Medical School Experiences Associated with Change in Implicit Racial Bias Among 3547 Students: A Medical Student CHANGES Study Report

BACKGROUND

Physician implicit (unconscious, automatic) bias has been shown to contribute to racial disparities in medical care. The impact of medical education on implicit racial bias is unknown.

OBJECTIVE

To examine the association between change in student implicit racial bias towards African Americans and student reports on their experiences with 1) formal curricula related to disparities in health and health care, cultural competence, and/or minority health; 2) informal curricula including racial climate and role model behavior; and 3) the amount and favorability of interracial contact during school.

DESIGN

Prospective observational study involving Web-based questionnaires administered during first (2010) and last (2014) semesters of medical school.

PARTICIPANTS

A total of 3547 students from a stratified random sample of 49 U.S. medical schools.

MAIN OUTCOME(S) AND MEASURE(S)

Change in implicit racial attitudes as assessed by the Black-White Implicit Association Test administered during the first semester and again during the last semester of medical school.

KEY RESULTS

In multivariable modeling, having completed the Black-White Implicit Association Test during medical school remained a statistically significant predictor of decreased implicit racial bias (−5.34, p ≤ 0.001: mixed effects regression with random intercept across schools). Students'' self-assessed skills regarding providing care to African American patients had a borderline association with decreased implicit racial bias (−2.18, p = 0.056). Having heard negative comments from attending physicians or residents about African American patients (3.17, p = 0.026) and having had unfavorable vs. very favorable contact with African American physicians (18.79, p = 0.003) were statistically significant predictors of increased implicit racial bias.

CONCLUSIONS

Medical school experiences in all three domains were independently associated with change in student implicit racial attitudes. These findings are notable given that even small differences in implicit racial attitudes have been shown to affect behavior and that implicit attitudes are developed over a long period of repeated exposure and are difficult to change.KEY WORDS: disparities, medical education, implicit racial bias, physician–patient relations, attitude of health personnel     

The Effect of Patient Race on Total Joint Replacement Recommendations and Utilization in the Orthopedic Setting

BACKGROUND

The extent to which treatment recommendations in the orthopedic setting contribute to well-established racial disparities in the utilization of total joint replacement (TJR) in the treatment of advanced knee/hip osteoarthritis has not been explored.

OBJECTIVE

To examine whether orthopedic surgeons are less likely to recommend TJR to African-American patients compared to white patients with similar clinical indications, and whether there are racial differences in the receipt of TJR within six months of study enrollment.

DESIGN

Prospective, observational study.

PARTICIPANTS

African-American (AA; n = 120) and white (n = 337) patients seeking treatment for knee or hip osteoarthritis in Veterans Affairs orthopedic clinics.

MAIN MEASURES

Patients completed surveys that assessed socio-demographic and clinical variables that could influence osteoarthritis treatment. Orthopedic surgeons’ notes were reviewed to determine whether patients had been recommended for TJR and whether they underwent the procedure within 6 months of study enrollment.

RESULTS

Rate of TJR recommendation was 19.5%. Odds of receiving a TJR recommendation were lower for AA than white patients of similar age and disease severity (OR = 0.46, 95% CI = 0.26–0.83; P = 0.01). However, this difference was not significant after adjusting for patient preference for TJR (OR = 0.69, 95% CI = 0.36–1.31, P = 0.25). Overall, 10.3% of patients underwent TJR within 6 months. TJR was less likely for AA patients than for white patients of similar age and disease severity (OR = 0.41, 95% CI = 0.16–1.05, P = 0.06), but this difference was reduced after adjusting for whether patients had received a recommendation for the procedure at the index visit (OR = 0.57, 95% CI = 0.21–1.54, P = 0.27).

