Stefanie Vassar - Academia.edu (original) (raw)

Papers by Stefanie Vassar

Ethnicity & Disease, 2016

The American journal of managed care

To calculate intervention costs and the potential cost offset of a care management intervention t... more To calculate intervention costs and the potential cost offset of a care management intervention that substantially improved the quality of dementia care. From both a payer perspective and a social planner perspective, we analyzed data from a cluster randomized controlled trial (RCT) evaluating this intervention versus usual care. The RCT included 408 pairs of older adults with dementia and their caregivers. Caregivers were surveyed at baseline, at 12 months, and at 18 months to assess patient healthcare utilization and out-of-pocket costs. We calculated fixed and per-patient intervention costs from RCT records. We combined the monthly per-patient costs of healthcare services, informal caregiving, and out-of-pocket costs, and we conducted multivariate analyses comparing this sum (potential cost offset) for intervention versus usual care patients. Covariates included patient age, sex, and baseline costs. We limited the main analysis to patients who survived until the 12-month survey or the 18-month survey. The intervention required a start-up cost of 70,256andmeaninterventionper−patientpermonthcostsof70,256 and mean intervention per-patient per month costs of 70,256andmeaninterventionper−patientpermonthcostsof118. There were no significant differences in the mean monthly cost of healthcare and caregiving services for intervention versus usual care patients using the societal perspective (difference of -$555 per month, P = .28) or the payer perspective (difference of -$219 per month [including nursing home costs], P = .55; difference of -$256 per month [excluding nursing home costs], P = .47). Although this analysis of a dementia care management intervention did not demonstrate a significant cost offset, the intervention may represent a worthwhile approach to improving the quality of care and health outcomes for patients with dementia and their caregivers.

Journal of the American Geriatrics Society

The American journal of managed care, 2012

To analyze whether types of providers and frequency of encounters are associated with higher qual... more To analyze whether types of providers and frequency of encounters are associated with higher quality of care within a coordinated dementia care management (CM) program for patients and caregivers. Secondary analysis of intervention-arm data from a dementia CM cluster-randomized trial, where intervention participants interacted with healthcare organization care managers (HOCMs), community agency care managers (CACMs), and/ or healthcare organization primary care providers (HOPCPs) over 18 months. Encounters of 238 patient/caregivers (dyads) with HOCMs, CACMs, and HOPCPs were abstracted from care management electronic records. The quality domains of assessment, treatment, education/support, and safety were measured from medical record abstractions and caregiver surveys. Mean percentages of met quality indicators associated with exposures to each provider type and frequency were analyzed using multivariable regression, adjusting for participant characteristics and baseline quality. As ...

Medical Care, 2009

Assessment of health-related quality of life (HRQOL) is important for cost-effectiveness analyses... more Assessment of health-related quality of life (HRQOL) is important for cost-effectiveness analyses, but the validity of generic HRQOL instruments has not been adequately evaluated in persons with dementia. To evaluate the validity (including responsiveness to change) of the Health Utilities Index Mark 2 (HUI2) and Mark 3 (HUI3), 2 commonly used generic HRQOL measures, in patients with dementia. Four hundred eight patient-caregiver dyads in an 18-month dementia care management trial. We assessed construct validity by evaluating correlations of proxy (caregiver)-reported HUI2 and HUI3 with the Blessed Dementia Rating Scale, the Charlson Comorbidity Index, and a behavior rating scale. Responsiveness was estimated using effect size (ES) statistics for behavior scale change (unchanged, small, medium, large change) and for residential status change (home to skilled nursing facility), as a global external change criterion. The HUI2 and HUI3 were responsive to behavioral worsening (multiattribute ES range: -0.48 to -0.78) and global decline (multiattribute ES range: -0.50 to -0.76), but not improvement. The HUI2 was more responsive than the HUI3. Correlations with the Blessed Dementia Rating Scale (r = -0.69 with both HUI2 and HUI3 multiattribute scores) and behavior scale (r = 0.44 and 0.41, respectively, for HUI2 and HUI3 multiattribute scores) supported the validity of the HUI in patients with dementia. Our results support the construct validity of the proxy-rated HUI2/3 in patients with moderate to severe dementia, but responsiveness results were mixed. Further studies are needed of the HUI2/3's validity, including responsiveness, in patients across the full range of dementia severity, using both self and proxy report, with particular attention to the impact of general population preference weights. When possible, multiple HRQOL measures need to be used to confirm the robustness of the findings. The proxy-rated HUI should be used in patients with moderate to severe dementia, but the self-rated HUI may be appropriate for subjects with milder cognitive impairment.

