Longevity, Metabolic Disease, and Community Health.

In the United States, the average lifespan has increased despite the dramatic increase in obesity, diabetes, and other conditions that worsen during aging. As the longevity of US population increases, it is critical to understand the factors that impact aging populations especially as age-related disease and declining health becomes more prevalent. Diabetes related to obesity has become much more prevalent throughout the United States and globally. Further, the prevalence of age-related health problems accelerate in lower income communities with less access to health care. All these factors become critical as individuals age. Furthermore, in communities with less availability to health care, diagnosis may be delayed and treatments are initiated at a much later stage in disease. As such, the costs of medical care skyrocket leading to higher costs both to the community and to taxpayers. This chapter reviews some key health problems and issues in community health and healthy aging, recognizing the importance of organizations and programs that provide education and support to the aging population. Finally, cultural differences in approaches to healthy aging provide important insights and lessons for optimizing quality of life during aging.

Management of newly diagnosed type 2 Diabetes Mellitus (T2DM) in children and adolescents.

Over the past 3 decades, the prevalence of childhood obesity has increased dramatically in North America, ushering in a variety of health problems, including type 2 diabetes mellitus (T2DM), which previously was not typically seen until much later in life. The rapid emergence of childhood T2DM poses challenges to many physicians who find themselves generally ill-equipped to treat adult diseases encountered in children. This clinical practice guideline was developed to provide evidence-based recommendations on managing 10- to 18-year-old patients in whom T2DM has been diagnosed. The American Academy of Pediatrics (AAP) convened a Subcommittee on Management of T2DM in Children and Adolescents with the support of the American Diabetes Association, the Pediatric Endocrine Society, the American Academy of Family Physicians, and the Academy of Nutrition and Dietetics (formerly the American Dietetic Association). These groups collaborated to develop an evidence report that served as a major source of information for these practice guideline recommendations. The guideline emphasizes the use of management modalities that have been shown to affect clinical outcomes in this pediatric population. Recommendations are made for situations in which either insulin or metformin is the preferred first-line treatment of children and adolescents with T2DM. The recommendations suggest integrating lifestyle modifications (ie, diet and exercise) in concert with medication rather than as an isolated initial treatment approach. Guidelines for frequency of monitoring hemoglobin A1c (HbA1c) and finger-stick blood glucose (BG) concentrations are presented. Decisions were made on the basis of a systematic grading of the quality of evidence and strength of recommendation. The clinical practice guideline underwent peer review before it was approved by the AAP. This clinical practice guideline is not intended to replace clinical judgment or establish a protocol for the care of all children with T2DM, and its recommendations may not provide the only appropriate approach to the management of children with T2DM. Providers should consult experts trained in the care of children and adolescents with T2DM when treatment goals are not met or when therapy with insulin is initiated. The AAP acknowledges that some primary care clinicians may not be confident of their ability to successfully treat T2DM in a child because of the child's age, coexisting conditions, and/or other concerns. At any point at which a clinician feels he or she is not adequately trained or is uncertain about treatment, a referral to a pediatric medical subspecialist should be made. If a diagnosis of T2DM is made by a pediatric medical subspecialist, the primary care clinician should develop a comanagement strategy with the subspecialist to ensure that the child continues to receive appropriate care consistent with a medical home model in which the pediatrician partners with parents to ensure that all health needs are met.

Management of type 2 diabetes mellitus in children and adolescents.

