Disentangling the effects of race and socioeconomic factors on liver transplantation rates for hepatocellular carcinoma.

INTRODUCTION: Liver transplantation is the most effective treatment for hepatocellular carcinoma (HCC) in eligible patients, but is not accessed equally by all. We explored the effects of race and socioeconomic factors on transplantation for HCC while controlling for stage, resection status, and transplant candidacy. PATIENTS AND METHODS: All HCC patients, 2003-2013, were retrospectively analyzed using multivariate analysis to explore differences in transplantation rates among cohorts. RESULTS: Of 3078 HCC patients, 754 (24%) were considered transplant eligible. Odds of transplantation were significantly higher for those with commercial insurance (OR = 1.99, 95% CI [1.42, 2.79]) and lower for black patients (OR = 0.55, 95% CI [0.33, 0.91]). Asians were more likely to be resected than white patients with similarly staged tumors and transplant criteria (p < 0.001). Patients not listed for transplantation for non-medical reasons were more likely to be government-insured (p = 0.02) and not white (p = 0.05). No step along the transplantation pathway was identified as the dominant hurdle. DISCUSSION: Patients who are black or government-insured are significantly less likely to undergo transplantation for HCC despite controlling for tumor stage, resection status, and transplant eligibility. Asian patients have higher rates of hepatic resection, but also appear to have lower transplantation rates beyond this effect.

Self-management behaviors in older adults with asthma: associations with health literacy.

OBJECTIVES: To examine self-management behaviors, including medication adherence and inhaler technique, in older adults with asthma and their association with health literacy. DESIGN: Observational cohort study. SETTING: Primary care and pulmonary specialty practices in two tertiary academic medical centers and three federally qualified health centers in New York, New York, and Chicago, Illinois. PARTICIPANTS: Adults with moderate or severe persistent asthma aged 60 and older (N = 433). MEASUREMENTS: Outcomes were adherence to asthma controller medications, metered dose inhaler (MDI) and dry powder inhaler (DPI) techniques, having a usual asthma physician, and avoidance of four common triggers. Health literacy was assessed using the Short Test of Functional Health Literacy in Adults. RESULTS: The mean age was 67, and 36% of participants had marginal or low health literacy. Adherence was low (38%) overall and worse in individuals with low health literacy (22%) than in those with adequate literacy (47%, P < .001) and after adjusting for demographic factors and health status (odds ratio (OR) = 0.48, 95% confidence interval (CI) = 0.31-0.73). Similarly, inhaler technique was poor; only 38% and 54% had good MDI and DPI technique, respectively. Technique was worse in those with low health literacy (MDI technique: OR = 0.57, 95% CI = 0.38-0.85; DPI technique: OR = 0.42, 95% CI = 0.25-0.71). Asthma self-monitoring and avoidance of triggers occurred infrequently but were less consistently associated with low health literacy. CONCLUSION: Adherence to medications and inhaler technique are poor in older adults with asthma and worse in those with low health literacy. Clinicians should routinely assess controller medication adherence and inhaler technique and use low-literacy communication strategies to support self-management in older adults with asthma.

Asthma outcomes are poor among older adults with low health literacy.

OBJECTIVE: To examine the association of health literacy (HL) with asthma outcomes among older asthmatics. METHODS: The study included adults ages ≥60 with moderate to severe asthma in New York City and Chicago. We assessed asthma control with the Asthma Control Questionnaire (ACQ) and the percent predicted forced expiratory volume at 1 s (FEV1) by spirometry, hospitalizations and emergency department (ED) visits in the past 6 months, and quality of life. HL was assessed with the Short Test of Functional Health Literacy in Adults (S-TOFHLA). Multivariate logistic regression models controlled for age, sex, race, income, general health and years with asthma. RESULTS: Among 433 individuals, 36% had low HL, 55% were over age 65, 38% were Hispanic and 22% were black. Poor asthma control was reported by 40% and 32% had FEV1 <70% of predicted; 9% had a hospital stay, 23% had an ED and 38% had poor quality of life. In multivariable analysis, individuals with low HL were more likely to have FEV1 <70% predicted (odds ratio [OR] 2.34, 95% confidence interval [CI] 1.39-3.94, p = 0.001), hospitalizations (OR 2.53, 95% CI 1.17-5.49, p = 0.02) and ED visits for asthma (OR 1.81, 95% CI 1.05-3.10, p = 0.03). There were no differences in self-reported asthma control and quality of life. CONCLUSIONS: Low HL is associated with poor asthma control by objective measure, and greater likelihood of ED visits and hospitalization. HL is a modifiable target for interventions to improve asthma outcomes in the elderly.

Efficacy of an evidence-based clinical decision support in primary care practices: a randomized clinical trial.

