Publications

BACKGROUND

Awareness of chronic kidney disease (CKD) is low. Efforts are underway to increase recognition of CKD among patients, assuming that such an increase will lead to better outcomes through greater adherence to proven therapies. Few studies have tested this assumption.

METHODS

CKD awareness, defined by a 'yes' answer to 'Have you ever been told by a healthcare provider you have weak or failing kidneys?', was assessed among 2,404 adults with CKD stages 1-4, who participated in the 2003-2008 National Health and Nutrition Examination Surveys. Odds of blood pressure (BP) control, self-reported use of angiotensin-converting enzyme inhibitors (ACEI) or angiotensin receptor blockers (ARB), and glycemic control, were determined among those aware vs. unaware of their CKD.

RESULTS

Optimal BP control, ACEI/ARB use and glycemic control were low in the US adult population with CKD, although there was a recent increase in attainment of guideline-concordant BP control. Odds of BP control and ACEI/ARB use were not different among individuals aware of their CKD compared to those unaware (adjusted odds ratio (AOR) 0.91; 95% CI 0.52-1.58 and AOR 0.75; 0.44-1.30, respectively). CKD awareness among diabetic participants was not associated with glycemic control (AOR 0.41; 95% CI 0.14-1.18).

CONCLUSION

Awareness of CKD is not associated with more optimal BP control, ACEI/ARB use or glycemic control. Future efforts in this area should further explore the measurement of CKD awareness and behaviors associated with CKD awareness.

PURPOSE

Little is known about parental attitudes toward return of individual research results (IRRs) in pediatric genomic research. The aim of this study was to understand the views of the parents who enrolled their children in a genomic repository in which IRRs will be returned.

METHODS

We conducted focus groups with parents of children with developmental disorders enrolled in the Gene Partnership (GP), a genomic research repository that offers to return IRRs, to learn about their understanding of the GP, motivations for enrolling their children, and expectations regarding the return of IRRs.

RESULTS

Parents hoped to receive IRRs that would help them better understand their children's condition(s). They understood that this outcome was unlikely, but hoped that their children's participation in the GP would contribute to scientific knowledge. Most parents wanted to receive all IRRs about their child, even for diseases that were severe and untreatable, citing reasons of personal utility. Parents preferred electronic delivery of the results and wanted to designate their preferences regarding what information they would receive.

CONCLUSIONS

It is important for researchers to understand participant expectations in enrolling in a research repository that offers to disclose children's IRRs in order to effectively communicate the implications to parents during the consenting process.

BACKGROUND

Health information technology can enhance self-management and quality of life for patients with chronic disease and overcome healthcare barriers for patients with limited English proficiency. After a randomized controlled trial of a multilingual automated telephone self-management support program (ATSM) improved patient-centered dimensions of diabetes care in safety net clinics, we collaborated with a nonprofit Medicaid managed care plan to translate research into practice, offering ATSM as a covered benefit and augmenting ATSM to promote medication activation. This paper describes the protocol of the Self-Management Automated and Real-Time Telephonic Support Project (SMARTSteps).

METHODS/DESIGN

This controlled quasi-experimental trial used a wait-list variant of a stepped wedge design to enroll 362 adult health plan members with diabetes who speak English, Cantonese, or Spanish and receive care at 4 publicly-funded clinics. Through language-stratified randomization, participants were assigned to four intervention statuses: SMARTSteps-ONLY, SMARTSteps-PLUS, or wait-list for either intervention. In addition to usual primary care, intervention participants received 27 weekly calls in their preferred language with rotating queries and response-triggered education about self-care, medication adherence, safety concerns, psychological issues, and preventive services. Health coaches from the health plan called patients with out-of-range responses for collaborative goal setting and action planning. SMARTSteps-PLUS also included health coach calls to promote medication activation, adherence and intensification, if triggered by ATSM-reported non-adherence, refill non-adherence from pharmacy claims, or suboptimal cardiometabolic indicators. Wait-list patients crossed-over to SMARTSteps-ONLY or -PLUS at 6 months. For participants who agreed to structured telephone interviews at baseline and 6 months (n = 252), primary outcomes will be changes in quality of life and functional status with secondary outcomes of 6-month changes in self-management behaviors/efficacy and patient-centered processes of care. We will also evaluate 6-month changes in cardiometabolic (HbA1c, blood pressure, and LDL) and utilization indicators for all participants.

DISCUSSION

Outcomes will provide evidence regarding real-world implementation of ATSM within a Medicaid managed care plan serving safety net settings. The evaluation trial will provide insight into translating and scaling up health information technology interventions for linguistically and culturally diverse vulnerable populations with chronic disease.

TRIAL REGISTRATION

ClinicalTrials.gov: NCT00683020.

AIMS

The interval between the T-wave's peak and end (Tpe), an electrocardiographic (ECG) index of ventricular repolarization, has been proposed as an indicator of arrhythmic risk. We aimed to clarify the clinical usefulness of Tpe for risk stratification.

METHODS AND RESULTS

We evaluated 327 patients with left ventricular ejection fraction (LVEF) ≤ 35% (75% male, LVEF 23 ± 7%). All patients had an implanted implantable cardioverter-defibrillator (ICD). Clinical data and ECGs were analysed at baseline. Prospective follow-up for the endpoints of appropriate ICD therapy and mortality was conducted via periodic device interrogation, chart review, and the Social Security Death Index. During device clinic follow-up of 17 ± 12 months, 59 (18%) patients had appropriate ICD therapy, and during mortality follow-up of 30 ± 13 months, 67 (21%) patients died. A longer Tpe(c) predicted appropriate ICD therapy, death, and the combination of appropriate ICD therapy or death (P< 0.01 for each endpoint). On multivariable analysis correcting for other univariable predictors, Tpe(c) remained predictive of ICD therapy [hazard ratio (HR) per 10 ms increase: 1.16, P= 0.02], all-cause mortality (HR per 10 ms: 1.14, P= 0.03), and the composite endpoint of ICD therapy or death (HR per 10 ms: 1.16, P< 0.01).

CONCLUSIONS

In patients with left ventricular systolic dysfunction and an implanted ICD, Tpe(c) independently predicts both ventricular tachyarrhythmia and overall mortality.