Leonard E Egede

Medical University of South Carolina, Charleston, South Carolina, United States

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Publications (182)599.2 Total impact

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    ABSTRACT: Many older adults with major depression, particularly veterans, do not have access to evidence-based psychotherapy. Telemedicine could increase access to best-practice care for older adults facing barriers of mobility, stigma, and geographical isolation. We aimed to establish non-inferiority of behavioural activation therapy for major depression delivered via telemedicine to same-room care in largely male, older adult veterans. In this randomised, controlled, open-label, non-inferiority trial, we recruited veterans (aged ≥58 years) meeting DSM-IV criteria for major depressive disorder from the Ralph H Johnson Veterans Affairs Medical Center and four associated community outpatient-based clinics in the USA. We excluded actively psychotic or demented people, those with both suicidal ideation and clear intent, and those with substance dependence. The study coordinator randomly assigned participants (1:1; block size 2-6; stratified by race; computer-generated randomisation sequence by RGK) to eight sessions of behavioural activation for depression either via telemedicine or in the same room. The primary outcome was treatment response according to the Geriatric Depression Scale (GDS) and Beck Depression Inventory (BDI; defined as a 50% reduction in symptoms from baseline at 12 months), and Structured Clinical Interview for DSM-IV, clinician version (defined as no longer being diagnosed with major depressive disorder at 12 months follow-up), in the per-protocol population (those who completed at least four treatment sessions and for whom all outcome measurements were done). Those assessing outcomes were masked. The non-inferiority margin was 15%. This trial is registered with ClinicalTrials.gov, number NCT00324701. Between April 1, 2007, and July 31, 2011, we screened 780 patients, and the study coordinator randomly assigned participants to either telemedicine (120 [50%]) or same-room treatment (121 [50%]). We included 100 (83%) patients in the per-protocol analysis in the telemedicine group and 104 (86%) in the same-room group. Treatment response according to GDS did not differ significantly between the telemedicine (22 [22·45%, 90% CI 15·52-29·38] patients) and same-room (21 [20·39%, 90% CI 13·86-26·92]) groups, with an absolute difference of 2·06% (90% CI -7·46 to 11·58). Response according to BDI also did not differ significantly (telemedicine 19 [24·05%, 90% CI 16·14-31·96] patients; same room 19 [23·17%, 90% CI 15·51-30·83]), with an absolute difference of 0·88% (90% CI -10·13 to 11·89). Response on the Structured Clinical Interview for DSM-IV, clinician version, also did not differ significantly (39 [43·33%, 90% CI 34·74-51·93] patients in the telemedicine group and 46 [48·42%, 90% CI 39·99-56·85] in the same-room group), with a difference of -5·09% (-17·13 to 6·95; p=0·487). Results from the intention-to-treat population were similar. MEM analyses showed that no significant differences existed between treatment trajectories over time for BDI and GDS. The criteria for non-inferiority were met. We did not note any adverse events. Telemedicine-delivered psychotherapy for older adults with major depression is not inferior to same-room treatment. This finding shows that evidence-based psychotherapy can be delivered, without modification, via home-based telemedicine, and that this method can be used to overcome barriers to care associated with distance from and difficulty with attendance at in-person sessions in older adults. US Department of Veterans Affairs. Copyright © 2015 Elsevier Ltd. All rights reserved.
    The Lancet Psychiatry 08/2015; 2(8):693-701. DOI:10.1016/S2215-0366(15)00122-4
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    ABSTRACT: This study assessed the prevalence and specific costs associated with discrete multimorbid mental health disease clusters in adults with diabetes mellitus (DM). Longitudinal analysis of a retrospective cohort. We performed a 5-year longitudinal analysis of a retrospective cohort of 733,071 patients with DM from the US Veterans Health Administration (VHA) between 2002 and 2006. The mental health comorbidities (MHCs) examined included depression, substance abuse, and psychosis. Our primary outcomes of interest were total inpatient, outpatient, and pharmacy costs measured in 2012 US$ from the perspective of the VHA. DM was present with comorbid depression, substance abuse, and psychosis in 12.1%, 3.7%, and 4.2% of patients, respectively. Overall, 13.5% of patients had 1 MHC, 2.5% had 2 MHCs, and 0.5% had all MHCs. Total inpatient ($1,435,651,415), outpatient ($366,137,435), and pharmacy ($90,064,725) costs were highest for patients with DM and comorbid depression alone. At the per-patient level, DM plus psychosis and substance abuse had the highest inpatient costs ($35,518), DM plus all MHCs had the highest outpatient costs ($6962), and DM plus depression and psychosis had the highest pharmacy costs ($1753). DM with comorbid depression is the most prevalent MHC combination and is associated with the highest total VHA healthcare costs. However, other comorbidity clusters are associated with higher mean per patient costs, and may therefore benefit from more intensive intervention. Analysis of healthcare expenditures by multimorbid disease clusters can be a useful tool for healthcare policy planning.
