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Employing an ecological approach, we sought to identify social determinants of obesity among Hispanics/Latinos and non-Hispanic whites living in the Southeast US. Data on social determinants of obesity (individual, family, community and cultural/contextual) were collected from 217 participants [106 Hispanics/Latinos; 111 non-Hispanic whites]; height and weight were objectively measured. We compared prevalence of overweight and obese between ethnic groups and BMI values within each group by social determinants. Hispanics had a 1.9-fold increase (OR 1.93, 95% CI: 1.05-3.55) in overweight prevalence compared to non-Hispanic whites after adjusting for age and gender. We found positive estimates between unfavorable family-level determinants and BMI among Hispanic/Latinos. In contrast, non-Hispanic whites who reported unfavorable neighborhood characteristics had higher BMI's. Findings highlight the need for targeted approaches for the prevention and control of obesity.

Diabetes self-management education and support enhance self-efficacy and promote self-management behaviors essential for diabetes management. We investigated the mediating effect of self-efficacy on the association between diabetes education or care coordination and self-care activities. We surveyed a population-based sample of adults with type 2 diabetes (19–64 years of age) covered by Alabama Medicaid. We examined whether receipt of diabetes education or care coordination were associated with improvements in diabetes self-care activities. We then examined if improvements were mediated by self-efficacy. Models were adjusted for age, gender, race, education, insulin use, diabetes duration, and depressive symptoms. Results A total of 1,318 participants were included in the study (mean age = 52.9 years, SD = 9.6; 72.5% female, 56.4% Black, 3.1% Hispanic). Diabetes education was associated with increases in self-care activity scores related to general diet, physical activity, glucose self-monitoring, and foot care; care coordination was associated with glucose self-monitoring. In addition, mediation analysis models confirmed that improvements in self-efficacy led to improved self-care activities scores, mediating the association of diabetes education and self-care activities. Conclusions Diabetes education and self-efficacy were associated with better self-care. Receiving diabetes education led to a higher likelihood of engaging in self-care activities, driven in part by increases in self-efficacy. Future interventions that aim to improve diabetes self-management behaviors can benefit from targeting self-efficacy constructs and from the integration of diabetes education in the care coordination structure.

Background: Cost-related medication nonadherence (CRMN) occurs when an individual takes less medication than what is prescribed due to difficulty affording their medications. In adults with diabetes, medication nonadherence is associated with worse glycemic control and increased healthcare costs. The goal of this study was to determine what proportion of Alabama’s Medicaid population with diabetes experiences CRMN and to evaluate for potential risk factors for CRMN in this financially-at-risk population. Methods: We conducted a cross-sectional study surveying a population-based sample of adults (ages 19-64) with diabetes covered by Alabama Medicaid. We classified participants as experiencing CRMN if they responded yes to “Not including over the counter medications, was there a time in the past 12 months when you didn't take your medication as prescribed because of cost?” Using multivariable logistic regression, we examined what variables were associated with CRMN adjusting for demographic and clinical factors (insulin use, diabetes duration, receipt of care coordination, and self-rated health) . Results: We included 1893 of 2235 (84.7%) participants who completed the survey and had complete data for the variables of interest in the analysis. This sample was predominantly nonwhite (60.7%) , female (73.9%) with a mean age of 52 ±10.1 years. Overall, 23.7% of participants reported CRMN. In the fully adjusted model, insulin use (OR 1.41, 95% CI 1.11, 1.79) , use of a discount prescription plan (OR 1.55, 95% CI 1.20, 2.00) , and self-report of poor health (OR 1.67, 95% CI 1.33, 2.09) were significantly associated with CRMN. Conclusion: We found that almost a quarter of a population-based sample of adults with diabetes covered by Alabama Medicaid experienced cost-related medication nonadherence. More research is needed to determine how to address this among this vulnerable population. Disclosure E.C.Ness: None. L.Juarez: None. C.R.Howell: None. L.Hohmann: None. A.Cherrington: Consultant; Bayer AG, Other Relationship; Novo Nordisk. C.A.Presley: None. Funding National Institute of Diabetes and Digestive and Kidney Diseases (R18DK109501) UAB Diabetes Research Center (P30 DK079626)

