Urmimala Sarkar

University of California, San Francisco, San Francisco, California, United States

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Publications (60)217.94 Total impact

  • Courtney R Lyles, Urmimala Sarkar
    Journal of General Internal Medicine 01/2015; DOI:10.1007/s11606-014-3166-5 · 3.42 Impact Factor
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    ABSTRACT: Objectives To determine the prevalence of preadmission functional disability in late-middle-aged and older safety-net inpatients and to identify characteristics associated with functional disability by age.DesignCross-sectional analysis.SettingSafety-net hospital in San Francisco, California.ParticipantsEnglish-, Spanish-, and Chinese-speaking community-dwelling individuals aged 55 and older admitted to a safety-net hospital with anticipated return to the community (N = 699).MeasurementsAt hospital admission, participants reported their need for help performing five activities of daily living (ADLs) and seven instrumental activities of daily living (IADLs) 2 weeks before admission. ADL disability was defined as needing help performing one or more ADLs and IADL disability as needing help performing two or more IADLs. Participant characteristics were assessed, including sociodemographic characteristics, health status, health-related behaviors, and health-seeking behaviors.ResultsOverall, 28.3% of participants reported that they had an ADL disability 2 weeks before admission, and 40.4% reported an IADL disability. The prevalence of preadmission ADL disability was 28.9% of those aged 55 to 59, 20.7% of those aged 60 to 69, and 41.2% of those aged 70 and older (P < .001). The prevalence of IADL disability had a similar distribution. The characteristics associated with functional disability differed according to age; in participants aged 55 to 59, African Americans had a higher odds of ADL and IADL disability, whereas in participants aged 60 to 69 and aged 70 and older, inadequate health literacy was associated with functional disability.Conclusion Preadmission functional disability is common in individuals aged 55 and older admitted to a safety-net hospital. Late-middle-aged individuals admitted to safety-net hospitals may benefit from models of acute care currently used for older adults that prevent adverse outcomes associated with functional disability.
    Journal of the American Geriatrics Society 11/2014; DOI:10.1111/jgs.13103 · 4.22 Impact Factor
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    ABSTRACT: Hospitals are implementing discharge support programs to reduce readmissions, and these programs have had mixed success.
    Annals of internal medicine 10/2014; 161(7):472-481. DOI:10.7326/M14-0094 · 16.10 Impact Factor
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    ABSTRACT: Background: Delayed and missed diagnoses lead to significant patient harm. Because physician actions are fundamental to the outpatient diagnostic process, a study was conducted to explore physician perspectives on diagnosis.Methods: As part of a quality improvement initiative, an integrated health system conducted six physician focus groups in 2004 and 2005. The focus groups included questions about the process of diagnosis, specific factors contributing to missed diagnosis, use of guidelines, atypical vs. typical presentations of disease, diagnostic tools, and follow-up, all with regard to delays in the diagnostic process. The interviews were analyzed (1) deductively, with application of the Systems Engineering Initiative for Patient Safety (SEIPS) model, which addresses systems design, quality management, job design, and technology implementations that affect safety-related patient and organizational and/or staff outcomes, and (2) inductively, with identification of novel themes using content analysis.Results: A total of 25 physicians participated in the six focus groups, which yielded 12 hours of discussion. Providers identified multiple barriers to timely and accurate diagnosis, including organizational culture, information availability, and communication factors.Conclusions: Multiple themes relating to each of the participants in the diagnostic process—health system, provider, and patient—emerged. Concerns about health system structure and providers' interactions with one another and with patients far exceeded discussion of the cognitive factors that might affect the diagnostic process. The results suggest that, at least in physicians' views, improving the diagnostic process requires attention to the organization of the health system in addition to the cognitive aspects of diagnosis.
    Joint Commission journal on quality and patient safety / Joint Commission Resources 10/2014; 40(10).
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    ABSTRACT: Consumer health technologies can educate patients about diabetes and support their self-management, yet usability evidence is rarely published even though it determines patient engagement, optimal benefit of any intervention, and an understanding of generalizability. Therefore, we conducted a narrative review of peer-reviewed articles published from 2009 to 2013 that tested the usability of a web- or mobile-delivered system/application designed to educate and support patients with diabetes. Overall, the 23 papers included in our review used mixed (n = 11), descriptive quantitative (n = 9), and qualitative methods (n = 3) to assess usability, such as documenting which features performed as intended and how patients rated their experiences. More sophisticated usability evaluations combined several complementary approaches to elucidate more aspects of functionality. Future work pertaining to the design and evaluation of technology-delivered diabetes education/support interventions should aim to standardize the usability testing processes and publish usability findings to inform interpretation of why an intervention succeeded or failed and for whom.