OBJECTIVE: Over the last 3 decades, the prevalence of childhood obesity has increased dramatically in North America, ushering in a variety of health problems, including type 2 diabetes mellitus (T2DM), which previously was not typically seen until much later in life. This technical report describes, in detail, the procedures undertaken to develop the recommendations given in the accompanying clinical practice guideline, "Management of Type 2 Diabetes Mellitus in Children and Adolescents," and provides in-depth information about the rationale for the recommendations and the studies used to make the clinical practice guideline's recommendations. METHODS: A primary literature search was conducted relating to the treatment of T2DM in children and adolescents, and a secondary literature search was conducted relating to the screening and treatment of T2DM's comorbidities in children and adolescents. Inclusion criteria were prospectively and unanimously agreed on by members of the committee. An article was eligible for inclusion if it addressed treatment (primary search) or 1 of 4 comorbidities (secondary search) of T2DM, was published in 1990 or later, was written in English, and included an abstract. Only primary research inquiries were considered; review articles were considered if they included primary data or opinion. The research population had to constitute children and/or adolescents with an existing diagnosis of T2DM; studies of adult patients were considered if at least 10% of the study population was younger than 35 years. All retrieved titles, abstracts, and articles were reviewed by the consulting epidemiologist. RESULTS: Thousands of articles were retrieved and considered in both searches on the basis of the aforementioned criteria. From those, in the primary search, 199 abstracts were identified for possible inclusion, 58 of which were retained for systematic review. Five of these studies were classified as grade A studies, 1 as grade B, 20 as grade C, and 32 as grade D. Articles regarding treatment of T2DM selected for inclusion were divided into 4 major subcategories on the basis of type of treatment being discussed: (1) medical treatments (32 studies); (2) nonmedical treatments (9 studies); (3) provider behaviors (8 studies); and (4) social issues (9 studies). From the secondary search, an additional 336 abstracts relating to comorbidities were identified for possible inclusion, of which 26 were retained for systematic review. These articles included the following: 1 systematic review of literature regarding comorbidities of T2DM in adolescents; 5 expert opinions presenting global recommendations not based on evidence; 5 cohort studies reporting natural history of disease and comorbidities; 3 with specific attention to comorbidity patterns in specific ethnic groups (case-control, cohort, and clinical report using adult literature); 3 reporting an association between microalbuminuria and retinopathy (2 case-control, 1 cohort); 3 reporting the prevalence of nephropathy (cohort); 1 reporting peripheral vascular disease (case series); 2 discussing retinopathy (1 case-control, 1 position statement); and 3 addressing hyperlipidemia (American Heart Association position statement on cardiovascular risks; American Diabetes Association consensus statement; case series). A breakdown of grade of recommendation shows no grade A studies, 10 grade B studies, 6 grade C studies, and 10 grade D studies. With regard to screening and treatment recommendations for comorbidities, data in children are scarce, and the available literature is conflicting. Therapeutic recommendations for hypertension, dyslipidemia, retinopathy, microalbuminuria, and depression were summarized from expert guideline documents and are presented in detail in the guideline. The references are provided, but the committee did not independently assess the supporting evidence. Screening tools are provided in the Supplemental Information.

Primary care physicians' use of an informed decision-making process for prostate cancer screening.

PURPOSE: Leading professional organizations acknowledge the importance of an informed decision-making process for prostate cancer screening. We describe primary care physicians' reports of their prescreening discussions about the potential harms and benefits of prostate cancer screening. METHODS: Members of the American Academy of Family Physicians National Research Network responded to a survey that included (1) an indicator of practice styles related to discussing harms and benefits of prostate-specific antigen testing and providing a screening recommendation or letting patients decide, and (2) indicators reflecting physicians' beliefs about prostate cancer screening. The survey was conducted between July 2007 and January 2008. RESULTS: Of 426 physicians 246 (57.7%) completed the survey questionnaire. Compared with physicians who ordered screening without discussion (24.3%), physicians who discussed harms and benefits with patients and then let them decide (47.7%) were more likely to endorse beliefs that scientific evidence does not support screening, that patients should be told about the lack of evidence, and that patients have a right to know the limitations of screening; they were also less likely to endorse the belief that there was no need to educate patients because they wanted to be screened. Concerns about medicolegal risk associated with not screening were more common among physicians who discussed the harms and benefits and recommended screening than among physicians who discussed screening and let their patients decide. CONCLUSIONS: Much of the variability in physicians' use of an informed decision-making process can be attributed to beliefs about screening. Concerns about medicolegal risk remain an important barrier for shared decision making.

Entertainment education for breast cancer surgery decisions: a randomized trial among patients with low health literacy.

OBJECTIVE: To evaluate an entertainment-based patient decision aid for early stage breast cancer surgery in low health literacy patients. METHODS: Newly diagnosed female patients with early stage breast cancer from two public hospitals were randomized to receive an entertainment-based decision aid for breast cancer treatment along with usual care (intervention arm) or to receive usual care only (control arm). Pre-decision (baseline), pre-surgery, and 1-year follow-up assessments were conducted. RESULTS: Patients assigned to the intervention arm of the study were more likely than the controls to choose mastectomy rather than breast-conserving surgery; however, they appeared better informed and clearer about their surgical options than women assigned to the control group. No differences in satisfaction with the surgical decision or the decision-making process were observed between the patients who viewed the intervention and those assigned to the control group. CONCLUSIONS: Entertainment education may be a desirable strategy for informing lower health literate women about breast cancer surgery options. PRACTICE IMPLICATIONS: Incorporating patient decision aids, particularly computer-based decision aids, into standard clinical practice remains a challenge; however, patients may be directed to view programs at home or at public locations (e.g., libraries, community centers).