BACKGROUND Differences in socioenvironmental exposures influence overall child health, but their association with pediatric cystic fibrosis (CF) outcomes is less clear. This observational study investigated the relationship between area-level socioeconomic deprivation, state child health, and CF respiratory outcomes in a national cohort. METHODS We assessed relationships between the 2015 area deprivation index, a composite measure of socioeconomic disadvantage; the 2016 child health index, a state-specific measure of overall child health; and CF respiratory outcomes in the 2016 CF Foundation Patient Registry. RESULTS The sample included 9934 individuals with CF, aged 6-18 years. In multiple regression analysis adjusted for demographic and clinical covariates, those residing in the worst tertile for area deprivation had 2.8% lower percent predicted forced expiratory volume in 1 s (ppFEV1 ; 95% confidence interval [CI]: -4.1 to -1.5), 1.2 more intravenous (IV) treatment nights (CI: 0.1-2.4), and 20% higher odds of ≥2 pulmonary exacerbations (odds ratio [OR]: 1.2, CI: 1.0-1.5) than best-tertile counterparts. Children with CF in states at the worst tertile for child health had 2.3% lower ppFEV1 (CI: -4.5 to -0.2), 2.2 more IV treatment nights (CI: 0.5-3.6), and 40% higher odds of ≥2 exacerbations (OR: 1.4, CI: 1.1-1.8) than best-tertile counterparts. State child health accounted for the association between area deprivation and multiple exacerbations and more IV treatment nights. CONCLUSIONS Both area socioeconomic characteristics and state child health play a role in pediatric CF outcomes. The residual association of the state child health with CF outcomes after controlling for area deprivation reflects the ability of state programs to mitigate the effect of poverty.

Objectives: Nonadherence to medications has been documented, but the combined effect of social risk factors on medication nonadherence has not been investigated. Methods: We conducted a cross-sectional analysis of data from the Coronary Artery Risk Development in Young Adults (CARDIA) study, a population-based prospective cohort. The sample (N = 1506) included subjects who at Year 20 (2005-06) were taking prescription medications and completed a 4-item Medication Adherence Scale. Social risk factors were education of high school or less, annual household income Results: In a fully adjusted logistic regression model, income 3 times higher odds of nonadherence than counterparts with no social risk factors (OR = 3.26 [95% CI 1.72–6.19], p < .001). Conclusion: Low income and chronic stress are associated with medication nonadherence, and the odds of nonadherence increase with the accumulation of social risk factors. Findings may be used to develop risk prediction tools to identify individuals who can benefit from adherence-promoting interventions.

BACKGROUND: Real or perceived discrimination contributes to lower quality of care for Black compared to white patients. Some forms of discrimination come from non-physician and non-nursing (non-MD/RN) staff members (e.g., receptionists). METHODS: Utilizing the Burgess Model as a framework for racial bias intervention development, we developed an online intervention with five, 30-min modules: (1) history and effects of discrimination and racial disparities in healthcare, (2) implicit bias and how it may influence interactions with patients, (3) strategies to handle stress at work, (4) strategies to improve communication and interactions with patients, and (5) personal biases. Modules were designed to increase understanding of bias, enhance internal motivation to overcome bias, enhance emotional regulation skills, and increase empathy in patient interactions. Participants were non-MD/RN staff in nine primary care clinics. Effectiveness of the intervention was assessed using Implicit Association Test and Symbolic Racism Scale, to measure implicit and explicit racial bias, respectively, before and after the intervention. Acceptability was assessed through quantitative and qualitative feedback. RESULTS: Fifty-eight non-MD/RN staff enrolled. Out of these, 24 completed pre- and post-intervention assessments and were included. Among participants who reported characteristics, most were Black, with less than college education and average age of 43.2 years. The baseline implicit bias d-score was 0.22, indicating slight pro-white bias. After the intervention, the implicit bias score decreased to −0.06 (p=0.01), a neutral score indicating no pro-white or Black bias. Participant rating of the intervention, scored from 1 (strongly disagree) to 5 (strongly agree), for questions including whether “it was made clear how to apply the presented content in practice” and “this module was worth the time spent” was ≥4.1 for all modules. CONCLUSIONS: There was a decrease in implicit pro-white bias after, compared with before, the intervention. Intervention materials were highly rated. SUPPLEMENTARY INFORMATION: The online version contains supplementary material available at 10.1007/s11606-022-07464-x.

