Faculty Bibliography

BACKGROUND:The way a construct is measured can differ across cohort study visits, complicating longitudinal comparisons. We demonstrated the use of factor analysis to link differing cognitive test batteries over visits to common metrics representing general cognitive performance, memory, executive functioning, and language. METHODS:We used data from three visits (over 26 years) of the Atherosclerosis Risk in Communities Neurocognitive Study (N = 14,252). We allowed individual tests to contribute information differentially by race, an important factor to consider in cognitive aging. Using generalized estimating equations, we compared associations of diabetes with cognitive change using general and domain-specific factor scores versus averages of equally weighted standardized test scores. RESULTS:Factor scores provided stronger associations with diabetes at the expense of greater variability around estimates (e.g., for general cognitive performance, -0.064 standard deviation units/year, standard error = 0.015, vs. -0.041 standard deviation units/year, standard error = 0.014), which is consistent with the notion that factor scores more explicitly address error in measuring assessed traits than averages of standardized tests. CONCLUSIONS:Factor analysis facilitates use of all available data when measures change over time, and further, it allows objective evaluation and correction for differential item functioning.

OBJECTIVE:To determine whether duration and degree of weight gain are differentially associated with diabetes risk in younger versus middle-aged black and white adults. RESEARCH DESIGN AND METHODS/METHODS:We combined data from three cohort studies: Atherosclerosis Risk in Communities (ARIC), Coronary Artery Risk Development in Young Adults (CARDIA), and the Framingham Heart Study. A total of 17,404 participants (56% women; 21% black) were stratified by baseline age (younger: ≥30 and <45 years; middle-aged: ≥45 and <60 years) and examined for incident diabetes (median follow-up 9 years). Duration and degree of gain in BMI were calculated as "BMI-years" above one's baseline BMI. RESULTS:Diabetes incidence per 1,000 person-years in the younger and middle-aged groups was 7.2 (95% CI 5.7, 8.7) and 24.4 (22.0, 26.8) in blacks, respectively, and 3.4 (2.8, 4.0) and 10.5 (9.9, 11.2) in whites, respectively. After adjusting for sex, baseline BMI and other cardiometabolic factors, and age and race interaction terms, gains in BMI-years were associated with higher risk of diabetes in the younger compared with middle-aged groups: hazard ratios for 1-unit increase in log BMI-years in younger versus middle-aged blacks were 1.18 (P = 0.02) and 1.02 (P = 0.39), respectively (P for interaction by age-group = 0.047), and in whites were 1.35 (P < 0.001) and 1.11 (P < 0.001), respectively (P for interaction by age-group = 0.008). CONCLUSIONS:Although middle-aged adults have higher rates of diabetes, younger adults are at greater relative risk of developing diabetes for a given level of duration and degree of weight gain.

OBJECTIVE:Relative to European Americans, African Americans manifest lower levels of computed tomography-based calcified atherosclerotic plaque (CP), a measure of subclinical cardiovascular disease (CVD). Potential relationships between CP and cerebral structure are poorly defined in the African American population. We assessed associations among glycemic control, inflammation, and CP with cerebral structure on MRI and with cognitive performance in 268 high-risk African Americans with type 2 diabetes. RESEARCH DESIGN AND METHODS/METHODS:Associations among hemoglobin A1c (HbA1c), C-reactive protein (CRP), and CP in coronary arteries, carotid arteries, and the aorta with MRI volumetric analysis (white matter volume, gray matter volume [GMV], cerebrospinal fluid volume, and white matter lesion volume) were assessed using generalized linear models adjusted for age, sex, African ancestry proportion, smoking, BMI, use of statins, HbA1c, hypertension, and prior CVD. RESULTS:Participants were 63.4% female with mean (SD) age of 59.8 years (9.2), diabetes duration of 14.5 years (7.6), HbA1c of 7.95% (1.9), estimated glomerular filtration rate of 86.6 mL/min/1.73 m(2) (24.6), and coronary artery CP mass score of 215 mg (502). In fully adjusted models, GMV was inversely associated with coronary artery CP (parameter estimate [β] -0.47 [SE 0.15], P = 0.002; carotid artery CP (β -1.92 [SE 0.62], P = 0.002; and aorta CP [β -0.10 [SE 0.03] P = 0.002), whereas HbA1c and CRP did not associate with cerebral volumes. Coronary artery CP also associated with poorer global cognitive function on the Montreal Cognitive Assessment. CONCLUSIONS:Subclinical atherosclerosis was associated with smaller GMV and poorer cognitive performance in African Americans with diabetes. Cardioprotective strategies could preserve GMV and cognitive function in high-risk African Americans with diabetes.