An overview of incretin clinical trials.

This article reviews many of the key incretin clinical trials, with a focus on the efficacy and safety of glucagon-like peptide-1 (GLP-1) receptor agonists and dipeptidyl peptidase-4 (DPP-4) inhibitors compared with placebo and other glucose-lowering agents used as comparators. These agents have been tested either as monotherapy or in combination with one or more oral antidiabetic drugs (OADs). The article also discusses some of the important clinical differences between GLP-1 receptor agonists and DPP-4 inhibitors.

Entertainment education for prostate cancer screening: a randomized trial among primary care patients with low health literacy.

OBJECTIVE: To evaluate an entertainment-based patient decision aid for prostate cancer screening among patients with low or high health literacy. METHODS: Male primary care patients from two clinical sites, one characterized as serving patients with low health literacy (n=149) and the second as serving patients with high health literacy (n=301), were randomized to receive an entertainment-based decision aid for prostate cancer screening or an audiobooklet-control aid with the same learner content but without the entertainment features. Postintervention and 2-week follow-up assessments were conducted. RESULTS: Patients at the low-literacy site were more engaged with the entertainment-based aid than patients at the high-literacy site. Overall, knowledge improved for all patients. Among patients at the low-literacy site, the entertainment-based aid was associated with lower decisional conflict and greater self-advocacy (i.e., mastering and obtaining information about screening) when compared to patients given the audiobooklet. No differences between the aids were observed for patients at the high-literacy site. CONCLUSION: Entertainment education may be an effective strategy for promoting informed decision making about prostate cancer screening among patients with lower health literacy. PRACTICE IMPLICATIONS: As barriers to implementing computer-based patient decision support programs decrease, alternative models for delivering these programs should be explored.

Conducting medication safety research projects in a primary care physician practice-based research network.

OBJECTIVE: To describe a roadmap for developing a practice-based research network (PBRN) through the experience of conducting medication safety research projects in a primary care physician PBRN. SETTING: Southern Primary-care Urban Research Network (SPUR-Net) in Houston, Tex., from 2000 to 2007. PRACTICE DESCRIPTION: SPUR-Net is a partnership of six health care organizations in Houston and includes 32 clinics with 313 primary care clinicians (50% family physicians, 25% general internists, and 25% pediatricians) who provide care for approximately 1 million patient encounters annually. PRACTICE INNOVATION: The pharmacist principal investigator collaborates with physicians and researchers in primary care clinics to investigate medication safety practice in SPUR-Net. MAIN OUTCOME MEASURES: (1) A roadmap for PBRN research and (2) initiation of a research program focusing on medication safety through the PBRN. RESULTS: A roadmap with 10 steps for conducting practice-based research is recommended: (1) form collaborative partnership, (2) develop research infrastructure, (3) formulate research questions, (4) design study methods, (5) obtain funding support, (6) develop study instruments, (7) implement the study, (8) manage and analyze data, (9) disseminate results, and (10) translate research into practice. Four research projects focusing on medication safety were conducted in SPUR-Net from 2002 to 2007. Medication outcomes include improved medication use, increased awareness for medication counseling, decreased medication errors, and identification of best practices for medication reconciliation. CONCLUSION: Practice-based research conducted in primary care settings identifies, studies, and evaluates common problems encountered in busy clinic practice. With feedback from stakeholders, best practices and improved practice can be identified and "translated" back to practice. Grant funding for research projects helps sustain PBRNs. The implementation of medication safety research projects has helped primary care clinics, clinicians, and patients increase appropriate medication use and explore ways to further improve medication safety.

Concordance of couples' prostate cancer screening recommendations from a decision analysis.

OBJECTIVE: To determine whether different utilities for prostate cancer screening outcomes for couples, and husbands and wives separately, lead to incongruent screening recommendations. METHODS: We evaluated survey results of 168 married couples from three family practice centers in Texas, USA. Utilities for eight adverse outcomes of prostate cancer screening and treatment were assessed using the time trade-off method. We assessed utilities separately for each partner and jointly for each couple. Using a previously published decision-analytic model of prostate cancer screening, we input the husband's age (starting point) and utilities for outcomes from the husband's, wife's, and couple's perspectives (to adjust for quality of life). Both group-level and individualized models were run. We also asked husbands (and wives) if they intended to be screened (or have their husbands screened) for prostate cancer in the future. RESULTS: Husbands' lower tolerance for adverse outcomes (lower utilities) was associated with lower quality-adjusted life expectancy (than their wives) for the choice of screening versus not screening. Depending on the perspective, 48 husbands (28.6%), 89 wives (53.0%), and 58 couples (34.5%) preferred screening in the individual decision-analytic models. Comparing the three perspectives, agreement in model recommendations was greatest between the husbands and the couples (82.1%), intermediate between the wives and couples (63.7%), and lowest between the husbands and wives (55.4%). Using group-aggregated utilities in the decision-analytic model tended to mask the variation in recommended strategies amongst individuals. There was no relationship between screening preferences from the model and the husbands' and wives' reported desire for screening, as the majority of subjects wanted screening. CONCLUSIONS: Discordant health preferences may yield conflicting recommendations for prostate cancer screening. The results have broad implications for informed healthcare decision making for couples.