    Current Diabetes Reports 10/2014; 14(10):534. DOI:10.1007/s11892-014-0534-9 · 3.38 Impact Factor
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    ABSTRACT: OBJECTIVES: To describe barriers to recovery at home for vulnerable older adults after leaving the hospital. DESIGN: Standard qualitative research techniques, including purposeful sampling of participants according to age, sex, race, and English proficiency, were used to ensure a wide breadth of experiences. All participants were interviewed in their native language (English, Spanish, or Chinese). Two investigators independently coded interviews using the constant comparative method. The entire research team, with diverse backgrounds in primary care, hospital medicine, geriatrics, and nursing, performed thematic analysis. SETTING: Urban public safety-net teaching hospital. PARTICIPANTS: Vulnerable older adults (low income and health literacy, limited English proficiency) enrolled in a larger discharge interventional study. MEASUREMENTS: Qualitative data (participant quotations) were organized into themes. RESULTS: Twenty-four individuals with a mean age of 63 (range 55-84), 66% male, 67% nonwhite, 16% Spanish speaking, 16% Chinese speaking were interviewed. An overarching theme of "missing pieces" was identified in the plan for postdischarge recovery at home, from which three specific subthemes emerged: functional limitations and difficulty with mobility and self-care tasks, social isolation and lack of support from family and friends, and challenges from poverty and the built environment at home. In contrast, participants described mostly supportive experiences with traditional focuses of transition, care such as following prescribed medication and diet regimens. CONCLUSION: Hospital-based discharge interventions that focus on traditional aspects of care may overlook social and functional gaps in postdischarge care at home for vulnerable older adults. Postdischarge interventions that address these challenges may be necessary to reduce readmissions in this population.
    Journal of the American Geriatrics Society 06/2014; 62(8). DOI:10.1111/jgs.12928 · 4.22 Impact Factor
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    Journal of alternative and complementary medicine (New York, N.Y.); 05/2014
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    ABSTRACT: Adverse drug events (ADEs) among patients self-administering medications in home/community settings are a common cause of emergency department (ED) visits, but the causes of these ambulatory ADEs remain unclear. Root cause analysis, rarely applied in outpatient settings, may reveal the underlying factors that contribute to adverse events. To elicit patient and provider perspectives on ambulatory ADEs and apply root cause analysis methodology to identify cross-cutting themes among these events. Emergency department clinical pharmacists screened, identified, and enrolled a convenience sample of adult patients 18 years or older who presented to a single, urban, academic ED with symptoms or diagnoses consistent with suspected ADEs. Semistructured phone interviews were conducted with the patients and their providers. We conducted a qualitative analysis. We applied a prespecified version of the injury prevention framework (deductive coding), identifying themes relating to the agent (drug), host (patient), and environment (social and health systems). These themes were used to construct a root cause analysis for each ADE. From 18 interviews overall, we identified the following themes within the injury prevention framework. Agent factors included high-risk drugs, narrow therapeutic indices, and uncommon severe effects. Host factors included patient capacity or understanding of how to use medications, awareness of side effects, mistrust of the medical system, patients with multiple comorbidities, difficult risk-benefit assessments, and high health-care users. Environmental factors included lack of social support, and health systems issues included access to care, encompassing medication availability, access to specialists, and a lack of continuity and communication among prescribing physicians. Root cause analysis revealed multiple underlying factors relating to agent, host, and environment for each event. Patient and physician perspectives can inform a root cause analysis of ambulatory ADEs. Such methodology may be applied to understand the factors that contribute to ambulatory ADEs and serve as the formative work for future interventions improving home/community medication use.
