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Neil R Powe

Publications and source records attributed to Neil R Powe.

At least 37 records · Page 2Linked to original sources
PubMed2005

Report of the National Heart, Lung, and Blood Institute working group on outcomes research in cardiovascular disease.

The National Heart, Lung, and Blood Institute convened a working group on outcomes research in cardiovascular disease (CVD). The working group sought to provide guidance on research priorities in outcomes research related to CVD. For the purposes of this document, "outcomes research" is defined as investigative endeavors that generate knowledge to improve clinical decision making and healthcare delivery to optimize patient outcomes. The working group identified the following priority areas: (1) national surveillance projects for high-prevalence CV conditions; (2) patient-centered care; (3) translation of the best science into clinical practice; and (4) studies that place the cost of interventions in the context of their real-world effectiveness. Within each of these topics, the working group described examples of initiatives that could serve the Institute and the public. In addition, the group identified the following areas that are important to the field: (1) promotion of the use of existing data; (2) facilitation of collaborations with other federal agencies; (3) investigations into the basic science of outcomes research, with an emphasis on methodological advances; (4) strengthening of appropriate study sections with individuals who have expertise in outcomes research; and (5) expansion of opportunities to train new outcomes research investigators. The working group concluded that a dedicated investment in CV outcomes research could directly improve the care delivered in the United States.

Cardiovascular Diseases↗
PubMed2005

High lipoprotein(a) levels and small apolipoprotein(a) size prospectively predict cardiovascular events in dialysis patients.

Lipoprotein(a) [Lp(a)] levels are increased in dialysis patients, suggesting that they may play a role in the elevated atherosclerotic cardiovascular disease (ASCVD) risk in this population. Few prospective studies of Lp(a) level, apolipoprotein(a) [apo(a)] size, and ASCVD have been performed in the dialysis population. An inception cohort of 833 incident dialysis patients were followed prospectively. Baseline Lp(a) was measured by apo(a) size-independent ELISA and apo(a) size by Western blot after SDS-agarose gel electrophoresis. A combined prospective nonfatal and fatal ASCVD end point included myocardial infarction, coronary revascularization, cerebrovascular accident, carotid endarterectomy, peripheral revascularization, gangrene, or limb amputation. Survival analyses were performed with adjustment for baseline demographics, comorbid conditions, ASCVD risk factors, albumin, lipids, and C-reactive protein. Median follow-up was 27.4 mo, with 297 ASCVD events, 130 non-ASCVD deaths, and seven losses to follow-up over 1649 person-years. In multivariate Cox regression models, both high Lp(a) concentration (>/=53 nmol/L) and low molecular weight (LMW) apo(a) isoforms (</=22 Kringle-IV repeats) predicted ASCVD events (relative hazard [RH] = 1.38, P = 0.02; RH = 1.58, P < 0.0005, respectively). In models that included both Lp(a) concentration and apo(a) size, only apo(a) size remained associated with ASCVD. Among those with both LMW apo(a) and Lp(a) level >123 nmol/L, the relative hazard (RH) of ASCVD was 1.73 (P < 0.0005), compared with high molecular weight apo(a) and Lp(a) level <123 nmol/L. No interactions by age, race, gender, diabetes, or ASCVD were present. Both LMW apo(a) size and high Lp(a) level predict ASCVD risk in dialysis patients, but the association of ASCVD with LMW isoforms is stronger than the association with high Lp(a) concentration.

Aged↗
PubMed2005

Type of vascular access and survival among incident hemodialysis patients: the Choices for Healthy Outcomes in Caring for ESRD (CHOICE) Study.