CONCLUSIONS

In this study, race differences in patient preferences for TJR appeared to underlie race differences in TJR recommendations, which led to race differences in utilization of the procedure. Our findings suggest that patient treatment preferences play an important role in racial disparities in TJR utilization in the orthopedic setting.KEY WORDS: healthcare disparities, total joint replacement, orthopedic surgery, osteoarthritis, patient preference     

Accuracy of Race,Ethnicity, and Language Preference in an Electronic Health Record

BACKGROUND

Collection of data on race, ethnicity, and language preference is required as part of the “meaningful use” of electronic health records (EHRs). These data serve as a foundation for interventions to reduce health disparities.

OBJECTIVE

Our aim was to compare the accuracy of EHR-recorded data on race, ethnicity, and language preference to that reported directly by patients.

DESIGN/SUBJECTS/MAIN MEASURES

Data collected as part of a tobacco cessation intervention for minority and low-income smokers across a network of 13 primary care clinics (n = 569).

KEY RESULTS

Patients were more likely to self-report Hispanic ethnicity (19.6 % vs. 16.6 %, p < 0.001) and African American race (27.0 % vs. 20.4 %, p < 0.001) than was reported in the EHR. Conversely, patients were less likely to complete the survey in Spanish than the language preference noted in the EHR suggested (5.1 % vs. 6.3 %, p < 0.001). Thirty percent of whites self-reported identification with at least one other racial or ethnic group, as did 37.0 % of Hispanics, and 41.0 % of African Americans. Over one-third of EHR-documented Spanish speakers elected to take the survey in English. One-fifth of individuals who took the survey in Spanish were recorded in the EHR as English-speaking.

CONCLUSION

We demonstrate important inaccuracies and the need for better processes to document race/ ethnicity and language preference in EHRs.KEY WORDS: disparities, race, ethnicity, health information technology     

The Relationship Between Food Insecurity and Depression,Diabetes Distress and Medication Adherence Among Low-Income Patients with Poorly-Controlled Diabetes

BACKGROUND

Food insecurity— lack of dependable access to adequate food—may play a role in poor diabetes control.

OBJECTIVE

We aimed to determine the relationship between food security status and depression, diabetes distress, medication adherence and glycemic control.

DESIGN

Secondary analysis of baseline data from Peer Support for Achieving Independence in Diabetes, a randomized controlled trial that enrolled patients from November 2011 to October 2013.

PARTICIPANTS

Participants had poorly controlled type 2 diabetes (A1c ≥ 8.0 % on eligibility screen), household income < 250 % of the federal poverty level, were 30–70 years old, and were recruited from a large public hospital, a VA medical center and a community-health center in King County, Washington.

MAIN MEASURES

We measured food insecurity determined by the Department of Agriculture’s 6-Item Food Security Module. Depression, diabetes distress and medication adherence measured by PHQ-8, Diabetes Distress Scale and Morisky Medication Adherence Scale, respectively. Diet was assessed through Summary of Diabetes Self-Care Activities and Starting the Conversation tool. Incidence of hypoglycemic episodes was by patient report. Glycemic control was assessed with glycosylated hemoglobin (A1c) values from fingerstick blood sample.

KEY RESULTS

The prevalence of food insecurity was 47.4 %. Chi-square tests revealed participants with food insecurity were more likely to be depressed (40.7 % vs. 15.4 %, p < 0.001), report diabetes distress (55.2 % vs. 33.8 %, p < 0.001) and have low medication adherence (52.9 % vs. 37.2 %, p = 0.02). Based on linear regression modeling, those with food insecurity had significantly higher mean A1c levels (β = 0.51; p = 0.02) after adjusting for sex, age, race/ethnicity, language, education, marital status, BMI, insulin use, depression, diabetes distress and low medication adherence.

