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Farmer’s markets, cultural competence, pharmacy practice – do these dots connect?

By on November 20, 2013 in Cultural Competence, News, Pharmacy Practice, Racial and ethnic health disparities

A walk through the farmer’s market can be a step on the way to cultural competence.

I visited Gainesville, Florida at the end of October, and my hosts from the College of Pharmacy took me through the local farmer’s market. My attention was piqued by the sub-tropical produce such as persimmons and pecans, items I don’t see at my farmer’s market in New England. Passing up the opportunity to purchase wild boar liver and other wild boar products, I stopped in my tracks when I saw a red, fruit-like thing, exotic and new to me, the calyx of the hibiscus flower. The calyx is a capsule surrounding the seeds, and it is about an inch in diameter.

Cultural competence

Photo: Jeff McMillian, used with permission

 

The hand written sign said, “sorrelle”. Walking further we found more “sorrelle”, also labeled “roselle”, and the stand owners explained that these were used to make a tea similar to the red zinger teas we could buy in the supermarket. From this I inferred that we were looking at hibiscus, and I bought a dried sample to take home with me. Once back home, I learned that the plant has many names. The scientific name is Hibiscus sabdariffa L, but it is also called Roselle, its original Arabic name is Karkade. and other common names are Sorrel, Red sorrel, Jamaica Sorrel, Lozey, Cabitutu, Vinuela, Oseille de Guinee, Pink Lemonade Flower, Vinagrillo, Afrika Bamya, sour-sour and Florida cranberry. The names hint at the many places around the world where it is used to make teas or iced beverages, and it is easy to access recipes for the beverage, including a recipe by Martha Stewart for Hibiscus Iced Tea.

As shown on this US Department of Agriculture map, Florida is the only place in the mainland United States where this plant grows. http://plants.usda.gov/core/profile?symbol=hisa2

USDA map showing where H. sabdariffa L grows in the United States.

USDA map showing where H. sabdariffa L grows in the United States.

A number of sources refer to widely held beliefs about the herb’s efficacy in lowering blood pressure, and it is not clear where and when these beliefs arose. Even less clear is the scientific evidence supporting such beliefs. A study funded by the USDA Agricultural Research Service and Celestial Seasonings and published in 2008 reported that hibiscus tea lowered blood pressure by 7.2 in a group of pre-hypertensive and mildly hypertensive adults compared to 1.3 points in a similar group of people drinking placebo beverage. Another USDA funded study confirmed antimicrobial activity of sorrel (Hibiscus sabdariffa) on Esherichia coli 0157:H7 isolates from food, veterinary and clinical samples.  It is possible to find other studies about H. sabdariffa L, and its potential effects on blood pressure, and even cholesterol, and this might make an interesting topic for a systematic literature review.

Whether or not there is a biologic effect on health, we are left wondering about the number of people in the area drinking the beverage, as well as their beliefs about the tea. Do people believe that the herb will lower their blood pressure? If so, does this affect their adherence to pharmacologic therapies? We can begin to envision some interesting lines of inquiry. At minimum it might be an interesting way to engage the local community and learn about local customs and beliefs.

Walking around a farmer’s market (or other local sites) is a pleasant way to begin learning about a community, and a nice metaphor for one aspect of cultural competence: Go out into the community you serve, look around, ask questions, taste, learn – repeat!

References
United States Department of Agriculture Natural Resources Conservation Service Plants Profile for Hibiscus sabdariffa (roselle). Available at http://plants.usda.gov/core/profile?symbol=hisa2
Fullerton M, Khatiwada J, Johnson JU, et al., “Determination of Antimicrobial Activity of Sorrel (Hibiscus sabdariffa) on Esherichia coli 0157:H7 Isolated from Food, Veterinary, and Clinical Samples” J Med Food 2011 September 14(9):950-956. Available at http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3157304/
Bliss M, “Study Shows Consuming Hibiscus Tea Lowers Blood Pressure” USDA Agricultural Research Service News 2008. Available at http://www.ars.usda.gov/is/pr/2008/081110.htm

Learning module – Patient Reported Outcomes (PROs)

By on May 10, 2013 in News, Patient Reported Outcomes (PROs)

Just released by ISPOR’s Distance Learning Program, the module, “Patient Reported Outcomes – Analysis and Interpretation”, Tamar Lasky, PhD, faculty.