Arteriovenous fistulae (AVF) have advantages over arteriovenous grafts (AVG) and central venous catheters (CVC), but whether AVF are associated independently with better survival is unclear. Recent studies showing such a survival benefit did not include early access experience or account for changes in access type over time and did not include data on some important confounders. Reported here are survival rates stratified by the type of access in use up to 3 yr after initiation of hemodialysis among 616 incident patients who were enrolled in the Choices for Healthy Outcomes in Caring for ESRD (CHOICE) Study. A total of 1084 accesses (185 AVF, 296 AVG, 603 CVC) were used for a total of 1381 person-years. At initiation, 409 (66%) patients were using a CVC, 122 (20%) were using an AVG, and 85 (14%) were using an AVF. After 6 mo, 34% were using a CVC, 40% were using an AVG, and 26% were using an AVF. Annual mortality rates were 11.7% for AVF, 14.2% for AVG, and 16.1% for CVC. Adjusted relative hazards (RH) of death compared with AVF were 1.5 (95% confidence interval, 1.0 to 2.2) for CVC and 1.2 (0.8 to 1.8) for AVG. The increased hazards associated with CVC, as compared with AVF, were stronger in men (n = 334; RH = 2.0; P = 0.01) than women (n = 282; RH = 1.0 for CVC; P = 0.92). These results strongly support existing clinical practice guidelines and suggest that the use of venous catheters should be minimized to reduce the frequency of access complications and to improve patient survival, especially among male hemodialysis patients.

Adult↗
PubMed2005

Frequency of patient-physician contact in chronic kidney disease care and achievement of clinical performance targets.

OBJECTIVE: To examine whether the frequency of physician contact is associated with accepted quality of care measures reflecting clinical performance in chronic kidney disease patients. DESIGN: Prospective cohort study of end-stage renal disease patients begun in 1995, followed for 2.5 years. SETTING: 76 not-for-profit US dialysis clinics. STUDY PARTICIPANTS: 678 incident hemodialysis patients for whom we had information on average frequency of patient-physician contact at each clinic (low, monthly or less frequent; intermediate, between monthly and weekly; high, more than weekly), determined by clinic survey. MAIN OUTCOME MEASURES: Achievement of accepted 6 month clinical performance targets of albumin (> or =3.5 g/dl), calcium-phosphate (Ca-P) product (<60 mg(2)/dl(2)), dialysis dose (Kt/V > or = 1.2), vascular access type (fistula), and hemoglobin (> or =11 g/dl). RESULTS: By logistic regression, patients treated at clinics reporting less frequent physician contact had lower odds of achieving most targets, statistically significantly for albumin [low, adjusted odds ratio (OR) = 0.83, 95% confidence interval (CI), 0.55-1.25; intermediate, adjusted OR = 0.62, 95% CI, 0.42-0.93; reference, high] and dialysis dose (low, adjusted OR = 0.26, 95% CI, 0.08-0.89; intermediate, adjusted OR = 0.67, 95% CI, 0.20-2.27); however, they had greater odds of achieving the hemoglobin target (low, adjusted OR = 1.94, 95% CI, 1.24-3.04; intermediate, adjusted OR = 1.89, 95% CI, 1.27-2.83). Additionally, the number of targets reached was statistically significantly lower in the monthly or less group (adjusted OR = 0.43, 95% CI, 0.20-0.94). CONCLUSIONS: More frequent patient-physician contact is positively associated with the achievement of clinical performance targets in chronic kidney disease care.

Aged↗
PubMed2005

Association between screening for osteoporosis and the incidence of hip fracture.

BACKGROUND: Because direct evidence for the effectiveness of screening is lacking, guidelines disagree on whether people should be screened for osteoporosis. OBJECTIVE: To determine whether population-based screening for osteoporosis in older adults is associated with fewer incident hip fractures than usual medical care. DESIGN: Nonconcurrent cohort study. SETTING: Population-based cohort enrolled in the Cardiovascular Health Study (CHS) from 4 states (California, Pennsylvania, Maryland, and North Carolina). PATIENTS: 3107 adults 65 years of age and older who attended their CHS study visits in 1994-1995. MEASUREMENTS: 31 participant characteristics (including demographic characteristics, medical histories, medications, and physical examination findings) and incident hip fractures over 6 years of follow-up. INTERVENTION: Bone density scans (dual-energy x-ray absorptiometry [DEXA] at the hip) for participants in California and Pennsylvania (n = 1422) and usual care for participants in Maryland and North Carolina (n = 1685). RESULTS: The incidence of hip fractures per 1000 person-years was 4.8 in the screened group and 8.2 in the usual care group. Screening was associated with a statistically significant lower hazard of hip fracture than usual care after adjustment for sex and propensity to be screened (Cox proportional hazard ratio, 0.64 [95% CI, 0.41 to 0.99]). LIMITATIONS: The mechanism of the association was unclear. A small unmeasured confounder that decreased the hazard of hip fracture could diminish or erase the observed association. CONCLUSIONS: Use of hip DEXA scans to screen for osteoporosis in older adults was associated with 36% fewer incident hip fractures over 6 years compared with usual medical care. Further research is needed to explore the mechanism of this association.

