Faculty Bibliography

The following prospective longitudinal study considers the ways that protracted exposure to verbal and physical aggression between parents may take a substantial toll on emotional adjustment for 1,025 children followed from 6 to 58 months of age. Exposure to chronic poverty from infancy to early childhood as well as multiple measures of household chaos were also included as predictors of children's ability to recognize and modulate negative emotions in order to disentangle the role of interparental conflict from the socioeconomic forces that sometimes accompany it. Analyses revealed that exposure to greater levels of interparental conflict, more chaos in the household, and a higher number of years in poverty can be empirically distinguished as key contributors to 58-month-olds' ability to recognize and modulate negative emotion. Implications for models of experiential canalization of emotional processes within the context of adversity are discussed.

OBJECTIVES: To compare the effectiveness and costs of telephone-only approach to in-person plus telephone for delivering an evidence-based, coordinated care management program for dementia. METHODS: We randomized 151 patient-caregiver dyads from an underserved predominantly Latino community to two arms that shared a care management protocol but implemented in different formats: in-person visits at home and/or in the community plus telephone and mail, versus telephone and mail only. We compared between-arm caregiver burden and care-recipient problem behaviors (primary outcomes) and patient-caregiver dyad retention, care quality, health care utilization, and costs (secondary outcomes) at 6- and 12-months follow-up. RESULTS: Care quality improved substantially over time in both arms. Caregiver burden, care-recipient problem behaviors, retention, and health care utilization did not differ across arms but the in-person program cost more to deliver. DISCUSSION: Dementia care quality improved regardless of how care management was delivered; large differences in effectiveness or cost offsets were not detected.

PURPOSE: Prescription drug overdose (PDO) deaths are a critical public health problem in the United States. This study aims to assess the association between emergency department (ED) utilization patterns in a cohort of ED patients and the risk of subsequent unintentional PDO mortality. METHODS: Using data from the New York Statewide Planning and Research Cooperative System for 2006-2010, a nested case-control design was used to examine the relationship between ED utilization patterns in New York State residents of age 18-64 years and subsequent PDO death. RESULTS: The study sample consisted of 2732 case patients who died of PDO and 2732 control ED patients who were selected through incidence density sampling. With adjustment for demographic characteristics, and diagnoses of pain, substance abuse, and psychiatric disorders, the estimated odds ratios of PDO death relative to one ED visit or less in the previous year were 4.90 (95% confidence interval [CI]: 4.50-5.34) for those with two ED visits, 16.61 (95% CI: 14.72-18.75) for those with three ED visits, and 48.24 (95% CI: 43.23-53.83) for those with four ED visits or more. CONCLUSIONS: Frequency of ED visits is strongly associated with the risk of subsequent PDO death. Intervention programs targeting frequent ED users are warranted to reduce PDO mortality.

Diabetic kidney disease (DKD) is the most common etiology of chronic kidney disease (CKD) in the industrialized world and accounts for much of the excess mortality in patients with diabetes mellitus. Approximately 45% of U.S. patients with incident end-stage kidney disease (ESKD) have DKD. Independent of glycemic control, DKD aggregates in families and has higher incidence rates in African, Mexican, and American Indian ancestral groups relative to European populations. The Family Investigation of Nephropathy and Diabetes (FIND) performed a genome-wide association study (GWAS) contrasting 6,197 unrelated individuals with advanced DKD with healthy and diabetic individuals lacking nephropathy of European American, African American, Mexican American, or American Indian ancestry. A large-scale replication and trans-ethnic meta-analysis included 7,539 additional European American, African American and American Indian DKD cases and non-nephropathy controls. Within ethnic group meta-analysis of discovery GWAS and replication set results identified genome-wide significant evidence for association between DKD and rs12523822 on chromosome 6q25.2 in American Indians (P = 5.74x10-9). The strongest signal of association in the trans-ethnic meta-analysis was with a SNP in strong linkage disequilibrium with rs12523822 (rs955333; P = 1.31x10-8), with directionally consistent results across ethnic groups. These 6q25.2 SNPs are located between the SCAF8 and CNKSR3 genes, a region with DKD relevant changes in gene expression and an eQTL with IPCEF1, a gene co-translated with CNKSR3. Several other SNPs demonstrated suggestive evidence of association with DKD, within and across populations. These data identify a novel DKD susceptibility locus with consistent directions of effect across diverse ancestral groups and provide insight into the genetic architecture of DKD.