    The American journal of managed care 08/2015; 21(8):535-544. · 2.17 Impact Factor
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    Mukoso N Ozieh · Kinfe G Bishu · Clara E Dismuke · Leonard E Egede
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    ABSTRACT: Direct medical cost of diabetes in the U.S. has been estimated to be 2.3 times higher relative to individuals without diabetes. This study examines trends in healthcare expenditures by expenditure category in U.S. adults with diabetes between 2002 and 2011. We analyzed 10 years of data representing a weighted population of 189,013,514 U.S. adults aged ≥18 years from the Medical Expenditure Panel Survey. We used a novel two-part model to estimate adjusted mean and incremental medical expenditures by diabetes status, while adjusting for demographics, comorbidities, and time. Relative to individuals without diabetes ($5,058 [95% CI $4,949-$5,166]), individuals with diabetes ($12,180 [$11,775-$12,586]) had more than double the unadjusted mean direct expenditures over the 10-year period. After adjusting for confounders, individuals with diabetes had $2,558 ($2,266-$2,849) significantly higher direct incremental expenditures compared with those without diabetes. For individuals with diabetes, inpatient expenditures rose initially from $4,014 in 2002/2003 to $4,183 in 2004/2005 and then decreased continuously to $3,443 in 2010/2011, while rising steadily for individuals without diabetes. The estimated unadjusted total direct expenditures for individuals with diabetes were $218.6 billion/year and adjusted total incremental expenditures were approximately $46 billion/year. Our findings show that compared with individuals without diabetes, individuals with diabetes had significantly higher health expenditures from 2002 to 2011 and the bulk of the expenditures came from hospital inpatient and prescription expenditures. © 2015 by the American Diabetes Association. Readers may use this article as long as the work is properly cited, the use is educational and not for profit, and the work is not altered.
    Diabetes care 07/2015; DOI:10.2337/dc15-0369 · 8.57 Impact Factor
  • Joni S Williams · Cheryl P Lynch · Delia Voronca · Leonard E Egede
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    ABSTRACT: Perceptions of control impact outcomes in veterans with chronic disease. The purpose of this study was to examine the association between control orientation and clinical and quality of life (QOL) outcomes in male veterans with type 2 diabetes (T2DM). Cross-sectional study of 283 male veterans from a primary care clinic in the southeastern US. Health locus of control (LOC) was the main predictor and assessed using the Multidimensional Health LOC Scale. Clinical outcomes were glycosylated hemoglobin A1c (HbA1c), systolic and diastolic blood pressure, and low-density lipoprotein cholesterol (LDL-C). Physical (PCS) and mental (MCS) health component scores for QOL were assessed using the Veterans RAND 12-Item Health Survey. Unadjusted and adjusted multivariate analyses were performed to assess associations between LOC and outcomes. Unadjusted analyses showed internal LOC associated with HbA1c (β = 0.036; 95 % CI 0.001, 0.071), external LOC:powerful others inversely associated with LDL-C (β = -0.794; 95 % CI -1.483, -0.104), and external LOC:chance inversely associated with MCS QOL (β = -0.418; 95 % CI -0.859, -0.173). These associations remained significant when adjusting for relevant covariates. Adjusted analyses also demonstrated a significant relationship between external LOC:chance and PCS QOL (β = 0.308; 95 % CI 0.002, 0.614). In this sample of male veterans with T2DM, internal LOC was significantly associated with glycemic control, and external was significantly associated with QOL and LDL-C, when adjusting for relevant covariates. Assessments of control orientation should be performed to understand the perceptions of patients, thus better equipping physicians with information to maximize care opportunities for veterans with T2DM.