Journal of the American Geriatrics Society, 2000

Journal of the American Geriatrics Society, 2000

International Journal of Geriatric Psychiatry, 2012

Care management approaches have been proven to improve outcomes for patients with dementia and th... more Care management approaches have been proven to improve outcomes for patients with dementia and their family caregivers (dyads). However, acceptance of services in these programs is incomplete, impacting effectiveness. Acceptance may be related to dyad as well as healthcare system characteristics, but knowledge about factors associated with program acceptance is lacking. This study investigates patient, caregiver, and healthcare system characteristics associated with acceptance of offered care management services. This study analyzed data from the intervention arm of a cluster randomized controlled trial of a comprehensive dementia care management intervention. There were 408 patient-caregiver dyads enrolled in the study, of which 238 dyads were randomized to the intervention. Caregiver, patient, and health system factors associated with participation in offered care management services were assessed through bivariate and multivariate regression analyses. Out of the 238 dyads, 9 were ineligible for this analysis, leaving data of 229 dyads in this sample. Of these, 185 dyads accepted offered care management services, and 44 dyads did not. Multivariate analyses showed that higher likelihood of acceptance of care management services was uniquely associated with cohabitation of caregiver and patient (p < 0.001), lesser severity of dementia (p = 0.03), and higher patient comorbidity (p = 0.03); it also varied across healthcare organization sites. Understanding factors that influence care management participation could result in increased adoption of successful programs to improve quality of care. Using these factors to revise both program design as well as program promotion may also benefit external validity of future quality improvement research trials.

Annals of Internal Medicine, 2006

Adherence to dementia guidelines is poor despite evidence that some guideline recommendations can... more Adherence to dementia guidelines is poor despite evidence that some guideline recommendations can improve symptoms and delay institutionalization of patients. To test the effectiveness of a dementia guideline-based disease management program on quality of care and outcomes for patients with dementia. Clinic-level, cluster randomized, controlled trial. 3 health care organizations collaborating with 3 community agencies in southern California. 18 primary care clinics and 408 patients with dementia age 65 years or older paired with 408 informal caregivers. Disease management program led by care managers and provided to 238 patient-caregiver pairs at 9 intervention clinics for more than 12 months. Adherence to 23 guideline recommendations (primary outcome) and receipt of community resources and patient and caregiver health and quality-of-care measures (secondary outcomes). The mean percentage of per-patient guideline recommendations to which care was adherent was significantly higher in the intervention group than in the usual care group (63.9% vs. 32.9%, respectively; adjusted difference, 30.1% [95% CI, 25.2% to 34.9%]; P < 0.001). Participants who received the intervention had higher care quality on 21 of 23 guidelines (P < or = 0.013 for all), and higher proportions received community agency assistance (P < or = 0.03) than those who received usual care. Patient health-related quality of life, overall quality of patient care, caregiving quality, social support, and level of unmet caregiving assistance needs were better for participants in the intervention group than for those in the usual care group (P < 0.05 for all). Caregiver health-related quality of life did not differ between the 2 groups. Participants were well-educated, were predominantly white, had a usual source of care, and were not institutionalized. Generalizability to other patients and geographic regions is unknown. Also, costs of a care management program under fee-for-service reimbursement may impede adoption. A dementia guideline-based disease management program led to substantial improvements in quality of care for patients with dementia. Current Controlled Trials identifier: ISRCTN72577751.

