Debbi Main - Academia.edu (original) (raw)

Papers by Debbi Main

Transportation Research Board 90th Annual MeetingTransportation Research Board, 2011

Inductive loops are commonly used for bicycle detection both on- and off- street, but until recen... more Inductive loops are commonly used for bicycle detection both on- and off- street, but until recently, few such detectors are able to differentiate between bicycles and motor vehicles. For this reason, automated bicycle counting is usually confined to off-street locations. With bicycle use increasing around the world, particularly on shared roadway facilities such as bicycle boulevards, there is a growing need to detect bicycles in on-street traffic conditions. This study tests the accuracy of the Eco-Counter Zelt, an off-the-shelf inductive-loop technology that is designed to count bicycles in mixed traffic, and compares this accuracy to that of similar inductive loop technology for detection on separated bicycle facilities. The results show that the Zelt inductive loop technology is capable of differentiating bicycles from motor vehicles and does count bicycles in traffic with reasonable accuracy, but an individual bicycle may be undetected or counted more than once. Overall, there was a 3 percent undercount for the counter on the separated path and a 4 percent overcount for the counter on the shared roadway. The results show that refinements in inductive loop detector/counter software and set up have made it possible to distinguish bicycles from motor vehicles; however, care must be taken in installation, calibration, and maintenance to ensure that the counters are and continue to be accurate.

Circulation, Nov 10, 2015

Background: Physician bias may contribute to gender disparities in the use of angiography. We per... more Background: Physician bias may contribute to gender disparities in the use of angiography. We performed the first study using the Implicit Association Test (IAT) to examine gender biases and their associations with angiography decisions. Methods: Cardiology physicians were emailed a web-based survey that included 2 gender-IATs and a two-part clinical vignette randomized by patient gender. The IATs measured attitudes about men versus women on strength and risk-taking. The vignette represented an intermediate likelihood of CAD regardless of gender; part-1 described a patient with symptoms of CAD and part-2 described an abnormal stress test. Physicians rated the likelihood of CAD and their agreement with the usefulness of angiography for that patient. We examined the association between gender attitudes and rated usefulness of angiography for the male and female patient, adjusting for the perceived likelihood of CAD. Results: Of the 503 cardiologists who responded, over half associated strength and willingness to take risks with males. For both parts of the case, cardiologists’ estimated the likelihood of CAD similarly by patient gender; yet, cardiologists’ more often rated the usefulness of angiography as “high” for the male versus female patient (Part-1: 19.7% vs. 9.8%; Part-2: 73.7% vs. 64.3%; p<0.05 for both). These differences varied by gender attitudes; those with higher male-risk bias or male-strength bias rated angiography as more useful for men than for women. (Figure) After adjustment, only the relationship with male-risk bias and higher angiography rating for male patients persisted (p=0.01 for interaction). Conclusions: Despite similar estimates of CAD likelihood, cardiology physicians rated the usefulness of angiography higher for a standardized male than female patient. This difference significantly varied by gender-risk bias suggesting the concept of riskiness influenced decisions about angiography differently in women and male patients.

Circulation-cardiovascular Quality and Outcomes, Jul 1, 2014

Background: Physician bias is a likely contributor to gender disparities in the use of cardiac pr... more Background: Physician bias is a likely contributor to gender disparities in the use of cardiac procedures. The Implicit Association Test (IAT) is a validated tool to measure implicit (unconscious) attitudes but has not been used to study gender disparities in health care. We measured attitudes around patient gender among cardiology physicians using the IAT. Methods: We developed two web-based IATs focused on gender attitudes applicable to cardiology procedures. The IAT measures implicit biases by comparing the speed with which concepts can be sorted, when paired in different combinations (i.e. women=strength and men=weakness vs. men=strength and women=weakness). The Strong-IAT measured gender associations with “strength versus weakness” and the Risk-IAT measured gender associations with “risk-taker versus risk-averse”. The IAT is scored from –2.0 to +2.0 with negative scores suggesting a pro-female bias (e.g. women are stronger than men), a positive score suggesting a pro-male bias (e.g. men are stronger than women) and “0” meaning no bias. We emailed a web-based survey including the IATs to all physician members of a state cardiology association. Potential participants received three weekly reminders and, for validation purposes, a subset re-took the survey after 30-days. Results: Of the 317 cardiology physicians with valid email addresses, 52 (16.4%) completed the survey. Participants’ mean age was 48.2 (+/- 12.1), 81% were male, and 77% were white. Most (63%) were non-invasive cardiologists (22% interventional cardiologists and 16% electrophysiologists) and 67% practiced in an academic setting. The mean Strong-IAT score was 0.60 (SD = 0 .42) and Risk-IAT score was 0.45 (SD = 0.54) revealing a significant pro-male bias. Over 38% had a high degree of pro-male bias for both IATs (Figure). Among the 11 participants who retook the survey, test-retest reliability was high (Strong-IAT r=0.68; Risk-IAT r=0.79). Conclusions: On average, cardiology physicians exhibited implicit gender bias suggesting they are more likely to view men as being stronger and more likely to take risks than women. These attitudes appeared to be relatively stable over time. Future work is needed to understand whether these attitudes influence treatment decisions and contribute to gender disparities in cardiology care.

