Hazel Tapp - Academia.edu (original) (raw)

Papers by Hazel Tapp

Journal of the American Board of Family Medicine : JABFM

Asthma is a chronic airway disease that can be difficult to manage, resulting in poor outcomes an... more Asthma is a chronic airway disease that can be difficult to manage, resulting in poor outcomes and high costs. Asthma action plans assist patients with self-management, but provider compliance with this recommendation is limited in part because of guideline complexity. This project aimed to embed an electronic asthma action plan decision support tool (eAAP) into the medical record to streamline evidence-based guidelines for providers at the point of care, create individualized patient handouts, and evaluate effects on disease outcomes. eAAP development occurred in 4 phases: web-based prototype creation, multidisciplinary team engagement, pilot, and system-wide dissemination. Medical record and hospital billing data compared frequencies of asthma exacerbations before and after eAAP receipt with matched controls. Between December 2012 and September 2014, 5174 patients with asthma (∼10%) received eAAPs. Results showed an association between eAAP receipt and significant reductions in pe...

Journal of comparative effectiveness research, 2013

Community-based participatory research (CBPR) has emerged to bridge the gap between research and ... more Community-based participatory research (CBPR) has emerged to bridge the gap between research and primary-care practice through community engagement and social action to increase health equity. It is widely acknowledged that access to high-quality primary care services is important to the overall health of a community. Here, CBPR studies in a primary care setting are reviewed to assess the use of CBPR associated with common health problems seen in primary care such as access to care and disparities in chronic disease management across vulnerable populations. CBPR involves building relationships with local communities, determining areas of need and establishing priorities for health concerns. Studies showing improved access to care for a Hispanic population, reduced asthma symptoms and weight loss are highlighted.

The Journal of biological chemistry, Jan 18, 2005

Myristoylated alanine-rich C kinase substrate (MARCKS) is an unfolded protein that contains well ... more Myristoylated alanine-rich C kinase substrate (MARCKS) is an unfolded protein that contains well characterized actin-binding sites within the phosphorylation site domain (PSD), yet paradoxically, we now find that intact MARCKS does not bind to actin. Intact MARCKS also does not bind as well to calmodulin as does the PSD alone. Myristoylation at the N terminus alters how calmodulin binds to MARCKS, implying that, despite its unfolded state, the distant N terminus influences binding events at the PSD. We show that the free PSD binds with site specificity to MARCKS, suggesting that long-range intramolecular interactions within MARCKS are also possible. Because of the unusual primary sequence of MARCKS with an overall isoelectric point of 4.2 yet a very basic PSD (overall charge of +13), we speculated that ionic interactions between oppositely charged domains of MARCKS were responsible for long-range interactions within MARCKS that sterically influence binding events at the PSD and that...

Implementation Science, 2014

Background: Asthma is a common disease that affects people of all ages and has significant morbid... more Background: Asthma is a common disease that affects people of all ages and has significant morbidity and mortality. Poor outcomes and health disparities related to asthma result in part from the difficulty of disseminating new evidence and care delivery methods such as shared decision making (SDM) into clinical practice. This 3-year study explores the ideal framework for rapid dissemination of an evidence-based SDM toolkit for asthma management. The study leverages a partnership between the North Carolina (NC) statewide Medicaid network and the NC Network Consortium of practice-based research networks (PBRNs). Methods/design: This non-blinded study will randomize 30 primary care clinics in NC stratified by four PBRNs. We will test dissemination across these practices using a facilitator-led participatory approach to dissemination (FLOW), a novel method of participatory dissemination involving key principles of community-based participatory research, and a more typical "lunch and learn" dissemination method. Specifically, we will use cluster randomization to assign each of the 30 practices to one of three arms: (1) control, no dissemination; (2) traditional dissemination, one didactic session a year and distribution of educational material; and (3) FLOW dissemination. We hypothesize that at the unit of randomization, the clinic, patients in the FLOW dissemination arm will be more likely to share in their treatment decisions compared to patients in the traditional dissemination or control arms. All outcomes will be measured at the level of the clinic. Adoption of the SDM approach will be evaluated by 1) asthma exacerbations, 2) level of patient involvement in the decision making process, and 3) qualitative assessments from patients and providers. The research question is: What dissemination strategy most effectively increases practice level adoption of a shared decision making approach to asthma management? This study will provide important data to support best practices in dissemination of an evidence-based toolkit and implementation of shared decision making into primary care practices.

Trials, 2014

Background: Screening can reduce colorectal cancer (CRC) incidence and mortality. However, screen... more Background: Screening can reduce colorectal cancer (CRC) incidence and mortality. However, screening is underutilized in vulnerable patient populations, particularly among Latinos. Patient-directed decision aids can increase CRC screening knowledge, self-efficacy, and intent; however, their effect on actual screening test completion tends to be modest. This is probably because decision aids do not address some of the patient-specific barriers that prevent successful completion of CRC screening in these populations. These individual barriers might be addressed though patient navigation interventions. This study will test a combined decision aid and patient navigator intervention on screening completion in diverse populations of vulnerable primary care patients.

The Journal of the American Board of Family Medicine, 2010

A key element for reducing health care costs and improving community health is increased access t... more A key element for reducing health care costs and improving community health is increased access to primary care and preventative health services. Geographic information systems (GIS) have the potential to assess patterns of health care utilization and community-level attributes to identify geographic regions most in need of primary care access.