CONCLUSIONS

Almost half of participants had food insecurity. Food insecurity was associated with depression, diabetes distress, low medication adherence and worse glycemic control. Even with adjustment, people with food insecurity had higher mean A1c levels than their food-secure counterparts, suggesting there may be other mediating factors, such as diet, that explain the relationship between food security status and diabetes control.KEY WORDS: food insecurity, diabetes, glycemic control     

Asking the Patient About Patient-Centered Medical Homes: A Qualitative Analysis

Background

What patients perceive and experience within a patient-centered medical home (PCMH) is an understudied area, and to date, the patient perspective has not been an integral component of existing PCMH measurement standards. However, upcoming guidelines necessitate the use of patient-reported experiences and satisfaction in evaluations of practice and provider performance.

Objective

To characterize patients’ experiences with care after PCMH adoption and their understanding and perceptions of the PCMH model and its key components, and to compare responses by degree of practice-level PCMH adoption and patient race/ethnicity.

Design

Qualitative study.

Participants

Adult patients with diabetes and/or hypertension (n = 48).

Approach

We surveyed and ranked all PCMH adult primary care practices affiliated with one academic medical center with at least three providers (n = 23), using an instrument quantifying the degree of PCMH adoption. We purposively sampled minority and non-minority patients from the four highest-ranked and four lowest-ranked PCMH-adopting practices to determine whether responses varied by degree of PCMH adoption or patient race/ethnicity. We conducted semi-structured telephone interviews with patients about their experiences with care and their perceptions and understanding of key PCMH domains. Interviews were recorded, transcribed, and imported into NVivo 10 for coding and analysis, using a modified grounded theory approach.

Key Results

We found that patients uniformly lacked awareness of the PCMH concept, and the vast majority perceived no PCMH-related structural changes, regardless of the degree of practice-reported PCMH adoption or the patient''s race/ethnicity. Despite this lack of awareness, patients overwhelmingly reported positive relationships with their provider and positive overall experiences.

Conclusions

As we continue to redesign primary care delivery with an emphasis on patient experience measures as performance metrics, we need to better understand what, if any, aspects of practice structure relate to patient experience and satisfaction with care.KEY WORDS: Patient-centered care, Primary care redesign, Health care delivery, Health services research, Health policy     

Patients Report Better Satisfaction with Part-Time Primary Care Physicians,Despite Less Continuity of Care and Access

BACKGROUND

The growing number of primary care physicians (PCPs) reducing their clinical work hours has raised concerns about meeting the future demand for services and fulfilling the continuity and access mandates for patient-centered care. However, the patient’s experience of care with part-time physicians is relatively unknown, and may be mediated by continuity and access to care outcomes.

OBJECTIVE

We aimed to examine the relationships between a physicians’ clinical full-time equivalent (FTE), continuity of care, access to care, and patient satisfaction with the physician.

DESIGN

We used a multi-level structural equation estimation, with continuity and access modeled as mediators, for a cross-section in 2010.

PARTICIPANTS

The study included family medicine (n = 104) and internal medicine (n = 101) physicians in a multi-specialty group practice, along with their patient satisfaction survey responses (n = 12,688).

MAIN MEASURES

Physician level FTE, continuity of care received by patients, continuity of care provided by physician, and a Press Ganey patient satisfaction with the physician score, on a 0–100 % scale, were measured. Access to care was measured as days to the third next-available appointment.

KEY RESULTS

Physician FTE was directly associated with better continuity of care received (0.172 % per FTE, p < 0.001), better continuity of care provided (0.108 % per FTE, p < 0.001), and better access to care (−0.033 days per FTE, p < 0.01), but worse patient satisfaction scores (−0.080 % per FTE, p = 0.03). The continuity of care provided was a significant mediator (0.016 % per FTE, p < 0.01) of the relationship between FTE and patient satisfaction; but overall, reduced clinical work hours were associated with better patient satisfaction (−0.053 % per FTE, p = 0.03).

CONCLUSIONS

These results suggest that PCPs who choose to work fewer clinical hours may have worse continuity and access, but they may provide a better patient experience. Physician workforce planning should consider these care attributes when considering the role of part-time PCPs in practice redesign efforts and initiatives to meet the demand for primary care services.

