Association between PEG3 DNA methylation and high-grade cervical intraepithelial neoplasia.

BACKGROUND: Epigenetic mechanisms are hypothesized to contribute substantially to the progression of cervical intraepithelial neoplasia (CIN) to cervical cancer, although empirical data are limited. METHODS: Women (n = 419) were enrolled at colposcopic evaluation at Duke Medical Center in Durham, North Carolina. Human papillomavirus (HPV) was genotyped by HPV linear array and CIN grade was ascertained by biopsy pathologic review. DNA methylation was measured at differentially methylated regions (DMRs) regulating genomic imprinting of the IGF2/H19, IGF2AS, MESTIT1/MEST, MEG3, PLAGL1/HYMAI, KvDMR and PEG10, PEG3 imprinted domains, using Sequenom-EpiTYPER assays. Logistic regression models were used to evaluate the associations between HPV infection, DMR methylation and CIN risk overall and by race. RESULTS: Of the 419 participants, 20 had CIN3+, 52 had CIN2, and 347 had ≤ CIN1 (CIN1 and negative histology). The median participant age was 28.6 (IQR:11.6) and 40% were African American. Overall, we found no statistically significant association between altered methylation in selected DMRs and CIN2+ compared to ≤CIN1. Similarly, there was no significant association between DMR methylation and CIN3+ compared to ≤CIN2. Restricting the outcome to CIN2+ cases that were HR-HPV positive and p16 staining positive, we found a significant association with PEG3 DMR methylation (OR: 1.56 95% CI: 1.03-2.36). CONCLUSIONS: While the small number of high-grade CIN cases limit inferences, our findings suggest an association between altered DNA methylation at regulatory regions of PEG3 and high grade CIN in high-risk HPV positive cases.

Long-Term Impact of an Electronic Health Record-Enabled, Team-Based, and Scalable Population Health Strategy Based on the Chronic Care Model.

The Chronic Care Model (CCM) is a promising framework for improving population health, but little is known regarding the long-term impact of scalable, informatics-enabled interventions based on this model. To address this challenge, this study evaluated the long-term impact of implementing a scalable, electronic health record (EHR)- enabled, and CCM-based population health program to replace a labor-intensive legacy program in 18 primary care practices. Interventions included point-of-care decision support, quality reporting, team-based care, patient engagement, and provider education. Among 6,768 patients with diabetes receiving care over 4 years, hemoglobin A1c levels remained stable during the 2-year pre-intervention and post-intervention periods (0.03% and 0% increases, respectively), compared to a 0.42% increase expected based on A1c progression observed in the United Kingdom Prospective Diabetes Study long-term outcomes cohort. The results indicate that an EHR-enabled, team- based, and scalable population health strategy based on the CCM may be effective and efficient for managing population health.

HPV genotypes and cervical intraepithelial neoplasia in a multiethnic cohort in the southeastern USA.

PURPOSE: For poorly understood reasons, invasive cervical cancer (ICC) incidence and mortality rates are higher in women of African descent. Oncogenic human papillomavirus (HPV) genotypes distribution may vary between European American (EA) and African-American (AA) women and may contribute to differences in ICC incidence. The current study aimed at disentangling differences in HPV distribution among AA and EA women. METHODS: Five-hundred and seventy-two women were enrolled at the time of colposcopic evaluation following an abnormal liquid-based cytology screen. HPV infections were detected using HPV linear array, and chi-squared tests and linear regression models were used to compare HPV genotypes across racial/ethnic groups by CIN status. RESULTS: Of the 572 participants, 494 (86 %) had detectable HPV; 245 (43 %) had no CIN lesion, 239 (42 %) had CIN1, and 88 (15 %) had CIN2/3. Seventy-three percent of all women were infected with multiple HPV genotypes. After adjusting for race, age, parity, income, oral contraception use, and current smoking, AAs were two times less likely to harbor HPV 16/18 (OR 0.48, 95 % CI 0.21-0.94, p = 0.03) when all women were considered. This association remained unchanged when only women with CIN2/3 lesions were examined (OR 0.22, 95 % CI 0.05-0.95, p = 0.04). The most frequent high-risk HPV genotypes detected among EAs were 16, 18, 56, 39, and 66, while HPV genotypes 33, 35, 45, 58, and 68 were the most frequent ones detected in AAs. CONCLUSIONS: Our data suggest that while HPV 16/18 are the most common genotypes among EA women with CIN, AAs may harbor different genotypes.

