Leonard E Egede

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

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Publications (197)651.75 Total impact

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    Joni Strom Williams · Rebekah J. Walker · Leonard E. Egede
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    ABSTRACT: For decades, disparities in health have been well documented in the United States and regrettably, remain prevalent despite evidence and appeals for their elimination. Compared with the majority, racial and ethnic minorities continue to have poorer health status and health outcomes for most chronic conditions, including diabetes mellitus, cardiovascular disease, cancer and end-stage renal disease. Many factors, such as affordability, access and diversity in the healthcare system, influence care and outcomes, creating challenges that make the task of eliminating health disparities and achieving health equity daunting and elusive. Novel strategies are needed to bring about much needed change in the complex and evolving United States healthcare system. Although not exhaustive, opportunities such as (1) developing standardized race measurements across health systems, (2) implementing effective interventions, (3) improving workforce diversity, (4) using technological advances and (5) adopting practices such as personalized medicine may serve as appropriate starting points for moving toward health equity. Over the past several decades, diversity in the U.S. population has increased significantly and is expected to increase exponentially in the near future. As the population becomes more diverse, it is important to recognize the possibilities of new and emerging disparities. It is imperative that steps are taken to eliminate the current gap in care and prevent new disparities from developing. Therefore, we present challenges and offer recommendations for facilitating the process of eliminating health disparities and achieving health equity across diverse populations.
    Preview · Article · Jan 2016 · The American Journal of the Medical Sciences
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    ABSTRACT: The purpose of this review was to determine whether mHealth interventions were effective in low- and middle-income countries in order to create a baseline for the evidence to support mHealth in developing countries. Studies were identified by searching Medline on 02 October 2014 for articles published in the English language between January 2000 and September 2014. Inclusion criteria were: 1) written in English, 2) completion of an mHealth intervention in a low or middle-income country, 3) measurement of patient outcomes, and 4) participants 18 years of age or older. 7,920 titles were reviewed and 7 were determined eligible based on inclusion criteria. Interventions included a cluster randomized trial, mixed methods study, retrospective comparison of an opt-in text message program, a two-arm proof of concept, single arm trial, a randomized trial, and a single subject design. Five out of seven of the studies showed significant difference between the control and intervention. Currently there is little evidence on mHealth interventions in developing countries, and existing studies are very diverse; however initial studies show changes in clinical outcomes, adherence, and health communication, including improved communication with providers, decrease in travel time, ability to receive expert advice, changes in clinical outcomes, and new forms of cost-effective education. While this initial review is promising, more evidence is needed to support and direct system-level resource investment.
    No preview · Article · Jan 2016 · Global journal of health science
  • Mukoso N. Ozieh · David J. Taber · Leonard E. Egede
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    ABSTRACT: There is a lack of studies assessing if race impacts the efficacy of 3-hydroxy-3-methyl-glutaryl-CoA reductase (HMGCR) inhibitor ("statin") therapy on renal transplantation (RTx) outcomes. We examined the association between statin therapy and RTx outcomes, while concurrently quantifying the effect modification African American (AA) race has on statin efficacy.This was a retrospective longitudinal cohort study of solitary adult RTx (n = 1176) between June 2005 and May 2013. The Cox proportional hazard model was used to examine the impact of statin therapy on graft loss, death, and acute rejection and determine if significant interactions exist between statin therapy and race. Models were adjusted for demographics, socioeconomic status, cardiovascular history, medication use, and transplant characteristics.AAs (n = 624) and non-African Americans (n = 552) were equally likely to receive statin therapy (P = 0.922). Mean LDL and TGs in AA were 94 mg/dL and 133 mg/dL compared to 90 mg/dL and 163 mg/dL in non-AA, respectively. After adjusting for confounders, high statin users had 52% lower risk of developing graft loss (HR 0.48, 95% CI 0.29-0.80) and a nonstatistically significant reduction in death (HR 0.50, 95% CI 0.23-1.06) compared to low statin users. Acute rejection was not significantly influenced by statin use (HR 0.77 95% CI 0.46-1.27). There was a significant interaction between race and statin therapy for death (P = 0.007), but not for graft loss (P = 0.121) or rejection (P = 0.605). After stratifying by race, high statin use reduced the risk of death in AAs (HR 0.43, 95% CI 0.20-0.94), but not in non-AAs (HR 1.09, 95% CI 0.49-2.44).High statin use reduces the risk of graft loss in RTx, with a mortality benefit in AAs compared to non-AA, despite similar LDL levels. These results suggest a compelling reason to optimize statin therapy in renal transplant recipients (RTR), especially in AAs.
