Publications by authors named "James Willig"

121 Publications

Disaster Medicine and Pandemic Response: A Novel Curriculum to Improve Understanding of Complex Care Delivery During the COVID-19 Pandemic.

AEM Educ Train 2021 Jul 28:e10647. Epub 2021 Jul 28.

Department of Emergency Medicine University of Alabama at Birmingham.

Background: Despite a 2009 recommendation from the AMA that disaster medicine and public health response training should be implemented in medical schools, anywhere from 31% to 47% of medical education programs lack a formalized disaster medicine curriculum. A need for disaster medicine response training for University of Alabama medical students in an appropriately socially distanced format was identified during the COVID-19 pandemic.

Methods: Our emergency medicine faculty in collaboration with the Federal Emergency Management Agency Center for Disaster Preparedness (FEMA CDP) created and implemented a novel virtual disaster medicine and pandemic response course for third year medical students at the University of Alabama at Birmingham. The course was administered via a teleconferencing platform (Zoom, Zoom Video Communications, Inc.) in the spring of 2020 to greater than 130 medical students.

Results: Using pre and post course surveys, we assessed a change in student confidence levels for their ability to explain topics covered in the course and their understanding of a chosen disaster. The students reported an average increase of 2.183 on a 5-point scale, with a score of 5 representing "completely confident" and a score of 1 representing "not at all confident". This course established the feasibility of a virtual instructor led training (VILT) format for disaster medicine education and provided a template for the delivery of over 300 courses to more than 4,000 first responders and medical professionals through the FEMA CDP.

Conclusions: Through collaboration with the FEMA CDP, our UAB faculty were able to successfully deliver a novel virtual disaster preparedness and response course. The course resulted in subjective improvement of students' content understanding while also establishing the feasibility and effectiveness of a VILT format that could be readily applied to future courses in undergraduate medical education and beyond.
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http://dx.doi.org/10.1002/aet2.10647DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8420303PMC
July 2021

A critical analysis of COVID-19 research literature: Text mining approach.

Intell Based Med 2021 17;5:100036. Epub 2021 Jun 17.

Department of Medicine, The University of Alabama at Birmingham, USA.

Objective: Among the stakeholders of COVID-19 research, clinicians particularly experience difficulty keeping up with the deluge of SARS-CoV-2 literature while performing their much needed clinical duties. By revealing major topics, this study proposes a text-mining approach as an alternative to navigating large volumes of COVID-19 literature.

Materials And Methods: We obtained 85,268 references from the NIH COVID-19 Portfolio as of November 21. After the exclusion based on inadequate abstracts, 65,262 articles remained in the final corpus. We utilized natural language processing to curate and generate the term list. We applied topic modeling analyses and multiple correspondence analyses to reveal the major topics and the associations among topics, journal countries, and publication sources.

Results: In our text mining analyses of NIH's COVID-19 Portfolio, we discovered two sets of eleven major research topics by analyzing abstracts and titles of the articles separately. The eleven major areas of COVID-19 research based on abstracts included the following topics: 1) Public Health, 2) Patient Care & Outcomes, 3) Epidemiologic Modeling, 4) Diagnosis and Complications, 5) Mechanism of Disease, 6) Health System Response, 7) Pandemic Control, 8) Protection/Prevention, 9) Mental/Behavioral Health, 10) Detection/Testing, 11) Treatment Options. Further analyses revealed that five (2,3,4,5, and 9) of the eleven abstract-based topics showed a significant correlation (ranked from moderate to weak) with title-based topics.

Conclusion: By offering up the more dynamic, scalable, and responsive categorization of published literature, our study provides valuable insights to the stakeholders of COVID-19 research, particularly clinicians.
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http://dx.doi.org/10.1016/j.ibmed.2021.100036DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8214804PMC
June 2021

Contemporary practice of standardised bedside teaching rounds.

Clin Teach 2020 10 28;17(5):483-488. Epub 2020 Jul 28.

Department of Infectious Disease, University of Alabama School of Medicine, Birmingham, Alabama, USA.

Background: The purpose of this article is to review the extant literature on bedside teaching rounds within the context of ward rounds performed with the entire clinical team at the patient's bedside, and to assess the effects of standardisation of this process on patient and learner satisfaction, as well as other duty-hour restrictions and patient care metrics in the academic inpatient setting. Ultimately, the intent of this review is to inform faculty development sessions for educators on the benefits and challenges of standardised rounding protocols.

Methods: We performed a search of PubMed, Scopus and CINAHL databases (from 2003 to August 2019). Randomised, controlled trials, pre- and post-interventional studies and cohort studies, in English, were eligible for inclusion. Two reviewers independently searched, screened and analysed the studies, and a narrative synthesis was performed. Articles were evaluated methodologically using the Medical Education Research Quality Study Instrument (MERQSI).

Results: Five articles were included, with one randomised controlled trial, three cohort studies, and one pre- and post-interventional study. The collective MERSQI score for the studies was 12.3. Patient satisfaction increased uniformly across studies when standardised practices were used. Attempts to improve learner satisfaction, however, achieved mixed results. In addition, the time of bedside rounds was found to decrease with standardised interventions overall.

Conclusion: In light of generally positive albeit limited evidence for standardised rounding practices, faculty development initiatives might use these data to inform and educate faculty members regarding the use of standardised protocols for bedside rounds.
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http://dx.doi.org/10.1111/tct.13228DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7589403PMC
October 2020

Clinical Investigator Training Program (CITP) - A practical and pragmatic approach to conveying clinical investigator competencies and training to busy clinicians.

Contemp Clin Trials Commun 2020 Sep 12;19:100589. Epub 2020 Jun 12.

University of Alabama at Birmingham, Department of Medicine, Division of Pulmonary, Allergy and Critical Care, United States.

Introduction: Clinical investigation is a critical component of clinical medicine. Yet, other than mentorship by an experienced senior physician, young physicians have few formal training opportunities that fit into their clinical training and convey the pre-requisite clinical investigator competencies. To address this training gap, we designed the Clinical Investigator Training Program (CITP); a practical and pragmatic curriculum weaved into the constant pressures of balancing patient care with academic pursuit required of the academic practitioner.

Methods: Between January 2016 and December 2018, we conducted four CITP courses, with each comprised of four 4-h sessions that included didactic lectures, group projects including the development of a mock clinical protocol, and expert's panel discussions. Each course enrolled 15 participants from an average of 28 applicants. We assessed the knowledge acquired following each course via a pre- and post-course test (-test with positive scores indicating improvement in knowledge base). In addition, we also tracked which participants became first time principal investigator following completion of CITP.