OBJECTIVE: To examine health care costs in diverse older Medicare beneficiaries with epilepsy. METHODS: Using 2008–2010 claims data, we conducted a longitudinal cohort study of a random sample of Medicare beneficiaries augmented for minority representation. Epilepsy cases (n = 36 912) had ≥1 International Classification of Diseases, Ninth Edition (ICD-9) 345.x or ≥2 ICD-9 780.3x claims, and ≥1 antiepileptic drug (AED) in 2009; new cases (n = 3706) had no seizure/epilepsy claims nor AEDs in the previous 365 days. Costs were measured by reimbursements for all care received. High cost was defined as follow-up 1-year cost ≥ 75th percentile. Logistic regressions examined association of high cost with race/ethnicity, adjusting for demographic, clinical, economic, and treatment quality factors. In cases with continuous 2-year data, we obtained costs in two 6-month periods before and two after the index event. RESULTS: Cohort was ~62% African Americans (AAs), 11% Hispanics, 5% Asians, and 2% American Indian/Alaska Natives. Mean costs in the follow-up were ~$30 000 (median = $11 547; new cases, mean = $44 642; median = $25 008). About 19% white compared to 27% AA cases had high cost. AA had higher odds of high cost in adjusted analyses (odds ratio [OR] = 1.20, 95% confidence interval [CI] = 1.11–1.29), although this was only marginally significant when adjusting for AED adherence (OR = 1.09, 95% CI = 1.01–1.18, P = 0.03). Factors associated with high cost included ≥1 comorbidity, neurological care, and low AED adherence. Costs were highest at ~$17 000 in the 6 months immediately before and after the index event (>$29 000 for new cases). SIGNIFICANCE: The financial sequelae of epilepsy among older Americans disproportionally affect minorities. Studies should examine contributors to high costs.

Aims Diabetes distress affects approximately 36% of adults with diabetes and is associated with worse diabetes self-management and poor glycaemic control. We characterized participants' diabetes distress and studied the relationship between social support and diabetes distress. Methods In this cross-sectional study, we surveyed a population-based sample of adults with type 2 diabetes covered by Alabama Medicaid. We used the Diabetes Distress Scale assessing emotional burden, physician-related, regimen-related and interpersonal distress. We assessed participants' level of diabetes-specific social support and satisfaction with this support, categorized as low or moderate-high. We performed multivariable logistic regression of diabetes distress by level of and satisfaction with social support, adjusting for demographics, disease severity, self-efficacy and depressive symptoms. Results In all, 1147 individuals participated; 73% were women, 41% White, 58% Black and 3% Hispanic. Low level of or satisfaction with social support was reported by 11% of participants; 7% of participants had severe diabetes distress. Participants with low satisfaction with social support were statistically significantly more likely to have severe diabetes distress than those with moderate-high satisfaction, adjusted odds ratio 2.43 (95% CI 1.30, 4.54). Conclusions Interventions addressing diabetes distress in adults with type 2 diabetes may benefit from a focus on improving diabetes-specific social support.

Genotype-phenotype association studies often combine phenotype data from multiple studies to increase statistical power. Harmonization of the data usually requires substantial effort due to heterogeneity in phenotype definitions, study design, data collection procedures, and data-set organization. Here we describe a centralized system for phenotype harmonization that includes input from phenotype domain and study experts, quality control, documentation, reproducible results, and data-sharing mechanisms. This system was developed for the National Heart, Lung, and Blood Institute’s Trans-Omics for Precision Medicine (TOPMed) program, which is generating genomic and other -omics data for more than 80 studies with extensive phenotype data. To date, 63 phenotypes have been harmonized across thousands of participants (recruited in 1948–2012) from up to 17 studies per phenotype. Here we discuss challenges in this undertaking and how they were addressed. The harmonized phenotype data and associated documentation have been submitted to National Institutes of Health data repositories for controlled access by the scientific community. We also provide materials to facilitate future harmonization efforts by the community, which include 1) the software code used to generate the 63 harmonized phenotypes, enabling others to reproduce, modify, or extend these harmonizations to additional studies, and 2) the results of labeling thousands of phenotype variables with controlled vocabulary terms.