    No preview · Article · Dec 2015 · Medicine
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    ABSTRACT: Objective: There are few empirical data regarding effective treatment of trauma-related symptoms among individuals with severe mental illness (SMI; e.g., bipolar disorder, schizophrenia). This under-examined clinical issue is significant because rates of trauma and PTSD are higher among individuals with SMI relative to the general population, and there are sufficient data to suggest that PTSD symptoms exacerbate the overall course and prognosis of SMI. Method: 34 veterans with SMI received prolonged exposure (PE) for PTSD using an open trial study design. Results: Data suggest that PE is feasible to implement, well-tolerated, and results in clinically significant decreases in PTSD severity in patients with SMI. Mean CAPS scores improved 27.2 points from baseline to immediate post [95% CI for mean change: -44.3, - 10.1; p = 0.002, paired t-test, and treatment gains were maintained at 6 months [mean change from baseline to 6-months, -16.1; 95% CI: -31.0, -1.2; p = 0.034, paired t-test]. Conclusions: The current data support the use of exposure-based interventions for PTSD among individuals with SMI and highlight the need for rigorous randomized efficacy trials investigating frontline PTSD interventions in this patient population.
    No preview · Article · Dec 2015 · Behaviour Research and Therapy
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    ABSTRACT: Positive continuous outcomes with a point mass at zero are prevalent in biomedical research. To model the point mass at zero and to provide marginalized covariate effect estimates, marginalized two part models (MTP) have been developed for outcomes with lognormal and log skew normal distributions. In this paper, we propose MTP models for outcomes from a generalized gamma (GG) family of distributions. In the proposed MTP-GG model, the conditional mean from a two-part model with a three-parameter GG distribution is parameterized to provide regression coefficients that have marginal interpretation. MTP-gamma and MTP-Weibull are developed as special cases of MTP-GG. We derive marginal covariate effect estimators from each model and through simulations assess their finite sample operating characteristics in terms of bias, standard errors, 95% coverage, and rate of convergence. We illustrate the models using data sets from The Medical Expenditure Survey (MEPS) and from a randomized trial of addictive disorders and we provide SAS code for implementation. The simulation results show that when the response distribution is unknown or mis-specified, which is usually the case in real data sets, the MTP-GG is preferable over other models.
    Preview · Article · Nov 2015
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    ABSTRACT: Objective: This study examined the association between cardiovascular disease (CVD) risk factor control and elevated depressive symptoms (EDS), serious psychological distress (SPD), and diabetes distress (DD) in patients with type 2 diabetes (T2DM). Methods: This was a cross-sectional study of adults seen at an academic medical center and Veterans Affairs Medical Center in the southeastern US. Linear regression models were computed using CVD risk factors as clinically meaningful outcomes (glycosylated hemoglobin A1c (HbA1c); systolic (SBP) and diastolic (DBP) blood pressure; and low-density lipoprotein cholesterol (LDL-C)); EDS, SPD, and DD were primary independent variables. Covariates included sociodemographics and comorbidities. Results: The sample consisted of 361 adults. Correlation analyses showed significant relationships between DD and HbA1c, DBP, and LDL-C. Adjusted linear regression models showed DD to be significantly associated with HbA1c and LDL-C, and SPD to be significantly associated only with LDL-C. In the fully adjusted model, DD remained significantly associated with HbA1c (β=4.349; 95% CI (-0.649, 2.222)). Conclusions: In this sample of adults with T2DM, DD and SPD were significantly associated with CVD risk factors; however, after controlling for covariates, only DD was shown to be significantly associated with poor glycemic control. Practice implications: Strategies are warranted to examine the relationship between DD and CVD risk factor control in patients with T2DM.
