Theresa I Shireman

Hennepin County Medical Center, Minneapolis, Minnesota, United States

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Publications (75)248.39 Total impact

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    ABSTRACT: Time-dependent covariates can be modeled within the Cox regression framework and can allow both proportional and nonproportional hazards for the risk factor of research interest. However, in many areas of health services research, interest centers on being able to estimate residual longevity after the occurrence of a particular event such as stroke. The survival trajectory of patients experiencing a stroke can be potentially influenced by stroke type (hemorrhagic or ischemic), time of the stroke (relative to time zero), time since the stroke occurred, or a combination of these factors. In such situations, researchers are more interested in estimating lifetime lost due to stroke rather than merely estimating the relative hazard due to stroke. To achieve this, we propose an ensemble approach using the generalized gamma distribution by means of a semi-Markov type model with an additive hazards extension. Our modeling framework allows stroke as a time-dependent covariate to affect all three parameters (location, scale, and shape) of the generalized gamma distribution. Using the concept of relative times, we answer the research question by estimating residual life lost due to ischemic and hemorrhagic stroke in the chronic dialysis population.
    No preview · Article · Sep 2015 · Statistical Methods in Medical Research
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    ABSTRACT: Background and objective: The comparative effectiveness of dihydropyridine (DHP) and non-DHP calcium channel blockers (CCBs) in maintenance dialysis patients has not been well-studied. Methods: A retrospective cohort of hypertensive patients initiating dialysis was created. New CCB initiators, defined as individual who had no evidence of CCB use in the first 90 days of dialysis but who were initiated by day 180, were followed from their first day of medication exposure until event or censoring; events consisted of all-cause mortality (ACM) and a combined endpoint of cardiovascular morbidity or mortality (CVMM). Cox proportional hazards models were used to determine adjusted hazard ratios (AHRs) comparing the effect of DHPs vs. non-DHPs. Results: There were 2900 and 2704 new initiators of CCBs in the ACM and CVMM models, respectively. Adjusted for other factors, use of DHPs, compared to non-DHPs, was associated with an AHR of 0.77 (99% confidence intervals, 0.64 - 0.93, P = 0.0004) for ACM and 0.86 (0.72 - 1.02, P = 0.024) for CVMM. Results were similar when individuals who initiated therapy at any point after the cohort inception were included, with AHRs of 0.60 (0.53 - 0.69, P < 0.0001) and 0.77 (0.67 - 0.89, P < 0.0001) for ACM and CVMM, respectively. Further, elimination of individuals with chronic atrial fibrillation resulted in AHRs of 0.71 and 0.70 for ACM and CVVM, respectively. Conclusion: DHPs, as compared to non-DHPs, were associated with reduced hazard of death or cardiovascular morbidity and mortality; potential mechanisms of action require further study. Copyright © 2015 John Wiley & Sons, Ltd.
    No preview · Article · Sep 2015 · Pharmacoepidemiology and Drug Safety
  • Utku Uysal · Mark Quigg · Brennen Bittel · Nancy Hammond · Theresa I Shireman
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    ABSTRACT: To determine factors associated with continuous anesthetic drug (IVAD) use in nonconvulsive status epilepticus (NCSE). Retrospective cohort study of patients who met clinical and EEG criteria of NCSE from 2009 to 2014 at a tertiary academic medical center. Patients were categorized according to IVAD use. Outcome variables were response to treatment and in-hospital death. We used descriptive analyses for baseline characteristics and outcome variable differences among patients who did and did not receive IVAD. Forty-three patients had a total of 45 NCSE episodes. IVAD was used in 69% of the episodes. Patients treated with IVAD were younger (53.1±14.1 vs 64.1±13.3, p=0.019). The episodes treated with IVAD occurred more frequently in patients with an acute neurologic pathology (58% vs 21%, p=0.024) and those presenting in a coma (39% vs 7%, p=0.030). NCSE resolved in 74% of the patients who received IVAD. Duration of NCSE did not differ significantly by treatment group. There were total 13 in-hospital deaths: ten in IVAD users vs three in the no-IVAD group (p>0.05). Only one in-hospital death appeared to be a direct consequence of IVAD use. Mortality was more common among episodes that were not treated according to the published status epilepticus treatment guidelines compared to the episodes where guidelines were followed. Our findings showed that factors such as younger age, acute neurologic pathology and coma at presentation were associated with IVAD use in patients with NCSE. These factors should be controlled in the future outcome and effectiveness studies to determine the effect of IVAD use on outcome of NCSE. Copyright © 2015 Elsevier B.V. All rights reserved.