Many organizations rely on community festivals and other events as one means of reaching out to a... more Many organizations rely on community festivals and other events as one means of reaching out to and enrolling children in Family Medicaid and Children's Health Insurance Program Plus (CHP+). While this is a popular outreach strateg y, there has been little research on the effectiveness of these methods in increasing enrollment. This report provides a brief examination of this issue among The Colorado Trust's Outreach & Enrollment grantees. Based on published research and the experience of Trust grantees, it appears ill advised for organizations to attend broadbased events such as health fairs and community festivals as a primary method of identifying and enrolling children. Participating in such events is time consuming and results in few, if any, completed insurance applications. However, promoting Medicaid and CHP+ at community events may be an effective way to raise awareness about insurance options for children. 1 NOVEMBER 2010 Every year across Colorado, groups dedicated to increasing the number of children with health insurance attend community festivals and other events in a push to enroll eligible children in Family Medicaid and/or the Children's Health Insurance Program Plus (CHP+), the two primary public health insurance programs for low-income children and families. While much has been written to promote the use of community-based strategies to identify and enroll uninsured children in public health insurance, little research has examined the effectiveness of specific outreach methods such as community events. 1-3 Nonetheless, such events remain a favorite approach among many children's health insurance advocates. What can be learned about the effectiveness of such an approach to outreach and enrollment? Based on the experience of The Colorado Trust's community-based outreach and enrollment grantees, as well as literature examining other outreach projects around the country, this brief explores lessons learned about the strengths and limitations of using community events as an outreach and enrollment strategy. It also offers recommendations from practitioners for designing events to improve results. BACKGROUND Colorado has a long history of event-based outreach to the uninsured. Approximately a decade ago, the Colorado Department of Health Care Policy and Financing (HCPF) hired Child Health Advocates (CHA), a nonprofit organization, to promote the CHP+ program to new families. Along with investing in a mass-media marketing campaign, CHA discovered what states across the country have found true: coordinating with community partners to attend small events such as back-to-school nights and community gatherings seemed to be an effective way to raise parents' awareness of the program. 4 Several years later, outreach workers with the Medicaid program began engaging in similar methods but with the specific aim of helping already-enrolled clients understand and use these benefits. In recent years, the goals of increasing enrollment and assisting clients have merged, and most organizations that promote Medicaid and/or CHP+ now view "outreach" holistically, including application completion and enrollment, making certain the enrolled receive health care services and re-enroll in coverage, as necessary.

Journal of The American College of Surgeons, Jun 1, 2007

The majority of studies relating processes and structures of surgical care to outcomes focus on m... more The majority of studies relating processes and structures of surgical care to outcomes focus on mortality alone, even though morbidity outcomes are frequent, costly, and can have an adverse effect on a patient's short- and longterm survival and quality of life. The purpose of this study was to identify the important processes and structures of surgical care that relate to 30-day, risk-adjusted postoperative morbidity in general surgery. Department of Veterans Affairs general surgery patients operated on in the period October 1, 2003 to September 30, 2004 at medical centers that participated in the Patient Safety in Surgery (PSS) Study and responded to a process and structure of care survey were included in this study. The patient's risk information was combined with key process and structure variables in a hierarchical maximum likelihood analysis to predict 30-day postoperative morbidity. A number of hospital-level processes and structures of care were identified that predicted 30-day postoperative morbidity. The dominant factor was university affiliation. Affiliated hospitals showed an increase in risk of morbidity even after adjustment for patient risk. Risk-adjusted morbidity is higher in Veterans Affairs hospitals that are affiliated with university medical centers. These findings mandate additional study to identify the exact factors responsible for this increased morbidity.