    No preview · Article · Nov 2015 · Journal of diabetes and its complications
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    ABSTRACT: Rationale: Smoking is the largest contributor to lung cancer risk, those who continue to smoke post-diagnosis have a worse survival. Screening for lung cancer with low-dose computed tomography (LDCT) reduces mortality in high-risk individuals. Smoking cessation is an essential component of a high-quality screening program. Objective: To quantify the effects of smoking history and abstinence on mortality in high-risk individuals who participated in the National Lung Screening Trial (NLST). Methods: This is a secondary analysis of a randomized controlled trial (NLST). Measurements: Measurements included self-reported demographics, medical and smoking history, lung cancer-specific and all-cause mortality. Cox regression was used to study the association of mortality with smoking status and pack-years. Kaplan-Meier survival curves were examined for differences in survival based on trial arm and smoking status. Main results: Current smokers had an increased lung cancer-specific (HR range 2.14-2.29) and all-cause mortality (HR range 1.79-1.85) compared to former smokers irrespective of screening arm. Former smokers in the control arm abstinent for seven years had a 20% mortality reduction comparable to the benefit reported with LDCT screening in the NLST. The maximum benefit was seen with the combination of smoking abstinence at 15 years and LDCT screening, which resulted in a 38% reduction in lung cancer-specific mortality (HR 0.62, 95% CI 0.51 - 0.76). Conclusions: Seven years of smoking abstinence reduced lung cancer-specific mortality at a magnitude comparable to LDCT screening. This reduction was greater when abstinence was combined with screening highlighting the importance of smoking cessation efforts in screening programs.
    No preview · Article · Oct 2015 · American Journal of Respiratory and Critical Care Medicine
  • Jennifer A Campbell · Rebekah J Walker · Leonard E Egede
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    ABSTRACT: Introduction: Adverse childhood experiences (ACEs) are associated with early mortality and morbidity. This study evaluated the association among ACEs, high-risk health behaviors, and comorbid conditions, as well as the independent effect of ACE components. Methods: Data were analyzed on 48,526 U.S. adults from five states in the 2011 Behavioral Risk Factor Surveillance System survey. Exposures included psychological, physical, and sexual forms of abuse as well as household dysfunction such as substance abuse, mental illness, violence, and incarceration. Main outcome measures included risky behaviors and morbidity measures, including binge drinking, heavy drinking, current smoking, high-risk HIV behavior, obesity, diabetes, myocardial infarction, coronary heart disease, stroke, depression, disability caused by poor health, and use of special equipment because of disability. Multiple logistic regression assessed the independent relationship between ACE score categories and risky behaviors/comorbidities in adulthood, and assessed the independent relationship between individual ACE components and risky behaviors/comorbid conditions in adulthood controlling for covariates. Results: A total of 55.4% of respondents reported at least one ACE and 13.7% reported four or more ACEs. An ACE score ≥4 was associated with increased odds for binge drinking, heavy drinking, smoking, risky HIV behavior, diabetes, myocardial infarction, coronary heart disease, stroke, depression, disability caused by health, and use of special equipment because of disability. In addition, the individual components had different effects on risky behavior and comorbidities. Conclusions: In addition to having a cumulative effect, individual ACE components have differential relationships with risky behaviors, morbidity, and disability in adulthood after controlling for important confounders.