    No preview · Article · Jul 2015 · Epilepsy research
  • Theresa I Shireman
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    ABSTRACT: Widespread, effective identification and management of uncontrolled hypertension remains elusive, undermining our ability to reduce the impact of stroke and heart disease. The statistics are widely appreciated: roughly 30% of North Americans have hypertension and almost half are uncontrolled. Nearly 1,000 people a day die from complications attributed to hypertension, and direct and indirect costs amount to $46 billion a year in the United States alone.(1) Effective management of blood pressure for the 70 million adults in the US who currently have hypertension would clearly overwhelm our existing primary care system. There are already roughly 39 million physician office visits for essential hypertension per year.(2).
    No preview · Article · Jun 2015 · Circulation

  • No preview · Article · Jun 2015 · Journal of Medical Internet Research
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    ABSTRACT: Background: In rural America, cigarette smoking is prevalent and health care providers lack the time and resources to help smokers quit. Telephone quitlines are important avenues for cessation services in rural areas, but they are poorly integrated with local health care resources. Objective: The intent of the study was to assess the comparative effectiveness and cost effectiveness of two models for delivering expert tobacco treatment at a distance: telemedicine counseling that was integrated into smokers' primary care clinics (Integrated Telemedicine-ITM) versus telephone counseling, similar to telephone quitline counseling, delivered to smokers in their homes (Phone). Methods: Smokers (n=566) were recruited offline from 20 primary care and safety net clinics across Kansas. They were randomly assigned to receive 4 sessions of ITM or 4 sessions of Phone counseling. Patients in ITM received real-time video counseling, similar to Skype, delivered by computer/webcams in clinic exam rooms. Three full-time equivalent trained counselors delivered the counseling. The counseling duration and content was the same in both groups and was available in Spanish or English. Both groups also received identical materials and assistance in selecting and obtaining cessation medications. The primary outcome was verified 7-day point prevalence smoking abstinence at month 12, using an intent-to-treat analysis. Results: There were no significant baseline differences between groups, and the trial achieved 88% follow-up at 12 months. Verified abstinence at 12 months did not significantly differ between ITM or Phone (9.8%, 27/280 vs 12%, 34/286; P=.406). Phone participants completed somewhat more counseling sessions than ITM (mean 2.6, SD 1.5 vs mean 2.4, SD 1.5; P=.0837); however, participants in ITM were significantly more likely to use cessation medications than participants in Phone (55.9%, 128/280 vs 46.1%, 107/286; P=.03). Compared to Phone participants, ITM participants were significantly more likely to recommend the program to a family member or friend (P=.0075). From the combined provider plus participant (societal) perspective, Phone was significantly less costly than ITM. Participants in ITM had to incur time and mileage costs to travel to clinics for ITM sessions. From the provider perspective, counseling costs were similar between ITM (US $45.46, SD 31.50) and Phone (US $49.58, SD 33.35); however, total provider costs varied widely depending on how the clinic space for delivering ITM was valued. Conclusions: Findings did not support the superiority of ITM over telephone counseling for helping rural patients quit smoking. ITM increased utilization of cessation pharmacotherapy and produced higher participant satisfaction, but Phone counseling was significantly less expensive. Future interventions could combine elements of both approaches to optimize pharmacotherapy utilization, counseling adherence, and satisfaction. Such an approach could commence with a telemedicine-delivered clinic office visit for pharmacotherapy guidance, and continue with telephone or real-time video counseling delivered via mobile phones to flexibly deliver behavioral support to patients where they most need it-in their homes and communities. Trial registration: NCT00843505; (Archived by WebCite at
    No preview · Article · May 2015 · Journal of Medical Internet Research
  • Christina E. Ciaccio · Theresa I. Shireman

    No preview · Article · Feb 2015 · Journal of Allergy and Clinical Immunology
  • Yuexin Tang · John M Brooks · James B Wetmore · Theresa I Shireman