Absorptiometry, Photon↗
PubMed2005

Racial disparities in the optimal delivery of chronic kidney disease care.

This article provides evidence that the current and growing burden of CKD in racial and ethnic minority populations is likely to be multifactorial involving the interplay of biologic, clinical, social, and behavioral determinants. To eliminate these disparities, crafting successful solutions requires more attention to the constellation of contributing factors not only by specialists, primary care physicians, and other health care providers involved in CKD care, but also clinical and behavioral scientists, payers of health care, and patients.

Delivery of Health Care↗
PubMed2005

Use of dialysis educators beyond nurses and physicians and outcomes in patients with kidney failure.

This study examined whether patient education by nonmedical personnel (eg, social workers, dietitians) is associated with patient outcomes in a prospective cohort study of 1,005 incident dialysis patients treated at 79 United States clinics. Logistic and Poisson regression and Cox proportional hazards models were used to assess the relationship between clinic use of nonmedical educators and patient satisfaction and self-management, hospitalization, and survival, respectively. Patients treated at clinics reporting use of nonmedical educators (84%) were more likely to be satisfied with the amount of information on dialysis modalities (odds ratio [OR]=.67, 95% confidence interval [CI] 1.08--2.58) and with the amount of information they received on dialysis (OR=1.23, 95% CI 0.90--1.67; marginally significant) than those treated at clinics without nonmedical educators (16%). These patients were also less likely to be hospitalized (incidence rate ratio [IRR]=0.91, 95% CI 0.80--1.03), but the association was of borderline statistical significance. Overall satisfaction, patient self-management, and mortality were not significantly associated with use of nonmedical educators. Use of nonmedical staff for patient education at dialysis centers has a limited but positive effect on patient satisfaction and hospitalization.

Adult↗
PubMed2005

Area socioeconomic status and progressive CKD: the Atherosclerosis Risk in Communities (ARIC) Study.

BACKGROUND: Individual-level socioeconomic status (SES) has been found to be associated inversely with progressive chronic kidney disease (CKD); the effect of area-level SES on progressive CKD is less known. We conducted a cohort study of 12,856 Atherosclerosis Risk in Communities Study participants to examine the independent risk for progressive CKD associated with living in a low SES area. METHODS: Progressive CKD is defined as a creatinine level elevation of 0.4 mg/dL or greater (> or = 35 micromol/L) during a 9-year follow-up, hospitalization for CKD, or death. Area-level SES was characterized by using measures of income, wealth, education, and occupation for 1990 US Census block groups of residence. RESULTS: Age- and center-adjusted incidence rates (per 1,000 person-years) of progressive CKD by quartiles of area-level SES score showed increasing rates with decreasing SES for African-American women: quartile 1 (Q1; low) = 11.1, Q2 = 10.5, Q3 = 6.4, and Q4 = 7.1 and white men: Q1 = 6.6, Q2 = 4.8, Q3 = 4.0, and Q4 (high) = 3.5, but not for African-American men or white women. Cox proportional hazards models showed that living in the lowest versus the highest SES-area quartile was associated with a 60% greater risk for progressive CKD in white men after adjusting for age, center, baseline creatinine level, body mass index, and individual-level SES (hazard ratio, 1.6; 95% confidence interval, 1.0 to 2.5). This risk and trend persisted after adjusting for such potential mediators as health awareness, health care access, and behavioral and physiological factors. We found no significant association of progressive CKD risk and area SES in white women, African-American women, or African-American men after adjustment. CONCLUSION: For white men, living in a low SES area is independently associated with greater risk for progressive CKD. Future research is needed to examine this association, considering the disparate effects found by race/sex groups.

Black or African American↗
PubMed2005

Skipped treatments, markers of nutritional nonadherence, and survival among incident hemodialysis patients.