    No preview · Article · Oct 2015 · American journal of preventive medicine
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    ABSTRACT: Background: Socioeconomic status (SES) is a significant determinant of health outcomes and may be an important component of the causal chain surrounding racial disparities in kidney transplantation. The social adaptability index (SAI) is a validated and quantifiable measure of SES, with a lack of studies analyzing this measure longitudinally or between races. Methods: Longitudinal cohort study in adult kidney transplantation transplanted at a single-center between 2005 and 2012. The SAI score includes 5 domains (employment, education, marital status, substance abuse and income), each with a minimum of 0 and maximum of 3 for an aggregate of 0 to 15 (higher score → better SES). Results: One thousand one hundred seventy-one patients were included; 624 (53%) were African American (AA) and 547 were non-AA. African Americans had significantly lower mean baseline SAI scores (AAs 6.5 vs non-AAs 7.8; P < 0.001). Cox regression analysis demonstrated that there was no association between baseline SAI and acute rejection in non-AAs (hazard ratio [HR], 0.92; 95% confidence interval [95% CI], 0.81-1.05), whereas it was a significant predictor of acute rejection in AAs (HR, 0.89; 95% CI, 0.80-0.99). Similarly, a 2-stage approach to joint modelling of time to graft loss and longitudinal SAI did not predict graft loss in non-AAs (HR, 1.01; 95% CI, 0.28-3.62), whereas it was a significant predictor of graft loss in AAs (HR, 0.23; 95% CI, 0.06-0.93). Conclusions: After controlling for confounders, SAI scores were associated with a lower risk of acute rejection and graft loss in AA kidney transplant recipients, whereas neither baseline nor follow-up SAI predicted outcomes in non-AA kidney transplant recipients.
    No preview · Article · Oct 2015 · Transplantation
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    ABSTRACT: Background Studies have shown that community and neighborhood characteristics can impact health outcomes of those with chronic illness, including T2DM. Factors, such as crime, violence, and lack of resources have been shown to be barriers to optimal health outcomes in diabetes. Thus, the objective of this study is to assess the effects of neighborhood factors on diabetes-related health outcomes and self-care behaviors. Methods Adult patients (N = 615) with type 2 diabetes mellitus (T2DM) were recruited from an academic medical center and a Veterans Affairs medical center in the southeastern United States. Validated scales and indices were used to assess neighborhood factors and diabetes-related self-care behaviors. The most recent HbA1c, blood pressure, and LDL cholesterol were abstracted from each patients’ electronic medical record. Results In the fully adjusted model, significant associations were between neighborhood aesthetics and diabetes knowledge (β = 0.141) and general diet (β = -0.093); neighborhood comparison and diabetes knowledge (β = 0.452); neighborhood activities and general diet (β = -0.072), exercise (β = -0.104), and foot care (β = -0.114); food insecurity and medication adherence (β = -0.147), general diet (β = -0.125), and blood sugar testing (β = -0.172); and social support and medication adherence (β = 0.009), foot care (β = 0.010), and general diet (β = 0.016). Significant associations were also found between neighborhood violence and LDL Cholesterol (β = 4.04), walking environment and exercise (β = -0.040), and social cohesion and HbA1c (β = -0.086). Discussion We found that neighborhood violence, aesthetics, walking environment, activities, food insecurity, neighborhood comparison, social cohesion and social support have statistically significant associations with self-care behaviors and outcomes to varying degrees. However, the key neighborhood factors that had independent associations with multiple self-care behaviors and outcomes were food insecurity, neighborhood activities and social support. Conclusion This study suggests that food insecurity, neighborhood activities, aesthetics, and social support may be important targets for interventions in individuals with T2DM. Electronic supplementary material The online version of this article (doi:10.1186/s12913-015-1086-7) contains supplementary material, which is available to authorized users.
