Faculty Bibliography

BACKGROUND:Many Veterans Affairs (VA) primary care (PC) patients prefer telephone-delivered care to other health care delivery modalities. OBJECTIVE:To evaluate PC patients' telephone experiences and outcomes before and after a national telephone transformation quality improvement (QI) collaborative. METHODS:Cross-sectional surveys were conducted pre- and post-collaborative. We used bivariate analyses to assess differences in pre/post outcomes and multivariate regression to identify variables associated with patients' perceptions of poor quality care. RESULTS:Patients from 13 VA facilities participated (n = 730; pre-intervention = 314, post-intervention = 416); most of them were males (90%) with a mean age of 62 years. After the collaborative (versus pre-collaborative), few experienced transfers (52% versus 62%, P = 0.0006) and most reported timely call answer (88% versus 80%, P = 0.003). Improvements in staff understanding why patients were calling and providing needed medical information were also found. There were measurable improvements in patient satisfaction (87% versus 82% very/mostly satisfied, P = 0.04) and perceived quality of telephone care (85% versus 78% excellent/good quality, P = 0.01) post- collaborative. The proportion of veterans who reported delayed care due to telephone access issues decreased from 41% to 15% after the collaborative, P < 0.0001. Perceptions of poor quality care were higher when calls were for urgent care needs did not result in receipt of needed information and included a transfer or untimely answer. CONCLUSIONS:The QI collaborative led to improvements in timeliness of answering calls, patient satisfaction and perceptions of high-quality telephone care and fewer reports of health care delays. Barriers to optimal telephone care 'quality' include untimely answer, transfers, non-receipt of needed information and urgent care needs.

If 1 begin these reflections on Taylor Mead, who died at the age of eighty-eight on May 8, 2013, with brief mention of two underexplored periods in the artist's life-his years in the late Beat scene in Venice and his European period of self-imposed exile from New York in the mid-'60s-it is to suggest that we have yet to account for the breadth, diversity, and wide-ranging importance of more than five decades of work by the disarmingly affable man considered the first superstar of underground film and the "doyen of underground performance. Rice's movie, shot on outdated 16-mm film stock that lent the black-and-white images a wistful look, was both a document of the last remnants of San Francisco's North Beach Beat scene and a lyrical portrayal of Mead's joyful embodiment of flexibility and spontaneity

BACKGROUND: Electronic communication between providers occurs daily in clinical practice but has not been well studied. PURPOSE: To assess the impact of provider-to-provider electronic communication tools on communication and healthcare outcomes through literature review. DATA SOURCES: Ovid MEDLINE, PubMed, Google Scholar, Cumulative Index to Nursing and Allied Health Literature, and Academic Search Premier. STUDY SELECTION: Publication in English-language peer-reviewed journals. Studies provided quantitative provider-to-provider communication data, provider satisfaction statistics, or electronic health record (EHR) communication data. DATA EXTRACTION: Literature review. DATA SYNTHESIS: Two reviewers conducted the title review to determine eligible studies from initial search results. Three reviewers independently reviewed titles, abstracts, and full text (where appropriate) against inclusion and exclusion criteria. LIMITATIONS: Small number of eligible studies; few described trial design (20%). Homogeneous provider type (physicians). English-only studies. CONCLUSIONS: Of 25 included studies, all focused on physicians; most were observational (68%). Most (60%) described electronic specialist referral tools. Although overall use has been measured, there were no studies of the effectiveness of intra-EHR messaging. Literature describing the effectiveness of provider-to-provider electronic communications is sparse and narrow in scope. Complex care, such as that envisioned for the Patient Centered Medical Home, necessitates further research.

PURPOSE: Participation in therapeutic clinical trials rarely reflects the race and ethnic composition of the patient population. To meet National Institutes of Health-mandated goals, strategies to increase participation are required. We present a framework for institutional enhancement of minority clinical trial accrual. METHODS: We implemented structural changes on four levels to induce and sustain minority accrual to clinical trials: (1) leadership support; (2) center-wide policy change; (3) infrastructural process control, data analysis, and reporting; and (4) follow-up with clinical investigators. A Protocol Review and Monitoring Committee reviews studies and monitors accrual, and the Program for the Elimination Cancer Disparities leads efforts for proportional accrual, supporting the system through data tracking, Web tools, and feedback to investigators. RESULTS: Following implementation in 2005, minority accrual to therapeutic trials increased from 12.0 % in 2005 to 14.0 % in 2010. The "rolling average" minority cancer incidence at the institution during this timeframe was 17.5 %. In addition to therapeutic trial accrual rates, we note significant increase in the number of minorities participating in all trials (therapeutic and nontherapeutic) from 2005 to 2010 (346-552, 60 % increase, p < 0.05) compared to a 52 % increase for Caucasians. CONCLUSIONS: Implementing a system to aid investigators in planning and establishing targets for accrual, while requiring this component as a part of annual protocol review and monitoring of accrual, offers a successful strategy that can be replicated in other cancer centers, an approach that may extend to other clinical and translational research centers.