Results: A total of 60 participants enrolled in the 4 CITP courses, and there was a statistically significant improvement in mean post-test scores (p < 0.01). The number of participants achieving first time principal investigator status nearly doubled following CITP from 17 to 33. Conversely, applicants not selected for CITP demonstrated no similar improvement during the same follow up period.

Conclusion: The improvement in test scores and the substantive uptake in first time principal investigator responsibilities following CITP affirms that CITP provides a viable option to convey investigator competencies and encourage clinicians to take on the role of principal investigators.
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http://dx.doi.org/10.1016/j.conctc.2020.100589DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7322677PMC
September 2020

Racial disparities and factors associated with prescription for smoking cessation medications among smokers receiving routine clinical care for HIV.

AIDS Care 2020 10 12;32(10):1207-1216. Epub 2020 Jun 12.

Division of Infectious Diseases, School of Medicine, University of Alabama at Birmingham, Birmingham, AL, USA.

Factors associated with prescription of smoking cessation medication (SCM), including the impact of race, have not been well described among a large population of people living with HIV (PLWH) engaged in routine clinical care. Our study investigated whether there are racial differences between African-American and White PLWH regarding SCM prescription and sought to identify other factors associated with these prescriptions at a large HIV clinic in the Southeastern United States. Among 1899 smokers, 38.8% of those prescribed SCMs were African-American and 61.2% were White. Factors associated with lower odds of SCM prescription included African-American race (AOR, 0.63 [95% CI: 0.47, 0.84]) or transferring care from another HIV provider during the study period (AOR, 0.63 [95% CI: 0.43, 0.91]). Whereas major depression (AOR, 1.54 [95% CI: 1.10, 2.15]), anxiety symptoms (AOR, 1.43 [95% CI: 1.05, 1.94]), and heavy smoking (>20 cigarettes/day) (OR, 3.50 [95% CI: 2.11, 5.98]) were associated with increased likelihood of SCM prescription. There were racial disparities in the prescription of SCM in African Americans with HIV. These findings underscore the need to increase pharmacotherapy use among African Americans to improve smoking cessation outcomes across racial groups among PLWH.
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http://dx.doi.org/10.1080/09540121.2020.1776821DOI Listing
October 2020

Factors Associated with HIV Disclosure Status Among iENGAGE Cohort of New to HIV Care Patients.

AIDS Patient Care STDS 2020 05;34(5):213-227

Department of Medicine, University of Alabama at Birmingham, Birmingham, Alabama.

HIV disclosure is an important behavior with implications for HIV treatment and prevention but understudied among new to HIV care patients who face unique challenges adjusting to a new diagnosis. This study evaluated the factors associated with HIV disclosure status and patterns of HIV disclosure among new to HIV care patients. A cross-sectional study was conducted evaluating the iENGAGE (integrating ENGagement and Adherence Goals upon Entry) cohort. Participants were enrolled in this randomized behavioral trial between December 2013 and June 2016. The primary and secondary outcomes included HIV disclosure status (Yes/No) and patterns of disclosure (Broad, Selective and Nondisclosure), respectively. Logistic and Multinomial Logistic Regression were used to evaluate the association of participant factors with HIV disclosure and patterns of HIV disclosure, respectively. Of 371 participants, the average age was 37 ± 12 years, 79.3% were males, and 62.3% were African Americans. A majority of participants (78.4%) disclosed their HIV status at baseline, 63.1% were broad disclosers and 15.2% were selective disclosers. In multivariable regression, black race, emotional support, and unmet needs predicted any HIV and broad disclosure, whereas males, emotional support, active coping, and acceptance were associated with selective disclosure. Interventions to promote early disclosure should focus on coping strategies and unmet needs, particularly among black and male people living with HIV initiating care.
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http://dx.doi.org/10.1089/apc.2019.0271DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7232702PMC
May 2020

Creating and testing a GCP game in an asynchronous course environment: The game and future plans.

J Clin Transl Sci 2020 Feb 29;4(1):36-42. Epub 2019 Oct 29.

Center for Clinical and Translational Science, University of Alabama at Birmingham, Birmingham, AL, USA.

Introduction: The National Institute of Health has mandated good clinical practice (GCP) training for all clinical research investigators and professionals. We developed a GCP game using the Kaizen-Education platform. The GCP Kaizen game was designed to help clinical research professionals immerse themselves into applying International Conference on Harmonization GCP (R2) guidelines in the clinical research setting through case-based questions.

Methods: Students were invited to participate in the GCP Kaizen game as part of their 100% online academic Masters during the Spring 2019 semester. The structure of the game consisted of 75 original multiple choice and 25 repeated questions stemming from fictitious vignettes that were distributed across 10 weeks. Each question presented a teachable rationale after the answers were submitted. At the end of the game, a satisfaction survey was issued to collect player satisfaction data on the game platform, content, experience as well as perceptions of GCP learning and future GCP concept application.

Results: There were 71 total players who participated and answered at least one question. Of those, 53 (75%) answered all 100 questions. The game had a high Cronbach's alpha, and item analyses provided information on question quality, thus assisting us in future quality edits before re-testing and wider dissemination.

Conclusions: The GCP Kaizen game provides an alternative method for mandated GCP training using principles of gamification. It proved to be a reliable and an effective educational method with high player satisfaction.
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http://dx.doi.org/10.1017/cts.2019.423DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7103470PMC
February 2020

Gamification: An Innovative Approach to Reinforce Clinical Knowledge for MD-PhD Students During Their PhD Research Years.

Med Sci Educ 2019 Sep 30;29(3):739-747. Epub 2019 Apr 30.

UAB School of Medicine, University of Alabama at Birmingham, 1825 University Blvd, Birmingham, AL 35294, USA.

A longstanding challenge facing MD-PhD students and other dual-degree medical trainees is the loss of clinical knowledge that occurs during the non medical phases of training. Academic medical institutions nationwide have developed continued clinical training and exposure to maintain clinical competence; however, quantitative assessment of their usefulness remains largely unexplored. The current study therefore sought to both implement and optimize an online game platform to support MD-PhD students throughout their research training. Sixty three current MD-PhD students completing the PhD research phase of training were enrolled in an institutionally-developed online game platform for 2 preliminary and 4 competition rounds of 3-4 weeks each. During preliminary game rounds, we found that participation, though initially high, declined precipitously throughout the duration of each round, with 37 students participating to some extent. Daily reminders were implemented in subsequent rounds, which markedly improved player participation. Average participation in competition rounds exceeded 35% (23/63) active participants each round, with trending improvement in scores throughout the duration of PhD training. Both player participation and progress through the research phase of the MD-PhD program correlated positively with game performance and therefore knowledge retention and/or acquisition. Coupled with positive survey-based feedback from participants, our data therefore suggest that gamification is an effective tool for MD-PhD programs to combat loss of clinical knowledge during research training.
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http://dx.doi.org/10.1007/s40670-019-00725-1DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7028303PMC
September 2019

Physical activity trends and metabolic health outcomes in people living with HIV in the US, 2008-2015.

