Cache County, Utah. Participants comprised 335 individuals with incident AD followed for up to 11 years. Patient descriptors included sex, age, education, dementia duration at baseline, and APOE genotype. Measures of health status made at each visit included the General Medical Health Rating (GMHR), number of comorbid medical conditions, and number of non-psychiatric medications. Dementia outcomes included the Mini-Mental State Examination (MMSE), Clinical Dementia Rating - sum of boxes (CDR-sb), and the Neuropsychiatric Inventory (NPI). RESULTS: Health status tended to fluctuate over time within individuals. None of the baseline medical variables (GMHR, comorbidities, and non-psychiatric medications) was associated with differences in rates of decline in longitudinal linear mixed effects models. Over time, low GMHR ratings, but not comorbidities or medications, were associated with poorer outcomes (MMSE: ß = -1.07 p = 0.01; CDR-sb: ß = 1.79 p < 0.001; NPI: ß = 4.57 p = 0.01). CONCLUSIONS: Given that time-varying GMHR, but not baseline GMHR, was associated with the outcomes, it seems likely that there is a dynamic relationship between medical and cognitive health. GMHR is a more sensitive measure of health than simple counts of comorbidities or medications. Since health status is a potentially modifiable risk factor, further study is warranted.

Prevalence of Guideline-Directed Medical Therapy for Cardiovascular Disease Among Baltimore City Adults in the Healthy Aging in Neighborhoods of Diversity Across the Life Span (HANDLS) Study.

OBJECTIVE: Guideline-directed medical therapy (GDMT) has been shown to improve outcomes for people with cardiovascular disease (CVD). Our goal was to assess racial and socioeconomic differences in GDMT use among a diverse population. METHODS: We examined the cross-sectional association of race and poverty status with GDMT among 441 participants with CVD in a longitudinal cohort of urban-dwelling Black and White adults in Baltimore City, Maryland, using multivariable logistic regression. CVD status and GDMT were self-reported. RESULTS: The participants' mean age was 60.5 (SD 8.5) years, with 61.7% women, 64.4% Black, and 46.9% living below poverty. Of the 126 participants with coronary artery disease (CAD), 37.3%, 54.8%, and 62.7% were on aspirin, antiplatelets, and statins, respectively. Black participants with CAD were less likely to be on aspirin, OR 0.29 (95% CI 0.13-0.67), and on combination GDMT (antiplatelet and statin), OR 0.36 (0.16-0.78) compared to Whites. There were no differences by poverty status in GDMT for CAD. Fully, 222 participants reported atrial fibrillation (AF), but only 10.5% were on anticoagulation with no significant difference by race or poverty status. The use of GDMT for heart failure and stroke was also low overall, but there were no differences by race or poverty status. CONCLUSIONS: Among an urban-dwelling population of adults, the use of secondary prevention of CVD was low, with lower aspirin and combination GDMT for Black participants with CAD. Efforts to improve GDMT use at the patient and provider levels may be needed to improve morbidity and mortality and reduce disparities in CVD.