    Journal of Patient Safety 02/2014; DOI:10.1097/PTS.0000000000000072 · 0.88 Impact Factor
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    ABSTRACT: Improved drug labelling for chronic pill-form medications has been shown to promote patient comprehension, adherence and safety. We extended health literacy principles and included patients' perspectives to improve instructions for: (1) non-pill form, (2) short term, (3) 'as needed,' (4) tapered and (5) escalating dose medications. Participants were recruited via convenience sampling from primary care clinics in Chicago, Illinois and San Francisco, California, USA. 40 adult, English-speaking participants who reported taking at least one prescription drug in the past 12 months were enrolled in the study. Participant opinions, preferences and comprehension of standard and improved medication instructions were assessed during four iterative waves of discussion groups. Brief interviews preceding the discussion groups measured individuals' literacy skills, sociodemographic and health characteristics. On average, participants were 46 years old, took four medications and reported two chronic health conditions. Patients varied sociodemographically; 40% were men and 33% had limited literacy skills. Patients agreed on the need for simpler terminology and specificity in instructions. Discussions addressed optimal ways of presenting numeric information, indication and duration of use information to promote comprehension and safe medication use. Consensus was reached on how to improve most of the instructions. Through this patient-centred approach, we developed a set of health literacy-informed instructions for more challenging medications. Findings can inform current drug labelling initiatives and promote safe and appropriate medication use.
    BMJ Open 01/2014; 4(1):e003699. DOI:10.1136/bmjopen-2013-003699 · 2.06 Impact Factor
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    ABSTRACT: Background. Social risk factors for hypoglycemia are not well understood. Methods. Cross-sectional analysis from the DISTANCE study, a multi-language, ethnically-stratified random sample of adults in the Kaiser Permanente Northern California diabetes registry, conducted in 2005-2006 (response rate 62%). Exposures were income and educational attainment; outcome was patient report of severe hypoglycemia. To test the association, we used multivariable logistic regression to adjust for demographic and clinical factors. Results. 14,357 patients were included. Reports of severe hypoglycemia were common (11%), and higher in low-income vs. high-income (16% vs. 8.8) and low-education vs. high-education (11.9% vs. 8.9%) groups. In multivariable analysis, incomes of less than $15,000 (OR 1.51 95%CI 1.19-1.91), $15,000-$24,999 (OR 1.57 95%CI 1.27-1.94), and high school or less education (OR 1.42, 95% CI 1.24-1.63) were associated with increased hypoglycemia, similar to insulin use (OR 1.44 95%CI 1.19-1.74). Conclusions. Low income and educational attainment are important risk factors for hypoglycemia.
    Journal of Health Care for the Poor and Underserved 01/2014; 25(2):478-90. DOI:10.1353/hpu.2014.0106 · 1.10 Impact Factor
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    ABSTRACT: Safety net systems need innovative diabetes self-management programs for linguistically diverse patients. A low-income government-sponsored managed care plan implemented a 27-week automated telephone self-management support/health coaching intervention for English-, Spanish-, and Cantonese-speaking members from 4 publicly funded clinics in a practice-based research network. Compared to waitlist, immediate intervention participants had greater 6-month improvements in overall diabetes self-care behaviors (standardized effect size [ES] = 0.29, P < .01) and 12-Item Short Form Health Survey physical scores (ES = 0.25, P = .03); changes in patient-centered processes of care and cardiometabolic outcomes did not differ. Automated telephone self-management is a strategy for improving patient-reported self-management and may also improve some outcomes.
    The Journal of ambulatory care management 01/2014; 37(2):127-37. DOI:10.1097/JAC.0000000000000019
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    ABSTRACT: Online patient portals are being widely implemented, but their impact on health behaviors are not well-studied. To determine whether statin adherence improved after initiating use of the portal refill function. Observational cohort study within an integrated health care delivery system. Diabetic patients on statins who had registered for online portal access by 2010. A total of 8705 subjects initiated the online refill function use within the study window, including "exclusive" and "occasional" users (ie, requesting all vs. some refills online, respectively). Using risk-set sampling, we temporally matched 9055 reference group patients who never used online refills. We calculated statin adherence before and after refill function initiation, assessed as percent time without medications (nonadherence defined as a gap of >20%). Secondary outcome was dyslipidemia [low-density lipoprotein (LDL)≥100]. Difference-in-differences regression models estimated pre-post changes in nonadherence and dyslipidemia, comparing refill function users to the reference group and adjusting for age, sex, race/ethnicity, medications, frequency of portal use, and outpatient visits. In unadjusted examinations, nonadherence decreased only among patients initiating occasional or exclusive use of the refill function (26%-24% and 22%-15%, respectively). In adjusted models, nonadherence declined by an absolute 6% (95% confidence interval, 4%-7%) among exclusive users, without significant changes among occasional users. Similar LDL decreases were also seen among exclusive users. Compared with portal users who did not refill medications online, adherence to statin medications and LDL levels improved among diabetic patients who initiated and exclusively used the patient portal for refills, suggesting that wider adoption of online refills may improve adherence.
