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Andrea J Apter,
Fei Wan,
Susan Reisine,
Bruce Bender,
Cynthia Rand,
Daniel K Bogen,
Ian M Bennett,
Tyra Bryant-Stephens,
Jason Roy,
Rodalyn Gonzalez,
Chantel Priolo, Thomas Ten Have,
Knashawn H Morales
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ABSTRACT: BACKGROUND: Low health literacy is associated with poor outcomes in asthma and other diseases, but the mechanisms governing this relationship are not well defined. OBJECTIVE: We sought to assess whether literacy is related to subsequent asthma self-management, measured as adherence to inhaled steroids, and asthma outcomes. METHODS: In a prospective longitudinal cohort study, numeric (Asthma Numeracy Questionnaire) and print literacy (Short Test of Functional Health Literacy in Adults) were assessed at baseline in adults with moderate or severe asthma for their impact on subsequent electronically monitored adherence and asthma outcomes (asthma control, asthma-related quality of life, and FEV1) over 26 weeks, using mixed-effects linear regression models. RESULTS: A total of 284 adults participated: age, 48 ± 14 years, 71% females, 70% African American, 6% Latino, mean FEV1 66% ± 19%, 86 (30%) with hospitalizations, and 148 (52%) with emergency department visits for asthma in the prior year. Mean Asthma Numeracy Questionnaire score was 2.3 ± 1.2 (range, 0-4); mean Short Test of Functional Health Literacy in Adults score was 31 ± 8 (range, 0-36). In unadjusted analyses, numeric and print literacy were associated with better adherence (P = .01 and P = .08, respectively), asthma control (P = .005 and P < .001, respectively), and quality of life (P < .001 and P < .001, respectively). After controlling for age, sex, and race/ethnicity, the associations diminished and only quality of life (numeric P = .03, print P = .006) and asthma control (print P = .005) remained significantly associated with literacy. Race/ethnicity, income, and educational attainment were correlated (P < .001). CONCLUSION: While the relationship between literacy and health is complex, interventions that account for and address the literacy needs of patients may improve asthma outcomes.
The Journal of allergy and clinical immunology 04/2013; · 9.17 Impact Factor
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ABSTRACT: BACKGROUND:: Economic disadvantage is associated with depression and suicide. We sought to determine whether economic disadvantage reduces the effectiveness of depression treatments received in primary care. METHODS:: We conducted differential-effects analyses of the Prevention of Suicide in Primary Care Elderly: Collaborative Trial, a primary-care-based randomized, controlled trial for late-life depression and suicidal ideation conducted between 1999 and 2001, which included 514 patients with major depression or clinically significant minor depression. RESULTS:: The intervention effect, defined as change in depressive symptoms from baseline, was stronger among persons reporting financial strain at baseline (differential effect size = -4.5 Hamilton Depression Rating Scale points across the study period [95% confidence interval = -8.6 to -0.3]). We found similar evidence for effect modification by neighborhood poverty, although the intervention effect weakened after the initial 4 months of the trial for participants residing in poor neighborhoods. There was no evidence of substantial differences in the effectiveness of the intervention on suicidal ideation and depression remission by economic disadvantage. CONCLUSIONS:: Economic conditions moderated the effectiveness of primary-care-based treatment for late-life depression. Financially strained individuals benefited more from the intervention; we speculate this was because of the enhanced treatment management protocol, which led to a greater improvement in the care received by these persons. People living in poor neighborhoods experienced only temporary benefit from the intervention. Thus, multiple aspects of economic disadvantage affect depression treatment outcomes; additional work is needed to understand the underlying mechanisms.