    Preview · Article · Oct 2015 · BMC Health Services Research
  • Rebekah J Walker · Brittany L Smalls · Leonard E Egede
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    ABSTRACT: Aims: Socioeconomic, psychosocial, and neighborhood factors influence clinical outcomes and self-care behaviors in diabetes; however, few studies simultaneously assessed the impact of multiple social determinant of health factors on glycemic control. We used an explanatory model to examine the differential contribution of social determinants and clinical factors on glycemic control. Secondarily, we examined the contribution of mutable and immutable factors to identify meaningful future interventions. Methods: Six hundred and fifteen adults with type 2 diabetes in the southeastern United States were recruited. A hierarchical model was run with HbA1c as the dependent variable and independent variables entered in blocks: demographics (block 1), socioeconomic (block 2), psychosocial (block 3), built environment (block 4), clinical (block 5), and knowledge/self-care (block 6). Results: Significant associations for HbA1c included self-efficacy (β=-0.10, p<0.001), social support (β=0.01, p<0.05), comorbidity (β=-0.09, p<0.05), insulin use (β=0.95, p<0.001), medication adherence (β=-0.11, p<0.05), and being a former smoker (β=0.34, p<0.05); accounting for 24.4% of the variance. Conclusions: Important factors that drive glycemic control are mutable, and amenable to health interventions. Greater attention should be given to interventions that increase self-efficacy and social support, reduce the burden of comorbidities, and enhance medication adherence and smoking cessation.
    No preview · Article · Sep 2015 · Diabetes research and clinical practice
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    ABSTRACT: Many older adults with major depression, particularly veterans, do not have access to evidence-based psychotherapy. Telemedicine could increase access to best-practice care for older adults facing barriers of mobility, stigma, and geographical isolation. We aimed to establish non-inferiority of behavioural activation therapy for major depression delivered via telemedicine to same-room care in largely male, older adult veterans. In this randomised, controlled, open-label, non-inferiority trial, we recruited veterans (aged ≥58 years) meeting DSM-IV criteria for major depressive disorder from the Ralph H Johnson Veterans Affairs Medical Center and four associated community outpatient-based clinics in the USA. We excluded actively psychotic or demented people, those with both suicidal ideation and clear intent, and those with substance dependence. The study coordinator randomly assigned participants (1:1; block size 2-6; stratified by race; computer-generated randomisation sequence by RGK) to eight sessions of behavioural activation for depression either via telemedicine or in the same room. The primary outcome was treatment response according to the Geriatric Depression Scale (GDS) and Beck Depression Inventory (BDI; defined as a 50% reduction in symptoms from baseline at 12 months), and Structured Clinical Interview for DSM-IV, clinician version (defined as no longer being diagnosed with major depressive disorder at 12 months follow-up), in the per-protocol population (those who completed at least four treatment sessions and for whom all outcome measurements were done). Those assessing outcomes were masked. The non-inferiority margin was 15%. This trial is registered with ClinicalTrials.gov, number NCT00324701. Between April 1, 2007, and July 31, 2011, we screened 780 patients, and the study coordinator randomly assigned participants to either telemedicine (120 [50%]) or same-room treatment (121 [50%]). We included 100 (83%) patients in the per-protocol analysis in the telemedicine group and 104 (86%) in the same-room group. Treatment response according to GDS did not differ significantly between the telemedicine (22 [22·45%, 90% CI 15·52-29·38] patients) and same-room (21 [20·39%, 90% CI 13·86-26·92]) groups, with an absolute difference of 2·06% (90% CI -7·46 to 11·58). Response according to BDI also did not differ significantly (telemedicine 19 [24·05%, 90% CI 16·14-31·96] patients; same room 19 [23·17%, 90% CI 15·51-30·83]), with an absolute difference of 0·88% (90% CI -10·13 to 11·89). Response on the Structured Clinical Interview for DSM-IV, clinician version, also did not differ significantly (39 [43·33%, 90% CI 34·74-51·93] patients in the telemedicine group and 46 [48·42%, 90% CI 39·99-56·85] in the same-room group), with a difference of -5·09% (-17·13 to 6·95; p=0·487). Results from the intention-to-treat population were similar. MEM analyses showed that no significant differences existed between treatment trajectories over time for BDI and GDS. The criteria for non-inferiority were met. We did not note any adverse events. Telemedicine-delivered psychotherapy for older adults with major depression is not inferior to same-room treatment. This finding shows that evidence-based psychotherapy can be delivered, without modification, via home-based telemedicine, and that this method can be used to overcome barriers to care associated with distance from and difficulty with attendance at in-person sessions in older adults. US Department of Veterans Affairs. Copyright © 2015 Elsevier Ltd. All rights reserved.