Electronic supplementary material

The online version of this article (doi:10.1007/s11606-014-3104-6) contains supplementary material, which is available to authorized users.KEY WORDS: part-time work, continuity of care, access to care, patient satisfaction     

Patient Perceptions of Whom is Most Involved in Their Care with Successive Duty Hour Limits

BACKGROUND

Although direct patient care is necessary for experiential learning during residency, inpatient perceptions of the roles of resident and attending physicians in their care may have changed with residency duty hours.

OBJECTIVE

We aimed to assess if patients’ perceptions of who is most involved in their care changed with residency duty hours.

DESIGN

This was a prospective observational study over 12 years at a single institution.

PARTICIPANTS

Participants were 22,408 inpatients admitted to the general medicine teaching service from 2001 to 2013, who completed a 1-month follow-up phone interview.

MAIN MEASURES

Percentage of inpatients who reported an attending, resident, or intern as most involved in their care by duty hour period (pre-2003, post-2003–pre-2011, post-2011).

KEY RESULTS

With successive duty hour limits, the percentage of patients who reported the attending as most involved in their care increased (pre-2003 20 %, post-2003–pre-2011 29 %, post-2011 37 %, p < 0.001). Simultaneously, fewer patients reported a housestaff physician (resident or intern) as most involved in their care (pre-2003 20 %, post-2003–pre-2011 17 %, post-2011 12 %, p < 0.001). In multinomial regression models controlling for patient age, race, gender and hospitalist as teaching attending, the relative risk ratio of naming the resident versus the attending was higher in the pre-2003 period (1.44, 95 % CI 1.28-1.62, p < 0.001) than the post-2003–pre-2011 (reference group). In contrast, the relative risk ratio for naming the resident versus the attending was lower in the post-2011 period (0.79, 95 % CI 0.68-0.93, p = 0.004) compared to the reference group.

CONCLUSIONS

After successive residency duty hours limits, hospitalized patients were more likely to report the attending physician and less likely to report the resident or intern as most involved in their hospital care. Given the importance of experiential learning to the formation of clinical judgment for independent practice, further study on the implications of these trends for resident education and patient safety is warranted.KEY WORDS: resident duty hours, patient perceptions, hospital care     

Geographic and Educational Factors and Risk of the First Peritonitis Episode in Brazilian Peritoneal Dialysis Study (BRAZPD) Patients

Summary

Background and objectives

Peritonitis remains as the most frequent cause of peritoneal dialysis (PD) failure, impairing patient''s outcome. No large multicenter study has addressed socioeconomic, educational, and geographic issues as peritonitis risk factors in countries with a large geographic area and diverse socioeconomic conditions, such as Brazil.

Design, setting, participants, & measurements

Incident PD patients recruited from 114 dialysis centers and reporting to BRAZPD, a multicenter observational study, from December 2004 through October 2007 were included. Clinical, dialysis-related, demographic, and socioeconomic variables were analyzed. Patients were followed up until their first peritonitis. Cox proportional model was used to determine independent factors associated with peritonitis.

Results

In a cumulative follow-up of 2032 patients during 22.026 patient-months, 474 (23.3%) presented a first peritonitis episode. In contrast to earlier findings, PD modality, previous hemodialysis, diabetes, gender, age, and family income were not risk predictors. Factors independently associated with increased hazard risk were lower educational level, non-white race, region where patients live, shorter distance from dialysis center, and lower number of patients per center.

Conclusions

Educational level and geographic factors as well as race and center size are associated with risk for the first peritonitis, independent of socioeconomic status, PD modality, and comorbidities.     

Potential Impact of Incorporating a Patient-Selected Support Person into mHealth for Depression

Background

Although telephone care management improves depression outcomes, its implementation as a standalone strategy is often not feasible in resource-constrained settings. Moreover, little research has examined the potential role of self-management support from patients’ trusted confidants.

Objective

To investigate the potential benefits of integrating a patient-selected support person into automated mobile health (mHealth) for depression.