Course Description

The module will review definitions of patient reported outcomes and the contexts in which they are used, including applications to health quality improvement, clinical trials and drug safety. The module will provide an overview of methodologic issues to consider when using patient reported outcomes or research with patient reported outcomes, and the concepts that are assessed by government agencies such as FDA and NIH. Measurement concepts such as content validity will be introduced, and limitations of discussed.

After the overview, the module will walk through all issues related to statistical analysis of patient reported outcomes after the instrument has been validated, calibrated, approved and finalized. Concepts related to development will be introduced only as they relate to ultimate analysis of the data (development will be covered more thoroughly in a separate module). The use of multiple endpoints and composite endpoints will be covered, as well as approaches to continuous, categorical and time to event analysis. Approaches to analysis of missing data will be introduced.

Three case studies will be used to illustrate analysis of PRO data in different contexts. The first case study will describe the work being done by PROMIS, and the status of the outcome measures available for measuring health care quality. The second case study will describe work being done in the United Kingdome National Health Service (NHS) in PROMs, and analysis of data within a health system. The final case study will illustrate the use of PROs in clinical trials, in support of FDA labeling claims. All modules will discuss statistical analysis, and interpretation of statistical results.

Learning Objectives

By the end of the Patient Reported Outcomes – Analysis and Interpretation module, you will be able to describe what patient-reported outcomes are, general statistical issues to consider when analyzing data collected from PRO instruments, and three case studies demonstrating use of PRO instruments.

MIE Resource publishes “What Pharmacists Need to Know About Racial and Ethnic Health Disparities”

By on February 13, 2013 in News, Pharmacy Practice, Public Health, Racial and ethnic health disparities

MIE Resources is proud to announce publication of “What Pharmacists Need to Know About Racial and Ethnic Health Disparities” by Tamar Lasky, PhD,

a text for use in public health, health disparities, health services research, and related courses for pharmacy students in their second, third, and fourth years of training.

Racial and ethnic health disparities

This book, the first of its kind, introduces pharmacy students to basic concepts about race and ethnicity, and the classification of race and ethnicity in the United States for data collection. It then moves on to an overview  of the data collected regarding disparities in mortality, morbidity, provision of health care, and other health indicators and epidemiological studies of mechanisms and pathways to demonstrate the extensive body of evidence describing racial and ethnic health disparities. The text describes mechanisms through which race and ethnicity may affect health outcomes.

After laying a general background, the text addresses racial and ethnic health disparities that can occur in real-world pharmacy care, such as differences in disease conditions, response to medication, access to care, health literacy, and understanding of health and medications. It concludes with a discussion of the pharmacist commitment to eliminating racial and ethnic health disparities.

Available at amazon.com

Variation in Vancomycin Use in Pediatric Hospitalizations in the 2008 Premier Database

By on August 21, 2012 in Antibiotic use, Databases, Epidemiology, News, Pediatric Medication Use

How much variation in use is too much?

Vancomycin is indicated for the treatment of serious or severe infections caused by susceptible strains of methicillin-resistant (beta-lactam-resistant) staphylococci.  Because of concerns about the development of drug-resistant bacteria, recommendations to prevent the spread of vancomycin resistance have been in place since 1995 and include guidelines for inpatient pediatric use of vancomycin.  With such guidelines in place, it is of special interest to compare inpatient pediatric vancomycin administration across hospitals.

Our recent publication, “Pediatric Vancomycin Use in 421 Hospitals in the United States 2008” published in PLOS ONE on 8/16/2012 (Lasky T, Greenspan J, Ernst FR, and Gonzalez L), compares vancomycin use in all pediatric hospitalizations (hospitalizations of children under age 18) in 421 hospitals in the Premier database.