Genotype-phenotype association studies often combine phenotype data from multiple studies to increase power. Harmonization of the data usually requires substantial effort due to heterogeneity in phenotype definitions, study design, data collection procedures, and data set organization. Here we describe a centralized system for phenotype harmonization that includes input from phenotype domain and study experts, quality control, documentation, reproducible results, and data sharing mechanisms. This system was developed for the National Heart, Lung and Blood Institute’s Trans-Omics for Precision Medicine (TOPMed) program, which is generating genomic and other omics data for >80 studies with extensive phenotype data. To date, 63 phenotypes have been harmonized across thousands of participants from up to 17 TOPMed studies per phenotype. We discuss the challenges faced in this undertaking and how they were addressed. The harmonized phenotype data and associated documentation have been submitted to National Institutes of Health data repositories for controlled-access by the scientific community. We also provide materials to facilitate future harmonization efforts by the community, which include (1) the code used to generate the 63 harmonized phenotypes, enabling others to reproduce, modify or extend these harmonizations to additional studies; and (2) results of labeling thousands of phenotype variables with controlled vocabulary terms.

Introduction Older minority groups are more likely to have poor AED adherence. We describe adherence to antiepileptic drugs (AEDs) among older Americans with epilepsy. Methods In retrospective analyses of 2008–2010 Medicare claims for a 5% random sample of beneficiaries augmented by minority representation, epilepsy cases in 2009 were those with ≥ 1 claim with ICD-9345.x or ≥ 2 with 780.3x, and ≥ 1 AED. New-onset cases had no such claims or AEDs in the year before the 2009 index event. We calculated the Proportion of Days Covered (PDC) (days with ≥ 1 AED over total follow-up days) and used logistic regression to estimate associations of non-adherence (PDC Results Of 36,912 epilepsy cases (19.2% White, 62.5% African American (AA), 11.3% Hispanic, 5.0% Asian and 2% American Indian/Alaskan Native), 31.8% were non-adherent (range: 24.1% Whites to 34.3% AAs). Of 3706 new-onset cases, 37% were non-adherent (range: 28.7% Whites to 40.5% AAs). In adjusted analyses, associations with minority group were significant among prevalent cases, and for AA and Asians vs. Whites among new cases. Among other findings, beneficiaries from high-poverty ZIP codes were more likely to be non-adherent than their counterparts, and those in cost-sharing drug benefit phases were less likely to be non-adherent than those in deductible phases. Conclusion About a third of older adults with epilepsy have poor AED adherence; minorities are more likely than Whites. Investigations of reasons for non-adherence, and interventions to promote adherence, are needed with particular attention to the effect of cost-sharing and poverty.

Bridges, railways stations, warehouses, bandstands, fountains, shop fronts, lamps, gates and other cast-iron elements can still be found throughout Argentina. Some of these elements are impressive, others humble; some are abandoned, others are still in use. Many are part of important monuments; others are so incorporated into the urban landscape that they almost go unnoticed. When one’s attention is drawn to these features, however, a company nameplate and place of origin—“London,” “Liverpool...

High-quality single phase p-type nanometric films of cuprous oxide with controllable properties were produced by thermal oxidation of copper thin films from 600 to 950°C in a nitrogen (N2) atmosphere with 5ppm of oxygen content at atmospheric pressure. The resistivity of films was of 300 Ω-cm for samples produced at high temperatures and decreased below of 80 Ω-cm for samples grown at lower temperatures. The minimum hole concentration was 8×1014 cm-3 for films grown at high temperatures and increased up to 8×1015 cm-3 for low temperatures, the corresponding Hall mobilities vary in the range of 20-45 cm2/V-s with the best values for samples grown at high temperatures. The observed electrical behavior is related to the structural lattice defects controlled mainly by the oxidation kinetics process under low oxygen atmosphere concentration conditions. When the oxidation temperature was decreased some traces of the cupric oxide phase was observed, the formation of this phase was apparent because of the characteristic reddish color of the Cu2O films changes to the blackish aspect for the tenorite phase. The Cu2O phase was assessed through the XRD and Raman characterization techniques. This work demonstrates that the thermal oxidation method produces Cu2O nanometric films with enough quality to be used in electronic device applications.