    Endocrine 07/2015; DOI:10.1007/s12020-015-0677-8 · 3.53 Impact Factor
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    ABSTRACT: We examined the association between traumatic brain injury (TBI) severity and combat exposure by race/ethnicity. We estimated logit models of the fully adjusted association of combat exposure with TBI severity in separate race/ethnicity models for a national cohort of 132 995 veterans with TBI between 2004 and 2010. Of veterans with TBI, 25.8% had served in a combat zone. Mild TBI increased from 11.5% to 40.3%, whereas moderate or severe TBI decreased from 88.5% to 59.7%. Moderate or severe TBI was higher in non-Hispanic Blacks (80.0%) and Hispanics (89.4%) than in non-Hispanic Whites (71.9%). In the fully adjusted all-race/ethnicity model, non-Hispanic Blacks (1.44; 95% confidence interval [CI] = 1.37, 1.52) and Hispanics (1.47; 95% CI = 1.26, 1.72) had higher odds of moderate or severe TBI than did non-Hispanic Whites. However, combat exposure was associated with higher odds of mild TBI in non-Hispanic Blacks (2.48; 95% CI = 2.22, 2.76) and Hispanics (3.42; 95% CI = 1.84, 6.35) than in non-Hispanic Whites (2.17; 95% CI = 2.09, 2.26). Research is needed to understand racial differences in the effect of combat exposure on mild TBI and on interventions to prevent TBI across severity levels. (Am J Public Health. Published online ahead of print June 11, 2015: e1-e7. doi:10.2105/AJPH.2014.302545).
    American Journal of Public Health 06/2015; 105(8):e1-e7. DOI:10.2105/AJPH.2014.302545 · 4.23 Impact Factor
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    ABSTRACT: Overdispersion is a common problem in count data. It can occur due to extra population-heterogeneity, omission of key predictors, and outliers. Unless properly handled, this can lead to invalid inference. Our goal is to assess the differential performance of methods for dealing with overdispersion from several sources. We considered six different approaches: unadjusted Poisson regression (Poisson), deviance-scale-adjusted Poisson regression (DS-Poisson), Pearson-scale-adjusted Poisson regression (PS-Poisson), negative-binomial regression (NB), and two generalized linear mixed models (GLMM) with random intercept, log-link and Poisson (Poisson-GLMM) and negative-binomial (NB-GLMM) distributions. To rank order the preference of the models, we used Akaike's information criteria/Bayesian information criteria values, standard error, and 95% confidence-interval coverage of the parameter values. To compare these methods, we used simulated count data with overdispersion of different magnitude from three different sources. Mean of the count response was associated with three predictors. Data from two real-case studies are also analyzed. The simulation results showed that NB and NB-GLMM were preferred for dealing with overdispersion resulting from any of the sources we considered. Poisson and DS-Poisson often produced smaller standard-error estimates than expected, while PS-Poisson conversely produced larger standard-error estimates. Thus, it is good practice to compare several model options to determine the best method of modeling count data. © The Author(s) 2015 Reprints and permissions: sagepub.co.uk/journalsPermissions.nav.
    Statistical Methods in Medical Research 05/2015; DOI:10.1177/0962280215588569 · 2.96 Impact Factor
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    ABSTRACT: Although the national cost of missed workdays associated with diabetes has been estimated previously, we use the most recent available national data and methodology to update the individual and national estimates for the U.S population. We identified 14,429 employed individuals ≥ 18 years of age in 2011 Medical Expenditure Panel Survey (MEPS) data. Diabetes and missed workdays were based on self-report, and cost was based on multiplying the daily wage rate for each individual by the number of missed days. Adjusted total national burden of missed workdays associated with diabetes was calculated using a novel two-part model to simultaneously estimate the association of diabetes with the number and cost of missed workdays. The unadjusted annual mean 2011 cost of missed workdays was $277 (95 % CI 177.0-378.0) for individuals with diabetes relative to $160 (95 % CI $130-$189) for those without. The incremental cost of missed workdays associated with diabetes was $120 (95 % CI $30.7-$209.1). Based on the US population in 2011, the unadjusted national burden of missed workdays associated with diabetes was estimated to be $2.7 billion, while the fully adjusted incremental national burden was estimated to be $1.1 billion. We provide more precise estimates of the cost burden of diabetes due to missed workdays on the U.S population. The high incremental and total cost burden of missed workdays among Americans with diabetes suggests the need for interventions to improve diabetes care management among employed individuals.
