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Background: Poor blood pressure (BP) control and racial disparities therein may be a function of clinical inertia and ineffective communication about BP care.Methods: We compared two different interventions (electronic medical record reminder for BP care (Reminder only, [RO]), and clinician training on BP care-related communication skills plus the reminder (Reminder + Training, [R+T]) with usual care in three primary care clinics, examining BP outcomes among 8,866 patients, and provider-patient communication and medication adherence among a subsample of 793.Results: Clinician counseling improved most at R+T. BP improved overall; R+T had a small but significantly greater reduction in diastolic BP (DBP; -1.7 mm Hg). White patients at RO experienced greater overall improvements in BP control. Site and race disparities trends suggested that disparities decreased at R+T, either stayed the same or decreased at Control; and stayed the same or increased at RO.Conclusions: More substantial or racial/ethnically tailored interventions are needed. [ABSTRACT FROM AUTHOR]

Objectives. We sought to improve public health surveillance by using a geographic analysis of emergency department (ED) visits to determine local chronic disease prevalence. Methods. Using an all-payer administrative database, we determined the proportion of unique ED patients with diabetes, hypertension, or asthma. We compared these rates to those determined by the New York City Community Health Survey. For diabetes prevalence, we also analyzed the fidelity of longitudinal estimates using logistic regression and determined disease burden within census tracts using geocoded addresses. Results. We identified 4.4 million unique New York City adults visiting an ED between 2009 and 2012. When we compared our emergency sample to survey data, rates of neighborhood diabetes, hypertension, and asthma prevalence were similar (correlation coefficient = 0.86, 0.88, and 0.77, respectively). In addition, our method demonstrated less year-to-year scatter and identified significant variation of disease burden within neighborhoods among census tracts. Conclusions. Our method for determining chronic disease prevalence correlates with a validated health survey and may have higher reliability overtime and greater granularity at a local level. Our findings can improve public health surveillance by identifying local variation of disease prevalence. [ABSTRACT FROM AUTHOR]

Purpose The purpose of this study is to identify factors associated with perceived control of diabetes in a group of poorly controlled patients. Identifying factors associated with perceived control in these patients is an important step in improving actual control as measured by A1C. As health literacy is essential for understanding complex medical information, we hypothesized that low health literacy would be associated with inaccurate perceptions of diabetes control. Methods A cross-sectional analysis was performed on 280 adults with type 2 diabetes whose last 2 A1C measurements were >8.0%. Participants were recruited primarily from 6 University of Pennsylvania primary care practices. Perceived control and factors potentially associated with this outcome, including health literacy, were assessed during an in-person interview. Health literacy was measured using the Rapid Estimate of Adult Literacy. Results Thirty-nine percent of patients responded that they were managing to control their diabetes well or very well. However, 57% of those at the seventh to eighth-grade health literacy level and 61% of those at the level of sixth grade and below reported that they were controlling their diabetes well or very well. Conclusions In this population of patients with poorly controlled diabetes, a majority of those with low health literacy believed that they were controlling their disease well or very well. Patients who believe that they are already controlling their diabetes well may be less likely to make changes to improve control. Health care providers and educators should consider health literacy when discussing control of diabetes and when setting management goals with patients. [ABSTRACT FROM AUTHOR]

An estimated 17.6 million American households were food insecure in 2012, meaning they were unable to obtain enough food for an active and healthy life. Programs to augment local access to healthy foods are increasingly widespread, with unclear effects on food security. At the same time, the US government has recently enacted major cuts to federal food assistance programs. In this study, we examined the association between food insecurity (skipping or reducing meal size because of budget), neighborhood food access (self-reported access to fruits and vegetables and quality of grocery stores), and receipt of food assistance using the 2008, 2010, and 2012 waves of the Southeastern Pennsylvania Household Health Survey. Of 11,599 respondents, 16.7 % reported food insecurity; 79.4 % of the food insecure found it easy or very easy to find fruits and vegetables, and 60.6 % reported excellent or good quality neighborhood grocery stores. In our regression models adjusting for individual- and neighborhood-level covariates, compared to those who reported very difficult access to fruits and vegetables, those who reported difficult, easy or very easy access were less likely to report food insecurity (OR 0.62: 95 % CI 0.43-0.90, 0.33: 95 % CI 0.23-0.47, and 0.28: 95 % CI 0.20-0.40). Compared to those who reported poor stores, those who reported fair, good, and excellent quality stores were also less likely to report food insecurity (OR 0.81: 95 % CI 0.60-1.08, 0.58: 95 % CI 0.43-0.78, and 0.43: 95 % CI 0.31-0.59). Compared to individuals not receiving food assistance, those receiving Supplemental Nutrition Assistance Program (SNAP) benefits were significantly more likely to be food insecure (OR 1.36: 95 % CI 1.11-1.67), while those receiving benefits from the Special Supplemental Nutrition Program for Women, Infants, and Children (WIC) (OR 1.17: 95 % CI 0.77-1.78) and those receiving both SNAP and WIC (OR 0.84: 95 % CI 0.61-1.17) did not have significantly different odds of food insecurity. In conclusion, better neighborhood food access is associated with lower risk of food insecurity. However, most food insecure individuals reported good access. Improving diet in communities with high rates of food insecurity likely requires not only improved access but also greater affordability. [ABSTRACT FROM AUTHOR]

