Paul Muntner

University of Alabama at Birmingham, Birmingham, Alabama, United States

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Publications (329)1903.95 Total impact

  • JAMA The Journal of the American Medical Association 08/2014; 312(7):750. · 29.98 Impact Factor
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    ABSTRACT: Visit-to-visit variability of blood pressure (BP) has been associated with cardiovascular disease (CVD) and mortality in some but not all studies. We conducted a systematic review and meta-analysis to examine the association between visit-to-visit variability of BP and CVD and all-cause mortality. Medical databases were searched through June 4, 2014, for studies meeting the following eligibility criteria: adult participants; BP measurements at ≥3 visits; follow-up for CVD, coronary heart disease, stroke, or mortality outcomes; events confirmed via database, death certificate, or event ascertainment committee; and adjustment for confounders. Data were extracted by 2 reviewers and pooled using a random-effects model. Overall, 8870 abstracts were identified of which 37 studies, representing 41 separate cohorts, met inclusion criteria. Across studies, visit-to-visit variability of systolic BP and diastolic BP showed significant associations with outcomes in 181 of 312 (58.0%) and 61 of 188 (32.4%) analyses, respectively. Few studies provided sufficient data for pooling risk estimates. For each 5 mm Hg higher SD of systolic BP, the pooled hazard ratio for stroke across 7 cohorts was 1.17 (95% confidence interval [CI], 1.07-1.28), for coronary heart disease across 4 cohorts was 1.27 (95% CI, 1.07-1.51), for CVD across 5 cohorts was 1.12 (95% CI, 0.98-1.28), for CVD mortality across 5 cohorts was 1.22 (95% CI, 1.09-1.35), and for all-cause mortality across 4 cohorts was 1.20 (95% CI, 1.05-1.36). In summary, modest associations between visit-to-visit variability of BP and CVD and all-cause mortality are present in published studies. However, these findings are limited by the small amount of data available for meta-analysis.
    Hypertension 07/2014; · 6.87 Impact Factor
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    ABSTRACT: Few studies have assessed the effectiveness of different drugs for osteoporosis (OP). We aimed to determine if fracture and mortality rates vary among patients initiating different OP medications.
    Clinical and experimental rheumatology 07/2014; · 2.66 Impact Factor
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    ABSTRACT: Introduction: The aim of the study was to identify the association of systolic blood pressure (SBP) levels with cardiovascular events, all-cause mortality, and falls among elderly persons taking antihypertensive medication. Methods: US adults ≥ 45 years of age taking antihypertensive medication enrolled in the REGARDS study were categorized into 3 age groups: 55-64, 65-74 and ≥ 75 years old and baseline on-treatment SBP levels. Our primary analyses focused on incident cardiovascular disease (CVD) (n = 9,787) and all-cause mortality (n = 13,948). Results: During follow-up, 530 (5.4%) participants had CVD events and 2095 (15%) participants died. After multivariable adjustment among participants ≥ 75, the incidence of CVD per 1,000 person-years (95% confidence interval) was 16.9 (11.1-25.7), 13.4 (9.2-19.7), 11.6 (7.6-17.7), 17.8 (11.2-27.5) and 36.7 (26.6-50.8) at SBP levels of < 120, 120-129, 130-139, 140-149, and ≥ 150 mmHg, respectively. For the same SBP categories, the adjusted CVD incidence rates were 9.3 (7.2-12.0), 10.0 (8.1-12.3), 9.4 (7.5-11.8), 14.0 (11.0-17.8), and 16.4 (12.5-21.4), respectively, among participants 55-64 years, and 16.5 (13.6-21.5), 17.4 (14.8-20.6), 19.2 (16.4-22.5), 22.3 (18.6-26.9), and 27.6 (22.7-33.4), respectively, for participants 65-74 years. Among participants aged 55-64 and 65-74 years, a linear association was present between higher SBP categories and all-cause mortality risk (each p-trend < 0.001). In contrast, for participants ≥ 75 years no association was present between SBP and all-cause mortality (p-trend = 0.319). No association was observed between SBP and falls among participants in all age groups. Conclusions: Among adults aged ≥ 55 taking antihypertensive medication, SBP between 120-139 mmHg was significantly associated with a reduced risk for cardiovascular and all-cause mortality outcomes.
