Dr. Thom is a family medicine physician and PhD-trained epidemiologist, who has over 30 years of experience in clinical care, research and teaching, primarily at Stanford and at the University of California San Francisco (UCSF). Over the course of his career, Dr. Thom has conducted over 20 studies, in the areas of cardiovascular disease, women’s health, the doctor-patient relationship and on health coaching for patients with chronic disease. He has published over 100 peer-reviewed, original research articles and over a dozen book chapters and has presented his work at numerous national and international meetings. Dr. Thom recently served as the Vice Chair for Research in the UCSF Department of Family and Community Medicine from 2015 until his retirement from UCSF in 2018.

In addition to teaching medical students and residents, Dr. Thom has been a research and/or career mentor to over 50 students, residents, fellows and junior faculty members. He served as a core faculty member for the UCSF Primary Care Research Fellowship Program from 2014 to 2018.

Dr. Thom is currently a Clinical Professor of Medicine in the Division of Primary Care and Population Health at Stanford. He provides clinical care and teaches medical students at the Stanford Family Medicine clinic. As a family physician, Dr. Thom diagnoses and treats a wide range of conditions, provides preventive care for patients of all ages, and performs a variety of office procedures.

Clinical Focus

  • Family Medicine

Academic Appointments

Professional Education

  • Medical Education: University of California San Diego School of Medicine (1983) CA
  • PhD, University of Washington School of Public Health, Epidemiology (1991)
  • MPH, University of Washington School of Public Health, Epidemiology (1989)
  • Board Certification: American Board of Family Medicine, Family Medicine (1986)
  • Residency: Santa Rosa Family Practice (1986) CA
  • AB, Stanford University, Human Biology (1979)

Clinical Trials

  • Aides in Respiration Health Coaching for COPD Not Recruiting

    This study examined whether health coaches can improve the management of chronic obstructive pulmonary disease (COPD) in a population of vulnerable patients cared for in 'safety-net' clinics. The study is designed as a randomized controlled trial for patients with moderate to severe COPD. Patients were randomized into a health coaching group and a usual care group. Those in the health coaching group received 9 months of active health coaching. Outcome variables were measured at baseline and after 9 months

    Stanford is currently not accepting patients for this trial.

    View full details

All Publications

  • Diabetes distress mediates the relationship between depressive symptoms and glycemic control among adults with type 2 diabetes: findings from a multi-site diabetes peer support intervention. Diabetic medicine : a journal of the British Diabetic Association Qian, Y., Emmerling, D. A., Kowitt, S. D., Ayala, G. X., Cherrington, A. L., Heisler, M., Safford, M. M., Tang, T. S., Thom, D. H., Fisher, E. B. 2023: e15065


    AIMS: Diabetes distress is positively associated with HbA1c and may mediate the relationship between depressive symptoms and HbA1c. This study examined these relationships in a geographically, socioeconomically, and ethnically diverse sample of adults with type 2 diabetes.METHODS: Using data from five US sites evaluating peer support for diabetes management (n=917), Structural Equation Modeling (SEM) examined whether diabetes distress (four items from Diabetes Distress Scale) mediated the relationship between depressive symptoms (PHQ-8) and HbA1c. Sites compared interventions of varying content and duration with control conditions. Time from Baseline Assessment to Final Assessment varied from six to 18 months. Site characteristics were controlled by entering site as a covariate along with age, sex, education, diabetes duration, insulin use, and intervention/control assignment.RESULTS: Depressive symptoms, diabetes distress, and HbA1c were all intercorrelated cross-sectionally and from Baseline to Final Assessment (rs from .10 to .57; ps<0.05). In SEM analyses, diabetes distress at Final Assessment mediated the relationship between Baseline depressive symptoms and HbA1c at Final Assessment (indirect effect: b=.031, p<0.001), controlling for Baseline HbA1c and covariates. Parallel analysis of whether depressive symptoms mediated the relationship between Baseline diabetes distress and HbA1c at Final Assessment was not significant.CONCLUSIONS: In this diverse sample, diabetes distress mediated the influence of depressive symptoms on HbA1c but the reverse, depressive symptoms mediating the effect of distress, was not found. These findings add to the evidence that diabetes distress is a worthy intervention target to improve clinical status and quality of life among individuals with type 2 diabetes.

    View details for DOI 10.1111/dme.15065

    View details for PubMedID 36762953

  • Interpersonal Violence and Painful Bladder Symptoms in Community-Dwelling Midlife to Older Women OBSTETRICAL & GYNECOLOGICAL SURVEY Raphael, E., Van den Eeden, S. K., Gibson, C. J., Tonner, C., Thom, D. H., Subak, L., Huang, A. J. 2022; 77 (5): 269-271
  • Implementation and Impact of the Pulmonary Specialist Health Coach Consultation Model to Improve Care for Patients with COPD JOINT COMMISSION JOURNAL ON QUALITY AND PATIENT SAFETY Tsao, S., Willard-Grace, R., Wolf, J., Chirinos, C., De Vore, D., Huang, B., Su, G., Thom, D. H. 2021; 47 (11): 739-747


    Health coaching has emerged as an important tool for improving patient-centered care in primary care practice but has not specifically been evaluated for patients whose care is shared by a primary care provider (PCP) and specialist.As part of a nine-month randomized controlled trial comparing health coaching to usual care for patients with chronic obstructive pulmonary disease (COPD), the authors developed the Pulmonary Specialist Health Coach Consultation (PuSHCon). In this novel model, health coaches facilitated pulmonary specialist consultations for patients with COPD without the need for an in-person visit. Observational data from the randomized controlled trial were analyzed to study the implementation, adoption, and impact of the PuSHCon model for 70 of 92 patients randomized to the health coaching arm and for 17 of 100 patients in the control arm (who received PuSHCon after the end of the study). Quality of care was measured using the Patient Assessment of Chronic Illness Care (PACIC).Of 87 patients who participated in PuSHCon, 74 (85.1%) received one or more specialist recommendations, of which 86.8% were implemented. Only 12 patients (13.8%) subsequently required an in-person visit with the PuSHCon specialist. The proportion of PuSHCon participants receiving guideline-concordant care increased from 64.7% to 94.1% (p < 0.001). The mean PACIC item score increased from 3.48 to 3.74 (p = 0.03).The PuSHCon model facilitated consultations that resulted in changes in care, which were implemented for a majority of patients. Guideline-concordant care and patient-reported quality of care increased over nine months. This model could potentially be expanded to help patients with other chronic conditions when PCPs and specialists share patient care.

    View details for DOI 10.1016/j.jcjq.2021.08.003

    View details for Web of Science ID 000713169400009

    View details for PubMedID 34489189

  • Association of Patients' Past Misdiagnosis Experiences with Trust in Their Current Physician Among Japanese Adults. Journal of general internal medicine Suzuki, R., Yajima, N., Sakurai, K., Oguro, N., Wakita, T., Thom, D. H., Kurita, N. 2021


    BACKGROUND: Previous qualitative research has described that previous misdiagnoses may reduce patient and their families' trust in healthcare.OBJECTIVE: To quantify the associations between patients or family members' misdiagnosis experiences and trust in their physician.DESIGN: Cross-sectional study.PARTICIPANTS: Adult Japanese people with non-communicable diseases (cancer, diabetes, depression, heart disease, and connective tissue disease), recruited using a web-based panel survey.MAIN MEASURES: Surveys assessed the patient and the patient's family's experience with misdiagnosis. Trust in the respondent's current physician was measured using the Japanese version of the 11-item Trust in Physician Scale.KEY RESULTS: Among 661 patients (response rate 30.1%), 23.2% had a personal history of misdiagnosis and 20.4% had a family history of misdiagnosis. In a multivariable-adjusted general linear model, patients or a family members' misdiagnosis experiences were associated with lower confidence in their current physician (mean difference -4.3, 95%CI -8.1 to -0.49 and -3.2, 95%CI -6.3 to -0.05, respectively). The impact of having a personal and a family member's experience of misdiagnosis on trust was additive, with no evidence of interaction (P for interaction = 0.494).CONCLUSIONS: The patient's or family members' misdiagnosis experiences reduced trust in the patient's current physicians. Interventions specifically targeting misdiagnosed patients are needed to restore trust.

    View details for DOI 10.1007/s11606-021-06950-y

    View details for PubMedID 34159541

  • "She Showed Me How to Help Myself": A Qualitative Study of Health Coaching for Management of Chronic Obstructive Pulmonary Disease JOURNAL OF HEALTH CARE FOR THE POOR AND UNDERSERVED Willard-Grace, R., Masaki, S., Joseph, R., DeVore, D., Huang, B., Su, G., Thom, D. H. 2021; 32 (1): 449–62


    To explore attitudes and beliefs about the role of health coaching for vulnerable populations, including people experiencing substance use or homelessness.From May-July 2016, we conducted semi-structured qualitative interviews with patients, primary care clinicians, pulmonary specialists, and health coaches participating in a study of health coaching for chronic obstructive pulmonary disease (COPD). We developed a codebook and applied it in Atlas.ti, generating themes for frequently occurring codes.All stakeholder groups (n=20 patients, 11 primary care clinicians, three specialists, and two health coaches), reported improved COPD management and behavior change, even for patients experiencing substance use or homelessness. Clinicians observed greater symptom awareness and prioritization of COPD during the medical visit. The strength of the health coaching relationship and flexibility of the role were key to its effectiveness.Lay health coaching may provide a model to meet the needs of highly vulnerable populations with COPD.

    View details for Web of Science ID 000625296600035

    View details for PubMedID 33678707

  • Interpersonal violence and painful bladder symptoms in community-dwelling midlife to older women. American journal of obstetrics and gynecology Raphael, E., Van Den Eeden, S. K., Gibson, C. J., Tonner, C., Thom, D. H., Subak, L., Huang, A. J. 2021


    Women are more likely to present with genitourinary complaints immediately after exposure to interpersonal violence, but little is known about long-term effects on women's urologic health such as their susceptibility to bladder pain and infections.To determine whether lifetime interpersonal violence exposure and current post-traumatic stress disorder (PTSD) symptoms are associated with prevalence or severity of painful bladder symptoms as well as greater lifetime history of antibiotic-treated urinary tract infections in community-dwelling midlife and older women.We examined cross-sectional data from a multiethnic cohort of community-dwelling women aged 40-80 years enrolled in a northern California integrated healthcare system. Women completed structured self-report questionnaires about their past exposure to physical and verbal/emotional intimate partner violence as well as sexual assault. Symptoms of PTSD were assessed using the PSTD Checklist for DSM-IV, Civilian Version. Additional structured self-report measures assessed current bladder pain, other lower urinary tract symptoms, and history of antibiotic-treated urinary tract infections. Multivariable logistic regression models examined self-reported interpersonal violence exposure history and current PTSD symptoms in relation to current bladder pain and antibiotic-treated urinary tract infection history.Among 1,974 women (39% non-Latina White, 21% Black, 20% Latina, and 19% Asian), 22% reported lifetime interpersonal violence exposure, 22% bladder pain, and 60% history of ever having an antibiotic-treated urinary tract infection. Lifetime experience of sexual assault (OR[95%CI] = 1.39 [1.02, 1.88]) and current PTSD symptoms (OR[95%CI] = 1.96 [1.45, 2.65]) were associated with current bladder pain. Lifetime experience of physical intimate partner violence was associated with ever having a urinary tract infection (OR[95%CI] = 1.38 [1.00, 1.86]), as was emotional IPV (OR[95%CI] = 1.88 [1.43, 2.48]), sexual assault (OR[95%CI] = 1.44 [1.09, 1.91]), and current PTSD symptoms (OR[95%CI] = 1.54 [1.16, 2.03]).In this ethnically diverse, community-based cohort, lifetime interpersonal violence exposures and current PTSD symptoms were independently associated with current bladder pain and lifetime history of antibiotic-treated urinary tract infections in midlife to older women. Findings suggest that interpersonal violence and PTSD symptoms may be under-recognized markers of risk for urologic pain and infections in women, highlighting a need for trauma-informed care of these issues.

    View details for DOI 10.1016/j.ajog.2021.09.017

    View details for PubMedID 34555321

  • Lay Health Coaching to Increase Appropriate Inhaler Use in COPD: A Randomized Controlled Trial. Annals of family medicine Willard-Grace, R., Chirinos, C., Wolf, J., DeVore, D., Huang, B., Hessler, D., Tsao, S., Su, G., Thom, D. H. 2020; 18 (1): 5–14


    PURPOSE: Poor adherence to medications is more prevalent for chronic obstructive pulmonary disease (COPD) than for other chronic conditions and is associated with unfavorable health outcomes. Few interventions have successfully improved adherence for COPD medications; none of these use unlicensed health care personnel. We explored the efficacy of lay health coaches to improve inhaler adherence and technique.METHODS: Within a randomized controlled trial, we recruited English- and Spanish-speaking patients with moderate to severe COPD from urban, public primary care clinics serving a low-income, predominantly African American population. Participants were randomized to receive 9 months of health coaching or usual care. Outcome measures included self-reported adherence to inhaled controller medications in the past 7 days and observed technique for all inhalers. We used generalized linear models, controlling for baseline values and clustering by site.RESULTS: Baseline adherence and inhaler technique were uniformly poor and did not differ by study arm. At 9 months, health-coached patients reported a greater number of days of adherence compared with usual care patients (6.4 vs 5.5 days; adjusted P = .02) and were more likely to have used their controller inhalers as prescribed for 5 of the last 7 days (90% vs 69%; adjusted P = .008). They were more than 3 times as likely to demonstrate perfect technique for all inhaler devices (24% vs 7%; adjusted P = .01) and mastery of essential steps (40% vs 11%; adjusted P <.001).CONCLUSIONS: Health coaching may provide a scalable model that can improve care for people living with COPD.

    View details for DOI 10.1370/afm.2461

    View details for PubMedID 31937527

  • Physicians' Trust in Patients. JAMA Thom, D. H. 2019; 322 (8): 782

    View details for DOI 10.1001/jama.2019.9169

    View details for PubMedID 31454033

  • Strategies for recruitment and retention of underrepresented populations with chronic obstructive pulmonary disease for a clinical trial. BMC medical research methodology Huang, B., De Vore, D., Chirinos, C., Wolf, J., Low, D., Willard-Grace, R., Tsao, S., Garvey, C., Donesky, D., Su, G., Thom, D. H. 2019; 19 (1): 39


    BACKGROUND: Recruitment and retention are two significant barriers in research, particularly for historically underrepresented groups, including racial and ethnic minorities, patients who are low-income, or people with substance use or mental health issues. Chronic obstructive pulmonary disease (COPD) is the third leading cause of death and disproportionately affects many underrepresented groups. The lack of representation of these groups in research limits the generalizability and applicability of clinical research and results. In this paper we describe our experience and rates of recruitment and retention of underrepresented groups for the Aides in Respiration (AIR) COPD Health Coaching Study.METHODS: A priori design strategies included minimizing exclusion criteria, including patients in the study process, establishing partnerships with the community clinics, and ensuring that the health coaching intervention was flexible enough to accommodate patient needs.RESULTS: Challenges to recruitment included lack of spirometric data in patient records, space constraints at the clinic sites, barriers to patient access to clinic sites, lack of current patient contact information and poor patient health. Of 282 patients identified as eligible, 192 (68%) were enrolled in the study and 158 (82%) completed the study. Race, gender, educational attainment, severity of disease, health literacy, and clinic site were not associated with recruitment or retention. However, older patients were less likely to enroll in the study and patients who used home oxygen or had more than one hospitalization during the study period were less likely to complete the study. Three key strategies to maximize recruitment and retention were identified during the study: incorporating the patient perspective, partnering with the community clinics, and building patient rapport.CONCLUSIONS: While the AIR study included design features to maximize the recruitment and retention of patients from underrepresented groups, additional challenges were encountered and responded to during the study. We also identified three key strategies recommended for future studies of COPD and similar conditions. Incorporating the approaches described into future studies may increase participation rates from underrepresented groups, providing results that can be more accurately applied to patients who carry a disparate burden of disease.TRIAL REGISTRATION: This trial was registered at at identifier NCT02234284 on August 12, 2014. Descriptor number: 2.9 Racial, ethnic, or social disparities in lung disease and treatment.

