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Objectives. We qualitatively assessed patients’ perceptions of discrimination and patient satisfaction in the health care setting specific to interactions with nonphysician health care staff. Methods. We conducted 12 focus-group interviews with African American and European American participants, stratified by race and gender, from June to November 2008. We used a topic guide to facilitate discussion and identify factors contributing to perceived discrimination and analyzed transcripts for relevant themes using a codebook. Results. We enrolled 92 participants: 55 African Americans and 37 European Americans, all of whom reported perceived discrimination and lower patient satisfaction as a result of interactions with nonphysician health care staff. Perceived discrimination was associated with 2 main characteristics: insurance or socioeconomic status and race. Both verbal and nonverbal communication style on the part of nonphysician health care staff were related to individuals’ perceptions of how they were treated. Conclusions. The behaviors of nonphysician health care staff in the clinical setting can potentially contribute to patients’ perceptions of discrimination and lowered patient satisfaction. Future interventions to reduce health care discrimination should include a focus on staff cultural competence and customer service skills.

PURPOSE It is unclear whether peer coaching is effective in minority populations living with diabetes in hard-to-reach, under-resourced areas such as the rural South. We examined the effect of an innovative peer-coaching intervention plus brief education vs brief education alone on diabetes outcomes. METHODS This was a community-engaged, cluster-randomized, controlled trial with primary care practices and their surrounding communities serving as clusters. The trial enrolled 424 participants, with 360 completing baseline and follow-up data collection (84.9% retention). The primary outcomes were change in glycated hemoglobin (HbA1c), systolic blood pressure (BP), low density lipopro- tein cholesterol (LDL-C), body mass index (BMI), and quality of life, with diabetes distress and patient activation as secondary outcomes. Peer coaches were trained for 2 days in community settings; the training emphasized motivational inter- viewing skills, diabetes basics, and goal setting. All participants received a 1-hour diabetes education class and a personalized diabetes report card at baseline. Intervention arm participants were also paired with peer coaches; the protocol called for telephone interactions weekly for the first 8 weeks, then monthly for a total of 10 months. RESULTS Due to real-world constraints, follow-up was protracted, and interven- tion effects varied over time. The analysis that included the 68% of participants followed up by 15 months showed only a significant increase in patient activation in the intervention group. The analysis that included all participants who eventu- ally completed follow-up revealed that intervention arm participants had signifi - cant differences in changes in systolic BP (P = .047), BMI (P = .02), quality of life (P = .003), diabetes distress (P = .004), and patient activation (P = .03), but not in HbA1c (P = .14) or LDL-C (P = .97). CONCLUSION Telephone-delivered peer coaching holds promise to improve health for individuals with diabetes living in under-resourced areas.

Background Young adults with sickle cell anemia are at high risk for increased hospitalization and death at the time of transition to adult care. This may be related to failure of the transition system to prepare young adults for the adult healthcare system. This qualitative study was designed to identify factors related to transition that may affect the health of adults with sickle cell anemia. Procedure Ten patients currently treated in an adult hematology clinic participated in semi-structured qualitative interviews to describe their experience transitioning from pediatric to adult care and differences in adult and pediatric healthcare systems. Results Participants were generally unprepared for the adult healthcare system. Negative issues experienced by participants included physician mistrust, difficulty with employers, keeping insurance, and stress in personal relationships. Positive issues experienced by participants included improved self efficacy with improved self care and autonomy. Conclusions In the absence of a formalized transition program, adults with sickle cell anemia experience significant barriers to adult care. In addition to medical history review and identification of an adult provider, transition programs should incorporate strategies to navigate the adult medical system, insurance and relationships as well as encouraging self efficacy.

Context: Rivaroxaban is a direct factor Xa inhibitor approved for the prevention of thromboembolism. Drug induced liver injury has been increasingly reported with rivaroxaban recently, but actual liver failure has not been reported. Case Report: We present a case report on the probable occurrence of acute liver failure with rivaroxaban therapy. An 89 year old woman with history of atrial fibrillation was hospitalized for biventricular congestive heart failure with passive congestion of liver, which responded to furosemide. She was discharged home on rivaroxaban for prevention of thrombo-embolism. Liver function tests upon discharge returned to almost normal range. One week later, she presented with abdominal pain and was found to have highly elevated liver enzymes, elevated bilirubin, and an abnormal coagulation profile. A day later, she developed hepatic encephalopathy, suggesting liver failure. Conclusion: Liver enzymes declined rapidly with the discontinuation of all of her medications, however patient died because of multi-organ failure. The causality assessment in this patient was “probable” with rivaroxaban.