Prog Cardiovasc Dis 2020 Mar - Apr;63(2):170-177. Epub 2020 Feb 12.

Division of Infectious Diseases, University of Alabama at Birmingham, Birmingham, AL, United States of America.

Despite its potential to improve metabolic health outcomes, longitudinal physical activity (PA) patterns and their association with cardiometabolic disease among people living with HIV (PLWH) have not been well characterized. We investigated this relationship among PLWH in the Centers for AIDS Research Network of Integrated Clinical Systems with at least one PA self-report between 2008 and 2015. The 4-item Lipid Research Clinics PA instrument was used to categorize habitual PA levels as: Very Low, Low, Moderate, or High. We analyzed demographic differences in PA patterns. Multivariable generalized estimating equation regression models were fit to assess longitudinal associations of PA with blood pressure, lipid, and glucose levels. Logistic regression modeling was used to assess the odds of being diagnosed with obesity, cardiovascular disease (CVD), cerebrovascular disease, hypertension, diabetes, or multimorbidity. A total of 40,462 unique PA assessments were provided by 11,719 participants. Only 13% of PLWH reported High PA, while 68% reported Very Low/Low PA at baseline and did not increase PA levels during the study period. Compared to those reporting High PA, participants with Very Low PA had almost 2-fold increased risk for CVD. Very Low PA was also associated with several risk factors associated with CVD, most notably elevated triglycerides (odds ratio 25.4), obesity (odds ratio 1.9), hypertension (odds ratio 1.4), and diabetes (odds ratio 2.3; all p < 0.01). Low levels of PA over time among PLWH are associated with increased cardiometabolic disease risk.
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http://dx.doi.org/10.1016/j.pcad.2020.02.005DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7315582PMC
June 2020

The 5-Es: a model for providing care for non-neurotypical patients.

Pediatr Res 2020 11 13;88(5):686-687. Epub 2020 Feb 13.

The University of Alabama at Birmingham, Birmingham, AL, USA.

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http://dx.doi.org/10.1038/s41390-020-0810-0DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7577849PMC
November 2020

Kaizen: Interactive Gaming for Diabetes Patient Education.

Games Health J 2019 Dec;8(6):423-431

UAB School of Medicine, Birmingham, Alabama.

An estimated 100 million Americans have diabetes, undiagnosed diabetes, a high risk of being diagnosed with diabetes, or prediabetes. Many complications can arise if diabetes is poorly managed. Hence, the need for adequate knowledge, skills, and ability to care for oneself, known as diabetes self-care management, is needed to reduce complication rates. We used an interactive platform that incorporates principles of gamification to enhance user engagement to enhance diabetes knowledge. The purpose of this descriptive pilot study was to discover what adult patients with diabetes thought about this novel educational approach to diabetes education. We collected focus group data from participants at a diabetes clinic after they played an interactive diabetes trivia game, on our software platform (Kaizen Education). Transcripts were coded and common themes were identified. We conducted 9 focus groups that included 33 adult (age >18) participants who had diabetes. An overarching theme of play/gaming as a form of learning was apparent, and after analyzing the coding several themes emerged, including preferences and desired environments (clinic and home) for learning, desired players (including family, significant others), and a good balance of question difficulty. Participants were overwhelmingly positive about gamified education and felt empowered to lead discussions with their health care providers about diabetes self-care education, in a sense "flipping" the traditional clinic patient education paradigm. These results suggested that a flipped clinic approach could be beneficial, empowering, and engaging for patients.
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http://dx.doi.org/10.1089/g4h.2018.0107DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6882451PMC
December 2019

Mental health disorders and alcohol use are associated with increased likelihood of smoking relapse among people living with HIV attending routine clinical care.

BMC Public Health 2019 Oct 29;19(1):1409. Epub 2019 Oct 29.

Department of Health Behavior, School of Public Health, University of Alabama at Birmingham, Birmingham, USA.

Background: People living with HIV (PLWH) have a high level of interest in quitting smoking, but only a small proportion have sustainable abstinence 6 months after cessation. Few investigations have focused on relapse to smoking among PLWH. In this investigation, we evaluated the prevalence of relapse after smoking cessation and the characteristics associated with smoking relapse using a retrospective, longitudinal cohort of PLWH during an eight-year observation.

Methods: All patients aged ≥19 years that reported current smoking during the study period and then reported not smoking on a subsequent tobacco use questionnaire (quitters) were eligible for the study. In addition, patients required at least one subsequent follow-up visit after quitting where smoking status was again reported to allow for assessment of relapse. A Cox proportional hazard model was fit to evaluate factors associated with smoking relapse in PLWH attending routine clinical care.

Results: Of the 473 patients who quit smoking in the study, 51% relapsed. In multivariable analysis, factors significantly associated with a higher likelihood of relapse were anxiety symptoms (HR = 1.55, 95% CI [1.11, 2.17]) and at-risk alcohol use (HR = 1.74, 95% CI [1.06, 2.85]), whereas antiretroviral therapy (ART) adherence (HR = 0.65, 95% CI [0.49, 0.99]) and longer time in care (HR = 0.94, 95% CI [0.91, 0.98]) were associated with a reduced likelihood of relapse after cessation.

Conclusion: Our study underscores the high prevalence of smoking relapse that exists among PLWH after they quit smoking. Successful engagement in mental health care may enhance efforts to reduce relapse in the underserved populations of PLWH.
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http://dx.doi.org/10.1186/s12889-019-7705-1DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6819600PMC
October 2019

Which patient reported outcome domains are important to the rheumatologists while assessing patients with rheumatoid arthritis?

BMC Rheumatol 2019 5;3:36. Epub 2019 Sep 5.

3Division of General Internal Medicine, Weill Cornell Medicine, 420 E 70th St., LH-363, New York, NY 10021 USA.

Background: Patient-reported outcomes (PROs) aid in rheumatoid arthritis (RA) management, but it is not well understood which measures would be most relevant to the rheumatologists for making treatment decisions.