The Journal of Clinical Hypertension, 2013

This study establishes preliminary validation of a measure that assesses hypertension self-care a... more This study establishes preliminary validation of a measure that assesses hypertension self-care activities with clinical blood pressure (BP). The Hypertension Self-Care Activity Level Effects (H-SCALE) was administered to patients with hypertension to assess levels of self-care. Patients (n=154) were predominantly female (68.6%) and black (79.2%). Greater adherence to self-care was associated with lower systolic and diastolic BP for 5 of the 6 self-care behaviors. Medication adherence was correlated with systolic BP (r=À0.19, P<.05) and weight management adherence was correlated with diastolic BP (r=À0.22, P<.05) after controlling for other covariates. Increased adherence to recommended dietary practices was strongly correlated with higher systolic (r=0.29, P<.05) and diastolic BP (r=0.32, P<.05). The H-SCALE was acceptable for use in clinical settings, and adherence to self-care was generally aligned with lower BP. Assessment of hypertension self-care is important when working with individuals to control their BP. J Clin Hypertens (Greenwich). 2013;15:637-643.

Journal of Asthma, 2014

Objective: Translating research findings into clinical practice is a major challenge to improve t... more Objective: Translating research findings into clinical practice is a major challenge to improve the quality of healthcare delivery. Shared decision making (SDM) has been shown to be effective and has not yet been widely adopted by health providers. This paper describes the participatory approach used to adapt and implement an evidence-based asthma SDM intervention into primary care practices. Methods: A participatory research approach was initiated through partnership development between practice staff and researchers. The collaborative team worked together to adapt and implement a SDM toolkit. Using the RE-AIM framework and qualitative analysis, we evaluated both the implementation of the intervention into clinical practice, and the level of partnership that was established. Analysis included the number of adopting clinics and providers, the patients' perception of the SDM approach, and the number of clinics willing to sustain the intervention delivery after 1 year. Results: All six clinics and physician champions implemented the intervention using half-day dedicated asthma clinics while 16% of all providers within the practices have participated in the intervention. Themes from the focus groups included the importance of being part the development process, belief that the intervention would benefit patients, and concerns around sustainability and productivity. One year after initiation, 100% of clinics have sustained the intervention, and 90% of participating patients reported a shared decision experience. Conclusions: Use of a participatory research process was central to the successful implementation of a SDM intervention in multiple practices with diverse patient populations.

BMC Health Services Research, 2011

Background: Asthma is a chronic lung disease that affects more than 23 million people in the Unit... more Background: Asthma is a chronic lung disease that affects more than 23 million people in the United States, including 7 million children. Asthma is a difficult to manage chronic condition associated with disparities in health outcomes, poor medical compliance, and high healthcare costs. The research network coordinating this project includes hospitals, urgent care centers, and outpatient clinics within Carolinas Healthcare System that share a common electronic medical record and billing system allowing for rapid collection of clinical and demographic data. This study investigates the impact of three interventions on clinical outcomes for patients with asthma. Interventions are: an integrated approach to care that incorporates asthma management based on the chronic care model; a shared decision making intervention for asthma patients in underserved or disadvantaged populations; and a school based care approach that examines the efficacy of school-based programs to impact asthma outcomes including effectiveness of linkages between schools and the healthcare providers. Methods/Design: This study will include 95 Practices, 171 schools, and over 30,000 asthmatic patients. Five groups (A-E) will be evaluated to determine the effectiveness of three interventions. Group A is the usual care control group without electronic medical record (EMR). Group B practices are a second control group that has an EMR with decision support, asthma action plans, and population reports at baseline. A time delay design during year one converts practices in Group B to group C after receiving the integrated approach to care intervention. Four practices within Group C will receive the shared decision making intervention (and become group D). Group E will receive a school based care intervention through case management within the schools. A centralized database will be created with the goal of facilitating comparative effectiveness research on asthma outcomes specifically for this study. Patient and community level analysis will include results from patient surveys, focus groups, and asthma patient density mapping. Community variables such as income and housing density will be mapped for comparison. Outcomes to be measured are reduced hospitalizations and emergency department visits; improved adherence to medication; improved quality of life; reduced school absenteeism; improved self-efficacy and improved school performance. Discussion: Identifying new mechanisms that improve the delivery of asthma care is an important step towards advancing patient outcomes, avoiding preventable Emergency Department visits and hospitalizations, while simultaneously reducing overall healthcare costs.

Orthopaedic tissues, such as bone, cartilage, intervertebral disc and tendon, contain cells that ... more Orthopaedic tissues, such as bone, cartilage, intervertebral disc and tendon, contain cells that are difficult to culture and stimulate in vitro for repair of damaged tissue. Stem cells have the ability to self-renew and differentiate into many tissue types. Recent progress in stem cell research has led to an enthusiastic effort to utilize stem cells for orthopaedic tissue regeneration. Due to ease of harvest and abundance, adipose-derived mesenchymal cells (ASC) are an attractive, readily available adult stem cell that has become increasingly popular for use in many stem cell applications. Recent progress has been made in characterizing ASC and looking mechanistically at gene expression and cellular pathways involved in differentiation. This review focuses on (i) the characterization of ASC through expression of appropriate surface markers; (ii) modulation of in vitro differentiation of ASC through different scaffolds, growth factors, and media; and (iii) the use of ASC in orthopaedic tissue repair. Strategies for repair involve the use of differentiated or undifferentiated, fresh or passaged ASC, in conjunction with appropriate choice of media, growth factors and scaffolds. Recent in vivo studies utilizing ASC are discussed giving results on defect repair and potential for clinical orthopaedic tissue regeneration.

