Allison P Squires

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Objective. To compare the incidence of hepatic decompensation in patients who are co-infected with HIV and hepatitis C (HCV) and who underwent antiretroviral treatment and patients who are HCV-monoinfected. Design. Retrospective cohort study. Participants and setting. This study used the Veterans Aging Cohort Study Virtual Cohort (VACS-VC), which includes electronic medical record data from patients who are HIV-infected and are receiving care at Veterans Affairs (VA) medical facilities in the United States. Inclusion criteria for patients who were co-infected were: detectable HCV RNA, recently initiated antiretroviral therapy (ART), defined as use of ≥ 3 antiretroviral drugs from 2 classes or ≥ 3 nucleoside analogues within the VA system, HIV RNA level > 500 copies/mL within 180 days before starting ART, and were seen in the VACS-VC for at least 12 months after initiating ART. Inclusion criteria for patients who were monoinfected with HCV were detectable HCV RNA, no HIV diagnosis or antiretroviral prescriptions, and seen in the VACS-VC for at least 12 months prior to inclusion into the study. Exclusion criteria were hepatic decompensation, hepatocellular carcinoma, and liver transplant during the 12-month baseline period or receipt of interferon-based HCV therapy. Main outcome measure. The primary outcome was incident hepatic decompensation, defined as diagnosis of ascites, spontaneous bacterial peritonitis, or esophageal variceal hemorrhage at hospital discharge or 2 such outpatient diagnoses.

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Objective. To investigate the clinical effectiveness and costs of nurses working as substitutes for physicians in primary care. Design. Systematic review and meta-analysis of published randomized controlled trials (RCTs) and 2 economic studies that compared nurse-led care with care by primary care physicians on numerous variables, including satisfaction, hospital admission, mortality, and costs of health care. Settings and participants. The 24 RCTs were drawn from 5 different countries (UK, Netherlands, USA, Russia, and South Africa). In total, there were 38, 974 participants. Eleven of the studies had less than 200 participants and 13 studies had more than 200 (median, 1624). Mean age was reported in 20 trials and ranged from 10 to 83 years. Analysis. The authors assessed risk of bias in the studies, calculated the study-specific and pooled relative risks (RR) or standardized mean differences (SMD), and performed fixed-effects meta-analyses. Main results. Nurse-led care was effective at reducing the overall risk of hospital admission (RR 0.76, 95% CI 0.64-0.91) and mortality (RR 0.89, 95% CI 0.84-0.96) in RCTs of ongoing or non-urgent care, longer (at least 12 months) follow-up episodes, and in in larger (n > 200) RCTs. Pooled analysis showed higher overall scores of patient satisfaction with nurse led care (SMD 0.18, 95% Cl 0.13-0.23). Higher-quality RCTs (with better allocation concealment and less attrition) showed higher rates of hospital admissions and mortality with nurse-led care, but the difference was not significant. Subgroup analysis showed that RNs had a stronger effect than nurse practitioners (NPs) on patient satisfaction. The results of cost-effectiveness and improved quality of care analysis with nurses were inconclusive. Conclusion. Nurse-led care appears to have a positive effect on patient care and outcomes but more rigorous research is needed to confirm these findings.

