Developing a comorbidity index for comparing cancer outcomes in Aboriginal and non-Aboriginal Australians

BACKGROUND:Comorbidity is known to increase risk of death in cancer patients, both Aboriginal and non-Aboriginal. The means of measuring comorbidity to assess risk of death has not been studied in any depth in Aboriginal patients in Australia. In this study, conventional and customized comorbidity indices were used to investigate effects of comorbidity on cancer survival by Aboriginal status and to determine whether comorbidity explains survival disparities. METHODS:A retrospective cohort study was undertaken using linked population-based South Australian Cancer Registry and hospital inpatient data for 777 Aboriginal people diagnosed with primary cancer between 1990 and 2010 and 777 randomly selected non-Aboriginal controls matched by sex, birth year, diagnosis year and tumour type. A customised comorbidity index was developed by examining associations of comorbid conditions with 1-year all-cause mortality within the Aboriginal and non-Aboriginal patient groups separately using Cox proportional hazard model, adjusting for age, stage, sex and primary site. The adjusted hazard ratios for comorbid conditions were used as weights for these conditions in index development. The comorbidity index score for combined analyses was the sum of the weights across the comorbid conditions for each case from the two groups. RESULTS:The two most prevalent comorbidities in the Aboriginal cohort were "uncomplicated" hypertension (13.5%) and diabetes without complications (10.8%), yet in non-Aboriginal people, the comorbidities were "uncomplicated" hypertension (7.1%) and chronic obstructive pulmonary disease (4.4%). Higher comorbidity scores were associated with higher all-cause and cancer-specific mortality. The new index showed minor improvements in predictive ability and model fit when compared with three common generic comparison indices. After accounting for the competing risk of other deaths, stage at diagnosis, socioeconomic status, area remoteness and comorbidity, the increased risk of cancer death in Aboriginal people remained. CONCLUSIONS:Our new customised index performed at least as well, although not markedly better than the generic indices. We conclude that in broad terms, the generic indices are reasonably effective for adjusting for comorbidity when comparing survival outcomes by Aboriginal status. Irrespective of the index used, comorbidity has a negative impact on cancer-specific survival, but this does not fully explain the lower survival in Aboriginal patients.Lettie Pule, Elizabeth Buckley, Theophile Niyonsenga, David Banham and David Rode

A Mediterranean-style dietary intervention supplemented with fish oil improves diet quality and mental health in people with depression: a randomized controlled trial (HELFIMED)

We investigated whether a Mediterranean-style diet (MedDiet) supplemented with fish oil can improve mental health in adults suffering depression.Adults with self-reported depression were randomized to receive fortnightly food hampers and MedDiet cooking workshops for 3 months and fish oil supplements for 6 months, or attend social groups fortnightly for 3 months. Assessments at baseline, 3 and 6 months included mental health, quality of life (QoL) and dietary questionnaires, and blood samples for erythrocyte fatty acid analysis.n = 152 eligible adults aged 18-65 were recruited (n = 95 completed 3-month and n = 85 completed 6-month assessments). At 3 months, the MedDiet group had a higher MedDiet score (t = 3.95, P < 0.01), consumed more vegetables (t = 3.95, P < 0.01), fruit (t = 2.10, P = 0.04), nuts (t = 2.29, P = 0.02), legumes (t = 2.41, P = 0.02) wholegrains (t = 2.63, P = 0.01), and vegetable diversity (t = 3.27, P < 0.01); less unhealthy snacks (t = -2.10, P = 0.04) and red meat/chicken (t = -2.13, P = 0.04). The MedDiet group had greater reduction in depression (t = -2.24, P = 0.03) and improved mental health QoL scores (t = 2.10, P = 0.04) at 3 months. Improved diet and mental health were sustained at 6 months. Reduced depression was correlated with an increased MedDiet score (r = -0.298, P = 0.01), nuts (r = -0.264, P = 0.01), and vegetable diversity (r = -0.303, P = 0.01). Other mental health improvements had similar correlations, most notably for increased vegetable diversity and legumes. There were some correlations between increased omega-3, decreased omega-6 and improved mental health.This is one of the first randomized controlled trials to show that healthy dietary changes are achievable and, supplemented with fish oil, can improve mental health in people with depression.Natalie Parletta, Dorota Zarnowiecki, Jihyun Cho, Amy Wilson, Svetlana Bogomolova, Anthony Villani, Catherine Itsiopoulos, Theo Niyonsenga, Sarah Blunden, Barbara Meyer, Leonie Segal, Bernhard T. Baune and Kerin O’De