Journal of the American Board of Family Medicine : JABFM

Asthma is a chronic airway disease that can be difficult to manage, resulting in poor outcomes an... more Asthma is a chronic airway disease that can be difficult to manage, resulting in poor outcomes and high costs. Asthma action plans assist patients with self-management, but provider compliance with this recommendation is limited in part because of guideline complexity. This project aimed to embed an electronic asthma action plan decision support tool (eAAP) into the medical record to streamline evidence-based guidelines for providers at the point of care, create individualized patient handouts, and evaluate effects on disease outcomes. eAAP development occurred in 4 phases: web-based prototype creation, multidisciplinary team engagement, pilot, and system-wide dissemination. Medical record and hospital billing data compared frequencies of asthma exacerbations before and after eAAP receipt with matched controls. Between December 2012 and September 2014, 5174 patients with asthma (∼10%) received eAAPs. Results showed an association between eAAP receipt and significant reductions in pe...

Journal of comparative effectiveness research, 2013

Community-based participatory research (CBPR) has emerged to bridge the gap between research and ... more Community-based participatory research (CBPR) has emerged to bridge the gap between research and primary-care practice through community engagement and social action to increase health equity. It is widely acknowledged that access to high-quality primary care services is important to the overall health of a community. Here, CBPR studies in a primary care setting are reviewed to assess the use of CBPR associated with common health problems seen in primary care such as access to care and disparities in chronic disease management across vulnerable populations. CBPR involves building relationships with local communities, determining areas of need and establishing priorities for health concerns. Studies showing improved access to care for a Hispanic population, reduced asthma symptoms and weight loss are highlighted.

. Pleiotrophin PTN is a secreted heparin-binding, developmentally regulated protein that is found... more . Pleiotrophin PTN is a secreted heparin-binding, developmentally regulated protein that is found in abundance in fetal, but Ž . not mature, cartilage. SDS-page and glycosaminoglycan GAG analysis of sulfate-radiolabeled proteoglycans isolated from the medium of mature cultured chondrocytes treated with PTN showed a threefold increase in the levels of proteoglycan synthesis. In contrast, in cultures of fetal chondrocytes, no changes in proteoglycan synthesis were observed. Thymidine incorporation experiments showed a dose-dependent decrease in proliferation of treated cells compared with control cultures, suggesting that pleiotrophin had an inhibitory effect on growth of chondrocytes. Neither FGF or heparin reversed the inhibitory effect of PTN. Capillary electrophoresis of chondroitinase ABC-digested proteoglycans isolated from mature chondrocytes showed 2᎐4-fold increases in the amounts of the 4S-and 6S-substituted GAG chains for the PTN-treated chondrocytes. Northern analysis showed a twofold upregulation in the mRNA levels of biglycan and collagen type II, but no difference in the message levels for decorin and aggrecan. These results establish that PTN inhibits cell proliferation, while stimulating the synthesis of proteoglycans in mature chondrocytes in vitro, suggesting that PTN may act directly or indirectly to regulate growth and proteoglycan synthesis in the developing matrix of fetal cartilage. ᮊ

Experientia, 1999

Extracellular matrix comprises approximately ulin and pleiotrophin). Other molecules, such as the... more Extracellular matrix comprises approximately ulin and pleiotrophin). Other molecules, such as the cartilage-derived C-type lectin and cartilage intermedi-90% of cartilage, with collagens and proteoglycans making up the bulk of the tissue. In recent years, several ate layer protein have no role as yet. Due to the difficulties associated with experimentally manipulating abundant cartilage proteins that are neither collagens nor proteoglycans have been characterized in detail. a tissue that is 90% extracellular matrix in a manner that can be readily transferred to the whole organism, The putative roles of these proteins range from involvement in matrix organization or matrix-cell signaling many of these molecules have been focused on by a surprisingly small number of researchers. This review (PRELP, chondroadherin, cartilage oligomeric protein and cartilage matrix protein) through to molecules that focuses on newly discovered proteins and glycoproteins in cartilage, with a bias towards those that have struc-are likely to be involved with modulation of the chondrocyte phenotype (CD-RAP, CDMPs, chondromod-tural roles or that are unique to cartilage.

Biochimica Et Biophysica Acta-gene Structure and Expression, 1999

Cartilage is a tissue that is primarily extracellular matrix, the bulk of which consists of prote... more Cartilage is a tissue that is primarily extracellular matrix, the bulk of which consists of proteoglycan aggregates constrained within a collagen framework. Candidate components that organize the extracellular assembly of the matrix consist of collagens, proteoglycans and multimeric glycoproteins. We describe the human gene structure of a potential organizing factor, a cartilage-derived member of the C-type lectin superfamily (CLECSF1; C-type

The Journal of the American Board of Family Medicine, 2010

Background: Hispanics are the largest and fastest growing minority group in the United States. Ch... more Background: Hispanics are the largest and fastest growing minority group in the United States. Charlotte, NC, had the 4th fastest growing Hispanic community in the nation between 1990 to 2000. Gaining understanding of the patterns of health care use for this changing population is a key step toward designing improved primary care access and community health.

