MED: Family Medicine Papers
Permanent URI for this collection
Browse
Recent Submissions
Item COVID-19 shines a light on health inequities in communities of color: a youth-driven photovoice inquiry(Wiley, 2022-09) Augsberger, Astraea; Toraif, Noor; Young, Adrienne; Dimitri, Noelle C.; Bautista, Rosaylin; Pierre, Ja'Karri; Le, Catherine; Idahor, Osasenaga; Jusme, Calvin; Gergen Barnett, Katherine A.This manuscript reports on a youth-driven health assessment engaging youth of color in identifying community health priorities during the coronavirus disease 2019 (COVID-19) pandemic. Photovoice, a participatory visual ethnographic health assessment strategy, was used to explore the question: What does health or healthiness mean to you and/or your community? Youth captured images that represented their priorities. The photos were discussed using the SHOWed framework and analyzed thematically. Four themes related to community health were identified. Additionally, youth captured their narrative of COVID-19 as "a revealing force that highlights systemic inequities, driving individuals and communities to both cultivate their resilience and take healthcare into their own hands in response to government and policy level failures." Youth are acutely aware of the historical and structural inequities that create multi-level barriers to healthcare access. Health inequities existed long before the pandemic, but the current crisis requires us to examine ways to transform the healthcare landscape moving forward.Item The Interdisciplinary eHealth Team: Chronic Care for the Future(Gunther Eysenbach, 2004-9-3) Wiecha, John; Pollard, Timothy. An interdisciplinary clinical team is a consistent grouping of people from relevant clinical disciplines, ideally inclusive of the patient, whose interactions are guided by specific team functions and processes to achieve team-defined favorable patient outcomes. Teamwork supported by properly designed eHealth applications could help create more effective systems of care for chronic disease. Given its synchronous and asynchronous communication capacity and information-gathering and -sharing capabilities, the Internet is a logical platform for supporting interdisciplinary clinical teamwork. Research is needed to better understand how interdisciplinary eHealth team members can work together in everyday practice and to guide the development of effective and efficient eHealth software applications to support greater clinical teamwork.Item Learning in a Virtual World: Experience With Using Second Life for Medical Education(Gunther Eysenbach, 2010-1-23) Wiecha, John; Heyden, Robin; Sternthal, Elliot; Merialdi, MarioBACKGROUND. Virtual worlds are rapidly becoming part of the educational technology landscape. Second Life (SL) is one of the best known of these environments. Although the potential of SL has been noted for health professions education, a search of the world's literature and of the World Wide Web revealed a limited number of formal applications of SL for this purpose and minimal evaluation of educational outcomes. Similarly, the use of virtual worlds for continuing health professional development appears to be largely unreported. METHODS We designed and delivered a pilot postgraduate medical education program in the virtual world, Second Life. Our objectives were to: (1) explore the potential of a virtual world for delivering continuing medical education (CME) designed for physicians; (2) determine possible instructional designs using SL for CME; (3) understand the limitations of SL for CME; (4) understand the barriers, solutions, and costs associated with using SL, including required training; and (5) measure participant learning outcomes and feedback. We trained and enrolled 14 primary care physicians in an hour-long, highly interactive event in SL on the topic of type 2 diabetes. Participants completed surveys to measure change in confidence and performance on test cases to assess learning. The post survey also assessed participants' attitudes toward the virtual learning environment. RESULTS Of the 14 participant physicians, 12 rated the course experience, 10 completed the pre and post confidence surveys, and 10 completed both the pre and post case studies. On a seven-point Likert scale (1, strongly disagree to 7, strongly agree), participants' mean reported confidence increased from pre to post SL event with respect to: selecting insulin for patients with type 2 diabetes (pre = 4.9 to post = 6.5, P= .002); initiating insulin (pre = 5.0 to post = 6.2, P= .02); and adjusting insulin dosing (pre = 5.2 to post = 6.2, P= .02). On test cases, the percent of participants providing a correct insulin initiation plan increased from 60% (6 of 10) pre to 90% (9 of 10) post (P= .2), and the percent of participants providing correct initiation of mealtime insulin increased from 40% (4 of 10) pre to 80% (8 of 10) post (P= .09). All participants (12 of 12) agreed that this experience in SL was an effective method of medical education, that the virtual world approach to CME was superior to other methods of online CME, that they would enroll in another such event in