Development of the Telehealth Usability Questionnaire (TUQ)

Current telehealth usability questionnaires are designed primarily for older technologies, where telehealth interaction is conducted over dedicated videoconferencing applications. However, telehealth services are increasingly conducted over computer-based systems that rely on commercial software and a user supplied computer interface. Therefore, a usability questionnaire that addresses the changes in telehealth service delivery and technology is needed.  The Telehealth Usability Questionnaire (TUQ) was developed to evaluate the usability of telehealth implementation and services.  This paper addresses: 1) the need for a new measure of telehealth usability, 2) the development of the TUQ, 3) intended uses for the TUQ, and 4) the reliability of the TUQ. Analyses indicate that the TUQ is a solid, robust, and versatile measure that can be used to measure the quality of the computer-based user interface and the quality of the telehealth interaction and services.   

A cross-sectional association of obesity with coronary calcium among Japanese, Koreans, Japanese-Americans, and US-Whites

[Aims] Conflicting evidence exists regarding whether obesity is independently associated with coronary artery calcium (CAC), a measure of coronary atherosclerosis. We examined an independent association of obesity with prevalent CAC among samples of multi-ethnic groups whose background populations have varying levels of obesity and coronary heart disease (CHD). [Methods and results] We analysed a population-based sample of 1212 men, aged 40–49 years free of clinical cardiovascular disease recruited in 2002–06; 310 Japanese in Japan (JJ), 294 Koreans in South Korea (KN), 300 Japanese Americans (JA), and 308 Whites in the USA (UW). We defined prevalent CAC as an Agatston score of ≥10. Prevalent CAC was calculated by tertile of the body mass index (BMI) in each ethnic group and was plotted against the corresponding median of tertile BMI. Additionally, logistic regression was conducted to examine whether an association of the BMI was independent of conventional risk factors. The median BMI and crude prevalence of CAC for JJ, KN, JA, and UW were 23.4, 24.4, 27.4, and 27.1 (kg/m2); 12, 11, 32, and 26 (%), respectively. Despite the absolute difference in levels of BMI and CAC across groups, higher BMI was generally associated with higher prevalent CAC in each group. After adjusting for age, smoking, alcohol, hypertension, lipids, and diabetes mellitus, the BMI was positively and independently associated with prevalent CAC in JJ, KN, UW, but not in JA. [Conclusion] In this multi-ethnic study, obesity was independently associated with subclinical stage of coronary atherosclerosis among men aged 40–49 years regardless of the BMI level

To weight or not to weight? Incorporating sampling designs into model-based analyses

Large-scale statistical surveys seldom use simple random sampling. Two fundamental approaches (design- and model-based) exist to incorporate complexities such as stratification, clustering and/or unequal probabilities of selection into the survey analysis. The debate about design- vs. model-based analysis has a long history and currently centers around the role of design-based sampling weights in model-based analyses. This thesis begins by investigating three different published proposals on how to insert the sampling weights into linear mixed-effects (LME) models. This component, which focuses on how the sampling weights are inserted into LME models, derives the three methods from a common starting place and emphasizes the unique decisions that distinguish the different approaches. The second component of this thesis compares the methods in a simulation study that varies the types of informative sampling and model misspecification. The goal of this component is to characterize when it is appropriate to include sampling weights into a model-based analysis, as well as which kinds of sampling and modeling errors weights can correct. Finally, the lessons from the first two components are extended to the Grade of Membership (GoM) model, a hierarchical Bayesian mixed-membership model whose variance components do not map well to the dependencies induced by complex sampling designs. The GoM model is modified to include a polytomous logistic mixed-effects regression prior to reflect the sampling design. A new type of weighting, called weighting based on the estimated parameter is developed and explored through a simulation study

Disparities in time spent seeking medical care in the US

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The opportunity costs of ambulatory medical care in the United States