    No preview · Article · Aug 2015 · The Lancet Psychiatry
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    ABSTRACT: This study assessed the prevalence and specific costs associated with discrete multimorbid mental health disease clusters in adults with diabetes mellitus (DM). Longitudinal analysis of a retrospective cohort. We performed a 5-year longitudinal analysis of a retrospective cohort of 733,071 patients with DM from the US Veterans Health Administration (VHA) between 2002 and 2006. The mental health comorbidities (MHCs) examined included depression, substance abuse, and psychosis. Our primary outcomes of interest were total inpatient, outpatient, and pharmacy costs measured in 2012 US$ from the perspective of the VHA. DM was present with comorbid depression, substance abuse, and psychosis in 12.1%, 3.7%, and 4.2% of patients, respectively. Overall, 13.5% of patients had 1 MHC, 2.5% had 2 MHCs, and 0.5% had all MHCs. Total inpatient ($1,435,651,415), outpatient ($366,137,435), and pharmacy ($90,064,725) costs were highest for patients with DM and comorbid depression alone. At the per-patient level, DM plus psychosis and substance abuse had the highest inpatient costs ($35,518), DM plus all MHCs had the highest outpatient costs ($6962), and DM plus depression and psychosis had the highest pharmacy costs ($1753). DM with comorbid depression is the most prevalent MHC combination and is associated with the highest total VHA healthcare costs. However, other comorbidity clusters are associated with higher mean per patient costs, and may therefore benefit from more intensive intervention. Analysis of healthcare expenditures by multimorbid disease clusters can be a useful tool for healthcare policy planning.
    No preview · Article · Aug 2015 · The American journal of managed care
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    Mukoso N Ozieh · Kinfe G Bishu · Clara E Dismuke · Leonard E Egede
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    ABSTRACT: Direct medical cost of diabetes in the U.S. has been estimated to be 2.3 times higher relative to individuals without diabetes. This study examines trends in healthcare expenditures by expenditure category in U.S. adults with diabetes between 2002 and 2011. We analyzed 10 years of data representing a weighted population of 189,013,514 U.S. adults aged ≥18 years from the Medical Expenditure Panel Survey. We used a novel two-part model to estimate adjusted mean and incremental medical expenditures by diabetes status, while adjusting for demographics, comorbidities, and time. Relative to individuals without diabetes ($5,058 [95% CI $4,949-$5,166]), individuals with diabetes ($12,180 [$11,775-$12,586]) had more than double the unadjusted mean direct expenditures over the 10-year period. After adjusting for confounders, individuals with diabetes had $2,558 ($2,266-$2,849) significantly higher direct incremental expenditures compared with those without diabetes. For individuals with diabetes, inpatient expenditures rose initially from $4,014 in 2002/2003 to $4,183 in 2004/2005 and then decreased continuously to $3,443 in 2010/2011, while rising steadily for individuals without diabetes. The estimated unadjusted total direct expenditures for individuals with diabetes were $218.6 billion/year and adjusted total incremental expenditures were approximately $46 billion/year. Our findings show that compared with individuals without diabetes, individuals with diabetes had significantly higher health expenditures from 2002 to 2011 and the bulk of the expenditures came from hospital inpatient and prescription expenditures. © 2015 by the American Diabetes Association. Readers may use this article as long as the work is properly cited, the use is educational and not for profit, and the work is not altered.