INTRODUCTION: Smoking prevalence is higher among sexual minorities compared to their heterosexual peers. However, very little is known about potential racial differences in smoking among sexual minority populations. We examined differences by race in smoking status among a robust sample of sexual minorities. METHODS: We used data from the 2010 Social Justice Sexuality project, a large national convenience sample of sexual minority adults that oversampled individuals from racial minority groups. Log-Poisson multivariable regression models were employed to determine the risk of current smoking among sexual minority individuals by race after controlling for socio-demographic characteristics. RESULTS: Among smokers, 22.35% identified as White, 26.98% identified as Black, 19.38% identified as Latino/Hispanic, 5.58% identified as Asian American, and 25.67% were other/multiracial. In fully adjusted gender stratified models, Black men (adjusted risk ratio [aRR] = 0.61, 95% confidence interval [CI] = 0.50, 0.75) and Asian American men (aRR = 0.61, 95% CI = 0.50, 0.75) were at lower risk of smoking compared to White men. Black women were the only to remain statistically significant for decreased risk of smoking in fully adjusted gender stratified models (aRR = 0.78, 95 % CI = 0.65, 0.95). CONCLUSIONS: Among sexual minorities, Black and Asian American individuals consistently were at decreased risk of current smoking compared to their White peers. Future research should seek to understand the mechanisms that contribute to decreased smoking status among racial sexual minorities.

To follow up on a previous study that examined how the mandated displaying of calorie information on menu boards in fast-food restaurants in New York City influenced consumers' behavior, we analyzed itemized cash register receipts and survey responses from 7,699 consumers at four fast-food chains. Using a difference-in-differences study design, we found that consumers exposed to menu labeling immediately after the mandate took effect in 2008 and at three points in 2013-14 reported seeing and using the information more often than their counterparts at fast-food restaurants without menu labeling. In each successive period of data collection, the percentage of respondents noticing and using the information declined, while remaining above the prelabeling baseline. There were no statistically significant changes over time in levels of calories or other nutrients purchased or in the frequency of visits to fast-food restaurants. Menu labeling at fast-food chain restaurants, which the Affordable Care Act requires to be implemented nationwide in 2016, remains an unproven strategy for improving the nutritional quality of consumer food choices at the population level. Additional policy efforts that go beyond labeling and possibly alter labeling to increase its impact must be considered.

BACKGROUND: Hospital care on weekends has been associated with delays in care, reduced quality, and poor clinical outcomes. OBJECTIVE: The purpose of this study was to evaluate the impact of a weekend hospital intervention on processes of care and clinical outcomes. The multifaceted intervention included expanded weekend diagnostic services, improved weekend discharge processes, and increased physician and care management services on weekends. DESIGN AND PATIENTS: This was an interrupted time series observational study of adult non-obstetric patients hospitalized at a single academic medical center between January 2011 and January 2014. The study included 18 months prior to and 19 months following the implementation of the intervention. Data were analyzed using segmented regression analysis with adjustment for confounders. MAIN MEASURES: The primary outcome was average length of stay. Secondary outcomes included percent of patients discharged on weekends, 30-day readmission rate, and in-hospital mortality rate. KEY RESULTS: The study included 57,163 hospitalizations. Following implementation of the intervention, average length of stay decreased by 13 % (95 % CI 10-15 %) and continued to decrease by 1 % (95 % CI 1-2 %) per month as compared to the underlying time trend. The proportion of weekend discharges increased by 12 % (95 % CI 2-22 %) at the time of the intervention and continued to increase by 2 % (95 % CI 1-3 %) per month thereafter. The intervention had no impact on readmissions or mortality. During the post-implementation period, the hospital was evacuated and closed for 2 months due to damage from Hurricane Sandy, and a new hospital-wide electronic health record was introduced. The contributions of these events to our findings are not known. We observed a lower inpatient census and found differences in patient characteristics, including higher rates of Medicaid insurance and comorbidities, in the post-Hurricane Sandy period as compared to the pre-Sandy period. CONCLUSIONS: The intervention was associated with a reduction in length of stay and an increase in weekend discharges. Our longitudinal study also illuminated the challenges of evaluating the effectiveness of a large-scale intervention in a real-world hospital setting.