Understanding the determinants of fighting is important for prevention efforts. Unfortunately, there is little research on how sibling fighting is related to peer fighting. Therefore, the aim of this study was to evaluate the association between sibling fighting and peer fighting. Data are from the Boston Youth Survey 2008, a school-based sample of youth in Boston, MA. To estimate the association between sibling fighting and peer fighting, we ran four multivariate regression models and estimated adjusted prevalence ratios and 95% confidence intervals. We fit generalized estimating equation models to account for the fact that students were clustered within schools. Controlling for school clustering, race/ethnicity, sex, school failure, substance use, and caregiver aggression, youth who fought with siblings were 2.49 times more likely to have reported fighting with peers. To the extent that we can confirm that sibling violence is associated with aggressive behavior, we should incorporate it into violence prevention programming.

BACKGROUND: Little is known about parental recognition of their child's overweight status over time. The aim of this study was to examine the prevalence of parental misperceptions related to preschool children's weight in the last two decades. METHODS: Data come from the National Health and Nutrition Examination Survey from 1988 to 1994 (early survey; n=3839) and 2007 to 2012 (recent survey; n=3153). Parents were asked whether they considered their child, ages 2-5 years, to be overweight, underweight, or just about the right weight. We estimated the probability ratio (PR) between the two surveys for parents perceiving their overweight child as overweight. RESULTS: Percentages of parents who inappropriately perceived their overweight child as just about the right weight was 96.6% and 94.9% for the early and recent survey, respectively. As high as 78.4% of parents perceived their obese child as just about the right weight in the recent survey. The probability of overweight/obese children being perceived as overweight in the early survey was 0.18 (95% confidence interval [CI]=0.14-0.22) and further lowered to 0.14 (95% CI=0.11-0.17) in the recent survey. After adjustment for sociodemographics and BMI z-scores of directly measured body weight, probability of being appropriately perceived by the parents declined by 30% between surveys (PR=0.70 [0.63, 0.78]). CONCLUSIONS: There was a declining tendency among parents to perceive overweight children appropriately. Strategies are needed to explore how to encourage clinician discussions with parents about appropriate weight for their child and strengthen capacity for childhood obesity prevention.

BACKGROUND:Only half of hypertensive adults achieve blood pressure (BP) control in the United States, and it is unclear how BP control rates may be improved most effectively and efficiently at the population level. OBJECTIVE:We sought to compare the potential effects of system-wide isolated improvements in medication adherence, visit frequency, and higher physician prescription rate on achieving BP control at 52 weeks. DESIGN/METHODS:We developed a Markov microsimulation model of patient-level, physician-level, and system-level processes involved in controlling hypertension with medications. The model is informed by data from national surveys, cohort studies and trials, and was validated against two multicenter clinical trials (ALLHAT and VALUE). SUBJECTS/METHODS:We studied a simulated, nationally representative cohort of patients with diagnosed but uncontrolled hypertension with a usual source of care. INTERVENTIONS/METHODS:We simulated a base case and improvements of 10 and 50%, and an ideal scenario for three modifiable parameters: visit frequency, treatment intensification, and medication adherence. Ideal scenarios were defined as 100% for treatment intensification and adherence, and return visits occurring within 4 weeks of an elevated office systolic BP. MAIN OUTCOME/RESULTS:BP control at 52 weeks of follow-up was examined. RESULTS:Among 25,000 hypothetical adult patients with uncontrolled hypertension (systolic BP ≥ 140 mmHg), only 18% achieved BP control after 52 weeks using base-case assumptions. With 10/50%/idealized enhancements in each isolated parameter, enhanced treatment intensification achieved the greatest BP control (19/23/71%), compared with enhanced visit frequency (19/21/35%) and medication adherence (19/23/26%). When all three processes were idealized, the model predicted a BP control rate of 95% at 52 weeks. CONCLUSION/CONCLUSIONS:Substantial improvements in BP control can only be achieved through major improvements in processes of care. Healthcare systems may achieve greater success by increasing the frequency of clinical encounters and improving physicians' prescribing behavior than by attempting to improve patient adherence to medications.