    Journal of General Internal Medicine 05/2015; DOI:10.1007/s11606-015-3338-y · 3.42 Impact Factor
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    ABSTRACT: Study Objective To determine the effect of tacrolimus trough concentrations on clinical outcomes in kidney transplantation, while assessing if African-American (AA) race modifies these associations.DesignRetrospective longitudinal cohort study of solitary adult kidney transplants.SettingLarge tertiary care transplant center.PatientsAdult solitary kidney transplant recipients (n=1078) who were AA (n=567) or non-AA (n=511).ExposureMean and regressed slope of tacrolimus trough concentrations. Subtherapeutic concentrations were lower than 8 ng/ml.Measurements and Main ResultsAA patients were 1.7 times less likely than non-AA patients to achieve therapeutic tacrolimus concentrations (8 ng/ml or higher) during the first year after kidney transplant (35% vs 21%, respectively, p<0.001). AAs not achieving therapeutic concentrations were 2.4 times more likely to have acute cellular rejection (ACR) as compared with AAs achieving therapeutic concentrations (20.8% vs 8.5%, respectively, p<0.01) and 2.5 times more likely to have antibody-mediated rejection (AMR; 8.9% vs 3.6%, respectively, p<0.01). Rates of ACR (8.3% vs 6.7%) and AMR (2.0% vs 0.9% p=0.131) were similar in non-AAs compared across tacrolimus concentration groups. Multivariate modeling confirmed these findings and demonstrated that AAs with low tacrolimus exposure experienced a mild protective effect for the development of interstitial fibrosis/tubular atrophy (IF/TA; hazard ratio [HR] 0.78, 95% confidence interval [CI] 0.47–1.32) with the opposite demonstrated in non-AAs (HR 2.2, 95% CI 0.90–5.1).Conclusion In contradistinction to non-AAs, AAs who achieve therapeutic tacrolimus concentrations have substantially lower acute rejection rates but are at risk of developing IF/TA. These findings may reflect modifiable time-dependent racial differences in the concentration-effect relationship of tacrolimus. Achievement of therapeutic tacrolimus trough concentrations, potentially through genotyping and more aggressive dosing and monitoring, is essential to minimize the risk of acute rejection in AA kidney transplant recipients.
    Pharmacotherapy 05/2015; 35(6). DOI:10.1002/phar.1591 · 2.20 Impact Factor
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    ABSTRACT: Blacks with lung cancer (LC) experience higher mortality because they present with more advanced disease and are less likely to undergo curative resection for early stage disease. The National Lung Screening Trial (NLST) demonstrated improved LC mortality by screening high-risk patients with low-dose computed tomography (LDCT). The benefit of LDCT screening in Blacks is unknown. Examine results of the NLST by race Methods: Secondary analysis of a randomized trial (NCT00047385) performed in 33 US centers. Overall and lung cancer specific mortality Main Results: Screening with LDCT reduced LC mortality in all racial groups but more so in Blacks (HR 0.61 vs 0.86). Smoking increased the likelihood of death from LC and when stratified by race Black smokers were twice as likely to die compared to White smokers (HR 4.10 vs 2.25). Adjusting for socio-demographic and behavioral characteristics, Blacks experienced higher all-cause mortality than Whites (HR 1.35; 95% CI, 1.22-1.49), however Blacks screened with LDCT had a reduction in all-cause mortality. Blacks were younger, more likely to be current smokers, had more co-morbidities, and fewer years of formal education than Whites (P<0.05). Blacks screened with LDCT had decreased mortality from lung cancer. However the demographics associated with improved LC survival were less commonly found in Blacks. The overall mortality in the NLST was higher for Blacks than Whites, but improved in Blacks screened suggesting that this subgroup may have had improved access to care. To realize the reductions in mortality from LC screening, dissemination efforts need to be tailored to meet the needs of this community.