Methods: We recruited rheumatologists nationally to participate in moderated structured group teleconference discussions using the nominal group technique. Participants in each group generated lists of the elements from patient's history and signs that they use to make treatment recommendations for RA. Each participant then selected the three most important elements from the generated list. The results of each group were then combined and summarized.

Results: Twenty-five rheumatologists participated in 4 groups (group size ranged from 4 to 8) and 150 available ranking votes across all groups. The statements generated across the 4 groups were categorized into 13 topics (including symptoms, physical function, comorbidities, social aspects, physical findings, response to treatment, treatment adherence, pain management, side effects, tests, access to care, contraception, and organ involvement), 10 of which received ranking votes. Symptoms received the highest ranking (46% of votes), followed by physical function (16%), and physical findings (13%). Among the unranked topics, social aspects had the highest number of statements (8 statements).

Conclusion: Rheumatologists highly valued patient-reported RA symptoms and physical function to inform their treatment decisions, even above objective data such as physical findings and test results. These results can guide the selection of validated PRO measures to assess these domains to inform the clinical care of patients with rheumatoid arthritis.
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http://dx.doi.org/10.1186/s41927-019-0087-2DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6727422PMC
September 2019

Assessing a novel way to measure three common rehabilitation outcome measures using a custom mobile phone application.

Gait Posture 2019 09 26;73:246-250. Epub 2019 Jul 26.

Department of Physical Therapy, University of Alabama at Birmingham, Birmingham, AL, United States.

Background: Clinicians often use thirty-second-sit (chair)-to-stand (30CST), timed-up-and-go (TUG), and the five-times-sit-to-stand (5xSTS) since these outcome measures (OMs) are sensitive for strength, balance and mobility.

Research Question: The purpose of this study was to validate a custom smart phone application (App) that can remotely assess the 30CST, TUG, and 5xSTS.

Methods: Thirty-one healthy adults (range: 22-55 y; 54.6-106.8 kg; 160-185 cm; 19 females) participated in this cross-sectional study. Each participant performed the 30CST, TUG, and 5xSTS at a slow and normal speed. They performed each OMs twice while the App collected their performance data using both an iOS and Android phone. The gold standard of each test was the average of the silent count of two investigators for the 30CST and the time recorded by two investigators using stopwatches for the TUG and 5xSTS. Investigators analyzed the data using Intraclass Correlation coefficients (ICC), Pearson R coefficients, Signed Rank Tests, and Wilcoxon Rank-Sum Tests.

Results And Significance: A significant correlation was observed between the performances recorded by the phones and the direct observation gold standard for all three OMs (r > 0.97). For 30CST, no significant mean count differences were found for the following comparisons: between phones, within phone types, or within phone-by-speed levels. (P-values range 0.06-1.00). While a statistically significant difference was found in all of the time comparisons when performing TUG and 5xSTS (p < 0.0001) except for the between phone comparison with TUG (p = 0.27). For TUG and 5xSTS, the time difference was less than a second when compared to the gold standard and ICCs showed moderate to strong agreement when comparing the phone application to the gold standard (ICCs range 0.60-0.99). These data suggested that the App could validly measure performance of these OMs.
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http://dx.doi.org/10.1016/j.gaitpost.2019.07.251DOI Listing
September 2019

Mortality following myocardial infarction among HIV-infected persons: the Center for AIDS Research Network Of Integrated Clinical Systems (CNICS).

BMC Med 2019 07 31;17(1):149. Epub 2019 Jul 31.

University of Washington School of Medicine, Seattle, USA.

Background: Persons with human immunodeficiency virus (HIV) have higher risks for myocardial infarction (MI) than the general population. This is driven in part by higher type 2 MI (T2MI, due to coronary supply-demand mismatch) rates among persons with HIV (PWH). In the general population, T2MI has higher mortality than type 1 MI (T1MI, spontaneous and generally due to plaque rupture and thrombosis). PWH have a greater burden of comorbidities and may therefore have an even greater excess risk for complication and death in the setting of T2MI. However, mortality patterns after T1MI and T2MI in HIV are unknown.

Methods: We analyzed mortality after MI among PWH enrolled in the multicenter, US-based Centers for AIDS Research Network of Integrated Clinical Systems (CNICS) cohort (N = 28,186). Incident MIs occurring between January 1, 1996, and December 31, 2014, were centrally adjudicated and classified as T1MI or T2MI. We first compared mortality following T1MI vs. T2MI among PWH. Cox survival analyses and Bayesian model averaging were then used to evaluate pre-MI covariates associated with mortality following T1MI and T2MI.

Results: Among the 596 out of 28,186 PWH who experienced MI (2.1%; 293 T1MI and 303 T2MI), mortality rates were significantly greater after T2MI (22.2/100 person-years; 1-, 3-, and 5-year mortality 39%, 52%, and 62%) than T1MI (8.2/100 person-years; 1-, 3-, and 5-year mortality 15%, 22%, and 30%). Significant mortality predictors after T1MI were higher HIV viral load, renal dysfunction, and older age. Significant predictors of mortality after T2MI were low body-mass index (BMI) and detectable HIV viral load.

Conclusions: Mortality is high following MI for PWH and substantially greater after T2MI than T1MI. Predictors of death after MI differed by type of MI, reinforcing the different clinical scenarios associated with each MI type and the importance of considering MI types separately.
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http://dx.doi.org/10.1186/s12916-019-1385-7DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6668167PMC
July 2019

Which Student Characteristics Are Most Important in Determining Clinical Honors in Clerkships? A Teaching Ward Attending Perspective.

Acad Med 2019 10;94(10):1581-1588

L.N. Herrera is a second-year internal medicine resident, Department of Medicine, Baylor College of Medicine, Houston, Texas. The author was a fourth-year medical student, University of Alabama at Birmingham School of Medicine, Birmingham, Alabama, at the time of the study. R. Khodadadi is a second-year internal medicine resident, Department of Medicine, Mayo Clinic School of Graduate Medical Education, Rochester, Minnesota. The author was a fourth-year medical student, University of Alabama at Birmingham School of Medicine, Birmingham, Alabama, at the time of the study. E. Schmit is a fellow, Pediatric Hospital Medicine, Department of Pediatrics, University of Alabama at Birmingham, Birmingham, Alabama. J. Willig is associate professor of medicine, Department of Medicine, University of Alabama at Birmingham, Birmingham, Alabama. A. Hoellein is associate dean for student affairs and associate professor of medicine, University of Kentucky College of Medicine, Lexington, Kentucky. C. Knudson is staff physician, Emory University Hospital Midtown, and assistant professor of medicine, Division of Hospital Medicine, Emory University School of Medicine, Atlanta, Georgia. K. Law is program director, J. Willis Hurst Internal Medicine Residency Program, Emory University, and associate vice chair of education and associate professor of medicine, Division of Rheumatology, Emory University School of Medicine, Atlanta, Georgia. N. Mingioni is staff physician, Thomas Jefferson University Hospital, and clinical associate professor of medicine, Sidney Kimmel Medical College at Thomas Jefferson University, Philadelphia, Pennsylvania. K. Walsh is assistant professor of clinical internal medicine, Division of Hematology and Department of Medicine, The Ohio State University, Columbus, Ohio. C. Estrada is staff physician, Birmingham Veterans Affairs Medical Center, and professor of medicine, Department of Medicine, University of Alabama at Birmingham, Birmingham, Alabama. W. Williams is clerkship codirector and assistant professor of medicine, Department of Medicine, University of Alabama at Birmingham, and staff physician, Birmingham Veterans Affairs Medical Center, Birmingham, Alabama.