Epidemiology (Cambridge, Mass.) 01/2013; 24(1):14-22. · 5.51 Impact Factor
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ABSTRACT: PURPOSE: Depression and suicide are major public health concerns, and are often unrecognized among the elderly. This study investigated social inequalities in depressive symptoms and suicidal ideation among older adults. METHODS: Data come from 1,226 participants in PROSPECT (Prevention of Suicide in Primary Care Elderly: Collaborative Trial), a large primary care-based intervention trial for late-life depression. Linear and logistic regressions were used to analyze depressive symptoms and suicidal ideation over the 2-year follow-up period. RESULTS: Mean Hamilton Depression Rating Scale (HDRS) scores were significantly higher among participants in financial strain [regression coefficient (b) = 1.78, 95 % confidence interval (CI) = 0.67-2.89] and with annual incomes below $20,000 (b = 1.67, CI = 0.34-3.00). Financial strain was also associated with a higher risk of suicidal ideation (odds ratio = 2.35, CI = 1.38-3.98). CONCLUSIONS: There exist marked social inequalities in depressive symptoms and suicidal ideation among older adults attending primary care practices, the setting in which depression is most commonly treated. Our results justify continued efforts to understand the mechanisms generating such inequalities and to recognize and provide effective treatments for depression among high-risk populations.
Social Psychiatry 09/2012; · 2.05 Impact Factor
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ABSTRACT: We consider longitudinal studies with binary outcomes that are measured repeatedly on subjects over time. The goal of our analysis was to fit a logistic model that relates the expected value of the outcomes with explanatory variables that are measured on each subject. However, additional care must be taken to adjust for the association between the repeated measurements on each subject. We propose a new maximum likelihood method for covariates that may be fixed or time varying. We also implement and make comparisons with two other approaches: generalized estimating equations, which may be more robust to misspecification of the true correlation structure, and alternating logistic regression, which models association via odds ratios that are subject to less restrictive constraints than are correlations. The proposed estimation procedure will yield consistent and asymptotically normal estimates of the regression and correlation parameters if the correlation on consecutive measurements on a subject is correctly specified. Simulations demonstrate that our approach can yield improved efficiency in estimation of the regression parameter; for equally spaced and complete data, the gains in efficiency were greatest for the parameter associated with a time-by-group interaction term and for stronger values of the correlation. For unequally spaced data and with dropout according to a missing-at-random mechanism, MARK1ML with correctly specified consecutive correlations yielded substantial improvements in terms of both bias and efficiency. We present an analysis to demonstrate application of the methods we consider. We also offer an R function for easy implementation of our approach.
Statistics in Medicine 01/2012; 31(10):931-48. · 1.88 Impact Factor
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ABSTRACT: Because cancers are a leading cause of death, these diseases receive a great deal of news attention. However, because news media frequently target specific racial or ethnic audiences, some populations may receive different information, and it is unknown whether reporting equally informs all audiences about the options for care at the end of life. This study of news reporting compared "mainstream" (general market) media with African American media, which serves the largest minority group. The specific goal of this study was to determine whether these news media communicate differently about cure-directed cancer treatment and end-of-life alternatives.
This content analysis included 660 cancer news stories from online and print media that targeted either African American or mainstream audiences. The main outcome measures included whether reporting discussed adverse events of cancer treatment, cancer treatment failure, cancer death/dying, and end-of-life palliative or hospice care.
Unadjusted and adjusted analyses indicated that the news stories in the African American media are less likely than those in mainstream media to discuss each of the topics studied. Comparing the proportions of news stories in mainstream versus African American media, 31.6% versus 13.6% discussed adverse events (odds ratio [OR], 2.92; 95% confidence interval [CI], 1.51-5.66; P = .001); 14.1% versus 4.2% mentioned treatment failure (OR, 3.79; 95% CI, 1.45-9.88; P = .006); and 11.9% versus 3.8% focused on death/dying (OR, 3.42; 95% CI, 1.39-8.38; P = .007). Finally, although very few news stories discussed end-of-life hospice or palliative care, all were found in mainstream media (7/396 vs 0/264).
The African American news media sampled are less likely than mainstream news media to portray negative cancer outcomes and end-of-life care. Given media's segmented audiences, these findings raise concerns that not all audiences are being informed equally well. Because media content is modifiable, there may be opportunities to improve public cancer communication.