Racial bias is associated with suboptimal healthcare treatment for minorities. Research focuses on bias among physicians rather than non-physician healthcare staff (e.g., receptionists). Patients spend considerable amounts of time with non-physician staff. Therefore, we investigate differences in implicit and explicit racial bias by healthcare staff race and occupation using the Implicit Association Test and Modern Racism Scale, respectively.Staff (n = 107) were recruited using the Alabama based Primary Care Research Coalition. Occupation was categorized into "medical doctors/registered nurses" (MD/RN) and "non-MD/RN" (e.g., receptionists).Implicit bias scores were higher among whites compared with blacks (0.62, -0.04, respectively; p 0.01). Among whites, non-MD/RNs demonstrated more pro-white implicit bias compared with MD/RNs (0.67, 0.44, respectively; p 0.01). Whites had higher explicit bias scores than blacks (17.7, 12.3, respectively; p 0.01).Non-MD/RNs should not be overlooked for cultural competency training, and efforts are needed to reduce racial bias among healthcare workers identified as having higher levels of bias.

Objective To examine self-reported weight discrimination and differences based on race, sex, and BMI in a biracial cohort of community-based middle-aged adults. Design and Methods Participants (3,466, mean age = 50 years, mean BMI = 30 kg/m2) of the Coronary Artery Risk Development in Young Adults (CARDIA) Study who completed the 25-year examination of this epidemiological investigation in 2010-2011 were reported. The sample included normal weight, overweight, and obese participants. CARDIA participants are distributed into four race–sex groups, with about half being African-American and half White. Participants completed a self-reported measure of weight discrimination. Results Among overweight/obese participants, weight discrimination was lowest for White men (12.0%) and highest for White women (30.2%). The adjusted odds ratio (95% CI) for weight discrimination in those with class 2/3 obesity (BMI ≥ 35 kg/m2) versus the normal-weight was most pronounced: African American men, 4.59 (1.71-12.34); African American women, 7.82 (3.57-17.13); White men, 6.99 (2.27-21.49); and White women, 18.60 (8.97-38.54). Being overweight (BMI = 25-29.9 kg/m2) vs. normal weight was associated with increased discrimination in White women only: 2.10 (1.11-3.96). Conclusions Novel evidence for a race–sex interaction on perceived weight discrimination, with White women more likely to report discrimination at all levels of overweight and obesity was provided. Pychosocial mechanisms responsible for these differences deserve exploration.

Alcohol intake has been shown to have a J-shaped association with blood pressure (BP). However, this association has not been examined in mixed race populations or in people with diabetes where tighter blood pressure control is recommended. Participants in the REGARDS study who were 45 years or older (n = 30,239) were included. Medical history (including self-reported alcohol intake) was collected by telephone while blood collection and clinical measurements were done during an in-home visit. We defined diabetes as use of medications and/or fasting glucose ≥ 126 mg/dL and hypertension as use of blood pressure lowering medications and/or BP ≥ 140/90 mmHg or BP ≥ 130/80 mmHg in people with diabetes. After adjustment for confounders, heavy drinking was associated with an increased odds of hypertension (OR = 1.59, 95% CI = 1.37, 1.87). Diabetes and gender significantly modified (interaction P < 0.05 for both) the association between alcohol use and hypertension, although heavy drinking remained associated with increased odds of hypertension in sub-group analyses. We did not observe the previously described J-shaped relationship in any sub-group except white females. These data suggest heavy alcohol consumption is associated with poor BP control and that heavy drinkers may want to consider limiting alcohol intake in order to manage hypertension.

Death certificates may lack accuracy and misclassify the cause of death. The validity of proxy-reported cause of death is not well established. The authors examined death records on 336 participants in the Reasons for Geographic and Racial Differences in Stroke (REGARDS) Study, a national cohort study of 30,239 community-dwelling US adults (2003–2010). Trained experts used study data, medical records, death certificates, and proxy reports to adjudicate causes of death. The authors computed agreement on cause of death from the death certificate, proxy, and adjudication, as well as sensitivity and specificity for certain diseases. Adjudicated cause of death had a higher rate of agreement with proxy reports (73%; Cohen's kappa (κ) statistic = 0.69) than with death certificates (61%; κ = 0.54). The agreement between proxy reports and adjudicators was better than agreement with death certificates for all disease-specific causes of death. Using the adjudicator assessments as the “gold standard,” for disease-specific causes of death, proxy reports had similar or higher specificity and higher sensitivity (sensitivity = 50%–89%) than death certificates (sensitivity = 31%–81%). Proxy reports may be more concordant with adjudicated causes of death than with the causes of death listed on death certificates. In many settings, proxy reports may represent a better strategy for determining cause of death than reliance on death certificates.

