North Carolina Health Research Articles

Saving Lives and Saving Money: The Role of North Carolina Health Departments in Medicaid Managed Care.

A new Medicaid system is emerging in North Carolina in which accountable care organizations will aim to improve both the quality and value of health care. We explore how local health departments can apply their expertise in population health to help achieve these goals.

The value of workforce data in shaping nursing workforce policy: A case study from North Carolina

BackgroundIn 2015, the Institute of Medicine's Committee for Assessing Progress on Implementing the Future of Nursing recommendations noted that little progress has been made in building the data infrastructure needed to support nursing workforce policy. PurposeThis article outlines a case study from North Carolina to demonstrate the value of collecting, analyzing, and disseminating state-level workforce data. MethodsData were derived from licensure renewal information gathered by the North Carolina Board of Nursing and housed at the North Carolina Health Professions Data System at the University of North Carolina at Chapel Hill. DiscussionState-level licensure data can be used to inform discussions about access to care, evaluate progress on increasing the number of baccalaureate nurses, monitor how well the ethnic and racial diversity in the nursing workforce match the population, and investigate the educational and career trajectories of licensed practical nurses and registered nurses. ConclusionAt the core of the IOM's recommendations is an assumption that we will be able to measure progress toward a “Future of Nursing” in which 80% of the nursing workforce has a BSN or higher, the racial and ethnic diversity of the workforce matches that of the population, and nurses currently employed in the workforce are increasing their education levels through lifelong learning. Without data, we will not know how fast we are reaching these goals or even when we have attained them. This article provides concrete examples of how a state can use licensure data to inform nursing workforce policy.

Advancing Professional Development Through Virtual Mentoring.

*PGY1 Pharmacy Practice Resident, University of North Carolina Health Care, Chapel Hill, NC; †Critical Care Pharmacist, Medical Intensive Care Unit/Pulmonary, Assistant Professor (Adjunct), College of Pharmacy, University of Kentucky HealthCare, Lexington, KY. Corresponding author: Timothy D. Lewis, PharmD, University of North Carolina Health Care, 101 Manning Drive, CB #7600, Chapel Hill, NC 27514; phone: 984-974-1701; e-mail: timothy.lewis@unchealth.unc.edu To the Editor: Advances in technology have made it possible to communicate in real time with individuals, regardless of geographic location. With these advances, mentorship has taken on new forms, including virtual mentorship, which allows individuals in different networks to connect instantly. It is logical for pharmacists and trainees to leverage technology and embrace virtual mentorship as a viable mechanism of professional development and networking. Numerous professional organizations, including the American Society of Health-System Pharmacists (ASHP) and the American College of Clinical Pharmacy (ACCP), offer opportunities for students and residents to connect with pharmacists across the country and electronically establish a mentoring relationship. It is easy to see the potential value this type of program offers to students and new practitioners who are interested in pursuing residency, developing their professional practice, or searching for other postgraduate opportunities as positions become increasingly competitive. The electronic mentor match programs allow students and new practitioners to create a profile, then search and request a specific mentor based on their professional interests. Establishing a mentoring relationship with a stranger may feel uncomfortable for some, but the potential benefit is worth any transient uneasiness. One of the most valuable services a mentor can provide to a student or new practitioner is a different perspective. Having a mentor in a different region, institution, or area of practice encourages a mentee to consider alternative viewpoints and ways to accomplish tasks. For example, whereas one institution may teach a certain format for presenting a journal club, a mentor outside this environment may have a different method that offers the mentee an alternative way to convey the information. A different set of eyes on a curriculum vitae (CV) can give insight into whether the CV is descriptive enough for individuals outside the school of pharmacy or health care facility’s local faculty and preceptors who are familiar with the mentee’s activities. In addition, a mentor who is external to the mentee’s sphere of influence can be a tremendous resource for expanding the mentee’s professional network. This connection could prove invaluable as the mentee applies for residency or employment, becomes involved in professional committees, or seeks to implement change in their school or workplace. Similar to many other endeavors, the success of a mentoring relationship is contingent on a strong foundation being established on a clear purpose. The mentee should allocate time to reflect on what he or she would benefit from at that specific point in their career and identify genuine needs, which will fuel conversations with mentors. One of the most helpful conversations in establishing purpose is to discuss goals for the mentorship relationship. Although they will vary for each pair, common goals include the following: expand professional network, take steps to become a more competitive residency or employment candidate, and learn ways to prepare for residency applications and/or interviews. It is wise to make these goals as specific as possible, however, they should not serve as a checklist of tasks to complete. Rather, these goals should be expanded upon throughout the relationship in order to further strengthen the mentorship and benefits gained from the experience. The mentor may assist in the creation of additional goals and topics to discuss based on their understanding of the mentee’s shortand long-term goals. Mentorship is most often a process that continues over an extended period of time. By exchanging dialogue multiple times on important topics, the pair can ensure that a well-rounded and thoughtful discussion takes place. The most vital action a mentee can take is to ensure regular communication with the mentor. Taking initiative and being proactive in maintaining the connection is a sign to the mentor that the mentee seeks to optimize the relationship. Once