Purpose: To explore faculty perspectives on which characteristics of high-performing clerkship students are most important when determining an honors or top grade designation for clinical performance.

Method: In 2016-2017, the authors surveyed faculty (teaching ward attendings) for internal medicine clerkships and 1 pediatrics clerkship in inpatient settings at 5 U.S. academic medical centers. Survey items were framed around competencies, 24 student characteristics, and attitudes toward evaluation. Factor analysis examined constructs defining high-performing students.

Results: Of 516 faculty invited, 319 (62%) responded. The top 5 characteristics as rated by respondents were taking ownership, clinical reasoning, curiosity, dependability, and high ethical standards (in descending order). Twenty-one characteristics fit into 3 factors (Cronbach alpha, 0.81-0.87). Clinical reasoning did not fit into a factor. Factor 1 was the most important (mean rating, 8.7/10 [95% confidence interval (CI), 8.6-8.8]). It included professionalism components (ownership, curiosity, dependability, high ethical standards), presentation and interviewing skills, seeking feedback, and documentation. Factor 2 (mean, 7.9 [95% CI, 7.7-8.0]) included aspects of teamwork and communication, such as positive attitude and comments from others. Factor 3 (mean, 7.6 [95% CI, 7.4-7.7]) addressed systems-based thinking, including patient safety and care transitions.

Conclusions: Professionalism components, clinical reasoning, and curiosity were among the most important characteristics distinguishing high-performing clerkship students. These may represent behaviors that are highly valued, observable, and relevant to training stage. Improved definition of the characteristics associated with clinical honors would assist students, faculty, and residency program directors when interpreting clinical performance within core clerkships.
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http://dx.doi.org/10.1097/ACM.0000000000002836DOI Listing
October 2019

Predictors of smoking cessation among people living with HIV receiving routine clinical care.

AIDS Care 2019 11 22;31(11):1353-1361. Epub 2019 May 22.

Department of Health Behavior, School of Public Health, University of Alabama , Birmingham , AL , USA.

People living with HIV (PLWH) have a higher prevalence of smoking and are less likely to quit smoking than the general population. Few studies involving a large sample of PLWH receiving routine care have evaluated factors associated with smoking cessation. This retrospective longitudinal cohort study evaluated factors associated with smoking cessation among PLWH from 2007 to 2018. Of 1,714 PLWH smokers included in the study, 27.6% reported quitting smoking. Suppressed plasma HIV-1 RNA (<200 copies/ml) was significantly associated with an increased likelihood of smoking cessation (HR = 1.27, 95% CI [1.03, 1.58]); whereas age/10 year increments (HR = 0.12, 95% CI [0.04, 0.38]), greater length of care at the HIV clinic (HR = 0.97, 95% CI [0.94, 0.99]), lack of insurance (HR = 0.77, 95% CI [0.61, 0.99]) or having public insurance (HR = 0.74, 95% CI [0.55, 0.97)]), current substance use (HR = 0.66, 95% CI [0.43, 0.97]) and risk of developing alcohol use disorder (HR = 0.60, 95% CI [0.43, 0.84]) were associated with a reduced likelihood of quitting smoking. These findings underscore the importance of early smoking cessation intervention among PLWH. In addition, targeted smoking cessation intervention strategies are needed for groups at risk for being less likely to quit, including older patients, and those with alcohol and substance use disorders.
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http://dx.doi.org/10.1080/09540121.2019.1619659DOI Listing
November 2019

Contemporary Trainee Knowledge of Autism: How Prepared Are Our Future Providers?

Front Pediatr 2019 26;7:165. Epub 2019 Apr 26.

Department of Pediatrics, University of Alabama at Birmingham, Birmingham, AL, United States.

Over the last several decades, the prevalence of Autism Spectrum Disorder (ASD) has continued to increase, creating a unique challenge for general physicians who are likely to encounter these patients in their practice. The primary aim of this cross-sectional study design was to identify potential knowledge gaps that were present among medical students and pediatric trainees (interns, residents, and fellows) particularly during the management of a sick child with ASD. A 23-question online survey was developed and distributed to medical students and pediatric trainees at a tertiary children's hospital affiliated with a medical school. Medical students and pediatric trainees reported a low general knowledge of ASD and were unfamiliar with sensory issues that are often present in these children. Increased discomfort and insufficient didactic and clinical training for providing care to children with ASD during an acute illness were also identified. Both medical students and trainees reported the need for increased education and training, preferentially via patient interaction and small group-based learning. We found that as education/training levels increased, participants perceived increased comfort, and knowledge in managing an ill child with ASD. A perceived knowledge gap and discomfort is present amongst medical students and pediatric trainees on the management of children with ASD. Across all education levels, awareness for sensory dysregulation in ASD children is low. Education programs using direct patient interaction and small group learning were the preferred training modalities to learn how to provide optimal care for children with ASD.
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http://dx.doi.org/10.3389/fped.2019.00165DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6498887PMC
April 2019

"Playing for Bragging Rights": A Qualitative Study of Students' Perceptions of Gamification.

J Nurs Educ 2019 Feb;58(2):79-85

Background: Nursing faculty sought to promote students' engagement with course material and their peers by using Kaizen, an online educational game. The purpose of this qualitative study was to learn more about nursing students' perceptions of team competition in an educational game and whether the game promoted their engagement with educational material in one fundamental nursing course.

Method: Qualitative data collection included focus groups, observations of students, documents showing leaderboards and game participation, and "status of competition" e-mails. Data were transcribed and coded to determine emerging themes.

Results: Four themes emerged from data analysis: learning in teams, motivators to play, learning course content, and suggestions for game improvement.