OBJECTIVE Persons with serious mental illness (SMI) may benefit from collocation of medical and mental health healthcare professionals and services in attending to their chronic comorbid medical conditions. We evaluated and compared glucose control and diabetes medication adherence among patients with SMI who received collocated care to those not receiving collocated care (which we call usual care). RESEARCH DESIGN AND METHODS We performed a cross-sectional, observational cohort study of 363 veteran patients with type 2 diabetes and SMI who received care from one of three Veterans Affairs medical facilities: two sites that provided both collocated and usual care and one site that provided only usual care. Through a survey, laboratory tests, and medical records, we assessed patient characteristics, glucose control as measured by a current HbA1c, and adherence to diabetes medication as measured by the medication possession ration (MPR) and self-report. RESULTS In the sample, the mean HbA1c was 7.4% (57 mmol/mol), the mean MPR was 80%, and 51% reported perfect adherence to their diabetes medications. In both unadjusted and adjusted analyses, there were no differences in glucose control and medication adherence by collocation of care. Patients seen in collocated care tended to have better HbA1c levels (β = 20.149; P = 0.393) and MPR values (β = 0.34; P = 0.132) and worse self-reported adherence (odds ratio 0.71; P = 0.143), but these were not statistically significant. CONCLUSIONS In a population of veterans with comorbid diabetes and SMI, patients on average had good glucose control and medication adherence regardless of where they received primary care. [ABSTRACT FROM AUTHOR]

Non-AIDS defining malignancies, particularly colorectal cancer (CRC), may be more prevalent among persons living with HIV (PLWH). Further, PLWH may be less likely to receive CRC screening (CRCS). We studied the epidemiology of CRC and CRCS patterns in PLWH and HIV-uninfected persons in a large US Medicaid population. We performed a matched cohort study examining CRC incidence in 2006 and CRCS between 1999 and 2007. Study participants were continuously enrolled in the Medicaid programs of California, Florida, New York, Ohio, and Pennsylvania. All PLWH enrollees were matched to five randomly sampled HIV-uninfected enrollees on 5-year age group, gender, and state. Adjusted odds ratios (AORs) for incident CRC (adjusted for comorbidity index) and the presence of CRCS (adjusted for comorbidity index and years in the data-set) among PLWH compared to HIV-uninfected enrollees were calculated. PLWH were not more likely to be diagnosed with CRC after adjusting for comorbidity index (unadjusted OR: 1.73, 95% confidence interval [CI]: 1.37–2.19; AOR 1.29; 95% CI: 0.98–1.70). While CRCS rates were low overall, PLWH were more likely to have received CRCS in unadjusted analyses (35.8% vs. 33.7%; OR 1.10, 95% CI: 1.07–1.13). This relationship was reversed after adjusting for comorbidity index and years in the data-set (AOR: 0.80, 95% CI: 0.77–0.83). Limitations of the study include a focus on the Medicaid population, an inability to detect fecal occult blood tests (FOBT), and having half of patients between 50 and 55 years of age. In conclusion, PLWH were not more likely to be diagnosed with CRC, but in adjusted analyses, were less likely to have received CRCS. As we showed a low rate of CRCS overall in this Medicaid population, researchers, clinicians, and policy-makers should improve access to and uptake of CRCS among all Medicaid patients, and particularly among PLWH. [ABSTRACT FROM AUTHOR]

There are limited data on HIV testing trends after 2006 when the Centers for Disease Control and Prevention (CDC) introduced opt-out HIV testing with the aims of identifying HIV-infected persons early and linking them to care. We used data from the Southeastern Pennsylvania Household Health Survey between 2002 and 2010 to evaluate HIV testing over time. 50,698 adult (≥18 years) survey respondents were included. HIV testing increased after the CDC recommendations: 42.1% of survey respondents received testing at least once in 2002 versus 51.4% in 2010, p<0.001. Testing trends increased among all demographic groups, but existing differences in testing before 2006 persisted after that year as follows: younger patients, racial/ethnic minorities, patients on Medicaid were all more likely to get tested than their counterparts. Blacks and patients seeking care in community health centers had the fastest rise in HIV testing. The probability of HIV testing in Blacks was 0.56 (95% CI 0.54-0.60) in 2002 and increased to 0.73 (0.70-0.76) by 2010. Patients seeking care in community health centers had a probability of HIV testing of 0.57 (0.47-0.66) in 2002, which increased to 0.69 (0.60-0.77) by 2010. In comparison, patients in private clinics had an HIV testing probability of 0.40 (0.36-0.43) in 2002 compared to 0.47 (0.40-0.54) in 2010. HIV testing is increasing, particularly among ethnic minorities and in community health centers. However, testing remains to be improved in that setting and across all clinic types. [ABSTRACT FROM AUTHOR]