    Full-text · Article · Jul 2015 · Diabetes care
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    Clara E. Dismuke · Mulugeta Gebregziabher · Leonard E. Egede
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    ABSTRACT: Objective: Primary: To examine Veterans Administration (VA) utilization and other potential mediators between racial/ethnic differentials and mortality in veterans diagnosed with traumatic brain injury (TBI). Design: A national cohort of veterans clinically diagnosed with TBI in 2006 was followed from January 1, 2006 through December 31, 2009 or until date of death. Utilization was tracked for 12 months. Differences in survival and potential mediators by race were examined via K-Wallis and chi-square tests. Potential mediation of utilization in the association between mortality and race/ethnicity was studied by fitting Cox models with and without adjustment for demographics and co-morbidities. Poisson regression was used to study the association of race/ethnicity with utilization of specialty services potentially important in the management of TBI. Setting: United States (US) Veterans Administration (VA) Hospitals and Clinics. Participants: 14, 690 US veterans clinically diagnosed with TBI in 2006. Interventions: Not Applicable. The study is a secondary data analysis. Main outcome measures: Mortality, Utilization. Results: Hispanic veterans were found to have significantly higher unadjusted mortality (6.69%) than Non-Hispanic White veterans (2.93%). Hispanic veterans relative to Non-Hispanic White were found to have significantly lower utilization of all services examined, except imaging. Neurology was found to be the utilization mediator with the highest percent of excess risk (3.40%) while age was the non utilization confounder with the highest percent of excess risk (31.49%). In fully adjusted models for demographics and co-morbidities, Hispanic veterans relative to Non-Hispanic Whites were found to have less total visits (IRR 0.89), TBI clinic (IRR 0.43), neurology (IRR 0.35), rehabilitation (IRR 0.37), and other visits (IRR 0.85) with only higher mental health visits (IRR 1.53). Conclusions: We found evidence that utilization is a partial mediator between race/ethnicity and mortality, especially neurology utilization. We also found that Hispanic veterans receive significantly less TBI clinic, neurology, rehabilitation and other types of utilization. The use of innovative system factors (decision aids, information tools, patient activation, and adherence support interventions) could be valuable in enhancing utilization of specific TBI related services, especially among ethnic minorities.
    Preview · Article · Jul 2015 · Global journal of health science
  • Joni S Williams · Cheryl P Lynch · Delia Voronca · Leonard E Egede
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    ABSTRACT: Perceptions of control impact outcomes in veterans with chronic disease. The purpose of this study was to examine the association between control orientation and clinical and quality of life (QOL) outcomes in male veterans with type 2 diabetes (T2DM). Cross-sectional study of 283 male veterans from a primary care clinic in the southeastern US. Health locus of control (LOC) was the main predictor and assessed using the Multidimensional Health LOC Scale. Clinical outcomes were glycosylated hemoglobin A1c (HbA1c), systolic and diastolic blood pressure, and low-density lipoprotein cholesterol (LDL-C). Physical (PCS) and mental (MCS) health component scores for QOL were assessed using the Veterans RAND 12-Item Health Survey. Unadjusted and adjusted multivariate analyses were performed to assess associations between LOC and outcomes. Unadjusted analyses showed internal LOC associated with HbA1c (β = 0.036; 95 % CI 0.001, 0.071), external LOC:powerful others inversely associated with LDL-C (β = -0.794; 95 % CI -1.483, -0.104), and external LOC:chance inversely associated with MCS QOL (β = -0.418; 95 % CI -0.859, -0.173). These associations remained significant when adjusting for relevant covariates. Adjusted analyses also demonstrated a significant relationship between external LOC:chance and PCS QOL (β = 0.308; 95 % CI 0.002, 0.614). In this sample of male veterans with T2DM, internal LOC was significantly associated with glycemic control, and external was significantly associated with QOL and LDL-C, when adjusting for relevant covariates. Assessments of control orientation should be performed to understand the perceptions of patients, thus better equipping physicians with information to maximize care opportunities for veterans with T2DM.