M. tuberculosis is evolving antibiotic resistance, threatening attempts at tuberculosis epidemic control. Mechanisms of resistance, including genetic changes favored by selection in resistant isolates, are incompletely understood. Using 116 newly sequenced and 7 previously sequenced M. tuberculosis whole genomes, we identified genome-wide signatures of positive selection specific to the 47 drug-resistant strains. By searching for convergent evolution--the independent fixation of mutations in the same nucleotide position or gene--we recovered 100% of a set of known resistance markers. We also found evidence of positive selection in an additional 39 genomic regions in resistant isolates. These regions encode components in cell wall biosynthesis, transcriptional regulation and DNA repair pathways. Mutations in these regions could directly confer resistance or compensate for fitness costs associated with resistance. Functional genetic analysis of mutations in one gene, ponA1, demonstrated an in vitro growth advantage in the presence of the drug rifampicin.

This study examined the predictors of posttraumatic stress disorder (PTSD) in a clinical sample of 875 immigrant survivors of political violence resettled in the United States, with a specific aim of comparing the relative predictive power of pre-migration and post-migration experiences. Results from a hierarchical OLS regression indicated that pre-migration experiences such as rape/sexual assault were significantly associated with worse PTSD outcomes, as were post-migration factors such as measures of financial and legal insecurity. Post-migration variables, which included immigration status in the US, explained significantly more variance in PTSD outcomes than premigration variables alone. Discussion focused on the importance of looking at postmigration living conditions when treating trauma in this population.

The development and progression of left ventricular hypertrophy is a consequence of multiple comorbid conditions associated with end-stage renal disease and large variations in interdialytic weight gains. The literature suggests that dietary sodium restriction alone significantly reduces interdialytic weight gains. A total of 124 hemodialysis participants in an ongoing randomized control trial participated in the validation in which psychometric properties of a self-efficacy survey were a secondary analysis. We evaluated the internal consistency, construct validity, and convergent validity of the instrument. The overall Cronbach alpha was 0.93. Three factors extracted explain 67.8% of the variance of the white and African American participants. The Self-Efficacy Survey has adequate internal consistency and construct and convergent validity. Future research is needed to evaluate the stability and discriminant validity of the instrument.

The risk of progression to multiple myeloma (MM) from the precursor condition smoldering MM (SMM) varies considerably among individual patients. Reliable markers for progression to MM are vital to advance the understanding of myeloma precursor disease and for the development of intervention trials designed to delay/prevent MM. The Mayo Clinic and Spanish PETHEMA have proposed models to stratify patient risk based on clinical parameters. The aim of our study was to define the degree of concordance between these two models by comparing the distribution of patients with SMM classified as low, medium and high risk for progression. A total of 77 patients with SMM were enrolled in our prospective natural history study. Per study protocol, each patient was assigned risk scores based on both the Mayo and the Spanish models. The Mayo Clinic model identified 38, 35 and four patients as low, medium and high risk, respectively. The Spanish PETHEMA model classified 17, 22 and 38 patients as low, medium and high risk, respectively. There was significant discordance in overall patient risk classification (28.6% concordance) and in classifying patients as low versus high (p < 0.0001), low versus non-low (p = 0.0007) and high versus non-high (p < 0.0001) risk. There is a need for prospectively validated models to characterize individual patient risk of transformation to MM.

The integration of genetics and the social sciences will lead to a more complex understanding of the articulation between social and biological processes, although the empirical difficulties inherent in this integration are large. One key challenge is the implications of moving "outside the lab" and away from the experimental tools available for research with model organisms. Social science research methods used to examine human behavior in nonexperimental, real-world settings to date have not been fully taken advantage of during this disciplinary integration, especially in the form of gene-environment interaction research. This article outlines and provides examples of several prominent research designs that should be used in gene-environment research and highlights a key benefit to geneticists of working with social scientists.