Design

Patient preference trial.

Participants

Depressed primary care patients who were at risk for antidepressant nonadherence (i.e., Morisky Medication Adherence Scale total score > 1).

Intervention

Patients received weekly interactive voice response (IVR) telephone calls for depression that included self-management guidance. They could opt to designate a lay support person from outside their home to receive guidance on supporting their self-management. Patients’ clinicians were automatically notified of urgent patient issues.

Main Measures

Each week over a period of 6 months, we used IVR calls to monitor depression with the Patient Health Questionnaire-9 (PHQ-9; with total < 5 classified as remission), adherence (single item reflecting perfect adherence over the past week), and functional impairment (any bed days due to mental health).

Key Results

Of 221 at-risk patients, 61% participated with a support person. Analyses were adjusted for race, medical comorbidity, and baseline levels of symptom severity and adherence. Significant interaction effects indicated that during the initial phase of the program, only patients who participated with a support person improved significantly in their likelihood of either adhering to antidepressant medication (AOR = 1.31, 95% CI: 1.16–1.47, p < 0.001) or achieving remission of depression symptoms (AOR = 1.24, 95% CI: 1.14–1.34, p < 0.001). These benefits were maintained throughout the 6-month observation period.

Conclusions

Incorporating the “human factor” of a patient-selected support person into automated mHealth for depression self-management may yield sustained improvements in antidepressant adherence and depression symptom remission. However, this needs to be confirmed in a subsequent randomized controlled trial.KEY WORDS: depression, mHealth, self-management, caregiving, social support     

Medical Student Perceptions of Cost-Conscious Care in an Internal Medicine Clerkship: A Thematic Analysis

Background

Although as much as 87 % of all healthcare spending is directed by physicians, studies have demonstrated that they lack knowledge about the costs of medical care. Similarly, learners have not traditionally received instruction on cost-conscious care.

Objective

To examine medical students'' perceptions of healthcare delivery as it relates to cost consciousness

Design

Retrospective qualitative analysis of medical student narratives

Participants

Third-year medical students during their inpatient internal medicine clerkship

Main Measures

Students completed a reflective exercise wherein they were asked to describe a scenario in which a patient experienced lack of attention to cost-conscious care, and were asked to identify solutions and barriers. We analyzed these reflections to learn more about students’ awareness and perceptions regarding the practice of cost-conscious care within our medical center.

Key Results

Eighty students submitted the assignment between July and December 2012. The most common problems identified included unnecessary tests and treatments (n = 69) and duplicative tests and treatments (n = 20.) With regards to solutions, students described 82 scenarios, with 125 potential solutions identified. Students most commonly used discussion with the team (speak up, ask why) as the process they would use (n = 28) and most often wanted to focus lab testing (n = 38) as the intervention. The most common barriers to high-value care included increased time and effort (n = 19), ingrained practices (n = 17), and defensive medicine or fear of missing something (n = 18.)

Conclusions

Even with minimal clinical experience, medical students were able to identify instances of lack of attention to cost-conscious care as well as potential solutions. Although students identified the hierarchy in healthcare teams as a potential barrier to improving high value care, most students stated they would feel comfortable engaging the team in discussion. Future efforts to empower learners at all levels to question value decisions and to develop and implement solutions may result in improved healthcare.     

Association Between Race, Depression, and Antiretroviral Therapy Adherence in a Low-Income Population with HIV Infection

Background

Racial disparities exist in many aspects of HIV/AIDS. Comorbid depression adds to the complexity of disease management. However, prior research does not clearly show an association between race and antiretroviral therapy (ART) adherence, or depression and adherence. It is also not known whether the co-existence of depression modifies any racial differences that may exist.

Objective

To examine racial differences in ART adherence and whether the presence of comorbid depression moderates these differences among Medicaid-enrolled HIV-infected patients.

Design

Retrospective cohort study.