    American Journal of Respiratory and Critical Care Medicine 04/2015; 192(2). DOI:10.1164/rccm.201502-0259OC · 11.99 Impact Factor
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    ABSTRACT: To assess differences among USA ethnic groups in psychological status of adult family members (FMs) and their involvement with the diabetes of another adult. Data are from the FM survey of the USA DAWN2 study, including 105 White non-Hispanics, 47 African Americans, 46 Hispanic Americans and 40 Chinese Americans. All FMs lived with and cared for an adult with diabetes. Analysis of covariance controlled for respondent and patient characteristics to assess ethnic group differences (P<0.05). Multiple regression analyses identified significant (P<0.05) independent correlates of psychological outcomes. FM psychological outcomes measured include well-being, quality of life (QoL), impact of diabetes on life domains, diabetes distress, and burden. NCT01507116. White non-Hispanics reported less diabetes burden and distress, more negative life impact, and lower well-being than FMs from ethnic minority groups. African Americans reported the highest well-being and lowest negative life impact, Chinese Americans reported the most diabetes burden, Hispanic Americans reported the highest distress. There were no ethnic group differences in QoL. Ethnic minority FMs reported having more involvement with diabetes, greater support success, and more access to a diabetes support network than White non-Hispanics. Higher FM diabetes involvement was associated with negative psychological outcomes, while diabetes education, support success and diabetes support network size were associated with better psychological outcomes. Potential limitations are the sample sizes and representativeness. Minority ethnic FMs experienced both advantages and disadvantages in psychological outcomes relative to each other and to White non-Hispanics. Ethnic minority FMs had more involvement in diabetes care, support success and support from others, with the first associated with worse and the latter two with better psychological outcomes. Additional studies are needed with larger samples and broader representation of ethnic groups to better understand these associations and identify areas for intervention.
    Current Medical Research and Opinion 04/2015; 31(7):1-34. DOI:10.1185/03007995.2015.1043251 · 2.37 Impact Factor
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    ABSTRACT: Approximately 1 in 3 adults with diabetes have CKD. However, there are no recent national estimates of the association of CKD with medical care expenditures in individuals with diabetes. Our aim is to assess the association of CKD with total medical expenditures in US adults with diabetes using a national sample and novel cost estimation methodology. Data on 2,053 adults with diabetes in the 2011 Medical Expenditure Panel Survey (MEPS) was analyzed. Individuals with CKD were identified based on self-report. Adjusted mean health services expenditures per person in 2011 were estimated using a two-part model after adjusting for demographic and clinical covariates. Of the 2,053 individuals with diabetes, approximately 9.7% had self-reported CKD. Unadjusted mean expenditures for individuals with CKD were $20,726 relative to $9,689.49 for no CKD. Adjusted mean expenditures from the 2-part model for individuals with CKD were $8473 higher relative to individuals without CKD. Additional significant covariates were Hispanic/other race, uninsured, urban dwellers, CVD, stroke, high cholesterol, arthritis, and asthma. The estimated unadjusted total expenditures for individuals with CKD were estimated to be in excess of $43 billion in 2011. We showed that CKD is a significant contributor to the financial burden among individuals with diabetes, and that minorities and the uninsured with CKD may experience barriers in access to care. Our study also provides a baseline national estimate of CKD cost in Diabetes by which future studies can be used for comparison. Published by Elsevier Ireland Ltd.
    Diabetes research and clinical practice 04/2015; 109(1). DOI:10.1016/j.diabres.2015.04.011 · 2.54 Impact Factor
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    Clara E. Dismuke · Rebekah J. Walker · Leonard E. Egede
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    ABSTRACT: Traumatic Brain Injury (TBI) has gained attention in the past decade as a "signature injury" in the conflicts in Iraq and Afghanistan. TBI is a major burden for both the military and civilian population in the US and worldwide. It is a leading cause of death and disability in the US and a major health services resource burden. We seek to answer two questions. What is the evidence regarding the association of TBI with health services utilization and costs in the US and worldwide? What is the evidence regarding racial/ethnic, gender, geographic, socio-economic and other disparities in health services utilization and cost in the US and worldwide? To attain this goal we searched several databases using key words to perform a systematic review of the literature since 2000. We found 36 articles to be eligible for inclusion in the review. The evidence demonstrates a wide variation in health services utilization and costs depending on population of study and severity of TBI. The evidence also supports the existence of racial/ethnic, gender, insurance, geographic disparities in the US as well as other unique disparities worldwide.