Climate amenity and BMI.

OBJECTIVES: Our goal was to examine the relationship between BMI and climate amenable for physical activity at the county level in the U.S. RESEARCH METHODS AND PROCEDURES: Using Geographic Information Systems tools and 6-year National Oceanic and Atmospheric Administration station hourly weather records, an index of amenable climate was derived for all U.S. counties. This index was linked to individual BMI in a multi-level analysis that accounted for other individual characteristics from the 2002 survey of the Behavioral Risk Factor Surveillance System. RESULTS: There was an inverse relationship between climate amenable to physical activity and BMI at the county level after controlling for individual risk factors, county road density, and median household income and unemployment rate. Residents in high climate-amenity counties tended to have a lower BMI. DISCUSSION: The contribution of less amenable climate to overweight and obesity in the U.S. is likely to be substantial because it cuts across wide geographic areas. Health promotion strategies that promote mixed land use or other urban design conducive to walking and other physical activities should consider broader environmental disamenities to mitigate their influence. Strategies for outdoor physical activity should also be tailored for people of different racial groups and educational backgrounds due to observed differences in their response to climate amenity.

Defining the concept of primary care in South Korea using a Delphi method.

BACKGROUNDS AND OBJECTIVES: There is no consensus on the definition of primary care in South Korea. This study's objective was to define the concept of primary care using a Delphi method. METHODS: Three expert panels were formed, consisting of 16 primary care policy researchers, 45 stakeholders, and 16 primary care physicians. Three rounds of voting, using 9-point appropriateness scales, were conducted. The first round involved rating the appropriateness of 20 previously established attributes of primary care. In round 2, panelists received a summary of the first-round results and were asked to once again vote on the 10 undetermined attributes and the provisional definition. The final round involved voting on the appropriateness of the revised definition. The Korean Language Society reviewed the revised definition. RESULTS: Four core (first-contact care, comprehensiveness, coordination, and longitudinality) and three ancillary (personalized care, family and community context, and community base) attributes were selected. The Korean definition of primary care was accomplished with all three panel groups arriving at a "very good" level of consensus. CONCLUSIONS: The Korean definition of primary care will provide a framework for evaluating performance of primary care in South Korea. It will also contribute to resolving confusion about the concept of primary care.

Preliminary testing of a just-in-time, user-defined values clarification exercise to aid lower literate women in making informed breast cancer treatment decisions.

OBJECTIVE: To report on the initial testing of a values clarification exercise utilizing a jewellery box within a computerized patient decision aid (CPtDA) designed to assist women in making a surgical breast cancer treatment decision. DESIGN: Pre-post design, with patients interviewed after diagnosis, and then after completing the CPtDA sometime later at their preoperative visit. SAMPLE: Fifty-one female patients, who are low literate and naïve computer users, newly diagnosed with early stage breast cancer from two urban public hospitals. INTERVENTION: A computerized decision aid that combines entertainment-education (edutainment) with enhanced (factual) content. An interactive jewellery box is featured to assist women in: (1) recording and reflecting over issues of concern with possible treatments, (2) deliberating over surgery decision, and (3) communicating with physician and significant others. OUTCOMES: Patients' use of the jewellery box to store issues during completion of the CPtDA, and perceived clarity of values in making a treatment decision, as measured by a low literacy version of the Decisional Conflict Scale (DCS). RESULTS: Over half of the participants utilized the jewellery box to store issues they found concerning about the treatments. On average, users flagged over 13 issues of concern with the treatments. Scores on the DCS Uncertainty and Feeling Unclear about Values subscales were lower after the intervention compared to before the decision was made. CONCLUSIONS: A values clarification exercise using an interactive jewellery box may be a promising method for promoting informed treatment decision making by low literacy breast cancer patients.

Management of type 2 diabetes in the primary care setting: a practice-based research network study.