Stroke

Residence in a socioeconomically disadvantaged community is associated with mortality, but the me... more Residence in a socioeconomically disadvantaged community is associated with mortality, but the mechanisms are not well understood. We examined whether socioeconomic features of the residential neighborhood contribute to poststroke mortality and whether neighborhood influences are mediated by traditional behavioral and biologic risk factors. We used data from the Cardiovascular Health Study, a multicenter, population-based, longitudinal study of adults ≥65 years. Residential neighborhood disadvantage was measured using neighborhood socioeconomic status (NSES), a composite of 6 census tract variables representing income, education, employment, and wealth. Multilevel Cox proportional hazard models were constructed to determine the association of NSES to mortality after an incident stroke, adjusted for sociodemographic characteristics, stroke type, and behavioral and biologic risk factors. Among the 3,834 participants with no prior stroke at baseline, 806 had a stroke over a mean 11.5 years of follow-up, with 168 (20%) deaths 30 days after stroke and 276 (34%) deaths at 1 year. In models adjusted for demographic characteristics, stroke type, and behavioral and biologic risk factors, mortality hazard 1 year after stroke was significantly higher among residents of neighborhoods with the lowest NSES than those in the highest NSES neighborhoods (hazard ratio 1.77, 95% confidence interval 1.17-2.68). Living in a socioeconomically disadvantaged neighborhood is associated with higher mortality hazard at 1 year following an incident stroke. Further work is needed to understand the structural and social characteristics of neighborhoods that may contribute to mortality in the year after a stroke and the pathways through which these characteristics operate.

Clinical and Translational Science, 2015

Grant writing is an essential skill necessary to secure financial support for community programs ... more Grant writing is an essential skill necessary to secure financial support for community programs and research projects. Increasingly, funding opportunities for translational biomedical research require studies to engage community partners, patients, or other stakeholders in the research process to address their concerns. However, there is little evidence on strategies to prepare teams of academic and community partners to collaborate on grants. This paper presents the description and formative evaluation of a two-part community-academic partnered grant writing series designed to help community organizations and academic institutions build infrastructure for collaborative research projects using a partnered approach. The first phase of the series was a half-day workshop on grant readiness, which was open to all interested community partners. The second phase, open only to community-academic teams that met eligibility criteria, was a 12-week session that covered partnered grant writing for foundation grants and National Institutes of Health grants. Participants in both phases reported an increase in knowledge and self-efficacy for writing partnered proposals. At 1-year follow-up, participants in Phase 2 had secured approximately $1.87 million in funding. This community-academic partnered grant writing series helped participants obtain proposal development skills and helped community-academic teams successfully compete for funding. Clin Trans Sci 2015; Volume #: 1-6.

Seizure, 2009

Although the clinical goal of resective epilepsy surgery is seizure freedom, patients have a wide... more Although the clinical goal of resective epilepsy surgery is seizure freedom, patients have a wide set of expectations for this invasive procedure. The goal of this study was to evaluate potential gender differences in expectations among patients undergoing resective epilepsy surgery. Ratings of the importance of 12 potential impacts ("expectations") of resective surgery were analyzed in a seven-center cohort study including 389 adults aged 16 and older who underwent resective epilepsy surgery. Men and women both ranked anticipated changes in driving and memory as the most important presurgical expectations. Women rated driving, physical activity limitations, and economic worries as less important, and fatigue and pregnancy concerns as more important than did men (p's< or =0.05). Exploratory factor analysis indicated a different pattern of associations among the 12 importance items for men and women. Whether gender differences in presurgical values are associated wit...

Journal of Neurosurgery: Pediatrics, 2013

Low income, government insurance, and minority status are associated with delayed treatment for n... more Low income, government insurance, and minority status are associated with delayed treatment for neurosurgery patients. Less is known about the influence of referral location and how socioeconomic factors and referral patterns evolve over time. For pediatric epilepsy surgery patients at the University of California, Los Angeles (UCLA), this study determined how referral location and sociodemographic features have evolved over 25 years. Children undergoing epilepsy neurosurgery at UCLA (453 patients) were classified by location of residence and compared with clinical epilepsy and sociodemographic factors. From 1986 to 2010, referrals from Southern California increased (+33%) and referrals from outside of California decreased (-19%). Over the same period, the number of patients with preferred provider organization (PPO) and health maintenance organization (HMO) insurance increased (+148% and +69%, respectively) and indemnity insurance decreased (-96%). Likewise, the number of Hispanics (+117%) and Asians (100%) increased and Caucasians/whites decreased (-24%). The number of insurance companies decreased from 52 carriers per 100 surgical patients in 1986-1990 to 19 per 100 in 2006-2010. Patients living in the Eastern US had a younger age at surgery (-46%), shorter intervals from seizure onset to referral for evaluation (-28%) and from presurgical evaluation to surgery (-61%) compared with patients from Southern California. The interval from seizure onset to evaluation was shorter (-33%) for patients from Los Angeles County compared with those living in non-California Western US states. Referral locations evolved over 25 years at UCLA, with more cases coming from local regions; the percentage of minority patients also increased. The interval from seizures onset to surgery was shortest for patients living farthest from UCLA but still within the US. Geographic location and race/ethnicity was not associated with differences in becoming seizure free after epilepsy surgery in children.