J Clin Hypertens (Greenwich). 2011;13:479–486.©2011 Wiley Periodicals, Inc. The authors analyzed data on 9950 participants taking antihypertensive medications in the nationwide Reasons for Geographic and Racial Differences in Stroke (REGARDS) study to determine the association between medication adherence and incident stroke symptoms. Medication adherence was assessed using a validated 4-item self-report scale and participants were categorized into 4 groups (scores of 0, 1, 2, and 3 or 4, with higher scores indicating worse adherence). The incidence of 6 stroke symptoms (sudden weakness on one side of the body, numbness, painless loss of vision in one or both eyes, loss of half vision, losing the ability to understand people, and losing the ability to express oneself verbally or in writing) was assessed via telephone interviews every 6 months. During a median of 4 years, the incidence of any stroke symptom was 14.6%, 17.9%, 20.2%, and 24.9% among participants with adherence scores of 0, 1, 2, and 3 or 4, respectively (P

BACKGROUND There are few available data on the epidemiology of prehypertension (preHTN).To determine racial, clinical, and demographic differences in the prevalence of preHTN and its cross-sectional association with vascular risk factors. METHODS Cross-sectional analysis of 5,553 prehypertensives, 20,351 hypertensive's, and 4,246 nonhypertensive participants (age ≥45), from a population-based national cohort study (REasons for Geographic And Racial Differences in Stroke (REGARDS) total population 30,239, of whom 30,150 had adequate blood pressure (BP) measurements) enrolled from January 2003-October 2007 with oversampling from the southeastern stroke belt, and black individuals. Baseline data were collected using a combination of telephone interview and in-home evaluation. preHTN was defined according to The Seventh Report of the Joint national Committee on Prevention, Detection, Evaluation, and Treatment of High Blood Pressure (JNC 7) guidelines. RESULTS The prevalence of preHTN was associated with age and black race (62.9% in blacks compared to 54.1 % in whites). A higher prevalence of preHTN was observed in obese individuals, self-reported heart disease; and, those with elevated high-sensitivity C reactive protein (hsCRP), diabetes, and microalbuminuria compared to those without these factors. Heavy alcohol consumption in white participants was associated with increased odds of preHTN (odds ratio (OR) = 1 . 3 2) but was even greater in black participants (OR =2.27). CONCLUSION The prevalence of preHTN increased by age and African-American race. In addition, a higher prevalence of preHTN was observed with elevated hsCRP, diabetes, microalbuminuria, and those with heavy alcohol consumption compared to those without these factors.

Observational studies can avoid biases by blinding medical records to characteristics of interest before outcome adjudication. However, blinding is costly. We assessed the effect of blinding race and geography on outcome ascertainment.The Reasons for Geographic and Racial Differences in Stroke - Myocardial Infarction (REGARDS-MI) Study is an ancillary study to the REGARDS national prospective cohort study including 30,228 participants. The primary characteristics of interest are race and geography, and the prespecified acceptable agreement rate between adjudicators is set at less than 80%. We selected 116 suspected cardiovascular events that underwent adjudication with usual blinding. At least 3 months later, cases were readjudicated without blinding race and geographic location of the patient. We assessed differences in outcome ascertainment using Cohen's kappa statistic and ARs.Agreement between blinded and unblinded reviews was good to excellent for all four outcomes. kappa statistics were 0.80 (chest pain), 0.85 (heart failure), 0.86 (revascularization), and 0.74 (MI) (P0.0001 for all). Within each outcome, ARs were similar for race and geographic groups (agreement: 83-100%).In observational studies, blinding medical record review for outcome ascertainment for some types of patient characteristics may cause an unwarranted expense.