Objective To determine the frequency of older Americans with epilepsy receiving concomitant prescriptions for antiepileptic drugs (AEDs) and non-epilepsy drugs (NEDs) which could result in significant pharmacokinetic (PK) interaction, and to assess the contributions of racial/ethnic, socioeconomic, and demographic factors. Methods Retrospective analyses of 2008-2010 Medicare claims for a 5% random sample of beneficiaries ≥67 years old in 2009 augmented for minority representation. Prevalent cases had ≥1 ICD-9 345.x or ≥2 ICD-9 780.3x, and ≥1 AED. Among them, incident cases had no seizure/epilepsy claim codes nor AEDs in preceding 365 days. Drug claims for AEDs, and for the 50 most common NEDs within +/- 60 days of the index epilepsy date were tabulated. Interacting pairs of AEDs/NEDs were identified by literature review. Logistic regression models were used to examine factors affecting the likelihood of interaction risk. Results Interacting drug pairs affecting NED efficacy were found in 24.5% of incident, 39% of prevalent cases. Combinations affecting AED efficacy were found in 20.4% of incident, 29.3% of prevalent cases. Factors predicting higher interaction risk included having ≥ 1 comorbidity, being eligible for Part D low Income Subsidy, and not living in the northeastern US. Protective factors were Asian race/ethnicity, and treatment by a neurologist. Significance A substantial portion of older epilepsy patients received NED-AED combinations that could cause important PK interactions. The lower frequency among incident vs. prevalent cases may reflect changes in prescribing practices. Avoidance of interacting AEDs is feasible for most persons because of the availability of newer drugs.

Aim Undiagnosed diabetes is more prevalent among racial/ethnic minorities in the United States (U.S.). Despite the proliferation of risk scores, few have been validated in Hispanics populations. The aim of this study is to systematically review published studies that developed risk scores to identify undiagnosed Type 2 Diabetes Mellitus based on self-reported information that were validated for Hispanics in the U.S. Methods The search included PubMed, EMBASE, Cochrane and CINAHL from inception to 2016 without language restrictions. Risk scores whose main outcome was undiagnosed Type 2 diabetes reporting performance measures for Hispanics were included. Results We identified three studies that developed and validated risk scores for undiagnosed diabetes based on questionnaire data. Two studies were conducted in Latin America and one in the U.S. All three studies reported adequate performance (area under the receiving curve (AUC) range between 0.68 and 0.78). The study conducted in the U.S. reported a higher sensitivity of their risk score for Hispanics than whites. The limited number of studies, small size and heterogeneity of the combined cohorts provide limited evidence of the validity of risk scores for Hispanics. Conclusions Efforts to develop and validate risk prediction models in Hispanic populations in the U.S are needed, particularly given the diversity of this fast growing population. Healthcare professionals should be aware of the limitations of applying risk scores developed for the general population on Hispanics.

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.

Background Enzyme-inducing antiepileptic drugs (EI-AEDs) are not recommended for older adults with epilepsy. Quality Indicator for Epilepsy Treatment 9 (QUIET-9) states that new patients should not receive EI-AEDs as first line of treatment. In light of reported racial/ethnic disparities in epilepsy care, we investigated EI-AED use and QUIET-9 concordance across major racial/ethnic groups of Medicare beneficiaries. Research design Retrospective analyses of 2008-2010 Medicare claims for a 5% random sample of beneficiaries 67 years old and above in 2009 augmented for minority representation. Logistic regressions examined QUIET-9 concordance differences by race/ethnicity adjusting for individual, socioeconomic, and geography factors. Subjects Epilepsy prevalent (≥1 International Classification of Disease-version 9 code 345.x or ≥2 International Classification of Disease-version 9 code 780.3x, ≥1 AED), and new (same as prevalent+no seizure/epilepsy events nor AEDs in 365 d before index event) cases. Measures Use of EI-AEDs and QUIET-9 concordance (no EI-AEDs for the first 2 AEDs). Results Cases were 21% white, 58% African American, 12% Hispanic, 6% Asian, 2% American Indian/Alaskan Native. About 65% of prevalent, 43.6% of new cases, used EI-AEDs. QUIET-9 concordance was found for 71% Asian, 65% white, 61% Hispanic, 57% African American, 55% American Indian/Alaskan new cases: racial/ethnic differences were not significant in adjusted model. Beneficiaries without neurology care, in deductible drug benefit phase, or in high poverty areas were less likely to have QUIET-9 concordant care. Conclusions EI-AED use is high, and concordance with recommendations low, among all racial/ethnic groups of older adults with epilepsy. Potential socioeconomic disparities and drug coverage plans may affect treatment quality and opportunities to live well with epilepsy.