Cancer 09/2011; 118(8):2157-62. · 4.77 Impact Factor
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Andrea J Apter,
Xingmei Wang,
Daniel K Bogen,
Cynthia S Rand,
Sean McElligott,
Daniel Polsky,
Rodalyn Gonzalez,
Chantel Priolo,
Bariituu Adam,
Sabrina Geer, Thomas Ten Have
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ABSTRACT: Improving inhaled corticosteroid (ICS) adherence should improve asthma outcomes.
In a randomized controlled trial we tested whether an individualized problem-solving (PS) intervention improves ICS adherence and asthma outcomes.
Adults with moderate or severe asthma from clinics serving urban neighborhoods were randomized to PS (ie, defining specific barriers to adherence, proposing/weighing solutions, trying the best, assessing, and revising) or standard asthma education (AE) for 3 months and then observed for 3 months. Adherence was monitored electronically. Outcomes included the following: asthma control, FEV(1), asthma-related quality of life, emergency department (ED) visits, and hospitalizations. In an intention-to-treat-analysis longitudinal models using random effects and regression were used.
Three hundred thirty-three adults were randomized: 49 ± 14 years of age, 72% female, 68% African American, 7% Latino, mean FEV(1) of 66% ± 19%, and 103 (31%) with hospitalizations and 172 (52%) with ED visits for asthma in the prior year. There was no difference between groups in overall change in any outcome (P > .20). Mean adherence (61% ± 27%) decreased significantly (P = .0004) over time by 14% and 10% in the AE and PS groups, respectively. Asthma control improved overall by 15% (P = .002). In both groups FEV(1) and quality of life improved by 6% (P = .01) and 18% (P < .0001), respectively. However, the improvement in FEV(1) only occurred during monitoring but not subsequently after randomization. Rates of ED visits and hospitalizations did not significantly decrease over the study period.
PS was not better than AE in improving adherence or asthma outcomes. However, monitoring ICS use with provision of medications and attention, which was imposed on both groups, was associated with improvement in FEV(1) and asthma control.
The Journal of allergy and clinical immunology 06/2011; 128(3):516-23.e1-5. · 9.17 Impact Factor
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ABSTRACT: This is a multisite, 12-week, open-label trial of lamotrigine augmentation in 57 older adults (≥ 60 years; mean ± SD age = 66.5 ± 6.7 years) with either type I or type II bipolar depression.
Primary outcome measure was change from baseline on the Montgomery-Åsberg Depression Rating Scale (MADRS). Secondary outcome measures included Hamilton Depression Rating Scale (HAM-D), Clinical Global Impression-Bipolar version (CGI-BP), and the WHO-Disability Assessment Schedule II (WHO-DAS II). The Udvalg for Kliniske Undersøgelser (UKU) was used to assess side effects.
A total of 77.2% of the study subjects had bipolar I disorder. The mean (SD) lamotrigine dose was 150.9 (68.5) mg/day. There was significant improvement in the MADRS, HAM-D, CGI-BP, and in most domains on the WHO-DAS II. For patients for whom final MADRS score was available: 31 (57.4%) met remission criteria and 35 (64.8%) met response criteria. There were 19/57 (33.3%) who dropped out of the study prematurely, with 6 dropouts due to adverse events (4 cases of rash, 1 manic switch, and 1 hyponatremia). Two cases of rash were possibly drug related and were resolved with drug discontinuation. The most common UKU adverse effects were reduced sleep duration (n = 14, 24.6%), weight loss (n = 12, 21.1%), increased dream activity (n = 12, 21.1%), polyuria/polydipsia (n = 11, 19.3%), weight gain (n = 9, 15.8%), diminished sexual desire (n = 9, 15.8%), increased sleep (n = 9, 15.8%), lassitude/fatigue (n = 8, 14%), and unsteady gait (n = 8, 14%). No significant changes in electrocardiogram or laboratory tests were observed.
In bipolar depressed elders, lamotrigine was associated with improvement in depression, psychopathology, and functional status. There was a moderate number of adverse events, although relationship of adverse events (particularly falls) to study medication could not be clearly determined in this uncontrolled trial. Controlled studies are needed to further evaluate efficacy and tolerability of lamotrigine therapy in geriatric bipolar depression.