    No preview · Article · Jul 2015 · Endocrine
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    ABSTRACT: We examined the association between traumatic brain injury (TBI) severity and combat exposure by race/ethnicity. We estimated logit models of the fully adjusted association of combat exposure with TBI severity in separate race/ethnicity models for a national cohort of 132 995 veterans with TBI between 2004 and 2010. Of veterans with TBI, 25.8% had served in a combat zone. Mild TBI increased from 11.5% to 40.3%, whereas moderate or severe TBI decreased from 88.5% to 59.7%. Moderate or severe TBI was higher in non-Hispanic Blacks (80.0%) and Hispanics (89.4%) than in non-Hispanic Whites (71.9%). In the fully adjusted all-race/ethnicity model, non-Hispanic Blacks (1.44; 95% confidence interval [CI] = 1.37, 1.52) and Hispanics (1.47; 95% CI = 1.26, 1.72) had higher odds of moderate or severe TBI than did non-Hispanic Whites. However, combat exposure was associated with higher odds of mild TBI in non-Hispanic Blacks (2.48; 95% CI = 2.22, 2.76) and Hispanics (3.42; 95% CI = 1.84, 6.35) than in non-Hispanic Whites (2.17; 95% CI = 2.09, 2.26). Research is needed to understand racial differences in the effect of combat exposure on mild TBI and on interventions to prevent TBI across severity levels. (Am J Public Health. Published online ahead of print June 11, 2015: e1-e7. doi:10.2105/AJPH.2014.302545).
    No preview · Article · Jun 2015 · American Journal of Public Health
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    ABSTRACT: Overdispersion is a common problem in count data. It can occur due to extra population-heterogeneity, omission of key predictors, and outliers. Unless properly handled, this can lead to invalid inference. Our goal is to assess the differential performance of methods for dealing with overdispersion from several sources. We considered six different approaches: unadjusted Poisson regression (Poisson), deviance-scale-adjusted Poisson regression (DS-Poisson), Pearson-scale-adjusted Poisson regression (PS-Poisson), negative-binomial regression (NB), and two generalized linear mixed models (GLMM) with random intercept, log-link and Poisson (Poisson-GLMM) and negative-binomial (NB-GLMM) distributions. To rank order the preference of the models, we used Akaike's information criteria/Bayesian information criteria values, standard error, and 95% confidence-interval coverage of the parameter values. To compare these methods, we used simulated count data with overdispersion of different magnitude from three different sources. Mean of the count response was associated with three predictors. Data from two real-case studies are also analyzed. The simulation results showed that NB and NB-GLMM were preferred for dealing with overdispersion resulting from any of the sources we considered. Poisson and DS-Poisson often produced smaller standard-error estimates than expected, while PS-Poisson conversely produced larger standard-error estimates. Thus, it is good practice to compare several model options to determine the best method of modeling count data. © The Author(s) 2015 Reprints and permissions: sagepub.co.uk/journalsPermissions.nav.
    Full-text · Article · May 2015 · Statistical Methods in Medical Research

  • No preview · Conference Paper · May 2015
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    ABSTRACT: Although the national cost of missed workdays associated with diabetes has been estimated previously, we use the most recent available national data and methodology to update the individual and national estimates for the U.S population. We identified 14,429 employed individuals ≥ 18 years of age in 2011 Medical Expenditure Panel Survey (MEPS) data. Diabetes and missed workdays were based on self-report, and cost was based on multiplying the daily wage rate for each individual by the number of missed days. Adjusted total national burden of missed workdays associated with diabetes was calculated using a novel two-part model to simultaneously estimate the association of diabetes with the number and cost of missed workdays. The unadjusted annual mean 2011 cost of missed workdays was $277 (95 % CI 177.0-378.0) for individuals with diabetes relative to $160 (95 % CI $130-$189) for those without. The incremental cost of missed workdays associated with diabetes was $120 (95 % CI $30.7-$209.1). Based on the US population in 2011, the unadjusted national burden of missed workdays associated with diabetes was estimated to be $2.7 billion, while the fully adjusted incremental national burden was estimated to be $1.1 billion. We provide more precise estimates of the cost burden of diabetes due to missed workdays on the U.S population. The high incremental and total cost burden of missed workdays among Americans with diabetes suggests the need for interventions to improve diabetes care management among employed individuals.
    No preview · Article · May 2015 · Journal of General Internal Medicine