Implementation Science, 2014

Background: Asthma is a common disease that affects people of all ages and has significant morbid... more Background: Asthma is a common disease that affects people of all ages and has significant morbidity and mortality. Poor outcomes and health disparities related to asthma result in part from the difficulty of disseminating new evidence and care delivery methods such as shared decision making (SDM) into clinical practice. This 3-year study explores the ideal framework for rapid dissemination of an evidence-based SDM toolkit for asthma management. The study leverages a partnership between the North Carolina (NC) statewide Medicaid network and the NC Network Consortium of practice-based research networks (PBRNs). Methods/design: This non-blinded study will randomize 30 primary care clinics in NC stratified by four PBRNs. We will test dissemination across these practices using a facilitator-led participatory approach to dissemination (FLOW), a novel method of participatory dissemination involving key principles of community-based participatory research, and a more typical "lunch and learn" dissemination method. Specifically, we will use cluster randomization to assign each of the 30 practices to one of three arms: (1) control, no dissemination; (2) traditional dissemination, one didactic session a year and distribution of educational material; and (3) FLOW dissemination. We hypothesize that at the unit of randomization, the clinic, patients in the FLOW dissemination arm will be more likely to share in their treatment decisions compared to patients in the traditional dissemination or control arms. All outcomes will be measured at the level of the clinic. Adoption of the SDM approach will be evaluated by 1) asthma exacerbations, 2) level of patient involvement in the decision making process, and 3) qualitative assessments from patients and providers. The research question is: What dissemination strategy most effectively increases practice level adoption of a shared decision making approach to asthma management? This study will provide important data to support best practices in dissemination of an evidence-based toolkit and implementation of shared decision making into primary care practices.

Trials, 2014

Background Screening can reduce colorectal cancer (CRC) incidence and mortality. However, scre... more Background

Screening can reduce colorectal cancer (CRC) incidence and mortality. However, screening is underutilized in vulnerable patient populations, particularly among Latinos. Patient-directed decision aids can increase CRC screening knowledge, self-efficacy, and intent; however, their effect on actual screening test completion tends to be modest. This is probably because decision aids do not address some of the patient-specific barriers that prevent successful completion of CRC screening in these populations. These individual barriers might be addressed though patient navigation interventions. This study will test a combined decision aid and patient navigator intervention on screening completion in diverse populations of vulnerable primary care patients.
Methods/Design

We will conduct a multisite, randomized controlled trial with patient-level randomization. Planned enrollment is 300 patients aged 50 to 75 years at average CRC risk presenting for appointments at two primary clinics in North Carolina and New Mexico. Intervention participants will view a video decision aid immediately before the clinic visit. The 14 to 16 minute video presents information about fecal occult blood tests and colonoscopy and will be viewed on a portable computer tablet in English or Spanish. Clinic-based patient navigators are bilingual and bicultural and will provide both face-to-face and telephone-based navigation. Control participants will view an unrelated food safety video and receive usual care. The primary outcome is completion of a CRC screening test at six months. Planned subgroup analyses include examining intervention effectiveness in Latinos, who will be oversampled. Secondarily, the trial will evaluate the intervention effects on knowledge of CRC screening, self-efficacy, intent, and patient-provider communication. The study will also examine whether patient ethnicity, acculturation, language preference, or health insurance status moderate the intervention effect on CRC screening.
Discussion

This pragmatic randomized controlled trial will test a combined decision aid and patient navigator intervention targeting CRC screening completion. Findings from this trial may inform future interventions and implementation policies designed to promote CRC screening in vulnerable patient populations and to reduce screening disparities.

Tissue Engineering Part A, 2010

Biologic therapies for disc degeneration hold great promise as an emerging concept. Due to ease o... more Biologic therapies for disc degeneration hold great promise as an emerging concept. Due to ease of harvest and abundance, adipose derived-mesenchymal stem cells (AD-MSC) are a readily available cell source for such therapies. Our objectives in this study were (1) to develop/validate methods to harvest AD-MSC and direct them to a disc-like phenotype by three-dimensional (3D) culture and transforming growth factor (TGF)-beta3 exposure, (2) to assess cell phenotypes with gene expression profiling for these human AD-MSC and annulus cells, and (3) to test whether disc cell-AD-MSC coculture could augment glycosaminoglycan (GAG) production. When AD-MSC were exposed to TGF-beta3, greater extracellular matrix was formed containing types I and II collagen, keratan sulfate, and decorin. Biochemical GAG measurement showed that production was significantly greater in TGF-beta3-treated AD-MSC in 3D culture versus untreated controls (p &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;amp;amp;amp;amp;lt; 0.05). Gene expression patterns in AD-MSC were compared to annulus cells; 4424 genes were significantly upregulated, and 2290 genes downregulated. Coculture resulted in a 44% greater GAG content compared with AD-MSC or annulus culture alone (p = 0.04). Data indicated that human AD-MSC can successfully be manipulated in 3D culture to express gene products important in the disc, and that coculture of annulus cells with AD-MSC enhances total GAG production.

Matrix Biology, 2000

Pleiotrophin and chondromodulin-I are low molecular weight proteins that are abundant (20 microg/... more Pleiotrophin and chondromodulin-I are low molecular weight proteins that are abundant (20 microg/g tissue) in fetal cartilage and difficult to detect in adult cartilage. We characterized their gene and protein expression patterns to gain a better understanding of their roles in the regulation of limb development and growth. In order to compare and contrast the relative amounts of the respective mRNA species within the developing epiphysis, a competitive PCR assay was developed. The results showed that the mRNAs for both proteins were abundant in fetal cartilage and while present in adult cartilage, were at 20-60-fold lower levels. Northern blotting revealed gradients of mRNA for both of these proteins in growth plate cartilage, with the highest levels in the resting zone, and the lowest in the hypertrophic zone. In contrast to pleiotrophin, chondromodulin-1 is down-regulated by retinoic acid with a pattern of expression similar to collagen type II and link protein, and may play a more specific role than pleiotrophin in modulating the chondrocyte phenotype.