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    ABSTRACT: While cardiovascular (CV) disease is a leading cause of morbidity and mortality in patients on chronic dialysis, utilization rates of cardioprotective drugs for dialysis patients remain low. This study sought to determine whether higher rates of cardioprotective drug use among dialysis patients might increase survival. A retrospective cohort of incident dialysis patients (n = 50,468) with dual eligibility for U.S. Medicare and Medicaid was constructed using USRDS data linked with billing claims. Medication exposures included angiotensin converting enzyme inhibitors/angiotensin receptor blockers (ACEIs/ARBs), β-blockers, calcium channel blockers (CCBs), and HMG-CoA reductase inhibitors (statins) prescribed within 90 days of dialysis initiation. The outcomes were one- and two-year survival and CV event-free survival. Variation in treatment rates based on local area practice styles were used as instruments in instrumental variable (IV) estimation, yielding average treatment effect estimates for patients whose treatment choices were affected by local area practice styles. Patients aged 65 years and older comprised 47.4% of the sample, while 59.5% were female and 35.0% were white. The utilization rate was 40.7% for ACEIs/ARBs, 43.0% for β-blockers, 50.7% for CCBs and 26.4% for statins. The local area practice style instruments were highly significantly related to cardioprotective drug use in dialysis patients (Chow-F values > 10). IV estimates showed only that higher rates of β-blockers increased one-year survival (β = 0.161, P-value = 0.020) and CV event-free survival (β = 0.189, P-value = 0.033), but that higher rates of CCBs decreased two-year CV event-free survival (β = -0.520, P-value = 0.009). This study suggests that higher utilization rates of β-blockers might yield higher survival rates for dialysis patients. However, higher rates of the other drugs studied had no correlations with survival, and higher CCB rates might actually reduce CV-event free survival. Since the benefits of cardioprotective drugs may vary across dialysis patients, the study findings should be interpreted only with respect to changes of utilization rates around the rates observed in this study. Copyright © 2015 Elsevier Inc. All rights reserved.
    No preview · Article · Dec 2014 · Research in Social and Administrative Pharmacy
  • Theresa I Shireman

    No preview · Article · Nov 2014 · Journal of General Internal Medicine
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    ABSTRACT: Background and objectivesStroke is common in patients undergoing long-term dialysis, but the implications for mortality after stroke in these patients are not fully understood.Design, setting, participants, & measurementsA large cohort of dually-eligible (Medicare and Medicaid) patients initiating dialysis from 2000 to 2005 and surviving the first 90 days was constructed. Medicare claims were used to ascertain ischemic and hemorrhagic strokes occurring after 90-day survival. A semi-Markov model with additive hazard extension was generated to estimate the association between stroke and mortality, to calculate years of life lost after a stroke, and to determine whether race was associated with differential survival after stroke.ResultsThe cohort consisted of 69,371 individuals representing >112,000 person-years of follow-up. Mean ageSD was 60.8 +/- 15.5 years. There were 21.1 (99% confidence interval [99% CI], 20.0 to 22.3) ischemic strokes and 4.7 (99% CI, 4.2 to 5.3) hemorrhagic strokes after cohort entry per 1000 patient-years. At 30 days, mortality was 17.9% for ischemic stroke and 53.4% for hemorrhagic stroke. The adjusted hazard ratio (AHR) depended on time since entry into the cohort; for patients who experienced a stroke at 1 year after cohort entry, for example, the AHR of hemorrhagic stroke for mortality was 25.4 (99% CI, 22.4 to 28.4) at 1 week, 9.9 (99% CI, 8.4 to 11.6) at 3 months, 5.9 (99% CI, 5.0 to 7.0) at 6 months, and 1.8 (99% CI, 1.5 to 2.1) at 24 months. The corresponding AHRs for ischemic stroke were 11.7 (99% CI, 10.2 to 13.1) at 1 week, 6.6 (99% CI, 6.4 to 6.7) at 3 months, and 4.7 (99% CI, 4.5 to 4.9) at 6 months, remaining significantly >1.0 even at 48 months. Median months of life lost were 40.7 for hemorrhagic stroke and 34.6 for ischemic stroke. For both stroke types, mortality did not differ by race.Conclusions Dialysis recipients have high mortality after a stroke with corresponding decrements in remaining years of life. Poststroke mortality does not differ by race.