    View details for PubMedID 30791871

  • Strategies for recruitment and retention of underrepresented populations with chronic obstructive pulmonary disease for a clinical trial BMC MEDICAL RESEARCH METHODOLOGY Huang, B., De Vore, D., Chirinos, C., Wolf, J., Low, D., Willard-Grace, R., Tsao, S., Garvey, C., Donesky, D., Su, G., Thom, D. H. 2019; 19
  • Re: Impact of Medical Scribes in Primary Care on Productivity, Face-to-Face Time, and Patient Comfort. Journal of the American Board of Family Medicine : JABFM Thom, D. H. 2019; 32 (1): 120

    View details for PubMedID 30610153

  • Keeping Pace with the Expanding Role of Health Coaching JOURNAL OF GENERAL INTERNAL MEDICINE Thom, D. H. 2019; 34 (1): 5–6
  • Re: Impact of Medical Scribes in Primary Care on Productivity, Face-to-Face Time, and Patient Comfort JOURNAL OF THE AMERICAN BOARD OF FAMILY MEDICINE Thom, D. H. 2019; 32 (1): 120
  • Interpersonal Trauma as a Marker of Risk for Urinary Tract Dysfunction in Midlife and Older Women. Obstetrics and gynecology Boyd, B. A., Gibson, C. J., Van Den Eeden, S. K., McCaw, B. n., Subak, L. L., Thom, D. n., Huang, A. J. 2019


    To examine relationships between interpersonal trauma exposures and urinary symptoms in community-dwelling midlife and older women.We analyzed cross-sectional data from a multiethnic cohort of women aged 40-80 years enrolled in an integrated health care system in California. Lifetime history of intimate partner violence (IPV) and sexual assault, current posttraumatic stress disorder (PTSD) symptoms, and current urinary symptoms were assessed using structured-item questionnaires. Multivariable-adjusted logistic regression models examined associations between traumatic exposures and PTSD symptoms with any weekly urinary incontinence, stress-type incontinence, urgency-type incontinence, and nocturia two or more times per night.Of the 1,999 participants analyzed, 21.7% women reported lifetime emotional IPV, 16.2% physical IPV, 19.7% sexual assault, and 22.6% reported clinically significant PTSD symptoms. Overall, 45% reported any weekly incontinence, 23% stress-type incontinence, 23% urgency-type incontinence, and 35% nocturia. Exposure to emotional IPV was associated with any weekly incontinence (odds ratio [OR] 1.33, 95% CI 1.04-1.70), stress-type incontinence (OR 1.30, 95% CI 1.00-1.65), urgency-type incontinence (OR 1.30, 95% CI 1.00-1.70), and nocturia (OR 1.73, 95% CI 1.36-2.19). Physical IPV exposure was associated with nocturia (OR 1.35, 95% CI 1.04-1.77), but not incontinence. Sexual assault history was not associated with weekly incontinence of any type or nocturia. Symptoms of PTSD were associated with all urinary symptoms assessed, including any weekly incontinence (OR 1.46, 95% CI 1.15-1.85), stress-type incontinence (OR 1.70, 95% CI 1.32-2.20), urgency-type incontinence (OR 1.60, 95% CI 1.24-2.06), and nocturia (OR 1.95, 95% CI 1.55-2.45).More than 20% of women in this multiethnic, community-based cohort reported a history of IPV, PTSD symptoms, or both, which were associated with symptomatic urinary tract dysfunction. Findings highlight the need to provide trauma-informed care of midlife and older women presenting with urinary symptoms.

    View details for DOI 10.1097/AOG.0000000000003586

    View details for PubMedID 31809425

  • Associations of Intimate Partner Violence, Sexual Assault, and Posttraumatic Stress Disorder With Menopause Symptoms Among Midlife and Older Women JAMA INTERNAL MEDICINE Gibson, C. J., Huang, A. J., McCaw, B., Subak, L. L., Thom, D. H., Van den Eeden, S. K. 2019; 179 (1): 80–87
  • Associations of Intimate Partner Violence, Sexual Assault, and Posttraumatic Stress Disorder With Menopause Symptoms Among Midlife and Older Women. JAMA internal medicine Gibson, C. J., Huang, A. J., McCaw, B., Subak, L. L., Thom, D. H., Van Den Eeden, S. K. 2018


    Importance: Little is known about the prevalence of traumatic exposures among midlife and older women and the association of these traumatic exposures with health issues.Objective: To examine the associations of intimate partner violence (IPV), sexual assault, and posttraumatic stress with menopause symptoms among midlife and older women.Design, Setting, and Participants: A cross-sectional analysis of data from a multiethnic cohort of 2016 women 40 to 80 years of age in the Kaiser Permanente Northern California health care system was conducted from November 15, 2008, to March 30, 2012. Statistical analysis was conducted from June 8, 2016, to September 6, 2017.Exposures: Lifetime physical or emotional IPV, sexual assault, and current symptoms of posttraumatic stress disorder, assessed with standardized questionnaires.Main Outcomes and Measures: Difficulty sleeping, vasomotor symptoms, and vaginal symptoms, assessed with standardized questionnaires.Results: Among the 2016 women enrolled, the mean (SD) age was 60.5 (9.5) years, and 792 of 2011 with race/ethnicity data (39.4)% were non-Latina white (403 [20.0%] Latina, 429 [21.3%] black, and 387 [19.2%] Asian). Lifetime emotional IPV was reported by 423 women (21.0%), lifetime physical IPV was reported by 316 women (15.7%), sexual assault was reported by 382 women (18.9%), and 450 of 2000 women (22.5%) had current clinically significant symptoms of posttraumatic stress disorder. In multivariable analyses adjusted for age, race/ethnicity, educational level, body mass index, menopause status, hormone therapy, and parity, symptoms of posttraumatic stress disorder were associated with difficulty sleeping (odds ratio [OR], 3.02; 95% CI, 2.22-4.09), vasomotor symptoms (hot flashes: OR, 1.69; 95% CI, 1.34-2.12; night sweats: OR, 1.72; 95% CI, 1.37-2.15), and vaginal symptoms (vaginal dryness: OR, 1.73; 95% CI, 1.37-2.18; vaginal irritation: OR, 2.20; 95% CI, 1.66-2.93; pain with intercourse: OR, 2.16; 95% CI, 1.57-2.98). Emotional IPV was associated with difficulty sleeping (OR, 1.36; 95% CI, 1.09-1.71), night sweats (OR, 1.50; 95% CI, 1.19-1.89), and pain with intercourse (OR, 1.60; 95% CI, 1.14-2.25). Physical IPV was associated with night sweats (OR, 1.33; 95% CI, 1.03-1.72). Sexual assault was associated with vaginal symptoms (vaginal dryness: OR, 1.41; 95% CI, 1.10-1.82; vaginal irritation: OR, 1.42; 95% CI, 1.04-1.95; pain with intercourse: OR 1.44; 95% CI, 1.00-2.06).Conclusions and Relevance: Lifetime history of IPV or sexual assault and current clinically significant symptoms of posttraumatic stress disorder are common and are associated with menopause symptoms. These findings highlight the need for greater recognition of these exposures by clinicians caring for midlife and older women.

    View details for PubMedID 30453319

  • Keeping Pace with the Expanding Role of Health Coaching. Journal of general internal medicine Thom, D. H. 2018

    View details for PubMedID 30406571

  • Randomized Controlled Trial of Health Coaching for Vulnerable Patients with Chronic Obstructive Pulmonary Disease. Annals of the American Thoracic Society Thom, D. H., Willard-Grace, R., Tsao, S., Hessler, D., Huang, B., DeVore, D., Chirinos, C., Wolf, J., Donesky, D., Garvey, C., Su, G. 2018; 15 (10): 1159-1168


    Socioeconomically disadvantaged patients with chronic obstructive pulmonary disease (COPD) often face barriers to evidence-based care that are difficult to address in public care settings with limited resources.To determine the benefit of health coaching for patients with moderate to severe COPD relative to usual care.We conducted a randomized controlled trial of 9 months of health coaching versus usual care for English- or Spanish-speaking patients at least 40 years of age with moderate to severe COPD. Primary outcomes were COPD-related quality of life and the dyspnea subscale of the Chronic Respiratory Disease Questionnaire. Secondary outcomes were self-efficacy for managing COPD, exercise capacity (6-min walk test), and number of COPD exacerbations. Additional outcomes were COPD symptoms, lung function (forced expiratory volume in 1 s percent predicted), smoking status, bed days owing to COPD, quality of care (Patient Assessment of Chronic Illness Care), COPD knowledge, and symptoms of depression (Patient Health Questionnaire). Outpatient visits, emergency department visits, and hospitalizations were assessed by review of medical records. Generalized linear modeling was used to adjust for baseline values and account for clustering by clinic.Of 192 patients enrolled, 158 (82%) completed 9 months of follow-up. There were no significant differences between study arms for the primary or secondary outcomes. At 9 months, patients in the coached group reported better quality of care (mean Patient Assessment of Chronic Illness Care score, 3.30 vs. 3.18; adjusted P = 0.02) and were less likely to report symptoms of moderate to severe depression (Patient Health Questionnaire score, ≥15) than those in the usual care arm (6% vs. 20%; adjusted P = 0.01). During the study, patients in the coaching arm had 48% fewer hospitalizations related to COPD (0.27/patient/yr vs. 0.52/patient/yr), but this difference was not significant in the adjusted analysis.These results help inform expectations regarding the limitations and benefits of health coaching for patients with COPD. They may be useful to health policy experts in assessing the potential value of reimbursement and incentives for health coaching-type activities for patients with chronic disease. Clinical trial registered with (NCT02234284).

    View details for DOI 10.1513/AnnalsATS.201806-365OC

    View details for PubMedID 30130430

  • Extension for Community Healthcare Outcomes (ECHO): a new model for community health worker training and support. Journal of public health policy Komaromy, M., Ceballos, V., Zurawski, A., Bodenheimer, T., Thom, D. H., Arora, S. 2018; 39 (2): 203-216


    More than 50,000 community health workers (CHWs) are employed in the United States (US), a country with no national accreditation or certification program. In the US, CHWs are trained, formally and/or on-the-job, and rarely is long-term mentoring included. We developed a CHW training program using the Extension for Community Healthcare Outcomes (ECHO) model™, distance education using video teleconferencing to support case-based learning, and mentoring of healthcare providers from medically underserved communities. We describe the ECHO model for CHW training and mentoring using case examples and pre/post-surveys from our obesity prevention and addiction recovery programs. Using the ECHO model to train and support CHWs offers advantages over traditional training methods, and can be adapted in other countries to support CHWs to improve health in their communities.

    View details for DOI 10.1057/s41271-017-0114-8

    View details for PubMedID 29263437

  • What do health coaches do? Direct observation of health coach activities during medical and patient-health coach visits at 3 federally qualified health centers. Patient education and counseling Johnson, C., Saba, G., Wolf, J., Gardner, H., Thom, D. H. 2018; 101 (5): 900-907


    To examine activities of health coaches during patient medical visits and when meeting one-on-one with patients at 3 urban federally qualified health centers.Encounters were videotaped and transcribed. Data was analyzed using a matrix analysis approach that allowed a priori identification of expected categories of activity, based on the health coach training model and previously developed conceptual framework, which were modified based on activities observed.A total of 10 medical visits (patient, clinician and health coach), and 8 patient-coach visits were recorded. We identified 9 categories common to both medical and patient-coach visits and 2 categories unique to the medical visit. While observed activities were generally consistent with expected categories, some activities were observed infrequently or not at all. We also observed additional activity categories, including information gathering and personal conversation. The average amount of time spent on some categories of coaching activities differed substantially between medical visits and patient-coach visits.Health coaching activities observed differed in several respects to those expected, and differed between medical visits and coaching only visits.These results provide insights into health coaching behaviors that can be used to inform training and improve utilization of health coaches in practice.

    View details for DOI 10.1016/j.pec.2017.11.017

    View details for PubMedID 29195719

  • Interpersonal Violence, Posttraumatic Stress Disorder, and Menopause-Related Sexual Dysfunction in an Ethnically-Diverse, Community-Based Sample of Women Gibson, C., Huang, A., McCaw, B., Shan, J., Subak, L., Thom, D., Van den Eeden, S. LIPPINCOTT WILLIAMS & WILKINS. 2017: 1433
  • Health coaching to improve self-management and quality of life for low income patients with chronic obstructive pulmonary disease (COPD): protocol for a randomized controlled trial. BMC pulmonary medicine Huang, B., Willard-Grace, R., De Vore, D., Wolf, J., Chirinos, C., Tsao, S., Hessler, D., Su, G., Thom, D. H. 2017; 17 (1): 90


    Chronic obstructive pulmonary disease (COPD) severely hinders quality of life for those affected and is costly to the health care system. Care gaps in areas such as pharmacotherapy, inhaler technique, and knowledge of disease are prevalent, particularly for vulnerable populations served by community clinics. Non-professionally licensed health coaches have been shown to be an effective and cost-efficient solution in bridging care gaps and facilitating self-management for patients with other chronic diseases, but no research to date has explored their efficacy in improving care for people living with COPD.This is multi-site, single blinded, randomized controlled trial evaluates the efficacy of health coaches to facilitate patient self-management of disease and improve quality of life for patients with moderate to severe COPD. Spirometry, survey, and an exercise capacity test are conducted at baseline and at 9 months. A short survey is administered by phone at 3 and 6 months post-enrollment. The nine month health coaching intervention focuses on enhancing disease understanding and symptom awareness, improving use of inhalers; making personalized plans to increase physical activity, smoking cessation, or otherwise improve disease management; and facilitating care coordination.The results of this study will provide evidence regarding the efficacy and feasibility of health coaching to improve self-management and quality of life for urban underserved patients with moderate to severe identifier NCT02234284 . Registered 12 August 2014.

    View details for DOI 10.1186/s12890-017-0433-3

    View details for PubMedID 28599636

    View details for PubMedCentralID PMC5466738

  • A Qualitative Study of How Health Coaches Support Patients in Making Health-Related Decisions and Behavioral Changes ANNALS OF FAMILY MEDICINE Thom, D. H., Wolf, J., Gardner, H., DeVore, D., Lin, M., Ma, A., Ibarra-Castro, A., Saba, G. 2016; 14 (6): 509–16


    Although health coaches are a growing resource for supporting patients in making health decisions, we know very little about the experience of health. We undertook a qualitative study of how health coaches support patients in making decisions and implementing changes to improve their health.We conducted 6 focus groups (3 in Spanish and 3 in English) with 25 patients and 5 friends or family members, followed by individual interviews with 42 patients, 17 family members, 17 health coaches, and 20 clinicians. Audio recordings were transcribed and analyzed by at least 2 members of the study team in ATLAS.ti using principles of grounded theory to identify themes and the relationship between them.We identified 7 major themes that were related to each other in the final conceptual model. Similarities between health coaches and patients and the time health coaches spent with patients helped establish the health coach-patient relationship. The coach-patient relationship allowed for, and was further strengthened by, 4 themes of key coaching activities: education, personal support, practical support, and acting as a bridge between patients and clinicians.We identified a conceptual model that supports the development of a strong relationship, which in turn provides the basis for effective coaching. These results can be used to design health coach training curricula and to support health coaches in practice.

    View details for DOI 10.1370/afm.1988

    View details for Web of Science ID 000392297400005

    View details for PubMedID 28376437

    View details for PubMedCentralID PMC5389392

  • Can lay health workers achieve the triple aim? Results from the Engagement of Patients with Advanced Cancer (EPAC) trial Patel, M. I., Periyakoil, V., Bundorf, K., Thom, D., Milstein, A., Asch, S. M., Kahn, J. AMER SOC CLINICAL ONCOLOGY. 2016
  • What Happens After Health Coaching? Observational Study 1 Year Following a Randomized Controlled Trial. Annals of family medicine Sharma, A. E., Willard-Grace, R., Hessler, D., Bodenheimer, T., Thom, D. H. 2016; 14 (3): 200-7


    Health coaching is effective for chronic disease self-management in the primary care safety-net setting, but little is known about the persistence of its benefits. We conducted an observational study evaluating the maintenance of improved cardiovascular risk factors following a health coaching intervention.We performed a naturalistic follow-up to the Health Coaching in Primary Care Study, a 12-month randomized controlled trial (RCT) comparing health coaching to usual care for patients with uncontrolled diabetes, hypertension, or hyperlipidemia. Participants were followed up 24 months from RCT baseline. The primary outcome was the proportion at goal for at least 1 measure (hemoglobin A1c, systolic blood pressure, or LDL cholesterol) that had been above goal at enrollment; secondary outcomes included each individual clinical goal. Chi-square tests and paired t-tests compared dichotomous and continuous measures.290 of 441 participants (65.8%) participated at both 12 and 24 months. The proportion of patients in the coaching arm of the RCT who achieved the primary outcome dropped only slightly from 47.1% at 12 to 45.9% at 24 months (P = .80). The proportion at goal for hemoglobin A1c dropped from 53.4% to 36.2% (P = .03). All other clinical metrics had small, nonsignificant changes between 12 and 24 months.Results support the conclusion that most improved clinical outcomes persisted 1 year after the completion of the health coaching intervention.

    View details for DOI 10.1370/afm.1924

    View details for PubMedID 27184989

    View details for PubMedCentralID PMC4868557

  • Costs for a Health Coaching Intervention for Chronic Care Management AMERICAN JOURNAL OF MANAGED CARE Wagner, T. H., Willard-Grace, R., Chen, E., Bodenheimer, T., Thom, D. H. 2016; 22 (4): E141-E146


    Health coaches can help patients gain knowledge, skills, and confidence to manage their chronic conditions. Coaches may be particularly valuable in resource-poor settings, but they are not typically reimbursed by insurance, raising questions about their budgetary impact.The Health Coaching in Primary Care (HCPC) study was a randomized controlled trial that showed health coaches were effective at helping low-income patients improve control of their type 2 diabetes, hypertension, and/or hyperlipidemia at 12 months compared with usual care.We estimated the cost of employing 3 health coaches and mapped these costs to participants. We tested whether the added costs of the coaches were offset by any savings in healthcare utilization within 1 year. Healthcare utilization data were obtained from 5 sources. Multivariate models assessed differences in costs at 1 year controlling for baseline characteristics.Coaches worked an average of 9 hours with each participant over the length of the study. On average, the health coach intervention cost $483 per participant per year. The average healthcare costs for the coaching group was $3207 compared with $3276 for the control group (P = .90). There was no evidence that the coaching intervention saved money at 1 year.Health coaches have been shown to improve clinical outcomes related to chronic disease management. We found that employing health coaches adds an additional cost of $483 per patient per year. The data do not suggest that health coaches pay for themselves by reducing healthcare utilization in the first year.

