Faculty Bibliography

OBJECTIVES/OBJECTIVE:In 2009 and 2010, 17 primary care sites within 1 healthcare system became patient-centered medical homes (PCMHs), but the sites trained different personnel (pharmacists vs nurses) to improve diabetes care using self-management support (SMS). We report the challenges and successes of our efforts to: 1) assemble a new multipayer (Medicare, Medicaid, commercial) claims dataset linked to a clinical registry and 2) use the new dataset to perform comparative effectiveness research on implementation of the 2 SMS models. STUDY DESIGN/METHODS:Longitudinal cohort study. METHODS:We lost permission to use private-payer data. Therefore, we used claims from Medicare fee-for-service and Medicare/Medicaid dual-eligible patients merged with chronic disease registry data. We studied 2008 to 2010, which included 1 year pre- and 1 year post the 2009 implementation time period. Outcomes were outpatient and emergency department visits, hospitalizations, care process (use of statin), and 3 intermediate outcomes (glycemic control, blood pressure [BP], and low-density lipoprotein cholesterol [LDL-C]). RESULTS:In our sample of 2826 patients, quality of care improved and utilization decreased over the 2.5 years. Both approaches improved lipid control (LDL-C decreased by an average of 4 mg/dL for pharmacy-SMS and 5.6 mg/dL for nurse-SMS) and diastolic BP (-1.5 mm Hg for pharmacy-SMS and -1.3 mm Hg for nurse-SMS), whereas only the pharmacy-led approach decreased primary care visits (by 0.8 visits). The groups differed slightly on 2 measures (glycated hemoglobin, systolic BP) with respect to the trajectory of improvement over time, but performance was similar by 2.5 years. CONCLUSIONS:Diabetes care improved during PCMH implementation systemwide, supporting both nurse-led and pharmacist-led SMS models.

BACKGROUND: Morphologic macular abnormalities (MMAs) are frequently seen on macular optical coherence tomography (OCT) imaging in neuroimmunology practice, yet studies pragmatically assessing prevalence and risk factors of MMAs to date are limited. OBJECTIVE: To describe the characteristics of MMAs in a neuroimmunology-based academic practice. METHODS: Cross-sectional study of 1450 patients (2900 eyes) who underwent spectral-domain macular OCT between June 2010 and June 2012. The association between MMAs and demographic variables was analyzed using mixed-effects logistic regression. Odds ratios (ORs) were calculated per 5-year age increments. RESULTS: MMAs were observed in 338/2872 eyes (11.7%) of 232/1445 participants (16.1%). The most common abnormalities identified, included drusen (6.0%), epiretinal membrane (ERM; 5.5%), and microcystoid macular pathology (MMP; 1.9%). Overall, patients with MMAs were older (OR: 1.79, p = 5 x 10-5) and more likely to be males (OR: 2.45, p = 0.014). In particular, advancing age was associated with higher risk of drusen and ERM (OR: 1.80 and 4.26, p = 2 x 10-5 and 7 x 10-3, respectively). MMP prevalence declined with age (OR: 0.73, p = 0.015) and was associated with African-American ethnicity (OR: 15.0, p = 5 x 10-5). CONCLUSION: Unexpected or incidental MMAs are common in patients assessed with OCT in neuroimmunology practice, emphasizing the importance of comprehensive OCT image review for risk stratification and appropriate ophthalmology referral.

Background/UNASSIGNED:Reduced kidney function is a common public health problem that increases risk for a wide variety of adverse outcomes, making the identification of potentially modifiable factors associated with the development of incident chronic kidney disease (CKD) important. Alterations in the hypothalamic-pituitary-thyroid axis have been linked to reduced kidney function, but the association of thyroid function with the development of incident CKD is largely uncharacterized. Methods/UNASSIGNED:Concentrations of thyroid stimulating hormone (TSH), free thyroxine (FT4), triiodothyronine (T3) and thyroid peroxidase antibody (TPOAb) were quantified in 12 785 black and white participants of the ongoing community-based prospective Atherosclerosis Risk in Communities study. Thyroid markers and clinical categories of thyroid dysfunction (euthyroidism, combined subclinical and overt hypothyroidism, combined subclinical and overt hyperthyroidism) were also evaluated for their association with reduced kidney function (estimated glomerular filtration rate <60 mL/min/1.73 m2) at study baseline and with incident CKD over a median follow-up time of 19.6 years. Results/UNASSIGNED:Higher TSH and FT4 as well as lower T3 concentrations were strongly and independently associated with reduced kidney function at study baseline. The clinical entities hypothyroidism and hyperthyroidism were also associated with higher odds of baseline reduced kidney function, but this was not significant. However, none of the markers of thyroid function nor different clinical categories of thyroid dysfunction (hypothyroidism, hyperthyroidism or TPOAb positivity) were associated with incident CKD in adjusted analyses. Conclusions/UNASSIGNED:Elevated TSH, FT4 and reduced T3 concentrations were associated with reduced kidney function cross-sectionally. The lack of association with the development of incident CKD suggests that altered thyroid function in the general population is not causally related to CKD development, but screening for thyroidal status may be especially relevant in persons with reduced kidney function.