    International Journal of Cardiology 07/2014; · 6.18 Impact Factor
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    ABSTRACT: Low statin adherence and discontinuation of statins are common in patients with coronary heart disease. We hypothesized that low antihypertensive medication adherence would be associated with future statin discontinuation and low adherence in patients initiating statins. Using a 5% national sample of Medicare beneficiaries, we conducted a cohort study of Medicare beneficiaries initiating statins after hospitalization for acute myocardial infarction or coronary revascularization in 2007, 2008, and 2009. Antihypertensive medication adherence, defined using the average proportion of days covered across 5 classes during the 365 days before hospitalization, was categorized as ≥80% (high), 50% to <80% (medium), and <50% (low). Statin discontinuation was defined as failure to refill a statin within 365 days of hospital discharge, and low adherence was defined as proportion of days covered for statins <80%. In 2,695 Medicare beneficiaries who initiated statins after hospital discharge, 6.0%, 8.4%, and 14.5% with high, medium, and low antihypertensive medication adherence discontinued statins. After multivariable adjustment, the risk ratios (95% confidence interval) for statin discontinuation were 1.38 (0.98 to 1.95) and 2.41 (1.51 to 3.87) for beneficiaries with medium and low versus high antihypertensive medication adherence, respectively. In beneficiaries who did not discontinue statins, 36.2% had low statin adherence. Compared with high adherence, medium and low antihypertensive medication adherences were associated with multivariable adjusted risk ratios (95% confidence interval) for low statin adherence of 1.33 (1.14 to 1.55) and 1.62 (1.25 to 2.10), respectively. In conclusion, low antihypertensive medication adherence before initiating statins is associated with future statin discontinuation and low statin adherence.
    The American journal of cardiology. 07/2014;
  • The American Journal of the Medical Sciences 06/2014; · 1.33 Impact Factor
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    ABSTRACT: : The 2014 Evidence-Based Guideline for the Management of High Blood Pressure in Adults Report From the Panel Members Appointed to the Eighth Joint National Committee (JNC 8) was recently published. This guideline recommended that older adults (≥60 years) without diabetes or chronic kidney disease with systolic blood pressure (SBP) ≥150 mm Hg or diastolic blood pressure (DBP) ≥90 mm Hg be initiated on antihypertensive medication with a treatment goal SBP/DBP <150/90 mm Hg. In contrast, the previous 3 JNC guidelines recommended treatment for these individuals be initiated at SBP/DBP ≥140/90 mm Hg with goal SBP/DBP <140/90 mm Hg. In this article, we review randomized trials of antihypertensive medication and observational data on SBP and DBP with cardiovascular outcomes among older adults, possible explanations underlying the different findings from these randomized trials and observational studies, and contemporary antihypertensive treatment patterns among older U.S. adults. In closing, we highlight future research needs related to hypertension and outcomes among older adults.
    The American Journal of the Medical Sciences 06/2014; · 1.33 Impact Factor
  • Daichi Shimbo, Rikki M Tanner, Paul Muntner
    JAMA Internal Medicine 06/2014; · 10.58 Impact Factor
  • International Journal of Cardiology. 06/2014; 174(2):436–439.