    View details for Web of Science ID 000375069400004

    View details for PubMedID 27143350

  • Bridging the gap: determinants of undiagnosed or untreated urinary incontinence in women AMERICAN JOURNAL OF OBSTETRICS AND GYNECOLOGY Duralde, E. R., Walter, L. C., Van den Eeden, S. K., Nakagawa, S., Subak, L. L., Brown, J. S., Thom, D. H., Huang, A. J. 2016; 214 (2): 266.e1–266.e9


    More than a third of middle-aged or older women suffer from urinary incontinence, but less than half undergo evaluation or treatment for this burdensome condition. With national organizations now including an assessment of incontinence as a quality performance measure, providers and health care organizations have a growing incentive to identify and engage these women who are undiagnosed and untreated.We sought to identify clinical and sociodemographic determinants of patient-provider discussion and treatment of incontinence among ethnically diverse, community-dwelling women.We conducted an observational cohort study from 2003 through 2012 of 969 women aged 40 years and older enrolled in a Northern California integrated health care delivery system who reported at least weekly incontinence. Clinical severity, type, treatment, and discussion of incontinence were assessed by structured questionnaires. Multivariable regression evaluated predictors of discussion and treatment.Mean age of the 969 participants was 59.9 (±9.7) years, and 55% were racial/ethnic minorities (171 black, 233 Latina, 133 Asian or Native American). Fifty-five percent reported discussing their incontinence with a health care provider, 36% within 1 year of symptom onset, and with only 3% indicating that their provider initiated the discussion. More than half (52%) reported being at least moderately bothered by their incontinence. Of these women, 324 (65%) discussed their incontinence with a clinician, with 200 (40%) doing so within 1 year of symptom onset. In a multivariable analysis, women were less likely to have discussed their incontinence if they had a household income < $30,000/y vs ≥ $120,000/y (adjusted odds ratio [AOR], 0.49, 95% confidence interval [CI], 0.28-0.86) or were diabetic (AOR, 0.71, 95% CI, 0.51-0.99). They were more likely to have discussed incontinence if they had clinically severe incontinence (AOR, 3.09, 95% CI, 1.89-5.07), depression (AOR, 1.71, 95% CI, 1.20-2.44), pelvic organ prolapse (AOR, 1.98, 95% CI, 1.13-3.46), or arthritis (AOR, 1.44, 95% CI, 1.06-1.95). Among the subset of women reporting at least moderate subjective bother from incontinence, black race (AOR, 0.45, 95% CI, 0.25-0.81, vs white race) and income < $30,000/y (AOR, 0.37, 95% CI, 0.17-0.81, vs ≥ $120,000/y) were associated with a reduced likelihood of discussing incontinence. Those with clinically severe incontinence (AOR, 2.93, 95% CI, 1.53-5.61, vs low to moderate incontinence by the Sandvik scale) were more likely to discuss it with a clinician.Even in an integrated health care system, lower income was associated with decreased rates of patient-provider discussion of incontinence among women with at least weekly incontinence. Despite being at increased risk of incontinence, diabetic women were also less likely to have discussed incontinence or received care. Findings provide support for systematic screening of women to overcome barriers to evaluation and treatment.

    View details for DOI 10.1016/j.ajog.2015.08.072

    View details for Web of Science ID 000369518200019

    View details for PubMedID 26348382

    View details for PubMedCentralID PMC4830485

  • Health coaching by medical assistants improves patients' chronic care experience. The American journal of managed care Thom, D. H., Hessler, D., Willard-Grace, R., DeVore, D., Prado, C., Bodenheimer, T., Chen, E. H. 2015; 21 (10): 685-91


    We sought to test the hypothesis that training medical assistants to provide health coaching would improve patients' experience of care received and overall satisfaction with their clinic.Randomized controlled trial.Low-income English- or Spanish-speaking patients aged 18 to 75 years with poorly controlled type 2 diabetes, hypertension, and/or hyperlipidemia were randomized to receive either a health coach or usual care for 12 months. Patient care experience was measured using the Patient Assessment of Chronic Illness Care (PACIC) scale at baseline and at 12 months. Patient overall satisfaction with the clinic was assessed with a single item asking if they would recommend the clinic to a friend or family member. PACIC and satisfaction scores were compared between study arms using generalized estimating equations to account for clustering at the clinician level.PACIC scores were available from baseline and at 12 months on 366 (76%) of the 441 patients randomized. At baseline, patients receiving health coaching were similar to those in the usual care group with respect to demographic and other characteristics, including mean PACIC scores (3.00 vs 3.06) and the percent who would "definitely recommend" their clinic (73% and 73%, respectively). At 12 months, coached patients had a significantly higher mean PACIC score (3.82 vs 3.13; P < .001) and were more likely to report they would definitely recommend their clinic (85% vs 73%; P = .002).Using medical assistants trained in health coaching significantly improved the quality of care that low-income patients with poorly controlled chronic disease reported receiving from their healthcare team.

    View details for PubMedID 26633093

  • Clinician perspectives on working with health coaches: A mixed methods approach. Families, systems & health : the journal of collaborative family healthcare Dubé, K., Willard-Grace, R., O'Connell, B., DeVore, D., Prado, C., Bodenheimer, T., Hessler, D., Thom, D. H. 2015; 33 (3): 213-21


    We sought to understand how health coaches affect the work of primary care clinicians and influence their perception of patient care. As a mixed methods hypothesis-generating study, we administered a structured post-visit survey and conducted in-depth individual interviews with primary care clinicians who worked with health coaches at two urban community health centers. Survey responses were compared using t tests. Interviews were transcribed and analyzed using Atlas.ti software and modified grounded theory. Surveys were completed by 15 of 17 clinicians for 61% of eligible patient visits (269/441). Compared to usual care patients, clinicians rated visits with health-coached patients as less demanding (2.44 vs. 3.06, p < .001) and were more likely to feel that they had adequate time with their patient (3.96 vs. 3.57, p < .001). Qualitative findings expanded upon these results and uncovered four key health coach activities thought to improve patient care. Through developing a rapport with patients over time and working with patients between medical visits, health coaches (a) empower patients by offering self-management support, (b) bridge communication gaps between clinicians and patients, (c) assist patients in navigating the health care system, and (d) act as a point of contact for patients.

    View details for DOI 10.1037/fsh0000110

    View details for PubMedID 25751177

  • Are Low-Income Peer Health Coaches Able to Master and Utilize Evidence-Based Health Coaching? Annals of family medicine Goldman, M. L., Ghorob, A., Hessler, D., Yamamoto, R., Thom, D. H., Bodenheimer, T. 2015; 13 Suppl 1: S36-41


    A randomized controlled trial found that patients with diabetes had lower HbA1c levels after 6 months of peer health coaching than patients who did not receive coaching. This paper explores whether the peer coaches in that trial, all low-income patients with diabetes, mastered and utilized an evidence-based health coaching training curriculum. The curriculum included 5 core features: ask-tell-ask, closing the loop, know your numbers, behavior-change action plans, and medication adherence counseling.This paper includes the results of exams administered to trainees, exit surveys performed with peer coaches who completed the study and those who dropped out, observations of peer coaches meeting with patients, and analysis of in-depth interviews with peer coaches who completed the study.Of the 32 peer coach trainees who completed the training, 71.9% lacked a college degree; 25.0% did not graduate from high school. The 26 trainees who passed the exams attended 92.7% of training sessions compared with 80.6% for the 6 trainees who did not pass. Peer coaches who completed the study wanted to continue peer coaching work and had confidence in their abilities despite their not consistently employing the coaching techniques with their patients. Quotations describe coaches' perceptions of the training.Of low-income patients with diabetes who completed the evidenced-based health coaching training, 81% passed written and oral exams and became effective peer health coaches, although they did not consistently use the techniques taught.

    View details for DOI 10.1370/afm.1756

    View details for PubMedID 26304970

    View details for PubMedCentralID PMC4648140

  • Health coaching by medical assistants to improve control of diabetes, hypertension, and hyperlipidemia in low-income patients: a randomized controlled trial. Annals of family medicine Willard-Grace, R., Chen, E. H., Hessler, D., DeVore, D., Prado, C., Bodenheimer, T., Thom, D. H. 2015; 13 (2): 130-8


    Health coaching by medical assistants could be a financially viable model for providing self-management support in primary care if its effectiveness were demonstrated. We investigated whether in-clinic health coaching by medical assistants improves control of cardiovascular and metabolic risk factors when compared with usual care.We conducted a 12-month randomized controlled trial of 441 patients at 2 safety net primary care clinics in San Francisco, California. The primary outcome was a composite measure of being at or below goal at 12 months for at least 1 of 3 uncontrolled conditions at baseline as defined by hemoglobin A1c, systolic blood pressure, and low-density lipoprotein (LDL) cholesterol. Secondary outcomes were meeting all 3 goals and meeting individual goals. Data were analyzed using χ(2) tests and linear regression models.Participants in the coaching arm were more likely to achieve both the primary composite measure of 1 of the clinical goals (46.4% vs 34.3%, P = .02) and the secondary composite measure of reaching all clinical goals (34.0% vs 24.7%, P = .05). Almost twice as many coached patients achieved the hemoglobin A1c goal (48.6% vs 27.6%, P = .01). At the larger study site, coached patients were more likely to achieve the LDL cholesterol goal (41.8% vs 25.4%, P = .04). The proportion of patients meeting the systolic blood pressure goal did not differ significantly.Medical assistants serving as in-clinic health coaches improved control of hemoglobin A1c and LDL levels, but not blood pressure, compared with usual care. Our results highlight the need to understand the relationship between patients' clinical conditions, interventions, and the contextual features of implementation.

    View details for DOI 10.1370/afm.1768

    View details for PubMedID 25755034

    View details for PubMedCentralID PMC4369595

  • Day-to-Day Impact of Vaginal Aging questionnaire: a multidimensional measure of the impact of vaginal symptoms on functioning and well-being in postmenopausal women. Menopause (New York, N.Y.) Huang, A. J., Gregorich, S. E., Kuppermann, M., Nakagawa, S., Van Den Eeden, S. K., Brown, J. S., Richter, H. E., Walter, L. C., Thom, D., Stewart, A. L. 2015; 22 (2): 144-54


    This study aims to develop a self-report questionnaire assessing the impact of vaginal dryness, soreness, itching, irritation, and pain on functioning and well-being in postmenopausal women.Structured self-report items were developed to address the impact of vaginal symptoms on functioning and well-being based on findings from focus groups with racially/ethnically diverse, symptomatic postmenopausal women. Items were refined after cognitive interview pretesting and field-tested among symptomatic postmenopausal women enrolled in a multiethnic cohort study in California. Exploratory factor analysis (SAS PROC VARCLUS) and confirmatory factor analysis evaluated factor structure and eliminated poorly fitting items. Additional evidence of construct validity was obtained via examination of correlations with other measures of related constructs. Internal consistency and test-retest reliability were assessed using Cronbach α and correlation coefficients, respectively.For the 745 postmenopausal women who completed the draft questionnaire, the mean (SD) age was 56.2 (8.5) years, and 66% of the respondents were racial/ethnic minorities. The refined questionnaire included four multi-item scales addressing symptom impact on (1) activities of daily living, (2) emotional well-being, (3) sexual functioning, and (4) self-concept and body image. The four-factor model provided good approximate fit (comparative fit index, 0.987; standardized root-mean-square residual, 0.038). Correlations with other measures of symptom bothersomeness, sexual function, depression, and anxiety conformed to hypotheses. Cronbach α values ranged from 0.82 to 0.93. Intraclass coefficients ranged from 0.47 to 0.72.The Day-to-Day Impact of Vaginal Aging questionnaire is a new multidimensional self-report measure designed to facilitate evaluation of the impact of vaginal symptoms on postmenopausal women of diverse backgrounds.

    View details for DOI 10.1097/GME.0000000000000281

    View details for PubMedID 24983271

    View details for PubMedCentralID PMC4280352

  • The impact of health coaching on medication adherence in patients with poorly controlled diabetes, hypertension, and/or hyperlipidemia: a randomized controlled trial. Journal of the American Board of Family Medicine : JABFM Thom, D. H., Willard-Grace, R., Hessler, D., DeVore, D., Prado, C., Bodenheimer, T., Chen, E. 2015; 28 (1): 38-45


    Lack of concordance between medications listed in the medical record and taken by the patient contributes to poor outcomes. We sought to determine whether patients who received health coaching by medical assistants improved their medication concordance and adherence.This was a nonblinded, randomized, controlled, pragmatic intervention trial. English- or Spanish-speaking patients, age 18 to 75 years, with poorly controlled type 2 diabetes, hypertension, and/or hyperlipidemia were enrolled from 2 urban safety net clinics and randomized to receive 12 months of health coaching versus usual care.Outcomes included concordance between medications documented in the medical record and those reported by the patient and adherence based on the patient-reported number of days (of the last 7) on which patient took all prescribed medications. The proportion of medications completely concordant increased in the coached group versus the usual care group (difference in change, 10%; P = .05). The proportion of medications listed in the chart but not taken significantly decreased in the coached group compared with the usual care group (difference in change, 17%; P = .013). The mean number of adherent days increased in the coached but not in the usual care group (difference in change, 1.08; P < .001).Health coaching by medical assistants significantly increases medication concordance and adherence.

    View details for DOI 10.3122/jabfm.2015.01.140123

    View details for PubMedID 25567821

  • The burden of nocturia among middle-aged and older women. Obstetrics and gynecology Hsu, A., Nakagawa, S., Walter, L. C., Van Den Eeden, S. K., Brown, J. S., Thom, D. H., Lee, S. J., Huang, A. J. 2015; 125 (1): 35-43


    To examine the prevalence, predictors, and effects of nocturia in women and evaluate overlaps with established urinary tract disorders.This was a cross-sectional analysis of 2,016 women, aged 40 years and older, recruited from Kaiser Permanente Northern California from 2008 to 2012. Nocturia and other urinary symptoms were assessed using structured interviewer-administered questionnaires. Nocturia was defined as patient-reported nocturnal voiding of two or more times per night over a typical week.Thirty-four percent (n=692) reported nocturia, and 40% of women with nocturia reported no other urinary tract symptom. Women with nocturia were older (mean age 58 compared with 55 years) (odds ratio [OR] per 5-year increase 1.21, 95% confidence interval [CI] 1.12-1.31), more likely black (45%) (OR 1.75, 95% CI 1.30-2.35) or Latina (37%) (OR 1.36, 95% CI 1.02-1.83) compared with non-Latina white (30%), have worse depression (mean Hospital Anxiety and Depression Scale score 3.8 compared with 2.8) (OR per 1-point increase in Hospital Anxiety and Depression Scale score 1.08, 95% CI 1.04-1.12), and worse mobility (mean Timed Up-and-Go 11.3 compared with 10 seconds) (OR per 5-second increase in Timed Up-and-Go 1.29, 95% CI 1.05-1.58). Nocturia occurred more among women with hysterectomy (53% compared with 33%) (OR 1.78, 95% CI 1.08-2.94), hot flushes (38% compared with 32%) (OR 1.49, 95% CI 1.19-1.87), and vaginal estrogen use (42% compared with 34%) (OR 1.50, 95% CI 1.04-2.18).Nocturia is common in women and not necessarily attributable to other urinary tract disorders. Factors not linked to bladder function may contribute to nocturia risk, underlining the need for multiorgan prevention and treatment strategies.II.

    View details for DOI 10.1097/AOG.0000000000000600

    View details for PubMedID 25560101

    View details for PubMedCentralID PMC4286307

  • The Impact of Multimorbidity on Sexual Function in Middle-Aged and Older Women: Beyond the Single Disease Perspective JOURNAL OF SEXUAL MEDICINE Appa, A. A., Creasman, J., Brown, J. S., Van den Eeden, S. K., Thom, D. H., Subak, L. L., Huang, A. J. 2014; 11 (11): 2744–55


    Little is known about sexual activity and function in women with multiple chronic health conditions.To examine the impact of multimorbidity on sexual activity and function in middle-aged and older women.Multiethnic cross-sectional cohort of 1,997 community-dwelling women (mean age of 60.2 [±9.5] years) in California. Structured questionnaires assessed prior diagnoses of common cardiometabolic, colorectal, neuropsychiatric, respiratory, musculoskeletal, and genitourinary conditions.Sexual desire, frequency of sexual activity, overall sexual satisfaction, and specific sexual problems (i.e., difficulty with arousal, lubrication, orgasm, and pain) were assessed by structured questionnaires.Seventy-one percent of women had two or more diagnosed chronic conditions. Fifty-nine percent reported low sexual desire, 53% reported less than monthly sexual activity, and 47% reported low overall sexual satisfaction. Multimorbidity was associated with increased odds of reporting low sexual desire (OR = 1.11, 95% CI = 1.06-1.17, per each additional chronic condition), less than monthly sexual activity (OR = 1.11, 95% CI = 1.05-1.17 per each additional condition), and low sexual satisfaction (OR = 1.10, 95% CI = 1.04-1.16 per each additional condition), adjusting for age, race/ethnicity, and partner status. Depression and urinary incontinence were each independently associated with low desire (OR = 1.53, 95% CI = 1.19-1.97, and OR = 1.23, 95% CI = 1.00-1.52, respectively), less than monthly sexual activity (OR = 1.39, 95% CI = 1.06-1.83, and OR = 1.29, 95% CI = 1.02-1.62, respectively), and low sexual satisfaction (OR = 1.49, 95% CI = 1.14-1.93, and OR = 1.38, 95% CI = 1.11-1.73, respectively), adjusting for other types of conditions. After adjustment for total number of chronic conditions, age remained a significant predictor of low desire and less than monthly sexual activity, but not sexual satisfaction.Women with multiple chronic health conditions are at increased risk for decreased sexual function. Depression and incontinence may have particularly strong effects on sexual desire, frequency of activity, and satisfaction in women, independent of other comorbid conditions. Women's overall sexual satisfaction may be more strongly influenced by multimorbidity than age.