Despite national calls for insuring all children, families face a host of barriers to enrolling t... more Despite national calls for insuring all children, families face a host of barriers to enrolling their children in public health insurance programs. Many of these barriers are rooted in the complexity of enrollment processes, in families' relationships with some traditional enrollment assistance sites and in the accessibility and carrying capacity of the limited number of settings where families can receive enrollment assistance. This shortage of enrollment and retention assistance sites results in a significant number of children who, despite eligibility for programs such as Medicaid or the Children's Health Insurance Program (CHIP), remain uninsured. Economic downturns-whether at the local, state or national level-can exacerbate these barriers as demand for public health insurance grows. 1

Circulation-cardiovascular Quality and Outcomes, Jul 1, 2014

Background: Physician bias is a likely contributor to gender disparities in the use of cardiac pr... more Background: Physician bias is a likely contributor to gender disparities in the use of cardiac procedures. The Implicit Association Test (IAT) is a validated tool to measure implicit (unconscious) attitudes but has not been used to study gender disparities in health care. We measured attitudes around patient gender among cardiology physicians using the IAT. Methods: We developed two web-based IATs focused on gender attitudes applicable to cardiology procedures. The IAT measures implicit biases by comparing the speed with which concepts can be sorted, when paired in different combinations (i.e. women=strength and men=weakness vs. men=strength and women=weakness). The Strong-IAT measured gender associations with “strength versus weakness” and the Risk-IAT measured gender associations with “risk-taker versus risk-averse”. The IAT is scored from –2.0 to +2.0 with negative scores suggesting a pro-female bias (e.g. women are stronger than men), a positive score suggesting a pro-male bias (e.g. men are stronger ...

Circulation, 2015

Background: Physician bias may contribute to gender disparities in the use of angiography. We per... more Background: Physician bias may contribute to gender disparities in the use of angiography. We performed the first study using the Implicit Association Test (IAT) to examine gender biases and their associations with angiography decisions. Methods: Cardiology physicians were emailed a web-based survey that included 2 gender-IATs and a two-part clinical vignette randomized by patient gender. The IATs measured attitudes about men versus women on strength and risk-taking. The vignette represented an intermediate likelihood of CAD regardless of gender; part-1 described a patient with symptoms of CAD and part-2 described an abnormal stress test. Physicians rated the likelihood of CAD and their agreement with the usefulness of angiography for that patient. We examined the association between gender attitudes and rated usefulness of angiography for the male and female patient, adjusting for the perceived likelihood of CAD. Results: Of the 503 cardiologists who responded, over half associated...

INTRODUCTION: In April 2011, Colorado passed a law requiring all public elementary schools to pro... more INTRODUCTION: In April 2011, Colorado passed a law requiring all public elementary schools to provide a minimum of 30 minutes of physical activity per school day. Denver Public Schools (DPS), a leader and early adopter in improving the quality of physical education (PE) in its schools, has instituted a series of teacher trainings to improve the quality of PE, targeting a total of 90 pre K-12 schools and 55,738 students. Through Denver's Community Transformation Grant (CTG), we are evaluating the implementation and impact of this policy on physical activity and obesity in DPS students. METHODS: Designed as a modified time series design, with multiple measures over the course of CTG, we are measuring (1) change in the quality of PE using data from the System for Observing Fitness Instruction Time (SOFIT) and (2) changes in student health using BMI data and self-reported physical activity. RESULTS: Although only in year 2 of a multi-year evaluation, we will present findings to date...

Purpose: Despite their mortality benefit, Implantable Cardioverter Defibrillators (ICDs) have pot... more Purpose: Despite their mortality benefit, Implantable Cardioverter Defibrillators (ICDs) have potential risks. This study aims to understand cardiologists' perspectives about the factors important in their decision to recommend ICD implantation for the primary prevention of sudden cardiac death. Method: This qualitative study utilized open-ended in-depth interviews with 12 cardiologists (including 4 electrophysiologists) with experience in counseling patients surrounding ICD decision making. The interviews were recorded and transcribed and the data were analyzed through the theoretical lens of patient-centered care using the constant comparative method. Results: Study cardiologists reported that the ICD mortality benefit should be conveyed to all patients; they assume that patients want this mortality benefit (table). Cardiologists also reported that the following ICD risks should be mentioned at the time of implantation: inappropriate shocks, cosmetic concerns, procedural compl...