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    ABSTRACT: Guidelines recommend lifestyle modification for patients with coronary heart disease (CHD). Few data demonstrate which lifestyle modifications, if sustained, reduce recurrent CHD and mortality risk in cardiac patients after the postacute rehabilitation phase. We determined the association between ideal lifestyle factors and recurrent CHD and all-cause mortality in REasons for Geographic and Racial Differences in Stroke study participants with CHD (n = 4,174). Ideal lifestyle factors (physical activity ≥4 times/week, nonsmoking, highest quartile of Mediterranean diet score, and waist circumference <88 cm for women and <102 cm for men) were assessed through questionnaires and an in-home study visit. There were 447 recurrent CHD events and 745 deaths over a median 4.3 and 4.5 years, respectively. After multivariable adjustment, physical activity ≥4 versus no times/week and non-smoking versus current smoking were associated with reduced hazard ratios (HRs; 95% confidence interval [CI]) for recurrent CHD (HR 0.69, 95% CI 0.54 to 0.89 and HR 0.50, 95% CI 0.39 to 0.64, respectively) and death (HR 0.71, 95% CI 0.59 to 0.86 and HR 0.53, 95% CI 0.44 to 0.65, respectively). The multivariable-adjusted HRs (and 95% CIs) for recurrent CHD and death comparing the highest versus lowest quartile of Mediterranean diet adherence were 0.77 (95% CI 0.55 to 1.06) and 0.84 (95% CI 0.67 to 1.07), respectively. Neither outcome was associated with waist circumference. Comparing participants with 1, 2, and 3 versus 0 ideal lifestyle factors (non-smoking, physical activity ≥4 times/week, and highest quartile of Mediterranean diet score), the HRs (and 95% CIs) were 0.60 (95% CI 0.44 to 0.81), 0.49 (95% CI 0.36 to 0.67), and 0.38 (95% CI 0.21 to 0.67), respectively, for recurrent CHD and 0.65 (95% CI 0.51 to 0.83), 0.57 (95% CI 0.43 to 0.74), and 0.41 (95% CI 0.26 to 0.64), respectively, for death. In conclusion, maintaining smoking cessation, physical activity, and Mediterranean diet adherence is important for secondary CHD prevention.
    The American Journal of Cardiology. 06/2014; 113(12):1933–1940.
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    ABSTRACT: Few data exist on whether healthy lifestyle factors are associated with better prognosis among individuals with apparent treatment-resistant hypertension, a high-risk phenotype of hypertension. The purpose of this study was to assess the association of healthy lifestyle factors with cardiovascular events, all-cause mortality, and cardiovascular mortality among individuals with apparent treatment-resistant hypertension. We studied participants (n=2043) from the population-based Reasons for Geographic and Racial Differences in Stroke (REGARDS) study with apparent treatment-resistant hypertension (blood pressure ≥140/90 mm Hg despite the use of 3 antihypertensive medication classes or the use of ≥4 classes of antihypertensive medication regardless of blood pressure control). Six healthy lifestyle factors adapted from guidelines for the management of hypertension (normal waist circumference, physical activity ≥4 times/week, nonsmoking, moderate alcohol consumption, high Dietary Approaches to Stop Hypertension diet score, and low sodium-to-potassium intake ratio) were examined. A greater number of healthy lifestyle factors were associated with lower risk for cardiovascular events (n=360) during a mean follow-up of 4.5 years. Multivariable-adjusted hazard ratios [HR (95% confidence interval)] for cardiovascular events comparing individuals with 2, 3, and 4 to 6 versus 0 to 1 healthy lifestyle factors were 0.91 (0.68-1.21), 0.80 (0.57-1.14), and 0.63 (0.41-0.95), respectively (P-trend=0.020). Physical activity and nonsmoking were individual healthy lifestyle factors significantly associated with lower risk for cardiovascular events. Similar associations were observed between healthy lifestyle factors and risk for all-cause and cardiovascular mortality. In conclusion, healthy lifestyle factors, particularly physical activity and nonsmoking, are associated with a lower risk for cardiovascular events and mortality among individuals with apparent treatment-resistant hypertension.
    Hypertension 06/2014; · 6.87 Impact Factor
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    ABSTRACT: Statins reduce the risk of coronary heart disease (CHD) in individuals with a history of CHD or risk equivalents. A 10-year CHD risk >20% is considered a risk equivalent but is frequently not detected. Statin use and low-density lipoprotein cholesterol (LDL-C) control were examined among participants with CHD or risk equivalents in the nationwide Reasons for Geographic and Racial Differences in Stroke study (n = 8812).
    The American Journal of the Medical Sciences 06/2014; · 1.33 Impact Factor
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    ABSTRACT: The prevalence of reduced estimated glomerular filtration rate (eGFR) among U.S. adults aged 80 years and older increased between 1988 to 1994 and 2005 to 2010. Trends in the prevalence of albuminuria over this time period have not been reported in this population.
