Affiliated Clinics Research Articles

Pollutant Chemicals, Thyrotropin, and Thyroid Hormone in Infants

ISEE-0440 Background and Objective: Infants are exposed to chemicals that might interfere with thyroid function, such as perchlorate, thiocyanate, and nitrate. There are no studies available with individual measures of these chemicals and thyroid function in infants. We examined whether urinary perchlorate, nitrate, or thiocyanate is associated with urinary thyroxine (T4) and thyroid stimulating hormone (TSH) in infants. Because background perchlorate exposure has been associated with changes in thyroid hormone levels in adults, we specifically examined whether perchlorate was associated with higher TSH in infants with low iodide and in infant girls, as was seen in US females over age 12 years. Methods: The study was conducted at the Children’s Hospital of Philadelphia, the Hospital of the University of Pennsylvania, and affiliated clinics, among 92 full term infants (47 males and 45 females) between birth and 1 year of age. We used data from the Study of Estrogen Activity and Development, which was a partly cross-sectional, partly longitudinal study designed to assess hormone levels of full term infants over the first 12 months of life. We analyzed urine samples collected in that study. Main Outcome Measures: Urinary perchlorate, thiocyanate, nitrate, iodide, TSH and T4, and blood TSH and T4. Results: In models with single chemical agents, infants with higher perchlorate had higher TSH and T4. In models with all three chemical agents, infants with low iodide and higher perchlorate had higher T4 and TSH; infants with higher urinary thiocyanate or higher urinary nitrate had higher urinary TSH and T4. Conclusions: The association of perchlorate exposure with increased urinary TSH in infants with low urinary iodide is consistent with previous findings in females aged 12 and older. Higher thiocyanate and nitrate exposure is also associated with higher urinary TSH in infants. (Supported in part by the intramural research program of NIH.)

Access to What? An Evaluation of the Key Ingredients to Effective Advanced Mental Health Access at a VA Medical Center and Its Affiliated Community-Based Outreach Clinics

Initial evaluation of an advanced access clinic developed at a VA medical center (VAMC) found decreased Mental Health wait times and improved quality of care for veterans with depression. Subsequently, modified advanced access models were implemented at affiliated community-based outreach clinics (CBOCs). By comparing each site, we sought to determine whether less resource-intensive models could improve care to the same degree. We assessed contributions of the model's components to the improvement of care (i.e., wait times and depression treatment adequacy). The modified advanced access models led to significant improvements, although no such improvements were seen at 2 control sites. Six features related to rapid access, short-term treatment, and barrier-free access to mental health services accounted for most of the observed improvements. CBOCs can implement limited advanced mental health access models and derive similar improvements to those seen in more extensive models at the VAMCs to which they are affiliated.

Monozygotic twins in infertile patients with advanced maternal age: case reports and review of the literature

To report two cases of successful monozygotic twin pregnancies in women undergoing infertility treatment and to review possible etiologic factors. Case report and review of the literature. University of Toronto-affiliated infertility clinic. A 43-year-old woman and a 44-year-old woman with history of secondary infertility. In vitro fertilization and ET. Monozygotic twin pregnancy. Delivery of two sets of monozygotic twins. The only identified potential risk factors for monozygotic twins are maternal age and assisted reproductive technologies. Both patients reported here were aged >40 years and underwent assisted reproduction procedures, including high-dose gonadotropin stimulation, embryo culture, and, in case 2, intracytoplasmic sperm injection plus assisted hatching.