Journal of the American Board of Family Medicine : JABFM

Asthma is a chronic airway disease that can be difficult to manage, resulting in poor outcomes an... more Asthma is a chronic airway disease that can be difficult to manage, resulting in poor outcomes and high costs. Asthma action plans assist patients with self-management, but provider compliance with this recommendation is limited in part because of guideline complexity. This project aimed to embed an electronic asthma action plan decision support tool (eAAP) into the medical record to streamline evidence-based guidelines for providers at the point of care, create individualized patient handouts, and evaluate effects on disease outcomes. eAAP development occurred in 4 phases: web-based prototype creation, multidisciplinary team engagement, pilot, and system-wide dissemination. Medical record and hospital billing data compared frequencies of asthma exacerbations before and after eAAP receipt with matched controls. Between December 2012 and September 2014, 5174 patients with asthma (∼10%) received eAAPs. Results showed an association between eAAP receipt and significant reductions in pe...

Journal of comparative effectiveness research, 2013

Community-based participatory research (CBPR) has emerged to bridge the gap between research and ... more Community-based participatory research (CBPR) has emerged to bridge the gap between research and primary-care practice through community engagement and social action to increase health equity. It is widely acknowledged that access to high-quality primary care services is important to the overall health of a community. Here, CBPR studies in a primary care setting are reviewed to assess the use of CBPR associated with common health problems seen in primary care such as access to care and disparities in chronic disease management across vulnerable populations. CBPR involves building relationships with local communities, determining areas of need and establishing priorities for health concerns. Studies showing improved access to care for a Hispanic population, reduced asthma symptoms and weight loss are highlighted.

The Journal of biological chemistry, Jan 18, 2005

Myristoylated alanine-rich C kinase substrate (MARCKS) is an unfolded protein that contains well ... more Myristoylated alanine-rich C kinase substrate (MARCKS) is an unfolded protein that contains well characterized actin-binding sites within the phosphorylation site domain (PSD), yet paradoxically, we now find that intact MARCKS does not bind to actin. Intact MARCKS also does not bind as well to calmodulin as does the PSD alone. Myristoylation at the N terminus alters how calmodulin binds to MARCKS, implying that, despite its unfolded state, the distant N terminus influences binding events at the PSD. We show that the free PSD binds with site specificity to MARCKS, suggesting that long-range intramolecular interactions within MARCKS are also possible. Because of the unusual primary sequence of MARCKS with an overall isoelectric point of 4.2 yet a very basic PSD (overall charge of +13), we speculated that ionic interactions between oppositely charged domains of MARCKS were responsible for long-range interactions within MARCKS that sterically influence binding events at the PSD and that...

Implementation Science, 2014

Background: Asthma is a common disease that affects people of all ages and has significant morbid... more Background: Asthma is a common disease that affects people of all ages and has significant morbidity and mortality. Poor outcomes and health disparities related to asthma result in part from the difficulty of disseminating new evidence and care delivery methods such as shared decision making (SDM) into clinical practice. This 3-year study explores the ideal framework for rapid dissemination of an evidence-based SDM toolkit for asthma management. The study leverages a partnership between the North Carolina (NC) statewide Medicaid network and the NC Network Consortium of practice-based research networks (PBRNs). Methods/design: This non-blinded study will randomize 30 primary care clinics in NC stratified by four PBRNs. We will test dissemination across these practices using a facilitator-led participatory approach to dissemination (FLOW), a novel method of participatory dissemination involving key principles of community-based participatory research, and a more typical "lunch and learn" dissemination method. Specifically, we will use cluster randomization to assign each of the 30 practices to one of three arms: (1) control, no dissemination; (2) traditional dissemination, one didactic session a year and distribution of educational material; and (3) FLOW dissemination. We hypothesize that at the unit of randomization, the clinic, patients in the FLOW dissemination arm will be more likely to share in their treatment decisions compared to patients in the traditional dissemination or control arms. All outcomes will be measured at the level of the clinic. Adoption of the SDM approach will be evaluated by 1) asthma exacerbations, 2) level of patient involvement in the decision making process, and 3) qualitative assessments from patients and providers. The research question is: What dissemination strategy most effectively increases practice level adoption of a shared decision making approach to asthma management? This study will provide important data to support best practices in dissemination of an evidence-based toolkit and implementation of shared decision making into primary care practices.

Trials, 2014

Background: Screening can reduce colorectal cancer (CRC) incidence and mortality. However, screen... more Background: Screening can reduce colorectal cancer (CRC) incidence and mortality. However, screening is underutilized in vulnerable patient populations, particularly among Latinos. Patient-directed decision aids can increase CRC screening knowledge, self-efficacy, and intent; however, their effect on actual screening test completion tends to be modest. This is probably because decision aids do not address some of the patient-specific barriers that prevent successful completion of CRC screening in these populations. These individual barriers might be addressed though patient navigation interventions. This study will test a combined decision aid and patient navigator intervention on screening completion in diverse populations of vulnerable primary care patients.

The Journal of the American Board of Family Medicine, 2010

A key element for reducing health care costs and improving community health is increased access t... more A key element for reducing health care costs and improving community health is increased access to primary care and preventative health services. Geographic information systems (GIS) have the potential to assess patterns of health care utilization and community-level attributes to identify geographic regions most in need of primary care access.