SummaryObjective Disparities in epilepsy treatment are not uncommon; therefore, we examined population-based estimates of initial antiepileptic drugs (AEDs) in new-onset epilepsy among racial/ethnic minority groups of older US Medicare beneficiaries. Methods We conducted retrospective analyses of 2008–2010 Medicare administrative claims for a 5% random sample of beneficiaries augmented for minority representation. New-onset epilepsy cases in 2009 had ≥1 International Classification of Diseases, Ninth Revision (ICD-9) 345.x or ≥2 ICD-9 780.3x, and ≥1 AED, AND no seizure/epilepsy claim codes or AEDs in preceding 365 days. We examined AED use and concordance with Quality Indicators of Epilepsy Treatment (QUIET) 6 (monotherapy as initial treatment = ≥30 day first prescription with no other concomitant AEDs), and prompt AED treatment (first AED within 30 days of diagnosis). Logistic regression examined likelihood of prompt treatment by demographic (race/ethnicity, gender, age), clinical (number of comorbid conditions, neurology care, index event occurring in the emergency room (ER)), and economic (Part D coverage phase, eligibility for Part D Low Income Subsidy [LIS], and ZIP code level poverty) factors. Results Over 1 year of follow-up, 79.6% of 3,706 new epilepsy cases had one AED only (77.89% of whites vs. 89% of American Indian/Alaska Native [AI/AN]). Levetiracetam was the most commonly prescribed AED (45.5%: from 24.6% AI/AN to 55.0% whites). The second most common was phenytoin (30.6%: from 18.8% Asians to 43.1% AI/AN). QUIET 6 concordance was 94.7% (93.9% for whites to 97.3% of AI/AN). Only 50% received prompt AED therapy (49.6% whites to 53.9% AI/AN). Race/ethnicity was not significantly associated with AED patterns, monotherapy use, or prompt treatment. Significance Monotherapy is common across all racial/ethnic groups of older adults with new-onset epilepsy, older AEDs are commonly prescribed, and treatment is frequently delayed. Further studies on reasons for treatment delays are warranted. Interventions should be developed and tested to develop paradigms that lead to better care.

In this study, we examined the provision of care to older adults with epilepsy and compliance with the “Quality Indicator for Epilepsy Treatment 15” (QUIET-15) measure. We analyzed 2008–2010, 5% random sample of Medicare beneficiaries augmented with data from all beneficiaries who identified as a minority with claims related to seizures (780.3x) or epilepsy (345.xx). Of 36,912 identified epilepsy cases, 12.6% had ≥ 1 emergency room (ER) visit for seizure(s). For those who presented to ER, among those taking anti-epileptic drugs (AEDs), AED was changed in 15.4%, dose adjusted in 19.7%, and stopped in 14.9%; among those not taking AED, therapy was initiated in 68.5%. In adjusted logistic regressions, African–Americans were more likely to have recurrent seizures than Whites (OR 1.41, 95%CI 1.27–1.56), while Asians were less likely to have recurrent seizures (OR 0.71, 95%CI 0.57–0.89). There were no significant racial/ethnic differences in the likelihood of a post-seizure intervention. The chance of seizure recurrence leading to ER visit decreased with age and increased with the number of comorbidities. Patients with seizure recurrence were more likely to be taking an enzyme-inducing AED (OR 1.69, 95%CI 1.57–1.82) and receiving Part D Low Income Subsidy (OR 1.36, 95%CI 1.22–1.51). The probability of AED change after a seizure was higher for patients with ≥ 4 comorbidities (OR 1.69, 95%CI 1.25–2.27), patients who saw a neurologist (OR 1.49, 95%CI 1.30–1.70), and patients who were taking an enzyme-inducing AED (OR 1.47, 95%CI 1.27–1.71). Overall, a minority of Medicare beneficiaries experienced seizure recurrence that resulted in an ER visit. However, only half of them received treatment concordant with QUIET-15. Though racial differences were observed in occurrence of seizures, none were noted in the provision of care.

Objective Arthritis is the most common chronic condition and the most common cause of disability among older US adults. We studied social participation, disabilities in many life domains, accommodations used (buffers), and accommodations needed (barriers) for US adults with arthritis disability compared with adults with disability from other conditions. Methods The data source is the National Health Interview Survey Disability Supplement Phase Two. Arthritis-disabled individuals named arthritis as the main cause of ≥1 disabilities. Other-disabled individuals named only other conditions as causes of their disabilities. We compared outcomes for the groups, taking sample weights and complex variances into account. Results Arthritis-disabled individuals get out and about less often than other-disabled individuals, but they manage to maintain active social ties. They have more disabilities of all types (personal care, household management, physical tasks, transportation, home, work), and the disabilities often cause fatigue, long task time, and pain. Despite this, arthritis-disabled individuals use less personal assistance than other-disabled individuals; they do use more equipment assistance. Arthritis-disabled individuals report more barriers in getting around outside their home and at their workplace. Conclusion The distinctive profile of arthritis disability includes extensive and uncomfortable disabilities, yet there are active management strategies to handle these disabilities. Problems away from home and at work should inspire engineers and planners to improve public access and equipment for persons with this high-prevalence disability.