Impact of Community-Based Patient-Centered Medical Homes on Appropriate Health Care Utilization at Carolinas Medical Center

NCMed J July/August 2009, Volume 70, Number 4 here are numerous reports that link the economic downturn to increased use of emergency departments (EDs). For example, in The Washington Post, Larry Gage, president of the National Association of Public Hospitals and Health Systems, stated that “the absolute number of people using emergency rooms has gone up asmuch as 20% to 30% in the last six to eightmonths due to the recession.”The same article reported that Providence Hospital in Washington,DCexperienceda 13% increase in emergency roomvisits in theprevious year. Carolinas HealthCare System, centered in Charlotte, North Carolina provides the majority of safety net care for theCharlotteMecklenburg region; yet interestingly enough, the EDs at our hospitals are not experiencing similar trends as the rest of the nation. Comparing the first five months of 2009 to the first five months of 2008 shows only a slight increase in ED visits (0.5%) for all of the Carolinas HealthCare System’s Mecklenburg County hospitals. This is during a period in which our region is experiencing overall population growth, rising unemployment rates, and increasing numbers of people without health insurance. This commentary will explain some of the strategies implemented at Carolinas Medical Center over the past decade that are helping to control ED utilization. Carolinas HealthCare System (CHS) is a large, vertically integrated health care system with facilities in North and South Carolina. The flagship hospital, Carolinas Medical Center (CMC), is an 808 bed facility and a Level I Trauma Center. As in many cities, our safety net hospital serves a significant role in providing access to services for underserved populations. CMC also serves as one of North Carolina’s five academic medical center teaching hospitals, providing residency training for over 200 physicians in 15 medical specialties. Additionally, CMC operates primary care clinics for uninsured and underinsured patients in four strategically located areas of the city. These clinics, along with affiliated specialty care clinics, provide medical care to over 70,000 low-income individuals in 250,000 annual visits.

Self-management Behaviors (physical Activity) Among Primary Care Patients With Pain And Depression

PURPOSE: To determine the long term effects of a combined pharmacological and behavioral intervention on self-management behaviors in primary care patients with musculoskeletal pain and depression. METHODS: We conducted a randomized controlled trial and recruited 250 primary care patients from University affiliated and VA primary care clinics. At baseline, all patients met inclusion criteria of having chronic pain in low back, knee or hip, and half met criteria for clinical depression. Participants were randomized to either usual care or a stepped intervention that consisted up 12 weeks of optimized antidepressant therapy followed by a pain self-management (PSM) program delivered biweekly over 6 sessions during the following 12 weeks, and continuation of the antidepressant therapy over the remaining 6 months with 2 self-management booster sessions at 8 and 10 months. We assessed engagement in self-management behaviors (e.g., physical activity) using validated surveys both at baseline and 12 months later. We compared between group differences between intervention and usual care using intention to treat analyses. We analyzed the data using t-tests to compare group means. RESULTS: Participants were 52% men; 62% White; 33% African-American and had a mean age of 59 years. Compared to usual care, participants in the intervention group significantly increased the time spent on performing self-management behaviors in the following areas: strength exercises (p<.03); stretching exercises (p<.00); progressive muscle relaxation (p<.00); visualizing (p<.02); and mental stress relaxation (p<.00). In addition, intervention participants reported more time spent in walking and engaging in positive thinking than those in usual care, but the differences were not significant. CONCLUSIONS: A combined pharmacological and behavioral intervention may effectively increase the patient self-management behaviors in particular, physical activity, among urban, primary care patients with chronic musculoskeletal pain and depression.

Using a Multifaceted Approach to Improve the Follow-Up of Positive Fecal Occult Blood Test Results