    No preview · Article · Oct 2014 · Clinical Journal of the American Society of Nephrology
  • B. L. Svarstad · J. K. Mount · T. I. Shireman

    No preview · Article · Sep 2014 · Research in Social and Administrative Pharmacy
  • Jean P. Hall · Noelle K. Kurth · Shawna L.C. Chapman · Theresa I. Shireman
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    ABSTRACT: Background States are increasingly turning to managed care arrangements to control costs in their Medicaid programs. Historically, such arrangements have excluded people with disabilities who use long-term services and supports (LTSS) due to their complex needs. Now, however, some states are also moving this population to managed care. Little is known about the experiences of people with disabilities during and after this transition. Objective To document experiences of Medicaid enrollees with disabilities using long-term services and supports during transition to Medicaid managed care in Kansas. Methods During the spring of 2013, 105 Kansans with disabilities using Medicaid long-term services and supports (LTSS) were surveyed via telephone or in-person as they transitioned to managed care. Qualitative data analysis of survey responses was conducted to learn more about the issues encountered by people with disabilities under Medicaid managed care. Results Respondents encountered numerous disability-related difficulties, particularly with transportation, durable medical equipment, care coordination, communication, increased out of pocket costs, and access to care. Conclusions As more states move people with disabilities to Medicaid managed care, it is critically important to address these identified issues for a population that often experiences substantial health disparities and a smaller margin of health. It is hoped that the early experiences reported here can inform policy-makers in other states as they contemplate and design similar programs.
    No preview · Article · Aug 2014 · Disability and Health Journal
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    ABSTRACT: In a population of chronic dialysis patients with an extensive burden of cardiovascular disease, estimation of the effectiveness of cardioprotective medication in literature is based on calculation of a hazard ratio comparing hazard of mortality for two groups (with or without drug exposure) measured at a single point in time or through the cumulative metric of proportion of days covered (PDC) on medication. Though both approaches can be modeled in a time-dependent manner using a Cox regression model, we propose a more complete time-dependent metric for evaluating cardioprotective medication efficacy. We consider that drug effectiveness is potentially the result of interactions between three time-dependent covariate measures, current drug usage status (ON versus OFF), proportion of cumulative exposure to drug at a given point in time, and the patient's switching behavior between taking and not taking the medication. We show that modeling of all three of these time-dependent measures illustrates more clearly how varying patterns of drug exposure affect drug effectiveness, which could remain obscured when modeled by the more standard single time-dependent covariate approaches. We propose that understanding the nature and directionality of these interactions will help the biopharmaceutical industry in better estimating drug efficacy.