    Global journal of health science 04/2015; 7(6). DOI:10.5539/gjhs.v7n6p156
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    ABSTRACT: Investigations into personal factors influencing quality of life are important for those developing strategies to support patients with diabetes. This study aimed to investigate the influence of meaning of illness on quality of life in patients with type 2 diabetes. Veterans from primary care clinics in the southeastern United States completed a questionnaire including questions from the validated 5-scale Meaning of Illness Questionnaire (MIQ). Unadjusted and adjusted linear regression models investigated the physical and mental components of quality of life with the 5 MIQ factors. The sample comprised 302 Black and White veterans. The physical component of quality of life (PCS) was positively associated with type of stress/attitude of harm (β=2.43, CI: 0.94 to 3.93) and challenge/motivation/hope (β=3.02, CI: 0.40 to 5.64) after adjustment, whereas the mental component of quality of life (MCS) was positively associated with the degree of stress/change in commitment (β=2.58, CI: 0.78 to 4.38), and negatively associated with challenge/motivation/hope (β=-2.55, CI: -4.99 to -0.11). Attitudes of challenge, motivation and hope had opposite effects on mental and physical components of quality of life in this sample of veterans. Additionally, whereas, the type of stress and attitude towards harm or loss was associated with the physical component, the degree of stress and change in commitments was associated with the mental component. This suggests addressing the meaning of an illness may be complex but is an important consideration in improving both physical and mental components of quality of life in patients with type 2 diabetes. Copyright © 2015. Published by Elsevier Inc.
    Journal of diabetes and its complications 04/2015; 29(5). DOI:10.1016/j.jdiacomp.2015.04.006 · 1.93 Impact Factor
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    ABSTRACT: Inadequate health literacy has been associated with poorer health behaviors and outcomes in individuals with diabetes or depression. This study was conducted to examine the associations between inadequate health literacy and behavioral and cardiometabolic parameters in individuals with type 2 diabetes and to explore whether these associations are affected by concurrent depression. The authors used cross-sectional data from a study of 343 predominantly African Americans with type 2 diabetes. Inadequate health literacy was significantly and modestly associated with diabetes knowledge (r = -0.34) but weakly associated with self-efficacy (r = 0.16) and depressive symptoms (r = 0.24). In multivariate regression models, there were no associations between health literacy and A1c, blood pressure, or body mass index or control of any of these parameters. There was no evidence that depression was an effect-modifier of the associations between health literacy and outcomes. Although inadequate health literacy was modestly associated with worse knowledge and weakly associated with self-efficacy, it was not associated with any of the cardiometabolic parameters the authors studied. Because this study showed no association between health literacy and behavioral and cardiometabolic outcomes, it is unseemly and premature to embark on trials or controlled interventions to improve health literacy for the purposes of improving patient-related outcomes in diabetes.
    Journal of Health Communication 03/2015; 20(5):1-8. DOI:10.1080/10810730.2015.1012235 · 1.61 Impact Factor
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    Clara E. Dismuke · Leonard E. Egede
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    ABSTRACT: As much as 45% of the US population has at least one chronic condition while 21% have multiple chronic diseases. The study examined the impact of cognitive, social and physical limitations on the personal income of U.S. adults with seven chronic diseases. A cross-sectional analysis of 19,357 US adults with seven chronic diseases (diabetes, hypertension, heart disease, stroke, depression, emphysema and joint disease) from the 2006 Medical Expenditure Panel Survey (MEPS) was performed. The effect of seven chronic diseases and their associated cognitive, social, and physical limitations on personal income was assessed using a two-stage Heckman model. Depression emerged as the only chronic disease that was independently associated with a significant $1,914 decrease in personal income (95% CI -$2,938--$890). Social and cognitive limitations resulted in $1,944 (95% CI -$3,378--$511) and $3,039 (95% CI -$4,418-$1,659) decreases in personal incomes respectively while physical limitations did not result in a statistically significant reduction. Being Non-Hispanic Black, Hispanic, Other Race, female, never married, married, less than a bachelor's degree, publicly insured, uninsured, or having a health status less than very good were also associated with significant reductions in personal income. The findings of this study suggest a need to determine the specific limitations associated with common chronic diseases and identify appropriate compensatory strategies to reduce their impact on income.