Does North Carolina's Health Care Workforce Reflect the Diversity of the State's Population?

Does North Carolina's Health Care Workforce Reflect the Diversity of the State's Population?

Prevalence of pelvic floor disorders in women with suspected gynecological malignancy: a survey-based study.

Understanding of pelvic floor disorders among women with gynecological cancer is limited. The objective of this study was to describe the prevalence of pelvic floor disorders in women with suspected gynecological malignancy before surgery. A cross-sectional study was performed of women aged ≥18 with a suspected gynecological malignancy who enrolled in the University of North Carolina Health Registry/Cancer Survivorship Cohort (HR/CSC) from August 2012 to June 2013. Demographics were obtained from the HR/CSC self-reported data; clinical data were abstracted from the electronic medical record. Subjects completed validated questionnaires (Rotterdam Symptom Checklist and the International Consultation on Incontinence Questionnaire-Female Lower Urinary Tract Symptoms) to assess bladder and bowel function. Among 186 women scheduled for surgery for gynecological malignancy, 152 (82%) completed baseline assessments before surgery. Mean age was 58.1 ± 13.3years, and mean BMI was 33.6 ± 8.8kg/m(2). The majority of subjects had uterine cancer (61.8%), followed by ovarian (17.1%) and cervical (11.1%). At baseline, the rate of urinary incontinence (UI) was 40.9%. A third of subjects reported stress UI, and one quarter reported urge UI. The overall rate of fecal incontinence was 3.9%, abdominal pain was 47.4%, constipation was 37.7%, and diarrhea was 20.1%. When comparing cancer types, there were no differences in pelvic floor symptoms. Pelvic floor disorders are common in women with suspected gynecological malignancy at baseline before surgery. Recognizing pelvic floor disorders in the preoperative setting will allow for more individualized, comprehensive care for these women.

Associations Between Practice Characteristics and Demonstration of Stage 1 Meaningful Use for the Electronic Health Record Incentive Program

The Medicare and Medicaid meaningful use (MU) incentive programs promote adoption and "meaningful use" of certified electronic health records among hospitals and eligible providers in outpatient settings, with a goal of improving the quality of patient care. Despite the potential importance of MU for providers and patients, little is currently known about the practice characteristics that facilitate providers' demonstration of MU. This study examined whether selected practice characteristics were associated with providers' meeting Stage 1 MU objectives at the end of 1 year in a single large North Carolina integrated delivery system. Our retrospective database analysis included all 702 eligible providers from 54 ambulatory care practices on the main campus of the University of North Carolina Health Care System. We assessed associations between providers' ability to meet Stage 1 MU objectives as of December 2012 and the following practice characteristics: practice specialty, size, and mix of Medicare- and Medicaid-eligible providers. The following practice characteristics were associated with providers' ability to meet MU objectives: primary care practices as compared to specialty practices (odds ratio [OR] = 2.49; 95% CI, 1.11-5.62), small practices as compared to medium-sized practices (OR = 0.29; 95% CI, 0.09-0.89), and the presence of only Medicare-eligible providers in the practice as compared to the presence of only Medicaid-eligible providers (OR = 6.48; 95% Cl, 1.08-38.97). Because our sample was drawn from a single integrated delivery system, results may not be generalizable to all ambulatory practice settings. This study suggests that larger practices, primary care practices, and practices comprised of Medicare-eligible providers may be better able to meet MU objectives. Further research is needed to evaluate strategies that account for practice characteristics and other contextual factors in the MU implementation process.