The relation between alcohol consumption and incident hypertension is unclear, and most observational studies have not accounted for socioeconomic factors. This study examined the association between alcohol consumption in a diverse group of young adults and incident hypertension over 20 years. Participants (n ¼ 4,711) were from the Coronary Artery Risk Development in Young Adults Study cohort, recruited in 1985 (aged 18–30 years) from Birmingham, Alabama; Chicago, Illinois; Minneapolis, Minnesota; and Oakland, California. The 20-year incidence of hypertension for never, former, light, moderate, and at-risk drinkers was 25.1%, 31.8%, 20.9%, 22.2%, and 18.8%, respectively (P < 0.001). Race, gender, age, family history of hypertension, body mass index, income, education, and difficulty paying for basics and medical care were associated with hypertension. Adjustment using Cox proportional hazard models revealed no association between baseline alcohol consumption and incident hypertension, except among European-American women in whom any current alcohol consumption was associated with lower risk of incident hypertension. The lack of association between alcohol and hypertension in the majority of this socioeconomically diverse cohort is not definitive. Future studies should include social factors, such as income and education, and consider additional characteristics that may modify or confound associations between alcohol and blood pressure. African continental ancestry group; alcohol drinking; cohort studies; European continental ancestry group; hypertension; incidence

INTRODUCTION Blood pressure measurement in clinical care settings seldom follows the protocol recommended by national guidelines, potentially leading to overestimates or underestimates of blood pressure control. We evaluated blood pressure measurement methods as a source of bias in determining blood pressure control among community-dwelling adults with diabetes. METHODS In a community-based trial of patients with diabetes, we measured both "clinical blood pressure" (clinical BP) (taken by a community nurse or medical assistant instructed to "take the participant's blood pressure like you do in your own clinic") and "research blood pressure" (research BP) (research staff followed a guideline-concordant protocol). Each participant had both types of blood pressure assessment on the same day over the course of 2 hours. RESULTS The 227 participants had a mean age of 59 years; 86% were black and 74% were women. The mean clinical BP was 5 mm Hg higher than the mean research BP for systolic blood pressure (P < .001) and 2 mm Hg higher for diastolic blood pressure (P < .001). The proportion of participants whose clinical BP was 130/80 mm Hg or higher was 8 percentage points higher than the proportion whose research BP was 130/80 mm Hg or higher (P < .001), and the proportion whose clinical BP was 140/90 mm Hg or higher was 10 percentage points higher than the proportion whose research BP was 140/90 mm Hg or higher (P < .001). Among those aged 65 years or older, the proportion whose clinical BP was 130/80 mm Hg or higher was 10 percentage points higher than proportion whose research BP was 130/80 mm Hg or higher, and the proportion whose clinical BP was 140/90 mm Hg or higher was 14 percentage points higher than the proportion whose research BP was 140/90 mm Hg or higher. Whites and smokers had the greatest risk for having a clinical BP 5 mm Hg or more higher than their research BP. CONCLUSION Measurement biases in clinical settings may be a component of observed poor blood pressure control rates in real-world settings.

OBJECTIVE—With performance-based reimbursement pressures, it is concerning that most performance measurements treat each condition in isolation, ignoring the complexities of patients with multiple comorbidities. We sought to examine the relationship between comorbidity and commonly assessed services for diabetic patients in a managed care organization. RESEARCH DESIGN AND METHODS—In 6,032 diabetic patients, we determined the association between the independent variable medical comorbidity, measured by the Charlson Comorbidity Index (CCI), and the dependent variables A1C testing, lipid testing, dilated eye exam, and urinary microalbumin testing. We calculated predicted probabilities of receiving tests for patients with increasing comorbid illnesses, adjusting for patient demographics. RESULTS—A1C and lipid testing decreased slightly at higher CCI: predicted probabilities for CCI quartiles 1, 2, 3, and 4 were 0.83 (95% CI 0.70–0.91), 0.83 (0.69–0.92), 0.82 (0.68–0.91), and 0.78 (0.61–0.88) for A1C, respectively, and 0.82 (0.69–0.91), 0.81(0.67–0.90), 0.79 (0.64–0.89), and 0.77 (0.61–0.88) for lipids. Dilated eye exam and urinary microalbumin testing did not differ across CCI quartiles: for quartiles 1, 2, 3, and 4, predicted probabilities were 0.48 (0.33–0.63), 0.54 (0.38–0.69), 0.50 (0.34–0.65), and 0.50 (0.34–0.65) for eye exam, respectively, and 0.23 (0.12–0.40), 0.24 (0.12–0.42), 0.24 (0.12–0.41), and 23 (0.11–0.40) for urinary microalbumin. CONCLUSIONS—Services received did not differ based on comorbid illness burden. Because it is not clear whether equally aggressive care confers equal benefits to patients with varying comorbid illness burden, more evidence confirming such benefits may be warranted before widespread implementation of pay-for-performance programs using currently available “one size fits all” performance measures.