    View details for DOI 10.1111/jsm.12665

    View details for Web of Science ID 000344473800013

    View details for PubMedID 25146458

    View details for PubMedCentralID PMC4309673

  • Does health coaching change patients' trust in their primary care provider? Patient education and counseling Thom, D. H., Hessler, D., Willard-Grace, R., Bodenheimer, T., Najmabadi, A., Araujo, C., Chen, E. H. 2014; 96 (1): 135-8


    To assess the impact of health coaching on patients' in their primary care provider.Randomized controlled trial comparing health coaching with usual care.Low-income English or Spanish speaking patients age 18-75 with poorly controlled type 2 diabetes, hypertension and/or hyperlipidemia.Patient trust in their primary care provider measured by the 11-item Trust in Physician Scale, converted to a 0-100 scale.Linear mixed modeling.A total of 441 patients were randomized to receive 12 months of health coaching (n=224) vs. usual care (n=217). At baseline, the two groups were similar to those in the usual care group with respect to demographic characteristics and levels of trust in their provider. After 12 months, the mean trust level had increased more in patients receiving health coaching (3.9 vs. 1.5, p=0.47), this difference remained significant after adjustment for number of visits to primary care providers (adjusted p=.03).Health coaching appears to increase patients trust in their primary care providers.Primary care providers should consider adding health coaches to their team as a way to enhance their relationship with their patients.

    View details for DOI 10.1016/j.pec.2014.03.018

    View details for PubMedID 24776175

  • Diabetes peer coaching: do "better patients" make better coaches? The Diabetes educator Rogers, E. A., Hessler, D. M., Bodenheimer, T. S., Ghorob, A., Vittinghoff, E., Thom, D. H. 2013; 40 (1): 107-15


    The purpose of this study was to identify characteristics of peer coaches associated with improvement in diabetes control among low-income patients with type 2 diabetes.Low-income patients with type 2 diabetes who spoke English or Spanish from 6 urban clinics in San Francisco, California, were invited to participate in the study. Twenty participants received training and provided peer coaching to 109 patients over a 6-month peer coaching intervention. Primary outcome was average change in patient glycosylated hemoglobin (A1C). Characteristics of peer coaches included age, gender, years with diabetes, A1C, body mass index (BMI), levels of diabetes-related distress, self-efficacy in diabetes self-management, and depression.Patient improvement in A1C was associated with having a coach with a lower sense of self-efficacy in diabetes management (P < .001), higher level of diabetes-related distress (P = .01), and lower depression score (P = .03).Coach characteristics are associated with patient success in improving A1C. "Better" levels of coach diabetes self-efficacy and distress were not helpful and, in fact, were associated with less improvement in patient A1C, suggesting that some coach uncertainty about his or her own diabetes might foster improved patient self-management. These coach characteristics should be considered when recruiting peer coaches.

    View details for DOI 10.1177/0145721713513178

    View details for PubMedID 24258250

  • Childbirth and Female Sexual Function Later in Life OBSTETRICS AND GYNECOLOGY Fehniger, J. E., Brown, J. S., Creasman, J. M., Van Den Eeden, S. K., Thom, D. H., Subak, L. L., Huang, A. J. 2013; 122 (5): 988–97


    To examine relationships among parity, mode of delivery, and other parturition-related factors with women's sexual function later in life.Self-administered questionnaires examined sexual desire, activity, satisfaction, and problems in a multiethnic cohort of women aged 40 years and older with at least one past childbirth event. Trained abstractors obtained information on parity, mode of delivery, and other parturition-related factors from archived records. Multivariable regression models examined associations with sexual function controlling for age, race or ethnicity, partner status, diabetes, and general health.Among 1,094 participants, mean (standard deviation) age was 56.3 (±8.7) years, 568 (43%) were racial or ethnic minorities (214 African American, 171 Asian, and 183 Latina), and 963 (88%) were multiparous. Fifty-six percent (n=601) reported low sexual desire; 53% (n=577) reported less than monthly sexual activity, and 43% (n=399) reported low overall sexual satisfaction. Greater parity was not associated with increased risk of reporting low sexual desire (adjusted odds ratio [OR] 1.08, confidence interval [CI] 0.96-1.21 per each birth), less than monthly sexual activity (adjusted OR 1.05, CI 0.93-1.20 per each birth), or low sexual satisfaction (adjusted OR 0.96, CI 0.85-1.09 per each birth). Compared with vaginal delivery alone, women with a history of cesarean delivery were not significantly more likely to report low desire (adjusted OR 0.71, CI 0.34-1.47), less than monthly sexual activity (adjusted OR 1.03, CI 0.46-2.32), or low sexual satisfaction (adjusted OR 0.57, CI 0.26-1.22). Women with a history of operative-assisted delivery were more likely to report low desire (adjusted OR 1.38, CI 1.04-1.83).Among women with at least one childbirth event, parity and mode of delivery are not major determinants of sexual desire, activity, or satisfaction later in life.II.

    View details for DOI 10.1097/AOG.0b013e3182a7f3fc

    View details for Web of Science ID 000330448500010

    View details for PubMedID 24104776

    View details for PubMedCentralID PMC3813451

  • Clinical predictors and significance of postvoid residual volume in women with diabetes. Diabetes research and clinical practice Appa, A. A., Brown, J. S., Creasman, J., Van Den Eeden, S. K., Subak, L. L., Thom, D. H., Ferrara, A., Huang, A. J. 2013; 101 (2): 164-9


    To identify women with diabetes at risk of increased postvoid residual volume (PVR) and investigate the relationship of increased PVR to urinary symptoms in women with diabetes.PVR was measured by bladder ultrasonography in a cross-sectional cohort of 427 middle-aged and older women with diabetes. Participants completed questionnaires assessing urgency incontinence, stress incontinence, daytime frequency, nocturia, obstructive voiding, and diabetes-related end-organ complications: heart disease, stroke, neuropathy. Serum HbA1c and creatinine were recorded.75% of participants had a PVR of 0-49, 13% had a PVR of 50-99, and 12% had a PVR ≥ 100 mL. Approximately 59% of women with a PVR < 50 mL reported at least one lower urinary tract symptom. Women with diabetes and a PVR ≥ 100 mL were more likely to report urgency incontinence (OR 2.18, CI 1.08-4.41) and obstructive voiding symptoms (OR 2.47, CI 1.18-5.17) than women with PVR < 50 mL. In multivariable models, poorer glycemic control was associated with an increased likelihood of PVR ≥ 100 mL (OR 1.30, CI 1.06-1.59 per 1.0-U increase in HbA1c).PVR volumes ≥ 100 mL may indicate increased risk of urgency incontinence and obstructive voiding. Glycemic control may play a role in preventing increased PVR in women with diabetes.

    View details for DOI 10.1016/j.diabres.2013.05.005

    View details for PubMedID 23773505

    View details for PubMedCentralID PMC3742560

  • Peer coaching to improve diabetes self-management: which patients benefit most? Journal of general internal medicine Moskowitz, D., Thom, D. H., Hessler, D., Ghorob, A., Bodenheimer, T. 2013; 28 (7): 938-42


    Peer health coaching is an effective method of enhancing self-management support in patients with diabetes. It is unclear whether peer health coaching is equally beneficial to all patients with poor glycemic control, or is most effective for subgroups of patients.To examine whether the effect of peer health coaching on hemoglobin A1c (A1c) is modified by characteristics that are known to be associated with diabetes control.Sub-group analyses of randomized control trial.Two hundred and ninety nine patients with diabetes receiving care in public health clinics who participated in a randomized controlled trial of peer health coaches.We examined whether the association between study group and change in A1c was modified by differences in patients' demographic, behavioral or psychosocial characteristics. Analyses were adjusted for co-variables associated with change in A1c.The effect of coaching on patient A1c was modified by patients' level of self-management and degree of medication adherence as baseline (p=.02, and p=.03 respectively in adjusted models). For participants with "low" self-management (one standard deviation below the mean score), the usual care group experienced a slight increase in A1c (0.3 %), while the health coaching group experienced a decrease (-0.9 %). For participants with "high" self-management (one standard deviation above the mean score), both groups experienced a similar decrease in A1c (usual care group: -1.0 %; health coaching group: -1.1 %). Participants with "low" medication adherence in the usual care group experienced an increase in A1c (0.5 %), while the health coaching group experienced a decrease (-0.8 %). Participants with "high" medication adherence experienced similar decreases (usual care group: -1.1 %; health coaching group: -1.3 %).Peer health coaching had a larger effect on lowering A1c in patients with low levels of medication adherence and self-management support than in patients with higher levels. Peer health coaching interventions may be most effective if targeted to high-risk patients with diabetes with poor glycemic control and with poor self-management and medication adherence.

    View details for DOI 10.1007/s11606-013-2367-7

    View details for PubMedID 23404203

    View details for PubMedCentralID PMC3682027

  • Impact of peer health coaching on glycemic control in low-income patients with diabetes: a randomized controlled trial. Annals of family medicine Thom, D. H., Ghorob, A., Hessler, D., De Vore, D., Chen, E., Bodenheimer, T. A. 2013; 11 (2): 137-44


    Peer health coaches offer a potential model for extending the capacity of primary care practices to provide self-management support for patients with diabetes. We conducted a randomized controlled trial to test whether clinic-based peer health coaching, compared with usual care, improves glycemic control for low-income patients who have poorly controlled diabetes.We undertook a randomized controlled trial enrolling patients from 6 public health clinics in San Francisco. Twenty-three patients with a glycated hemoglobin (HbA1C) level of less than 8.5%, who completed a 36-hour health coach training class, acted as peer coaches. Patients from the same clinics with HbA1C levels of 8.0% or more were recruited and randomized to receive health coaching (n = 148) or usual care (n = 151). The primary outcome was the difference in change in HbA1C levels at 6 months. Secondary outcomes were proportion of patients with a decrease in HbA1C level of 1.0% or more and proportion of patients with an HbA1C level of less than 7.5% at 6 months. Data were analyzed using a linear mixed model with and without adjustment for differences in baseline variables.At 6 months, HbA1C levels had decreased by 1.07% in the coached group and 0.3% in the usual care group, a difference of 0.77% in favor of coaching (P = .01, adjusted). HbA1C levels decreased 1.0% or more in 49.6% of coached patients vs 31.5% of usual care patients (P = .001, adjusted), and levels at 6 months were less than 7.5% for 22.0% of coached vs 14.9% of usual care patients (P = .04, adjusted).Peer health coaching significantly improved diabetes control in this group of low-income primary care patients.

    View details for DOI 10.1370/afm.1443

    View details for PubMedID 23508600

    View details for PubMedCentralID PMC3601392

  • The effectiveness of medical assistant health coaching for low-income patients with uncontrolled diabetes, hypertension, and hyperlipidemia: protocol for a randomized controlled trial and baseline characteristics of the study population. BMC family practice Willard-Grace, R., DeVore, D., Chen, E. H., Hessler, D., Bodenheimer, T., Thom, D. H. 2013; 14: 27


    Many patients with chronic disease do not reach goals for management of their conditions. Self-management support provided by medical assistant health coaches within the clinical setting may help to improve clinical outcomes, but most studies to date lack statistical power or methodological rigor. Barriers to large scale implementation of the medical assistant coach model include lack of clinician buy-in and the absence of a business model that will make medical assistant health coaching sustainable. This study will add to the evidence base by determining the effectiveness of health coaching by medical assistants on clinical outcomes and patient self-management, by assessing the impact of health coaching on the clinician experience, and by examining the costs and potential savings of health coaching.This randomized controlled trial will evaluate the effectiveness of clinic-based medical assistant health coaches to improve clinical outcomes and self-management skills among low-income patients with uncontrolled type 2 diabetes, hypertension, or hyperlipidemia. A total of 441 patients from two San Francisco primary care clinics have been enrolled and randomized to receive a health coach (n = 224) or usual care (n = 217). Patients participating in the health coaching group will receive coaching for 12 months from medical assistants trained as health coaches. The primary outcome is a change in hemoglobin A1c, systolic blood pressure, or LDL cholesterol among patients with uncontrolled diabetes, hypertension and hyperlipidemia, respectively. Self-management behaviors, perceptions of the health care team and clinician, BMI, and chronic disease self-efficacy will be measured at baseline and after 12 months. Clinician experience is being assessed through surveys and qualitative interviews. Cost and utilization data will be analyzed through cost-predictive models.Medical assistants are an untapped resource to provide self-management support for patients with uncontrolled chronic disease. Having successfully completed recruitment, this study is uniquely poised to assess the effectiveness of the medical assistant health coaching model, to describe barriers and facilitators to implementation, and to develop a business case for identifier NCT-01220336.

    View details for DOI 10.1186/1471-2296-14-27

    View details for PubMedID 23433349

    View details for PubMedCentralID PMC3616979

  • Fecal Incontinence Decreases Sexual Quality of Life, But Does Not Prevent Sexual Activity in Women DISEASES OF THE COLON & RECTUM Imhoff, L. R., Brown, J. S., Creasman, J. M., Subak, L. L., Van den Eeden, S. K., Thom, D. H., Varma, M. G., Huang, A. J. 2012; 55 (10): 1059–65


    The impact of anal incontinence on women's sexual function is poorly understood.The aim of this study was to investigate the relationship between anal incontinence and sexual activity and functioning in women.This is a cross-sectional study.This investigation was conducted in a community-based integrated health care delivery system.Included were 2269 ethnically diverse women aged 40 to 80 years.Self-administered questionnaires assessed accidental leakage of gas (flatal incontinence) and fluid/mucus/stool (fecal incontinence) in the past 3 months. Additional questionnaires assessed sexual activity, desire and satisfaction, as well as specific sexual problems (difficulty with arousal, lubrication, orgasm, or pain). Multivariable logistic regression models compared sexual function in women with 1) isolated flatal incontinence, 2) fecal incontinence (with or without flatal incontinence), and 3) no fecal/flatal incontinence, controlling for potential confounders.Twenty-four percent of women reported fecal incontinence and 43% reported isolated flatal incontinence in the previous 3 months. The majority were sexually active (62% of women without fecal/flatal incontinence, 66% with isolated flatal incontinence, and 60% with fecal incontinence; p = 0.06). In comparison with women without fecal/flatal incontinence, women with fecal incontinence were more likely to report low sexual desire (OR: 1.41 (CI: 1.10-1.82)), low sexual satisfaction (OR: 1.56 (CI: 1.14-2.12)), and limitation of sexual activity by physical health (OR: 1.65 (CI: 1.19-2.28)) after adjustment for confounders. Among sexually active women, women with fecal incontinence were more likely than women without fecal/flatal incontinence to report difficulties with lubrication (OR: 2.66 (CI: 1.76-4.00)), pain (OR: 2.44 (CI: 1.52-3.91)), and orgasm (OR: 1.68 (CI: 1.12-2.51)). Women with isolated flatal incontinence reported sexual functioning similar to women without fecal/flatal incontinence.The cross-sectional design prevented evaluation of causality.Although most women with fecal incontinence are at high risk for several aspects of sexual dysfunction, the presence of fecal incontinence does not prevent women from engaging in sexual activity. This indicates that sexual function is important to women with anal incontinence and should be prioritized during therapeutic management.

    View details for DOI 10.1097/DCR.0b013e318265795d

    View details for Web of Science ID 000308797600020

    View details for PubMedID 22965405

    View details for PubMedCentralID PMC3720983

  • Diabetes Mellitus and Sexual Function in Middle-Aged and Older Women OBSTETRICS AND GYNECOLOGY Copeland, K. L., Brown, J. S., Creasman, J. M., Van Den Eeden, S. K., Subak, L. L., Thom, D. H., Ferrara, A., Huang, A. J. 2012; 120 (2): 331–40


    Diabetes mellitus is an established risk factor for sexual dysfunction in men, but its effect on female sexual function is poorly understood. We examined the relationship of diabetes to sexual function in middle-aged and older women.Sexual function was examined in a cross-sectional cohort of ethnically diverse women aged 40-80 years using self-administered questionnaires. Multivariable regression models compared self-reported sexual desire, frequency of sexual activity, overall sexual satisfaction, and specific sexual problems (difficulty with lubrication, arousal, orgasm, or pain) among insulin-treated diabetic, non-insulin-treated diabetic, and nondiabetic women. Additional models assessed relationships between diabetic end-organ complications (heart disease, stroke, renal dysfunction, and peripheral neuropathy) and sexual function.Among the 2,270 participants, mean±standard deviation age was 55±9.2 years, 1,006 (44.4%) were non-Latina white, 486 (21.4%) had diabetes, and 139 (6.1%) were taking insulin. Compared with 19.3% of nondiabetic women, 34.9% of insulin-treated diabetic women (adjusted odds ratio [OR] 2.04, 95% confidence interval [CI] 1.32-3.15) and 26.0% of non-insulin-treated diabetic women (adjusted OR 1.42, 95% CI 1.03-1.94) reported low overall sexual satisfaction. Among sexually active women, insulin-treated diabetic women were more likely to report problems with lubrication (OR 2.37, 95% CI 1.35-4.16) and orgasm (OR 1.80, 95% CI 1.01-3.20) than nondiabetic women. Among all diabetic women, end-organ complications such as heart disease, stroke, renal dysfunction, and peripheral neuropathy were associated with decreased sexual function in at least one domain.Compared with nondiabetic women, diabetic women are more likely to report low overall sexual satisfaction. Insulin-treated diabetic women also appear at higher risk for problems such as difficulty with lubrication and orgasm. Prevention of end-organ complications may be important in preserving sexual activity and function in diabetic women.II.

    View details for DOI 10.1097/AOG.0b013e31825ec5fa

    View details for Web of Science ID 000306713100020

    View details for PubMedID 22825093

    View details for PubMedCentralID PMC3404429

  • Analysis of clerkship student-patient interviews in underserved clinics. Family medicine Shore, W. B., Muller, J., Thom, D., Mergendoller, J., Saba, G. W. 2012; 44 (7): 508-13


    Third-year family medicine clerkship students at our urban medical school are assigned to clinics in diverse settings, where they are required to video record one patient interview. Our research goals were to describe student communication behaviors and compare the frequency of these behaviors at clinics serving primarily uninsured patients to clinics with primarily insured patients.Eighty-seven student-patient recordings were reviewed and analyzed.Seventy-two percent of students performed general interviewing skills at an adequate or outstanding level; however, only a small number of students asked contextual questions about patients' use of social services (7%), barriers to care (6%), or patients' cultural/spiritual values and health concerns (13%), regardless of clinic type (underserved or insured). In visits with female patients, all students were more likely to show a personal interest in the patient (88% versus 71%). In visits where there was gender concordance between the patient and student, the students were more likely to face the patient (98% versus 73%).This study indicates that, even though third-year students may have adequate general interviewing skills, they may need additional training and practice in obtaining contextual information about patients in all clinical settings. These findings also suggest that the gender of the patient, as well as gender concordance between patient and student, play a role in student-patient interactions.