Inadequate follow-up of abnormal fecal occult blood test (FOBT) results occurs in several types of practice settings. Our institution implemented multifaceted quality improvement (QI) activities in 2004-2005 to improve follow-up of FOBT-positive results. Activities addressed precolonoscopy referral processes and system-level factors such as electronic communication, provider education, and feedback. We evaluated their effects on timeliness and appropriateness of positive-FOBT follow-up and identified factors that affect colonoscopy performance. Retrospective electronic medical record review was used to determine outcomes before and after QI activities in a multispecialty ambulatory clinic of a tertiary care Veterans Affairs facility and its affiliated satellite clinics. From 1869 FOBT-positive cases, 800 were randomly selected from time periods before and after QI activities. Two reviewers used a pretested standardized data collection form to determine whether colonoscopy was appropriate or indicated based on predetermined criteria and if so, the timeliness of colonoscopy referral and performance before and after QI activities. In cases where a colonoscopy was indicated, the proportion of patients who received a timely colonoscopy referral and performance were significantly higher post-implementation (60.5% vs. 31.7%, P<0.0001 and 11.4% vs. 3.4%, P=0.0005). A significant decrease also resulted in median times to referral and performance (6 vs. 19 days, P<0.0001 and 96.5 vs. 190 days, P<0.0001) and in the proportion of positive-FOBT test results that had received no follow-up by the time of chart review (24.3% vs. 35.9%, P=0.0045). Significant predictors of absence of the performance of an indicated colonoscopy included performance of a non-colonoscopy procedure such as barium enema or flexible sigmoidoscopy (OR=16.9; 95% CI, 1.9-145.1), patient non-adherence (OR=33.9; 95% CI, 17.3-66.6), not providing an appropriate provisional diagnosis on the consultation (OR=17.9; 95% CI, 11.3-28.1), and gastroenterology service not rescheduling colonoscopies after an initial cancellation (OR=11.0; 95% CI, 5.1-23.7). Multifaceted QI activities improved rates of timely colonoscopy referral and performance in an electronic medical record system. However, colonoscopy was not indicated in over one third of patients with positive FOBTs, raising concerns about current screening practices and the appropriate denominator used for performance measurement standards related to colon cancer screening.

The project ENABLE II randomized controlled trial to improve palliative care for rural patients with advanced cancer: Baseline findings, methodological challenges, and solutions

There is a paucity of randomized controlled trials (RCTs) to evaluate models of palliative care. Although interventions vary, all have faced a variety of methodological challenges including adequate recruitment, missing data, and contamination of the control group. We describe the ENABLE II intervention, methods, and sample baseline characteristics to increase intervention and methodological transparency, and to describe our solutions to selected methodological issues. Half of the participants recruited from our rural U.S. comprehensive cancer center and affiliated clinics were randomly assigned to a phone-based, nurse-led educational, care coordination palliative care intervention model. Intervention services were provided to half of the participants weekly for the first month and then monthly until death, including bereavement follow-up call to the caregiver. The other half of the participants were assigned to care as usual. Symptoms, quality of life, mood, and functional status were assessed every 3 months until death. Baseline data of 279 participants were similar to normative samples. Solutions to methodological challenges of recruitment, missing data, and "usual care" control group contamination are described. It is feasible to overcome many of the methodological challenges to conducting a rigorous palliative care RCT.

A Randomized Breast-feeding Promotion Intervention Did Not Reduce Child Obesity in Belarus

The evidence that breast-feeding protects against obesity is based on observational studies, with potential for confounding and selection bias. This article summarizes a previously published study in which we assessed whether an intervention designed to promote exclusive and prolonged breast-feeding affects children's height, weight, adiposity, and blood pressure (BP) at age 6.5 y. The Promotion of Breastfeeding Intervention Trial (PROBIT) is a cluster-randomized trial of a breast-feeding promotion intervention based on the WHO/UNICEF Baby-Friendly Hospital Initiative. A total of 17,046 healthy breast-fed infants were enrolled from 31 Belarussian maternity hospitals and affiliated clinics, of whom 13,889 (81.5%) were followed up at 6.5 y with duplicate measurements of height, weight, waist circumference, triceps and subscapular skinfold thicknesses, systolic and diastolic BP. Analysis was based on intention to treat, with statistical adjustment for clustering within hospitals/clinics to permit inferences at the individual level. The experimental intervention led to a large increase in exclusive breast-feeding at 3 mo (43.3% vs. 6.4%, P < 0.001) and a significantly higher prevalence of any breast-feeding throughout infancy. No significant intervention effects were observed on height, BMI, adiposity measures, or BP. The breast-feeding promotion intervention resulted in substantial increases in the duration and exclusivity of breast-feeding yet did not reduce measures of adiposity at age 6.5 y. Previous reports of protective effects against obesity may reflect uncontrolled bias caused by confounding and selection.

