Browsing by Author "Shah, Bimal R"

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    ItemOpen Access
    A Novel Approach to Practice-Based Learning and Improvement Using a Web-Based Audit and Feedback Module.
    (Journal of Graduate Medical Education, 2014-09) Boggan, Joel C; Cheely, George; Shah, Bimal R; Heffelfinger, Randy; Springall, Deanna; Thomas, Samantha M; Zaas, Aimee; Bae, Jonathan
    Systematically engaging residents in large programs in quality improvement (QI) is challenging.To coordinate a shared QI project in a large residency program using an online tool.A web-based QI tool guided residents through a 2-phase evaluation of performance of foot examinations in patients with diabetes. In phase 1, residents completed reviews of health records with online data entry. Residents were then presented with personal performance data relative to peers and were prompted to develop improvement plans. In phase 2, residents again reviewed personal performance. Rates of performance were compared at the program and clinic levels for each phase, with data presented for residents. Acceptability was measured by the number of residents completing each phase. Feasibility was measured by estimated faculty, programmer, and administrator time and costs.Seventy-nine of 86 eligible residents (92%) completed improvement plans and reviewed 1471 patients in phase 1, whereas 68 residents (79%) reviewed 1054 patient charts in phase 2. Rates of performance of examination increased significantly between phases (from 52% to 73% for complete examination, P < .001). Development of the tool required 130 hours of programmer time. Project analysis and management required 6 hours of administrator and faculty time monthly.An online tool developed and implemented for program-wide QI initiatives successfully engaged residents to participate in QI activities. Residents using this tool demonstrated improvement in a selected quality target. This tool could be adapted by other graduate medical education programs or for faculty development.
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    ItemOpen Access
    Association between perceived life chaos and medication adherence in a postmyocardial infarction population.
    (Circulation. Cardiovascular quality and outcomes, 2013-11) Zullig, Leah L; Shaw, Ryan J; Crowley, Matthew J; Lindquist, Jennifer; Grambow, Steven C; Peterson, Eric; Shah, Bimal R; Bosworth, Hayden B

    Background

    The benefits of medication adherence to control cardiovascular disease (CVD) are well defined, yet multiple studies have identified poor adherence. The influence of life chaos on medication adherence is unknown. Because this is a novel application of an instrument, our preliminary objective was to understand patient factors associated with chaos. The main objective was to evaluate the extent to which an instrument designed to measure life chaos is associated with CVD-medication nonadherence.

    Methods and results

    Using baseline data from an ongoing randomized trial to improve postmyocardial infarction (MI) management, multivariable logistic regression identified the association between life chaos and CVD-medication nonadherence. Patients had hypertension and a myocardial infarction in the past 3 years (n=406). Nearly 43% reported CVD-medication nonadherence in the past month. In simple linear regression, the following were associated with higher life chaos: medication nonadherence (β=1.86; 95% confidence interval [CI], 0.96-2.76), female sex (β=1.22; 95% CI [0.22-2.24]), minority race (β=1.72; 95% CI [0.78-2.66]), having less than high school education (β=2.05; 95% CI [0.71-3.39]), low health literacy (β=2.06; 95% CI [0.86-3.26]), and inadequate financial status (β=1.93; 95% CI [0.87-3.00]). Being married (β=-2.09, 95% CI [-3.03 to -1.15]) was associated with lower life chaos. As chaos quartile increased, patients exhibited more nonadherence. In logistic regression, adjusting for sex, race, marital status, employment, education, health literacy, and financial status, a 1-unit life chaos increase was associated with a 7% increase (odds ratio, 1.07; 95% CI [1.02-1.12]) in odds of reporting medication nonadherence.

    Conclusions

    Our results suggest that life chaos may be an important determinant of medication adherence. Life chaos screenings could identify those at risk for nonadherence.

    Clinical trial registration

    URL: http://www.clinicaltrials.gov. Unique identifier: NCT000901277.
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    Healthy Lifestyles and Attitudes Towards Preventive Counseling: a Survey of Chinese and US Medical Students
    (2013) Sebranek, Matthew Paul

    BACKGROUND: Non-communicable diseases are currently the leading cause of death worldwide. Leading healthy lifestyles as a means of prevention is one of the most important aspects of preventing the occurrence of non-communicable diseases. Working from the premise that physicians globally serve as role models for patients and their health beliefs can influence how they interact and counsel patients, this international study ("MedLife") seeks to examine the self-report of health behaviors and clinical practice attitudes towards preventive counseling of medical students at institutions in China and the US, and identify any associations between these behaviors and students' clinical practice attitudes towards preventive counseling of future patients.