Conclusion: Students were overwhelmingly positive about using a gamified platform for its educational rewards. They perceived that playing the game increased their knowledge retention, and they believed it helped them improve their test-taking skills. [J Nurs Educ. 2019;58(2):79-85.].
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http://dx.doi.org/10.3928/01484834-20190122-04DOI Listing
February 2019

Contributions of traditional and HIV-related risk factors on non-AIDS-defining cancer, myocardial infarction, and end-stage liver and renal diseases in adults with HIV in the USA and Canada: a collaboration of cohort studies.

Lancet HIV 2019 02 22;6(2):e93-e104. Epub 2019 Jan 22.

University of North Carolina, Chapel Hill, NC, USA.

Background: Adults with HIV have an increased burden of non-AIDS-defining cancers, myocardial infarction, end-stage liver disease, and end-stage renal disease. The objective of this study was to estimate the population attributable fractions (PAFs) of preventable or modifiable HIV-related and traditional risk factors for non-AIDS-defining cancers, myocardial infarction, end-stage liver disease, and end-stage renal disease outcomes.

Methods: We included participants receiving care in academic and community-based outpatient HIV clinical cohorts in the USA and Canada from Jan 1, 2000, to Dec 31, 2014, who contributed to the North American AIDS Cohort Collaboration on Research and Design and who had validated non-AIDS-defining cancers, myocardial infarction, end-stage liver disease, or end-stage renal disease outcomes. Traditional risk factors were tobacco smoking, hypertension, elevated total cholesterol, type 2 diabetes, renal impairment (stage 4 chronic kidney disease), and hepatitis C virus and hepatitis B virus infections. HIV-related risk factors were low CD4 count (<200 cells per μL), detectable plasma HIV RNA (>400 copies per mL), and history of a clinical AIDS diagnosis. PAFs and 95% CIs were estimated to quantify the proportion of outcomes that could be avoided if the risk factor was prevented.

Findings: In each of the study populations for the four outcomes (1405 of 61 500 had non-AIDS-defining cancer, 347 of 29 515 had myocardial infarctions, 387 of 35 044 had end-stage liver disease events, and 255 of 35 620 had end-stage renal disease events), about 17% were older than 50 years at study entry, about 50% were non-white, and about 80% were men. Preventing smoking would avoid 24% (95% CI 13-35) of these cancers and 37% (7-66) of the myocardial infarctions. Preventing elevated total cholesterol and hypertension would avoid the greatest proportion of myocardial infarctions: 44% (30-58) for cholesterol and 42% (28-56) for hypertension. For liver disease, the PAF was greatest for hepatitis C infection (33%; 95% CI 17-48). For renal disease, the PAF was greatest for hypertension (39%; 26-51) followed by elevated total cholesterol (22%; 13-31), detectable HIV RNA (19; 9-31), and low CD4 cell count (13%; 4-21).

Interpretation: The substantial proportion of non-AIDS-defining cancers, myocardial infarction, end-stage liver disease, and end-stage renal disease outcomes that could be prevented with interventions on traditional risk factors elevates the importance of screening for these risk factors, improving the effectiveness of prevention (or modification) of these risk factors, and creating sustainable care models to implement such interventions during the decades of life of adults living with HIV who are receiving care.

Funding: National Institutes of Health, US Centers for Disease Control and Prevention, the US Agency for Healthcare Research and Quality, the US Health Resources and Services Administration, the Canadian Institutes of Health Research, the Ontario Ministry of Health and Long Term Care, and the Government of Alberta.
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http://dx.doi.org/10.1016/S2352-3018(18)30295-9DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6589140PMC
February 2019

Gamification as a tool for resident education in otolaryngology: A pilot study.

Laryngoscope 2019 02 13;129(2):358-361. Epub 2018 Nov 13.

Department of Otolaryngology-Head and Neck Surgery, Birmingham, Alabama, U.S.A.

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http://dx.doi.org/10.1002/lary.27286DOI Listing
February 2019

Assessing a novel way to measure step count while walking using a custom mobile phone application.

PLoS One 2018 6;13(11):e0206828. Epub 2018 Nov 6.

Division of Infectious Disease, University of Alabama at Birmingham, Birmingham, Alabama, United States of America.

Introduction: Walking speed has been associated with many clinical outcomes (e.g., frailty, mortality, joint replacement need, etc.). Accurately measuring walking speed (stride length x step count/time) typically requires significant clinician/staff time or a gait lab with specialized equipment (i.e., electronic timers or motion capture). In the present study, our goal was to measure "step count" via smartphones through novel software and to compare with step tracking software that come standard with iOS and Android smartphones as a first step in walking speed measurement.

Methods: A separate calibration and validation data collection was performed. Individuals in the calibration collection (n = 5) walked 20m at normal and slow speed (<1.0 m/s). Appropriate settings for the novel mobile application were chosen to measure step count. Individuals in the validation (n = 52) collection walked at 6m, 10m, and 20m at normal and slow walking speeds. We compared step difference (absolute difference) from observed step counts to native step tracking software and our novel software derived step counts. We used generalized estimated equation adjusted (participant level) negative binomial regression models of absolute step difference from observed step counts, to determine optimal settings (calibration) and subsequently to gauge performance of the shake algorithm settings and native step tracking software across different distances and speeds (validation).

Results: For iOS/iPhone 6, when compared to observed step count, the shake service (software driven approach) significantly outperformed the embedded native step tracking software across all distances at slow speed, and for short distance (6m) at normal speed. On the Android phone, the shake service outperformed the native step tracking software at slow speed at 6 meters and 20 meters, while its performance eclipsed the native step tracking software only at 20 meters at normal speed.

Discussion: Our software based approach outperformed native step tracking software across various speeds and distances and carries the advantage of having adjustable measurement parameters that can be further optimized for specific medical conditions. Such software applications will provide an effective way to capture standardized data across multiple commercial smartphone devices, facilitating the future capture of walking speed and other clinically important performance parameters that will influence clinical and home care in the era of value based care.
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http://journals.plos.org/plosone/article?id=10.1371/journal.pone.0206828PLOS
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6219786PMC
April 2019

Educational Analytics: A New Frontier for Gamification?

Comput Inform Nurs 2018 Sep;36(9):458-465

Author Affiliations: Family, Community, and Health Systems (Drs Roche and Azuero) and Acute, Chronic and Continuing Care (Dr Wingo), University of Alabama at Birmingham (UAB) School of Nursing; Biostatistics, UAB School of Public Health (Mr Westfall); UAB Center for Clinical and Translational Science (Mr Dempsey); and Division of Infectious Diseases, UAB School of Medicine (Dr Willig).