Purpose To examine the association of depressive symptoms with coronary heart disease (CHD) end points by race and income. Methods Study participants were blacks and whites ( n = 24,443) without CHD at baseline from the national Reasons for Geographical and Racial Differences in Stroke cohort. Outcomes included acute CHD and CHD or revascularization. We estimated race-stratified multivariate Cox proportional hazards models of incident CHD and incident CHD or revascularization with the 4-item Center for Epidemiological Studies Depression Scale, adjusting for risk factors. Results Mean follow-up was 4.2 ± 1.5 years; CHD incidence was 8.3 events per 1000 person-years ( n = 366) among blacks and 8.8 events per 1000 person-years ( n = 613) among whites. After adjustment for age, sex, marital status, region, and socioeconomic status, depressive symptoms were significantly associated with incident CHD among blacks (hazard ratio [HR], 1.39; 95% confidence interval [CI], 1.00–1.91) but not among whites (HR, 1.10; 95% CI, 0.74–1.64). In the fully adjusted model, compared with blacks who reported no depressive symptoms, those reporting depressive symptoms had greater risk for the composite end point of CHD or revascularization (HR, 1.36; 95% CI, 1.01–1.81). Depressive symptoms were not associated with incident CHD end points among whites. Conclusions High depressive symptoms were associated with higher risk of CHD or revascularization for blacks but not whites.

It is unknown whether long-standing disparities in incidence of coronary heart disease (CHD) among US blacks and whites persist.To examine incident CHD by black and white race and by sex.Prospective cohort study of 24,443 participants without CHD at baseline from the Reasons for Geographic and Racial Differences in Stroke (REGARDS) cohort, who resided in the continental United States and were enrolled between 2003 and 2007 with follow-up through December 31, 2009.Expert-adjudicated total (fatal and nonfatal) CHD, fatal CHD, and nonfatal CHD (definite or probable myocardial infarction [MI]; very small non-ST-elevation MI [NSTEMI] had peak troponin level0.5 μg/L).Over a mean (SD) of 4.2 (1.5) years of follow-up, 659 incident CHD events occurred (153 in black men, 138 in black women, 254 in white men, and 114 in white women). Among men, the age-standardized incidence rate per 1000 person-years for total CHD was 9.0 (95% CI, 7.5-10.8) for blacks vs 8.1 (95% CI, 6.9-9.4) for whites; fatal CHD: 4.0 (95% CI, 2.9-5.3) vs 1.9 (95% CI, 1.4-2.6), respectively; and nonfatal CHD: 4.9 (95% CI, 3.8-6.2) vs 6.2 (95% CI, 5.2-7.4). Among women, the age-standardized incidence rate per 1000 person-years for total CHD was 5.0 (95% CI, 4.2-6.1) for blacks vs 3.4 (95% CI, 2.8-4.2) for whites; fatal CHD: 2.0 (95% CI, 1.5-2.7) vs 1.0 (95% CI, 0.7-1.5), respectively; and nonfatal CHD: 2.8 (95% CI, 2.2-3.7) vs 2.2 (95% CI, 1.7-2.9). Age- and region-adjusted hazard ratios for fatal CHD among blacks vs whites was near 2.0 for both men and women and became statistically nonsignificant after multivariable adjustment. The multivariable-adjusted hazard ratio for incident nonfatal CHD for blacks vs whites was 0.68 (95% CI, 0.51-0.91) for men and 0.81 (95% CI, 0.58-1.15) for women. Of the 444 nonfatal CHD events, 139 participants (31.3%) had very small NSTEMIs.The higher risk of fatal CHD among blacks compared with whites was associated with cardiovascular disease risk factor burden. These relationships may differ by sex.