    METHODS: From 2012-2013, a total of 860/1,216 (response rate = 71%) medical students from Duke University in the US and Peking University Health Science Center and Xi'an Jiaotong University in China completed culturally-adapted web versions of the 33-item "MedLife" questionnaire. Items from the survey were pulled from previously validated survey tools and included questions on diet, exercise, smoking, and alcohol consumption. Alcohol consumption was divided into heavy drinking and binge drinking. Prevalence estimates of health behaviors and attitudes towards preventive counseling in the domains of diet, exercise, smoking, and alcohol consumption were obtained in addition to measures of association between health behaviors and clinical practice attitudes towards counseling future patients on these issues. Finally, multivariate logistic regression analyses were performed to assess the associations between personal habits and clinical practice attitudes towards preventive counseling while adjusting for gender.

    RESULTS: The median ages of students at Duke University in years 1, 2, 3, and 4 were 23 years, 24 years, 25 years, and 26 years, respectively. The median ages of students at both schools in China among second, fourth, and seventh year students were 19 years, 22 years, and 24 years, respectively. In addition, the percentage of total females at Duke University and in China who completed the survey was 51% and 54%, respectively. Prevalence estimates of a healthy lifestyle, defined as complying with widely recognized recommendations at Duke University in the domains of diet, exercise, smoking, non-binge drinking, and non-heavy drinking were 30%, 42%, 99%, 41%, and 97%, respectively. Prevalence estimates in China of a healthy lifestyle in diet, exercise, smoking, non-binge drinking, and non-heavy drinking were 17%, 33%, 97%, 94%, and 99%, respectively. Overall, approximately 30% of medical students at Duke and 25% of medical students in China had positive clinical practice attitudes towards preventive counseling in terms of diet, exercise, smoking, and alcohol consumption combined. No statistically significant associations between the self-report of health behaviors and clinical practice towards preventive counseling were found among Duke medical students. Second, fourth, and seventh year medical students in China together who complied with all lifestyle recommendations were two times more likely to have a positive clinical practice attitude towards preventive counseling on all healthy lifestyle domains (diet, exercise, smoking, and alcohol) combined (OR=2.03 95% CI=1.06-3.92; p=0.03). When adjusted for gender, this positive association among Chinese medical students was still statistically significant (OR=1.98 95% CI=1.02-3.83; p=0.04).

    CONCLUSION: Medical students self-reported that they led unhealthy lifestyles in the domains of diet, exercise, and alcohol binge drinking at Duke and in the domains of diet and exercise in China. However, there was little evidence of an association between self-report of health behaviors and clinical practice towards preventive counseling for Duke medical students. But there was evidence among Chinese medical students to support an association between an overall self-reported healthy lifestyle and positive clinical practice attitudes towards preventive counseling on diet, exercise, smoking, and alcohol consumption combined, even after adjusting for gender. If clinicians are going to serve as role models and have their behaviors and lifestyle choices influence patients, medical schools need to ensure students lead healthy lifestyles in these areas and improve positive clinical practice attitudes towards preventive counseling on diet, exercise, smoking, and alcohol consumption to help curb the global cardiovascular disease epidemic. Student health and positive clinical practice attitudes towards preventive counseling should be a top priority for all medical schools, and it seems that policies aimed at improving student health in China are likely to be associated with positive clinical practice attitudes towards preventive counseling.

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    ItemOpen Access
    Medication non-adherence after myocardial infarction: an exploration of modifying factors.
    (Journal of general internal medicine, 2015-01) Crowley, Matthew J; Zullig, Leah L; Shah, Bimal R; Shaw, Ryan J; Lindquist, Jennifer H; Peterson, Eric D; Bosworth, Hayden B

    Background

    Medication non-adherence is a major impediment to the management of cardiovascular disease risk factors. A better understanding of the modifying factors underlying medication non-adherence among individuals with known cardiovascular disease may inform approaches for addressing non-adherence.

    Objective

    The purpose of this study was to identify demographic and patient characteristics, medical comorbidities, psychosocial factors, and health belief-related factors associated with medication non-adherence among patients with known cardiovascular disease.

    Design

    We performed secondary analysis of baseline data from a randomized trial.