ObjectiveTo measure the prevalence of cooking dinner at home in the USA and test whether home dinner preparation habits are associated with socio-economic status, race/ethnicity, country of birth and family structure.DesignCross-sectional analysis. The primary outcome, self-reported frequency of cooking dinner at home, was divided into three categories: 0–1 dinners cooked per week (‘never’), 2–5 (‘sometimes’) and 6–7 (‘always’). We used bivariable and multivariable regression analyses to test for associations between frequency of cooking dinner at home and factors of interest.SettingThe 2007–2008 National Health and Nutrition Examination Survey (NHANES).SubjectsThe sample consisted of 10 149 participants.ResultsAmericans reported cooking an average of five dinners per week; 8 % never, 43 % sometimes and 49 % always cooked dinner at home. Lower household wealth and educational attainment were associated with a higher likelihood of either always or never cooking dinner at home, whereas wealthier, more educated households were more likely to sometimes cook dinner at home (P < 0·05). Black households cooked the fewest dinners at home (mean = 4·4, 95 % CI 4·2, 4·6). Households with foreign-born reference persons cooked more dinners at home (mean = 5·8, 95 % CI 5·7, 6·0) than households with US-born reference persons (mean = 4·9, 95 % CI 4·7, 5·1). Households with dependants cooked more dinners at home (mean = 5·2, 95 % CI 5·1, 5·4) than households without dependants (mean = 4·6, 95 % CI 4·3, 5·0).ConclusionsHome dinner preparation habits varied substantially with socio-economic status and race/ethnicity, associations that likely will have implications for designing and appropriately tailoring interventions to improve home food preparation practices and promote healthy eating. [ABSTRACT FROM PUBLISHER]

Background. Older adults of low socioeconomic status are at high risk for poor post-hospital outcomes. Design. A qualitative researcher, who was also an outreach worker from the West Philadelphia community, conducted in-depth interviews with 25 participants within 30 days of their hospital discharge. Participants. Eligible participants were: 1) residents of high-poverty ZIP codes; 2) dually eligible for Medicare and Medicaid; 3) had capacity or a caregiver who could be interviewed as a proxy; 4) general medicine or cardiology patients. Results. Participants were unable to access the care and accommodations needed to cope with post-hospital frailty. As a result, medical disability was amplified by socioeconomic disability. Participants were ashamed of the resulting loss of control and had difficulty asking for help, particularly from potential supports who were perceived as emotionally controlling or judgmental. Conclusion. Strategies that address socioeconomic Stressors of hospitalization and provide empathic support may improve the post-hospital transition for these high-risk individuals. [ABSTRACT FROM AUTHOR]

BACKGROUND: Patients with low socioeconomic status (low-SES) are at risk for poor outcomes during the post-hospital transition. Few prior studies explore perceived reasons for poor outcomes from the perspectives of these high-risk patients. OBJECTIVE: We explored low-SES patients' perceptions of hospitalization, discharge and post-hospital transition in order to generate hypotheses and identify common experiences during this transition. DESIGN: We conducted a qualitative study using in-depth semi-structured interviewing. PARTICIPANTS: We interviewed 65 patients who were: 1) uninsured, insured by Medicaid or dually eligible for Medicaid and Medicare; 2) residents of five low-income ZIP codes; 3) had capacity or a caregiver who could be interviewed as a proxy; and 4) hospitalized on the general medicine or cardiology services of two academically affiliated urban hospitals. APPROACH: Our interview guide investigated patients' perceptions of hospitalization, discharge and the post-hospital transition, and their performance of recommended post-hospital health behaviors related to: 1) experience of hospitalization and discharge; 2) external constraints on patients' ability to execute discharge instructions; 3) salience of health behaviors; and 4) self-efficacy to execute discharge instructions. We used a modified grounded theory approach to analysis. KEY RESULTS: We identified six themes that low-SES patients shared in their narratives of hospitalization, discharge and post-hospital transition. These were: 1) powerlessness during hospitalization due to illness and socioeconomic factors; 2) misalignment of patient and care team goals; 3) lack of saliency of health behaviors due to competing issues; 4) socioeconomic constraints on patients' ability to perform recommended behaviors; 5) abandonment after discharge; and 6) loss of self-efficacy resulting from failure to perform recommended behaviors. CONCLUSIONS: Low-SES patients describe discharge goals that are confusing, unrealistic in the face of significant socioeconomic constraints, and in conflict with their own immediate goals. We hypothesize that this goal misalignment leads to a cycle of low achievement and loss of self-efficacy that may underlie poor post-hospital outcomes among low-SES patients. [ABSTRACT FROM AUTHOR]