Bipolar Disorders 05/2011; 13(3):294-302. · 5.29 Impact Factor
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ABSTRACT: We describe the cognitive function of older adults presenting with bipolar disorder (BD) and mania and examine whether longer lifetime duration of BD is associated with greater cognitive dysfunction. We also examine whether there are negative, synergistic effects between lifetime duration of BD and vascular disease burden on cognition.
A total of 87 nondemented individuals with bipolar I disorder, age 60 years and older, experiencing manic, hypomanic, or mixed episodes, were assessed with the Dementia Rating Scale (DRS) and the Framingham Stroke Risk Profile (FSRP) as a measure of vascular disease burden.
Subjects had a mean (SD) age of 68.7 (7.1) years and 13.6 (3.1) years of education; 50.6% (n = 44) were females, 89.7% (n = 78) were white, and 10.3% (n = 9) were black. They presented with overall and domain-specific cognitive impairment in memory, visuospatial ability, and executive function compared to age-adjusted norms. Lifetime duration of BD was not related to DRS total score, any other subscale scores, or vascular disease burden. FSRP scores were related to the DRS memory subscale scores, but not total scores or any other domain scores. A negative interactive effect between lifetime duration of BD and FSRP was only observed with the DRS construction subscale.
In this study, lifetime duration of BD had no significant relationship with overall cognitive function in older nondemented adults. Greater vascular disease burden was associated with worse memory function. There was no synergistic relationship between lifetime duration of BD and vascular disease burden on overall cognition function. Addressing vascular disease, especially early in the course of BD, may mitigate cognitive impairment in older age.
Bipolar Disorders 12/2010; 12(8):851-8. · 5.29 Impact Factor
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ABSTRACT: Exposure to community violence (ECV) has been associated with asthma morbidity of children living in inner-city neighborhoods.
To examine with prospective longitudinal data whether ECV is independently associated with asthma-related health outcomes in adults.
Adults with moderate-severe asthma, recruited from clinics serving inner-city neighborhoods, completed questionnaires covering sociodemographics, asthma severity, and ECV and were followed for 26 weeks. Longitudinal models were used to assess unadjusted and adjusted associations of subsequent asthma outcomes (emergency department [ED] visits, hospitalizations, FEV(1), quality of life).
A total of 397 adults, 47 +/- 14 years old, 73% women, 70% African American, 7% Latino, mean FEV(1) 66% +/- 19%, 133 with hospitalizations and 222 with ED visits for asthma in the year before entry, were evaluated. Ninety-one reported ECV. Controlling for age, sex, race/ethnicity, and household income, those exposed to violence had 2.27 (95% CI, 1.32-3.90) times more asthma-related ED visits per month and 2.49 (95% CI, 1.11-5.60) times more asthma-related hospitalizations per month over the 26-week study period compared with those unexposed. Violence-exposed participants also had 1.71 (95% CI, 1.14-2.56) times more overall ED visits per month and 1.72 (95% CI, 0.95-3.11) times more overall hospitalizations per month from any cause. Asthma-related quality of life was lower in the violence-exposed participants (-0.40; 95% CI, -0.77 to -0.025; P = .04). Effect modification by depressive symptoms was only statistically significant for the ECV association with overall ED visits and quality-of-life outcomes (P < .01).
In adults, ECV is associated with increased asthma hospitalizations and emergency care for asthma or any condition and with asthma-related quality of life.
The Journal of allergy and clinical immunology 09/2010; 126(3):552-7. · 9.17 Impact Factor
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ABSTRACT: Cancer receives a great deal of news media attention. Although approximately half of all US patients with cancer die of their illness or of related complications, it is unknown whether reports in the news media reflect this reality.
To determine how cancer news coverage reports about cancer care and outcomes, we conducted a content analysis of US cancer news reporting in 8 large-readership newspapers and 5 national magazines. Trained coders determined the proportion of articles reporting about cancer survival, cancer death and dying, aggressive cancer treatment, cancer treatment failure, adverse events of cancer treatment, and end-of-life palliative or hospice care.