SL, and that they would recommend that their colleagues participate in an SL CME course. Only 17% (2 of 12) disagreed with the statement that this potential Second Life method of CME is superior to face-to-face CME. CONCLUSIONS The results of this pilot suggest that virtual worlds offer the potential of a new medical education pedagogy to enhance learning outcomes beyond that provided by more traditional online or face-to-face postgraduate professional development activities. Obvious potential exists for application of these methods at the medical school and residency levels as well.Item Factors and Common Conditions Associated with Adolescent Dietary Supplement Use: An Analysis of the National Health and Nutrition Examination Survey (NHANES)(BioMed Central, 2008-3-31) Gardiner, Paula; Buettner, Catherine; Davis, Roger B.; Phillips, Russell S.; Kemper, Kathi J.BACKGROUND. Little is known about the prevalence of dietary supplement (DS) use in American adolescents. We conducted this study to analyze the prevalence of DS use and factors associated with this use in a national population-based sample. METHODS. We used data from the 1999 – 2002 National Health and Nutrition Examination Surveys (NHANES) for adolescents age 11 to 19. Using weighted logistic regression, we identified demographic and clinical factors associated with the use of any DS, vitamins or minerals, herbs and other DS. RESULTS. Among the 5,306 responses representing approximately 36 million Americans 11–19 years old, 27% reported use of one or more DS in the prior month. The most commonly used DS were: multivitamins (16%) and vitamin C (6%). In the multivariable analysis, African American [adjusted odds ratio 0.40 (0.31–0.50) 95% CI] and Mexican American [0.55 (0.44–0.69)] adolescents were less likely to use DS compared with non-Hispanic whites. DS use was more common in those who used prescription medications [1.37 (1.10–1.72)] and among those who had a diagnosis of chronic headaches [1.25 (1.04–1.50)]. DS use was less common among those reporting fair or poor health status [0.59 (0.40–0.88)]. CONCLUSION. Twenty seven percent of American adolescents use DS. DS use is higher among teens that use prescription medications; physicians and pharmacists should be aware of this, ask patients, and check for potential interactions.Item A Lifeline to Treatment: The Role of Indian Generic Manufacturers in Supplying Antiretroviral Medicines to Developing Countries(BioMed Central, 2010-9-14) Waning, Brenda; Diedrichsen, Ellen; Moon, SuerieBACKGROUND Indian manufacturers of generic antiretroviral (ARV) medicines facilitated the rapid scale up of HIV/AIDS treatment in developing countries though provision of low-priced, quality-assured medicines. The legal framework in India that facilitated such production, however, is changing with implementation of the World Trade Organization Agreement on Trade-Related Aspects of Intellectual Property Rights, and intellectual property measures being discussed in regional and bilateral free trade agreement negotiations. Reliable quantitative estimates of the Indian role in generic global ARV supply are needed to understand potential impacts of such measures on HIV/AIDS treatment in developing countries. METHODS We utilized transactional data containing 17,646 donor-funded purchases of ARV tablets made by 115 low- and middle-income countries from 2003 to 2008 to measure market share, purchase trends and prices of Indian-produced generic ARVs compared with those of non-Indian generic and brand ARVs. RESULTS Indian generic manufacturers dominate the ARV market, accounting for more than 80% of annual purchase volumes. Among paediatric ARV and adult nucleoside and non-nucleoside reverse transcriptase inhibitor markets, Indian-produced generics accounted for 91% and 89% of 2008 global purchase volumes, respectively. From 2003 to 2008, the number of Indian generic manufactures supplying ARVs increased from four to 10 while the number of Indian-manufactured generic products increased from 14 to 53. Ninety-six of 100 countries purchased Indian generic ARVs in 2008, including high HIV-burden sub-Saharan African countries. Indian-produced generic ARVs used in first-line regimens were consistently and considerably less expensive than non-Indian generic and innovator ARVs. Key ARVs newly recommended by the World Health Organization are three to four times more expensive than older regimens. CONCLUSIONS Indian generic producers supply the majority of ARVs in developing countries. Future scale up using newly recommended ARVs will likely be hampered until Indian generic producers can provide the dramatic price reductions and improved formulations observed in the past. Rather than agreeing to inappropriate intellectual property obligations through free trade agreements, India and its trade partners - plus international organizations, donors, civil society and pharmaceutical manufacturers - should ensure that there is sufficient policy space for Indian pharmaceutical manufacturers to continue their central role in supplying developing countries with low-priced, quality-assured generic medicines.Item