Adoption of Evidence-Based Interventions in Local Health Departments: "1-2-3 Pap NC".

Descriptions of barriers and facilitators to adoption of evidence-based interventions in local health departments (LHDs) are limited. This study was conducted by the North Carolina Public Health Practice-Based Research Network to identify factors associated with adoption of an evidence-based human papillomavirus video intervention, "1-2-3 Pap NC," in North Carolina LHDs. A sequential mixed-method study design was used. Data from the 2013 National Profile of Local Health Departments were used to test associations between LHD characteristics and adoption of the intervention. Qualitative, key stakeholder interviews with LHD directors provided the context for quantitative data. Data collection and analysis continued from March 3, 2014, to September 15, 2014. Overall, 28% of North Carolina health jurisdictions (33 of 100 counties) implemented the intervention. Of the three channels used to deliver the intervention to clients, most LHDs opted to show the video in the exam room (42%), followed by website/other social media (36%) and video loop in the lobby/waiting room (22%). In logistic regression, gender of the director (female) was significantly and positively associated with adoption of the intervention (AOR=4.44, p<0.05). Being a first-time director was marginally significant (AOR=0.28, p=0.074), suggesting first-time directors were less likely to adopt. Qualitative results suggested that aspects of communication (awareness and positive attitudes) and agency directors' evaluation of resources, balanced against intervention complexity and flexibility, competing priorities, and mandates, influenced adoption. Adoption of evidence-based interventions by LHDs is critical to improve population health. Practice-based research can contribute to understanding facilitators and modifying barriers to this process.

Treatment decisional regret among men with prostate cancer: Racial differences and influential factors in the North Carolina Health Access and Prostate Cancer Treatment Project (HCaP-NC).

It has been demonstrated that treatment decisional regret affects quality of life in patients with prostate cancer (CaP); however, there are limited studies that identify factors associated with treatment decisional regret, particularly within a racially diverse patient population that has extended follow-up. Logistic regression analysis was used to determine associations between decisional regret and potential predictors in a population-based cohort of 348 African American men and 446 Caucasian American men approximately 3 years after CaP diagnosis. Of 794 research participants, 12% experienced treatment decisional regret. Decisional regret was associated with androgen-deprivation therapy (odds ratio [OR], 2.1; 95% confidence interval [CI], 1.1-4.0), recent urinary bother (OR, 3.4; 95% CI, 1.6-7.3), satisfaction with understanding potential treatment side effects (very unsatisfied: OR, 13.3; 95% CI, 5.5-32.2; somewhat unsatisfied: OR, 5.0; 95% CI, 2.3-11.2; neutral: OR, 3.8; 95% CI, 1.9-7.6), and CaP treatment effect on the spousal relationship (very affected: OR, 3.9; 95% CI, 2.0-7.6; somewhat affected: OR, 3.1; 95% CI, 1.4-7.3; neutral: OR, 2.4; 95% CI, 1.9-7.6). Younger African Americans were more likely to experience regret than older African Americans (OR, 3.0; 95% CI, 1.1-8.1), and older African Americans were less likely to experience regret than older Caucasian Americans (OR, 0.2; 95% CI, 0.1-0.7). Treatment decisional regret remains an important issue in CaP survivors beyond initial treatment. Potential interventions should involve younger African Americans and patient spouses. Increased regret may reflect the unexpected influence of treatment side effects on the patient's everyday life; helping the patient relate potential side effects to his individual situation could improve patient satisfaction.