Of 436 articles about cancer, 140 (32.1%; 95% confidence interval [CI], 28%-37%) focused on survival and only 33 (7.6 %; 5%-10%) focused on death and dying (P < .001, chi(2) test). Only 57 articles (13.1%; 10%-17%) reported that aggressive cancer treatments can fail, and 131 (30.0%; 26%-35%) reported that aggressive treatments can result in adverse events. Although most articles (249 of 436 [57.1%]; 95% CI, 52%-62%) discussed aggressive treatments exclusively, almost none (2 of 436; [0.5%]; 0%-2%) discussed end-of-life palliative or hospice care exclusively (P < .001, chi(2) test), and only a few (11 of 436 [2.5%]; 1%-6%) discussed aggressive treatment and end-of-life care.
News reports about cancer frequently discuss aggressive treatment and survival but rarely discuss treatment failure, adverse events, end-of-life care, or death. These portrayals of cancer care in the news media may give patients an inappropriately optimistic view of cancer treatment, outcomes, and prognosis.
Archives of internal medicine 03/2010; 170(6):515-8. · 11.46 Impact Factor
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Robert C Young,
Herbert C Schulberg,
Ariel G Gildengers,
Martha Sajatovic,
Benoit H Mulsant,
Laszlo Gyulai,
John Beyer,
Lauren Marangell,
Mark Kunik, Thomas Ten Have,
Martha L Bruce,
Ruben Gur,
Patricia Marino,
Jovier D Evans,
Charles F Reynolds,
George S Alexopoulos
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ABSTRACT: This report considers the conceptual and methodological concerns confronting clinical investigators seeking to generate knowledge regarding the tolerability and benefits of pharmacotherapy in geriatric bipolar disorder (BD) patients.
There is continuing need for evidence-based guidelines derived from randomized controlled trials that will enhance drug treatment of geriatric BD patients. Therefore, we present the complex conceptual and methodological choices encountered in designing a multisite clinical trial and the decisions reached by the investigators with the intention that study findings be pertinent to, and can facilitate, routine treatment decisions.
Guided by a literature review and input from peers, the tolerability and antimanic effects of lithium and valproate were judged to be the key mood stabilizers to investigate with regard to treating bipolar I disorder manic, mixed, and hypomanic states. The patient selection criteria are intended to generate a sample that not only experiences common treatment needs but also represents the variety of older patients seen in university-based clinical settings. The clinical protocol guides titration of lithium and valproate to target serum concentrations, with lower levels allowed when necessitated by limited tolerability. The protocol emphasizes initial monotherapy. However, augmentation with risperidone is permitted after three weeks when indicated by operational criteria.
A randomized, controlled trial that both investigates commonly prescribed mood stabilizers and maximizes patient participation can meaningfully address high-priority clinical concerns directly relevant to the routine pharmacologic treatment of geriatric BD patients.
Bipolar Disorders 02/2010; 12(1):56-67. · 5.29 Impact Factor
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ABSTRACT: The authors examined the impact of the wish to die on mortality over a 5-year period, stratified by baseline depressive status (i.e., major, minor, and no depression diagnosis). The authors also examined whether a depression care management intervention would minimize these relationships.
Longitudinal analyses of the practice-randomized Prevention of Suicide in Primary Care Elderly: Collaborative Trial (PROSPECT).
Twenty primary care practices from New York City, Philadelphia, and Pittsburgh.
One thousand two hundred two participants were identified through two-stage, age-stratified (60-74 years; 75 years and older) depression screening of randomly sampled participants.
Practices randomized to Care Management Intervention or Usual Care conditions.
Vital status at 5 years using the National Death Index.
Rates of the wish to die were 29% (major depression), 11% (minor depression), and 7% (no depression). In Usual Care, the wish to die was associated with an increased risk of 5-year mortality across depressive status (adjusted hazard ratios ranging from 1.62 to 1.71). In intervention practices, this association was greater among the no depression (adjusted hazard ratio 1.64) compared with major depression group (adjusted hazard ratio 0.68).