Setting

Multi-state Medicaid database (Thomson Reuters MarketScan®).

Participants

Data for 7,034 HIV-infected patients with at least two months of antiretroviral drug claims between 2003 and 2007 were assessed.

Main Measures

Antiretroviral therapy adherence (90 % days covered) were measured for a 12-month period. The main independent variables of interest were race and depression. Other covariates included patient variables, clinical variables (comorbidity and disease severity), and therapy-related variables.

Key Results

In this study sample, over 66 % of patients were of black race, and almost 50 % experienced depression during the study period. A significantly higher portion of non-black patients were able to achieve optimal adherence (≥90 %) compared to black patients (38.6 % vs. 28.7 %, p < 0.001). In fact, black patients had nearly 30 % decreased odds of being optimally adherent to antiretroviral drugs compared to non-black patients (OR = 0.70, 95 % CI: 0.63–0.78), and was unchanged regard less of whether the patient had depression. Antidepressant treatment nearly doubled the odds of optimal ART adherence among patients with depression (OR = 1.92, 95 % CI: 1.12–3.29).

Conclusions

Black race was significantly associated with worse ART adherence, which was not modified by the presence of depression. Under-diagnosis and under-treatment of depression may hinder ART adherence among HIV-infected patients of all races.KEY WORDS: HIV, adherence, depression, race, Medicaid     

The Effectiveness of a Physician-Only and Physician–Patient Intervention on Colorectal Cancer Screening Discussions Between Providers and African American and Latino Patients

BACKGROUND

Physician recommendation of colorectal cancer (CRC) screening is a critical facilitator of screening completion. Providing patients a choice of screening options may increase CRC screening completion, particularly among racial and ethnic minorities.

OBJECTIVE

Our purpose was to assess the effectiveness of physician-only and physician–patient interventions on increasing rates of CRC screening discussions as compared to usual care.

DESIGN

This study was quasi-experimental. Clinics were allocated to intervention or usual care; patients in intervention clinics were randomized to receipt of patient intervention.

PARTICIPANTS

Patients aged 50 to 75 years, due for CRC screening, receiving care at either a federally qualified health care center or an academic health center participated in the study.

INTERVENTION

Intervention physicians received continuous quality improvement and communication skills training. Intervention patients watched an educational video immediately before their appointment.

MAIN MEASURES

Rates of patient-reported 1) CRC screening discussions, and 2) discussions of more than one screening test.

KEY RESULTS

The physician–patient intervention (n = 167) resulted in higher rates of CRC screening discussions compared to both physician-only intervention (n = 183; 61.1 % vs.50.3 %, p = 0.008) and usual care (n = 153; 61.1 % vs. 34.0 % p = 0.03). More discussions of specific CRC screening tests and discussions of more than one test occurred in the intervention arms than in usual care (44.6 % vs. 22.9 %,p = 0.03) and (5.1 % vs. 2.0 %, p = 0.036), respectively, but discussion of more than one test was uncommon. Across all arms, 143 patients (28.4 %) reported discussion of colonoscopy only; 21 (4.2 %) reported discussion of both colonoscopy and stool tests.

CONCLUSIONS

Compared to usual care and a physician-only intervention, a physician–patient intervention increased rates of CRC screening discussions, yet discussions overwhelmingly focused solely on colonoscopy. In underserved patient populations where access to colonoscopy may be limited, interventions encouraging discussions of both stool tests and colonoscopy may be needed.KEY WORDS: colorectal cancer screening, health literacy, randomized trial, physician communication of preventive care     

Prevalence and Demographic and Clinical Associations of Health Literacy in Patients on Maintenance Hemodialysis

Summary

Background and objectives

Although limited health literacy is estimated to affect over 90 million Americans and is recognized as an important public health concern, there have been few studies examining this issue in patients with chronic kidney disease. We sought to characterize the prevalence of and associations of demographic and clinical characteristics with limited health literacy in patients receiving maintenance hemodialysis.