BACKGROUND: Skipping hemodialysis treatments and failing to adhere to prescribed diets are thought to injure hemodialysis patients. METHODS: We examined predictors of hemodialysis skipping and laboratory measures of nonadherence and then examined the association of dialysis skipping and serum potassium and phosphate levels with survival. RESULTS: Of 739 patients, 67 were classified as skippers because they were absent for greater than 3% of scheduled treatments. Black race (odds ratio [OR], 2.26; 95% confidence interval [CI], 1.30 to 3.92), current smoking (OR, 1.79; 95% CI, 1.02 to 3.13), and use of illicit drugs (OR, 3.96; 95% CI, 2.16 to 7.24) were associated with skipping. White race, increased serum phosphate level, greater creatinine level, and lower body mass index increased the likelihood of a serum potassium level greater than 5.0 mEq/L (mmol/L); younger age, greater serum potassium level, and greater serum creatinine level were associated with a serum phosphate level greater than 5.5 mg/dL (>1.78 mmol/L). Skipping was associated with an increased risk for death (hazard ratio [HR], 1.69; 95% CI, 1.24 to 2.31), as were phosphate level greater than 5.5 mg/dL (HR, 1.59; 95% CI, 1.16 to 2.17) and potassium level greater than 5.0 mEq/L (HR, 1.50; 95% CI, 1.10 to 2.06). Skipping was associated with a lower likelihood of kidney transplantation in those younger than 65 years (OR, 0.41; 95% CI, 0.18 to 0.93). CONCLUSION: These findings show that hemodialysis patients of black race and those with current tobacco or illicit drug use are at risk for skipping dialysis treatments. Skipping treatments and markers of poor dietary adherence are strongly associated with greater risk for death. Targeting high-risk patients to understand reasons for nonadherence and to intervene could prevent premature death.

Adult↗
PubMed2005

A systematic review of the methodological rigor of studies evaluating cultural competence training of health professionals.

PURPOSE: To systematically examine the methodological rigor of studies using cultural competence training as a strategy to improve minority health care quality. To the authors' knowledge, no prior studies of this type have been conducted. METHOD: As part of a systematic review, the authors appraised the methodological rigor of studies published in English from 1980 to 2003 that evaluate cultural competence training, and determined whether selected study characteristics were associated with better study quality as defined by five domains (representativeness, intervention description, bias and confounding, outcome assessment, and analytic approach). RESULTS: Among 64 eligible articles, most studies (no. = 59) were published recently (1990-2003) in education (no. = 26) and nursing (no. = 14) journals. Targeted learners were mostly nurses (no. = 32) and physicians (no. = 19). Study designs included randomized or concurrent controlled trials (no. = 10), pretest/posttest (no. = 22), posttest only (no. = 27), and qualitative evaluation (no. = 5). Curricular content, teaching strategies, and evaluation methods varied. Most studies reported provider outcomes. Twenty-one articles adequately described provider representativeness, 21 completely described curricular interventions, eight had adequate comparison groups, 27 used objective evaluations, three blinded outcome assessors, 14 reported the number or reason for noninclusion of data, and 15 reported magnitude differences and variability indexes. Studies targeted at physicians more often described providers and interventions. Most trials completely described targeted providers, had adequate comparison groups, and reported objective evaluations. Study quality did not differ over time, by journal type, or by the presence or absence of reported funding. CONCLUSIONS: Lack of methodological rigor limits the evidence for the impact of cultural competence training on minority health care quality. More attention should be paid to the proper design, evaluation, and reporting of these training programs.

Cultural Diversity↗
PubMed2005

Cultural competence: a systematic review of health care provider educational interventions.

OBJECTIVE: We sought to synthesize the findings of studies evaluating interventions to improve the cultural competence of health professionals. DESIGN: This was a systematic literature review and analysis. METHODS: We performed electronic and hand searches from 1980 through June 2003 to identify studies that evaluated interventions designed to improve the cultural competence of health professionals. We abstracted and synthesized data from studies that had both a before- and an after-intervention evaluation or had a control group for comparison and graded the strength of the evidence as excellent, good, fair, or poor using predetermined criteria. MAIN OUTCOME MEASURES: We sought evidence of the effectiveness and costs of cultural competence training of health professionals. RESULTS: Thirty-four studies were included in our review. There is excellent evidence that cultural competence training improves the knowledge of health professionals (17 of 19 studies demonstrated a beneficial effect), and good evidence that cultural competence training improves the attitudes and skills of health professionals (21 of 25 studies evaluating attitudes demonstrated a beneficial effect and 14 of 14 studies evaluating skills demonstrated a beneficial effect). There is good evidence that cultural competence training impacts patient satisfaction (3 of 3 studies demonstrated a beneficial effect), poor evidence that cultural competence training impacts patient adherence (although the one study designed to do this demonstrated a beneficial effect), and no studies that have evaluated patient health status outcomes. There is poor evidence to determine the costs of cultural competence training (5 studies included incomplete estimates of costs). CONCLUSIONS: Cultural competence training shows promise as a strategy for improving the knowledge, attitudes, and skills of health professionals. However, evidence that it improves patient adherence to therapy, health outcomes, and equity of services across racial and ethnic groups is lacking. Future research should focus on these outcomes and should determine which teaching methods and content are most effective.