A multi-level system quality improvement intervention to reduce racial disparities in hypertension care and control: study protocol

BACKGROUND: Racial disparities in blood pressure control have been well documented in the United States. Research suggests that many factors contribute to this disparity, including barriers to care at patient, clinician, healthcare system, and community levels. To date, few interventions aimed at reducing hypertension disparities have addressed factors at all of these levels. This paper describes the design of Project ReD CHiP (Reducing Disparities and Controlling Hypertension in Primary Care), a multi-level system quality improvement project. By intervening on multiple levels, this project aims to reduce disparities in blood pressure control and improve guideline concordant hypertension care. METHODS: Using a pragmatic trial design, we are implementing three complementary multi-level interventions designed to improve blood pressure measurement, provide patient care management services and offer expanded provider education resources in six primary care clinics in Baltimore, Maryland. We are staggering the introduction of the interventions and will use Statistical Process Control (SPC) charting to determine if there are changes in outcomes at each clinic after implementation of each intervention. The main hypothesis is that each intervention will have an additive effect on improvements in guideline concordant care and reductions in hypertension disparities, but the combination of all three interventions will result in the greatest impact, followed by blood pressure measurement with care management support, blood pressure measurement with provider education, and blood pressure measurement only. This study also examines how organizational functioning and cultural competence affect the success of the interventions. DISCUSSION: As a quality improvement project, Project ReD CHiP employs a novel study design that specifically targets multi-level factors known to contribute to hypertension disparities. To facilitate its implementation and improve its sustainability, we have incorporated stakeholder input and tailored components of the interventions to meet the specific needs of the involved clinics and communities. Results from this study will provide knowledge about how integrated multi-level interventions can improve hypertension care and reduce disparities. TRIAL REGISTRATION: ClinicalTrials.gov NCT0156686

Prevalence and Correlates of Sexual Risk Behaviors by Gender among Multi-Ethnic Adolescents

Risky sex and its related behaviors (initiation of sex, alcohol, and drugs, school performance, delinquency) among adolescents are known to vary between genders. However, such variations among multi-ethnic adolescents of Florida are relatively understudied. The purpose of the study was to assess the prevalence of sexual and its related behaviors and evaluate the probability of sexual risks between genders. This study utilized the state-specific High School Youth Risk Behavior Survey (YRBS) of 2003. Weighted frequencies and stratified analyses using Rao-Scott chi-square (χ 2) test and survey logistic regression models were utilized. Adjusted odds ratios and their corresponding confidence limits and Rao-Scott χ 2 statistics for significance testing of parameter estimates were presented. There were 2,025 females and 1,828 males (n=3,853). Over 50% of participants were Whites, with 24.1% Hispanics, 20.3% African Americans, and 4.4% other. More females (20.3%) reported nonuse of condom compared with males (17.8%). Prevalence of other sexual risks (multiple sex partners, injection drug use, and sex under the influence of alcohol) was more common in males. Common correlates of at least one sexual risk behavior included older age, grade level, and early sexual debut. Surprisingly, school performance, delinquent behaviors, and early initiation of alcohol or drugs were not significantly associated with risky sex in males or females. Underlying variation of risks between males and females should be explored further. Health professionals working with adolescent populations should consider collecting locally relevant epidemiologic, survey, and social systems data to assess gender-variations in behaviors. Moreover, health prevention/promotion programs should be designed with reference to specific gender, and other differences especially among ethnically diverse adolescent populations