BACKGROUND:Relationships between early kidney disease, neurocognitive function, and brain anatomy are poorly defined in African Americans with type 2 diabetes mellitus (T2DM). STUDY DESIGN/METHODS:Cross-sectional associations were assessed between cerebral anatomy and cognitive performance with estimated glomerular filtration rate (eGFR) and urine albumin-creatinine ratio (UACR) in African Americans with T2DM. SETTING & PARTICIPANTS/METHODS:African Americans with cognitive testing and cerebral magnetic resonance imaging (MRI) in the African American-Diabetes Heart Study Memory in Diabetes (AA-DHS MIND; n=512; 480 with MRI) and Action to Control Cardiovascular Risk in Diabetes (ACCORD) MIND (n=484; 104 with MRI) studies. PREDICTORS/METHODS:eGFR (CKD-EPI creatinine equation), spot UACR. MEASUREMENTS/METHODS:concentration, low-density lipoprotein cholesterol concentration, smoking, hypertension, and cardiovascular disease were used to test for associations between kidney phenotypes and the brain in each study; a meta-analysis was performed. RESULTS:; and UACR, 119.2±336.4mg/g. In the fully adjusted meta-analysis, higher GMV associated with lower UACR (P<0.05), with a trend toward association with higher eGFR. Higher white matter lesion volume was associated with higher UACR (P<0.05) and lower eGFR (P<0.001). WMV was not associated with either kidney parameter. Higher UACR was associated with lower Digit Symbol Coding performance (P<0.001) and a trend toward association with higher Stroop interference; eGFR was not associated with cognitive tests. LIMITATIONS/CONCLUSIONS:Cross-sectional; single UACR measurement. CONCLUSIONS:In African Americans with T2DM, mildly high UACR and mildly low eGFR were associated with smaller GMV and increased white matter lesion volume. UACR was associated with poorer processing speed and working memory.

Glutathione S-transferase mu 1 (GSTM1) encodes an enzyme that catalyzes the conjugation of electrophilic compounds with glutathione to facilitate their degradation or excretion. The loss of one or both copies of GSTM1 is common in many populations and has been associated with CKD progression. With the hypothesis that the loss of GSTM1 is also associated with incident kidney failure and heart failure, we estimated GSTM1 copy number using exome sequencing reads in the Atherosclerosis Risk in Communities (ARIC) Study, a community-based prospective cohort of white and black participants. Overall, 51.2% and 39.8% of white participants and 25.6% and 48.5% of black participants had zero or one copy of GSTM1, respectively. Over a median follow-up of 24.6 years, 256 kidney failure events occurred in 5715 participants without prevalent kidney failure, and 1028 heart failure events occurred in 5368 participants without prevalent heart failure. In analysis adjusted for demographics, diabetes, and hypertension, having zero or one copy of GSTM1 associated with higher risk of kidney failure and heart failure (adjusted hazard ratio [95% confidence interval] for zero or one versus two copies of GSTM1: kidney failure, 1.66 [1.27 to 2.17]; heart failure, 1.16 [1.04 to 1.29]). Risk did not differ significantly between participants with zero and one copy of GSTM1 (P>0.10). In summary, the loss of GSTM1 was significantly associated with incident kidney and heart failure, independent of traditional risk factors. These results suggest GSTM1 function is a potential treatment target for the prevention of kidney and heart failure.