    Medical care 12/2013; 52(3). DOI:10.1097/MLR.0000000000000069 · 2.94 Impact Factor
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    ABSTRACT: Background: Explicit knowledge of CAM use can help clinicians and patients make informed treatment plans. However, CAM use among patients with chronic illnesses is poorly understood, as is the extent to which CAM use is self-disclosed to providers. Objective: To report the prevalence of CAM use and disclosure to providers among ethnically diverse safety-net patients with diabetes enrolled in a diabetes self-management support program. Methods: Within a Medicaid managed care program providing language-concordant health coaching to patients with poorly controlled diabetes, the San Francisco Health Plan's Smart Steps Program enrolled 362 participants between 2009-2011. Six and twelve month telephone interviews collected self-reported CAM use in the preceding 30 days, based on a 12-domain validated instrument in English, Spanish and Cantonese. Results: Seventy-seven percent (n=278) of participants completed follow-up interviews including demographics and CAM use. Participants were predominantly Asian (60.1%) or Latino (22.6%), female (74.1%), and non-English-speaking (71.9%). Mean age was 55 years, with a mean of 7.0 years with diabetes. Any CAM use was reported by 51.4% of participants. Specific modalities included: vitamins/nutritional supplements (25.9%), natural remedies/herbs (24.5%), massage/acupressure (11.5%), and meditation/yoga/tai chi (10.4%) at a median monthly cost of $33 (range 0-$1200). Nearly a third (30.0%) used CAM specifically for diabetes; 47.2% did not disclose CAM use to a clinician, for reasons including no one asked' and didn't think they needed to know'. Conclusions: CAM use is common among this diverse safety net population, for general health and for diabetes, but disclosure to clinicians is incomplete. Barriers to disclosure should be explored to improve health communication around diabetes care.
    141st APHA Annual Meeting and Exposition 2013; 11/2013
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    ABSTRACT: Health reform requires safety net settings to transform care delivery, but how they will innovate in order to achieve this transformation is unknown. Two series of key informant interviews (N = 28) were conducted in 2012 with leadership from both California's public hospital systems and community health centers. Interviews focused on how innovation was conceptualized and solicited examples of successful innovations. In contrast to disruptive innovation, interviewees often defined innovation as improving implementation, making incremental changes, and promoting integration. Many leaders gave examples of existing innovative practices to meeting their diverse patient needs, such as patient-centered approaches. Participants expressed challenges to adapting quickly, but a desire to partner together. Safety net systems have already begun implementing innovative practices supporting their key priority areas. However, more support is needed, specifically to accelerate the change needed to succeed under health reform.
    American Journal of Medical Quality 10/2013; 29(6). DOI:10.1177/1062860613507474 · 1.78 Impact Factor
  • Alissa Detz, Andrea López, Urmimala Sarkar
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    ABSTRACT: Continuity of patient care is one of the cornerstones of primary care. To examine publicly available, Internet-based reviews of adult primary care physicians, specifically written by patients who report long-term relationships with their physicians. This substudy was nested within a larger qualitative content analysis of online physician ratings. We focused on reviews reflecting an established patient-physician relationship, that is, those seeing their physicians for at least 1 year. Of the 712 Internet reviews of primary care physicians, 93 reviews (13.1%) were from patients that self-identified as having a long-term relationship with their physician, 11 reviews (1.5%) commented on a first-time visit to a physician, and the remainder of reviews (85.4%) did not specify the amount of time with their physician. Analysis revealed six overarching domains: (1) personality traits or descriptors of the physician, (2) technical competence, (3) communication, (4) access to physician, (5) office staff/environment, and (6) coordination of care. Our analysis shows that patients who have been with their physician for at least 1 year write positive reviews on public websites and focus on physician attributes.
    Journal of Medical Internet Research 07/2013; 15(7):e131. DOI:10.2196/jmir.2552 · 4.67 Impact Factor
    This article is viewable in ResearchGate's enriched format
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    ABSTRACT: Patient-provider relationships influence diabetes care; less is known about their impact on online patient portal use. Diabetes patients rated provider communication and trust. In this study, we linked responses to electronic medical record data on being a registered portal user and using secure messaging (SM). We specified regression models to evaluate main effects on portal use, and subgroup analyses by race/ethnicity and age. 52% of subjects were registered users; among those, 36% used SM. Those reporting greater trust were more likely to be registered users (relative risk (RR)=1.14) or SM users (RR=1.29). In subgroup analyses, increased trust was associated with being a registered user among white, Latino, and older patients, as well as SM use among white patients. Better communication ratings were also related to being a registered user among older patients. Since increased trust and communication were associated with portal use within subgroups, this suggests that patient-provider relationships encourage portal engagement.