    The American Journal of the Medical Sciences 05/2014; · 1.33 Impact Factor
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    ABSTRACT: To examine the association of serum inflammatory markers (erythrocyte sedimentation rate (ESR) and C-reactive protein (CRP)) and serum lipid measures (low-density lipoprotein (LDL)- and high-density lipoprotein (HDL)-cholesterol) with risk of myocardial infarction (MI) and ischaemic stroke (IS) among rheumatoid arthritis (RA) patients. We conducted a retrospective cohort study using 2005-2010 data from a US commercial health plan. Eligible patients had two or more physician diagnoses of RA during a baseline period of at least 180 days with continuous medical and pharmacy coverage. We computed age-adjusted incidence rates of MI and IS, and used spline regression to assess non-linear associations and Cox-regression to quantify the independent association between the laboratory values and the outcomes. We identified 44 418 eligible RA patients (mean age 49 years; 76% women). CRP>10 mg/L compared with <1 mg/L was associated with increased MI risk (HR 2.12; 95% CI 1.02 to 4.38). ESR>42 mm/h compared with <14 mm/h was associated with increased risk of MI (HR 2.53; 95% CI 1.48 to 4.31) and IS (HR 2.51; 95% CI 1.33 to 4.75) risk. HDL-cholesterol ≥60 mg/dL (1.6 mmol/L) compared with <40 mg/dL (1.0 mmol/L) was associated with reduced MI risk (HR 0.37; 0.21 to 0.66). The association between LDL and MI was not linear; the lowest risk was observed among patients with LDL between 70 mg/L (1.8 mmol/L) and 100 mg/L (2.6 mmol/L). We did not observe a significant association between LDL and IS. This study provides evidence supporting the hypothesis that RA-related systemic inflammation plays a role in determining cardiovascular risk and a complex relationship between LDL and cardiovascular risk.
    Annals of the rheumatic diseases 05/2014; · 8.11 Impact Factor
  • Usman Baber, Paul Muntner
    American Journal of Kidney Diseases 05/2014; 63(5):736-8. · 5.29 Impact Factor
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    ABSTRACT: Databases of medical claims can be valuable resources for cardiovascular research, such as comparative effectiveness and pharmacovigilance studies of cardiovascular medications. However, claims data do not include all of the factors used for risk stratification in clinical care. We sought to develop claims-based algorithms to identify individuals at high estimated risk for coronary heart disease (CHD) events, and to identify uncontrolled low-density lipoprotein (LDL) cholesterol among statin users at high risk for CHD events. We conducted a cross-sectional analysis of 6,615 participants >=66 years old using data from the REasons for Geographic And Racial Differences in Stroke (REGARDS) study baseline visit in 2003-2007 linked to Medicare claims data. Using REGARDS data we defined high risk for CHD events as having a history of CHD, at least 1 risk equivalent, or Framingham CHD risk score >20%. Among statin users at high risk for CHD events we defined uncontrolled LDL cholesterol as LDL cholesterol >=100 mg/dL. Using Medicare claims-based variables for diagnoses, procedures, and healthcare utilization, we developed algorithms for high CHD event risk and uncontrolled LDL cholesterol. REGARDS data indicated that 49% of participants were at high risk for CHD events. A claims-based algorithm identified high risk for CHD events with a positive predictive value of 87% (95% CI: 85%, 88%), sensitivity of 69% (95% CI: 67%, 70%), and specificity of 90% (95% CI: 89%, 91%). Among statin users at high risk for CHD events, 30% had LDL cholesterol >=100 mg/dL. A claims-based algorithm identified LDL cholesterol >=100 mg/dL with a positive predictive value of 43% (95% CI: 38%, 49%), sensitivity of 19% (95% CI: 15%, 22%), and specificity of 89% (95% CI: 86%, 90%). Although the sensitivity was low, the high positive predictive value of our algorithm for high risk for CHD events supports the use of claims to identify Medicare beneficiaries at high risk for CHD events.