The wish to die was associated with mortality in the usual care of elderly primary care patients, suggesting that the wish to die has clinical significance and may be worth assessing even in patients without other evidence of depression. This association was not observed among depressed patients located in primary care practices that implemented the PROSPECT intervention, suggesting potential long-term benefits of treatment and management of depression.
The American journal of geriatric psychiatry: official journal of the American Association for Geriatric Psychiatry 11/2009; 18(4):341-50. · 3.35 Impact Factor
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ABSTRACT: PurposeTo examine the effect of antihypertensive adherence on blood pressure and barriers to adherence in racially diverse elderly patients.Methods
Telephone survey of a representative sample of 300 of all 3416 hypertensive patients aged >70 from four urban primary care practices. From electronic records, we calculated subjects' annual mean systolic blood pressure. We asked about the last missed antihypertensive dose in six time intervals. Based on association with blood pressure control, non-adherence was defined as missing any dose in the past 3 months. Subjects were also asked about six domains of adherence barriers: health, personal support, drug coverage, medication filling and use, doctor–patient interaction and knowledge. All models adjust for demographics, treatment regimen and sampling weights.ResultsThe 202 subjects (67% response rate) were: female (65.9%), black (64.8%), mean age 77.4 years (5.49) and on mean 2.4 (SD 1.3) antihypertensive drugs. Mean annual systolic pressure for non-adherent subjects (22% of the cohort) was higher than adherent subjects (137.7 vs.133.4 mmHg, p = 0.065). After adjustment, the association between adherence and blood pressure was stronger in black than white patients (p = 0.007). In an initial model, being unaware of Medicare Part D had a lower adjusted odds ratio (AOR) of adherence (p < 0.05). In the final model, adherence barriers were: medication filling/use (run out of pills [AOR 0.25, CI 0.09-0.66] and 28% reduction per each of eight barriers); doctor–patient interaction (less important to discuss hypertension [AOR 0.32, CI 0.12–0.84]); and knowledge (38% lower AOR per incorrect answer about diseases unrelated to hypertension).Conclusion
Self-reported adherence was associated with a higher blood pressure, especially in elderly black patients. To promote adherence, our data suggest targeting: filling prescriptions, prioritizing hypertension care and educating about effects of hypertension. Copyright © 2009 John Wiley & Sons, Ltd.
Pharmacoepidemiology and Drug Safety 07/2009; 18(8):672 - 681. · 2.53 Impact Factor
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ABSTRACT: The Prevention of Suicide in Primary Care Elderly: Collaborative Trial (PROSPECT) evaluated the impact of a care management intervention on suicidal ideation and depression in older primary care patients. This is the first report of outcomes over a 2-year period.
Study participants were patients 60 years of age or older (N=599) with major or minor depression selected after screening 9,072 randomly identified patients of 20 primary care practices randomly assigned to provide either the PROSPECT intervention or usual care. The intervention consisted of services of 15 trained care managers, who offered algorithm-based recommendations to physicians and helped patients with treatment adherence over 24 months.
Compared with patients receiving usual care, those receiving the intervention had a higher likelihood of receiving antidepressants and/or psychotherapy (84.9%-89% versus 49%-62%) and had a 2.2 times greater decline in suicidal ideation over 24 months. Treatment response occurred earlier on average in the intervention group and increased from months 18 to 24, while no appreciable increase in treatment response occurred in the usual care group during the same period. Among patients with major depression, a greater number achieved remission in the intervention group than in the usual-care group at 4 months (26.6% versus 15.2%), 8 months (36% versus 22.5%), and 24 months (45.4% versus 31.5%). Patients with minor depression had favorable outcomes regardless of treatment assignment.
Sustained collaborative care maintains high utilization of depression treatment, reduces suicidal ideation, and improves the outcomes of major depression over 2 years.