IMPORTANCE: There is consensus that incorporating clinical decision support into electronic health records will improve quality of care, contain costs, and reduce overtreatment, but this potential has yet to be demonstrated in clinical trials. OBJECTIVE: To assess the influence of a customized evidence-based clinical decision support tool on the management of respiratory tract infections and on the effectiveness of integrating evidence at the point of care. DESIGN, SETTING, AND PARTICIPANTS: In a randomized clinical trial, we implemented 2 well-validated integrated clinical prediction rules, namely, the Walsh rule for streptococcal pharyngitis and the Heckerling rule for pneumonia. INTERVENTIONS AND MAIN OUTCOMES AND MEASURES: The intervention group had access to the integrated clinical prediction rule tool and chose whether to complete risk score calculators, order medications, and generate progress notes to assist with complex decision making at the point of care. RESULTS: The intervention group completed the integrated clinical prediction rule tool in 57.5% of visits. Providers in the intervention group were significantly less likely to order antibiotics than the control group (age-adjusted relative risk, 0.74; 95% CI, 0.60-0.92). The absolute risk of the intervention was 9.2%, and the number needed to treat was 10.8. The intervention group was significantly less likely to order rapid streptococcal tests compared with the control group (relative risk, 0.75; 95% CI, 0.58-0.97; P= .03). CONCLUSIONS AND RELEVANCE: The integrated clinical prediction rule process for integrating complex evidence-based clinical decision report tools is of relevant importance for national initiatives, such as Meaningful Use. TRIAL REGISTRATION clinicaltrials.gov Identifier: NCT01386047.

The association of health literacy with illness and medication beliefs among older adults with asthma.

OBJECTIVE: Suboptimal health literacy (HL) and asthma beliefs are associated with poor asthma self-management and outcomes. We tested the hypothesis that low HL is associated with inaccurate beliefs. METHODS: Asthmatics ≥60 were recruited from hospital and community practices in New York, NY and Chicago, IL (n=420). HL was measured with the Short Test of Functional Health Literacy in Adults; validated instruments derived from the self regulation model were used to assess beliefs. The association of beliefs with HL was evaluated with multivariate models. RESULTS: Thirty-six percent of patients had low HL; 54% believed they only have asthma when symptoms are present, 29% believed they will not always have asthma and 20% believed that their doctor can cure asthma. HL was associated with beliefs of not having asthma all the time and that asthma can be cured (OR: 1.84, 95% CI: 1.2-2.82; OR: 2.22, 95% CI: 1.29-3.82, respectively). Patients with low HL were also more likely to be concerned about medication use (ß=0.92, p=.05), despite recognizing their necessity (ß=-1.36, p=.01). CONCLUSIONS: Older asthmatics with low HL endorse erroneous asthma beliefs. PRACTICE IMPLICATIONS: Health communications for improving self-management behaviors in asthma should employ both health literacy-appropriate strategies and messages to counter illness-related misconceptions.

Depressive symptoms, low adherence, and poor asthma outcomes in the elderly.

OBJECTIVE: To examine the impact of depressive symptoms on asthma outcomes and medication adherence in inner-city elderly patients with asthma. METHODS: Cohort study of elderly asthmatics receiving primary care at three clinics in New York City and Chicago from 1 January 2010 to 1 January 2012. Depressive symptoms were ascertained with the Patient Health Questionnaire (PHQ-9). Outcomes included asthma control (Asthma Control Questionnaire, ACQ), asthma-related quality of life (Asthma Quality of Life Questionnaire, AQLQ), and acute resource utilization (inpatient and outpatient visits). Asthma medication adherence was evaluated using the Medication Adherence Reporting Scale (MARS). RESULTS: Three hundred and seventeen participants ≥60 years were included in the study (83% women, 30% Hispanic, and 31% Black). In unadjusted analyses, participants with depressive symptoms were more likely to report poor asthma control (p < .001), worse AQLQ scores (p < .001), and higher rates of inpatient asthma-related visits (odds ratio [OR]: 2.03, 95% confidence interval [CI]: 1.04-3.99). Those with depressive symptoms also reported lower medication adherence (OR: 0.23, 95%CI: 0.10-0.54). Similar results were obtained in analyses adjusting for age, sex, race/ethnicity, income, asthma medication prescription, years with asthma, intubation history, comorbidities, and health literacy. CONCLUSION: In this cohort of elderly inner-city participants, depressive symptoms were associated with poorer asthma control and quality of life, as well as with lower rates of adherence to controller medications. Future work exploring possible mediators, including adherence, might elucidate the relationship between depression and poorer asthma outcomes in this population.

Asthma beliefs are associated with medication adherence in older asthmatics.