PURPOSE: We wanted to describe how primary care clinicians care for patients with type 2 diabetes. METHODS: We undertook a cross-sectional study of 95 primary care clinicians and 822 of their established patients with type 2 diabetes from 4 practice-based, primary care research networks in the United States. Clinicians were surveyed about their training and practice. Patients completed a self-administered questionnaire about their care, and medical records were reviewed for complications, treatment, and diabetes-control indicators. RESULTS: Participating clinicians (average age, 45.7 years) saw an average of 32.6 adult patients with diabetes per month. Patients (average age, 59.7 years) reported a mean duration of diabetes of 9.1 years, with 34.3% having had the disease more than 10 years. Nearly one half (47.5%) of the patients had at least 1 diabetes-related complication, and 60.8% reported a body mass index greater than 30. Mean glycosylated hemoglobin (HbA1c) level was 7.6% (SD 1.73), and 40.5% of patients had values <7%. Only 35.3% of patients had adequate blood pressure control (<130/85 mm Hg), and only 43.7% had low-density lipoprotein cholesterol (LDL-C) levels <100 mg/dL. Only 7.0% of patients met all 3 control targets. Multilevel models showed that patient ethnicity, practice type, involvement of midlevel clinicians, and treatment were associated with HbA1c level; patient age, education level, and practice type were associated with blood pressure control; and patient ethnicity was associated with LDL-C control. CONCLUSIONS: Only modest numbers of patients achieve established targets of diabetes control. Reengineering primary care practice may be necessary to substantially improve care.

Entertainment education for informed breast cancer treatment decisions in low-literate women: development and initial evaluation of a patient decision aid.

BACKGROUND: We report on the development and initial evaluation of a novel computerized decision support system (CDSS) that utilizes concepts from entertainment education (edutainment) to assist low-literate, multiethnic women in making initial surgical treatment decisions. METHOD: We randomly assigned 51 patients diagnosed with early stage breast cancer to use the decision aid. RESULTS: Patients who viewed the CDSS improved their knowledge of breast cancer treatment; found the application easy to use and understand, informative, and enjoyable; and were less worried about treatment. CONCLUSION: The system clearly reached its intended objectives to create a usable decision aid for low-literate, novice computer users.

Comparison of the instructional efficacy of Internet-based CME with live interactive CME workshops: a randomized controlled trial.

CONTEXT: Despite evidence that a variety of continuing medical education (CME) techniques can foster physician behavioral change, there have been no randomized trials comparing performance outcomes for physicians participating in Internet-based CME with physicians participating in a live CME intervention using approaches documented to be effective. OBJECTIVE: To determine if Internet-based CME can produce changes comparable to those produced via live, small-group, interactive CME with respect to physician knowledge and behaviors that have an impact on patient care. DESIGN, SETTING, AND PARTICIPANTS: Randomized controlled trial conducted from August 2001 to July 2002. Participants were 97 primary care physicians drawn from 21 practice sites in Houston, Tex, including 7 community health centers and 14 private group practices. A control group of 18 physicians from these same sites received no intervention. INTERVENTIONS: Physicians were randomly assigned to an Internet-based CME intervention that could be completed in multiple sessions over 2 weeks, or to a single live, small-group, interactive CME workshop. Both incorporated similar multifaceted instructional approaches demonstrated to be effective in live settings. Content was based on the National Institutes of Health National Cholesterol Education Program--Adult Treatment Panel III guidelines. MAIN OUTCOME MEASURES: Knowledge was assessed immediately before the intervention, immediately after the intervention, and 12 weeks later. The percentage of high-risk patients who had appropriate lipid panel screening and pharmacotherapeutic treatment according to guidelines was documented with chart audits conducted over a 5-month period before intervention and a 5-month period after intervention. RESULTS: Both interventions produced similar and significant immediate and 12-week knowledge gains, representing large increases in percentage of items correct (pretest to posttest: 31.0% [95% confidence interval {CI}, 27.0%-35.0%]; pretest to 12 weeks: 36.4% [95% CI, 32.2%-40.6%]; P<.001 for all comparisons). Chart audits revealed high baseline screening rates in all study groups (> or =93%) with no significant postintervention change. However, the Internet-based intervention was associated with a significant increase in the percentage of high-risk patients treated with pharmacotherapeutics according to guidelines (preintervention, 85.3%; postintervention, 90.3%; P = .04). CONCLUSIONS: Appropriately designed, evidence-based online CME can produce objectively measured changes in behavior as well as sustained gains in knowledge that are comparable or superior to those realized from effective live activities.