Design, setting, participants, & measurements

As part of a prospective clinical trial of symptom management strategies in 288 patients treated with chronic hemodialysis, we assessed health literacy using the Rapid Estimate of Adult Literacy in Medicine (REALM). We defined limited health literacy as a REALM score ≤60 and evaluated independent associations of demographic and baseline clinical characteristics with limited health literacy using multivariable logistic regression.

Results

Of the 260 patients who completed the REALM, 41 demonstrated limited health literacy. African-American race, lower educational level, and veteran status were independently associated with limited health literacy. There was no association of limited health literacy with age, gender, serologic values, dialysis adequacy, overall symptom burden, quality of life, or depression.

Conclusions

Limited health literacy is common among patients receiving chronic hemodialysis. African-American race and socioeconomic factors are strong independent predictors of limited health literacy. These findings can help inform the design and implementation of interventions to improve health literacy in the hemodialysis population.     

Assessing Glomerular Filtration Rate in Hospitalized Patients: A Comparison Between CKD-EPI and Four Cystatin C-Based Equations

Summary

Background and objectives

A specific method is required for estimating glomerular filtration rate GFR in hospitalized patients. Our objective was to validate the Chronic Kidney Disease Epidemiology Collaboration (CKD-EPI) equation and four cystatin C (CysC)–based equations in this setting.

Design, setting, participants, & measurements

This was an epidemiologic, cross-sectional study in a random sample of hospitalized patients (n = 3114). We studied the accuracy of the CKD-EPI and four CysC-based equations—based on (1) CysC alone or (2) adjusted by gender; (3) age, gender, and race; and (4) age, gender, race, and creatinine, respectively—compared with GFR measured by iohexol clearance (mGFR). Clinical, biochemical, and nutritional data were also collected.

Results

The CysC equation 3 significantly overestimated the GFR (bias of 7.4 ml/min per 1.73 m²). Most of the error in creatinine-based equations was attributable to calculated muscle mass, which depended on patient''s nutritional status. In patients without malnutrition or reduced body surface area, the CKD-EPI equation adequately estimated GFR. Equations based on CysC gave more precise mGFR estimates when malnutrition, extensive reduction of body surface area, or loss of muscle mass were present (biases of 1 and 1.3 ml/min per 1.73 m² for equations 2 and 4, respectively, versus 5.9 ml/min per 1.73 m² for CKD-EPI).

Conclusions

These results suggest that the use of equations based on CysC and gender, or CysC, age, gender, and race, is more appropriate in hospitalized patients to estimate GFR, since these equations are much less dependent on patient''s nutritional status or muscle mass than the CKD-EPI equation.     

Does Patient Gender Impact Resident Physicians’ Approach to the Cardiac Exam?

Background

Physical examination remains an important part of the initial evaluation of patients presenting with chest pain but little is known about the effect of patient gender on physician performance of the cardiovascular exam.

Objective

To determine if resident physicians are less likely to perform five key components of the cardiovascular exam on female versus male standardized patients (SPs) presenting with acute chest pain.

Design

Videotape review of SP encounters during Objective Structured Clinical Examinations (OSCEs) administered by the Emory University Internal Medicine Residency Program in 2006 and 2007. Encounters were reviewed to assess residents’ performance of five cardiac exam skills: auscultation of the aortic, pulmonic, tricuspid, and mitral valve areas and palpation for the apical impulse.

Participants

One hundred forty-nine incoming residents.

Main Measures

Residents’ performance for each skill was classified as correct, incorrect, or unknown.