Oral Health Care Access for Children in North Carolina: Profile of General and Pediatric Dentists

General practicing dentists (GPs) and pediatric dentists are recognized as primary dental care providers for children. The purpose of this study was to assess the changes from 1990 to 2010 in demographics and practice distribution of these two groups in North Carolina (NC). Dental practitioner and practice data were obtained from the North Carolina Health Professions Data System and county population data from the North Carolina State Data Center. Provider location/patient ratios were higher in 2010 than 1990 and were consistently higher in metropolitan counties than rural counties. The mean age of GPs increased each decade and in 2010 was higher in rural counties than metropolitan counties (P<0.001). From 1990 to 2010, an increase in the gender and racial diversity of GPs and pediatric dentists occurred in NC (P< 0.002). These changes were almost exclusively in metropolitan counties. This trend was most pronounced in pediatric dentistry. Although the number of primary care providers and their location to population ratios increased from 1990 to 2010 in NC, the disparity between rural and metropolitan counties appears to be increasing. The aging dental workforce, especially in rural counties, is a major concern and could exacerbate future workforce balance. The dental health of residents, particularly children, in NC, and possibly other states experiencing similar trends, may be negatively impacted by the disparity in provider ratios. This issue could be exacerbated if the incidence of dental caries increases in children.

The University of North Carolina's Health Care Pharmacy Assistance Progam.

UNC Health Care has a Pharmacy Assistance Program (PAP) that provides financial assistance to uninsured patients in North Carolina who need prescription medications. Despite significant investment in the program, little is known about the patients accessing it or the specific health care services they use. Our objectives were to describe the PAP population, to examine their use of prescription medications and health services, and to characterize changes in prescription medication use and expenditures from 2009 through 2011. We used a repeated cross-sectional study design, merging prescription claims with health records from Carolina Data Warehouse for Health, to measure use of prescription medications and use of inpatient, outpatient, and emergency department care by PAP participants. Prescription claims were grouped into therapeutic categories. We generated descriptive statistics for key variables to examine health service utilization from 2009 through 2011. From 2009 through 2011, PAP served 7,180 patients from 81 counties in North Carolina. PAP users received a mean of 23 prescriptions, at an average cost of $754 per recipient per year. An average of $2.93 million per year was spent on the program, with an 8% rise in spending from 2009 to 2011. Inpatient care and emergency department care were utilized by 30% and 31% of PAP users, respectively, and there was minimal change in these rates over 3 years. Data were limited to medications dispensed through PAP and to health services provided by UNC Health Care. With the state's decision to not expand Medicaid, PAP will continue to be an important resource for North Carolina's low income citizens.

Patterns of medication adherence and health care utilization among patients with chronic disease who were enrolled in a pharmacy assistance program.

Poor medication adherence due to high drug costs is a barrier to optimal health outcomes among low-income uninsured patients with chronic conditions. Charitable pharmacy assistance programs provide medications to such patients, but little is known about the utilization patterns of program participants. We used a retrospective cohort design to investigate 6-month outcomes for participants in the University of North Carolina (UNC) Health Care Pharmacy Assistance Program (PAP) who received medications indicated for hypertension, diabetes, and/or hyperlipidemia from 2009 through 2011. Logistic regression was used to analyze predictors of medication adherence and to evaluate the association between adherence and use of emergency and inpatient care. The 3 study cohorts included 866 patients receiving antihypertensive agents, 265 patients receiving oral glucose-lowering agents, and 455 patients receiving statins. When assessed 6 months after program enrollment, 52%, 45%, and 38% of patients in these 3 groups, respectively, were at least 80% adherent to treatment. Adherent patients in all cohorts had lower odds of requiring inpatient or emergency department care, but the decrease was only statistically significant among those taking antihypertensive agents (odds ratio for hospitalization = 0.58; 95% confidence interval, 0.39-0.87). Selection bias and inability to capture utilization data from sources other than UNC Health Care may have biased results. Approximately 50% of PAP participants were adherent to chronic disease medications. Adherence to such therapies among patients who are receiving financial assistance with medications may reduce their need for costly health care services. Future research should assess the long-term ability of pharmacy assistance programs to promote medication adherence and should examine alternative strategies for improving adherence and health outcomes among low-income uninsured patients.