Inductive loops are commonly used for bicycle detection both on- and off- street, but until recen... more Inductive loops are commonly used for bicycle detection both on- and off- street, but until recently, few such detectors are able to differentiate between bicycles and motor vehicles. For this reason, automated bicycle counting is usually confined to off-street locations. With bicycle use increasing around the world, particularly on shared roadway facilities such as bicycle boulevards, there is a growing need to detect bicycles in on-street traffic conditions. This study tests the accuracy of the Eco-Counter Zelt, an off-the-shelf inductive-loop technology that is designed to count bicycles in mixed traffic, and compares this accuracy to that of similar inductive loop technology for detection on separated bicycle facilities. The results show that the Zelt inductive loop technology is capable of differentiating bicycles from motor vehicles and does count bicycles in traffic with reasonable accuracy, but an individual bicycle may be undetected or counted more than once. Overall, there was a 3 percent undercount for the counter on the separated path and a 4 percent overcount for the counter on the shared roadway. The results show that refinements in inductive loop detector/counter software and set up have made it possible to distinguish bicycles from motor vehicles; however, care must be taken in installation, calibration, and maintenance to ensure that the counters are and continue to be accurate.

Journal of the American College of Surgeons, 2007

With increased focus on improving surgical care quality, understanding structures and processes t... more With increased focus on improving surgical care quality, understanding structures and processes that influence surgical care is timely and important, as is more precise specification of these through improved measurement. We conducted a qualitative study to help design a quantitative survey of structures and processes of surgical care. We audiotaped 44 face-to-face interviews with surgical care leaders and other diverse members of the surgical care team from 6 hospitals (two Veterans Affairs, four private sector). Qualitative interviews were transcribed and analyzed to identify common structures and processes mentioned by interviewees to include on a quantitative survey and to develop a rich description of salient themes on indicators of effective surgical care services and surgical care teams. Qualitative analyses of transcripts resulted in detailed descriptions of structures and processes of surgical care services that affected surgical care team performance--and how particular structures led to effective and ineffective processes that impacted quality and outcomes of surgical care. Communication and care coordination were most frequently mentioned as essential to effective surgical care services and teams. Informants also described other influences on surgical quality and outcomes, such as staffing, the role of residents, and team composition and continuity. Surgical care team members reinforced the importance of understanding surgical care processes and structures to improve both quality and outcomes of surgical care. The analysis of interviews helped the study team identify potential measures of structures and processes to include in our quantitative survey.

The Lancet, 1982

Hamilton scores in the three groups (see table). (Termination values were used as the dependent m... more Hamilton scores in the three groups (see table). (Termination values were used as the dependent measures; the covariates were % of normal weight on pretreatment days 1 and 7, and Hamilton scores on pretreatment days 2 and 5.) The analysis revealed a significant drug effect (F2,31 = 3 .5, p<0 . 041) on Hamilton scores and on weight gain (F2,31 = 3 32 p<0-049). Post-hoc comparisons revealed that these significant differences were mainly due to the contrast of the cyproheptadine group against the placebo group. Since cyproheptadine is a comparatively safe drug with no complicating side-effects such as hypotension, disturbance of cardiac rhythm, and undesirable interactions with other drugs, it is an attractive drug to use. Cyproheptadine antagonises a wide variety of pharmacological effects produced by serotonin and histamine in the laboratory animal. 10 It is possible that the antidepressant effects of cyproheptadine are mediated through its serotonin antagonist action.

Providing integrated care is exceptionally challenging in community health centers (CHCs), where ... more Providing integrated care is exceptionally challenging in community health centers (CHCs), where patients are from diverse cultural backgrounds, live in poverty, and have poorer physical and mental health than the general population. The extent and nature of these challenges is poorly understood but vital to identifying potential improvements for settings in which disadvantaged individuals are most likely to seek mental as well as physical health care. We sought to describe primary care providers' (PCPs) approaches to mental health care in CHCs and to identify factors that influence those approaches. We used semi-structured interviews with 48 PCPs in 7 CHCs in the Denver, Colorado metropolitan area to explore PCPs' experiences with adults whose chronic disease care is complicated by psychosocial issues. PCPs' descriptions of specific care situations revealed the practice of reluctant psychiatry a PCP's approach to mental health care when the patient's needs are c...

Many organizations rely on community festivals and other events as one means of reaching out to a... more Many organizations rely on community festivals and other events as one means of reaching out to and enrolling children in Family Medicaid and Children’s Health Insurance Program Plus (CHP+). While this is a popular outreach strategy, there has been little research on the effectiveness of these methods in increasing enrollment. This report provides a brief examination of this issue among The Colorado Trust’s Outreach & Enrollment grantees.