We examined diffusion of troponin testing in Medicare patients with unstable angina before the release of year 2000 American College of Cardiology/American Heart Association guidelines recommending measurement in all patients with acute coronary syndromes.We identified unstable angina admissions from Medicare administrative files for 22 Alabama hospitals over two time periods: 03/1997-02/1998 and 01/99-12/1999. Data were obtained from chart abstraction. Patients not confirmed for unstable angina by a clinical algorithm were eliminated.For 1997-1998, 1116 (87.7%) of all identified cases were clinically confirmed for unstable angina, and 1176 (90.3%) were confirmed for 1999. In 1997-1998, 235 (21%) of unstable angina patients had troponin measured, compared to 822 (70%) in 1999. From 1999, patients with troponin measurement, vs. those without, more likely had typical angina (50.9%, 37.4%), chest pain on arrival (72.8%, 57.1%), and chest pain at rest (45.4%, 37.2%) and more often received EKG within 20 min of presentation (46.3%, 27.9%) (P.0005 for all). Patients with abnormal troponin levels more often received angiotensin converting enzyme inhibitors (54.6%, 18.3%), cardiac catheterization (45.4%, 31.2%), and percutaneous coronary intervention (18.6%, 4.8%) (P.05 for all). These associations remained significant after multivariable adjustment for patient and hospital characteristics.This study demonstrates increasing and appropriate use of troponin before guideline release. Our findings suggest that guidelines may codify currently accepted practice rather than always disseminate new knowledge. The same forces that lead to guideline development and release may also lead to changes in clinical practice before guideline release.

This study examines the gender-specific contextual and individual socioeconomic predictors of the timing of first intercourse among low-achieving African American youth. Following financial deprivation and collective socialization theories, the authors test separate models for males and females and include neighborhood poverty and race composition, family social class position, and social control mechanisms such as family structure, parental involvement, and prosocial activities as predictors. The sample comprises 558 African American high school students followed over a 3-year period. For young women, the significant predictors are age, mother's education, time with mother, and involvement in church activities. For young men, the significant factors are school achievement, an interaction between living in an two-parent family and time with father, participation in family decision making, and neighborhood poverty level. Thus, males and females are differently affected by social control processes and neighborhood poverty plays a significant role in young African American men's sexual behaviors.

Using the 1994–95 National Health Interview Supplement Disability Supplement, the authors study levels of disabilities and accommodations among US adults with arthritis disability, compared to people with disability due to other conditions. Arthritis-disabled people are defined in two ways. One definition covers a broad range of arthritis and rheumatic conditions, and the other concentrates solely on arthritis. The authors find that arthritis-disabled people have more total disabilities than other-disabled people. However, their disabilities are less severe, have shorter durations, and accumulate more gradually over time. Despite more disabilities, people with arthritis disability use fewer assistive and service accommodations than other-disabled people. They do use more mobility aids. Because arthritis is the leading chronic condition for middle-aged and older adults, this profile of extensive but mild-to-moderate disability is experienced by many millions of adults. Accommodations for arthritis may also be extensive but aimed more toward self-care than toward assistive and medical services.

Objective: To assess associations between race/ethnicity and medication adherence, and the potential modifying effects of weight category (normal, overweight, obese) in a community-based sample. Study design and setting: We studied 1355 participants from the CARDIA (Coronary Artery Risk Development in Young Adults) study who were taking prescription medications in 2000-1. Medication adherence, as rated on the four-item Morisky medication adherence scale (score of 4 = maximum adherence), was reported for all participants. Results: The mean age ± SD of participants was 40 ± 3.6 years; 45% were African American and 36% were male. Overall, Whites had a higher proportion of maximum adherence than African Americans (59 vs 41%, respectively; p = 0.001). However, this difference was statistically significant only for participants within the normal weight category, of whom 54% of Whites were maximally adherent versus 35% of African Americans (p < 0.05). After adjustment for possible confounding covariates, race/ethnicity was associated with adherence only in those of normal weight: the odds ratio for maximum adherence in Whites versus African Americans of normal weight was 1.98 (95% CI 1.13, 3.47). Within race/ethnicity subgroups, weight category was associated with adherence in Whites but not in African Americans. Conclusion: Weight category modifies the association of race/ethnicity with medication adherence. The high levels of non-adherence observed among African Americans and obese and overweight Whites bodes poorly for treatment of obesity-associated diseases such as cardiovascular disease or diabetes mellitus.