Objectives: The typical focus in discussions of healthcare spending is on direct medical costs such as physician reimbursement. The indirect costs of healthcare—patient opportunity costs associated with seeking care, for example—have not been adequately quantified. We aimed to quantify the opportunity costs for adults seeking medical care for themselves or others. Study Design: Secondary analysis of the 2003-2010 American Time Use Survey (ATUS). Methods: We used the nationally representative 2003-2010 ATUS to estimate opportunity costs associated with ambulatory medical visits. We estimated opportunity costs for employed adults using self-reported hourly wages and for unemployed adults using a Heckman selection model. We used the Medical Expenditure Panel Survey to compare opportunity costs with direct costs (ie, patient out-of-pocket, provider reimbursement) in 2010. Results: Average total time per visit was 121 minutes (95% CI, 118-124), with 37 minutes (95% CI, 36-39) of travel time and 84 minutes (95% CI, 81-86) of clinic time. The average opportunity cost per visit was $43, which exceeds the average patient’s out-of-pocket payment. Total opportunity costs per year for all physician visits in the United States were$52 billion in 2010. For every dollar spent in visit reimbursement, an additional 15 cents were spent in opportunity costs. Conclusions: In the United States, opportunity costs associated with ambulatory medical care are substantial. Accounting for patient opportunity costs is important for examining US healthcare system efficiency and for evaluating methods to improve the efficient delivery of patient-centered care

Prognostic Value of Adipokines in Predicting Cardiovascular Outcome:Explaining the Obesity Paradox

OBJECTIVE: To evaluate the cardiovascular (CV) prognostic value of adipokines in a large prospective cohort of patients participating in the Bypass Angioplasty Revascularization Investigation 2 Diabetes (BARI 2D) trial. PATIENTS AND METHODS: The effects of the adipokine levels at baseline and change from baseline on the composite outcome (CV death, myocardial infarction and stroke) were analyzed using unadjusted and fully adjusted Cox models in 2330 patients with type 2 diabetes (DM) and coronary artery disease (CAD) who had participated in BARI2D trial (January 2001, through November 2008). RESULTS: In a fully adjusted model, baseline leptin and change from baseline leptin were protective for CV events, while baseline adiponectin, baseline tumor necrosis factor-alpha (TNF- α), change from baseline TNF-α, baseline C-reactive protein (CRP), and change from baseline CRP were harmful. The effect of baseline leptin on CV events depended on the body mass index (BMI), such that the hazard ratios (HR) varied between 0.6 and 1.4 across the BMI quintiles (interaction P=.03). The same was true for baseline adiponectin (HR varied between 0.7 and 1.7, interaction P=.01), change from baseline monocyte chemoattractant protein-1 (MCP-1) (HR varied between 0.8 and 1.8, interaction P=.03), change from baseline TNF-α (HR varied between 0.9 to 1.4, interaction P=.02), and change from baseline CRP (HR varied between 0.7 to 1.2, interaction P=.02). CONCLUSIONS: Adipokines are independent predictors of CV events in patients with DM and CAD. The association between the specific adipokines and CV outcome varies depending on BMI. This reflects the complex pathophysiology of CV disease in obesity and may help explain the “obesity paradox”. CLINICAL TRIAL REGISTRATION: http://www.clinicaltrials.gov/ct2/show/NCT0000630

The effect of frailty on HAI response to influenza vaccine among community-dwelling adults ≥ 50 years of age

The immune response to vaccine antigens is less robust in older adults because of changes in the aging immune system. Frailty, the multi-dimensional syndrome marked by losses in function and physiological reserve, is increasingly prevalent with advancing age. Frailty accelerates this immunosenescence but the consequence of frailty on immune response specific to influenza vaccine among older adults, is mixed. An observational, prospective study of 114 adults was conducted in the fall of 2013 to assess the association of physical frailty with immune response to standard dose influenza vaccine in community-dwelling adults ≥ 50 years of age. Participants were stratified by age (<65 years and ≥65 years), and vaccine strain (Influenza A/H1N1, A/H3N2 and B) was analyzed separately adjusting for body mass index (BMI) and baseline log2 hemagglutination inhibition (HAI) titers. Overall, immune responses were lower among those ≥65 years of age than those <65 years. Among those ≥65 years there were no significant differences between frail and non-frail individuals in seroprotection or seroconversion for any influenza strain. Frail individuals <65 years of age compared with non-frail individuals were more likely to be seroprotected and to seroconvert post vaccination. Linear regression models show the same pattern of significant differences between frail and non-frail for those <65 years but no significant differences between frailty groups for those ≥65 years. Additional research may elucidate the reasons for the differences observed between younger frail and non-frail adults