Health care providers’ use of a drug information service for pregnancy-related inquiries

ObjectivesTo characterize pregnancy and lactation-related medication inquiries to a drug information center to identify classes of medications of most concern to providers. A secondary objective was to identify any trends in provider inquiries over the study period. DesignA retrospective descriptive study of pregnancy and lactation-related inquiries to the University of North Carolina Health Care System Drug Information Center database between January 2001 and December 2010. SettingUniversity of North Carolina Health Care System Drug Information Center. InterventionProvider inquiries and responses were extracted and characterized by indication for treatment and reason for inquiry. Comparison of the first and second 5-year periods was performed to delineate trends. Descriptive statistics, Fisher's Exact and χ2 tests were used for analysis. Main outcome measuresInquiry origin, time, and subject. Results433 inquiries were retrieved over the study period from physicians (50%), pharmacists (21%), and nurses (18%). Inquiries were most often made during the antepartum period (34%), followed by the postpartum (28%) and preconception (22%) periods. The most frequent indications for inquiry were psychiatry (15%) and infectious diseases (14%), which remained constant throughout the study period. Safety was the most common reason for inquiry (52%). The responses provided to callers were limited due to lack of information availability 37% of the time. ConclusionPsychiatry and infectious disease-related indications are the most frequent subjects of provider inquiry regarding medication use in pregnancy. Rates of inquiry remained constant throughout the past decade in most therapeutic areas. These findings are consistent with previous observations in other developed countries and suggest high-yield areas for pharmacist education.

Use of administrative and electronic health record data for development of automated algorithms for childhood diabetes case ascertainment and type classification: the SEARCH for Diabetes in Youth Study.

The performance of automated algorithms for childhood diabetes case ascertainment and type classification may differ by demographic characteristics. This study evaluated the potential of administrative and electronic health record (EHR) data from a large academic care delivery system to conduct diabetes case ascertainment in youth according to type, age, and race/ethnicity. Of 57 767 children aged <20 yr as of 31 December 2011 seen at University of North Carolina Health Care System in 2011 were included. Using an initial algorithm including billing data, patient problem lists, laboratory test results, and diabetes related medications between 1 July 2008 and 31 December 2011, presumptive cases were identified and validated by chart review. More refined algorithms were evaluated by type (type 1 vs. type 2), age (<10 vs. ≥10 yr) and race/ethnicity (non-Hispanic White vs. 'other'). Sensitivity, specificity, and positive predictive value were calculated and compared. The best algorithm for ascertainment of overall diabetes cases was billing data. The best type 1 algorithm was the ratio of the number of type 1 billing codes to the sum of type 1 and type 2 billing codes ≥0.5. A useful algorithm to ascertain youth with type 2 diabetes with 'other' race/ethnicity was identified. Considerable age and racial/ethnic differences were present in type-non-specific and type 2 algorithms. Administrative and EHR data may be used to identify cases of childhood diabetes (any type), and to identify type 1 cases. The performance of type 2 case ascertainment algorithms differed substantially by race/ethnicity.

Meeting North Carolina's Health Care Needs Through Interprofessional Education and Practice

To meet the future health care needs of North Carolinians, health professions students must learn how to work together as part of an interdisciplinary team. This commentary describes how interprofessional education and team-based care can decrease the number of adverse events, improve health care delivery, and support consistent outcomes.