Key Results

One hundred ten of 149 (74 %) of encounters were available for review. Residents were less likely to correctly perform each of the five skills on female versus male SPs. This difference was statistically significant for auscultation of the tricuspid (p = 0.004, RR = 0.62, 95 % CI 0.46–0.83) and mitral (p = 0.007, RR = 0.58, 95 % CI = 0.41–0.83) valve regions and palpation for the apical impulse (p < 0.001, RR = 0.27, 95 % CI = 0.16–0.47). Male residents were less likely than female residents to correctly perform each maneuver on female versus male SPs. The interaction of SP gender and resident gender was statistically significant for auscultation of the mitral valve region (p = 0.006) and palpation for the apical impulse (p = 0.01).

Conclusions

We observed significant differences in the performance of key elements of the cardiac exam for female versus male SPs presenting with chest pain. This observation represents a previously unidentified but potentially important source of gender bias in the evaluation of patients presenting with cardiovascular complaints.KEY WORDS: cardiovascular disease, clinical skills assessment, disparities, women’s health, medical student and residency education     

Risk for Tuberculosis Disease Among Contacts with Prior Positive Tuberculin Skin Test: A retrospective Cohort Study,New York City

Background

Patients with prior positive tuberculin skin test (TST) results may benefit from prophylaxis after repeat exposure to infectious tuberculosis (TB).

Objective

To evaluate factors associated with active TB disease among persons with prior positive TST results named as contacts of persons with infectious TB.

Design

Population-based retrospective cohort study.

Participants

A total of 2,933 contacts with prior positive TST results recently exposed to infectious TB identified in New York City’s TB registry during the period from January 1, 1997 through December 31, 2003.

Main Measurements

Contacts developing active TB disease ≤ 4 years after exposure were identified and compared with those who did not, using Poisson regression analysis. Genotyping was performed on selected Mycobacterium tuberculosis-positive isolates.

Key Results

Among contacts with prior positive TST results, 39 (1.3 %) developed active TB disease ≤ 4 years after exposure (≤2 years: 34). Risk factors for contacts that were independently associated with TB were age < 5 years (adjusted prevalence ratio [aPR] = 19.48; 95 % confidence interval [CI] = 7.15–53.09), household exposure (aPR = 2.60;CI = 1.30–5.21), exposure to infectious patients (i.e., cavities on chest radiograph, acid-fast bacilli on sputum smear; aPR = 1.9 3;CI = 1.01–3.71), and exposure to a U.S.-born index patient (aPR = 4.04; CI = 1.95–8.38). Receipt of more than1 month of treatment for latent TB infection following the current contact investigation was found to be protective (aPR = 0.27; CI = 0.08–0.93). Genotype results were concordant with the index patients among 14 of 15 contacts who developed active TB disease and had genotyping results available.

Conclusions

Concordant genotype results and a high proportion of contacts developing active TB disease within 2 years of exposure indicate that those with prior positive TST results likely developed active TB disease from recent rather than remote infection. Healthcare providers should consider prophylaxis for contacts with prior TB infection, especially young children and close contacts of TB patients (e.g., those with household exposure).KEY WORDS: contact tracing, tuberculosis infection, prevention and control, epidemiology     

Impact of vitamin D supplementation on adiposity in African-Americans

Background:

African-Americans have higher rates of obesity-associated chronic diseases. Serum 25-hydroxyvitamin D (25(OH)D) shows an inverse association with obesity status. We investigated whether vitamin D supplementation changes body mass index (BMI).

Subjects:

In total, 328 overweight African-Americans were enrolled over three consecutive winter periods (2007–2010) into a randomized, double-blind, placebo-controlled trial to receive cholecalciferol supplementation (0, 1000 international units (IU), 2000 IU or 4000 IU per day) for 3 months. Plasma concentrations of 25(OH)D and anthropometric measurements were done at baseline, 3 and 6 months.

Results:

At 3 months, vitamin D supplementation in three dose groups (1000 IU, 2000 IU or 4000 IU per day) did not cause any significant changes in BMI as compared with placebo group 3-month change in BMI per 1000 IU per day estimate (SE): 0.01 (0.039); P=0.78.

Conclusions:

In overweight African-Americans, short-term high-dose vitamin D supplementation did not alter BMI.