The Journal of Clinical Hypertension, 2013

This study establishes preliminary validation of a measure that assesses hypertension self-care a... more This study establishes preliminary validation of a measure that assesses hypertension self-care activities with clinical blood pressure (BP). The Hypertension Self-Care Activity Level Effects (H-SCALE) was administered to patients with hypertension to assess levels of self-care. Patients (n=154) were predominantly female (68.6%) and black (79.2%). Greater adherence to self-care was associated with lower systolic and diastolic BP for 5 of the 6 self-care behaviors. Medication adherence was correlated with systolic BP (r=À0.19, P<.05) and weight management adherence was correlated with diastolic BP (r=À0.22, P<.05) after controlling for other covariates. Increased adherence to recommended dietary practices was strongly correlated with higher systolic (r=0.29, P<.05) and diastolic BP (r=0.32, P<.05). The H-SCALE was acceptable for use in clinical settings, and adherence to self-care was generally aligned with lower BP. Assessment of hypertension self-care is important when working with individuals to control their BP. J Clin Hypertens (Greenwich). 2013;15:637-643.

Journal of Asthma, 2014

Objective: Translating research findings into clinical practice is a major challenge to improve t... more Objective: Translating research findings into clinical practice is a major challenge to improve the quality of healthcare delivery. Shared decision making (SDM) has been shown to be effective and has not yet been widely adopted by health providers. This paper describes the participatory approach used to adapt and implement an evidence-based asthma SDM intervention into primary care practices. Methods: A participatory research approach was initiated through partnership development between practice staff and researchers. The collaborative team worked together to adapt and implement a SDM toolkit. Using the RE-AIM framework and qualitative analysis, we evaluated both the implementation of the intervention into clinical practice, and the level of partnership that was established. Analysis included the number of adopting clinics and providers, the patients' perception of the SDM approach, and the number of clinics willing to sustain the intervention delivery after 1 year. Results: All six clinics and physician champions implemented the intervention using half-day dedicated asthma clinics while 16% of all providers within the practices have participated in the intervention. Themes from the focus groups included the importance of being part the development process, belief that the intervention would benefit patients, and concerns around sustainability and productivity. One year after initiation, 100% of clinics have sustained the intervention, and 90% of participating patients reported a shared decision experience. Conclusions: Use of a participatory research process was central to the successful implementation of a SDM intervention in multiple practices with diverse patient populations.

BMC Health Services Research, 2011

Background: Asthma is a chronic lung disease that affects more than 23 million people in the Unit... more Background: Asthma is a chronic lung disease that affects more than 23 million people in the United States, including 7 million children. Asthma is a difficult to manage chronic condition associated with disparities in health outcomes, poor medical compliance, and high healthcare costs. The research network coordinating this project includes hospitals, urgent care centers, and outpatient clinics within Carolinas Healthcare System that share a common electronic medical record and billing system allowing for rapid collection of clinical and demographic data. This study investigates the impact of three interventions on clinical outcomes for patients with asthma. Interventions are: an integrated approach to care that incorporates asthma management based on the chronic care model; a shared decision making intervention for asthma patients in underserved or disadvantaged populations; and a school based care approach that examines the efficacy of school-based programs to impact asthma outcomes including effectiveness of linkages between schools and the healthcare providers. Methods/Design: This study will include 95 Practices, 171 schools, and over 30,000 asthmatic patients. Five groups (A-E) will be evaluated to determine the effectiveness of three interventions. Group A is the usual care control group without electronic medical record (EMR). Group B practices are a second control group that has an EMR with decision support, asthma action plans, and population reports at baseline. A time delay design during year one converts practices in Group B to group C after receiving the integrated approach to care intervention. Four practices within Group C will receive the shared decision making intervention (and become group D). Group E will receive a school based care intervention through case management within the schools. A centralized database will be created with the goal of facilitating comparative effectiveness research on asthma outcomes specifically for this study. Patient and community level analysis will include results from patient surveys, focus groups, and asthma patient density mapping. Community variables such as income and housing density will be mapped for comparison. Outcomes to be measured are reduced hospitalizations and emergency department visits; improved adherence to medication; improved quality of life; reduced school absenteeism; improved self-efficacy and improved school performance. Discussion: Identifying new mechanisms that improve the delivery of asthma care is an important step towards advancing patient outcomes, avoiding preventable Emergency Department visits and hospitalizations, while simultaneously reducing overall healthcare costs.

Orthopaedic tissues, such as bone, cartilage, intervertebral disc and tendon, contain cells that ... more Orthopaedic tissues, such as bone, cartilage, intervertebral disc and tendon, contain cells that are difficult to culture and stimulate in vitro for repair of damaged tissue. Stem cells have the ability to self-renew and differentiate into many tissue types. Recent progress in stem cell research has led to an enthusiastic effort to utilize stem cells for orthopaedic tissue regeneration. Due to ease of harvest and abundance, adipose-derived mesenchymal cells (ASC) are an attractive, readily available adult stem cell that has become increasingly popular for use in many stem cell applications. Recent progress has been made in characterizing ASC and looking mechanistically at gene expression and cellular pathways involved in differentiation. This review focuses on (i) the characterization of ASC through expression of appropriate surface markers; (ii) modulation of in vitro differentiation of ASC through different scaffolds, growth factors, and media; and (iii) the use of ASC in orthopaedic tissue repair. Strategies for repair involve the use of differentiated or undifferentiated, fresh or passaged ASC, in conjunction with appropriate choice of media, growth factors and scaffolds. Recent in vivo studies utilizing ASC are discussed giving results on defect repair and potential for clinical orthopaedic tissue regeneration.