Barriers to adopting a healthy lifestyle: insight from postpartum women.

BACKGROUND: Postpartum weight retention can contribute to obesity. There may be unique barriers to weight loss in this period. FINDINGS: Cases are presented for three postpartum women who declined to participate in a postpartum weight loss intervention.Despite their desire to engage in healthier behaviors, or partake in an intervention uniquely designed to promote healthy lifestyles for postpartum women, some find it too difficult to make such commitments. Barriers women face in adopting a healthier lifestyle in this period include 1) time availability; 2) prioritizing other competing life responsibilities above their own health; 3) support from family members, friends, and/or co-workers; and 4) lack of flexibility in the intervention structure. These illustrations describe their perspectives in the context of life balance, perceived health, and support, and reflect the multi-dimensional nature of their lives during the life cycle change of the postpartum period. CONCLUSION: Postpartum women face difficult and complex challenges to prioritizing their health and their weight management.

Family physicians as team leaders: "time" to share the care.

A major contributor to shortfalls in delivery of recommended health care services is lack of physician time. On the basis of recommendations from national clinical care guidelines for preventive services and chronic disease management, and including the time needed for acute concerns, sufficiently addressing the needs of a standard patient panel of 2,500 would require 21.7 hours per day. The problem of insufficient time indicates that primary care requires broad, fundamental changes. The creation of primary care teams that include members such as physician assistants, nurse practitioners, dietitians, health educators, and lay coaches is important to meeting patients' primary care needs.

Estimated time spent on preventive services by primary care physicians.

BACKGROUND: Delivery of preventive health services in primary care is lacking. One of the main barriers is lack of time. We estimated the amount of time primary care physicians spend on important preventive health services. METHODS: We analyzed a large dataset of primary care (family and internal medicine) visits using the National Ambulatory Medical Care Survey (2001-4); analyses were conducted 2007-8. Multiple linear regression was used to estimate the amount of time spent delivering each preventive service, controlling for demographic covariates. RESULTS: Preventive visits were longer than chronic care visits (M = 22.4, SD = 11.8, M = 18.9, SD = 9.2, respectively). New patients required more time from physicians. Services on which physicians spent relatively more time were prostate specific antigen (PSA), cholesterol, Papanicolaou (Pap) smear, mammography, exercise counseling, and blood pressure. Physicians spent less time than recommended on two "A" rated ("good evidence") services, tobacco cessation and Pap smear (in preventive visits), and one "B" rated ("at least fair evidence") service, nutrition counseling. Physicians spent substantial time on two services that have an "I" rating ("inconclusive evidence of effectiveness"), PSA and exercise counseling. CONCLUSION: Even with limited time, physicians address many of the "A" rated services adequately. However, they may be spending less time than recommended for important services, especially smoking cessation, Pap smear, and nutrition counseling. Future research is needed to understand how physicians decide how to allocate their time to address preventive health.

Use of email in a family practice setting: opportunities and challenges in patient- and physician-initiated communication.