Quality of Life Research, 2014

To assess (1) whether the generic Short Form (SF)-36, an integrated component of the epilepsy-tar... more To assess (1) whether the generic Short Form (SF)-36, an integrated component of the epilepsy-targeted Quality of Life in Epilepsy Inventory-89 (QOLIE-89), is able to detect differences in the health-related quality of life (HRQOL) between young adults with epilepsy and healthy sibling controls and (2) whether the generic components are as sensitive to within-disease symptom severity as the epilepsy-targeted components of the QOLIE-89 in young adults with epilepsy. A cohort of young adults with epilepsy (N = 108, age 21.6 years SD = 3.8), followed since diagnosis in a prospective community-based study of childhood-onset epilepsy, completed the QOLIE-89, an epilepsy-targeted HRQOL instrument that includes within it a generic core measure (SF-36). Sibling controls (N = 82, age = 20.7 years, SD = 2.1) completed the generic core, SF-36. Age- and gender-adjusted QOLIE-89 epilepsy-targeted and cognitive-distress composite scores and the overall score were strongly associated with seizure-free duration: seizure-free ≥5 years (higher HRQOL), n = 57; seizure-free 1-5 years, n = 22; or seizure-free &amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;lt;1 year, n = 29 (lower HRQOL) (p &amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;lt; 0.001). However, on QOLIE-89 physical health and mental health composite scores, there were no differences across these seizure-free duration groups. For cases compared with sibling controls, there were no differences on SF-36 physical and mental health composite scores or the global composite score, using either classical test or item-response theory scoring procedures. While the epilepsy-targeted components of the QOLIE-89 are sensitive to seizure-related factors in young adults with epilepsy, the SF-36 generic core measures are not, thereby limiting HRQOL comparisons between young adults with epilepsy and sibling controls.

Parkinson's Disease, 2011

Parkinson's Disease, 2012

Stroke, 2011

Neighborhood characteristics may influence the risk of stroke and contribute to socioeconomic dis... more Neighborhood characteristics may influence the risk of stroke and contribute to socioeconomic disparities in stroke incidence. The objectives of this study were to examine the relationship between neighborhood socioeconomic status and incident ischemic stroke and examine potential mediators of these associations. We analyzed data from 3834 whites and 785 blacks enrolled in the Cardiovascular Health Study, a multicenter, population-based, longitudinal study of adults ages≥65 years from 4 US counties. The primary outcome was adjudicated incident ischemic stroke. Neighborhood socioeconomic status was measured using a composite of 6 census tract variables. Race-stratified multilevel Cox proportional hazard models were constructed adjusted for sociodemographic, behavioral, and biological risk factors. Among whites, in models adjusted for sociodemographic characteristics, stroke hazard was significantly higher among residents of neighborhoods in the lowest compared with the highest neighborhood socioeconomic status quartile (hazard ratio, 1.32; 95% CI, 1.01-1.72) with greater attenuation of the hazard ratio after adjustment for biological risk factors (hazard ratio, 1.16; 0.88-1.52) than for behavioral risk factors (hazard ratio, 1.30; 0.99-1.70). Among blacks, we found no significant associations between neighborhood socioeconomic status and ischemic stroke. Higher risk of incident ischemic stroke was observed in the most disadvantaged neighborhoods among whites, but not among blacks. The relationship between neighborhood socioeconomic status and stroke among whites appears to be mediated more strongly by biological than behavioral risk factors.