Collaborative care for adolescent depression: a pilot study

Objective The main objectives of this study were to explore the preliminary outcomes and assess the feasibility and acceptability of a collaborative care intervention designed to improve treatment and outcomes of depression among youth seen in primary care settings. Methods We conducted a pilot intervention study at three clinics in a university affiliated primary care clinic network. The intervention model was designed to support the provision of depression treatment by primary care providers using methods adapted from the IMPACT study developed for the improvement of depression among older adults. Specific components include the provision of regular case management by a nurse depression care manager (DCM), enhanced patient and parent education about depression and its treatment, encouragement of patient self-management with a choice of starting medications or therapy or both, and oversight of the DCM by a mental health specialist. Study participants were assessed regularly by the DCM for 6 months and completed written self-report assessments at baseline, 3, and 6 months after starting the intervention. Results 40 youth (12-18 years) with major and minor depression enrolled in the intervention. Study participants were predominantly female (90%). The baseline Patient Health Questionnaire (PHQ-9) score was 14.2 (SD=4.5). Patients were similarly divided among initiating medications (n=12), therapy (n=15), or combination therapy (n=8). Five patients withdrew prior to initiating treatment. The mean number of in person and telephone contacts with the DCM was 9 (range=5 to 17). Eighty-seven percent of youth completed the 6-month intervention. At 6 month follow-up, 74% of youth had a 50% or more reduction in depressive symptoms as measured by the PHQ-9. Parents, youth and physicians indicated high levels of satisfaction with the intervention on written surveys and in qualitative exit interviews. Conclusion The collaborative care model is feasible and highly acceptable to adolescents and parents as demonstrated both by self-report and by engagement in the intervention. It is also associated with improved depressive outcomes at similar levels to adult interventions. Future studies should evaluate these models in a randomized controlled trial.

Aripiprazole in Children and Adolescents with Tourette Disorder with and without Explosive Outbursts

We conducted a retrospective, observational study of aripiprazole for the treatment of tics and/or co-morbid explosive outbursts in 37 children and adolescents with Tourette disorder (TD). Thirty seven children and adolescents with TD, with and without explosive outbursts, and refractory to previous treatment were treated at one of two university affiliated specialty clinics. All diagnoses were made using Diagnostic and Statistical Manual of Mental Disorders, 4th edition, Text Revision (DSM-IV-TR) criteria. Tic severity was rated using the Clinical Global Impressions Scale for tics (CGI-Tics) and frequency of explosive outbursts was assessed using the CGI-Rage; both measures were obtained at pretreatment baseline and at posttreatment follow up. High rates of psychiatric co-morbidity were observed in these subjects: 31 of 37 (84%) subjects met criteria for obsessive-compulsive disorder (OCD), and 31 of 37 (84%) met criteria for attention-deficit/hyperactivity disorder (ADHD). Twenty nine of 37 (78%) subjects met criteria for intermittent explosive disorder (IED) minus criterion C; the remaining 8 subjects had TD only. Eight subjects (22%) discontinued treatment before 12 weeks due to inability to tolerate the drug. At follow up, tics reduced at a mean daily dose of 12.3 (7.50) mg in 29 of 29 (100%) subjects who completed the study, and explosive outbursts improved in 24/25 subjects (96%) who completed the study. Aripiprazole was tolerated reasonably well, although 8/37 (22%) subjects discontinued treatment; most common side effects included weight gain, akathisia, and sedation. Aripiprazole should be investigated further as a treatment option for TD with and without co-morbid explosive outbursts.