BACKGROUND: Electronic mail (email) has the potential to improve communication between physicians and patients. METHODS: We conducted two research studies in a family practice setting: 1) a brief, anonymous patient survey of a convenience sample to determine the number of clinic patients receptive to communicating with their physician via email, and 2) a randomized, controlled pilot study to assess the feasibility of providing health education via email to family practice patients. RESULTS: Sixty-eight percent of patients used email, and the majority of those (80%) were interested in using email to communicate with the clinic. The majority also reported that their email address changed less frequently than their home address (65%, n = 173) or telephone number (68%, n = 181). Forty-two percent were willing to pay an out-of-pocket fee to have email access to their physicians. When evaluating email initiated by the clinic, 26% of otherwise eligible patients could not participate because they lacked email access; those people were more likely to be black and to be insured through Medicaid. Twenty-four subjects agreed to participate, but one-third failed to return the required consent form by mail. All participants who received the intervention emails said they would like to receive health education emails in the future. CONCLUSION: Our survey results show that patients are interested in email communication with the family practice clinic. Our feasibility study also illustrates important challenges in physician-initiated electronic communication. The 'digital divide' - decreased access to electronic technologies in lower income groups - is an ethical concern in the use of email for patient-physician communication.

Just for Us: an academic medical center-community partnership to maintain the health of a frail low-income senior population.

PURPOSE: To promote health and maintain independence, Just for Us provides financially sustainable, in-home, integrated care to medically fragile, low-income seniors and disabled adults living in subsidized housing. DESIGN AND METHODS: The program provides primary care, care management, and mental health services delivered in patient's homes by a multidisciplinary, multiagency team. RESULTS: After 2 years of operation, Just for Us is serving nearly 300 individuals in 10 buildings. The program is demonstrating improvement in individual indices of health. Medicaid expenditures for enrollees are shifting from ambulances and hospital services to pharmacy, personal care, and outpatient visits. The program is not breaking even, but it is moving toward that goal. The program's success is based on a partnership involving an academic medical center, a community health center, county social and mental health agencies, and a city housing authority to coordinate and leverage services. IMPLICATIONS: Just for Us is becoming a financially sustainable way of creating a "system within a nonsystem" for low-income elderly persons in clustered housing.

Alternative models for academic family practices.

BACKGROUND: The Future of Family Medicine Report calls for a fundamental redesign of the American family physician workplace. At the same time, academic family practices are under economic pressure. Most family medicine departments do not have self-supporting practices, but seek support from specialty colleagues or hospital practice plans. Alternative models for academic family practices that are economically viable and consistent with the principles of family medicine are needed. This article presents several "experiments" to address these challenges. METHODS: The basis of comparison is a traditional academic family medicine center. Apart of the faculty practice plan, our center consistently operated at a deficit despite high productivity. A number of different practice types and alternative models of service delivery were therefore developed and tested. They ranged from a multi-specialty office arrangement, to a community clinic operated as part of a federally-qualified health center, to a team of providers based in and providing care for residents of an elderly public housing project. Financial comparisons using consistent accounting across models are provided. RESULTS: Academic family practices can, at least in some settings, operate without subsidy while providing continuity of care to a broad segment of the community. The prerequisites are that the clinicians must see patients efficiently, and be able to bill appropriately for their payer mix. CONCLUSION: Experimenting within academic practice structure and organization is worthwhile, and can result in economically viable alternatives to traditional models.

Is there time for management of patients with chronic diseases in primary care?

PURPOSE: Despite the availability of national practice guidelines, many patients fail to receive recommended chronic disease care. Physician time constraints in primary care are likely one cause. METHODS: We applied guideline recommendations for 10 common chronic diseases to a panel of 2,500 primary care patients with an age-sex distribution and chronic disease prevalences similar to those of the general population, and estimated the minimum physician time required to deliver high-quality care for these conditions. The result was compared with time available for patient care for the average primary care physician. RESULTS: Eight hundred twenty-eight hours per year, or 3.5 hours a day, were required to provide care for the top 10 chronic diseases, provided the disease is stable and in good control. We recalculated this estimate based on increased time requirements for uncontrolled disease. Estimated time required increased by a factor of 3. Applying this factor to all 10 diseases, time demands increased to 2,484 hours, or 10.6 hours a day. CONCLUSIONS: Current practice guidelines for only 10 chronic illnesses require more time than primary care physicians have available for patient care overall. Streamlined guidelines and alternative methods of service delivery are needed to meet recommended standards for quality health care.