    Patients

    The study included 405 patients with a diagnosis of hypertension and history of acute myocardial infarction that was diagnosed within a three-year period prior to enrollment.

    Main measures

    Baseline demographics and patient characteristics, medical comorbidities, psychosocial factors, health belief-related factors, and patient-reported medication non-adherence were analyzed.

    Key results

    Of 405 patients, 173 (42.7 %) reported medication non-adherence. Factors associated with non-adherence in bivariate analysis included younger age, non-white race, having less than 12 years of education, smoking, financial insecurity, identifying as nervous or tense, higher life chaos score, greater worry about having a myocardial infarction, and greater worry about having a stroke. Using multivariable modeling, we determined that age (OR 0.97 per additional year, 95 % CI, 0.95-0.99), life chaos (OR 1.06 per additional point, 95 % CI, 1.00-1.11), and worry about stroke (OR 1.12 per additional point, 95 % CI, 1.01-1.25) remained significantly associated with self-reported medication non-adherence.

    Conclusions

    We found that worry about having a stroke, higher life chaos, and younger age were all significantly associated with self-reported medication non-adherence in patients with cardiovascular disease and a history of myocardial infarction. Further research exploring these factors as targets for intervention is needed, as is additional research examining modifiable causes of medication non-adherence among patients with cardiovascular disease.
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    ItemOpen Access
    Patient-provider communication, self-reported medication adherence, and race in a postmyocardial infarction population.
    (Patient Prefer Adherence, 2015) Zullig, Leah L; Shaw, Ryan J; Shah, Bimal R; Peterson, Eric D; Lindquist, Jennifer H; Crowley, Matthew J; Grambow, Steven C; Bosworth, Hayden B
    OBJECTIVES: Our objectives were to: 1) describe patient-reported communication with their provider and explore differences in perceptions of racially diverse adherent versus nonadherent patients; and 2) examine whether the association between unanswered questions and patient-reported medication nonadherence varied as a function of patients' race. METHODS: We conducted a cross-sectional analysis of baseline in-person survey data from a trial designed to improve postmyocardial infarction management of cardiovascular disease risk factors. RESULTS: Overall, 298 patients (74%) reported never leaving their doctor's office with unanswered questions. Among those who were adherent and nonadherent with their medications, 183 (79%) and 115 (67%) patients, respectively, never left their doctor's office with unanswered questions. In multivariable logistic regression, although the simple effects of the interaction term were different for patients of nonminority race (odds ratio [OR]: 2.16; 95% confidence interval [CI]: 1.19-3.92) and those of minority race (OR: 1.19; 95% CI: 0.54-2.66), the overall interaction effect was not statistically significant (P=0.24). CONCLUSION: The quality of patient-provider communication is critical for cardiovascular disease medication adherence. In this study, however, having unanswered questions did not impact medication adherence differently as a function of patients' race. Nevertheless, there were racial differences in medication adherence that may need to be addressed to ensure optimal adherence and health outcomes. Effort should be made to provide training opportunities for both patients and their providers to ensure strong communication skills and to address potential differences in medication adherence in patients of diverse backgrounds.
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    Patterns, predictors, variations, and temporal trends in emergency medical service hospital prenotification for acute ischemic stroke.
    (J Am Heart Assoc, 2012-08) Lin, Cheryl B; Peterson, Eric D; Smith, Eric E; Saver, Jeffrey L; Liang, Li; Xian, Ying; Olson, Daiwai M; Shah, Bimal R; Hernandez, Adrian F; Schwamm, Lee H; Fonarow, Gregg C
    BACKGROUND#ENTITYSTARTX02014;: Emergency medical services (EMS) hospital prenotification of an incoming stroke patient is guideline recommended as a means of increasing the timeliness with which stroke patients are evaluated and treated. Still, data are limited with regard to national use of, variations in, and temporal trends in EMS prenotification and associated predictors of its use. METHODS AND RESULTS#ENTITYSTARTX02014;: We examined 371 988 patients with acute ischemic stroke who were transported by EMS and enrolled in 1585 hospitals participating in Get With The Guidelines-Stroke from April 1, 2003, through March 31, 2011. Prenotification occurred in 249 197 EMS-transported patients (67.0%) and varied widely by hospital (range, 0% to 