    View details for PubMedID 22791537

  • Health coaching to improve hypertension treatment in a low-income, minority population. Annals of family medicine Margolius, D., Bodenheimer, T., Bennett, H., Wong, J., Ngo, V., Padilla, G., Thom, D. H. 2012; 10 (3): 199-205


    Poor blood pressure control is common in the United States. We conducted a study to determine whether health coaching with home titration of antihypertensive medications can improve blood pressure control compared with health coaching alone in a low-income, predominantly minority population.We randomized 237 patients with poorly controlled hypertension at a primary care clinic to receive either home blood pressure monitoring, weekly health coaching, and home titration of blood pressure medications if blood pressures were elevated (n = 129) vs home blood pressure monitoring and health coaching but no home titration (n = 108). The primary outcome was change in systolic blood pressure from baseline to 6 months.Both the home-titration arm and the no-home-titration arm had a reduction in systolic blood pressure, with no significant difference between them. When both arms were combined and analyzed as a before-after study, there was a mean decrease in systolic blood pressure of 21.8 mm Hg (P <.001) as well as a decrease in the number of primary care visits from 3.5 in the 6 months before the study to 2.6 during the 6-month study period (P <.001) and 2.4 in the 6 months after the study (P <.001). The more coaching encounters patients had, the greater their reduction in blood pressure.Blood pressure control in a low-income, minority population can be improved by teaching patients to monitor their blood pressure at home and having nonprofessional health coaches assist patients, in particular, by counseling them on medication adherence. The improved blood pressure control can be achieved while reducing the time spent by physicians.

    View details for DOI 10.1370/afm.1369

    View details for PubMedID 22585883

    View details for PubMedCentralID PMC3354968

  • A Cross-Sectional Study of Barriers to Personal Health Record Use among Patients Attending a Safety-Net Clinic PLOS ONE Hilton, J. F., Barkoff, L., Chang, O., Halperin, L., Ratanawongsa, N., Sarkar, U., Leykin, Y., Munoz, R. F., Thom, D. H., Kahn, J. S. 2012; 7 (2)


    Personal health records (PHR) may improve patients' health by providing access to and context for health information. Among patients receiving care at a safety-net HIV/AIDS clinic, we examined the hypothesis that a mental health (MH) or substance use (SU) condition represents a barrier to engagement with web-based health information, as measured by consent to participate in a trial that provided access to personal (PHR) or general (non-PHR) health information portals and by completion of baseline study surveys posted there.Participants were individually trained to access and navigate individualized online accounts and to complete study surveys. In response to need, during accrual months 4 to 12 we enhanced participant training to encourage survey completion with the help of staff. Using logistic regression models, we estimated odds ratios for study participation and for survey completion by combined MH/SU status, adjusted for levels of computer competency, on-study training, and demographics.Among 2,871 clinic patients, 70% had MH/SU conditions, with depression (38%) and methamphetamine use (17%) most commonly documented. Middle-aged patients and those with a MH/SU condition were over-represented among study participants (N = 338). Survey completion was statistically independent of MH/SU status (OR, 1.85 [95% CI, 0.93-3.66]) but tended to be higher among those with MH/SU conditions. Completion rates were low among beginner computer users, regardless of training level (<50%), but adequate among advanced users (>70%).Among patients attending a safety-net clinic, MH/SU conditions were not barriers to engagement with web-based health information. Instead, level of computer competency was useful for identifying individuals requiring substantial computer training in order to fully participate in the study. Intensive on-study training was insufficient to enable beginner computer users to complete study surveys.

    View details for DOI 10.1371/journal.pone.0031888

    View details for Web of Science ID 000302871500097

    View details for PubMedID 22363761

    View details for PubMedCentralID PMC3282785

  • Urinary incontinence self-report questions: reproducibility and agreement with bladder diary. International urogynecology journal Bradley, C. S., Brown, J. S., Van Den Eeden, S. K., Schembri, M., Ragins, A., Thom, D. H. 2011; 22 (12): 1565-71


    This study aims to measure self-report urinary incontinence questions' reproducibility and agreement with bladder diary.Data were analyzed from the Reproductive Risk of Incontinence Study at Kaiser. Participating women reporting at least weekly incontinence completed self-report incontinence questions and a 7-day bladder diary. Self-report question reproducibility was assessed and agreement between self-reported and diary-recorded voiding and incontinence frequency was measured. Test characteristics and area under the curve were calculated for self-reported incontinence types using diary as the gold standard.Five hundred ninety-one women were included and 425 completed a diary. The self-report questions had moderate reproducibility and self-reported and diary-recorded incontinence and voiding frequencies had moderate to good agreement. Self-reported incontinence types identified stress and urgency incontinence more accurately than mixed incontinence.Self-report incontinence questions have moderate reproducibility and agreement with diary, and considering their minimal burden, are acceptable research tools in epidemiologic studies.

    View details for DOI 10.1007/s00192-011-1503-3

    View details for PubMedID 21796472

    View details for PubMedCentralID PMC3807739

  • Parturition events and risk of urinary incontinence in later life. Neurourology and urodynamics Thom, D. H., Brown, J. S., Schembri, M., Ragins, A. I., Creasman, J. M., Van Den Eeden, S. K. 2011; 30 (8): 1456-61


    To examine the association between specific events during vaginal deliveries and urinary incontinence later in life.A retrospective cohort study of 1,521 middle-aged and older women with at least one vaginal delivery who were long-term members of an integrated health delivery system. Age, race/ethnicity, current incontinence status, medical, surgical history, pregnancy and parturition history, menopausal status, hormone replacement, health habits, and general health were obtained by questionnaire. Labor and delivery records, archived since 1948, were abstracted by professional medical record abstractors to obtain parturition events including induction, length of labor stages, type of anesthesia, episiotomy, instrumental delivery, and birth weight. The primary dependent variable was current weekly urinary incontinence (once per week or more often) versus urinary incontinence less than monthly (including no incontinence) in past 12 months. Associations of parturition events and later incontinence were assessed in multivariate analysis with logistic regression.The mean age of participants was 56 years. After adjustment for multiple risk factors, weekly urinary incontinence significantly associated with age at first birth (P = 0.036), greatest birth weight (P = 0.005), and ever having been induced for labor (OR = 1.51; 95%CI = 1.06-2.16, P = 0.02). Risk of incontinence increased from OR = 1.35 (95%CI = 0.92-1.97, P = 0.12) for women with one induction to OR = 2.67 (95%CI = 1.25-5.71, P = 0.01) for women with two or more inductions (P = 0.01 for trend). No other parturition factors were associated with incontinence.Younger age at first birth, greatest birth weight, and induction of labor were associated with an increased risk of incontinence in later life.

    View details for DOI 10.1002/nau.21166

    View details for PubMedID 21780171

    View details for PubMedCentralID PMC3197896

  • Is primary care providers' trust in socially marginalized patients affected by race? Journal of general internal medicine Moskowitz, D., Thom, D. H., Guzman, D., Penko, J., Miaskowski, C., Kushel, M. 2011; 26 (8): 846-51


    Interpersonal trust plays an important role in the clinic visit. Clinician trust in the patient may be especially important when prescribing opioid analgesics because of concerns about misuse. Previous studies have found that non-white patients are perceived negatively by clinicians.To examine whether clinicians' trust in patients differed by patients' race/ethnicity in a socially marginalized cohort.Cross-sectional study of patient-clinician dyads.169 HIV infected indigent patients recruited from the community and their 61 primary care providers (PCPs.)The Physician Trust in Patients Scale (PTPS), a validated scale that measures PCPs' trust in patients.The mean PTPS score was 43.2 (SD 10.8) out of a possible 60. Reported current illicit drug use and prescription opioid misuse were similar across patients' race or ethnicity. However, both patient illicit drug use and patient non-white race/ethnicity were associated with lower PTPS scores. In a multivariate model, non-white race/ethnicity was independently associated with PTPS scores 6.3 points lower than whites (95% CI: -9.9, -2.7). Current illicit drug use was associated with PTSP scores 5.5 lower than no drug use (95% CI -8.5, -2.5).In a socially marginalized cohort, non-white patients were trusted less than white patients by their PCPs, despite similar rates of illicit drug use and opioid analgesic misuse. The effect was independent of illicit drug use. This finding may reflect unconscious stereotypes by PCPs and may underlie disparities in chronic pain management.

    View details for DOI 10.1007/s11606-011-1672-2

    View details for PubMedID 21394422

    View details for PubMedCentralID PMC3138986

  • The effectiveness of peer health coaching in improving glycemic control among low-income patients with diabetes: protocol for a randomized controlled trial. BMC public health Ghorob, A., Vivas, M. M., De Vore, D., Ngo, V., Bodenheimer, T., Chen, E., Thom, D. H. 2011; 11: 208


    Although self-management support improves diabetes outcomes, it is not consistently provided in health care settings strained for time and resources. One proposed solution to personnel and funding shortages is to utilize peer coaches, patients trained to provide diabetes education and support to other patients. Coaches share similar experiences about living with diabetes and are able to reach patients within and beyond the health care setting. Given the limited body of evidence that demonstrates peer coaching significantly improves chronic disease care, this present study examines the impact of peer coaching delivered in a primary care setting on diabetes outcomes.The aim of this multicenter, randomized control trial is to evaluate the effectiveness of utilizing peer coaches to improve clinical outcomes and self-management skills in low-income patients with poorly controlled diabetes. A total of 400 patients from six primary health centers based in San Francisco that serve primarily low-income populations will be randomized to receive peer coaching (n = 200) or usual care (n = 200) over 6 months. Patients in the peer coach group receive coaching from patients with diabetes who are trained and mentored as peer coaches. The primary outcome is change in HbA1c. Secondary outcomes include change in: systolic blood pressure, body mass index (BMI), LDL cholesterol, diabetes self-care activities, medication adherence, diabetes-related quality of life, diabetes self-efficacy, and depression. Clinical values (HbA1c, LDL cholesterol and blood pressure) and self-reported diabetes self-efficacy and self-care activities are measured at baseline and after 6 months for patients and coaches. Peer coaches are also assessed at 12 months.Patients with diabetes, who are trained as peer health coaches, are uniquely poised to provide diabetes self management support and education to patients. This study is designed to investigate the impact of peer health coaching in patients with poorly controlled diabetes. Additionally, we will assess disease outcomes in patients with well controlled diabetes who are trained and work as peer health identifier: NCT01040806.

    View details for DOI 10.1186/1471-2458-11-208

    View details for PubMedID 21457567

    View details for PubMedCentralID PMC3082244

  • Physician trust in the patient: development and validation of a new measure. Annals of family medicine Thom, D. H., Wong, S. T., Guzman, D., Wu, A., Penko, J., Miaskowski, C., Kushel, M. 2011; 9 (2): 148-54


    Mutual trust is an important aspect of the patient-physician relationship with positive consequences for both parties. Previous measures have been limited to patient trust in the physician. We set out to develop and validate a measure of physician trust in the patient.We identified candidate items for the scale by content analysis of a previous qualitative study of patient-physician trust and developed and validated a scale among 61 primary care clinicians (50 physicians and 11 nonphysicians) with respect to 168 patients as part of a community-based study of prescription opioid use for chronic, nonmalignant pain in HIV-positive adults. Polychoric factor structure analysis using the Pratt D matrix was used to reduce the number of items and describe the factor structure. Construct validity was tested by comparing mean clinician trust scores for patients by clinician and patient behaviors expected to be associated with clinician trust using a generalized linear mixed model.The final 12-item scale had high internal reliability (Cronbach α =.93) and a distinct 2-factor pattern with the Pratt matrix D. Construct validity was demonstrated with respect to clinician-reported self-behaviors including toxicology screening (P <.001), and refusal to prescribe opioids (P <.001) and with patient behaviors including reporting opioids lost or stolen (P=.008), taking opioids to get high (P <.001), and selling opioids (P<.001).If validated in other populations, this measure of physician trust in the patient will be useful in investigating the antecedents and consequences of mutual trust, and the relationship between mutual trust and processes of care, which can help improve the delivery of clinical care.

    View details for DOI 10.1370/afm.1224

    View details for PubMedID 21403142

    View details for PubMedCentralID PMC3056863

  • Incidence of and Risk Factors for Change in Urinary Incontinence Status in a Prospective Cohort of Middle-Aged and Older Women: The Reproductive Risk of Incontinence Study in Kaiser JOURNAL OF UROLOGY Thom, D. H., Brown, J. S., Schembri, M., Ragins, A. I., Subak, L. L., Van Den Eeden, S. K. 2010; 184 (4): 1394–1401


    Urinary incontinence is a dynamic condition that can progress and regress but few groups have examined risk factors for change in incontinence status.We used stratified random sampling to construct a racially and ethnically diverse, population based cohort of 2,109 women 40 to 69 years old. Data were collected by questionnaires and medical record review. A second survey approximately 5 years later was completed by 1,413 women (67%) from the original cohort. The frequency of urinary incontinence was categorized as less than weekly, weekly and daily. Change in incontinence status was defined as new onset incontinence, incontinence progression or regression between frequency categories and resolution of incontinence. Predictor variables were demographics, body mass index and other medical conditions. We used logistic regression to estimate the adjusted OR and 95% CI.Compared to white nonHispanic women, black women were less likely to have incontinence progression (OR 0.46, 95% CI 0.24-0.88). New onset incontinence was more common in women with a higher body mass index at baseline (p = 0.006) and those who experienced increased body mass index (p = 0.03) or decreased general health (p = 0.007) during the study. Participants with chronic obstructive pulmonary disorder at baseline were more likely to report incontinence progression (OR 2.64, 95% CI 1.22-5.70). Baseline incontinence type was not significantly associated with the risk of change in continence status independent of frequency.Identifying risk factors for change in incontinence status may be important to develop interventions to decrease the burden of incontinence in the general population.

    View details for DOI 10.1016/j.juro.2010.05.095

    View details for Web of Science ID 000282615400056

    View details for PubMedID 20727544

    View details for PubMedCentralID PMC2939171

  • Women With Diabetes: Understanding Urinary Incontinence and Help Seeking Behavior JOURNAL OF UROLOGY Doshi, A. M., Van Den Eeden, S. K., Morrill, M. Y., Schembri, M., Thom, D. H., Brown, J. S., Reproductive Risks Incontinence St 2010; 184 (4): 1402–7


    We examined the association of urinary incontinence with diabetes status and race, and evaluated beliefs about help seeking for incontinence in a population based cohort of women with vs without diabetes.We performed a cross-sectional analysis of 2,270 middle-aged and older racially/ethnically diverse women in the Diabetes Reproductive Risk factors for Incontinence Study at Kaiser. Incontinence, help seeking behavior and beliefs were assessed by self-report questionnaires and in-person interviews. We compared incontinence characteristics in women with and without diabetes using univariate analysis and multivariate models.Women with diabetes reported weekly incontinence significantly more than women without diabetes (weekly 35.4% vs 25.7%, p <0.001). Race prevalence patterns were similar in women with and without diabetes with the most vs the least prevalence of incontinence in white and Latina vs black and Asian women. Of women with diabetes 42.2% discussed incontinence with a physician vs 55.5% without diabetes (p <0.003). Women with diabetes were more likely than those without diabetes to report the belief that incontinence is rare (17% vs 6%, p <0.001).Incontinence is highly prevalent in women with diabetes. Race prevalence patterns are similar in those with and without diabetes. Understanding help seeking behavior is important to ensure appropriate patient care. Physicians should be alert for urinary incontinence since it is often unrecognized and, thus, under treated in women with diabetes.

    View details for DOI 10.1016/j.juro.2010.06.014

    View details for Web of Science ID 000282615400057

    View details for PubMedID 20727547

    View details for PubMedCentralID PMC2939193

  • Using the Teamlet Model to improve chronic care in an academic primary care practice. Journal of general internal medicine Chen, E. H., Thom, D. H., Hessler, D. M., Phengrasamy, L., Hammer, H., Saba, G., Bodenheimer, T. 2010; 25 Suppl 4: S610-4


    Team care can improve management of chronic conditions, but implementing a team approach in an academic primary care clinic presents unique challenges.To implement and evaluate the Teamlet Model, which uses health coaches working with primary care physicians to improve care for patients with diabetes and/or hypertension in an academic practice.Process and outcome measures were compared before and during the intervention in patients seen with the Teamlet Model and in a comparison patient group.First year family medicine residents, medical assistants, health workers, and adult patients with either type 2 diabetes or hypertension in a large public health clinic.Health coaches, in coordination with resident primary care physicians, met with patients before and after clinic visits and called patients between visits.Measurement of body mass index, assessment of smoking status, and formulation of a self-management plan prior to and during the intervention period for patients in the Teamlet Model group. Testing for LDL and HbA1C and the proportion of patients at goal for blood pressure, LDL, and HbA1C in the Teamlet Model and comparison groups in the year prior to and during implementation.Teamlet patients showed improvement in all measures, though improvement was significant only for smoking, BMI, and self-management plan documentation and testing for LDL (p = 0.02), with a trend towards significance for LDL at goal (p = 0.07). Teamlet patients showed a greater, but non-significant, increase in the proportion of patients tested for HbA1C and proportion reaching goal for blood pressure, HgbA1C, and LDL compared to the comparison group patients. The difference for blood pressure was marginally significant (p = 0.06). In contrast, patients in the comparison group were significantly more likely to have had testing for LDL (P = 0.001).The Teamlet Model may improve chronic care in academic primary care practices.