Key Findings

  • Vancomycin was administered to children at 374 hospitals in the Premier hospital database.
  • Another 47 hospitals with 17,271 pediatric hospitalizations (13,233 under age 2) reported no vancomycin use during 2008.
  • The number of pediatric hospitalizations with vancomycin use ranged from 0 to 1225 at individual hospitals.
  • Most hospitals (221) had fewer than 10 pediatric hospitalizations with vancomycin use in the study period.
  • 21 hospitals (5.6% of hospitals) each had over 200 hospitalizations with vancomycin use, and together, accounted for more than 50% of the pediatric hospitalizations with vancomycin use.
  • Percentage of hospitalizations with vancomycin use ranged up to 33.3% when hospitals with few pediatric hospitalizations were kept in the sample, the high percenetages being an artifact of the small number of hospitalizations in the denominator. For this reason, percentage, by itself, may not be a useful indicator in small hospitals.
  • In hospitals with more than 100 pediatric hospitalizations with vancomycin use, the percentage with vancomycin use ranged from 1.26 to 12.90, a 10 fold range in the prevalence of vancomycin use.
  • Our stratified analyses and logistic modeling showed variation in vancomycin use by individual hospital that was not explained by hospital or patient characteristics including: bed size, teaching status, region of the country, rural or urban geography, and patient sex, race, APR-DRG risk of mortality and APR-DRG severity of illness.

For Discussion and Further Investigation

Until recently, few studies have compared pediatric antibiotic use across large numbers of hospitals or geography, and it was not possible to assess variation in use across institutions. Hospital variation in care of adults has been studied for several decades, much of it made possible by large Medicare claims databases. With the availability of aggregated data for pediatric hospitalizations we can begin describing and attempting to understand variation in pediatric practice. This first study of hospital variation in pediatric vancomycin use raises questions for further research.

Crowdsourcing to obtain study samples and conduct epidemiologic surveys

By on May 26, 2012 in Communication, Epidemiology

It seemed like a fanciful idea, but the title caught my eye, “Crowdsourcing Graphical Perception: Using Mechanical Turk to Assess Visualization Design” (Jeffrey Heer, Michael Bostock ACM Human Factors in Computing Systems (CHI), 203–212, 2010).

OK, google “Mechanical Turk” – it is a service from Amazon that matches “workers or Turkers” with “requestors” for small tasks and asked “workers” to assess different visualization  designs.  If you know this already, you are way ahead of where I was last Tuesday. The authors got 186 respondents to assess some  visualizations for a total study cost of $367.77, and the authors were able to compare their study results to published literature to conclude that the method was viable.  If “Turkers” can assess visualizations, then they presumably they can respond to other types of questionnaires or surveys about a range of issues.

This piqued my curiosity, and I searched for more information on this issue.  One of the first questions of concern to any epidemiologist would be the degree and types of selection biases associated with using crowdsourcing and related approaches to obtain what are essentially survey samples and responses. I was surprised to see a growing body of literature in this arena, the most recent of which is Jennifer Jacquet’s article,on the Scientific American blog (July 7, 2011), “The Pros and Cons of Amazon Mechanical Turk for Scientific Surveys” (aren’t surveys some of what we do?).

I found several other studies characterizing the demographics of samples of respondents on Mechanical Turk:

“The New Demographics of Mechanical Turk”, March 9, 2010 Panos Ipeirotis, NYU School of Business, www.behind-the-enemy-lines.com/2010/03/new-demographics-of-mechanical-turk.html

Ross, Irani, Silberman, Zaldivar and Tomlinson, “Who are the Crowdworkers? Shifting Demographics in Mechanical Turk” CHI 2010, www.ics.uci.edu/~jwross/pubs/RossEtAl-WhoAreTheCrowdworkers-altCHI2010.pdf

Going further, some folks are pursuing the idea of using this methodology for subject recruitment in experimental research: “Using Mechanical Turk as a Subject Recruitment Tool for Experimental Research”, Berinsky, Huber and Lenz, October 7, 2011,

Clearly, some very bright minds are exploring the potential of this mechanism.  I would think that we epidemiologists will have a lot to contribute in this arena, and will see great benefits, as well.