Ethnicity & Disease, 2016

The American journal of managed care

To calculate intervention costs and the potential cost offset of a care management intervention t... more To calculate intervention costs and the potential cost offset of a care management intervention that substantially improved the quality of dementia care. From both a payer perspective and a social planner perspective, we analyzed data from a cluster randomized controlled trial (RCT) evaluating this intervention versus usual care. The RCT included 408 pairs of older adults with dementia and their caregivers. Caregivers were surveyed at baseline, at 12 months, and at 18 months to assess patient healthcare utilization and out-of-pocket costs. We calculated fixed and per-patient intervention costs from RCT records. We combined the monthly per-patient costs of healthcare services, informal caregiving, and out-of-pocket costs, and we conducted multivariate analyses comparing this sum (potential cost offset) for intervention versus usual care patients. Covariates included patient age, sex, and baseline costs. We limited the main analysis to patients who survived until the 12-month survey or the 18-month survey. The intervention required a start-up cost of 70,256andmeaninterventionper−patientpermonthcostsof70,256 and mean intervention per-patient per month costs of 70,256andmeaninterventionper−patientpermonthcostsof118. There were no significant differences in the mean monthly cost of healthcare and caregiving services for intervention versus usual care patients using the societal perspective (difference of -$555 per month, P = .28) or the payer perspective (difference of -$219 per month [including nursing home costs], P = .55; difference of -$256 per month [excluding nursing home costs], P = .47). Although this analysis of a dementia care management intervention did not demonstrate a significant cost offset, the intervention may represent a worthwhile approach to improving the quality of care and health outcomes for patients with dementia and their caregivers.

Journal of the American Geriatrics Society

The American journal of managed care, 2012

To analyze whether types of providers and frequency of encounters are associated with higher qual... more To analyze whether types of providers and frequency of encounters are associated with higher quality of care within a coordinated dementia care management (CM) program for patients and caregivers. Secondary analysis of intervention-arm data from a dementia CM cluster-randomized trial, where intervention participants interacted with healthcare organization care managers (HOCMs), community agency care managers (CACMs), and/ or healthcare organization primary care providers (HOPCPs) over 18 months. Encounters of 238 patient/caregivers (dyads) with HOCMs, CACMs, and HOPCPs were abstracted from care management electronic records. The quality domains of assessment, treatment, education/support, and safety were measured from medical record abstractions and caregiver surveys. Mean percentages of met quality indicators associated with exposures to each provider type and frequency were analyzed using multivariable regression, adjusting for participant characteristics and baseline quality. As ...

Medical Care, 2009

Assessment of health-related quality of life (HRQOL) is important for cost-effectiveness analyses... more Assessment of health-related quality of life (HRQOL) is important for cost-effectiveness analyses, but the validity of generic HRQOL instruments has not been adequately evaluated in persons with dementia. To evaluate the validity (including responsiveness to change) of the Health Utilities Index Mark 2 (HUI2) and Mark 3 (HUI3), 2 commonly used generic HRQOL measures, in patients with dementia. Four hundred eight patient-caregiver dyads in an 18-month dementia care management trial. We assessed construct validity by evaluating correlations of proxy (caregiver)-reported HUI2 and HUI3 with the Blessed Dementia Rating Scale, the Charlson Comorbidity Index, and a behavior rating scale. Responsiveness was estimated using effect size (ES) statistics for behavior scale change (unchanged, small, medium, large change) and for residential status change (home to skilled nursing facility), as a global external change criterion. The HUI2 and HUI3 were responsive to behavioral worsening (multiattribute ES range: -0.48 to -0.78) and global decline (multiattribute ES range: -0.50 to -0.76), but not improvement. The HUI2 was more responsive than the HUI3. Correlations with the Blessed Dementia Rating Scale (r = -0.69 with both HUI2 and HUI3 multiattribute scores) and behavior scale (r = 0.44 and 0.41, respectively, for HUI2 and HUI3 multiattribute scores) supported the validity of the HUI in patients with dementia. Our results support the construct validity of the proxy-rated HUI2/3 in patients with moderate to severe dementia, but responsiveness results were mixed. Further studies are needed of the HUI2/3&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 validity, including responsiveness, in patients across the full range of dementia severity, using both self and proxy report, with particular attention to the impact of general population preference weights. When possible, multiple HRQOL measures need to be used to confirm the robustness of the findings. The proxy-rated HUI should be used in patients with moderate to severe dementia, but the self-rated HUI may be appropriate for subjects with milder cognitive impairment.