Transportation Research Board 90th Annual MeetingTransportation Research Board, 2011

Inductive loops are commonly used for bicycle detection both on- and off- street, but until recen... more Inductive loops are commonly used for bicycle detection both on- and off- street, but until recently, few such detectors are able to differentiate between bicycles and motor vehicles. For this reason, automated bicycle counting is usually confined to off-street locations. With bicycle use increasing around the world, particularly on shared roadway facilities such as bicycle boulevards, there is a growing need to detect bicycles in on-street traffic conditions. This study tests the accuracy of the Eco-Counter Zelt, an off-the-shelf inductive-loop technology that is designed to count bicycles in mixed traffic, and compares this accuracy to that of similar inductive loop technology for detection on separated bicycle facilities. The results show that the Zelt inductive loop technology is capable of differentiating bicycles from motor vehicles and does count bicycles in traffic with reasonable accuracy, but an individual bicycle may be undetected or counted more than once. Overall, there was a 3 percent undercount for the counter on the separated path and a 4 percent overcount for the counter on the shared roadway. The results show that refinements in inductive loop detector/counter software and set up have made it possible to distinguish bicycles from motor vehicles; however, care must be taken in installation, calibration, and maintenance to ensure that the counters are and continue to be accurate.

Circulation, Nov 10, 2015

Background: Physician bias may contribute to gender disparities in the use of angiography. We per... more Background: Physician bias may contribute to gender disparities in the use of angiography. We performed the first study using the Implicit Association Test (IAT) to examine gender biases and their associations with angiography decisions. Methods: Cardiology physicians were emailed a web-based survey that included 2 gender-IATs and a two-part clinical vignette randomized by patient gender. The IATs measured attitudes about men versus women on strength and risk-taking. The vignette represented an intermediate likelihood of CAD regardless of gender; part-1 described a patient with symptoms of CAD and part-2 described an abnormal stress test. Physicians rated the likelihood of CAD and their agreement with the usefulness of angiography for that patient. We examined the association between gender attitudes and rated usefulness of angiography for the male and female patient, adjusting for the perceived likelihood of CAD. Results: Of the 503 cardiologists who responded, over half associated strength and willingness to take risks with males. For both parts of the case, cardiologists’ estimated the likelihood of CAD similarly by patient gender; yet, cardiologists’ more often rated the usefulness of angiography as “high” for the male versus female patient (Part-1: 19.7% vs. 9.8%; Part-2: 73.7% vs. 64.3%; p&amp;amp;lt;0.05 for both). These differences varied by gender attitudes; those with higher male-risk bias or male-strength bias rated angiography as more useful for men than for women. (Figure) After adjustment, only the relationship with male-risk bias and higher angiography rating for male patients persisted (p=0.01 for interaction). Conclusions: Despite similar estimates of CAD likelihood, cardiology physicians rated the usefulness of angiography higher for a standardized male than female patient. This difference significantly varied by gender-risk bias suggesting the concept of riskiness influenced decisions about angiography differently in women and male patients.

Circulation-cardiovascular Quality and Outcomes, Jul 1, 2014

Background: Physician bias is a likely contributor to gender disparities in the use of cardiac pr... more Background: Physician bias is a likely contributor to gender disparities in the use of cardiac procedures. The Implicit Association Test (IAT) is a validated tool to measure implicit (unconscious) attitudes but has not been used to study gender disparities in health care. We measured attitudes around patient gender among cardiology physicians using the IAT. Methods: We developed two web-based IATs focused on gender attitudes applicable to cardiology procedures. The IAT measures implicit biases by comparing the speed with which concepts can be sorted, when paired in different combinations (i.e. women=strength and men=weakness vs. men=strength and women=weakness). The Strong-IAT measured gender associations with “strength versus weakness” and the Risk-IAT measured gender associations with “risk-taker versus risk-averse”. The IAT is scored from –2.0 to +2.0 with negative scores suggesting a pro-female bias (e.g. women are stronger than men), a positive score suggesting a pro-male bias (e.g. men are stronger than women) and “0” meaning no bias. We emailed a web-based survey including the IATs to all physician members of a state cardiology association. Potential participants received three weekly reminders and, for validation purposes, a subset re-took the survey after 30-days. Results: Of the 317 cardiology physicians with valid email addresses, 52 (16.4%) completed the survey. Participants’ mean age was 48.2 (+/- 12.1), 81% were male, and 77% were white. Most (63%) were non-invasive cardiologists (22% interventional cardiologists and 16% electrophysiologists) and 67% practiced in an academic setting. The mean Strong-IAT score was 0.60 (SD = 0 .42) and Risk-IAT score was 0.45 (SD = 0.54) revealing a significant pro-male bias. Over 38% had a high degree of pro-male bias for both IATs (Figure). Among the 11 participants who retook the survey, test-retest reliability was high (Strong-IAT r=0.68; Risk-IAT r=0.79). Conclusions: On average, cardiology physicians exhibited implicit gender bias suggesting they are more likely to view men as being stronger and more likely to take risks than women. These attitudes appeared to be relatively stable over time. Future work is needed to understand whether these attitudes influence treatment decisions and contribute to gender disparities in cardiology care.