BACKGROUND: Work conditions in primary care are associated with physician burnout and lower quality of care. OBJECTIVE: We aimed to assess if improvements in work conditions improve clinician stress and burnout. SUBJECTS: Primary care clinicians at 34 clinics in the upper Midwest and New York City participated in the study. STUDY DESIGN: This was a cluster randomized controlled trial. MEASURES: Work conditions, such as time pressure, workplace chaos, and work control, as well as clinician outcomes, were measured at baseline and at 12-18 months. A brief worklife and work conditions summary measure was provided to staff and clinicians at intervention sites. INTERVENTIONS: Diverse interventions were grouped into three categories: 1) improved communication; 2) changes in workflow, and 3) targeted quality improvement (QI) projects. ANALYSIS: Multilevel regressions assessed impact of worklife data and interventions on clinician outcomes. A multilevel analysis then looked at clinicians whose outcome scores improved and determined types of interventions associated with improvement. RESULTS: Of 166 clinicians, 135 (81.3 %) completed the study. While there was no group treatment effect of baseline data on clinician outcomes, more intervention clinicians showed improvements in burnout (21.8 % vs 7.1 % less burned out, p = 0.01) and satisfaction (23.1 % vs 10.0 % more satisfied, p = 0.04). Burnout was more likely to improve with workflow interventions [Odds Ratio (OR) of improvement in burnout 5.9, p = 0.02], and with targeted QI projects than in controls (OR 4.8, p = 0.02). Interventions in communication or workflow led to greater improvements in clinician satisfaction (OR 3.1, p = 0.04), and showed a trend toward greater improvement in intention to leave (OR 4.2, p = 0.06). LIMITATIONS: We used heterogeneous intervention types, and were uncertain how well interventions were instituted. CONCLUSIONS: Organizations may be able to improve burnout, dissatisfaction and retention by addressing communication and workflow, and initiating QI projects targeting clinician concerns.

OBJECTIVES: To evaluate physician-perceived strengths and limitations of the Thrombolysis in Myocardial Infarction (TIMI) risk scores for use in older adults with acute myocardial infarction (AMI). BACKGROUND: The TIMI risk scores are risk stratification models developed to estimate mortality risk for patients hospitalized for AMI. However, these models were developed and validated in cohorts underrepresenting older adults (>/=75 years). METHODS: Qualitative study using semi-structured telephone interviews and the constant comparative method for analysis. RESULTS: Twenty-two physicians completed interviews ranging 10-30 min (mean = 18 min). Median sample age was 37 years, with a median of 11.5 years of clinical experience. TIMI strengths included familiarity, ease of use, and validation. Limitations included a lack of risk factors relevant to older adults and model scope and influence. CONCLUSIONS: Physicians report that the TIMI models, while widely used in clinical practice, have limitations when applied to older adults. New risk models are needed to guide AMI treatment in this population.

We assessed the association of mitral annular calcification (MAC) with atherosclerotic risk factors and severity and complexity of coronary artery disease (CAD). Cardiac catheterization reports and electronic medical records from 2010 to 2011 were retrospectively reviewed. A total of 481 patients were divided into 2 groups: MAC present (209) and MAC absent (272). All major cardiovascular risk factors, comorbidities, and coronary lesion characteristics were included. On linear regression analysis, age (P = .001, beta 1.12) and female gender (P = .031, beta 0.50) were the independent predictors of MAC. Mitral annular calcification was not independently associated with the presence of lesions with >70% stenosis (P = .283), number of obstructive vessels (P = .469), lesions with 50% to 70% stenosis (P = .458), and Synergy Between Percutaneous Coronary Intervention With Taxus and Cardiac Surgery score (P = .479). Mitral annular calcification is probably a benign marker of age-related degenerative changes in the heart independent of the severity and complexity of CAD.