100%). Substantial variations by geographic regions and by state, ranging from 19.7% in Washington, DC, to 93.4% in Montana, also were noted. Patient factors associated with lower use of prenotification included older age, diabetes mellitus, and peripheral vascular disease. Prenotification was less likely for black patients than for white patients (adjusted odds ratio 0.94, 95% confidence interval 0.92-0.97, P<0.0001). Hospital factors associated with greater EMS prenotification use were absence of academic affiliation, higher annual volume of tissue plasminogen activator administration, and geographic location outside the Northeast. Temporal improvements in prenotification rates showed a modest general increase, from 58.0% in 2003 to 67.3% in 2011 (P temporal trend <0.0001). CONCLUSIONS#ENTITYSTARTX02014;: EMS hospital prenotification is guideline recommended, yet among patients transported to Get With The Guidelines-Stroke hospitals it is not provided for 1 in 3 EMS-arriving patients with acute ischemic stroke and varies substantially by hospital, state, and region. These results support the need for enhanced implementation of stroke systems of care. (J Am Heart Assoc. 2012;1:e002345 doi: 10.1161/JAHA.112.002345.).
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    ItemOpen Access
    Perception Versus Actual Performance in Timely Tissue Plasminogen Activation Administration in the Management of Acute Ischemic Stroke.
    (J Am Heart Assoc, 2015-07-22) Lin, Cheryl B; Cox, Margueritte; Olson, DaiWai M; Britz, Gavin W; Constable, Mark; Fonarow, Gregg C; Schwamm, Lee; Peterson, Eric D; Shah, Bimal R
    BACKGROUND: Timely thrombolytic therapy can improve stroke outcomes. Nevertheless, the ability of US hospitals to meet guidelines for intravenous tissue plasminogen activator (tPA) remains suboptimal. What is unclear is whether hospitals accurately perceive their rate of tPA "door-to-needle" (DTN) time within 60 minutes and how DTN rates compare across different hospitals. METHODS AND RESULTS: DTN performance was defined by the percentage of treated patients who received tPA within 60 minutes of arrival. Telephone surveys were obtained from staff at 141 Get With The Guidelines hospitals, representing top, middle, and low DTN performance. Less than one-third (29.1%) of staff accurately identified their DTN performance. Among middle- and low-performing hospitals (n=92), 56 sites (60.9%) overestimated their performance; 42% of middle performers and 85% of low performers overestimated their performance. Sites that overestimated tended to have lower annual volumes of tPA administration (median 8.4 patients [25th to 75th percentile 5.9 to 11.8] versus 10.2 patients [25th to 75th percentile 8.2 to 17.3], P=0.047), smaller percentages of eligible patients receiving tPA (84.7% versus 89.8%, P=0.008), and smaller percentages of DTN ≤60 minutes among treated patients (10.6% versus 16.6%, P=0.002). CONCLUSIONS: Hospitals often overestimate their ability to deliver timely tPA to treated patients. Our findings indicate the need to routinely provide comparative provider performance rates as a key step to improving the quality of acute stroke care.
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    Secondary Prevention Risk Interventions via Telemedicine and Tailored Patient Education (SPRITE): A randomized trial to improve post myocardial infarction management.
    (Patient education and counseling, 2022-09) Zullig, Leah L; Peterson, Eric D; Shah, Bimal R; Grambow, Steven C; Oddone, Eugene Z; McCant, Felicia; Lindquist, Jennifer Hoff; Bosworth, Hayden B

    Objective

    We evaluated the impact of a low intensity web-based and intensive nurse-administered intervention to reduce systolic blood pressure (SBP) among patients with prior MI.

    Methods

    Secondary Prevention Risk Interventions via Telemedicine and Tailored Patient Education (SPRITE) was a three-arm trial. Patients were randomized to 1) post-MI education-only; 2) nurse-administered telephone program; or 3) web-based interactive tool. The study was conducted 2009-2013.

    Results

    Participants (n = 415) had a mean age of 61 years (standard deviation [SD], 11). Relative to the education-only group, the 12-month differential improvement in SBP was - 3.97 and - 3.27 mmHg for nurse-administered telephone and web-based groups, respectively. Neither were statistically significant. Post hoc exploratory subgroup analyses found participants who received a higher dose (>12 encounters) in the nurse-administered telephone intervention (n = 60; 46%) had an 8.8 mmHg (95% CI, 0.69, 16.89; p = 0.03) differential SBP improvement versus low dose (<11 encounters; n = 71; 54%). For the web-based intervention, those who had higher dose (n = 73; 53%; >1 web encounter) experienced a 2.3 mmHg (95% CI, -10.74, 6.14; p = 0.59) differential SBP improvement versus low dose (n = 65; 47%).