    BMC Health Services Research 04/2014; 14(1):195. · 1.77 Impact Factor
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    ABSTRACT: Elucidation of the relationship between age, kidney function, and absolute coronary risk would facilitate efforts to promote chronic kidney disease (CKD) as a high-risk state for future vascular events and justify current recommendations for statin treatment in CKD. Population-based study. 1,268,538 people with data for estimated glomerular filtration rate and albuminuria who were treated in a single Canadian province. CKD risk groups (G1, G2, G3a, G3b, and G4 had estimated glomerular filtration rate≥90, 60-89.9, 45-59.9, 30-44.9, and 15-29.9mL/min/1.73m(2), respectively; A1, A2, and A3 had albuminuria with albumin-creatinine ratio [ACR]<30mg/g or dipstick urinalysis negative, ACR of 30-300mg/g or dipstick trace or 1+, and ACR>300mg/g or dipstick ≥ 2+, respectively) and age (<40, 40-49, ≥50 years). Rates of coronary death or nonfatal myocardial infarction (expressed per 1,000 person-years), stratified by age, sex, and CKD stage. The first available serum creatinine value and the corresponding date were set as the index serum creatinine value and index date, respectively. ACR or dipstick urinalysis data were obtained from the periods defined by 6 months before and after the index creatinine value. Absolute rates of coronary death or nonfatal myocardial infarction were consistently greater than 10 per 1,000 person-years for people with CKD and 50 years or older, regardless of CKD stage. However, absolute rates of the composite outcome were consistently less than 10 per 1,000 person-years for those younger than 50 years. Single Canadian province, median follow-up only 4.0 years. People with CKD who are 50 years or older should be considered at the highest risk of coronary events. In contrast, consideration of other risk factors will be required when assessing future risk among people with CKD who are younger than 50 years.
    American Journal of Kidney Diseases 04/2014; · 5.29 Impact Factor
  • International journal of cardiology 04/2014; · 6.18 Impact Factor
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    ABSTRACT: Low adherence to bisphosphonate therapy is associated with increased fracture risk. Factors associated with discontinuation of osteoporosis medications have not been studied in-depth. This study assessed medication discontinuation and switching patterns among Medicare beneficiaries who were new users of bisphosphonates and evaluated factors possibly associated with discontinuation. We identified patients initiating bisphosphonate treatment using a 5% random sample of Medicare beneficiaries with at least 24 months of traditional fee-for-service and part D drug coverage from 2006 through 2009. We classified medication status at the end of follow-up as: continued original bisphosphonate, discontinued without switching or restarting, restarted the same drug after a treatment gap (>= 90 days), or switched to another anti-osteoporosis medication. We conducted logistic regression analyses to identify baseline characteristics associated with discontinuation and a case-crossover analysis to identify factors that precipitate discontinuation. Of 21,452 new users followed respectively for 12 months, 44% continued their original therapy, 36% discontinued without switching or restarting, 8% restarted the same drug after a gap greater than 90 days, and 11% switched to another anti-osteoporosis medication. Factors assessed during the 12-month period before initiation were weakly associated with discontinuation. Several Factors measured during follow-up were associated with discontinuation, including more physician visits, hospitalization, having a dual-energy X-ray absorptiometry test, higher Charlson comorbidity index scores, higher out-of-pocket drug payments, and upper gastrointestinal problems. Patterns were similar for 4,738 new users followed for 30 months. Among new bisphosphonates users, switching within and across drug classes and extended treatment gaps are common. Robust definitions and time-varying considerations should be considered to characterize medication discontinuation more accurately.
    BMC Musculoskeletal Disorders 04/2014; 15(1):112. · 1.88 Impact Factor
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    ABSTRACT: Few randomized trials have compared visit-to-visit variability (VVV) of systolic blood pressure (SBP) across drug classes. The authors compared VVV of SBP among 24,004 participants randomized to chlorthalidone, amlodipine, or lisinopril in the Antihypertensive and Lipid-Lowering Treatment to Prevent Heart Attack Trial (ALLHAT). VVV of SBP was calculated across 5 to 7 visits occurring 6 to 28 months following randomization. The standard deviation (SD) of SBP was 10.6 (SD=5.0), 10.5 (SD=4.9), and 12.2 (SD=5.8) for participants randomized to chlorthalidone, amlodipine, and lisinopril, respectively. After multivariable adjustment including mean SBP across visits and compared with participants randomized to chlorthalidone, participants randomized to amlodipine had a 0.36 (standard error [SE]: 0.07) lower SD of SBP and participants randomized to lisinopril had a 0.77 (SE=0.08) higher SD of SBP. Results were consistent using other VVV of SBP metrics. These data suggest chlorthalidone and amlodipine are associated with lower VVV of SBP than lisinopril.