To determine the effects of gamification on student education, researchers implemented "Kaizen," a software-based knowledge competition, among a first-year class of undergraduate nursing students. Multiple-choice questions were released weekly or biweekly during two rounds of play. Participation was voluntary, and students could play the game using any Web-enabled device. Analyses of data generated from the game included (1) descriptive, (2) logistic regression modeling of factors associated with user attrition, (3) generalized linear mixed model for retention of knowledge, and (4) analysis of variance of final examination performance by play styles. Researchers found a statistically significant increase in the odds of a correct response (odds ratio, 1.8; 95% confidence interval, 1.0-3.4) for a round 1 question repeated in round 2, suggesting retention of knowledge. They also found statistically significant differences in final examination performance among different play styles.To maximize the benefits of gamification, researchers must use the resulting data both to power educational analytics and to inform nurse educators how to enhance student engagement, knowledge retention, and academic performance.
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http://dx.doi.org/10.1097/CIN.0000000000000455DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6133730PMC
September 2018

Case Studies from the Clinic: Initiating and Implementing Patient-Reported Outcome Measures.

EGEMS (Wash DC) 2017 Jun 12;5(1). Epub 2017 Jun 12.

Flatiron Health.

Introduction: Self-reporting by patients though the use of electronic patient-reported outcome (PRO) measures has been shown to use increase patient satisfaction with care, and improve patient-provider communication, symptom management, and health quality. Additionally, PROs are increasingly used in research to expand understanding regarding the relative risks, benefits, and burdens of interventions. While experience embedding patient-reported outcomes (PROs) into registries and clinical workflow is growing, there is little in the literature to guide those interested in incorporating PROs into routine clinical care for use in research.

Case Descriptions: The NIH Health Care Systems Research Collaboratory PRO Core interviewed investigators from seven programs to get their first-hand experiences on the incorporation of PROs for both care and research, and the investigators have contributed to this manuscript as authors.

Findings: We use these case studies to present practical approaches to initiating and implementing PROS, including instrument selection, tips for integrating PRO collection systems into clinical workflow, considerations for user experience and data collection, and the methods to assess and monitor quality.

Conclusion: Because the decision to initiate and implement PRO collection impacts many different stakeholders, the solution requires collaboration among the involved parties, careful planning, and integration into clinical workflow.
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http://dx.doi.org/10.5334/egems.224DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC5994950PMC
June 2017

Perspectives of Rheumatoid Arthritis Patients on Electronic Communication and Patient-Reported Outcome Data Collection: A Qualitative Study.

Arthritis Care Res (Hoboken) 2019 01;71(1):80-87

Weill Cornell Medical College, New York, New York.

Objective: To identify the perspectives of patients with rheumatoid arthritis (RA) on electronic recording of between-visit disease activity and other patient-reported outcomes (PROs) and on sharing this information with health care providers or peers.

Methods: Patients with RA were recruited to participate in focus groups from December 2014 to April 2015. The topic guide and analysis were based on the Andersen-Newman framework. Sessions were audiorecorded, transcribed, independently coded, and analyzed for themes.

Results: Thirty-one patients participated in 7 focus groups. Their mean ± SD age was 51 ± 13.1 years, 94% were women, 52% were African American, 11% were Hispanic, and 37% were white. Three themes emerged: provider communication, information-seeking about RA, and social and peer support. Participants expressed a willingness to track disease activity data to share with health care providers electronically if providers would act on the information. Participants envisioned symptom tracking and information sharing as a mechanism to relay and obtain reliable information about RA. Participants were also interested in electronic communication between visits if it facilitated learning about symptom management and enhanced opportunities for social support among patients with RA.

Conclusion: Patients with RA may be amenable to electronic collection and sharing of PRO-type data between clinical encounters if it facilitates communication with health care providers and provides access to reliable information about RA. Providing patients with social support was important for enhancing PROs collection by helping them overcome barriers by using electronic devices and overcome reservations about the value of these data.
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http://dx.doi.org/10.1002/acr.23580DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6388703PMC
January 2019

Implications of DRG Classification in a Bundled Payment Initiative for COPD.

Am J Accountable Care 2017 Dec 8;5(4):12-18. Epub 2017 Dec 8.

Department of Medicine (TMP, SPB, JMW, dK, ASI, MM, JHW, MTD), and Division of Pulmonary, Allergy, and Critical Care (TMP, SPB, JMW, dK, ASI, MTD), and Division of Infectious Diseases (MM, JHW), University of Alabama at Birmingham, Birmingham, AL; UAB Lung Health Center (TMP, SPB, JMW, dK, ASI, MTD), Birmingham, AL; Department of Biostatistics (AOW), and Department of Health Behavior (MM), University of Alabama School of Public Health, Birmingham, AL; Birmingham VA Medical Center (JMW, MTD), Birmingham, AL.

Objectives: Institutions participating in the Medicare Bundled Payments for Care Improvement (BPCI) initiative invest significantly in efforts to reduce readmissions and costs for patients who are included in the program. Eligibility for the BPCI initiative is determined by diagnosis-related group (DRG) classification. The implications of this methodology for chronic diseases are not known. We hypothesized that patients included in a BPCI initiative for chronic obstructive pulmonary disease (COPD) would have less severe illness and decreased hospital utilization compared with those excluded from the bundled payment initiative.

Study Design: Retrospective observational study.

Methods: We sought to determine the clinical characteristics and outcomes of Medicare patients admitted to the University of Alabama at Birmingham Hospital with acute exacerbations of COPD between 2012 and 2014 who were included and excluded in a BPCI initiative. Patients were included in the analysis if they were discharged with a COPD DRG or with a non-COPD DRG but with an code for COPD exacerbation.

Results: Six hundred and ninety-eight unique patients were discharged for an acute exacerbation of COPD; 239 (34.2%) were not classified into a COPD DRG and thus were excluded from the BPCI initiative. These patients were more likely to have intensive care unit (ICU) admissions (63.2% vs 4.4%, respectively; <.001) and require noninvasive (46.9% vs 6.5%; <.001) and invasive mechanical ventilation (41.4% vs 0.7%; <.001) during their hospitalization than those in the initiative. They also had a longer ICU length of stay (5.2 vs 1.8 days; = .011), longer hospital length of stay (10.3 days vs 3.9 days; <.001), higher in-hospital mortality (14.6% vs 0.7%; <.001), and greater hospitalization costs (median = $13,677 [interquartile range = $7489-$23,054] vs $4281 [$2718-$6537]; <.001).