Background Limited financial and geographic access to primary care can adversely influence chronic disease outcomes. We examined variation in awareness, treatment, and control of hypertension, diabetes, and hyperlipidemia according to both geographic and financial access to care. Methods We analyzed data on 17,458 participants in the REasons for Geographic And Racial Differences in Stroke (REGARDS) study with either hypertension, hyperlipidemia, or diabetes and living in either complete Health Professional Shortage Area (HPSA) counties or non-HPSA counties in the U.S. All analyses were stratified by insurance status and adjusted for sociodemographics and health behaviors. Results 2,261 residents lived in HPSA counties and 15,197 in non-HPSA counties. Among the uninsured, HPSA residents had higher awareness of both hypertension (adjusted OR 2.30, 95% CI 1.08, 4.89) and hyperlipidemia (adjusted OR 1.50, 95% CI 1.01, 2.22) compared to non-HPSA residents. Also among the uninsured, HPSA residents with hypertension had lower blood pressure control (adjusted OR 0.45, 95% CI 0.29, 0.71) compared with non-HPSA residents. Similar differences in awareness and control according to HPSA residence were absent among the insured. Conclusions Despite similar or higher awareness of some chronic diseases, uninsured HPSA residents may achieve control of hypertension at lower rates compared to uninsured non-HPSA residents. Federal allocations in HPSAs should target improved quality of care as well as increasing the number of available physicians.

To explore sexual health knowledge among Latino immigrants in a Southern U.S. city, we conducted 20 qualitative interviews, (10 Women and 10 Men). We explored knowledge and factors associated with sexual health among male and female Latino immigrants in a Southern U.S. city experiencing a major growth of Latino immigrants in the past 10 years. Both genders demonstrated limited knowledge of Human Papillomavirus (HPV) and risks of sexually transmitted infection (STI) acquisition. Neither gender perceived that they could have an asymptomatic STI, including HPV. Gender differences exist in sexual behaviors and perceptions of STI risk. Females indicated that female Latinas tend to have older sexual initiation age, fewer lifetime sexual partners and more pro-active sexual health than did Latinos when referring to Latino males. Consequently, male and female Latino immigrants could benefit from culturally relevant programs to alleviate STI disparities.

Introduction Peer support is a promising strategy for the reduction of diabetes-related health disparities; however, few studies describe the development of such strategies in enough detail to allow for replication. The objective of this article is to describe the development of a 1-year peer support intervention to improve diabetes self-management among African American adults with diabetes in Alabama's Black Belt. Methods We used principles of intervention mapping, including literature review, interviews with key informants, and a discussion group with community health workers, to guide intervention development. Qualitative data were combined with behavioral constructs and principles of diabetes self-management to create a peer support intervention to be delivered by trained peer advisors. Feedback from a 1-month pilot was used to modify the training and intervention. Results The resulting intervention includes a 2-day training for peer advisors, who were each paired with 3 to 6 clients. A one-on-one in-person needs assessment begins an intensive intervention phase conducted via telephone for 8 to 12 weeks, followed by a maintenance phase of at least once monthly contacts for the remainder of the intervention period. A peer support network and process measures collected monthly throughout the study supplement formal data collection points at baseline, 6 months, and 12 months. Discussion Intervention mapping provided a useful framework for the development of culturally relevant diabetes peer support intervention for African Americans living in Alabama's Black Belt. The process described could be implemented by others in public health to develop or adapt programs suitable for their particular community or context.

The authors estimated the validity of algorithms for identification of mental health conditions (MHCs) in administrative data for the 133 068 diabetic patients who used Veterans Health Administration (VHA) nationally in 1998 and responded to the 1999 Large Health Survey of Veteran Enrollees. They compared various algorithms for identification of MHCs from International Classification of Diseases, 9th Revision (ICD-9) codes with self-reported depression, posttraumatic stress disorder, or schizophrenia from the survey. Positive predictive value (PPV) and negative predictive value (NPV) for identification of MHC varied by algorithm (0.65-0.86, 0.68-0.77, respectively). PPV was optimized by requiring > or =2 instances of MHC ICD-9 codes or by only accepting codes from mental health visits. NPV was optimized by supplementing VHA data with Medicare data. Findings inform efforts to identify MHC in quality improvement programs that assess health care disparities. When using administrative data in mental health studies, researchers should consider the nature of their research question in choosing algorithms for MHC identification.