Journal of the American Geriatrics Society, 2000

Journal of the American Geriatrics Society, 2000

International Journal of Geriatric Psychiatry, 2012

Care management approaches have been proven to improve outcomes for patients with dementia and th... more Care management approaches have been proven to improve outcomes for patients with dementia and their family caregivers (dyads). However, acceptance of services in these programs is incomplete, impacting effectiveness. Acceptance may be related to dyad as well as healthcare system characteristics, but knowledge about factors associated with program acceptance is lacking. This study investigates patient, caregiver, and healthcare system characteristics associated with acceptance of offered care management services. This study analyzed data from the intervention arm of a cluster randomized controlled trial of a comprehensive dementia care management intervention. There were 408 patient-caregiver dyads enrolled in the study, of which 238 dyads were randomized to the intervention. Caregiver, patient, and health system factors associated with participation in offered care management services were assessed through bivariate and multivariate regression analyses. Out of the 238 dyads, 9 were ineligible for this analysis, leaving data of 229 dyads in this sample. Of these, 185 dyads accepted offered care management services, and 44 dyads did not. Multivariate analyses showed that higher likelihood of acceptance of care management services was uniquely associated with cohabitation of caregiver and patient (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;lt; 0.001), lesser severity of dementia (p = 0.03), and higher patient comorbidity (p = 0.03); it also varied across healthcare organization sites. Understanding factors that influence care management participation could result in increased adoption of successful programs to improve quality of care. Using these factors to revise both program design as well as program promotion may also benefit external validity of future quality improvement research trials.

Annals of Internal Medicine, 2006

Adherence to dementia guidelines is poor despite evidence that some guideline recommendations can... more Adherence to dementia guidelines is poor despite evidence that some guideline recommendations can improve symptoms and delay institutionalization of patients. To test the effectiveness of a dementia guideline-based disease management program on quality of care and outcomes for patients with dementia. Clinic-level, cluster randomized, controlled trial. 3 health care organizations collaborating with 3 community agencies in southern California. 18 primary care clinics and 408 patients with dementia age 65 years or older paired with 408 informal caregivers. Disease management program led by care managers and provided to 238 patient-caregiver pairs at 9 intervention clinics for more than 12 months. Adherence to 23 guideline recommendations (primary outcome) and receipt of community resources and patient and caregiver health and quality-of-care measures (secondary outcomes). The mean percentage of per-patient guideline recommendations to which care was adherent was significantly higher in the intervention group than in the usual care group (63.9% vs. 32.9%, respectively; adjusted difference, 30.1% [95% CI, 25.2% to 34.9%]; 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;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;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;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; 0.001). Participants who received the intervention had higher care quality on 21 of 23 guidelines (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;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;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;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; or = 0.013 for all), and higher proportions received community agency assistance (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;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;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;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; or = 0.03) than those who received usual care. Patient health-related quality of life, overall quality of patient care, caregiving quality, social support, and level of unmet caregiving assistance needs were better for participants in the intervention group than for those in the usual care group (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;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;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;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 for all). Caregiver health-related quality of life did not differ between the 2 groups. Participants were well-educated, were predominantly white, had a usual source of care, and were not institutionalized. Generalizability to other patients and geographic regions is unknown. Also, costs of a care management program under fee-for-service reimbursement may impede adoption. A dementia guideline-based disease management program led to substantial improvements in quality of care for patients with dementia. Current Controlled Trials identifier: ISRCTN72577751.