Attitude of Health Personnel↗
PubMed2005

Extent and determinants of physician participation in expert witness testimony.

OBJECTIVES: In the recent past, law firms have had difficulties in finding physicians to review malpractice cases and serve as expert witnesses. Over the last few years, however, many clinicians have had a decline in their income, causing some physicians to seek alternative sources of revenue such as the review of legal cases. The purpose of this study was to qualify and quantify the extent of physician participation in legal activities. METHODS: We conducted a survey of 1,000 Maryland internal medicine physicians. The survey consisted of 24 items designed to collect information on demographics, practice patterns, income variables, and participation in legal review. RESULTS: Twenty-four percent of our respondents reported engaging in expert witness testimony/review to supplement their incomes. Engagement was significantly associated with internal medicine sub-specialty practice, academic practice, a self-perception that personal income was higher than the income of colleagues, and being in practice for 11 to 20 years. Economic factors were not found to be associated with engaging in these activities. CONCLUSIONS: Physician participation in legal review and expert witness activities is significant and appears not to be determined by economic factors. Both the positive effects of such participation on the legal system and the potential ethical concerns require further study.

Ethics, Medical↗
PubMed2005

The role of cultural diversity climate in recruitment, promotion, and retention of faculty in academic medicine.

BACKGROUND: Ethnic diversity among physicians may be linked to improved access and quality of care for minorities. Academic medical institutions are challenged to increase representation of ethnic minorities among health professionals. OBJECTIVES: To explore the perceptions of physician faculty regarding the following: (1) the institution's cultural diversity climate and (2) facilitators and barriers to success and professional satisfaction in academic medicine within this context. DESIGN: Qualitative study using focus groups and semi-structured interviews. PARTICIPANTS: Nontenured physicians in the tenure track at the Johns Hopkins University School of Medicine. APPROACH: Focus groups and interviews were audio-taped, transcribed verbatim, and reviewed for thematic content in a 3-stage independent review/adjudication process. RESULTS: Study participants included 29 faculty representing 9 clinical departments, 4 career tracks, and 4 ethnic groups. In defining cultural diversity, faculty noted visible (race/ethnicity, foreign-born status, gender) and invisible (religion, sexual orientation) dimensions. They believe visible dimensions provoke bias and cumulative advantages or disadvantages in the workplace. Minority and foreign-born faculty report ethnicity-based disparities in recruitment and subtle manifestations of bias in the promotion process. Minority and majority faculty agree that ethnic differences in prior educational opportunities lead to disparities in exposure to career options, and qualifications for and subsequent recruitment to training programs and faculty positions. Minority faculty also describe structural barriers (poor retention efforts, lack of mentorship) that hinder their success and professional satisfaction after recruitment. To effectively manage the diversity climate, our faculty recommended 4 strategies for improving the psychological climate and structural diversity of the institution. CONCLUSIONS: Soliciting input from faculty provides tangible ideas regarding interventions to improve an institution's diversity climate.

Academic Medical Centers↗
PubMed2005

Preferences, knowledge, communication and patient-physician discussion of living kidney transplantation in African American families.