Background: The lesbian, gay, bisexual, transgender, queer/questioning (LGBTQ) population is at higher risk for multiple types of cancers compared with the heterosexual population. Expert NCCN panels lead the nation in establishing clinical practice guidelines addressing cancer prevention, early detection, and treatment of cancer sites and populations. Given the emergence of new data identifying cancer disparities in the LGBTQ population, this study examined the inclusion of medical and/or psychosocial criteria unique to LGBTQ within NCCN Guidelines. Methods: Data were collected for 32 of the 50 NCCN Guidelines. Results: NCCN panel members reported that neither sexual orientation (84%) nor gender identity (94%) were relevant to the focus of their guidelines; 77% responded that their panels currently do not address LGBTQ issues, with no plans to address them in the future. Conclusions: Greater consideration should be given to the needs of LGBTQ patients across the cancer care continuum. Given that research concerning LGBTQ and cancer is in its infancy, additional empirical and evidence-based data are needed to bolster further integration of LGBTQ-specific criteria into clinical care guidelines.

BACKGROUND: Previous studies have reported that same-day laparoscopic cholecystectomy for acute cholecystitis is superior to delayed elective cholecystectomy. Although this practice is ideal, it requires significant hospital resources, particularly for an underprivileged inner-city population at a large, municipal hospital. We sought to evaluate the implementation of same-day laparoscopic cholecystectomy in a large, municipal hospital and assess the possible benefits of decreasing preoperative length of stay (LOS), particularly its effect on operative time and length of stay in patients with acute cholecystitis. MATERIALS AND METHODS: This was a retrospective chart review of patients treated for symptomatic gallstone disease between September 2012 and November 2013. Medical records were reviewed, and relevant data points were collected. Univariate and multivariate regressions were performed to assess the correlation between time to operation (<36 h [no delay] or >36 h [delay]) and the main outcomes (operative time and total length of stay). Inclusion criteria were patients age >/=18 y who underwent same-admission cholecystectomy and had a diagnosis of cholecystitis on pathology. Eighty-eight patients met all inclusion criteria. RESULTS: The mean (standard deviation) preoperative LOS was 76.2 (+/-48.6) h, the mean operative time was 2.3 (+/-1.1) h, and the mean postoperative LOS was 60.3 (+/-60.1) h. The average total LOS was 136 (+/-79.8) h. Operative times and postoperative LOS were similar for patients in the delay and no delay groups. Patients with >36 h wait before surgery had a total length of stay twice as long as patients with <36 h wait (152 versus 83.3 h; P = 0.0005). These findings remained significant when adjusted for age, sex, radiologic findings, number of preoperative tests, and pathology. CONCLUSIONS: Increased preoperative LOS is not associated with a significant increase in operative time. However, it was associated with significantly increased length of stay. Further analysis is needed to explore the potential cost savings of decreasing preoperative LOS.

OBJECTIVE:and diabetes duration) with brain volumes and vascular pathology on brain MRI and to assess whether the associations of diabetes with brain volumes are mediated by brain vascular pathology. RESEARCH DESIGN AND METHODS:≥6.5%] <7.0% vs. ≥7.0%), with further stratification by diabetes duration (<10 vs. ≥10 years). RESULTS:> 0.05). CONCLUSIONS:and longer disease duration) but not prediabetes or less-severe diabetes was associated with smaller brain volumes and an increased burden of brain vascular pathology. No evidence was found that associations of diabetes with smaller brain volumes are mediated by brain vascular pathology, suggesting that other mechanisms may be responsible for these associations.

BACKGROUND: Because of confounding from the urban/rural and socioeconomic organizations of territories and resulting correlation between residential and nonresidential exposures, classically estimated residential neighborhood-outcome associations capture nonresidential environment effects, overestimating residential intervention effects. Our study diagnosed and corrected this "residential" effect fallacy bias applicable to a large fraction of neighborhood and health studies. METHODS: Our empirical application investigated the effect that hypothetical interventions raising the residential number of services would have on the probability that a trip is walked. Using global positioning systems (GPS) tracking and mobility surveys over 7 days (227 participants, 7440 trips), we employed a multilevel linear probability model to estimate the trip-level association between residential number of services and walking to derive a naive intervention effect estimate; and a corrected model accounting for numbers of services at the residence, trip origin, and trip destination to determine a corrected intervention effect estimate (true effect conditional on assumptions). RESULTS: There was a strong correlation in service densities between the residential neighborhood and nonresidential places. From the naive model, hypothetical interventions raising the residential number of services to 200, 500, and 1000 were associated with an increase by 0.020, 0.055, and 0.109 of the probability of walking in the intervention groups. Corrected estimates were of 0.007, 0.019, and 0.039. Thus, naive estimates were overestimated by multiplicative factors of 3.0, 2.9, and 2.8. CONCLUSIONS: Commonly estimated residential intervention-outcome associations substantially overestimate true effects. Our somewhat paradoxical conclusion is that, to estimate residential effects, investigators critically need information on nonresidential places visited.