Conclusions: The use of DRGs to identify patients with COPD for inclusion in the BPCI initiative led to the exclusion of more than one-third of patients with acute exacerbations who had more severe illness and worse outcomes and who may benefit most from the additional interventions provided by the initiative.
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http://www.ncbi.nlm.nih.gov/pmc/articles/PMC5881946PMC
December 2017

Racial disparities in the prevalence and control of hypertension among a cohort of HIV-infected patients in the southeastern United States.

PLoS One 2018 29;13(3):e0194940. Epub 2018 Mar 29.

Division of Infectious Diseases, University of Alabama at Birmingham, Birmingham, Alabama, United States of America.

Background: African Americans are disproportionately affected by both HIV and hypertension. Failure to modify risk factors for cardiovascular disease and chronic kidney disease such as hypertension among HIV-infected patients may attenuate the benefits conferred by combination antiretroviral therapy. In the general population, African Americans with hypertension are less likely to have controlled blood pressure than whites. However, racial differences in blood pressure control among HIV-infected patients are not well studied.

Methods: We conducted a cross-sectional study evaluating racial differences in hypertension prevalence, treatment, and control among 1,664 patients attending the University of Alabama at Birmingham HIV Clinic in 2013. Multivariable analyses were performed to calculate prevalence ratios (PR) with 95% confidence intervals (CI) as the measure of association between race and hypertension prevalence and control while adjusting for other covariates.

Results: The mean age of patients was 47 years, 77% were male and 54% African-American. The prevalence of hypertension was higher among African Americans compared with whites (49% vs. 43%; p = 0.02). Among those with hypertension, 91% of African Americans and 93% of whites were treated (p = 0.43). Among those treated, 50% of African Americans versus 60% of whites had controlled blood pressure (systolic blood pressure <140 mmHg and diastolic blood pressure <90 mmHg) (p = 0.007). After multivariable adjustment for potential confounders, prevalence of hypertension was higher among African Americans compared to whites (PR 1.25; 95% CI 1.12-1.39) and prevalence of BP control was lower (PR 0.80; 95% CI 0.69-0.93).

Conclusions: Despite comparable levels of hypertension treatment, African Americans in our HIV cohort were less likely to achieve blood pressure control. This may place them at increased risk for adverse outcomes that disproportionately impact HIV-infected patients, such as cardiovascular disease and chronic kidney disease, and thus attenuate the benefits conferred by combination antiretroviral therapy.
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http://journals.plos.org/plosone/article?id=10.1371/journal.pone.0194940PLOS
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC5875791PMC
July 2018

Clinical Informatics Researcher's Desiderata for the Data Content of the Next Generation Electronic Health Record.

Appl Clin Inform 2017 10 21;8(4):1159-1172. Epub 2017 Dec 21.

Informatics Institute, School of Medicine, University of Alabama at Birmingham, Birmingham, Alabama, United States.

Objective: Clinical informatics researchers depend on the availability of high-quality data from the electronic health record (EHR) to design and implement new methods and systems for clinical practice and research. However, these data are frequently unavailable or present in a format that requires substantial revision. This article reports the results of a review of informatics literature published from 2010 to 2016 that addresses these issues by identifying categories of data content that might be included or revised in the EHR.

Materials And Methods: We used an iterative review process on 1,215 biomedical informatics research articles. We placed them into generic categories, reviewed and refined the categories, and then assigned additional articles, for a total of three iterations.

Results: Our process identified eight categories of data content issues: Adverse Events, Clinician Cognitive Processes, Data Standards Creation and Data Communication, Genomics, Medication List Data Capture, Patient Preferences, Patient-reported Data, and Phenotyping.

Discussion: These categories summarize discussions in biomedical informatics literature that concern data content issues restricting clinical informatics research. These barriers to research result from data that are either absent from the EHR or are inadequate (e.g., in narrative text form) for the downstream applications of the data. In light of these categories, we discuss changes to EHR data storage that should be considered in the redesign of EHRs, to promote continued innovation in clinical informatics.

Conclusion: Based on published literature of clinical informaticians' reuse of EHR data, we characterize eight types of data content that, if included in the next generation of EHRs, would find immediate application in advanced informatics tools and techniques.
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http://dx.doi.org/10.4338/ACI-2017-06-R-0101DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC5802316PMC
October 2017

Multisite Investigation of Outcomes With Implementation of CYP2C19 Genotype-Guided Antiplatelet Therapy After Percutaneous Coronary Intervention.

JACC Cardiovasc Interv 2018 01 1;11(2):181-191. Epub 2017 Nov 1.

Department of Medicine, University of Maryland, Baltimore, Maryland.

Objectives: This multicenter pragmatic investigation assessed outcomes following clinical implementation of CYP2C19 genotype-guided antiplatelet therapy after percutaneous coronary intervention (PCI).

Background: CYP2C19 loss-of-function alleles impair clopidogrel effectiveness after PCI.

Methods: After clinical genotyping, each institution recommended alternative antiplatelet therapy (prasugrel, ticagrelor) in PCI patients with a loss-of-function allele. Major adverse cardiovascular events (defined as myocardial infarction, stroke, or death) within 12 months of PCI were compared between patients with a loss-of-function allele prescribed clopidogrel versus alternative therapy. Risk was also compared between patients without a loss-of-function allele and loss-of-function allele carriers prescribed alternative therapy. Cox regression was performed, adjusting for group differences with inverse probability of treatment weights.

Results: Among 1,815 patients, 572 (31.5%) had a loss-of-function allele. The risk for major adverse cardiovascular events was significantly higher in patients with a loss-of-function allele prescribed clopidogrel versus alternative therapy (23.4 vs. 8.7 per 100 patient-years; adjusted hazard ratio: 2.26; 95% confidence interval: 1.18 to 4.32; p = 0.013). Similar results were observed among 1,210 patients with acute coronary syndromes at the time of PCI (adjusted hazard ratio: 2.87; 95% confidence interval: 1.35 to 6.09; p = 0.013). There was no difference in major adverse cardiovascular events between patients without a loss-of-function allele and loss-of-function allele carriers prescribed alternative therapy (adjusted hazard ratio: 1.14; 95% confidence interval: 0.69 to 1.88; p = 0.60).

Conclusions: These data from real-world observations demonstrate a higher risk for cardiovascular events in patients with a CYP2C19 loss-of-function allele if clopidogrel versus alternative therapy is prescribed. A future randomized study of genotype-guided antiplatelet therapy may be of value.
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http://dx.doi.org/10.1016/j.jcin.2017.07.022DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC5775044PMC
January 2018
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