    No preview · Article · Aug 2014 · Statistics in Biopharmaceutical Research
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    ABSTRACT: Background/aims: Our understanding of the effectiveness of cardioprotective medications in maintenance dialysis patients is based upon drug exposures assessed at a single point in time. We employed a novel, time-dependent approach to modeling medication use over time to examine outcomes in a large national cohort. Methods: We linked Medicaid prescription claims with United States Renal Data System registry data and Medicare claims for 52,922 hypertensive maintenance dialysis patients. All-cause mortality and a combined cardiovascular disease (CVD)-endpoint were modeled as functions of exposure to cardioprotective antihypertensive medications (renin angiotensin system antagonists, β-adrenergic blockers, and calcium channel blockers) measured with three time-dependent covariates (weekly exposure status, proportion of prior weeks with exposure, and number of switches in exposure status) and with propensity adjustment. Results: Current cardioprotective medication exposure status as compared to not exposed was associated with lower adjusted hazard ratios (AHRs) for mortality, though the magnitude depended upon the proportion of prior weeks with medication (duration) and the number of switches between active and non-active use (switches) (AHR range 0.54-0.90). Combined CVD-endpoints depended upon the proportion of weeks on medication: AHR = 1.18 for 10% and AHR = 0.90 for 90% of weeks. Combined CVD-endpoint was also lower for patients with fewer switches. Conclusions: Effectiveness depends not only on having a drug available but is tempered by duration and stability of use, likely reflecting variation in clinical stability and patient behavior.
    No preview · Article · Aug 2014 · American Journal of Nephrology
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    ABSTRACT: In rural America cigarette smoking is prevalent, few cessation services are available, and healthcare providers lack the time and resources to help smokers quit. This paper describes the design and participant characteristics of Connect2Quit (C2Q), a randomized control trial (RCT) that tests the effectiveness and cost-effectiveness of integrated telemedicine counseling delivered by 2-way webcams mounted on desktop computers in participant's physician office examining rooms (ITM) versus quitline counseling delivered by telephone in participant's homes (Phone) for helping rural smokers quit. /Design C2Q was implemented in twenty primary care and safety net clinics. Integrated Telemedicine consisted of real-time video counseling, delivered to patients in their primary care physician's (PCP) office. Phone counseling, was delivered to patients in their homes. All participants received educational materials and guidance in selecting cessation medications. The 566 participants were predominantly Caucasian (92%); 9% were Latino. Most (65%) earned<200% of federal poverty level. One out of three lacked home internet access, 40% were not comfortable using computers, and only 4% had been seen by a doctor via telemedicine in the past. Hypertension, chronic lung disease, and diabetes were highly prevalent. Participants smoked nearly a pack a day and were highly motivated to quit. C2Q is reaching a rural low-income population, with comorbid chronic diseases, that would benefit greatly from quitting smoking. ITM is a good delivery model, which integrates care by holding counseling sessions in the patient's PCP office and keeps the primary care team updated on patients' progress. Trial registration Clinical Trials Registration: NCT00843505.
    No preview · Article · Apr 2014 · Contemporary clinical trials
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    ABSTRACT: Obesity is a risk factor for breast cancer recurrence and death. Women who reside in rural areas have higher obesity prevalence and suffer from breast cancer treatment-related disparities compared to urban women. The objective of this 5-year randomized controlled trial is to compare methods for delivering extended care for weight loss maintenance among rural breast cancer survivors. Group phone-based counseling via conference calls addresses access barriers, is more cost-effective than individual phone counseling, and provides group support which may be ideal for rural breast cancer survivors who are more likely to have unmet support needs. Women (n=210) diagnosed with Stage 0 to III breast cancer in the past 10years who are≥3months out from initial cancer treatments, have a BMI 27-45kg/m(2), and have physician clearance were enrolled from multiple cancer centers. During Phase I (months 0 to 6), all women receive a behavioral weight loss intervention delivered through group phone sessions. Women who successfully lose 5% of weight enter Phase II (months 6 to 18) and are randomized to one of two extended care arms: continued group phone-based treatment or a mail-based newsletter. During Phase III, no contact is made (months 18 to 24). The primary outcome is weight loss maintenance from 6 to 18months. Secondary outcomes include quality of life, serum biomarkers, and cost-effectiveness. This study will provide essential information in how to reach rural survivors in future efforts to establish weight loss support for breast cancer survivors as a standard of care.