    Global journal of health science 02/2015; 7(5). DOI:10.5539/gjhs.v7n5p183
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    ABSTRACT: Purpose: The purpose of this study was to conduct a systematic review of published community interventions to evaluate different components of community interventions and their ability to positively impact glycemic control in African Americans with T2DM. Methods: Medline, PsychInfo, and CINAHL were searched for potentially eligible studies published from January 2000 through January 2012. The following inclusion criteria were established for publications: (1) describe a community intervention, not prevention; (2) specifically indicate, in data analysis and results, the impact of the community intervention on African American adults, 18 years and older; (3) measure glycemic control (HbA1C) as an outcome measure; and (4) involve patients in a community setting, which excludes hospitals and hospital clinics. Results: Thirteen studies out of 9,233 articles identified in the search met the predetermined inclusion criteria. There were 5 randomized control trials and 3 reported improved glycemic control in the intervention group compared to the control group at the completion of the study. Of the 8 studies that were not randomized control trials, 6 showed a statistically significant change in HbA1C. Conclusion: In general, the community interventions assessed led to significant reductions in HbA1C in African Americans with type 2 diabetes. Community health workers did not have a greater impact on glycemic control in this sample. The findings of this study provides insight for designing community-based interventions in the future, such as including use of multiple delivery methods, consideration of mobile device software, nutritionist educator, and curriculum-based approaches.
    Global journal of health science 02/2015; 7(5):171-182. DOI:10.5539/gihs.v7n5p171
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    ABSTRACT: The purpose of this study was to assess the relationship between meaning of illness, diabetes knowledge, self-care understanding, and behaviors in a group of individuals with type 2 diabetes. Patients diagnosed with type 2 diabetes completed questionnaires with measures for diabetes knowledge, self-care understanding, diet adherence, and control problems based on the validated Diabetes Care Profile, as well as a 5-factor Meaning of Illness Questionnaire (MIQ) measure. Linear regression investigated the associations between self-care outcomes and the 5 MIQ factors. After adjustment for possible confounders, both diabetes self-care understanding and diet adherence were negatively and significantly associated with little effect of illness. Control problems were negatively associated with degree of stress/change in commitments. Diabetes knowledge was not significantly associated with meaning of illness. Aspects of the meaning attributed to illness were significantly associated with self-care in patients with type 2 diabetes. Therefore, cognitive appraisals may explain variances observed in self-care understanding and behaviors. Based on these results, it is important to understand the negative effect that diabetes could have when promoting self-care understanding and diet adherence. In addition, it shows that helping patients address the stress and changing commitments that result from diabetes may help decrease the amount of diabetes control problems, even if there is little effect on diabetes understanding. Taking these differences into account may help in creating more personalized and effective self-care education plans. © 2015 The Author(s).