Stroke

Residence in a socioeconomically disadvantaged community is associated with mortality, but the me... more Residence in a socioeconomically disadvantaged community is associated with mortality, but the mechanisms are not well understood. We examined whether socioeconomic features of the residential neighborhood contribute to poststroke mortality and whether neighborhood influences are mediated by traditional behavioral and biologic risk factors. We used data from the Cardiovascular Health Study, a multicenter, population-based, longitudinal study of adults ≥65 years. Residential neighborhood disadvantage was measured using neighborhood socioeconomic status (NSES), a composite of 6 census tract variables representing income, education, employment, and wealth. Multilevel Cox proportional hazard models were constructed to determine the association of NSES to mortality after an incident stroke, adjusted for sociodemographic characteristics, stroke type, and behavioral and biologic risk factors. Among the 3,834 participants with no prior stroke at baseline, 806 had a stroke over a mean 11.5 years of follow-up, with 168 (20%) deaths 30 days after stroke and 276 (34%) deaths at 1 year. In models adjusted for demographic characteristics, stroke type, and behavioral and biologic risk factors, mortality hazard 1 year after stroke was significantly higher among residents of neighborhoods with the lowest NSES than those in the highest NSES neighborhoods (hazard ratio 1.77, 95% confidence interval 1.17-2.68). Living in a socioeconomically disadvantaged neighborhood is associated with higher mortality hazard at 1 year following an incident stroke. Further work is needed to understand the structural and social characteristics of neighborhoods that may contribute to mortality in the year after a stroke and the pathways through which these characteristics operate.

Clinical and Translational Science, 2015

Grant writing is an essential skill necessary to secure financial support for community programs ... more Grant writing is an essential skill necessary to secure financial support for community programs and research projects. Increasingly, funding opportunities for translational biomedical research require studies to engage community partners, patients, or other stakeholders in the research process to address their concerns. However, there is little evidence on strategies to prepare teams of academic and community partners to collaborate on grants. This paper presents the description and formative evaluation of a two-part community-academic partnered grant writing series designed to help community organizations and academic institutions build infrastructure for collaborative research projects using a partnered approach. The first phase of the series was a half-day workshop on grant readiness, which was open to all interested community partners. The second phase, open only to community-academic teams that met eligibility criteria, was a 12-week session that covered partnered grant writing for foundation grants and National Institutes of Health grants. Participants in both phases reported an increase in knowledge and self-efficacy for writing partnered proposals. At 1-year follow-up, participants in Phase 2 had secured approximately $1.87 million in funding. This community-academic partnered grant writing series helped participants obtain proposal development skills and helped community-academic teams successfully compete for funding. Clin Trans Sci 2015; Volume #: 1-6.

Seizure, 2009

Although the clinical goal of resective epilepsy surgery is seizure freedom, patients have a wide... more Although the clinical goal of resective epilepsy surgery is seizure freedom, patients have a wide set of expectations for this invasive procedure. The goal of this study was to evaluate potential gender differences in expectations among patients undergoing resective epilepsy surgery. Ratings of the importance of 12 potential impacts ("expectations") of resective surgery were analyzed in a seven-center cohort study including 389 adults aged 16 and older who underwent resective epilepsy surgery. Men and women both ranked anticipated changes in driving and memory as the most important presurgical expectations. Women rated driving, physical activity limitations, and economic worries as less important, and fatigue and pregnancy concerns as more important than did men (p's< or =0.05). Exploratory factor analysis indicated a different pattern of associations among the 12 importance items for men and women. Whether gender differences in presurgical values are associated wit...

Journal of Neurosurgery: Pediatrics, 2013

Low income, government insurance, and minority status are associated with delayed treatment for n... more Low income, government insurance, and minority status are associated with delayed treatment for neurosurgery patients. Less is known about the influence of referral location and how socioeconomic factors and referral patterns evolve over time. For pediatric epilepsy surgery patients at the University of California, Los Angeles (UCLA), this study determined how referral location and sociodemographic features have evolved over 25 years. Children undergoing epilepsy neurosurgery at UCLA (453 patients) were classified by location of residence and compared with clinical epilepsy and sociodemographic factors. From 1986 to 2010, referrals from Southern California increased (+33%) and referrals from outside of California decreased (-19%). Over the same period, the number of patients with preferred provider organization (PPO) and health maintenance organization (HMO) insurance increased (+148% and +69%, respectively) and indemnity insurance decreased (-96%). Likewise, the number of Hispanics (+117%) and Asians (100%) increased and Caucasians/whites decreased (-24%). The number of insurance companies decreased from 52 carriers per 100 surgical patients in 1986-1990 to 19 per 100 in 2006-2010. Patients living in the Eastern US had a younger age at surgery (-46%), shorter intervals from seizure onset to referral for evaluation (-28%) and from presurgical evaluation to surgery (-61%) compared with patients from Southern California. The interval from seizure onset to evaluation was shorter (-33%) for patients from Los Angeles County compared with those living in non-California Western US states. Referral locations evolved over 25 years at UCLA, with more cases coming from local regions; the percentage of minority patients also increased. The interval from seizures onset to surgery was shortest for patients living farthest from UCLA but still within the US. Geographic location and race/ethnicity was not associated with differences in becoming seizure free after epilepsy surgery in children.