    Journal of the American Medical Informatics Association 05/2013; DOI:10.1136/amiajnl-2012-001567 · 3.57 Impact Factor
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    ABSTRACT: Interactive health information technology (HIT) can support the complex self-management tasks for diabetes. However, less is known about between-visit interactions and patient safety among chronic illness patients treated in the outpatient setting. We classified 13 categories for safety events and potential safety events within a larger trial evaluating a multilingual automated telephone self-management support system for diabetes using interactive voice response. Participants could trigger safety concerns by reporting hyperglycemia or hypoglycemia, inability to obtain medications, medication nonadherence and side effects, and needing appointments and/or supplies. We then examined these triggers across patient demographic and health characteristics to determine which patients were most likely to experience safety events. Overall, there were 360 safety triggers that occurred among 155 participants, which represented 53% of individuals and 7.6% of all automated calls over the 27-week intervention. The most common triggers were for pain or medication side effects (22%) and not checking blood sugars (13%). In adjusted models, race/ethnicity and language were related to safety triggers; Spanish-speaking participants were significantly (p = .02) more likely than English-speaking participants to experience a safety trigger, and black participants were marginally more likely (p = .09) than white participants to experience a safety trigger. About half of patients enrolled in a self-management technology intervention triggered at least one potential safety event over the course of the trial, and this was more frequent among some patients. Systems implementing HIT strategies to improve self-care and remote monitoring should consider specific program design elements to address these potential safety events.
    Journal of diabetes science and technology 05/2013; 7(3):596-601. DOI:10.1177/193229681300700303
  • JAMA Internal Medicine 03/2013; 173(8):1-2. DOI:10.1001/jamainternmed.2013.2807 · 13.25 Impact Factor
  • Courtney R Lyles, Urmimala Sarkar
    BMJ quality & safety 03/2013; 22(8). DOI:10.1136/bmjqs-2013-001893 · 3.28 Impact Factor
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    ABSTRACT: Diabetes complications account for significant worldwide morbidity and mortality. Improving glycemic control decreases microvascular complications, particularly among patients with the worst control. Current performance measures fail to prioritize such individuals. The categorization of glycemic control within a safety-net clinic population was compared using a common performance measure against one derived from a metric accounting for change in glycated hemoglobin (A1c) over time. Retrospective cohort analysis of all patients in a safety-net primary care clinic population quality registry with confirmed diabetes mellitus who had at least two A1c values between 2007 through 2011. Patients were stratified into five groups' on the basis of maximum and earliest A1c level (< 7%, 7% to < 8%, 8% to < 9%, 9% to < 10%, and > 10%). The change in Alc was assessed over time and compared with standard healthcare effectiveness data and information set (HEDIS) performance measures. Some 1122 patients were included in the analysis, with mean A1c of 7.9%. There was a modest annual decrease in the average A1c, and > 19% of patients improved by 1% or more during each of the previous three years. For patients who had maximum A1c values > or = 10%, there was a significantly greater reduction in A1c (p < .01), which was not reflected in the standard performance measure. It is feasible for safety-net clinics to analyze their patients with diabetes by level of disease control on the basis of change in A1c over time. Patients with the worst glycemic control tend to have the greatest improvement but are often overlooked by conventional performance measures. Improved performance measures should focus on longitudinal diabetes control and emphasize reducing risk of complications among patients at highest risk.
    Joint Commission journal on quality and patient safety / Joint Commission Resources 03/2013; 39(3):109-13.

Publication Stats

779 Citations
217.94 Total Impact Points


  • 2006–2015
    • University of California, San Francisco
      • • Center for Vulnerable Populations (CVP)
      • • Division of Hospital Medicine
      • • Department of Medicine
      • • Division of General Internal Medicine
      San Francisco, California, United States
  • 2013
    • Beverly Hospital, Boston MA
      Beverly, Massachusetts, United States
  • 2012–2013
    • CSU Mentor
      • Department of Medicine
      Long Beach, California, United States
  • 2010–2013
    • San Francisco VA Medical Center
      San Francisco, California, United States
  • 2011
    • Kaiser Permanente
      Oakland, California, United States