    The Diabetes Educator 02/2015; 41(3). DOI:10.1177/0145721715572445 · 1.92 Impact Factor
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    ABSTRACT: Thirty-day readmissions (30DRA) are a highly scrutinized measure of healthcare quality and relatively frequent among kidney transplants (KTX). Development of predictive risk models is critical to reducing 30DRA and improving outcomes. Current approaches rely on fixed variables derived from administrative data. These models may not capture clinical evolution that is critical to predicting outcomes. We directed a retrospective analysis toward: (1) developing parsimonious risk models for 30DRA and (2) comparing efficiency of models based on the use of immutable versus dynamic data. Baseline and in-hospital clinical and outcomes data were collected from adult KTX recipients between 2005 and 2012. Risk models were developed using backward logistic regression and compared for predictive efficacy using receiver operating characteristic curves. Of 1147 KTX patients, 123 had 30DRA. Risk factors for 30DRA included recipient comorbidities, transplant factors, and index hospitalization patient level clinical data. The initial fixed variable model included 9 risk factors and was modestly predictive (area under the curve, 0.64; 95% confidence interval [95% CI], 0.58-0.69). The model was parsimoniously reduced to 6 risks, which remained modestly predictive (area under the curve, 0.63; 95% CI, 0.58-0.69). The initial predictive model using 13 fixed and dynamic variables was significantly predictive (AUC, 0.73; 95% CI, 0.67-0.80), with parsimonious reduction to 9 variables maintaining predictive efficacy (AUC, 0.73; 95% CI, 0.67-0.79). The final model using dynamically evolving clinical data outperformed the model using static variables (P = 0.009). Internal validation demonstrated that the final model was stable with minimal bias. We demonstrate that modeling dynamic clinical data outperformed models using immutable data in predicting 30DRA.
    Transplantation 01/2015; 99(2). DOI:10.1097/TP.0000000000000565 · 3.78 Impact Factor
  • Rebekah J Walker · Jennifer A Campbell · Leonard E Egede
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    ABSTRACT: The purpose of this narrative review was to synthesize the evidence on effective strategies for global health research, training and clinical care in order to identify common structures that have been used to guide program development. A Medline search from 2001 to 2011 produced 951 articles, which were reviewed and categorized. Thirty articles met criteria to be included in this review. Eleven articles discussed recommendations for research, 8 discussed training and 11 discussed clinical care. Global health program development should be completed within the framework of a larger institutional commitment or partnership. Support from leadership in the university or NGO, and an engaged local community are both integral to success and sustainability of efforts. It is also important for program development to engage local partners from the onset, jointly exploring issues and developing goals and objectives. Evaluation is a recommended way to determine if goals are being met, and should include considerations of sustainability, partnership building, and capacity. Global health research programs should consider details regarding the research process, context of research, partnerships, and community relationships. Training for global health should involve mentorship, pre-departure preparation of students, and elements developed to increase impact. Clinical care programs should focus on collaboration, sustainability, meeting local needs, and appropriate process considerations.
    Global journal of health science 01/2015; 7(2):39830. DOI:10.5539/gjhs.v7n2p119
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    ABSTRACT: Abstract Background: Discrimination has been linked to negative health outcomes, but little research has investigated different types of discrimination to determine if some have a greater impact on outcomes. We examined the differential effect of discrimination based on race, level of education, gender, and language on glycemic control in adults with type 2 diabetes. Patients and Methods: Six hundred two patients with type 2 diabetes from two adult primary care clinics in the southeastern United States completed validated questionnaires. Questions included perceived discrimination because of race/ethnicity, level of education, sex/gender, or language. A multiple linear regression model assessed the differential effect of each type of perceived discrimination on glycemic control while adjusting for relevant covariates, including race, site, gender, marital status, duration of diabetes, number of years in school, number of hours worked per week, income, and health status. Results: The mean age was 61.5 years, and the mean duration of diabetes was 12.3 years. Of the sample, 61.6% were men, and 64.9% were non-Hispanic black. In adjusted models, education discrimination remained significantly associated with glycemic control (β=0.47; 95% confidence interval, 0.03, 0.92). Race, gender and language discrimination were not significantly associated with poor glycemic control in either unadjusted or adjusted analyses. Conclusions: Discrimination based on education was found to be significantly associated with poor glycemic control. The findings suggest that education discrimination may be an important social determinant to consider when providing care to patients with type 2 diabetes and should be assessed separate from other types of discrimination, such as that based on race.
    Diabetes Technology &amp Therapeutics 12/2014; 17(4). DOI:10.1089/dia.2014.0285 · 2.29 Impact Factor

Publication Stats

4k Citations
599.20 Total Impact Points


  • 2001–2015
    • Medical University of South Carolina
      • • Department of Medicine
      • • Division of General Internal Medicine and Geriatrics
      • • Department of Rehabilitation Sciences
      Charleston, South Carolina, United States
  • 2000
    • Greater Baltimore Medical Center
      Baltimore, Maryland, United States