Quality of Life Research, 2014

To assess (1) whether the generic Short Form (SF)-36, an integrated component of the epilepsy-tar... more To assess (1) whether the generic Short Form (SF)-36, an integrated component of the epilepsy-targeted Quality of Life in Epilepsy Inventory-89 (QOLIE-89), is able to detect differences in the health-related quality of life (HRQOL) between young adults with epilepsy and healthy sibling controls and (2) whether the generic components are as sensitive to within-disease symptom severity as the epilepsy-targeted components of the QOLIE-89 in young adults with epilepsy. A cohort of young adults with epilepsy (N = 108, age 21.6 years SD = 3.8), followed since diagnosis in a prospective community-based study of childhood-onset epilepsy, completed the QOLIE-89, an epilepsy-targeted HRQOL instrument that includes within it a generic core measure (SF-36). Sibling controls (N = 82, age = 20.7 years, SD = 2.1) completed the generic core, SF-36. Age- and gender-adjusted QOLIE-89 epilepsy-targeted and cognitive-distress composite scores and the overall score were strongly associated with seizure-free duration: seizure-free ≥5 years (higher HRQOL), n = 57; seizure-free 1-5 years, n = 22; or seizure-free &amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;lt;1 year, n = 29 (lower HRQOL) (p &amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;lt; 0.001). However, on QOLIE-89 physical health and mental health composite scores, there were no differences across these seizure-free duration groups. For cases compared with sibling controls, there were no differences on SF-36 physical and mental health composite scores or the global composite score, using either classical test or item-response theory scoring procedures. While the epilepsy-targeted components of the QOLIE-89 are sensitive to seizure-related factors in young adults with epilepsy, the SF-36 generic core measures are not, thereby limiting HRQOL comparisons between young adults with epilepsy and sibling controls.

Parkinson's Disease, 2011

Parkinson's Disease, 2012

Stroke, 2011

Neighborhood characteristics may influence the risk of stroke and contribute to socioeconomic dis... more Neighborhood characteristics may influence the risk of stroke and contribute to socioeconomic disparities in stroke incidence. The objectives of this study were to examine the relationship between neighborhood socioeconomic status and incident ischemic stroke and examine potential mediators of these associations. We analyzed data from 3834 whites and 785 blacks enrolled in the Cardiovascular Health Study, a multicenter, population-based, longitudinal study of adults ages≥65 years from 4 US counties. The primary outcome was adjudicated incident ischemic stroke. Neighborhood socioeconomic status was measured using a composite of 6 census tract variables. Race-stratified multilevel Cox proportional hazard models were constructed adjusted for sociodemographic, behavioral, and biological risk factors. Among whites, in models adjusted for sociodemographic characteristics, stroke hazard was significantly higher among residents of neighborhoods in the lowest compared with the highest neighborhood socioeconomic status quartile (hazard ratio, 1.32; 95% CI, 1.01-1.72) with greater attenuation of the hazard ratio after adjustment for biological risk factors (hazard ratio, 1.16; 0.88-1.52) than for behavioral risk factors (hazard ratio, 1.30; 0.99-1.70). Among blacks, we found no significant associations between neighborhood socioeconomic status and ischemic stroke. Higher risk of incident ischemic stroke was observed in the most disadvantaged neighborhoods among whites, but not among blacks. The relationship between neighborhood socioeconomic status and stroke among whites appears to be mediated more strongly by biological than behavioral risk factors.