Prevalence of the Human Papillomavirus in an Inner-City Indigent Population With Previously Normal Pap Tests

To determine the prevalence of human papillomavirus (HPV) in our inner-city indigent population (clinic population) of women with previously normal Pap tests and to identify any associated risk factors. A prospective cohort of 187 women between the ages of 15 and 49 years, with previously normal Pap tests, was recruited from a university affiliated outpatient clinic. A demographic questionnaire of social and sexual history was elicited, and ThinPrep cytology (Cytyc, Marlborough, MA) and HPV Digene Hybrid Capture II results (Digine, Gaithersburg, MD) were obtained. The prevalence of HPV in our primarily Hispanic clinic population was 21%. The mean age of women with HPV was 28.9 years and those without were 32.1 years (p <.046). In women with HPV, 24% had abnormal Pap tests, whereas in those without HPV, 5% had abnormal Pap tests (p <.001). Women who were older and parous were less likely to have HPV (7.5%; p <.024). The presence of HPV was not influenced by sexual behaviors, sexually transmitted diseases, smoking, race, or contraceptive use. The prevalence of HPV in an inner-city indigent population, despite previously normal cytology, was consistent with earlier reported rates of HPV. Our data suggest that younger, nulliparous women have a high prevalence of HPV.

Hepatitis a and B Vaccination of Patients with Hepatitis C in Internal Medicine Residency Clinics

Purpose: The primary aims of this study were to evaluate and improve adherence of medical residents to guideline recommendations by the Advisory Committee on Immunization Practices of CDC, AASLD and NIH for administration of hepatitis A and B vaccines to patients with hepatitis C. Methods: This investigation consisted of a retrospective review with a prospective intervention arm performed at two university affiliated teaching hospital internal medicine residency clinics. Patients with ICD-9 code for hepatitis C (70.51) for the time period of January 2001 to June 2006 were identified. Demographic and clinical data including reasons for non-vaccination were abstracted from clinical charts and electronic medical records. Patients were excluded from vaccination if they were seropositive for hepatitis A and B. In a prospective phase, contact of patients with hepatitis C not vaccinated for hepatitis A and B was attempted by both mail and telephone to encourage them to return for free vaccinations. Results: A total of 230 patients were found to be hepatitis C antibody positive over 5 years in the two residency clinics. Vaccination practices were equivalent at both clinics: 80.8% and 82.9% of patients were not vaccinated for hepatitis A and 75.0% and 87.4% of patients were not vaccinated against hepatitis B. No reason for non-vaccination was recorded for 62% and 73% patients in the 2 clinics for hepatitis A and B. Hepatitis vaccination was mentioned in another 20% of cases but was not performed. Multivariate analysis of patient characteristics associated with vaccination identified only white ethnicity as a significant risk factor (OR 0.33, CI 0.12–0.91). Attempts to contact 186 patients non-vaccinated were made: 30% of patients were reached, 11% made appointments for vaccination clinic but only 7% attended. Conclusion: Adherence to hepatitis A and B vaccination guidelines in patients with hepatitis C followed in residency clinics was very low. The major reason for non-vaccination appeared to be that the option was not discussed with or offered to patients. Patients not vaccinated are difficult to reach and recall for vaccination. A significant opportunity exists to improve hepatitis vaccination practices in residency clinics serving high risk patients.