    View details for DOI 10.1007/s11606-010-1390-1

    View details for PubMedID 20737236

    View details for PubMedCentralID PMC2940441

  • Urinary incontinence, fecal incontinence and pelvic organ prolapse in a population-based, racially diverse cohort: prevalence and risk factors. Female pelvic medicine & reconstructive surgery Rortveit, G., Subak, L. L., Thom, D. H., Creasman, J. M., Vittinghoff, E., Van Den Eeden, S. K., Brown, J. S. 2010; 16 (5): 278–83


    OBJECTIVES: : We investigated the prevalence of and risk factors for combinations of urinary incontinence (UI), fecal incontinence (FI) and pelvic organ prolapse (POP) in racially diverse women older than 40 years.METHODS: : The Reproductive Risks for Incontinence Study at Kaiser is a population-based study with data from 2106 women older than 40 years. Pelvic floor conditions were determined by self-report. Risk factors were assessed by self-report, interview and record review. Independent risk factors were identified by multinomial logistic regression analysis.RESULTS: : At least one pelvic floor condition was reported by 714 (34%) women. Of these, 494 (69%) had only UI, 60 (8%) only POP, and 46 (6%) only FI. Both UI and FI were reported by 64 (9%) and both UI and POP by 51 (7%). Among women with FI, 60% reported more than one condition. Corresponding figures for POP and UI were 49% and 18%. Estrogen use and constipation were shared risk factors for UI, FI and POP. Body mass index was a unique risk factor UI only, diabetes FI only and parity POP only. No clear pattern could be found to support the hypothesis that risk factors for single conditions are more strongly associated with combined conditions.CONCLUSIONS: : Patients with FI or POP often have concomitant UI. These diseases both share and have unique risk factors in a complex pattern.

    View details for DOI 10.1097/SPV.0b013e3181ed3e31

    View details for PubMedID 22453506

  • Lactation and maternal risk of type 2 diabetes: a population-based study. The American journal of medicine Schwarz, E. B., Brown, J. S., Creasman, J. M., Stuebe, A., McClure, C. K., Van Den Eeden, S. K., Thom, D. 2010; 123 (9): 863.e1-6


    Lactation has been associated with improvements in maternal glucose metabolism.We explored the relationships between lactation and risk of type 2 diabetes in a well-characterized, population-representative cohort of women, aged 40-78 years, who were members of a large integrated health care delivery organization in California and enrolled in the Reproductive Risk factors for Incontinence Study at Kaiser (RRISK), between 2003 and 2008. Multivariable logistic regression was used to control for age, parity, race, education, hysterectomy, physical activity, tobacco and alcohol use, family history of diabetes, and body mass index while examining the impact of duration, exclusivity, and consistency of lactation on risk of having developed type 2 diabetes.Of 2233 women studied, 1828 were mothers; 56% had breastfed an infant for > or =1 month. In fully adjusted models, the risk of type 2 diabetes among women who consistently breastfed all of their children for > or =1 month remained similar to that of women who had never given birth (odds ratio [OR] 1.01; 95% confidence interval [CI], 0.56-1.81). In contrast, mothers who had never breastfed an infant were more likely to have developed type 2 diabetes than nulliparous women (OR 1.93; 95% CI, 1.14-3.27) [corrected]. Mothers who never exclusively breastfed were more likely to have developed type 2 diabetes than mothers who exclusively breastfed for 1-3 months (OR 1.52; 95% CI, 1.11-2.10).Risk of type 2 diabetes increases when term pregnancy is followed by <1 month of lactation, independent of physical activity and body mass index in later life. Mothers should be encouraged to exclusively breastfeed all of their infants for at least 1 month.

    View details for DOI 10.1016/j.amjmed.2010.03.016

    View details for PubMedID 20800156

    View details for PubMedCentralID PMC2930900

  • Developing a policy-relevant research agenda for the patient-centered medical home: a focus on outcomes. Journal of general internal medicine Rittenhouse, D. R., Thom, D. H., Schmittdiel, J. A. 2010; 25 (6): 593-600


    The Patient-Centered Medical Home (PCMH) is a widely endorsed model of delivery system reform that emphasizes primary care. Pilot demonstration projects are underway in many states, sponsored by Medicare, Medicaid, major health plans and multi-payer coalitions.In this paper we consider the development of a long-term policy-relevant research agenda on outcomes of the PCMH. We provide an overview of potential measures of PCMH impact, identify measurement challenges and recommend areas for further study. Although the PCMH should not be expected to solve every problem in the health care system, developing a research agenda for measuring outcomes of delivery system innovations such as the PCMH should be considered in the context of the larger effort to improve the US health care system, with the ultimate goal to improve population health.As a framework for our discussion, we have chosen the Institute of Medicine's six specific aims for 21st century health care: (1) safe, (2) effective, (3) patient-centered, (4) timely, (5) efficient and (6) equitable. In addition, we include potential areas of PCMH outcomes that do not easily fall under this framework and consider unintended consequences.Multi-stakeholder involvement will be essential in developing a long-term policy-relevant research agenda for outcomes of the PCMH.

    View details for DOI 10.1007/s11606-010-1289-x

    View details for PubMedID 20467908

    View details for PubMedCentralID PMC2869424

  • Personal health records in a public hospital: experience at the HIV/AIDS clinic at San Francisco General Hospital JOURNAL OF THE AMERICAN MEDICAL INFORMATICS ASSOCIATION Kahn, J. S., Hilton, J. F., Van Nunnery, T., Leasure, S., Bryant, K. M., Hare, C. B., Thorn, D. H. 2010; 17 (2): 224-228


    Personal health records (PHRs) are information repositories; however, PHRs may be less available to persons in the safety net setting. We deployed a free, secure, internet-based PHR for persons receiving care at the AIDS/HIV clinic at San Francisco General Hospital. In our initial rollout, 221 persons registered for the PHR. Compared to the entire clinic, these initial users were more likely to be Caucasian, male, non-Hispanic, on antiretroviral medications, and have better control of their HIV infection. The median number of online sessions was 7 and the median session length was 4 min. Laboratory results were the most commonly accessed feature. Patients were satisfied with the PHR and more than 80% of users agreed that the PHR helped them manage their medical problems; however, some users were concerned that their health information was not accurate or secure. Patients in a safety net setting will access and use an online PHR.

    View details for DOI 10.1136/jamia.2009.000315

    View details for Web of Science ID 000275488100018

    View details for PubMedID 20190069

    View details for PubMedCentralID PMC3000777

  • Pelvic floor disorders and quality of life in women with self-reported irritable bowel syndrome ALIMENTARY PHARMACOLOGY & THERAPEUTICS Wang, J., Varma, M. G., Creasman, J. M., Subak, L. L., Brown, J. S., Thom, D. H., van den Eeden, S. K. 2010; 31 (3): 424–31


    Quality of life among women with irritable bowel syndrome may be affected by pelvic floor disorders.To assess the association of self-reported irritable bowel syndrome with urinary incontinence, pelvic organ prolapse, sexual function and quality of life.We analysed data from the Reproductive Risks for Incontinence Study at Kaiser Permanente, a random population-based study of 2109 racially diverse women (mean age = 56). Multivariate analyses assessed the association of irritable bowel syndrome with pelvic floor disorders and quality of life.The prevalence of irritable bowel syndrome was 9.7% (n = 204). Women with irritable bowel had higher adjusted odds of reporting symptomatic pelvic organ prolapse (OR 2.4; 95% CI, 1.4-4.1) and urinary urgency (OR 1.4; 95% CI, 1.0-1.9); greater bother from pelvic organ prolapse (OR 4.3; 95% CI, 1.5-11.9) and faecal incontinence (OR 2.0; 95% CI, 1.3-3.2); greater lifestyle impact from urinary incontinence (OR 2.2; 95% CI, 1.3-3.8); and worse quality of life (P < 0.01). Women with irritable bowel reported more inability to relax and enjoy sexual activity (OR 1.8; 95% CI, 1.3-2.6) and lower ratings for sexual satisfaction (OR 1.8; 95% CI, 1.3-2.5), but no difference in sexual frequency, interest or ability to have an orgasm.Women with irritable bowel are more likely to report symptomatic pelvic organ prolapse and sexual dysfunction, and report lower quality of life.

    View details for DOI 10.1111/j.1365-2036.2009.04180.x

    View details for Web of Science ID 000273300700009

    View details for PubMedID 19863498

    View details for PubMedCentralID PMC2807921

  • The effectiveness of health coaching, home blood pressure monitoring, and home-titration in controlling hypertension among low-income patients: protocol for a randomized controlled trial BMC PUBLIC HEALTH Bennett, H., Laird, K., Margolius, D., Ngo, V., Thom, D. H., Bodenheimer, T. 2009; 9: 456


    Despite the many antihypertensive medications available, two-thirds of patients with hypertension do not achieve blood pressure control. This is thought to be due to a combination of poor patient education, poor medication adherence, and "clinical inertia." The present trial evaluates an intervention consisting of health coaching, home blood pressure monitoring, and home medication titration as a method to address these three causes of poor hypertension control.The randomized controlled trial will include 300 patients with poorly controlled hypertension. Participants will be recruited from a primary care clinic in a teaching hospital that primarily serves low-income populations.An intervention group of 150 participants will receive health coaching, home blood pressure monitoring, and home-titration of antihypertensive medications during 6 months. The control group (n=150) will receive health coaching plus home blood pressure monitoring for the same duration. A passive control group will receive usual care. Blood pressure measurements will take place at baseline, and after 6 and 12 months. The primary outcome will be change in systolic blood pressure after 6 and 12 months. Secondary outcomes measured will be change in diastolic blood pressure, adverse events, and patient and provider satisfaction.The present study is designed to assess whether the 3-pronged approach of health coaching, home blood pressure monitoring, and home medication titration can successfully improve blood pressure, and if so, whether this effect persists beyond the period of the identifier: NCT01013857.

    View details for DOI 10.1186/1471-2458-9-456

    View details for Web of Science ID 000273040000002

    View details for PubMedID 20003300

    View details for PubMedCentralID PMC2797520

  • Mixed urinary incontinence: greater impact on quality of life. The Journal of urology Frick, A. C., Huang, A. J., Van den Eeden, S. K., Knight, S. K., Creasman, J. M., Yang, J., Ragins, A. I., Thom, D. H., Brown, J. S. 2009; 182 (2): 596-600


    We compared the impact of mixed, stress and urge urinary incontinence on quality of life in middle-aged or older women.We analyzed cross-sectional data from a population based cohort of 2,109 ethnically diverse middle-aged or older women. Among participants reporting weekly incontinence, clinical type of incontinence was assessed by self-reported questionnaires and disease specific quality of life impact was evaluated using the Incontinence Impact Questionnaire. Multivariable logistic regression was used to compare the odds of greater quality of life impact from incontinence, defined as an Incontinence Impact Questionnaire score in the 75th percentile or greater in women with stress, urge and mixed incontinence.More than 28% (598) of women reported weekly incontinence, including 37% with stress, 31% with urge and 21% with mixed incontinence. Unadjusted Incontinence Impact Questionnaire scores were higher for women with mixed vs urge or stress incontinence (median score 29 vs 17 and 13, respectively, p <0.01). Adjusting for age, race/ethnicity, health status and clinical incontinence severity, women with mixed incontinence were more likely to report a greater overall quality of life impact compared to those with stress incontinence (OR 2.5, 95% CI 1.4-4.3), as well as a greater specific impact on travel (OR 2.2, 95% CI 1.3-3.7) and emotional (OR 1.8, 95% CI 1.0-3.4) Incontinence Impact Questionnaire domains. The overall impact of urge incontinence did not differ significantly from that of stress (urge vs stress OR 1.6, 95% CI 0.9-2.7) or mixed incontinence (mixed vs urge OR 1.6, 95% CI 0.9-2.8) in adjusted models.In middle-aged or older women mixed incontinence is associated with a greater quality of life impact than stress incontinence independent of age, race, health or incontinence severity. Identification of women with mixed incontinence symptoms may be helpful in discovering which women are most likely to experience functional limitations and decreased well-being from incontinence.

    View details for DOI 10.1016/j.juro.2009.04.005

    View details for PubMedID 19535107

    View details for PubMedCentralID PMC2746250

  • Sexual function and aging in racially and ethnically diverse women. Journal of the American Geriatrics Society Huang, A. J., Subak, L. L., Thom, D. H., Van Den Eeden, S. K., Ragins, A. I., Kuppermann, M., Shen, H., Brown, J. S. 2009; 57 (8): 1362-8


    To examine factors influencing sexual activity and functioning in racially and ethnically diverse middle-aged and older women.Cross-sectional cohort study.Integrated healthcare delivery system.One thousand nine hundred seventy-seven women aged 45 to 80.Self-administered questionnaires assessed sexual desire, activity, satisfaction, and problems.Of the 1,977 participants (876 white, 388 African American, 347 Latina, and 351 Asian women), 43% reported at least moderate sexual desire, and 60% had been sexually active in the previous 3 months. Half of sexually active participants (n=969) described their overall sexual satisfaction as moderate to high. Among sexually inactive women, the most common reason for inactivity was lack of interest in sex (39%), followed by lack of a partner (36%), physical problem of partner (23%), and lack of interest by partner (11%); only 9% were inactive because of personal physical problems. In multivariable analysis, African-American women were more likely than white women to report at least moderate desire (odds ratio (OR)=1.65, 95% confidence interval (CI)=1.25-2.17) but less likely to report weekly sexual activity (OR=0.68, 95% CI=0.48-0.96); sexually active Latina women were more likely than white women to report at least moderate sexual satisfaction (OR=1.75, 95% CI=1.20-2.55).A substantial proportion of community-dwelling women remain interested and engaged in sexual activity into older age. Lack of a partner capable of or interested in sex may contribute more to sexual inactivity than personal health problems in this population. Racial and ethnic differences in self-reported sexual desire, activity, and satisfaction may influence discussions about sexual difficulties in middle-aged and older women.

    View details for DOI 10.1111/j.1532-5415.2009.02353.x

    View details for PubMedID 19558473

    View details for PubMedCentralID PMC2749599

  • Racial differences in pelvic organ prolapse. Obstetrics and gynecology Whitcomb, E. L., Rortveit, G. n., Brown, J. S., Creasman, J. M., Thom, D. H., Van Den Eeden, S. K., Subak, L. L. 2009; 114 (6): 1271–77


    To compare the estimated prevalence of, risk factors for, and level of bother associated with subjectively reported and objectively measured pelvic organ prolapse in a racially diverse cohort.The Reproductive Risks for Incontinence Study at Kaiser 2 is a population-based cohort study of 2,270 middle-aged and older women. Symptomatic prolapse was self-reported, and bother was assessed on a five-point scale. In 1,137 women, prolapse was measured with the Pelvic Organ Prolapse Quantification (POP-Q) system. Multivariable logistic regression analysis was used to identify the independent association of prolapse and race while controlling for risk factors.The participants' mean (standard deviation) age was 55 (9) years, and 44% were white, 20% were African American, 18% were Asian American, and 18% were Latina or other race. Seventy-four women (3%) reported symptomatic prolapse. In multivariable analysis, the risk of symptomatic prolapse was higher in white (prevalence ratio 5.35, 95% confidence interval [CI] 1.89-15.12) and Latina (prevalence ratio 4.89, 95% CI 1.64-14.58) compared with African-American women. Race was not associated with report of moderate to severe bother. Degree of prolapse by POP-Q stage was similar across all racial groups; however, the risk of the leading edge of prolapse at or beyond the hymen was higher in white (prevalence ratio 1.40, 95% CI 1.02-1.92) compared with African-American women.Compared with African-American women, Latina and white women had four to five times higher risk of symptomatic prolapse, and white women had 1.4-fold higher risk of objective prolapse with leading edge of prolapse at or beyond the hymen.II.

    View details for DOI 10.1097/AOG.0b013e3181bf9cc8

    View details for PubMedID 19935029

    View details for PubMedCentralID PMC2879888

  • Obstructive defecation in middle-aged women. Digestive diseases and sciences Varma, M. G., Hart, S. L., Brown, J. S., Creasman, J. M., Van Den Eeden, S. K., Thom, D. H. 2008; 53 (10): 2702-9


    Obstructive defecation, a significant contributor to constipation, is frequently reported in middle-aged women, yet few population-based studies have established prevalence in this group. We analyzed data from the Reproductive Risks for Incontinence Study at Kaiser, a population-based cohort of racially diverse women, 40-69 years old, to describe the prevalence of obstructive defecation and identify associated risk factors. The Reproductive Risks for Incontinence Study at Kaiser is a randomly selected cohort of 2,109 women in the Kaiser Medical System. Obstructive defecation, determined by self-report, was defined as difficulty in passing stool, hard stool, straining for more than 15 min, or incomplete evacuation, occurring at least weekly. Age, race, income, education, drinking, health status, parity, pelvic organ prolapse, urinary incontinence, number of medications, hysterectomy, surgery for pelvic organ prolapse, colectomy, irritable bowel syndrome, and body mass index were assessed for both their univariate and multivariate association with obstructive defecation. Multivariate logistic regression was used to determine the independent association between associated factors and the primary outcome of obstructive defecation. Obstructive defecation that occurred at least weekly was reported by 12.3% of women. Significant independent risk factors included irritable bowel syndrome [odds ratio 1.78, (95% confidence interval 1.21-2.60)], vaginal or laparoscopic hysterectomy [2.01 (1.15-3.54)], unemployment [2.33 (1.39-3.92)], using three or more medications [1.81 (1.36-2.42)], symptomatic pelvic organ prolapse [2.34 (1.47-3.71)], urinary incontinence surgery [2.52 (1.29-4.90)], and other pelvic surgery [1.35 (1.03-1.78)]. We concluded that obstructive defecation is common in middle-aged women, especially those with a history of treatment for pelvic floor conditions. Women who had undergone laparoscopic/vaginal hysterectomies or surgery for pelvic organ prolapse or urinary incontinence had a nearly two times greater risk of weekly obstructive defecation. Demographic factors, with the exception of employment status, were not significant, indicating that obstructive defecation, although widespread, does not affect any particular group of women.