    Journal of Clinical Hypertension 04/2014; · 2.36 Impact Factor

Publication Stats

11k Citations
1,903.95 Total Impact Points


  • 2009–2014
    • University of Alabama at Birmingham
      • Department of Epidemiology
      Birmingham, Alabama, United States
    • University of Alberta
      • Department of Medicine
      Edmonton, Alberta, Canada
    • Kaiser Permanente
      • Center for Health Research (Oregon, Hawaii, and Georgia)
      Oakland, CA, United States
    • Mount Sinai Hospital
      New York City, New York, United States
  • 2013
    • University of California, San Francisco
      • Division of Hospital Medicine
      San Francisco, CA, United States
    • University of South Carolina School of Medicine - Greenville
      Greenville, South Carolina, United States
    • Wake Forest School of Medicine
      Winston-Salem, North Carolina, United States
  • 2012–2013
    • Columbia University
      • Department of Medicine
      New York City, NY, United States
    • East Carolina University
      North Carolina, United States
    • Boston University
      • Department of Medicine
      Boston, Massachusetts, United States
    • Beth Israel Deaconess Medical Center
      Boston, Massachusetts, United States
  • 2010–2013
    • University of Alabama
      Tuscaloosa, Alabama, United States
    • NYU Langone Medical Center
      New York City, New York, United States
    • Montefiore Medical Center
      • Albert Einstein College of Medicine
      New York City, NY, United States
  • 2008–2013
    • Mount Sinai School of Medicine
      • Department of Medicine
      Manhattan, NY, United States
    • University of Pennsylvania
      Philadelphia, Pennsylvania, United States
  • 2002–2013
    • Tulane University
      • • Department of Epidemiology
      • • Section of General Internal Medicine & Geriatrics
      • • Department of Medicine
      New Orleans, Louisiana, United States
  • 2010–2012
    • West Virginia University
      • Department of Community Medicine
      Morgantown, WV, United States
  • 2005–2012
    • Ochsner
      • Center for Health Research
      New Orleans, Louisiana, United States
    • Beijing Fuwai Hospital
      Peping, Beijing, China
  • 2011
    • Brigham and Women's Hospital
      • Division of Cardiovascular Medicine
      Boston, MA, United States
    • Loyola University Medical Center
      Maywood, Illinois, United States
    • Tufts Medical Center
      Boston, Massachusetts, United States
    • Tufts University
      • Tufts Center for Conservation Medicine
      Medford, MA, United States
    • Stanford University
      • Division of Nephrology
      Stanford, CA, United States
    • Rush University Medical Center
      Chicago, Illinois, United States
    • University of Texas Southwestern Medical Center
      • Department of Internal Medicine
      Dallas, TX, United States
  • 2008–2011
    • Albert Einstein College of Medicine
      • • Department of Epidemiology & Population Health
      • • Department of Medicine
      New York City, NY, United States
    • National Heart, Lung, and Blood Institute
      • Center for Population Studies (CPS)
      Maryland, United States
  • 2007–2011
    • Emory University
      • Division of Cardiology
      Atlanta, Georgia, United States
  • 2002–2011
    • Johns Hopkins Bloomberg School of Public Health
      • Department of Epidemiology
      Baltimore, MD, United States
  • 2002–2009
    • Johns Hopkins University
      • Department of Medicine
      Baltimore, Maryland, United States
  • 2004
    • Peking Union Medical College Hospital
      Peping, Beijing, China
    • University of North Carolina at Chapel Hill
      • Department of Epidemiology
      Chapel Hill, NC, United States
  • 2003
    • National Institute of Environmental Health Sciences
      • Epidemiology Branch
      Durham, NC, United States
  • 2000–2001
    • University of Geneva
      • Institute of Social and Preventive Medicine
      Genève, GE, Switzerland