Factors associated with herb and dietary supplement use by young adults in the United States(BioMed Central, 2007-11-30) Gardiner, Paula; Kemper, Kathi J.; Legedza, Anna; Phillips, Russell S.BACKGROUND. Little is known about the association between use of herbs and dietary supplements (HDS) and lifestyle/behavior factors in young adults in the US. METHODS. Analyzing the 2002 National Health Interview Survey (NHIS), we examined the patterns of HDS (excluding vitamins/minerals) use among young adults in the United States using descriptive statistics and logistic regression. RESULTS. In our sample of 18 to 30 year olds (n = 6666), 26% were current smokers, 24% were moderate/heavy drinkers, 43% had high physical activity, and 54% and 76% use prescription and over the counter (OTC) medications respectively. Non-vitamin, non-mineral HDS was used by 17% of the overall sample in the last 12 months. In the multivariable analysis, the lifestyle and behavioral factors associated with HDS use include: current smoking (odds ratio 1.41 95% CI [1.16–1.72]); being a former smoker (1.50 [1.15–1.95]); moderate/heavy alcohol use (2.02 [1.53–2.65]); high physical activity levels (2.45 [1.98–3.03]); and prescription medication use (1.51 [1.26–1.81]). Among HDS users, only 24% discussed their use with a health care professional. CONCLUSION. Nearly one in five young adults report using non-vitamin/non-mineral HDS.Item Collaborative E-Learning Using Streaming Video and Asynchronous Discussion Boards to Teach the Cognitive Foundation of Medical Interviewing: A Case Study(Gunther Eysenbach, 2003-6-27) Wiecha, John M; Gramling, Robert; Joachim, Phyllis; Vanderschmidt, HanneloreBACKGROUND Advances in electronic technology have created opportunities for new instructional designs of medical curricula. OBJECTIVE We created and evaluated a 4-week online elective course for medical students to teach the cognitive basis for interviewing skills. METHODS Ten students, from 2 medical schools, studied online modules on interviewing concepts and viewed videos illustrating the concepts. They then participated in asynchronous discussion groups designed to reinforce course concepts, stimulate reflective learning, and promote peer learning. RESULTS In qualitative evaluations, learners reported improvements in self-awareness; increased understanding of interviewing concepts; and benefits of online learning vs face to face learning. Participants reported high levels of satisfaction with online learning and with achievement of course objectives. Self-reported knowledge scores increased significantly from pre-course completion to post-course completion. CONCLUSIONS Online education has significant potential to augment curriculum on the medical interview, particularly among students trained in community settings geographically distant from their academic medical center.Item An Obesity Dietary Quality Index Predicts Abdominal Obesity in Women: Potential Opportunity for New Prevention and Treatment Paradigms(Hindawi Publishing Corporation, 2010-1-5) Wolongevicz, Dolores M.; Zhu, Lei; Pencina, Michael J.; Kimokoti, Ruth W.; Newby, P. K.; D'Agostino, Ralph B.; Millen, Barbara E.Background. Links between dietary quality and abdominal obesity are poorly understood. Objective. To examine the association between an obesity-specific dietary quality index and abdominal obesity risk in women. Methods. Over 12 years, we followed 288 Framingham Offspring/Spouse Study women, aged 30–69 years, without metabolic syndrome risk factors, cardiovascular disease, cancer, or diabetes at baseline. An 11-nutrient obesity-specific dietary quality index was derived using mean ranks of nutrient intakes from 3-day dietary records. Abdominal obesity (waist circumference >88cm) was assessed during follow-up. Results. Using multiple logistic regression, women with poorer dietary quality were more likely to develop abdominal obesity compared to those with higher dietary quality (OR 1.87; 95% CI, 1.01, 3.47; P for trend = .048) independent of age, physical activity, smoking, and menopausal status. Conclusions. An obesity-specific dietary quality index predicted abdominal obesity in women, suggesting targets for dietary quality assessment, intervention, and treatment to address abdominal adiposity.Item Towards equitable access to medicines for the rural poor: analyses of insurance claims reveal rural pharmacy initiative triggers price competition in Kyrgyzstan(BioMed Central, 2009-12-14) Waning, Brenda; Maddix, Jason; Tripodis, Yorghos; Laing, Richard; Leufkens, Hubert G.M.; Gokhale, ManjushaBACKGROUND: A rural pharmacy initiative (RPI) designed to increase access to medicines in rural Kyrgyzstan created a network of 12 pharmacies using a revolving drug fund mechanism in 12 villages where no pharmacies previously existed. The objective of this study was to determine if the establishment of the RPI resulted in the unforeseen benefit of triggering medicine price competition in pre-existing (non-RPI) private pharmacies located in the region. METHODS: We conducted descriptive and multivariate analyses on medicine insurance claims data from Kyrgyzstan's Mandatory