    View details for DOI 10.1007/s10620-008-0226-x

    View details for PubMedID 18340532

    View details for PubMedCentralID PMC3030249

  • African-American clinicians providing HIV care: The experience of the national HIV/AIDS clinicians' consultation center JOURNAL OF THE NATIONAL MEDICAL ASSOCIATION Mahoney, M. R., Sterkenburg, C., Thom, D. H., Goldschmidt, R. H. 2008; 100 (7): 779-782


    This analysis compares patient and provider characteristics of African-American clinicians and non-African-American clinicians who called the National HIV Telephone Consultation Service (Warmline). In 2004, a total of 2,077 consultations were provided for 1,020 clinicians, 70 (6.9%) of whom were African American. Compared to the non-African-American group, a higher percentage of African-American clinicians were nurses (20.0% vs. 8.8%, p=0.002). A significantly lower percentage of African-American physicians were infectious disease specialists (3.5% vs. 25.6%, p=0.007). African-American clinicians were more likely to work in a community clinic (48.5% vs. 34.1%, p=0.015). Both African-American and non-African American clinicians reported caring for a similar number of HIV-infected patients. Patient-provider racial concordance was common among African-American clinicians (76.4%), whereas non-African-American clinicians called about patients of more diverse racial and ethnic backgrounds. African-American clinicians who called Warmline exhibited differences in patient and provider characteristics when compared to all other clinicians. These findings contribute to the growing body of research on HIV providers in the United States.

    View details for Web of Science ID 000257844700001

    View details for PubMedID 18672554

  • Complementary and alternative medicine for menopause: a qualitative analysis of women's decision making. Journal of general internal medicine Hill-Sakurai, L. E., Muller, J., Thom, D. H. 2008; 23 (5): 619-22


    While almost half of women use complementary and alternative medicine (CAM) during their menopause, almost no literature explores why women choose CAM for menopausal symptoms. Clinician-patient conversations about CAM can be unsatisfactory, and exploration of women's choices may benefit communication.The objective of this study was to describe women's choices to use CAM for menopausal health issues.This is a qualitative study utilizing semi-structured interviews.Convenience sample of 44 menopausal women ages 45 to 60 recruited in two primary care clinics. Both users and non-users of CAM were included.Transcripts of semi-structured interviews were analyzed for themes that were refined through comparison of labeled text.Four themes emerged in decisions to use CAM: (1) valuing CAM as "natural", although the meaning of "natural" varied greatly, (2) perceiving menopause as marking a change in life stage, (3) seeking information about menopause generated from personal intuition and other women's experiences, and (4) describing experiences before menopause of using CAM and allopathic medication in patterns similar to current use (patterned responses).Women's decisions about using CAM during menopause can be understood through their perspectives on menopause and overall health. Increased clinician awareness of these themes may promote supportive discussions about CAM during counseling for menopause.

    View details for DOI 10.1007/s11606-008-0537-9

    View details for PubMedID 18299942

    View details for PubMedCentralID PMC2324155

  • Invited commentary: the contribution of the BACH Survey to the epidemiology of urinary incontinence. American journal of epidemiology Thom, D. H. 2008; 167 (4): 400-3; author reply 404-5


    Despite a substantial number of epidemiologic studies of urinary incontinence over the past two decades, relatively little is known about urinary incontinence in non-White women or in men. By enrolling White, Black, and Hispanic men and women, the Boston Area Community Health (BACH) Survey has added to our limited knowledge of incontinence in these groups. In general, the results from BACH, reported in the current issue of the American Journal of Epidemiology (Tennstedt et al., Am J Epidemiol 2008;167:390-399), confirm prior findings in women while extending our knowledge of the prevalence of and risk factors for incontinence in men. Interpretation of the BACH Survey results must be tempered by the low enrollment rate (less than 25% of eligible community members). The associations between cardiovascular disease and incontinence reported for some gender/race-ethnicity subgroups should be considered exploratory.

    View details for DOI 10.1093/aje/kwm352

    View details for PubMedID 18182377

  • Effects of urinary incontinence, comorbidity and race on quality of life outcomes in women. The Journal of urology Ragins, A. I., Shan, J., Thom, D. H., Subak, L. L., Brown, J. S., Van Den Eeden, S. K. 2008; 179 (2): 651-5; discussion 655


    We investigated the effects of comorbidity and urinary incontinence on both generic and incontinence specific quality of life outcome measures, and investigated whether the association between urinary incontinence and quality of life varies by race.Study participants were 2,109 women 40 to 69 years old randomly selected from an urban health maintenance organization and interviewed in person for a study of risk factors for urinary incontinence. The sample was racially diverse consisting of 48% white, 18% black, 17% Hispanic and 16% Asian-American women. In addition to incontinence, reproductive and medical history questionnaires, all participants completed the Medical Outcomes Study Short Form 36, a measure of health related quality of life. All participants with daily and weekly incontinence (29%) completed the Incontinence Impact Questionnaire, an incontinence specific quality of life measure. The health maintenance organization's inpatient and outpatient electronic databases were used to calculate a Charlson comorbidity index score for each participant. ANCOVA was used to produce a model adjusting for sociodemographic variables, comorbidity and incontinence frequency. The same model was run for each of 4 racial groupings to examine differences by race/ethnicity.Urinary incontinence is significantly associated with a decreased quality of life and those with more frequent incontinence have significantly lower quality of life scores. In our model the Charlson score, an objective measure of comorbidity based on hospital and physician records, also has a significant negative impact on quality of life. When comorbidity is controlled, incontinence frequency continues to have a significant negative association with quality of life except among the sickest women. For women with the greatest extent of comorbidity, incontinence frequency is not significantly associated with negative quality of life outcomes. We did not find clear patterns of variation by race.Urinary incontinence and comorbidity each have an independent and significant role in reducing quality of life outcomes for all but the sickest women.

    View details for DOI 10.1016/j.juro.2007.09.074

    View details for PubMedID 18082212

    View details for PubMedCentralID PMC2671469

  • Urinary incontinence in older community-dwelling women: the role of cognitive and physical function decline. Obstetrics and gynecology Huang, A. J., Brown, J. S., Thom, D. H., Fink, H. A., Yaffe, K. 2007; 109 (4): 909-16


    To examine the association between cognitive decline, physical function decline, and urinary incontinence in older community-dwelling women.This was an observational study of 6,361 community-dwelling women aged 65 years and older participating in the Study of Osteoporotic Fractures. Clinical frequency and functional disruptiveness of incontinence were assessed by self-report questionnaires. Cognitive function was assessed at visits using the modified Mini-Mental State Examination, Trails B test, and Digit Symbol Substitution Test. Physical function was assessed by measuring walking speed over a 6-meter course and time needed to complete five chair stands. Women were considered to have recent, significant decline in cognitive or physical function if their cognitive or physical performance declined by greater than 1 standard deviation beyond the mean decline in the 6 years preceding assessment of incontinence.Women with recent physical function decline were more likely to report weekly incontinence (odds ratio [OR] 1.31, 95% confidence interval [CI] 1.09-1.56 for walking speed decline; OR 1.40, 95% CI 1.19-1.64 for chair stand decline), after adjusting for multiple characteristics. Women with recent cognitive decline were more likely to report incontinence that interfered with activities (OR 1.55, 95% CI 1.10-2.17 for modified Mini-Mental State Examination decline; OR 1.53, 95% CI 1.01-2.31 for Digit Symbol Substitution Test decline), after adjusting for multiple characteristics.Both cognitive and physical function decline are likely important contributors to incontinence in community-dwelling women aged 65 years and older. Although cognitive decline may not be associated with greater frequency of incontinence, women with cognitive decline may have more difficulty coping with incontinence symptoms.II.

    View details for DOI 10.1097/01.AOG.0000258277.01497.4b

    View details for PubMedID 17400853

  • Concordance of chart abstraction and patient recall of intrapartum variables up to 53 years later. American journal of obstetrics and gynecology Hopkins, L. M., Caughey, A. B., Brown, J. S., Wassel Fyr, C. L., Creasman, J. M., Vittinghoff, E., Van den Eeden, S. K., Thom, D. H. 2007; 196 (3): 233.e1-6


    The purpose of this study was to determine the concordance of patient recall compared with chart abstraction for distant intrapartum variables and to evaluate predictors of concordance.A random sample from a cohort of diverse women aged 40-74 years. Intrapartum variables reported by participants were compared with the medical record. Outcomes were assessed for sensitivity, specificity, positive predictive value, and negative predictive value. Multivariate logistic regression was used to determine predictors of concordance of patient recall.Four hundred one births among 178 women were analyzed. Recall of cesarean delivery had the highest concordance (sensitivity, 0.98; specificity, 1.00; positive predictive value, 1.00; negative predictive value, 0.99). Laceration that required repair had the lowest concordance (sensitivity, 0.37; specificity, 0.68; positive predictive value, 0.34; negative predictive value, 0.81). No variables predicted concordance of recall for all variables.The concordance of patient recall to chart abstraction for intrapartum variables varies widely, although with a pattern of greater specificity and negative predictive value of recall. This should be kept in mind during patient interviews and in the performance of clinical research.

    View details for DOI 10.1016/j.ajog.2006.10.899

    View details for PubMedID 17346533

    View details for PubMedCentralID PMC2882204

  • Telephone counseling improves smoking cessation rates. American family physician Meites, E., Thom, D. H. 2007; 75 (5): 650

    View details for PubMedID 17375510

  • Urinary incontinence in women: Direct costs of routine care. American journal of obstetrics and gynecology Subak, L. n., Van Den Eeden, S. n., Thom, D. n., Creasman, J. M., Brown, J. S. 2007; 197 (6): 596.e1–9


    The purpose of this study was to estimate the direct costs of routine care for urinary incontinence (UI) in community-dwelling, racially diverse women.In the Reproductive Risks for Incontinence Study at Kaiser population-based study, 528 women with UI weekly or more quantified resources that were used for UI. Routine care costs were calculated with the use of national resource costs ($2005). Potential predictors of these outcomes were examined by multivariable linear regression.Mean age was 55 +/- 9 (SD) years. Among women with weekly UI, 69% reported incontinence-related costs. Median weekly cost was $1.83 (25%-75% interquartile range [IQR], $0.50, $5.23), increasing from $0.93 (IQR, $0, $3) for moderate to $7.82 (IQR, $5, $37) for very severe incontinence. Costs that increased with incontinence severity (P < .001) and body mass index (P < .001) were 2.2-fold higher for African American versus white women (P < .0001) and 42% higher for women with mixed versus stress incontinence (P < .05).Women pay a mean of >$250 per year out-of-pocket for UI routine care. Effective incontinence treatment may decrease costs.

    View details for DOI 10.1016/j.ajog.2007.04.029

    View details for PubMedID 17880904

  • Patients' race, ethnicity, language, and trust in a physician JOURNAL OF HEALTH AND SOCIAL BEHAVIOR Stepanikova, I., Mollborn, S., Cook, K. S., Thom, D. H., Kramer, R. M. 2006; 47 (4): 390-405


    We examine whether racial/ethnic/language-based variation in measured levels of patients' trust in a physician depends on the survey items used to measure that trust. Survey items include: (1) a direct measure of patients' trust that the doctor will put the patient's medical needs above all other considerations, and (2) three indirect measures of trust asking about expectations for specific physician behaviors, including referring to a specialist, being influenced by insurance rules, and performing unnecessary tests. Using a national survey, we find lower scores on indirect measures of trust in a physician among minority users of health care services than among non-Hispanic white users. In contrast, the direct measure of trust does not differ among non-Hispanic whites and nonwhites once we control for potential confounding factors. The results indicate that racial/ethnic/language-based differences exist primarily in those aspects of patients' trust in a physician that reflect specific physician behaviors.

    View details for Web of Science ID 000242750800006

    View details for PubMedID 17240927

  • Urinary incontinence and pelvic floor dysfunction in Asian-American women. American journal of obstetrics and gynecology Huang, A. J., Thom, D. H., Kanaya, A. M., Wassel-Fyr, C. L., Van den Eeden, S. K., Ragins, A. I., Subak, L. L., Brown, J. S. 2006; 195 (5): 1331-7


    The objective of the study was to describe the prevalence, risk factors, and impact of urinary incontinence and other pelvic floor disorders among Asian-American women.This was a population-based cohort study of older women randomly selected from age and race strata.Weekly urinary incontinence was reported by 65 of 345 Asian women (18%), with stress and urge incontinence being approximately equally common. In multivariate analysis, higher body mass index (greater than 25 kg/m2) was associated with both stress incontinence (odds ratio 4.90, 95% confidence interval 1.76 to 13.68) and urge incontinence (odds ratio 2.49, 95% confidence interval 1.01 to 6.16) in Asians. Hysterectomy was a significant risk factor for stress incontinence (odds ratio 2.79, 95% confidence interval 1.03 to 7.54). Only 34% of Asian women with weekly urinary incontinence reported ever having sought treatment. Pelvic floor exercises were the most common form of treatment, being used by 29% of Asian women with weekly incontinence. Asians were less likely then white women to report anal incontinence (21% versus 29%, P = .007), although this difference became nonsignificant after adjusting for differences in risk factors.Asian women share some risk factors for stress and urge urinary incontinence with white women. Urinary incontinence is associated with anal incontinence among Asian women.

    View details for DOI 10.1016/j.ajog.2006.03.052

    View details for PubMedID 16643821

    View details for PubMedCentralID PMC1630451

  • Development and evaluation of a cultural competency training curriculum. BMC medical education Thom, D. H., Tirado, M. D., Woon, T. L., McBride, M. R. 2006; 6: 38


    Increasing the cultural competence of physicians and other health care providers has been suggested as one mechanism for reducing health disparities by improving the quality of care across racial/ethnic groups. While cultural competency training for physicians is increasingly promoted, relatively few studies evaluating the impact of training have been published.We recruited 53 primary care physicians at 4 diverse practice sites and enrolled 429 of their patients with diabetes and/or hypertension. Patients completed a baseline survey which included a measure of physician culturally competent behaviors. Cultural competency training was then provided to physicians at 2 of the sites. At all 4 sites, physicians received feedback in the form of their aggregated cultural competency scores compared to the aggregated scores from other physicians in the practice. The primary outcome at 6 months was change in the Patient-Reported Physician Cultural Competence (PRPCC) score; secondary outcomes were changes in patient trust, satisfaction, weight, systolic blood pressure, and glycosylated hemoglobin. Multiple analysis of variance was used to control for differences patient characteristics and baseline levels of the outcome measure between groups.Patients had a mean of 2.8 + 2.2 visits to the study physician during the study period. Changes in all outcomes were similar in the "Training + Feedback" group compared to the "Feedback Only" group (PRPCC: 3.7 vs.1.8; trust: -0.7 vs. -0.2 ; satisfaction: 1.9 vs. 2.5; weight: -2.5 lbs vs. -0.7 lbs; systolic blood pressure: 1.7 mm Hg vs. 0.1 mm Hg; glycosylated hemoglobin 0.02% vs. 0.07%; p = NS for all).The lack of measurable impact of physician training on patient-reported and disease-specific outcomes in the current has several possible explanations, including the relatively limited nature of the intervention. We hope that the current study will help provide a basis for future studies, using more intensive interventions with different provider groups.

    View details for DOI 10.1186/1472-6920-6-38

    View details for PubMedID 16872504

    View details for PubMedCentralID PMC1555583

  • Sexual activity and function in middle-aged and older women. Obstetrics and gynecology Addis, I. B., Van Den Eeden, S. K., Wassel-Fyr, C. L., Vittinghoff, E., Brown, J. S., Thom, D. H. 2006; 107 (4): 755-64


    Data on the sexual activity of middle-aged and older women are scant and vary widely. This analysis estimates the prevalence and predictors of sexual activity and function in a diverse group of women aged 40-69 years.The Reproductive Risk Factors for Incontinence Study at Kaiser (RRISK) was a population-based study of 2,109 women aged 40-69 years who were randomly selected from long-term Kaiser Permanente members. Women completed self-report questionnaires on sexual activity, comorbidities, and general quality of life. Logistic and linear regression and proportional odds models were used when appropriate to identify correlates of sexual activity, frequency, satisfaction, and dysfunction.Mean age was 55.9 (+/- 8) years and nearly three fourths of the women were sexually active. Of the sexually active women, 60% had sexual activity at least monthly, approximately two thirds were at least somewhat satisfied, and 33% reported a problem in one or more domains. Monthly or more frequent sexual activity was associated with younger age, higher income, being in a significant relationship, a history of moderate alcohol use, and lower body mass index (BMI) (all P < .05). Satisfaction with sexual activity was associated with African-American race, lower BMI, and higher mental health score (all P < .05). More sexual dysfunction was associated with having a college degree or greater, poor health, being in a significant relationship, and a low mental health score (all P < .05).Middle-aged and older women engage in satisfying sexual activity, and one third reported problems with sexual function. Demographic factors as well as some issues associated with aging can adversely affect sexual frequency, satisfaction, and function.II-3.