The Closure of a Medical Practice Forces Older Patients to Make Difficult Decisions: A Qualitative Study of a Natural Experiment

The closure of a primary care practice and the relocation of the physicians and staff to a new office forced patients to decide whether to follow their primary care physicians (PCP) or to transfer their care elsewhere. This study explores the perspectives of the older patients affected by this change. Qualitative study. Two lists of patients older than 60 years from the original office were generated: (1) those who had followed their PCPs to the further practice and (2) those who chose new PCPs at an affiliated nearby clinic. One hundred forty patients from each of the two lists were randomly selected for study. Eight months after the clinic's closure, patients responded to an open-ended question asking patients to describe the transition. Using content analysis, two investigators independently coded all of the written responses. Over 85% of patients in both groups had been with their original PCP for longer than 2 years. Patients that elected to transition their care to a new PCP within their community were older (75 vs 70 years) and more likely to be living alone (38% vs 18%), both p < 0.01. There was still considerable frustration associated with the clinic's closure. Patients from both groups had variable levels of satisfaction with their new primary care arrangements. Patients who moved to the near clinic, now seeing a new physician, commented on being satisfied with the proximity of the site. On the other hand, these patients also expressed longing for the previous arrangement (the building, the staff, and especially their prior physician). Patients who transferred their care to the further clinic indicated a profound loyalty to their PCP and an appreciation of the added features at the new site. Yet, many patients still described being upset with the difficulties associated with the further distance. The closing of this practice was difficult for this cohort of older patients. Patients' decisions were considerably influenced by whether they imagined that convenience or their established relationship with their PCP was of a higher priority to them.

An Observational, Retrospective Analysis of Retreatment with Bortezomib for Multiple Myeloma

PurposeThe aim of this retrospective chart review of patients with multiple myeloma (MM) was to describe patterns of retreatment with bortezomib-based therapy and responses to retreatment in a community-based setting. Patients and MethodsData were retrospectively extracted from the medical records of patients treated in US Oncology—affiliated community oncology clinics who received 2 separate treatments with bortezomib-based therapy. Eligible patients had ≥ 60 days between treatments and ≥ 4 bortezomib doses during initial treatment. Responses were determined primarily by laboratory values. Response categories included (1) very good partial response (VGPR), ≥ 90% M-protein decrease; (2) partial response (PR), 50%–89% decrease; and (3) less than PR (< PR), < 50% decrease, excluding progressive disease (PD). ResultsRetreatment response data were available for 82 patients; 5 (6%) had VGPR, 12 (15%) had PR, 52 (63%) had < PR, 5 (6%) had PD, and 8 (10%) died. Among 62 patients with response assessments for initial treatment and retreatment, VGPR/PR rates to retreatment were 44%, 23%, and 13% among patients with VGPR, PR, and < PR to initial treatment, respectively. Median time between bortezomib treatments was 9.7 months; 29% of patients received non-bortezomib therapy between treatments. The most common treatment pattern (58% of patients) was single-agent bortezomib at initial treatment and retreatment. Toxicity contributed to discontinuation in 38% of patients during initial treatment and 22% during retreatment; rates of neuropathy contributing to discontinuation were 18% and 6%, respectively. ConclusionRetreatment with bortezomib-based therapy is feasible, with predictable toxicities. This observational analysis supports bortezomib alone or in combination as a retreatment option after initial bortezomib treatment in patients with relapsed MM.

Care management for depression and osteoarthritis pain in older primary care patients: a pilot study

To establish the feasibility of and to generate preliminary evidence for the efficacy of a care management program addressing both physical and emotional pain associated with late-life depression and osteoarthritis. Treatment development pilot study in three university affiliated primary care clinics. Participants were patients 60 years or older with depression and osteoarthritis pain. The intervention entailed a nurse administered care management program supporting depression and arthritis treatment by primary care physicians. Outcomes include depression, pain severity and functional impairment from pain assessed at baseline and 6 months. Fourteen patients participated in the pilot program. Between baseline and 6 months, mean HSCL-20 depression scores dropped from 1.78 (SD 0.56) to 1.06 (SD 0.59), a standardized effect size of 1.27 (p = 0.004). Pain intensity scores dropped from 5.67 (SD 1.69) to 4.18 (SD 1.98), an effect size of 0.88 (p = 0.021) and pain interference scores dropped from 4.91 (SD 1.75) to 3.49 (SD 2.14), an effect size of 0.81 (p = 0.013). Patients also experienced improvements in self efficacy, in satisfaction with depression care, and in timed 8-m walk and transfer tests. The combined intervention was feasible and well-received by patients. Preliminary outcomes are promising and comparisons to an earlier trial of care management for depression alone suggest that the combined program may be equally effective for depression but more effective for pain.