Journal of the American Board of Family Medicine : JABFM

Asthma is a chronic airway disease that can be difficult to manage, resulting in poor outcomes an... more Asthma is a chronic airway disease that can be difficult to manage, resulting in poor outcomes and high costs. Asthma action plans assist patients with self-management, but provider compliance with this recommendation is limited in part because of guideline complexity. This project aimed to embed an electronic asthma action plan decision support tool (eAAP) into the medical record to streamline evidence-based guidelines for providers at the point of care, create individualized patient handouts, and evaluate effects on disease outcomes. eAAP development occurred in 4 phases: web-based prototype creation, multidisciplinary team engagement, pilot, and system-wide dissemination. Medical record and hospital billing data compared frequencies of asthma exacerbations before and after eAAP receipt with matched controls. Between December 2012 and September 2014, 5174 patients with asthma (∼10%) received eAAPs. Results showed an association between eAAP receipt and significant reductions in pe...

Journal of comparative effectiveness research, 2013

Community-based participatory research (CBPR) has emerged to bridge the gap between research and ... more Community-based participatory research (CBPR) has emerged to bridge the gap between research and primary-care practice through community engagement and social action to increase health equity. It is widely acknowledged that access to high-quality primary care services is important to the overall health of a community. Here, CBPR studies in a primary care setting are reviewed to assess the use of CBPR associated with common health problems seen in primary care such as access to care and disparities in chronic disease management across vulnerable populations. CBPR involves building relationships with local communities, determining areas of need and establishing priorities for health concerns. Studies showing improved access to care for a Hispanic population, reduced asthma symptoms and weight loss are highlighted.

. Pleiotrophin PTN is a secreted heparin-binding, developmentally regulated protein that is found... more . Pleiotrophin PTN is a secreted heparin-binding, developmentally regulated protein that is found in abundance in fetal, but Ž . not mature, cartilage. SDS-page and glycosaminoglycan GAG analysis of sulfate-radiolabeled proteoglycans isolated from the medium of mature cultured chondrocytes treated with PTN showed a threefold increase in the levels of proteoglycan synthesis. In contrast, in cultures of fetal chondrocytes, no changes in proteoglycan synthesis were observed. Thymidine incorporation experiments showed a dose-dependent decrease in proliferation of treated cells compared with control cultures, suggesting that pleiotrophin had an inhibitory effect on growth of chondrocytes. Neither FGF or heparin reversed the inhibitory effect of PTN. Capillary electrophoresis of chondroitinase ABC-digested proteoglycans isolated from mature chondrocytes showed 2᎐4-fold increases in the amounts of the 4S-and 6S-substituted GAG chains for the PTN-treated chondrocytes. Northern analysis showed a twofold upregulation in the mRNA levels of biglycan and collagen type II, but no difference in the message levels for decorin and aggrecan. These results establish that PTN inhibits cell proliferation, while stimulating the synthesis of proteoglycans in mature chondrocytes in vitro, suggesting that PTN may act directly or indirectly to regulate growth and proteoglycan synthesis in the developing matrix of fetal cartilage. ᮊ

Experientia, 1999

Extracellular matrix comprises approximately ulin and pleiotrophin). Other molecules, such as the... more Extracellular matrix comprises approximately ulin and pleiotrophin). Other molecules, such as the cartilage-derived C-type lectin and cartilage intermedi-90% of cartilage, with collagens and proteoglycans making up the bulk of the tissue. In recent years, several ate layer protein have no role as yet. Due to the difficulties associated with experimentally manipulating abundant cartilage proteins that are neither collagens nor proteoglycans have been characterized in detail. a tissue that is 90% extracellular matrix in a manner that can be readily transferred to the whole organism, The putative roles of these proteins range from involvement in matrix organization or matrix-cell signaling many of these molecules have been focused on by a surprisingly small number of researchers. This review (PRELP, chondroadherin, cartilage oligomeric protein and cartilage matrix protein) through to molecules that focuses on newly discovered proteins and glycoproteins in cartilage, with a bias towards those that have struc-are likely to be involved with modulation of the chondrocyte phenotype (CD-RAP, CDMPs, chondromod-tural roles or that are unique to cartilage.

Biochimica Et Biophysica Acta-gene Structure and Expression, 1999

Cartilage is a tissue that is primarily extracellular matrix, the bulk of which consists of prote... more Cartilage is a tissue that is primarily extracellular matrix, the bulk of which consists of proteoglycan aggregates constrained within a collagen framework. Candidate components that organize the extracellular assembly of the matrix consist of collagens, proteoglycans and multimeric glycoproteins. We describe the human gene structure of a potential organizing factor, a cartilage-derived member of the C-type lectin superfamily (CLECSF1; C-type

The Journal of the American Board of Family Medicine, 2010

Background: Hispanics are the largest and fastest growing minority group in the United States. Ch... more Background: Hispanics are the largest and fastest growing minority group in the United States. Charlotte, NC, had the 4th fastest growing Hispanic community in the nation between 1990 to 2000. Gaining understanding of the patterns of health care use for this changing population is a key step toward designing improved primary care access and community health.