Background International guidelines recommend that the decision threshold for troponin should be the 99th percentile of a normal population, or, if the laboratory assay is not sufficiently precise at this low level, the level at which the assay achieves a 10% or better coefficient of variation (CV). Our objectives were to examine US hospital laboratory troponin reports to determine whether either the 99th percentile or the 10% CV level were clearly indicated, and whether nonconcordance with these guidelines was a potential barrier to detecting clinically important microscopic or ‘microsize’ myocardial infarctions (MIs). To confirm past reports of the clinical importance of microsize MIs, we also contrasted in-hospital, 28-day and 1-year mortality among those with microsize and nonmicrosize MI. Methods In the REasons for Geographic And Racial Differences in Stroke national prospective cohort study (n=30,239), 1029 participants were hospitalized for acute coronary syndrome (ACS) between 2003–2009. For each case, we recorded all thresholds of abnormal troponin on the laboratory report and whether the 99th percentile or 10% CV value were clearly identified. All cases were expert adjudicated for presence of MI. Peak troponin values were used to classify MIs as microsize MI (< five times the lowest listed upper limit of normal) and nonmicrosize MI. Results Participants were hospitalized at 649 acute care US hospitals, only 2% of whose lab reports clearly identified the 99th percentile or the 10% CV level; 52% of reports indicated an indeterminate range, a practice that is no longer recommended. There were 183 microsize MIs and 353 nonmicrosize MIs. In-hospital mortality tended to be lower in the microsize than in the nonmicrosize MI group (1.1 vs. 3.6%, p = 0.09), but 28-day and 1-year mortality were similar (2.5% vs. 2.7% [p = 0.93] and 5.2% vs. 4.3% [p = 0.64], respectively). Conclusions Current practices in many US hospitals created barriers to the clinical recognition of microsize MI, which was common and clinically important in our study. Improved hospital troponin reporting is warranted.

Abstract 3155 Background: With improvements in care in the pediatric age group, most patients with sickle cell disease (SCD) live to adulthood. Though life expectancy is increasing, there is evidence that patients experience increasing mortality at the time of transition from pediatric to adult care. As care of adult patients is beyond the scope of pediatrics, transition to adult providers becomes a necessary part of comprehensive care for youths with SCD. When present, transition programs often focus on development of self management skills, improving health literacy, and other life skills beyond simply identifying and transferring to an adult provider. Most studies of pediatric patients with SCD and other chronic illnesses have focused on the concerns of patients prior to transition, but few have examined the experience of patients who have entered adult care. Using semi-structured interviews, our study examined adult SCD patients' transition experiences and difficulties faced in adult care that may contribute to the increased mortality during this time. Methods: Participants seen at the UAB Sickle Cell Clinic were recruited to participate in a semi-structured interview. To elicit the broadest experiences of adult care, we did not restrict the interviews to young adults, but recruited any interested participant with SCD >18 years old. The interview consisted of open ended questions with additional prompts regarding specific barriers found in the literature. One author (CB) performed all interviews, either in the UAB Sickle Cell Clinic or by telephone. Interviews continued until data saturation was achieved. All interviews were audio recorded and transcribed, then analyzed in three stages. First, transcripts were reviewed and coded independently by two authors (CB and JL). Second, the authors met to reconcile code definitions and agree on an overall coding scheme, which was based both on a priori themes from previous studies as well as inductive codes noted during analysis. Finally, the authors re-coded the transcripts based on the agreed upon coding scheme and reconciled differences. Results: Interviews were completed with 10 participants aged 24–55 years old. All patients had medical insurance, with 9 on disability. Transition topics discussed included timing of and preparation for transfer, development of independence, feelings about and experiences in pediatric and adult care. We confirmed that adults with SCD experienced many of the concerns noted in previous studies of pre-transition adolescents. Participants experienced distrust from adult physicians, mostly regarding pain. Though all participants feel that as adults, they successfully transitioned to independence in care for their disease, a number of them continue to regularly consult their parents regarding their care and/or live with their parents. Participants confirmed that a number of physicians they encountered were not familiar with sickle cell care and were concerned that the care they received from non-hematologists was inappropriate. None of the participants received formal preparation for transfer, though half were referred directly to an adult hematologist from pediatric care. Participants noted poor coordination of care between primary care physicians and hematologists, and difficulty identifying physicians willing to care for them. Those who had spent time in the work force noted difficulty maintaining employment. Conclusions: We found that concerns expressed by adolescents prior to transition in previous studies were well-founded and experienced in adulthood by a number of participants. Many patients feel poorly treated and have found few adult providers familiar with SCD. Since this study included patients engaged in a specialized sickle cell clinic, selection bias is a limitation. Though skills taught in many transition programs may help to overcome these barriers, systemic changes must also take place to address these external issues reported by patients who have transitioned to adult care. Disclosures: No relevant conflicts of interest to declare.