    Conclusions

    The main effects were not statistically significant.

    Practical implications

    Completing the full dose of the intervention may be essential to experience the intervention effect.

    Clinical trial registration

    The unique identifier is NCT00901277 (http://www.

    Clinicaltrials

    gov/ct2/show/NCT00901277?term=NCT00901277&rank=1).
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    ItemOpen Access
    Secondary prevention risk interventions via telemedicine and tailored patient education (SPRITE): a randomized trial to improve postmyocardial infarction management.
    (Circulation. Cardiovascular quality and outcomes, 2011-03) Shah, Bimal R; Adams, Martha; Peterson, Eric D; Powers, Benjamin; Oddone, Eugene Z; Royal, Kira; McCant, Felicia; Grambow, Steven C; Lindquist, Jennifer; Bosworth, Hayden B

    Background

    Secondary prevention by risk factor modification improves patient outcomes, yet it is often not achieved in clinical practice. Reasons for failure stem from challenges of prioritizing risk factor reduction and engaging patients in changing their behaviors. We hypothesize that a novel telemedicine intervention with tailored patient education could improve cardiovascular risk factors.

    Methods

    To evaluate this intervention, we propose enrolling 450 patients with a recent myocardial infarction and hypertension into a 3-arm randomized, controlled trial. The first arm (n=150) will receive home blood pressure (BP) monitors plus a nurse-delivered, telephone-based tailored patient education intervention and will be enrolled into HealthVault, a Microsoft electronic health record platform. The second arm (n=150) will also receive BP monitors plus a tailored patient education intervention and be enrolled in HeartVault. However, the patient education intervention will be delivered by a Web-based program and will cover topics identical to those in the nurse-delivered intervention. Both arms will be compared with a control group receiving standard care (n=150). All participants will have an in-person assessment at baseline and at completion of the study, including standardized measurements of BP, LDL cholesterol, and glycosylated hemoglobin (in diabetic subjects). The study design will allow assessment of a telephone-based, nurse-administered disease management program versus standard care. The main outcome of interest is the reduction in systolic BP in each intervention group compared with the control group at 12 months. Secondary outcomes assessed will include reductions in LDL cholesterol, body weight, and glycosylated hemoglobin, as well as adherence to evidence-based therapies and improvement in health behaviors.

    Conclusion

    If successful in optimizing BP control, managing other coronary heart disease risk factors, and demonstrating a lower cost, the Web-based disease management tool has the potential to enhance coronary artery disease management, quality of care, and ultimately, patient outcomes. Clinical Trial Registration- URL: http://www.clinicaltrials.gov. Unique identifier: NCT00901277.
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    ItemOpen Access
    Willingness of Patients to Use Computers for Health Communication and Monitoring Following Myocardial Infarction.
    (Computers, informatics, nursing : CIN, 2015-09) Shaw, Ryan J; Zullig, Leah L; Crowley, Matthew J; Grambow, Steven C; Lindquist, Jennifer H; Shah, Bimal R; Peterson, Eric; Bosworth, Hayden B
    We describe the computer use characteristics of 406 post-myocardial infarction (MI) patients and their willingness to engage online for health communication and monitoring. Most participants were computer users (n = 259; 63.8%) and half (n = 209; 51.5%) read health information online at least monthly. However, most participants did not go online to track health conditions (n = 283; 69.7%), look at medical records (n = 287; 70.7%), or e-mail doctors (n = 351; 86.5%). Most participants would consider using a Web site to e-mail doctors (n = 275; 67.7%), share medical information with doctors (n = 302; 74.4%), send biological data to their doctor (n = 308; 75.9%), look at medical records (n = 321; 79.1%), track health conditions (n = 331; 81.5%), and read about health conditions (n = 332; 81.8%). Sharing health information online with family members (n = 181; 44.6%) or for support groups (n = 223; 54.9%) was not of much interest. Most post-MI participants reported they were interested in communicating with their provider and tracking their health conditions online. Because patients with a history of MI tend to be older and are disproportionately minority, researchers and clinicians must be careful to design interventions that embrace post-MI patients of diverse backgrounds that both improve their access to care and health outcomes.