    No preview · Article · Jan 2014 · Contemporary clinical trials
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    ABSTRACT: Geographic variation in stroke rates is well established in the general population, with higher rates in the South than in other areas of the United States. A similar pattern of geographic variation in ischemic strokes has also recently been reported in patients undergoing long-term dialysis, but whether this is also the case for hemorrhagic stroke is unknown. Medicare claims from 2000 to 2005 were used to ascertain hemorrhagic stroke events in a large cohort of incident dialysis patients. A Poisson generalized linear mixed model was generated to determine factors associated with stroke and to ascertain state-by-state geographic variability in stroke rates by generating observed-to-expected (O/E) adjusted rate ratios (ARRs) for stroke. A total of 265,685 Medicare-eligible incident dialysis patients were studied. During a median follow-up of 15.5 months, 2397 (0.9%) patients sustained a hemorrhagic stroke. African Americans (ARR, 1.43; 95% confidence interval [CI], 1.30 to 1.57), Hispanics (ARR, 1.78; 95% CI, 1.57 to 2.03), and individuals of other races (ARR, 1.51; 95% CI, 1.26 to 1.80) had a significantly higher risk for hemorrhagic stroke compared with whites. In models adjusted for age and sex, four states had O/E ARRs for hemorrhagic stroke that were significantly greater than 1.0 (California, 1.15; Maryland, 1.25; North Carolina, 1.25; Texas, 1.19), while only 1 had an ARR less than 1.0 (Wisconsin, 0.79). However, after adjustment for race and ethnicity, no states had ARRs that varied significantly from 1.0. Race and ethnicity, or other factors that covary with these, appear to explain a substantial portion of state-by-state geographic variation in hemorrhagic stroke. This finding suggests that the factors underlying the high rate of hemorrhagic strokes in dialysis patients are likely to be system-wide and that further investigations into regional variations in clinical practices are unlikely to identify large opportunities for preventive interventions for this disorder.
    No preview · Article · Jan 2014 · Clinical Journal of the American Society of Nephrology
  • James L Vacek · Suzanne L Hunt · Theresa Shireman
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    ABSTRACT: Adults with developmental disability (DD) have high prevalence of coronary artery disease risk factors, as well as impediments to optimal diagnosis and management. We analyzed antihypertensive medication (AM) use and adherence patterns in a Kansas Medicaid cohort. We studied adults (18-64 years) with DD and claims for HT from 7/1/05 to 8/31/06, with review of prescription records of AM use and adherence from 9/1/06 to 8/31/07. Adherence was calculated as proportion of days covered (PDC). Of 3079 eligible people, 280 (9%) had claims for HT: 51% male, mean age 42 ± 13, and 81% Caucasian. Of these, 280 (72%) had claims for at least 1 AM; 57% received ≥2 AM. Angiotensin converting enzyme inhibitor/angiotensin receptor blockers were most commonly prescribed (65%) followed by diuretics (50%), beta blockers (34%), and calcium channel blockers (26%). Mean PDCs by class ranged from 0.622 to 0.693: 55% had a PDC ≥0.80, a common goal for adherence. Younger individuals were more likely to be adherent (p <0.05), but adherence was not significantly associated with comorbid conditions, gender, or race. Of our cohort of adults with DD, 9% had HT of whom 72% submitted claims for AMs. A substantial proportion of subjects had inconsistent AM use suggesting suboptimal therapy. The association between younger ages and higher adherence may reflect better community-based support for younger adults. Further work is needed to identify barriers to optimal care for this vulnerable population.