Health Insurance Fund for the Jumgal District of Naryn Province from October 2003 to December 2007. We compared average quarterly medicine prices in competitor pharmacies before and after the introduction of the rural pharmacy initiative in October 2004 to determine the RPI impact on price competition. RESULTS. Descriptive analyses suggest competitors reacted to RPI prices for 21 of 30 (70%) medicines. Competitor medicine prices from the quarter before RPI introduction to the end of the study period decreased for 17 of 30 (57%) medicines, increased for 4 of 30 (13%) medicines, and remained unchanged for 9 of 30 (30%) medicines. Among the 9 competitor medicines with unchanged prices, five initially decreased in price but later reverted back to baseline prices. Multivariate analyses on 19 medicines that met sample size criteria confirm these findings. Fourteen of these 19 (74%) competitor medicines changed significantly in price from the quarter before RPI introduction to the quarter after RPI introduction, with 9 of 19 (47%) decreasing in price and 5 of 19 (26%) increasing in price. CONCLUSIONS: The RPI served as a market driver, spurring competition in medicine prices in competitor pharmacies, even when they were located in different villages. Initiatives designed to increase equitable access to medicines in rural regions of developing and transitional countries should consider the potential to leverage medicine price competition as a means of achieving their goal. Evaluations of interventions to increase rural access to medicines should include impact assessment on both formal and informal pharmaceutical markets.Item Intervening in Global Markets to Improve Access to HIV/AIDS Treatment: An Analysis of International Policies and the Dynamics of Global Antiretroviral Medicines Markets(BioMed Central, 2010-05-25) Waning, Brenda; Kyle, Margaret; Diedrichsen, Ellen; Soucy, Lyne; Hochstadt, Jenny; Bärnighausen, Till; Moon, SuerieBACKGROUND. Universal access to antiretroviral therapy (ART) in low- and middle-income countries faces numerous challenges: increasing numbers of people needing ART, new guidelines recommending more expensive antiretroviral (ARV) medicines, limited financing, and few fixed-dose combination (FDC) products. Global initiatives aim to promote efficient global ARV markets, yet little is known about market dynamics and the impact of global policy interventions. METHODS. We utilize several data sources, including 12,958 donor-funded, adult first-line ARV purchase transactions, to describe the market from 2002-2008. We examine relationships between market trends and: World Health Organization (WHO) HIV/AIDS treatment guidelines; WHO Prequalification Programme (WHO Prequal) and United States (US) Food and Drug Administration (FDA) approvals; and procurement policies of the Global Fund to Fight AIDS, Tuberculosis, and Malaria (GFATM), US President's Emergency Plan for AIDS Relief (PEPFAR) and UNITAID. RESULTS. WHO recommended 7, 4, 24, and 6 first-line regimens in 2002, 2003, 2006 and 2009 guidelines, respectively. 2009 guidelines replaced a stavudine-based regimen ($88/person/year) with more expensive zidovudine- ($154-260/person/year) or tenofovir-based ($244-465/person/year) regimens. Purchase volumes for ARVs newly-recommended in 2006 (emtricitabine, tenofovir) increased >15-fold from 2006 to 2008. Twenty-four generic FDCs were quality-approved for older regimens but only four for newer regimens. Generic FDCs were available to GFATM recipients in 2004 but to PEPFAR recipients only after FDA approval in 2006. Price trends for single-component generic medicines mirrored generic FDC prices. Two large-scale purchasers, PEPFAR and UNITAID, together accounted for 53%, 84%, and 77% of market volume for abacavir, emtricitabine, and tenofovir, respectively, in 2008. PEPFAR and UNITAID purchases were often split across two manufacturers. CONCLUSIONS. Global initiatives facilitated the creation of fairly efficient markets for older ARVs, but markets for newer ARVs are less competitive and slower to evolve. WHO guidelines shape demand, and their complexity may help or hinder achievement of economies of scale in pharmaceutical manufacturing. Certification programs assure ARV quality but can delay uptake of new formulations. Large-scale procurement policies may decrease the numbers of buyers and sellers, rendering the market less competitive in the longer-term. Global policies must be developed with consideration for their short- and long-term impact on market dynamics.Item The Global Pediatric Antiretroviral Market: Analyses of Product Availability and Utilization Reveal Challenges for Development of Pediatric Formulations and HIV/AIDS Treatment in Children(BioMed Central, 2010-10-17) Waning, Brenda; Diedrichsen, Ellen; Jambert, Elodie; Bärnighausen, Till; Li, Yun; Pouw, Mieke; Moon, SuerieBACKGROUND: Important advances in the development and production of quality-certified pediatric antiretroviral (ARV) formulations have recently been made despite significant market disincentives for manufacturers. This progress resulted from lobbying and innovative interventions