Dyslipidemia Control in Indigent Patients Receiving Medication Assistance Compared with Insured Patients

To compare dyslipidemia management with statin-based therapy in insured patients versus indigent patients receiving medication assistance, and to determine drug therapy adherence rates in the two groups. Retrospective medical record review. Setting. University-based health care system. Two hundred forty patients with dyslipidemia who received statin-based therapy from the outpatient pharmacies and clinical care at an affiliated clinic. Prescription records identified 665 patients between October 1, 2004, and September 30, 2005. Forty of these patients had insurance (with a single carrier), and the remaining 625 patients received health care subsidies from the Colorado Indigent Care Program (CICP). Using a block scheme, 200 patients from the CICP were randomly extracted. The primary objective was measured by assessment of low-density lipoprotein cholesterol (LDL) goal attainment and use of a moderate-potency, lipid-lowering regimen capable of achieving an LDL level reduction of least 30%. Of a total of 240 patients who met study criteria, 26 were excluded whose records lacked LDL measurements while receiving therapy. The LDL goal was achieved in 122 (68.9%) of the 177 patients in the CICP group versus 29 (78.4%) of the 37 patients in the insured group (p=0.34). A moderate-potency, LDL-lowering regimen was used by 90.5% of 200 patients in the CICP group and 85% of 40 patients in the insured group (p=0.45). In patients classified as having moderately high, high, or very high cardiovascular risk, LDL goals were attained in 103 (67.3%) of 153 patients in the CICP group versus 16 (69.6%) of 23 patients in the insured group (p=0.83). In this higher-risk subgroup, a moderate-potency regimen was used in 162 (92.6%) of 175 patients in the CICP group versus 23 (92%) of 25 patients in the insured group (p=0.92). Among the very high-risk patients from the two groups combined, 30 (52.6%) of 57 patients achieved LDL concentrations below 70 mg/dl, and 58 (95.1%) of 61 patients were administered a moderate-potency, LDL-lowering regimen. The secondary objective, overall adherence, as assessed by the medication possession ratio, was better in the CICP group than in the insured group. Our data suggest that quality of dyslipidemia management is similar for indigent and insured populations. Overall LDL goal attainment rates were higher than those reported in the literature. Most patients with significant cardiovascular risk, including those at very high risk, were treated according to established guidelines. Adherence rates were greater for indigent patients.

Association of Hepatitis C Virus Infection With Prevalence and Development of Kidney Disease