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Objective. To determine if there is an association between self-reported English language ability and glycemic control in Latinos with type 2 diabetes. Design. Descriptive correlational study using data from a larger cross-sectional study. Setting and participants. 167 adults with diabetes who selfidentified as Latino or Hispanic recruited at clinics in the Chicago area from May 2004 to May 2006. The dataset was collected using face-to-face interviews with diabetic patients aged ≥ 18 years. All participants attended clinics affiliated with an academic medical center or physician offices affiliated with a suburban hospital. Patients with type 1 diabetes and those with < 17 points on the Mini-Mental State Examination were excluded. English speaking ability was categorized as speaking English "not at all," "not well," "well," or "very well" based on patient self-report. A multivariable logistic regression model was used to examine the predictive relationship between English language skills and HbA1c levels, with covariates selected if they were significantly correlated with English language ability. The final regression model accounted for age, sex, education, annual income, health insurance status, duration of diabetes, birth in the United States, and years in the United States. Main outcome measure. HbA1c ≥ 7.0% as captured by chart review. Main results. Of the 167 patients, 38% reported speaking English very well, 21% reported speaking well, 26% reported speaking not very well, and 14% did not speak English at all. Reflecting immigration-sensitive patterns, patients who spoke English very well were younger and more likely to have graduated high school and have an annual income over $25,000 per year. Comorbidities and complications did not differ by English speaking ability except for diabetic eye disease, which was was more prevalent among those who did not speak English at all (42%, p = 0.04). Whether speaking ability was treated as a continuous or dichotomous variable, HbA1c levels formed a U-shaped curve: those who spoke English very well (odds ratio [OR] 2.32, 95% CI, 1.00-5.41) or not at all (OR 4.11, 95% CI 1.35-12.54) had higher odds of having an elevated HbA1c than those who spoke English well, although this was only statistically significant for those who spoke no English. In adjusted analyses, the U-shaped curve persisted with the highest odds among those who spoke English very well (OR 3.20, 95% CI 1.05-9.79) or not at all (OR 4.95, 95% CI 1.29-18.92). Conclusion. The relationship between English speaking ability and diabetes management is more complex than previously described. Interventions aimed at improving diabetes outcomes may need to be tailored to specific subgroups within the Latino population.

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Objective. To evaluate the usefulness of the Frailty Index (FI) as a prognostic indicator of adverse outcomes in geriatric trauma patients,. Design. Prospective cohort study. Setting and participants. Geriatric (aged 65 and over) trauma patients admitted to inpatient units at a Level 1 trauma center in Arizona were enrolled. Patients were excluded if they were intubated/nonresponsive with no family members present or transferred from another institution (eg, skilled nursing facility). The following categories of data were collected: (a) patient demographics, (b) type and mechanism of injury, (c) vital signs (eg, Glasgow coma scale score, systolic blood pressure, heart rate, body temperature), (d) need for operative intervention, (e) in-hospital complications, (f) hospital and intensive care unit (ICU) lengths of stay, and (g) discharge disposition. Patients or, in the case of nonresponsive patients, their closest relative, responded to the 50-item Frailty Index questionnaire, which includes questions regarding age, comorbid conditions, medications, activities of daily living (ADLs), social activities, mood, and nutrition. FI score ranges from 0 (non-frail) to 1 (frail), with an FI of 0.25 or more indicative of frailty based on established guidelines. Patients were categorized as frail or non-frail according to their FI scores and were followed during the course of their hospitalization. Main outcome measure. The primary outcome measure was in-hospital complications. In-hospital complications included myocardial infarction, cardiopulmonary arrest, pneumonia, pulmonary embolism, sepsis, urinary tract infection, deep venous thrombosis, disseminated intravascular coagulation, renal insufficiency, and reoperation. The secondary outcome measure was adverse discharge disposition, which was defined as death during the course of hospitalization or discharge to a skilled nursing facility. Main results. The sample consisted of 250 patients with a mean age of 77.9 years. Among these, 44.0% were considered frail. Patients with frailty were more likely to have a higher Injury Severity Score (P = 0.04) and a higher mean FI (P = 0.01) than those without frailty. There were no statistically significant differences with respect to age (P = 0.21), mechanism of injury (P = 0.09), systolic blood pressure (P = 0.30), or Glasgow Coma Scale score (P = 0.91) between the groups. Patients with frailty were more likely to develop in-hospital complications (37.3% vs 21.4%, P = 0.001) than those without frailty. Among these complications, pneumonia and urinary tract infection were the most common. There were no differences in the rate of reoperation (P = 0.54) between the 2 groups. An FI of 0.25 or higher was associated with the development of in-hospital complications (P = 0.001) even after adjusting for age, systolic blood pressure, heart rate, and Injury Severity Score. Frail patients had longer hospital length of stay (P = 0.01) and ICU length of stay (P = 0.01), and were more likely to have adverse discharge disposition (37.3% vs. 12.9%, P = 0.001). All patients who died during the course of hospitalization (n = 5) were considered frail. Frailty was also found to be a predictor of adverse discharge disposition (P = 0.001) after adjustment for age, male sex, Injury Severity Score, and mechanism of injury. Conclusion. The FI is effective in identifying geriatric trauma patients, who are vulnerable to poor health outcomes.