Pain predicts non-adherence to pap smear screening among middle-aged African American women.

BACKGROUND: Middle-aged African American women have the highest incidence and mortality of invasive cervical cancer in the United States and the lowest adherence to pap smear screening. METHODS: In 2001, we identified factors associated with non-adherence to screening recommendations using three focus group interviews and subsequently developed a questionnaire administered to 144 African American women aged 45 to 65 years. RESULTS: The perception that the Pap test was painful was associated with non-adherence to screening recommendations (OR = 4.78; 95%CI: 1.67-13.7). Difficulty to pay for the office visit coupled with perceived pain was associated with a nearly sixfold increase in risk of non-adherence (OR = 5.8; 95%CI: 2.8-15.5). Previously identified barriers to screening including lower education and socioeconomic status, poor access to care, knowledge of and exposure to known risk factors of invasive cervical cancer, cancer fatalism, and perceived racism were not independently associated with non-adherence. CONCLUSIONS: These data suggest that, among middle-aged African American women, future interventions addressing pain during a Pap test will likely increase acceptability of and adherence to cervical cancer screening. Pain could be addressed either by providing information during the pap test and/or using smaller lubricated speculums.

Reproducibility of self-reported pap test utilization in middle-aged African-American women.

Both clinicians who perform Pap tests and prescribe re-screens and public health officials, who periodically evaluate the success of Pap test screening programs, often depend on women to self-report their most recent Pap test. However, reliability of self-reported Pap test utilization is putatively low, and even lower in African-American women compared to Whites. Between 2001 and 2002, Pap test screening histories were obtained from 144 African-American women, aged 45 to 64 years at two in-person interviews conducted three to six weeks apart. Reproducibility of self-reported Pap test was substantial (kappa=0.64; 95% confidence interval: .46-.82), with the highest agreement among women with greater income and educational attainment, and those who were younger. This level of reproducibility is likely sufficient both to evaluate the population coverage of public health screening programs and for prescribing re-screens among younger African-American women and those of higher income and education. Not using self-reports to base clinic decisions may still be prudent among those with less education.

Risk classification of adult primary care patients by self-reported quality of life.

BACKGROUND: : Although patient-reported health-related quality of life (HRQOL) is known to predict health services utilization, most risk assessment systems use provider-reported diagnoses as predictors rather than HRQOL. OBJECTIVE: : We sought to classify adult primary care patients prospectively by utilization risk based on age, gender, and HRQOL at a single clinic visit. RESEARCH DESIGN: : Patients completed the Duke Health Profile. Providers completed the Duke Severity of Illness Checklist. Diagnoses were grouped with the Ambulatory Care Groups system. Predictive coefficients for 1-year primary care charges calculated from the age, gender, and HRQOL of 728 reference patients were used to classify 474 test patients into 4 risk classes. Comparisons were made with models that used diagnoses or severity of illness as predictors. RESULTS: : The positive likelihood ratio for predicting highest risk was 2.2 for the HRQOL model, compared with 1.8 for the diagnoses model, 1.6 for the severity model, and 1.5 for age and gender alone. One-year actual primary care visits and charges increased step-wise from lowest to highest risk class. Highest risk patients were older and more likely to be women, black, or Medicaid recipients. Although the highest-risk patients represented only 18.6% of the test group, they accounted for 26.7% of the primary care clinic visits, 31.6% of the clinic charges, 34.6% of the hospital days, 35.1% of hospital charges, and 30.8% of total charges at all healthcare sites. CONCLUSION: : The HRQOL risk classification system can identify primary care patients at risk for high future health services utilization.

Factors associated with condom use among at-risk women students and nonstudents seen in managed care.