American Journal of Psychiatry 07/2009; 166(8):882-90. · 12.54 Impact Factor
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ABSTRACT: The method of generalized estimating equations (GEE) models the association between the repeated observations on a subject with a patterned correlation matrix. Correct specification of the underlying structure is a potentially beneficial goal, in terms of improving efficiency and enhancing scientific understanding. We consider two sets of criteria that have previously been suggested, respectively, for selecting an appropriate working correlation structure, and for ruling out a particular structure(s), in the GEE analysis of longitudinal studies with binary outcomes. The first selection criterion chooses the structure for which the model-based and the sandwich-based estimator of the covariance matrix of the regression parameter estimator are closest, while the second selection criterion chooses the structure that minimizes the weighted error sum of squares. The rule out criterion deselects structures for which the estimated correlation parameter violates standard constraints for binary data that depend on the marginal means. In addition, we remove structures from consideration if their estimated parameter values yield an estimated correlation structure that is not positive definite. We investigate the performance of the two sets of criteria using both simulated and real data, in the context of a longitudinal trial that compares two treatments for major depressive episode. Practical recommendations are also given on using these criteria to aid in the efficient selection of a working correlation structure in GEE analysis of longitudinal binary data.
Statistics in Medicine 06/2009; 28(18):2338-55. · 1.88 Impact Factor
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ABSTRACT: To examine the effect of antihypertensive adherence on blood pressure and barriers to adherence in racially diverse elderly patients.
Telephone survey of a representative sample of 300 of all 3416 hypertensive patients aged >70 from four urban primary care practices. From electronic records, we calculated subjects' annual mean systolic blood pressure. We asked about the last missed antihypertensive dose in six time intervals. Based on association with blood pressure control, non-adherence was defined as missing any dose in the past 3 months. Subjects were also asked about six domains of adherence barriers: health, personal support, drug coverage, medication filling and use, doctor-patient interaction and knowledge. All models adjust for demographics, treatment regimen and sampling weights.
The 202 subjects (67% response rate) were: female (65.9%), black (64.8%), mean age 77.4 years (5.49) and on mean 2.4 (SD 1.3) antihypertensive drugs. Mean annual systolic pressure for non-adherent subjects (22% of the cohort) was higher than adherent subjects (137.7 vs.133.4 mmHg, p = 0.065). After adjustment, the association between adherence and blood pressure was stronger in black than white patients (p = 0.007). In an initial model, being unaware of Medicare Part D had a lower adjusted odds ratio (AOR) of adherence (p < 0.05). In the final model, adherence barriers were: medication filling/use (run out of pills [AOR 0.25, CI 0.09-0.66] and 28% reduction per each of eight barriers); doctor-patient interaction (less important to discuss hypertension [AOR 0.32, CI 0.12-0.84]); and knowledge (38% lower AOR per incorrect answer about diseases unrelated to hypertension).
Self-reported adherence was associated with a higher blood pressure, especially in elderly black patients. To promote adherence, our data suggest targeting: filling prescriptions, prioritizing hypertension care and educating about effects of hypertension.
Pharmacoepidemiology and Drug Safety 05/2009; 18(8):672-81. · 2.53 Impact Factor
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ABSTRACT: To develop a better understanding of how men react to being diagnosed with prostate cancer and identify factors that influence these responses, we conducted an observational study to identify sociocultural predictors of men's psychological reactions.
Participants were 70 African American and 124 white prostate cancer patients who completed a structured telephone interview that evaluated psychological reactions in terms of intrusive thoughts about cancer and attempts to avoid cancer-related thoughts and feelings. Perceptions of disease-specific stress, cultural beliefs and values, and social constraints were also assessed during the interview.
There were no racial differences in men's reactions to being diagnosed with prostate cancer; however, greater perceptions of disease-specific stress, increasing levels of present temporal orientation, and more social constraints had significant positive effects on avoidant reactions. Greater perceptions of stress also had a significant positive effect on intrusive thoughts.
The results of this study highlight the need for individualized approaches to help men address their thoughts and feelings about being diagnosed with prostate cancer. These efforts should include strategies that help men to communicate more effectively with social support resources and address cultural beliefs and values related to temporal orientation.