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BACKGROUND: The Veterans Affairs (VA) Healthcare System uses Patient-Aligned Care Teams (PACT) as part of its patient-centered medical home model. "Teamlets" often consist of an RN, an LPN, a program assistant, and a PCP who are tasked with screening for obesity, providing brief interventions, counseling patients, and advising eligible patients to attend MOVE!, an intensive weight management program. While every VA hospital has a MOVE! Program to address the high prevalence of overweight and obesity among Veterans, less than 10 % of eligible patients attend even one session. Since Veterans visit PACT 3.6 times per year, there are opportunities to improve counseling and service coordination. A single-center, qualitative research study of healthcare team members assessed attitudes and practices as well as elicited barriers and facilitators to care implementation for overweight and obese patients. METHODS: We recruited healthcare team members for individual key informant interviews using a combination of convenience and snowball sampling. We used a semi-structured interview guide with questions informed by the Theory of Planned Behavior. Interviews lasted 30-60 min and were conducted by a general internist in a private office while a research assistant took field notes. The interviews were audio recorded and transcribed by a transcription company. Research assistants reviewed transcripts to correct mistakes and de-identify content. Analysts then used an iterative and directed coding approach, facilitated by NVivo software and structured by an initial coding guide developed from field notes and recollections. The primary coder segmented and coded each transcript, allowing additional codes to emerge. A second researcher then independently coded each segment. The researchers met frequently to harmonize codes and synthesize themes that emerged from coded transcripts. RESULTS: There were 25 participants in the study (11MDor NP, 5 RN, 2 RD, 5 LPN, 2 Other, with 6 holding an additional managerial role); 80%were female, 48%identified as White, 28 % African American, 16 % Asian, and 8 % Hispanic. Emerging themes included: system constraints, patient barriers, and perceived role responsibility.We found that performance measures and reminders motivate and shape current practices by the PACT teamlets. Barriers to treating patients included time, competing demands, and lack of understanding about what happens in the MOVE! Program. Facilitators included having received training in motivational interviewing (MI) and having a personal interest in nutrition and physical activity. Perceptions about role responsibility varied, with some RNs, LPNs, and MDs perceiving that they play important roles in weight management counseling, while others stated that it was the role of other team members. Similarly, perceived counseling competency varied within and between the different professions. For instance, some RNs and PCPs described in great detail how they used MI to counsel patients around weight, while others questioned whether they had adequate time and training. CONCLUSIONS: These data allowed us to identify several approaches to improve weight management by the PACT teamlets and will inform the design of PACT-based weight management interventions. Findings, however, may be organization-specific, so replication of the study at other sites is necessary to determine common implementation issues.

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Obesity disproportionately affects Latina adults, and goal-setting is a technique often used to promote lifestyle behavior change and weight loss. To explore the meanings and dimensions of goal-setting in immigrant Latinas, we conducted four focus groups arranged by language ability and country of origin in an urban, public, primary care clinic. We used a narrative analytic approach to identify the following themes: the immigrant experience, family dynamics, and health care. Support was a common sub-theme that threaded throughout, with participants relying on the immigrant community, family, and the health care system to support their goals. Participants derived satisfaction from setting and achieving goals and emphasized personal willpower as crucial for success. These findings should inform future research on how goal-setting can be used to foster lifestyle behavior change and illustrate the importance of exploring the needs of Latino sub-groups in order to improve lifestyle behaviors in diverse Latino populations.