It is unknown whether patient-physician discussion about live kidney transplantation (LT) among African Americans (AA) is affected by preferences, knowledge and family discussions regarding LT. We recruited 182 AA dialysis patients and their families and assessed the relation of preferences, knowledge and family discussions regarding LT to the occurrence of patient-physician discussion using multivariable logistic regression. Most patients (76%) desired a transplant, and most patients (93%), spouses (91%) and children (88%) had knowledge of LT. Nearly half of the families discussed transplantation. Only 68% of patients and less than half of their spouses (41%) and children (31%) had discussed transplantation with physicians. Patient-physician discussion was more common among patients: whose spouses acknowledged their interest in transplantation (adjusted odds ratio (AOR) (95% CI):3.5 (1.61-7.8)); who discussed transplantation with spouses (AOR(95% CI):5.25 (2.22-12.41)); whose spouses agreed that they discussed transplantation with patients (AOR (95%CI):5.20 (1.76-15.37)) and whose children discussed transplantation with patients' physicians (AOR (95%CI):7.4 (1.3-40.0)). Universal patient-physician discussion of LT does not occur despite patient preferences. Rates of family-physician discussions are low, and rates of family discussions vary. Early family-physician discussion of LT, use of allied health professionals to promote family discussion of LT and the institution of culturally appropriate programs to enhance discussion of LT in AA families could improve rates of discussion and enhance patients' access to LT.

Adult↗
PubMed2005

Attitudes, psychology, and risk taking of potential live kidney donors: strangers, relatives, and the general public.

It is unclear whether potential living kidney donors and the general public differ in attitudes and psychological characteristics. We performed a case-control study to explore differences in these groups using a standardized questionnaire (analyzed using conditional logistic regression). Strangers (N = 42) were more willing than controls (N = 126) to incur risks: 64% strangers versus 35% controls accepting >50% medical complications (MC) risk; 90% strangers versus 61% controls accepting >8 days hospitalization; 71% strangers versus 43% controls accepting >3 months unpaid; 55% strangers versus 16% controls accepting 100% kidney failure (KF) risk; 70% strangers versus 34% controls accepting < or =10% likelihood of successful transplant (all p < 0.01). Relatives (N = 251) were also more willing than controls (N = 251) to incur risks. Strangers were most willing to incur MC, KF and transplant failure. Groups did not differ in attitudes, depression or anxiety. Potential stranger and related donors are willing to undergo greater risks with donation than the general public, but do not differ in other attitudes, depression or anxiety. This should help reassure transplant centers and the public that both forms of live donation do not necessarily involve increased ethical risks of donor coercion or irrational thought processes. Still, careful attention to communication of all risks of donation is warranted.

Adult↗
PubMed2004

Meta-analysis: glycosylated hemoglobin and cardiovascular disease in diabetes mellitus.

BACKGROUND: In persons with diabetes, chronic hyperglycemia (assessed by glycosylated hemoglobin level) is related to the development of microvascular disease; however, the relation of glycosylated hemoglobin to macrovascular disease is less clear. PURPOSE: To conduct a meta-analysis of observational studies of the association between glycosylated hemoglobin and cardiovascular disease in diabetic persons. DATA SOURCES: Search of the MEDLINE database by using Medical Subject Heading search terms and key words related to glycosylated hemoglobin, diabetes, and cardiovascular disease. STUDY SELECTION: Prospective cohort studies with data on glycosylated hemoglobin levels and incident cardiovascular disease. DATA EXTRACTION: Relative risk estimates were derived or abstracted from each cohort study that met the inclusion criteria. DATA SYNTHESIS: Adjusted relative risk estimates for glycosylated hemoglobin (total glycosylated hemoglobin, hemoglobin A1, or hemoglobin A1c levels) and cardiovascular disease events (coronary heart disease and stroke) were pooled by using random-effects models. Three studies involved persons with type 1 diabetes (n = 1688), and 10 studies involved persons with type 2 diabetes (n = 7435). The pooled relative risk for cardiovascular disease was 1.18; this represented a 1-percentage point increase in glycosylated hemoglobin level (95% CI, 1.10 to 1.26) in persons with type 2 diabetes. Results in persons with type 1 diabetes were similar but had a wider CI (pooled relative risk, 1.15 [CI, 0.92 to 1.43]). LIMITATIONS: This review largely reflects the limitations of the literature. Important concerns were residual confounding, the possibility of publication bias, the small number of studies, and the heterogeneity of study results. CONCLUSIONS: Pending confirmation from large, ongoing clinical trials, this analysis shows that observational studies are consistent with limited clinical trial data and suggests that chronic hyperglycemia is associated with an increased risk for cardiovascular disease in persons with diabetes.

Cardiovascular Diseases↗