Hepatitis C and chronic kidney disease (CKD) are both highly prevalent diseases in the United States. Data showed that hepatitis C may be causally linked to some glomerular diseases, and patients who are positive for hepatitis C have increased risk of albuminuria. To determine whether hepatitis C infection is associated with increased likelihood of CKD, we performed retrospective cross-sectional and longitudinal analyses of a large clinical database. Data for a study population of 13,139 African American and white patients tested for hepatitis C between 1994 and 2004 were extracted from a computerized database from a clinical population of an urban hospital and affiliated clinics. Hepatitis C by means of enzyme-linked immunosorbent assay. In cross-sectional analysis, CKD was defined as a minimum estimated glomerular filtration rate (eGFR) less than 60 mL/min/1.73 m(2) by using the 4-variable isotope dilution mass spectrometry-traceable Modification of Diet in Renal Disease Study equation or proteinuria. In longitudinal analysis, CKD was defined as eGFR less than 60 mL/min/1.73 m(2). Potential confounders investigated included sex, age, race, human immunodeficiency virus (HIV) status, chronic hypertension, diabetes, and other laboratory test result abnormalities. 3,938 patients (30.0%) were positive for hepatitis C and 2,549 (19.4%) had CKD. Of those with CKD, 1,999 (78.4%) had an eGFR less than 60 mL/min/1.73 m(2), 186 (7.3%) had proteinuria, and 364 (14.3%) had both. In cross-sectional analysis, after controlling for diabetes, hypertension, age, aspartate aminotransferase level, and HIV status, patients who tested positive for hepatitis C had a decreased risk of CKD (odds ratio, 0.69; 95% confidence interval, 0.62 to 0.77). A total of 7,038 subjects without CKD were followed up for a median of 3.5 years. Of these, 2,243 (31.8%) were hepatitis C positive at the onset of follow-up. In longitudinal analysis, after adjustment for age, baseline eGFR, diabetes, hypertension, aspartate aminotransferase level, and HIV status, the hazard ratio for the development of CKD compared with those who were hepatitis C negative was 0.896 (95% confidence interval, 0.790 to 1.015). Retrospective design, clinical database with missing values, different hepatitis C assays used during the study period, limited data for proteinuria. Our results do not support the hypothesis that infection with hepatitis C virus per se is associated with increased risk of having or developing CKD.

Medical Clinic Characteristics and Access to Behavioral Health Services for Persons With HIV

Medical Clinic Characteristics and Access to Behavioral Health Services for Persons With HIV

Prenatal Syphilis Screening Rates Measured Using Medicaid Claims and Electronic Medical Records

To prevent congenital syphilis, the Centers for Disease Control and Prevention and professional organizations recommend universal prenatal syphilis screening. State-level or larger-scale evaluations of adherence to these guidelines have relied on administrative data. We measured prenatal syphilis screening rates in Indiana women with prenatal Medicaid coverage and also used electronic medical records to examine the completeness of syphilis screening claims in Medicaid administrative data. In statewide Indiana Medicaid claims data, diagnosis and procedure codes were used to identify women who delivered an infant between October 1, 1998, and September 30, 2002. Claims for prenatal (that is, during the 40 weeks before and including the delivery date) syphilis screens, including the "obstetric panel" of tests, and for prenatal visits were extracted. A subset of the study population received prenatal care in a large public hospital and its affiliated clinics served by an electronic medical records system. For these women, claims data were compared with laboratory reports. Among 74,188 women with one delivery in Medicaid claims data, 60% had at least 1 prenatal syphilis screening claim, and 15% had 2 or more. Women with continuous Medicaid enrollment during pregnancy or with at least one prenatal visit claim had higher rates. Among the 3960 women for whom Medicaid claims and laboratory data were available, 49.8% had at least one prenatal syphilis screen in Medicaid claims, but 99.3% had at least one laboratory report of a syphilis screen. Measurements made using Medicaid administrative data appear to substantially underestimate true prenatal syphilis screening rates.

Breastfeeding and Infant Illness in Low-Income, Minority Women: A Prospective Cohort Study of the Dose-Response Relationship

The authors' objective was to determine whether cumulative weekly breastfeeding duration by 13 weeks was associated with infant otitis media, respiratory and gastrointestinal illness, and total illness visits up to 12 months. The authors performed a secondary analysis of data from a randomized clinical trial of low-income, primarily Hispanic and Black women enrolled from 2 medical center affiliated clinics. "Breastfeeding sensitive" (BFS) outpatient and emergency room (ER) visit data for the above illnesses were obtained for 255 mother/infant dyads. Outcome measures were unadjusted and adjusted rates of outpatient and ER visits with sick and BFS diagnoses. The authors found no significant associations between breastfeeding intensity and infant visits for otitis media, respiratory and gastrointestinal illness, or total illness visits. In this low-income, multiethnic sample, breastfeeding intensity was not associated with infant health service use, in contrast to other evidence-based reports. Low exclusive breastfeeding rates and lack of coverage for health visits may be reasons for this finding.