Improving Public Health Preparedness Capacity Measurement: Development of the Local Health Department Preparedness Capacities Assessment Survey

To address limitations in measuring the preparedness capacities of health departments, we developed and tested the Local Health Department Preparedness Capacities Assessment Survey (PCAS). Preexisting instruments and a modified 4-cycle Delphi panel process were used to select instrument items. Pilot test data were analyzed using exploratory factor analysis. Kappa statistics were calculated to examine rater agreement within items. The final instrument was fielded with 85 North Carolina health departments and a national matched comparison group of 248 health departments. Factor analysis identified 8 initial domains: communications, surveillance and investigation, plans and protocols, workforce and volunteers, legal infrastructure, incident command, exercises and events, and corrective action. Kappa statistics and z scores indicated substantial to moderate agreement among respondents in 7 domains. Cronbach α coefficients ranged from 0.605 for legal infrastructure to 0.929 for corrective action. Mean scores and standard deviations were also calculated for each domain and ranged from 0.41 to 0.72, indicating sufficient variation in the sample to detect changes over time. The PCAS is a useful tool to determine how well health departments are performing on preparedness measures and identify opportunities for future preparedness improvements. Future survey implementation will incorporate recent Centers for Disease Control and Prevention's Public Health Preparedness Capabilities: National Standards for State and Local Planning.

Understanding and Preventing Transmission of Healthcare-Associated Pathogens Due to the Contaminated Hospital Environment

Affiliation: 1. Department of Hospital Epidemiology, University of North Carolina Health Care, Chapel Hill, North Carolina; and Division of Infectious Diseases, University of North Carolina School of Medicine, Chapel Hill, North Carolina. Received February 5, 2013; accepted February 10, 2013; electronically published April 9, 2013. 2013 by The Society for Healthcare Epidemiology of America. All rights reserved. 0899-823X/2013/3405-0001$15.00. DOI: 10.1086/670223 More than 20 years ago, Dr Robert Weinstein estimated that the source of pathogens causing a healthcare-associated infection in the intensive care unit was as follows: patients’ endogenous flora, 40%–60%; cross infection via the hands of personnel, 20%–40%; antibiotic-driven changes in flora, 20%–25%; and other (including contamination of the environment), 20%. Over the past decade, substantial scientific evidence has accumulated indicating that contamination of environmental surfaces in hospital rooms plays an important role in the transmission of several key healthcare-associated pathogens, including methicillin-resistant Staphylococcus aureus (MRSA), vancomycin-resistant Enterococcus (VRE), Clostridium difficile, Acinetobacter, and norovirus (Table 1). All of these pathogens have been demonstrated to persist in the environment for hours to days (and, in some cases, months), to frequently contaminate the surface environment and medical equipment in the rooms of colonized or infected patients, to transiently colonize the hands of healthcare personnel (HCP), to be associated with person-to-person transmission via the hands of HCP, and to cause outbreaks in which environmental transmission was deemed to play a role. Furthermore, hospitalization in a room in which the previous patient had been colonized or infected with MRSA, VRE, C. difficile, multidrug-resistant Acinetobacter, or multidrugresistant Pseudomonas has been shown to be a risk factor for colonization or infection with the same pathogen for the next patient admitted to the room. Although pathogen transfer from a colonized or infected patient to a susceptible patient most commonly occurs via the hands of HCP, contaminated hospital surfaces and medical equipment (and, less commonly, water and air) can be directly or indirectly involved in the transmission pathways. These transmission pathways and methods to interrupt transmission have been diagramed. HCP have frequent contact with environmental surfaces in patients’ rooms, providing ample opportunity for contamination of gloves and/or hands. Importantly, hand contamination with MRSA has been demonstrated to occur with equal frequency when HCP have direct contact with a colonized or infected patient or through touching only contaminated surfaces. The most important risk factor for HCP hand and glove contamination with multidrug-resistant pathogens has been demonstrated to be positive environmental cultures. To decrease the frequency and level of contamination of environmental surfaces and medical equipment in hospital rooms, routine and terminal disinfection with a germicide has been recommended. Unfortunately, routine and terminal cleaning of room surfaces by environmental services personnel and medical equipment by nursing staff is frequently inadequate. Multiple studies have demonstrated that less than 50% of hospital room surfaces are adequately cleaned and disinfected when chemical germicides are used. Similarly, inadequate cleaning of portable medical equipment by nursing staff has also been demonstrated. The implementation of enhanced education, checklists, and methods to measure the effectiveness of room cleaning (eg, use of fluorescent dye) with immediate feedback to environmental services personnel has been found to improve cleaning and lead to a reduction in healthcare-associated infections. No-touch methods (eg, ultraviolet C [UV-C] light and hydrogen peroxide systems) have been developed to improve terminal room disinfection. UV-C light has been demonstrated to decrease the level of C. difficile spores on contaminated surfaces in patient rooms, while hydrogen peroxide systems used in rooms of patients colonized or infected with a multidrug-resistant organism has been shown to decrease the risk of a subsequent patient admitted to the room developing infection or colonization with any multidrug-resistant organism. This special issue of Infection Control and Hospital Epidemiology is focused on the epidemiology and prevention of healthcare-associated infections associated with the hospital environment and includes 21 papers. Although space precludes describing each individual paper here, this issue details