Psycho-Oncology 05/2009; 19(5):553-60. · 3.34 Impact Factor
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ABSTRACT: Peer-to-peer interactions are associated with enhanced psychosocial adjustment among women with breast cancer. Millions of women with cancer and others with various health conditions use the Internet to establish peer relationships, usually without professional moderation. This paper reports findings from the first randomized, controlled study of the benefits of these types of Internet-based peer interactions.
This pilot study involved seventy-eight women who were recently diagnosed with breast cancer. Participants were randomly assigned to either an Internet peer support condition or Internet-based educational control condition. Data were gathered at baseline and 4- and 12-months. Primary outcomes of interest were psychological distress and quality of life.
Contrary to hypotheses, participants in the Internet peer support condition tended to do worse over time on primary outcome measures. There were no differences between groups on secondary outcomes of perceived social support, self-efficacy, or hope. Paradoxically, many women in the Internet peer support condition actively participated and reported high levels of satisfaction, suggesting some self-perceived benefits.
These results suggest that Internet based peer-to-peer interactions may not necessarily be universally beneficial despite the positive experiences reported by many participants. Further research is needed to understand the magnitude of this effect with a larger sample. Moreover, these results raise questions about the need to understand the comparative effectiveness of Internet-based communications by group structure (i.e., unstructured/structured; unmoderated/moderated) and the effect of content (i.e., expression of fear/anxiety, insightful disclosures, etc.) on outcomes.
Psycho-Oncology 05/2009; 19(4):441-6. · 3.34 Impact Factor
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ABSTRACT: Mistrust of healthcare providers and systems is a significant barrier to quality healthcare. However, limited empirical data are available on perceptions of medical mistrust among individuals who are diagnosed with cancer. The objective of this study was to identify sociodemographic, clinical, and cultural determinants of mistrust among men diagnosed with prostate cancer.
The authors conducted an observational study among 196 African-American men (n = 71) and white men (n = 125) who were newly diagnosed with prostate cancer during 2003 through 2007.
Race, education, healthcare experiences, and cultural factors had significant effects on mistrust. African-American men (P = .01) and men who had fewer years of formal education (P = .001) reported significantly greater levels of mistrust compared with white men and men who had more education. Mistrust also was greater among men who had been seeing their healthcare provider for a longer period (P = .01) and among men with lower perceptions of interdependence (P = .01).
The current findings suggested that efforts to enhance trust among men who are diagnosed with prostate cancer should target African-American men, men with fewer socioeconomic resources, and men with lower perceptions of interdependence. Reasons for deterioration in trust associated with greater experience with specialty providers should be explored along with the effects of interventions that are designed to address the concerns of individuals who have greater mistrust.
Cancer 04/2009; 115(11):2553-61. · 4.77 Impact Factor
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ABSTRACT: To examine the correlation of numerical skills used in patients' self-management of asthma with asthma-related quality of life (AQOL).
Adults with moderate-severe asthma completed the Asthma Numeracy Questionnaire (ANQ), assessments of reading comprehension and self-efficacy, and the mini-Asthma Quality of Life Questionnaire (miniAQLQ). The numeracy-AQOL relationship was evaluated in the context of potential confounders (demographic variables) and mediators (e.g. income and self-efficacy), using tests of correlation then multivariable models to assess for confounders and mediators.
80 adults with moderate or severe asthma were evaluated. Mean ANQ score was 2.3+/-1.2 (range 0-4). ANQ was correlated with miniAQLQ (rho=0.24, p=0.03). This association was sustained (rho=0.27, p=0.02) when controlling for potential confounders significantly associated with AQOL (age, Latino ethnicity). The ANQ-miniAQLQ association was mediated by household income; the correlation was reduced by 81% when adjusting for income (rho=0.05, p=0.65). In contrast, self-efficacy less strongly mediated this association; the correlation was reduced by 26% when controlled for self-efficacy (rho=0.20, p=0.08).
Numerical skills needed for asthma self-management influence AQOL primarily through their impact on income and, to a lesser extent, on self-efficacy.
Adults with asthma will benefit from self-management instructions employing the simplest mathematical constructs whose understanding is confirmed by clinicians.
Patient Education and Counseling 03/2009; 75(3):386-91. · 2.31 Impact Factor