Implementation Science, 2014

Background: Asthma is a common disease that affects people of all ages and has significant morbid... more Background: Asthma is a common disease that affects people of all ages and has significant morbidity and mortality. Poor outcomes and health disparities related to asthma result in part from the difficulty of disseminating new evidence and care delivery methods such as shared decision making (SDM) into clinical practice. This 3-year study explores the ideal framework for rapid dissemination of an evidence-based SDM toolkit for asthma management. The study leverages a partnership between the North Carolina (NC) statewide Medicaid network and the NC Network Consortium of practice-based research networks (PBRNs). Methods/design: This non-blinded study will randomize 30 primary care clinics in NC stratified by four PBRNs. We will test dissemination across these practices using a facilitator-led participatory approach to dissemination (FLOW), a novel method of participatory dissemination involving key principles of community-based participatory research, and a more typical "lunch and learn" dissemination method. Specifically, we will use cluster randomization to assign each of the 30 practices to one of three arms: (1) control, no dissemination; (2) traditional dissemination, one didactic session a year and distribution of educational material; and (3) FLOW dissemination. We hypothesize that at the unit of randomization, the clinic, patients in the FLOW dissemination arm will be more likely to share in their treatment decisions compared to patients in the traditional dissemination or control arms. All outcomes will be measured at the level of the clinic. Adoption of the SDM approach will be evaluated by 1) asthma exacerbations, 2) level of patient involvement in the decision making process, and 3) qualitative assessments from patients and providers. The research question is: What dissemination strategy most effectively increases practice level adoption of a shared decision making approach to asthma management? This study will provide important data to support best practices in dissemination of an evidence-based toolkit and implementation of shared decision making into primary care practices.

Trials, 2014

Background Screening can reduce colorectal cancer (CRC) incidence and mortality. However, scre... more Background

Screening can reduce colorectal cancer (CRC) incidence and mortality. However, screening is underutilized in vulnerable patient populations, particularly among Latinos. Patient-directed decision aids can increase CRC screening knowledge, self-efficacy, and intent; however, their effect on actual screening test completion tends to be modest. This is probably because decision aids do not address some of the patient-specific barriers that prevent successful completion of CRC screening in these populations. These individual barriers might be addressed though patient navigation interventions. This study will test a combined decision aid and patient navigator intervention on screening completion in diverse populations of vulnerable primary care patients.
Methods/Design

We will conduct a multisite, randomized controlled trial with patient-level randomization. Planned enrollment is 300 patients aged 50 to 75 years at average CRC risk presenting for appointments at two primary clinics in North Carolina and New Mexico. Intervention participants will view a video decision aid immediately before the clinic visit. The 14 to 16 minute video presents information about fecal occult blood tests and colonoscopy and will be viewed on a portable computer tablet in English or Spanish. Clinic-based patient navigators are bilingual and bicultural and will provide both face-to-face and telephone-based navigation. Control participants will view an unrelated food safety video and receive usual care. The primary outcome is completion of a CRC screening test at six months. Planned subgroup analyses include examining intervention effectiveness in Latinos, who will be oversampled. Secondarily, the trial will evaluate the intervention effects on knowledge of CRC screening, self-efficacy, intent, and patient-provider communication. The study will also examine whether patient ethnicity, acculturation, language preference, or health insurance status moderate the intervention effect on CRC screening.
Discussion

This pragmatic randomized controlled trial will test a combined decision aid and patient navigator intervention targeting CRC screening completion. Findings from this trial may inform future interventions and implementation policies designed to promote CRC screening in vulnerable patient populations and to reduce screening disparities.

Tissue Engineering Part A, 2010

Biologic therapies for disc degeneration hold great promise as an emerging concept. Due to ease o... more Biologic therapies for disc degeneration hold great promise as an emerging concept. Due to ease of harvest and abundance, adipose derived-mesenchymal stem cells (AD-MSC) are a readily available cell source for such therapies. Our objectives in this study were (1) to develop/validate methods to harvest AD-MSC and direct them to a disc-like phenotype by three-dimensional (3D) culture and transforming growth factor (TGF)-beta3 exposure, (2) to assess cell phenotypes with gene expression profiling for these human AD-MSC and annulus cells, and (3) to test whether disc cell-AD-MSC coculture could augment glycosaminoglycan (GAG) production. When AD-MSC were exposed to TGF-beta3, greater extracellular matrix was formed containing types I and II collagen, keratan sulfate, and decorin. Biochemical GAG measurement showed that production was significantly greater in TGF-beta3-treated AD-MSC in 3D culture versus untreated controls (p &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;amp;amp;amp;amp;lt; 0.05). Gene expression patterns in AD-MSC were compared to annulus cells; 4424 genes were significantly upregulated, and 2290 genes downregulated. Coculture resulted in a 44% greater GAG content compared with AD-MSC or annulus culture alone (p = 0.04). Data indicated that human AD-MSC can successfully be manipulated in 3D culture to express gene products important in the disc, and that coculture of annulus cells with AD-MSC enhances total GAG production.

Matrix Biology, 2000

Pleiotrophin and chondromodulin-I are low molecular weight proteins that are abundant (20 microg/... more Pleiotrophin and chondromodulin-I are low molecular weight proteins that are abundant (20 microg/g tissue) in fetal cartilage and difficult to detect in adult cartilage. We characterized their gene and protein expression patterns to gain a better understanding of their roles in the regulation of limb development and growth. In order to compare and contrast the relative amounts of the respective mRNA species within the developing epiphysis, a competitive PCR assay was developed. The results showed that the mRNAs for both proteins were abundant in fetal cartilage and while present in adult cartilage, were at 20-60-fold lower levels. Northern blotting revealed gradients of mRNA for both of these proteins in growth plate cartilage, with the highest levels in the resting zone, and the lowest in the hypertrophic zone. In contrast to pleiotrophin, chondromodulin-1 is down-regulated by retinoic acid with a pattern of expression similar to collagen type II and link protein, and may play a more specific role than pleiotrophin in modulating the chondrocyte phenotype.