BACKGROUND: Empirical research and health policies on asthma have focused on children and young adults, even though asthma morbidity and mortality are higher among older asthmatics. OBJECTIVE: To explore the relationship of asthma-related beliefs and self-reported controller medication adherence in older asthmatics. DESIGN: An observational study of asthma beliefs and self-management among older adults. PARTICIPANTS: Asthmatics ages ≥ 60 years (N = 324, mean age 67.4 ± 6.8, 28 % white, 32 % black, 30 % Hispanic) were recruited from primary care practices in New York City and Chicago. MAIN MEASURES: Self-reported controller medication adherence was assessed using the Medication Adherence Report Scale. Based on the Common Sense Model of Self-Regulation, patients were asked if they believe they only have asthma with symptoms, their physician can cure their asthma, and if their asthma will persist. Beliefs on the benefit, necessity and concerns of treatment use were also assessed. Multivariate logistic regression was used to examine the association of beliefs with self-reported medication adherence. KEY RESULTS: The majority (57.0 %) of patients reported poor adherence. Poor self-reported adherence was more common among those with erroneous beliefs about asthma illness and treatments, including the "no symptoms, no asthma" belief (58.7 % vs. 31.7 %, respectively, p < 0.001), "will not always have asthma" belief (34.8 % vs. 12.5 %, p < 0.001), and the "MD can cure asthma" belief (21.7 % vs. 9.6 %, p = 0.01). Adjusting for illness beliefs, treatment beliefs and demographics, patients with a "no symptoms, no asthma" belief had lower odds of having good self-reported adherence (odds ratio [OR] 0.45, 95 % confidence interval [CI] 0.23-0.86), as did those with negative beliefs about the benefits (OR 0.73, 95 % CI 0.57-0.94) and necessity (OR 0.89, 95 % CI 0.83-0.96) of treatment. CONCLUSIONS: Illness and treatment beliefs have a strong influence on self-reported medication adherence in older asthmatics. Interventions to improve medication adherence in older asthmatics by modifying illness and treatment beliefs warrant study.

The association between language proficiency and outcomes of elderly patients with asthma.

BACKGROUND: Asthma is a growing cause of morbidity for elderly Americans and is highly prevalent among Hispanic people in the United States. The inability to speak English poses a barrier to patient-provider communication. OBJECTIVE: To evaluate associations between limited English proficiency, asthma self-management, and outcomes in elderly Hispanic patients. METHOD: Elderly patients with asthma receiving primary care at clinics in New York City and Chicago were studied. RESULTS: Of 268 patients in the study, 68% were non-Hispanic, 18% English-proficient Hispanic, and 14% Hispanic with limited English proficiency. Unadjusted analyses showed that Hispanic persons with limited English proficiency had worse asthma control (P = .0007), increased likelihood of inpatient visits (P = .002), and poorer quality of life (P < .0001). We also found significant associations between limited English proficiency and poorer medication adherence (P = .006). Similar results were obtained in multiple regression analyses adjusting for demographics, asthma history, comorbidities, depression, and health literacy. CONCLUSION: Limited English proficiency was associated with poorer self-management and worse outcomes among elderly patients with asthma. Further understanding of mechanisms underlying this relationship is necessary to develop interventions that improve asthma outcomes in this vulnerable population.

Differences in diet pattern adherence by nativity and duration of US residence in the Mexican-American population.

Literature on the diet of the Mexican-American population suggests that food consumption differs by nativity and duration of residence in the United States. However, no studies have used dietary pattern analysis to investigate these differences. To create dietary patterns, we used principal components analysis on food frequency questionnaire data for all adult respondents of the National Health and Nutrition Examination Survey years 2003-2006. Four dietary patterns were identified: Western, Healthy, Tomato/Tortilla, and Coffee/Sugar. Least squares means regression was used to test differences in adjusted mean dietary adherence scores among Mexico-born Mexican-American adults residing in the United States for <15 years (n=302), Mexico-born Mexican-American adults residing in the United States for ≥15 years (n=234), US-born Mexican-American adults (n=509), and US-born non-Hispanic whites (n=2,530) aged 18 to 69 years. Mean score for each diet pattern did not differ significantly by duration of US residence category in the Mexico-born Mexican-American population. However, in comparison to all Mexico-born Mexican Americans, US-born Mexican Americans had significantly lower score for the Tomato/Tortilla pattern, and significantly higher score for the Western pattern. Scores for the Healthy pattern were relatively low in all Mexican-American subgroups, indicating low adherence to the Healthy diet. However, Healthy diet scores of Mexico-born Mexican Americans among those aged ≤41 years appeared more similar to those of US-born non-Hispanic whites than US-born Mexican Americans. Education and policy action promoting healthy food access in Hispanic neighborhoods could help limit consumption of Western and Coffee/Sugar diet patterns and promote healthier choices in the Mexican-American population.