North Carolina Health Professionals’ Communication with Adolescents About Smoking

The middle school and high school years are a time when adolescents are at high risk for initiation of smoking and progression to nicotine addiction. This research examines the prevalence with which North Carolina students receive smoking-related communication from health professionals and how such communication relates to smoking behaviors. Data are from the 2009 North Carolina Youth Tobacco Survey (NCYTS), a biennial public and charter school-based survey of students in grades 6-12. The overall response rate was 78.2% (n = 3,301) for high school students and 79.2% (n = 3,805) for middle school students. Weighted multivariable logistic regression models were used to identify variables that are significantly related to health professionals' communication about smoking and/or advice against smoking. A majority of respondents reported that they had not been asked about or advised against smoking. Middle school and high school students who had tried to quit smoking in the past 12 months were significantly more likely to report having been asked about smoking (OR = 2.00 [95% CI, 1.23-3.28], OR = 1.96 [95% CI,1.44-2.661, respectively) or advised against smoking (OR = 2.25 [95% CI,1.13-4.50], OR = 2.02 [95% CI, 1.31-3.14], respectively) than were students who had not tried to quit. This research is based on a cross-sectional survey and is subject to the honesty of the participants. Results may not generalize beyond public and charter school students in North Carolina. North Carolina health professionals need to increase communication with adolescents in order to sustain the historically low rates of smoking in this age group.

Racial disparities in prostate cancer care: Is adherence to National Comprehensive Cancer Network guidelines good enough for our patients?

Racial disparities in prostate cancer care: Is adherence to National Comprehensive Cancer Network guidelines good enough for our patients?