OBJECTIVES: Sexually transmitted diseases (STD) research has focused on high-risk populations such as STD clinic patients and college students. This report examines predictors of unprotected sex among nonstudent women seen in primary care. STUDY DESIGN: Data are taken from the baseline survey of an intervention trial testing tailored print materials to encourage condom use. POPULATION: Eligible women were identified from automated databases of two managed care organizations and were ages 18-25, unmarried, heterosexually active in the prior 6 months, and not in a long-term monogamous relationship. OUTCOMES: The frequency of and relative contribution of risk behaviors to occurrences of unprotected vaginal sex were compared among non-full-time students (n=711) and full-time students (n=390). RESULTS: STD risk behaviors were prevalent and had similar associations with unprotected sex in both subsamples. Older age, using hormonal or no usual contraception, and having a "primary" partner increased unprotected sex; partner approval of condoms and having bought or carried condoms decreased unprotected sex. CONCLUSION: While sexually active single women seen in primary care perceive themselves at low STD risk, their risk profiles are similar to those of higher risk populations. Clinic-based interventions that include proactive identification of at-risk women and systems for encouraging safer sex practices are needed.

Primary care: is there enough time for prevention?

OBJECTIVES: We sought to determine the amount of time required for a primary care physician to provide recommended preventive services to an average patient panel. METHODS: We used published and estimated times per service to determine the physician time required to provide all services recommended by the US Preventive Services Task Force (USPSTF), at the recommended frequency, to a patient panel of 2500 with an age and sex distribution similar to that of the US population. RESULTS: To fully satisfy the USPSTF recommendations, 1773 hours of a physician's annual time, or 7.4 hours per working day, is needed for the provision of preventive services. CONCLUSIONS: Time constraints limit the ability of physicians to comply with preventive services recommendations.

Influence of stereotyping in smoking cessation counseling by primary care residents.

This study examined racial differences in primary care residents' rates of addressing smoking cessation. We expected residents to have higher rates of addressing cessation with White female patients as compared with African-American or Hispanic female patients, due, in part, to residents having higher outcome expectancies, self-efficacy, lower barriers, and less reliance on stereotypes. Residents (N = 90) were an average of 31 years old; two-thirds were White internal medicine residents. Residents viewed a video of a lower-middle class White, African-American, or Hispanic female interacting with her physician about stomach pain. Results indicate that residents were very likely to address smoking cessation, regardless of patients' race. Compared to residents assigned to an ethnic minority patient, residents assigned to the White patient were less likely to believe the patient would follow their advice (P < .03) and also perceived more barriers to address smoking cessation (P < .04). Reliance on the stereotype of Whites mediated the racial difference in outcome expectancies. Implications are that residents may be relying on stereotypes when they assess lower-middle class White female patients' receptivity to smoking cessation advice. Future research on the role of stereotyping in medical settings is warranted.

Factors associated with patient-recalled smoking cessation advice in a low-income clinic.

It is recommended that providers advise cessation to their patients who smoke. However, patients' reports of cessation advice indicate disparities based on patients' race, gender, age, and smoking level. Providers' reports do not corroborate these disparities. We investigated whether smokers who receive their care in a community health center recalled their providers advising them to quit smoking when their providers documented such advice. We examined 219 patient-provider dyads to assess factors associated with lack of agreement between providers' documentation and patient recall. Patients were asked to recall any provider advice to quit smoking in the post 2 years. After every visit, providers completed a form to record the content of the visit. Most of the patients were African American, married, and uninsured. Sixty-eight percent of the dyads agreed in their documentation/recall. Patient race was the only factor associated with lack of agreement; African-American patients were more likely than white patients to provide discrepant reports. Although this study can not disentangle the racial difference in patient-provider recall/documentation, results may indicate an important area in which health disparities exist. Future studies should address the dynamics of patient-provider communication about smoking cessation, especially in populations that include ethnically diverse patients.