OBJECTIVES: Understanding the factors associated with child communication during subspecialty encounters may inform interventions promoting shared decision-making in chronic disease management. Objectives were to (1) describe the quantity and quality of child communication during outpatient subspecialty encounters and (2) determine if and how the quantity and quality of child communication vary by demographic and visit characteristics. METHODS: We videotaped subspecialty clinic encounters involving 20 health care providers and 155 children with one of the following conditions: acute lymphoblastic leukemia (consolidation/maintenance), persistent asthma, cystic fibrosis, type 1 diabetes, and obesity. The Roter interaction analysis system was used to code child utterances into one of 10 discrete categories. RESULTS: Children exhibited a mean of 15% of all utterances made during clinical encounters. Children spoke more during obesity encounters. CONCLUSIONS: Similar to the findings of studies in primary care settings, children spoke infrequently during the subspecialty visits, and the most common utterances tended to be replies to questions from adults. PRACTICE IMPLICATIONS: In this study, there was relatively higher engagement of children during obesity clinic encounters in the area of lifestyle choices. Strategies used to engage children in conversation in obesity clinics may be useful for engaging children in other subspecialty clinics.

Purpose . To examine why high-risk individuals targeted for a telephone care management program participated at low rates. Design . Study design consisted of qualitative, semistructured interviews. Setting . The setting was a large national insurer's telephone-based care management program. The program employed registered nurses to provide individually tailored education and counseling about health and health care. Subjects . Study subjects comprised members of a national insurer who were recruited to participate in a care management program but had either dropped out of the program after a short period of initial engagement or had never participated despite recruitment efforts. Measures . Interview content was divided into four categories: knowledge of the case management program, barriers to program participation, perceptions of benefits of the program, and suggestions for program improvement. Analysis . Investigators conducted a directed content analysis. Results . The most commonly cited barriers to participation were a lack of perceived need and a sense of distrust toward the program and its staff. The most commonly cited benefits were psychosocial support and goal setting. Conclusion . Care management programs may benefit from changes to how insurance plan members are selected for the program and from adjusting program content to address perceived needs among members.

The association of cardiovascular risk factors and complexity and severity of coronary artery disease with contrast volume (CV) remains unknown. We assessed the predictive factors of CV use during elective and emergent cardiac catheterization (CC). Electronic medical records from 2010 to 2013 were retrospectively reviewed. A total of 708 patients were eligible. On multivariable regression analysis, the presence of obstructed coronary arteries was associated with CV (P = .01, beta = -14.17), with greater CV used in patients with single or double vessel disease compared to those with triple vessel disease. The presence of lesions with >70% stenosis in major epicardial arteries (P = .019, beta = 24.39) and ST-segment elevation myocardial infarction (P = .001, beta = 36.14) was associated with increased CV use. Elevated B-type natriuretic peptide (P = .036, beta = -17.23) and increase in Synergy between Percutaneous Coronary Intervention with Taxus and Cardiac Surgery score (P = .024, beta = -29.06) were associated with decreased CV use. These aforementioned associations were attenuated after adjusting for percutaneous coronary intervention. Our findings may help predict patient populations who could be exposed to increased CV during CC, thereby possibly increasing their risk of contrast-induced nephropathy.