To determine whether audit/feedback and educational materials improve adherence to recommendations for laboratory monitoring and cytoprotective agents to detect and prevent adverse events caused by nonsteroidal anti-inflammatory agents (NSAIDs).Controlled, cluster-randomized trial.Physicians commonly prescribing NSAIDs were identified within a large managed care organization and randomized to a control or an intervention group (audit/feedback with peer-derived benchmarks and continuing medical education). Medical records were examined 10 months before and after the intervention for clinical data and receipt of complete blood count (CBC), creatinine testing, and cytoprotective agents (process measures). Primary analysis compared intervention versus control physicians among those who initially performed below a peer-derived benchmark. General estimating equations accounted for patient clustering.Of 101 physicians initially randomized, 85 remained eligible (38 internists, 36 family physicians, 11 rheumatologists) postintervention. Mean percent change in performance between intervention and control physicians for CBC monitoring was 16% versus 10%; for creatinine monitoring, 0% versus 17%; and use of cytoprotective agents, -3% versus -1%. None of these changes were significant. Rheumatology specialty, number of NSAID prescriptions and physician visits, and patient risk factors for NSAID-related toxicity were more strongly associated with improved safety practices than the intervention.Audit/feedback and educational materials had no observed effect on improving NSAID-related safety practices. Potentially contributing factors include high baseline performance (ceiling effect), dilution of the intervention effect by case mix and provider factors, nonreceipt of intervention materials, and diverse indications for lab tests.

Severity and timing are key aspects of disability experience for individuals. They also generate a population's disability structure (prevalence, counts, patterns). We study links among severity, duration, and structure for community-dwelling adults in the US.The data source is the National Health Interview Survey Disability Supplement. Disabilities in personal care (ADL), household management (IADL), and physical functions (PLIM) are analyzed.Many combinations of disabilities are possible, but just a few are frequent; the top-10 patterns cover 70% of ADL, 89% of IADL, and 47% of PLIM disabled adults. Hierarchical patterns are common for ADLs and IADLs. People with many disabilities also have more-severe ones, and their disabilities often started at the same time.Disability structure reflects severity and timing of specific disabilities, sometimes strongly, and other times weakly due to exit processes from the community. Assumptions that disability occurs in "hard" tasks first and "easy" ones last, and that hard-and-early connotes mild disability whereas easy-and-late connotes severe, need direct empirical testing.

Objective To examine the effects of physician specialty and comorbidities on cyclooxygenase 2–selective nonsteroidal antiinflammatory drugs (NSAIDs; coxibs) utilization. Methods Medical records of 452 patients from a regional managed care organization with ≥3 consecutive NSAID prescriptions from June 1998 to April 2001 were abstracted. Multivariable adjusted associations between coxib initiation and discontinuation and patient and provider characteristics were examined. Results A total of 1,142 NSAID prescriptions were written over 9,398 total patient-months of followup. Compared with patients seeing family or general practitioners, patients seeing rheumatologists (odds ratio [OR] 3.4, 95% confidence interval [95% CI] 2.1–5.7) and internists (OR 2.3, 95% CI 1.5–3.6) were significantly more likely to receive a coxib, as well as patients with a history of osteoarthritis (OR 2.6, 95% CI 1.7–3.8), gastrointestinal disease (OR 2.3, 95% CI 1.2–4.5), and congestive heart failure (OR 4.1, 95% CI 1.0–16.4). Although specialists were more likely than generalists to prescribe coxibs, only family or general practitioners were significantly more likely to selectively use coxibs among their patients with a history of gastrointestinal disease. Fifty-four percent of NSAID prescriptions were discontinued, and coxibs were significantly less likely to be discontinued than were traditional NSAIDs (OR 0.6, 95% CI 0.5–0.8). Conclusion Our findings suggest significantly greater, but perhaps less selective use of coxibs among specialists, even after accounting for important covariates. The initiation and discontinuation of coxibs was influenced by physician specialty and by patient risk factors.