Background Multiple uncontrolled medical conditions may act as competing demands for clinical decision making. We hypothesized that multiple uncontrolled cardiovascular risk factors would decrease blood pressure (BP) medication intensification among uncontrolled hypertensive patients. Methods We observed 946 encounters at two VA primary care clinics from May through August 2006. After each encounter, clinicians recorded BP medication intensification (BP medication was added or titrated). Demographic, clinical, and laboratory information were collected from the medical record. We examined BP medication intensification by presence and control of diabetes and/or hyperlipidemia. 'Uncontrolled' was defined as hemoglobin A1c ≥ for diabetes, BP ≥ 140/90 mmHg (≥ 130/80 mmHg if diabetes present) for hypertension, and low density lipoprotein cholesterol (LDL-c) ≥ 130 mg/dl (≥ 100 mg/dl if diabetes present) for hyperlipidemia. Hierarchical regression models accounted for patient clustering and adjusted medication intensification for age, systolic BP, and number of medications. Results Among 387 patients with uncontrolled hypertension, 51.4% had diabetes (25.3% were uncontrolled) and 73.4% had hyperlipidemia (22.7% were uncontrolled). The BP medication intensification rate was 34.9% overall, but higher in individuals with uncontrolled diabetes and uncontrolled hyperlipidemia: 52.8% overall and 70.6% if systolic BP ≥ 10 mmHg above goal. Intensification rates were lowest if diabetes or hyperlipidemia were controlled, lower than if diabetes or hyperlipidemia were not present. Multivariable adjustment yielded similar results. Conclusions The presence of uncontrolled diabetes and hyperlipidemia was associated with more guideline-concordant hypertension care, particularly if BP was far from goal. Efforts to understand and improve BP medication intensification in patients with controlled diabetes and/or hyperlipidemia are warranted.

Background Emerging evidence indicates that patients with mental health conditions (MHCs) may receive less intensive medical care. Diabetes serves as a useful condition in which to test for MHC-related disparities in care. We examined whether quality measures for diabetes care are worse for patients with or without MHCs. Methods This national, cross-sectional study included 313 586 noninstitutionalized Veterans Health Administration patients with diabetes (identified from diagnostic codes and prescriptions) whose Veterans Health Administration facility transmitted laboratory data to a central database; 76 799 (25%) had MHCs (based on diagnostic codes for depressed mood, anxiety, psychosis, manic symptoms, substance use disorders, personality disorders, and other categories). National data from Veterans Health Administration records, Medicare claims, and a national survey were linked to characterize 1999 diabetes care. Results Failure to meet diabetes performance measures was more common in patients with MHCs: unadjusted odds ratio (95% confidence interval) was 1.24 (1.22-1.27) for no hemoglobin A 1c testing, 1.25 (1.23-1.28) for no low-density lipoprotein cholesterol testing, 1.05 (1.03-1.07) for no eye examination, 1.32 (1.30-1.35) for poor glycemic control, and 1.17 (1.15-1.20) for poor lipemic control. Disparities persisted after case mix adjustment and were more pronounced with specific MHCs (psychotic, manic, substance use, and personality disorders). The percentage not meeting diabetes care standards increased with increasing number of MHCs. Conclusion Patients with mental illness merit special attention in national diabetes quality improvement efforts.

Introduction Homelessness can limit access to preventive medical care, especially for the homeless with chronic disease. Although national data describe reduced access to a regular source of care among homeless individuals generally, no studies compare utilization for homeless and housed outpatients in systems that serve both groups. Many veterans are homeless. We used Veterans Health Administration (VHA) data to compare outpatient utilization for homeless and housed veterans with diabetes. Methods Using a 5% random sample of the national VHA outpatient database (FY2003), we identified 35,721 patients with diabetes-related diagnostic codes for two or more encounters. Utilization indicators were proportions of patients visiting each of the following clinic types: primary care with a diabetes diagnostic code (≥ 4 visits/year), diabetes/endocrinology (≥ 1), eye(≥ 1), and podiatry/foot-care (≥ 1). Separate logistic regressions modeled factors associated with failure to achieve each utilization indicator, including age, race, mental illness, alcohol and drug abuse as predictors. Results Homeless persons were 1.2% (n = 417) of the sample. The percentages of homeless versus housed failing to achieve each utilization indicator were primary care (72% vs. 79%, p Conclusions Many veterans with diabetes did not utilize important VHA outpatient services at recommended levels. Unexpectedly, veterans who were homeless, abused alcohol or had recognized mental illness utilized these outpatient services equally or slightly more than otherwise similar diabetic veterans. Only homeless diabetic veterans with recognized drug abuse were prone to underutilize diabetes-related primary care services. In this outpatient sample, homeless veterans with diabetes demonstrated remarkably similar access to VHA care as those who were housed.