Help‐Seeking for Incontinence by Individuals with Heart Failure

To the Editor: Urinary incontinence (UI) and heart failure (HF) are both prevalent conditions having significant impact on quality of life (1). Little information is available about HF patients seeking help for UI despite evidence that both conditions can be managed through intervention from a health care worker (1). The purpose of this study was to identify factors associated with help-seeking for UI in adults with HF. Secondary analyses were conducted using a dataset from a survey exploring prevalence and correlates of UI and other urinary symptoms conducted with HF patients from 2005 to 2007 (2). Participants were recruited from one in-patient HF unit and two ambulatory HF clinics. The study was approved by the University of North Carolina, Presbyterian, and Carolina Health Systems Institutional Review Boards. An affirmative response to a survey question, “Have you reported your urinary leakage or overactive bladder to your doctor or nurse?” defined help-seeking behavior for these analyses. The 7-item Incontinence Impact Questionnaire (IIQ) and the 6-item Urogenital Distress Inventory (UDI) were used to evaluate the impact of incontinence on quality of life and assess bother experienced from symptoms, respectively. Statistical analyses were performed using SAS, version 9.2 (SAS Institute, Inc., Cary, NC). One hundred and thirty-four patients (45%) in this sample reported UI. Proportionally more women (p<.001), out-patients (p<.001), people who self-reported poor health (p=.002), and people reporting more than two urinary symptoms (p<.001) also reported being incontinent. Of the 134 incontinent HF patients, only forty-five (34%) reported UI to a health care professional. Twenty-two percent of incontinent respondents reported they had talked to other people about incontinence, 13% reported they had asked for more information about incontinence, and 30% had read articles about UI in popular magazines. Each of these variables was significantly associated with help-seeking (χ2 = (1, N=134) = 18.3, p<.001; χ2 = (1, N=134) = 20.1, p<.001; χ2 = (1, N=134) = 5.3, p=.022, respectively). The majority of respondents (69%) responded they were interested in learning more about urinary leakage. Logistic regression was used for multivariate analyses. One unit increase of UDI-6 was associated with 17% increase of the likelihood of seeking help (β = .172, se=.059, p =.004); Odds Ratio 1.2 (95% CI 1.1 to 1.3). There was significant interaction between age and gender on help-seeking behavior (p=.027) (see Figure 1). Men younger than 50 years of age were more likely to seek help for incontinence than women (67% versus 9%, p=.027). After the age of 50, the proportion of men and women seeking help was similar (31% versus 36%, p= .600). Figure 1 Help-seeking for UI by Sex and Age Group UDI-6 score was associated with help-seeking, which suggests that bothersomeness and impact on quality of life may be important factors in the decision to seek help. Despite the low proportion of patients reporting UI, many engaged in behaviors to get information about UI or stated they would like to learn more about UI. These responses indicate HF patients have interest in knowing more about UI, perhaps to decrease the impact of UI on their lives. Our findings also indicate that UI may be more bothersome to younger men than younger women. Older men had a rate similar to older women in seeking help. It may be that with age people learn to adjust to being incontinent or consider it a part of growing older. Other researchers found a similar relationship between age and sex and help-seeking (3). Li et al. (2007) suggested that younger women may be less likely to seek help due to the availability of coping strategies, such as pads designed for the containment of urine or menstrual flow. Convenient methods to manage UI may be less known, less available, or less acceptable to younger men, which may promote early help-seeking from health care providers. Similarly, women may be more likely to view UI as a personal problem and therefore be less likely to seek help, while men may seek help, fearing that a serious medical problem may underlie their UI (3). It is widely believed that UI is a normal part of the aging process (4). When this belief is held by both health care professionals and patients, both may be unlikely to discuss the problem. Evidence suggests young women (from 45 to 54 years old) would seek help if they believed UI was related to a health condition (5). Screening for UI and its impact on quality of life at hospital admission, during hospitalization, and at clinical visits for all HF patients could begin the processes of education and intervening to improve continence and manage urinary symptoms.

The State of Racial/Ethnic Diversity in North Carolina’s Health Workforce

Increasing the racial and ethnic diversity of the health care workforce is vital to achieving accessible, equitable health care. This study provides baseline data on the diversity of health care practitioners in North Carolina compared with the diversity of the state's population. We analyzed North Carolina health workforce diversity using licensure data from the respective state boards of selected professions from 1994-2009; the data are stored in the North Carolina Health Professions Data System. North Carolina's health care practitioners are less diverse than is the state's population as a whole; only 17% of the practitioners are nonwhite, compared with 33% of the state's population. Levels of diversity vary among the professions, which are diversifying slowly over time. Primary care physicians are diversifying more rapidly than are other types of practitioners; the percentage who are nonwhite increased by 14 percentage points between 1994 and 2009, a period during which 1,630 nonwhite practitioners were added to their ranks. The percentage of licensed practical nurses who are nonwhite increased by 7 percentage points over the same period with the addition of 1,542 nonwhite practitioners to their ranks. Nonwhite health professionals cluster regionally throughout the state, and 79% of them practice in metropolitan counties. This study reports on only a selected number of health professions and utilizes race/ethnicity data that were self-reported by practitioners. Tracking the diversity among North Carolina's health care practitioners provides baseline data that will facilitate future research on barriers to health workforce entry, allow assessment of diversity programs, and be useful in addressing racial and ethnic health disparities.