Many organizations rely on community festivals and other events as one means of reaching out to a... more Many organizations rely on community festivals and other events as one means of reaching out to and enrolling children in Family Medicaid and Children's Health Insurance Program Plus (CHP+). While this is a popular outreach strateg y, there has been little research on the effectiveness of these methods in increasing enrollment. This report provides a brief examination of this issue among The Colorado Trust's Outreach & Enrollment grantees. Based on published research and the experience of Trust grantees, it appears ill advised for organizations to attend broadbased events such as health fairs and community festivals as a primary method of identifying and enrolling children. Participating in such events is time consuming and results in few, if any, completed insurance applications. However, promoting Medicaid and CHP+ at community events may be an effective way to raise awareness about insurance options for children. 1 NOVEMBER 2010 Every year across Colorado, groups dedicated to increasing the number of children with health insurance attend community festivals and other events in a push to enroll eligible children in Family Medicaid and/or the Children's Health Insurance Program Plus (CHP+), the two primary public health insurance programs for low-income children and families. While much has been written to promote the use of community-based strategies to identify and enroll uninsured children in public health insurance, little research has examined the effectiveness of specific outreach methods such as community events. 1-3 Nonetheless, such events remain a favorite approach among many children's health insurance advocates. What can be learned about the effectiveness of such an approach to outreach and enrollment? Based on the experience of The Colorado Trust's community-based outreach and enrollment grantees, as well as literature examining other outreach projects around the country, this brief explores lessons learned about the strengths and limitations of using community events as an outreach and enrollment strategy. It also offers recommendations from practitioners for designing events to improve results. BACKGROUND Colorado has a long history of event-based outreach to the uninsured. Approximately a decade ago, the Colorado Department of Health Care Policy and Financing (HCPF) hired Child Health Advocates (CHA), a nonprofit organization, to promote the CHP+ program to new families. Along with investing in a mass-media marketing campaign, CHA discovered what states across the country have found true: coordinating with community partners to attend small events such as back-to-school nights and community gatherings seemed to be an effective way to raise parents' awareness of the program. 4 Several years later, outreach workers with the Medicaid program began engaging in similar methods but with the specific aim of helping already-enrolled clients understand and use these benefits. In recent years, the goals of increasing enrollment and assisting clients have merged, and most organizations that promote Medicaid and/or CHP+ now view "outreach" holistically, including application completion and enrollment, making certain the enrolled receive health care services and re-enroll in coverage, as necessary.

Journal of The American College of Surgeons, Jun 1, 2007

The majority of studies relating processes and structures of surgical care to outcomes focus on m... more The majority of studies relating processes and structures of surgical care to outcomes focus on mortality alone, even though morbidity outcomes are frequent, costly, and can have an adverse effect on a patient&amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;#39;s short- and longterm survival and quality of life. The purpose of this study was to identify the important processes and structures of surgical care that relate to 30-day, risk-adjusted postoperative morbidity in general surgery. Department of Veterans Affairs general surgery patients operated on in the period October 1, 2003 to September 30, 2004 at medical centers that participated in the Patient Safety in Surgery (PSS) Study and responded to a process and structure of care survey were included in this study. The patient&amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;#39;s risk information was combined with key process and structure variables in a hierarchical maximum likelihood analysis to predict 30-day postoperative morbidity. A number of hospital-level processes and structures of care were identified that predicted 30-day postoperative morbidity. The dominant factor was university affiliation. Affiliated hospitals showed an increase in risk of morbidity even after adjustment for patient risk. Risk-adjusted morbidity is higher in Veterans Affairs hospitals that are affiliated with university medical centers. These findings mandate additional study to identify the exact factors responsible for this increased morbidity.