    No preview · Article · Oct 2013 · Disability and Health Journal
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    ABSTRACT: OBJECTIVE To assess the effectiveness and sustainability of a 6-month Team Education and Adherence Monitoring (TEAM) intervention for black patients with hypertension in community chain pharmacies. DESIGN Cluster randomized trial. SETTING 28 chain pharmacies (14 TEAM and 14 control) in five Wisconsin cities from December 2006 to February 2009. PARTICIPANTS 576 black patients with hypertension. INTERVENTION Trained pharmacist-technician teams implemented a 6-month intervention using scheduled visits, Brief Medication Questionnaires (BMQs), and novel toolkits for facilitating medication adherence and pharmacist feedback to patients and physicians. Control participants received patient information only. MAIN OUTCOME MEASURES Refill adherence (≥80% days covered) and changes in systolic blood pressure (SBP), diastolic blood pressure, and blood pressure control using blinded assessments at 6 and 12 months. RESULTS At baseline, all patients had blood pressure of 140/90 mm Hg or more. Of those eligible, 79% activated the intervention (mean 4.25 visits). Compared with control participants at 6 months, TEAM participants achieved greater improvements in refill adherence (60% vs. 34%, P < 0.001), SBP (-12.62 vs. -5.31 mm Hg, P < 0.001), and blood pressure control (50% vs. 36%, P = 0.01). Six months after intervention discontinuation, TEAM participants showed sustained improvements in refill adherence ( P < 0.001) and SBP ( P = 0.004), though the difference in blood pressure control was not significant ( P < 0.05) compared with control participants. Analysis of intervention fidelity showed that patients who received the full intervention during months 1 through 6 achieved significantly greater 6- and 12-month improvements in refill adherence and blood pressure control compared with control participants. CONCLUSION A team-based intervention involving community chain pharmacists, pharmacy technicians, and novel toolkits led to significant and sustained improvements in refill adherence and SBP in black patients with hypertension.
    No preview · Article · Sep 2013 · Journal of the American Pharmacists Association
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    ABSTRACT: Geographic variation in stroke rates is well established in the general population, with higher rates in the South than in other areas of the United States. ESRD is a potent risk factor for stroke, but whether regional variations in stroke risk exist among dialysis patients is unknown. Medicare claims from 2000 to 2005 were used to ascertain ischemic stroke events in a large cohort of 265,685 incident dialysis patients. A Poisson generalized linear mixed model was generated to determine factors associated with stroke and to ascertain state-by-state geographic variability in stroke rates by generating observed-to-expected (O/E) adjusted rate ratios for stroke. Older age, female sex, African American race and Hispanic ethnicity, unemployed status, diabetes, hypertension, history of stroke, and permanent atrial fibrillation were positively associated with ischemic stroke, whereas body mass index >30 kg/m(2) was inversely associated with stroke (P<0.001 for each). After full multivariable adjustment, the three states with O/E rate ratios >1.0 were all in the South: North Carolina, Mississippi, and Oklahoma. Regional efforts to increase primary prevention in the "stroke belt" or to better educate dialysis patients on the signs of stroke so that they may promptly seek care may improve stroke care and outcomes in dialysis patients.
    No preview · Article · Aug 2013 · Journal of the American Society of Nephrology

Publication Stats

1k Citations
248.39 Total Impact Points


  • 2015
    • Hennepin County Medical Center
      Minneapolis, Minnesota, United States
    • Brown University
      Providence, Rhode Island, United States
  • 2004-2015
    • Kansas City University of Medicine and Biosciences
      • Department of Internal Medicine
      Kansas City, Missouri, United States
  • 2002-2015
    • University of Kansas
      • • Department of Preventive Medicine and Public Health
      • • Division of General and Geriatric Medicine
      • • Center on Aging
      • • Department of Pharmacy Practice
      • • School of Pharmacy
      Lawrence, Kansas, United States
  • 2014
    • Vanderbilt University
      • Department of Psychology
      Nashville, Michigan, United States
  • 2012
    • University of Kansas Medical Center
      Kansas City, Kansas, United States