from HIV/AIDS activists, civil society organizations, and international organizations. Research on uptake and dispersion of these improved products across countries and international organizations has not been conducted but is needed to inform next steps towards improving child health. METHODS: We used information from the World Health Organization Prequalification Programme and the United States Food and Drug Administration to describe trends in quality-certification of pediatric formulations and used 7,989 donor-funded, pediatric ARV purchase transactions from 2002-2009 to measure uptake and dispersion of new pediatric ARV formulations across countries and programs. Prices for new pediatric ARV formulations were compared to alternative dosage forms. RESULTS: Fewer ARV options exist for HIV/AIDS treatment in children than adults. Before 2005, most pediatric ARVs were produced by innovator companies in single-component solid and liquid forms. Five 2-in1 and four 3-in-1 generic pediatric fixed-dose combinations (FDCs) in solid and dispersible forms have been quality-certified since 2005. Most (67%) of these were produced by one quality-certified manufacturer. Uptake of new pediatric FDCs outside of UNITAID is low. UNITAID accounted for 97-100% of 2008-2009 market volume. In total, 33 and 34 countries reported solid or dispersible FDC purchases in 2008 and 2009, respectively, but most purchases were made through UNITAID. Only three Global Fund country recipients reported purchase of these FDCs in 2008. Prices for pediatric FDCs were considerably lower than liquids but typically higher than half of an adult FDC. CONCLUSION: Pediatric ARV markets are more fragile than adult markets. Ensuring a long-term supply of quality, well-adapted ARVs for children requires ongoing monitoring and improved understanding of global pediatric markets, including country-based research to explain and address low uptake of new, improved formulations. Continued innovation in pediatric ARV development may be threatened by outdated procurement practices failing to connect clinicians making prescribing decisions, supply chain staff dealing with logistics, donors, international organizations, and pharmaceutical manufacturers. Perceptions of global demand must be better informed by accurate estimates of actual country-level demand.Item Balancing Medicine Prices and Business Sustainability: Analyses of Pharmacy Costs, Revenues and Profit Shed Light on Retail Medicine Mark-Ups in Rural Kyrgyzstan(BioMed Central, 2010-7-13) Waning, Brenda; Maddix, Jason; Soucy, LyneBACKGROUND: Numerous not-for-profit pharmacies have been created to improve access to medicines for the poor, but many have failed due to insufficient financial planning and management. These pharmacies are not well described in health services literature despite strong demand from policy makers, implementers, and researchers. Surveys reporting unaffordable medicine prices and high mark-ups have spurred efforts to reduce medicine prices, but price reduction goals are arbitrary in the absence of information on pharmacy costs, revenues, and profit structures. Health services research is needed to develop sustainable and "reasonable" medicine price goals and strategic initiatives to reach them. METHODS. We utilized cost accounting methods on inventory and financial information obtained from a not-for-profit rural pharmacy network in mountainous Kyrgyzstan to quantify costs, revenues, profits and medicine mark-ups during establishment and maintenance periods (October 2004-December 2007). RESULTS: Twelve pharmacies and one warehouse were established in remote Kyrgyzstan with < US $25,000 due to governmental resource-sharing. The network operated at break-even profit, leaving little room to lower medicine prices and mark-ups. Medicine mark-ups needed for sustainability were greater than originally envisioned by network administration. In 2005, 55%, 35%, and 10% of the network's top 50 products revealed mark-ups of < 50%, 50-99% and > 100%, respectively. Annual mark-ups increased dramatically each year to cover increasing recurrent costs, and by 2007, only 19% and 46% of products revealed mark-ups of < 50% and 50-99%, respectively; while 35% of products revealed mark-ups > 100%. 2007 medicine mark-ups varied substantially across these products, ranging from 32% to 244%. Mark-ups needed to sustain private pharmacies would be even higher in the absence of government subsidies. CONCLUSION: Pharmacy networks can be established in hard-to-reach regions with little funding using public-private partnership, resource-sharing models. Medicine prices and mark-ups must be interpreted with consideration for regional costs of business. Mark-ups vary dramatically across medicines. Some mark-ups appear "excessive" but are likely necessary for pharmacy viability. Pharmacy financial data is available in remote settings and can be used towards determination of "reasonable" medicine price goals. Health systems researchers must document the positive and negative financial experiences of pharmacy initiatives to inform future projects and advance access to medicines goals.