Despite national calls for insuring all children, families face a host of barriers to enrolling t... more Despite national calls for insuring all children, families face a host of barriers to enrolling their children in public health insurance programs. Many of these barriers are rooted in the complexity of enrollment processes, in families' relationships with some traditional enrollment assistance sites and in the accessibility and carrying capacity of the limited number of settings where families can receive enrollment assistance. This shortage of enrollment and retention assistance sites results in a significant number of children who, despite eligibility for programs such as Medicaid or the Children's Health Insurance Program (CHIP), remain uninsured. Economic downturns-whether at the local, state or national level-can exacerbate these barriers as demand for public health insurance grows. 1

Circulation-cardiovascular Quality and Outcomes, Jul 1, 2014

Background: Physician bias is a likely contributor to gender disparities in the use of cardiac pr... more Background: Physician bias is a likely contributor to gender disparities in the use of cardiac procedures. The Implicit Association Test (IAT) is a validated tool to measure implicit (unconscious) attitudes but has not been used to study gender disparities in health care. We measured attitudes around patient gender among cardiology physicians using the IAT. Methods: We developed two web-based IATs focused on gender attitudes applicable to cardiology procedures. The IAT measures implicit biases by comparing the speed with which concepts can be sorted, when paired in different combinations (i.e. women=strength and men=weakness vs. men=strength and women=weakness). The Strong-IAT measured gender associations with “strength versus weakness” and the Risk-IAT measured gender associations with “risk-taker versus risk-averse”. The IAT is scored from –2.0 to +2.0 with negative scores suggesting a pro-female bias (e.g. women are stronger than men), a positive score suggesting a pro-male bias (e.g. men are stronger ...

Circulation, 2015

Background: Physician bias may contribute to gender disparities in the use of angiography. We per... more Background: Physician bias may contribute to gender disparities in the use of angiography. We performed the first study using the Implicit Association Test (IAT) to examine gender biases and their associations with angiography decisions. Methods: Cardiology physicians were emailed a web-based survey that included 2 gender-IATs and a two-part clinical vignette randomized by patient gender. The IATs measured attitudes about men versus women on strength and risk-taking. The vignette represented an intermediate likelihood of CAD regardless of gender; part-1 described a patient with symptoms of CAD and part-2 described an abnormal stress test. Physicians rated the likelihood of CAD and their agreement with the usefulness of angiography for that patient. We examined the association between gender attitudes and rated usefulness of angiography for the male and female patient, adjusting for the perceived likelihood of CAD. Results: Of the 503 cardiologists who responded, over half associated...

INTRODUCTION: In April 2011, Colorado passed a law requiring all public elementary schools to pro... more INTRODUCTION: In April 2011, Colorado passed a law requiring all public elementary schools to provide a minimum of 30 minutes of physical activity per school day. Denver Public Schools (DPS), a leader and early adopter in improving the quality of physical education (PE) in its schools, has instituted a series of teacher trainings to improve the quality of PE, targeting a total of 90 pre K-12 schools and 55,738 students. Through Denver's Community Transformation Grant (CTG), we are evaluating the implementation and impact of this policy on physical activity and obesity in DPS students. METHODS: Designed as a modified time series design, with multiple measures over the course of CTG, we are measuring (1) change in the quality of PE using data from the System for Observing Fitness Instruction Time (SOFIT) and (2) changes in student health using BMI data and self-reported physical activity. RESULTS: Although only in year 2 of a multi-year evaluation, we will present findings to date...

Purpose: Despite their mortality benefit, Implantable Cardioverter Defibrillators (ICDs) have pot... more Purpose: Despite their mortality benefit, Implantable Cardioverter Defibrillators (ICDs) have potential risks. This study aims to understand cardiologists' perspectives about the factors important in their decision to recommend ICD implantation for the primary prevention of sudden cardiac death. Method: This qualitative study utilized open-ended in-depth interviews with 12 cardiologists (including 4 electrophysiologists) with experience in counseling patients surrounding ICD decision making. The interviews were recorded and transcribed and the data were analyzed through the theoretical lens of patient-centered care using the constant comparative method. Results: Study cardiologists reported that the ICD mortality benefit should be conveyed to all patients; they assume that patients want this mortality benefit (table). Cardiologists also reported that the following ICD risks should be mentioned at the time of implantation: inappropriate shocks, cosmetic concerns, procedural compl...

Inductive loops are commonly used for bicycle detection both on- and off- street, but until recen... more Inductive loops are commonly used for bicycle detection both on- and off- street, but until recently, few such detectors are able to differentiate between bicycles and motor vehicles. For this reason, automated bicycle counting is usually confined to off-street locations. With bicycle use increasing around the world, particularly on shared roadway facilities such as bicycle boulevards, there is a growing need to detect bicycles in on-street traffic conditions. This study tests the accuracy of the Eco-Counter Zelt, an off-the-shelf inductive-loop technology that is designed to count bicycles in mixed traffic, and compares this accuracy to that of similar inductive loop technology for detection on separated bicycle facilities. The results show that the Zelt inductive loop technology is capable of differentiating bicycles from motor vehicles and does count bicycles in traffic with reasonable accuracy, but an individual bicycle may be undetected or counted more than once. Overall, there was a 3 percent undercount for the counter on the separated path and a 4 percent overcount for the counter on the shared roadway. The results show that refinements in inductive loop detector/counter software and set up have made it possible to distinguish bicycles from motor vehicles; however, care must be taken in installation, calibration, and maintenance to ensure that the counters are and continue to be accurate.

Journal of the American College of Surgeons, 2007

With increased focus on improving surgical care quality, understanding structures and processes t... more With increased focus on improving surgical care quality, understanding structures and processes that influence surgical care is timely and important, as is more precise specification of these through improved measurement. We conducted a qualitative study to help design a quantitative survey of structures and processes of surgical care. We audiotaped 44 face-to-face interviews with surgical care leaders and other diverse members of the surgical care team from 6 hospitals (two Veterans Affairs, four private sector). Qualitative interviews were transcribed and analyzed to identify common structures and processes mentioned by interviewees to include on a quantitative survey and to develop a rich description of salient themes on indicators of effective surgical care services and surgical care teams. Qualitative analyses of transcripts resulted in detailed descriptions of structures and processes of surgical care services that affected surgical care team performance--and how particular structures led to effective and ineffective processes that impacted quality and outcomes of surgical care. Communication and care coordination were most frequently mentioned as essential to effective surgical care services and teams. Informants also described other influences on surgical quality and outcomes, such as staffing, the role of residents, and team composition and continuity. Surgical care team members reinforced the importance of understanding surgical care processes and structures to improve both quality and outcomes of surgical care. The analysis of interviews helped the study team identify potential measures of structures and processes to include in our quantitative survey.

The Lancet, 1982

Hamilton scores in the three groups (see table). (Termination values were used as the dependent m... more Hamilton scores in the three groups (see table). (Termination values were used as the dependent measures; the covariates were % of normal weight on pretreatment days 1 and 7, and Hamilton scores on pretreatment days 2 and 5.) The analysis revealed a significant drug effect (F2,31 = 3 .5, p<0 . 041) on Hamilton scores and on weight gain (F2,31 = 3 32 p<0-049). Post-hoc comparisons revealed that these significant differences were mainly due to the contrast of the cyproheptadine group against the placebo group. Since cyproheptadine is a comparatively safe drug with no complicating side-effects such as hypotension, disturbance of cardiac rhythm, and undesirable interactions with other drugs, it is an attractive drug to use. Cyproheptadine antagonises a wide variety of pharmacological effects produced by serotonin and histamine in the laboratory animal. 10 It is possible that the antidepressant effects of cyproheptadine are mediated through its serotonin antagonist action.

Providing integrated care is exceptionally challenging in community health centers (CHCs), where ... more Providing integrated care is exceptionally challenging in community health centers (CHCs), where patients are from diverse cultural backgrounds, live in poverty, and have poorer physical and mental health than the general population. The extent and nature of these challenges is poorly understood but vital to identifying potential improvements for settings in which disadvantaged individuals are most likely to seek mental as well as physical health care. We sought to describe primary care providers' (PCPs) approaches to mental health care in CHCs and to identify factors that influence those approaches. We used semi-structured interviews with 48 PCPs in 7 CHCs in the Denver, Colorado metropolitan area to explore PCPs' experiences with adults whose chronic disease care is complicated by psychosocial issues. PCPs' descriptions of specific care situations revealed the practice of reluctant psychiatry a PCP's approach to mental health care when the patient's needs are c...

Many organizations rely on community festivals and other events as one means of reaching out to a... more Many organizations rely on community festivals and other events as one means of reaching out to and enrolling children in Family Medicaid and Children’s Health Insurance Program Plus (CHP+). While this is a popular outreach strategy, there has been little research on the effectiveness of these methods in increasing enrollment. This report provides a brief examination of this issue among The Colorado Trust’s Outreach & Enrollment grantees.