    View details for DOI 10.1097/01.AOG.0000202398.27428.e2

    View details for PubMedID 16582109

    View details for PubMedCentralID PMC1557393

  • The prevalence of urinary incontinence among community-dwelling adult men: Results from the National Health and Nutrition Examination Survey Anger, J. T., Saigal, C. S., Stothers, L., Thom, D. H., Rodriguez, L. V., Litwin, M. S., Urologic Dis Am Project LIPPINCOTT WILLIAMS & WILKINS. 2006: 5
  • Childhood urinary symptoms predict adult overactive bladder symptoms. The Journal of urology Fitzgerald, M. P., Thom, D. H., Wassel-Fyr, C., Subak, L., Brubaker, L., Van Den Eeden, S. K., Brown, J. S. 2006; 175 (3 Pt 1): 989-93


    A relationship between childhood urinary symptoms and adult lower urinary tract symptoms in women is often clinically suspected. In this analysis we investigated the relationship between childhood and adult urinary symptoms in middle-aged women.A population based cohort of 2,109 women 40 to 69 years old who were members of a large health maintenance organization was randomly selected from age and race strata. Through self-reported questionnaires, women recalled a childhood history of and current urinary lower urinary tract symptoms, including frequent daytime urination, nocturia, urinary incontinence, nocturnal enuresis and UTIs. Current incontinence was also classified as urge or stress incontinence. Multivariate analysis was used to evaluate the association between childhood and current lower urinary tract symptoms controlling for age, race, hysterectomy status, parity, oral estrogen use, body mass index and diabetes.Women who reported childhood daytime frequency were more likely to report adult urgency (OR 1.9, 95% CI 1.3-2.6, p < 0.001). Frequent nocturia in childhood was strongly associated with adult nocturia (OR 2.3, 95% CI 1.5-3.5, p < 0.001). Childhood daytime incontinence was associated with adult urge incontinence (OR 2.6, 95% CI 1.1-5.9, p < 0.05), as was childhood nocturnal enuresis (OR 2.7, CI 1.3-5.5, p < 0.01). A history of more than 1 childhood UTI was associated with adult UTIs (OR 2.6, 95% CI 1.5-4.5, p < 0.001).Childhood urinary symptoms and UTIs were significantly associated with adult overactive bladder symptoms. There is a need to investigate the significance of childhood symptoms as predictors of eventual adult disorders to determine whether treatment of childhood symptoms will alter the prevalence of eventual adult disorders, and if such a history should alter clinical care of the older adult with OAB symptoms.

    View details for DOI 10.1016/S0022-5347(05)00416-7

    View details for PubMedID 16469599

    View details for PubMedCentralID PMC1820589

  • Differences in prevalence of urinary incontinence by race/ethnicity. The Journal of urology Thom, D. H., van den Eeden, S. K., Ragins, A. I., Wassel-Fyr, C. n., Vittinghof, E. n., Subak, L. L., Brown, J. S. 2006; 175 (1): 259–64


    We compared the prevalence of urinary incontinence by type among white, black, Hispanic and Asian-American women.The RRISK is a population based cohort study of 2,109 randomly selected middle-aged and older women. Incontinence and other variables were assessed by self-report questionnaires and in person interviews. Labor and delivery and surgical data were abstracted from medical records archived since 1946. Logistic regression was used to estimate the OR with 95% CIs for incontinence while adjusting for covariates.The age adjusted prevalence of weekly incontinence was highest among Hispanic women, followed by white, black and Asian-American women (36%, 30%, 25% and 19%, respectively, p <0.001). Type of incontinence also differed among groups, with weekly stress incontinence prevalence being 18%, 15%, 8% and 8% (p <0.001), and weekly urge incontinence prevalence being 10%, 9%, 14% and 7% (p <0.001). After adjustment for age, parity, hysterectomy, estrogen use, body mass, menopausal status and diabetes, the risk of stress incontinence remained significantly lower in black (adjusted OR 0.36, 95% CI 0.23-0.57) and Asian-American (adjusted OR 0.54, 95% CI 0.34-0.86) women compared to white women. In contrast, the risk of urge incontinence was similar in black (adjusted OR 1.19, 95% CI 0.79-1.81) and Asian-American (adjusted OR 0.86, 95% CI 0.52-1.43) women compared to white women.Significant differences in the adjusted risk of stress incontinence among Hispanic, white, black and Asian-American women suggest the presence of additional, as yet unrecognized, risk or protective factors for stress incontinence.

    View details for DOI 10.1016/S0022-5347(05)00039-X

    View details for PubMedID 16406923

    View details for PubMedCentralID PMC1557354

  • Fecal incontinence in females older than aged 40 years: who is at risk? Diseases of the colon and rectum Varma, M. G., Brown, J. S., Creasman, J. M., Thom, D. H., Van Den Eeden, S. K., Beattie, M. S., Subak, L. L. 2006; 49 (6): 841–51


    This study was designed to estimate the prevalence of, and identify risk factors associated with, fecal incontinence in racially diverse females older than aged 40 years.The Reproductive Risks for Incontinence Study at Kaiser is a population-based study of 2,109 randomly selected middle-aged and older females (average age, 56 years). Fecal incontinence, determined by self-report, was categorized by frequency. Females reported the level of bother of fecal incontinence and their general quality of life. Potential risk factors were assessed by self-report, interview, physical examination, and record review. Multivariate logistic regression analysis was used to determine the independent association between selected risk factors and the primary outcome of any reported fecal incontinence in the past year.Fecal incontinence in the past year was reported by 24 percent of females (3.4 percent monthly, 1.9 percent weekly, and 0.2 percent daily). Greater frequency of fecal incontinence was associated with decreased quality of life (Medical Outcome Short Form-36 Mental Component Scale score, P = 0.01), and increased bother (P < 0.001) with 45 percent of females with fecal incontinence in the past year and 100 percent of females with daily fecal incontinence reporting moderate or great bother. In multivariate analysis, the prevalence of fecal incontinence in the past year increased significantly [odds ratio per 5 kg/m2 (95 percent confidence interval)] with obesity [1.2 (1.1-1.3)], chronic obstructive pulmonary disease [1.9 (1.3-2.9)], irritable bowel syndrome [2.4 (1.7-3.4)], urinary incontinence [2.1 (1.7-2.6)], and colectomy [1.9 (1.1-3.1)]. Latina females were less likely to report fecal incontinence than white females [0.6 (0.4-0.9)].Fecal incontinence, a common problem for females, is associated with substantial adverse affects on quality of life. Several of the identified risk factors are preventable or modifiable, and may direct future research in fecal incontinence therapy.

    View details for DOI 10.1007/s10350-006-0535-0

    View details for PubMedID 16741640

    View details for PubMedCentralID PMC1557355

  • Urologic diseases in America project: urinary incontinence in women-national trends in hospitalizations, office visits, treatment and economic impact. The Journal of urology Thom, D. H., Nygaard, I. E., Calhoun, E. A. 2005; 173 (4): 1295-301


    We describe temporal trends in hospitalizations, outpatient visits and the treatment of female urinary incontinence (UI), and estimated the costs of incontinence using national databases.The analytic methods used to generate these results have been described previously.The rate of hospitalization with a primary diagnosis of UI decreased from 51/100,000 women in 1994 to 44/100,000 in 2000 and mean length of stay decreased from 3.1 days to 2.1. In contrast, outpatient visits for UI more than doubled during the same period from 845/100,000 women to 1,845/100,000. Rates of inpatient surgical treatment for UI decreased slightly from 1994 to 2000, while ambulatory surgical center visit rates for Medicare beneficiaries 65 years or older more than doubled from 60/100,000 in 1992 to 142/100,000 in 1998. Medical expenditures for UI increased substantially during the 1990s, almost doubling from 128.1 million dollars in 1992 to 234.4 million dollars in 1998 for Medicare beneficiaries 65 years or older. This increase was due almost entirely to increased outpatient costs, which increased from 25.4 million dollars or 9.1% of total costs in 1992 to 329 million dollars or 27.3% of total costs in 2000 in this group.While existing national databases generally capture only the minority of incontinent women with UI who seek and receive care for UI, they are useful for documenting treads in service use and surgical treatments, and estimating economic impact. This data can be helpful when formulating public policy and designing observational and clinical studies.

    View details for DOI 10.1097/01.ju.0000155679.77895.cb

    View details for PubMedID 15758785

  • Urologic diseases in America project: urinary incontinence in males--demographics and economic burden. The Journal of urology Stothers, L., Thom, D., Calhoun, E. 2005; 173 (4): 1302-8


    We quantified and describe the demographics and economic burden of male urinary incontinence in the United States of America.The analytic methods used to generate these results have been described previously.Urinary incontinence (UI) affects men of all ages, including 17% of males older than 60 years in the United States, which is an estimated 3.4 million men. There is a strong trend toward an increasing prevalence of UI with increasing age as well as an increase in the prevalence of UI in males with time. Ethnicity has less of a role in prevalence estimates in men than in women. The largest impact of UI in elderly men is in physician office visits, followed by outpatient services and surgeries. Resource use is greatest in the nursing home setting, where more than half of men have UI and require assistance with toileting. The overall economic burden for male UI is estimated at 18.8 billion dollars in direct medical costs in 1998/1999 dollars. Medical expenditures for UI for male Medicare beneficiaries 65 years and older have doubled since 1992. Compared to persons without UI the presence of UI increases the annual expenditures per person yearly from 3,204 dollars to 7,702 dollars.The direct and indirect costs of male UI increased throughout the 1990s with annual expenditures per person yearly in men with UI more than double that in men without UI. Given the aging population and staggering impact of UI in nursing home settings, there is a compelling need for further research into effective prevention, treatment and management strategies.

    View details for DOI 10.1097/01.ju.0000155503.12545.4e

    View details for PubMedID 15758786

  • Description and evaluation of an EBM curriculum using a block rotation. BMC medical education Thom, D. H., Haugen, J., Sommers, P. S., Lovett, P. 2004; 4: 19


    While previous authors have emphasized the importance of integrating and reinforcing evidence-based medicine (EBM) skills in residency, there are few published examples of such curricula. We designed an EBM curriculum to train family practice interns in essential EBM skills for information mastery using clinical questions generated by the family practice inpatient service. We sought to evaluate the impact of this curriculum on interns, residents, and faculty.Interns (n = 13) were asked to self-assess their level of confidence in basic EBM skills before and after their 2-week EBM rotation. Residents (n = 21) and faculty (n = 12) were asked to assess how often the answers provided by the EBM intern to the inpatient service changed medical care. In addition, residents were asked to report how often they used their EBM skills and how often EBM concepts and tools were used in teaching by senior residents and faculty. Faculty were asked if the EBM curriculum had increased their use of EBM in practice and in teaching.Interns significantly increased their confidence over the course of the rotation. Residents and faculty felt that the answers provided by the EBM intern provided useful information and led to changes in patient care. Faculty reported incorporating EBM into their teaching (92%) and practice (75%). Residents reported applying the EBM skills they learned to patient care (86%) and that these skills were reinforced in the teaching they received outside of the rotation (81%). All residents and 11 of 12 faculty felt that the EBM curriculum had improved patient care.To our knowledge, this is the first published EBM curriculum using an individual block rotation format. As such, it may provide an alternative model for teaching and incorporating EBM into a residency program.

    View details for DOI 10.1186/1472-6920-4-19

    View details for PubMedID 15476556

    View details for PubMedCentralID PMC524496

  • Measuring patients' trust in physicians when assessing quality of care. Health affairs (Project Hope) Thom, D. H., Hall, M. A., Pawlson, L. G. 2004; 23 (4): 124-32


    Trust is a fundamentally important aspect of medical treatment relationships. Studies have established that patient trust predicts instrumental variables such as use of preventive services, adherence, and continued enrollment at least as well as satisfaction does, and is more salient for measuring the quality of ongoing relationships. Measuring trust would help to inform public policy deliberations and balance market forces that threaten the doctor-patient relationship. Several validated measures could be easily included in surveys. While further studies to evaluate the cost-effectiveness of measuring trust and test interventions to improve trust are desirable, the action merits serious consideration.

    View details for DOI 10.1377/hlthaff.23.4.124

    View details for PubMedID 15318572

  • A new instrument to measure appropriateness of services in primary care INTERNATIONAL JOURNAL FOR QUALITY IN HEALTH CARE Thom, D. H., Kravitz, R. L., Kelly-Reif, S., Sprinkle, R. V., Hopkins, J. R., Rubenstein, L. V. 2004; 16 (2): 133-140


    To develop a new instrument for judging the appropriateness of three key services (new prescription, diagnostic test, and referral) as delivered in primary care outpatient visits.Candidate items were generated by a seven-member expert panel, using a five-step nominal technique, for each of three service categories in primary care: new prescriptions, diagnostic tests, and referrals. Expert panelists and a convenience sample of 95 community-based primary care physicians ranked items for (i) importance and (ii) feasibility of ascertaining from a typical office chart record. Resulting items were used to construct a measure of appropriateness using principals of structured implicit review. Two physician reviewers used this measure to judge the appropriateness of 421 services from 160 outpatient visits.Primary care practices in a staff model health maintenance organization and a large preferred provider network.Inter-rater agreement was measured using intraclass correlation coefficient (ICC) and kappa statistic.For overall appropriateness, the ICC and kappa were 0.52 and 0.44 for new medication, 0.35 and 0.32 for diagnostic test, and 0.40 and 0.41 for referral, respectively. Only 3% of services were judged to be inappropriate by either reviewer. The proportion of services judged to be less than definitely appropriate by one or both reviewers was 56% for new medication, 31% for diagnostic test, and 22% for referral.This new measure of appropriateness of primary care services has fair inter-rater agreement for new medications and referrals, similar to appropriateness measures of other general services, but poor agreement for diagnostic tests. It may be useful as a tool to assess the appropriateness of common primary care services in studies of health care quality, but is not suitable for evaluating performance of individual physicians.

    View details for DOI 10.1093/intqhc/mzh029

    View details for Web of Science ID 000220614500003

    View details for PubMedID 15051707

  • Knowledge and beliefs regarding Type 2 diabetes mellitus in rural Mexico ETHNICITY & HEALTH Valenzuela, G. A., Mata, J. E., Mata, A. S., Gabali, C., Gaona, E., Thom, D., LeBaron, S. 2003; 8 (4): 353-360


    To investigate adults with Type 2 diabetes mellitus (DM) in a rural area of Mexico in order to explore their knowledge and beliefs regarding diabetes.A pilot study was conducted in a rural town in Morelos, Mexico. Adults over the age of 40 were invited to participate in a screening program for DM, and those who had been previously diagnosed with Type 2 DM were invited for an interview to learn about their knowledge and beliefs regarding diabetes.The glucose screening project enrolled 521 participants, including 56 previously diagnosed with Type 2 DM. Interviews were conducted with 37 of those with previously diagnosed DM. Almost all individuals in the interview sample held causal explanations based on non-scientific beliefs. Home remedies were used by a majority, and most informants used one or more methods. Blood glucose monitoring was virtually non-existent. The most frequently reported source of social support was family members. Physicians appeared to be a less important source of support.Most respondents would like to improve management of their DM, and they try to do so with whatever resources they can afford; however, a lack of information and restricted economic resources appear to limit the availability of modern medical resources. Without the availability of glucose monitoring/screening programs and affordable medication, it appears unlikely that improved treatment of Type 2 DM will occur. Dietary changes and other management approaches may be best modified through family and community influence, instead of the individual lifestyle modification strategies described in the US Type 2 DM management model.

    View details for DOI 10.1080/1355785032000163920

    View details for Web of Science ID 000187491800005

    View details for PubMedID 14660126

  • Direct observation of requests for clinical services in office practice: what do patients want and do they get it? Archives of internal medicine Kravitz, R. L., Bell, R. A., Azari, R., Kelly-Reif, S., Krupat, E., Thom, D. H. 2003; 163 (14): 1673-81


    Requests can influence the conduct and content of the medical visit. However, little is known about the nature, frequency, and impact of such requests. We performed this study to ascertain the prevalence, antecedents, and consequences of patients' requests for clinical services in ambulatory practice.This observational study combined patient and physician surveys with audiotaping of 559 visits to 45 physicians in 2 health care systems between January and November 1999. All patients had a new problem or significant health concern. Main outcome measures included prevalence of 8 categories of requests for physician action; odds of patients' requesting tests, referrals, or new prescriptions; odds of physicians' ordering diagnostic tests, making specialty referrals, or writing new prescriptions; patient satisfaction; and physicians' perceptions of the visit.The 559 patients made 545 audiocoded requests for physician action; 23% requested at least 1 diagnostic test, specialty referral, or new prescription medication. Requests for diagnostic tests were more common among new patients (P<.001). Requests for any clinical service were more common among patients experiencing greater health-related distress (P<.05) and less common among patients of cardiologists (P<.001). After adjusting for predisposing, need, and contextual factors, referral requests were associated with higher odds of receiving specialty referrals (adjusted odds ratio [AOR], 4.1; 95% confidence interval [CI], 1.6-10.7) and prescription requests were associated with higher odds of receiving new prescription medications (AOR, 2.8; 95% CI, 1.2-6.3). Physicians reported that visits during which patients requested diagnostic tests were more demanding than visits in which no such requests were made (P =.02).Though more common in primary care than in cardiology, patients' requests for clinical services are both pervasive and influential. The results support placing greater emphasis on understanding and addressing the patient's role in determining health care utilization.

    View details for DOI 10.1001/archinte.163.14.1673

    View details for PubMedID 12885682

  • Use of antibiotics is not associated with decreased risk of myocardial infarction among patients with diabetes. Diabetes care Karter, A. J., Thom, D. H., Liu, J., Moffet, H. H., Ferrara, A., Selby, J. V. 2003; 26 (7): 2100-6


    To study the relationship between exposure to antibiotic treatment and risk of subsequent myocardial infarction (MI) in patients with diabetes.A case-control design was used to assess the effect of previous antibiotic exposure in diabetes patients with acute, nonfatal or fatal MI (case subjects) and individually matched control subjects (four control subjects to one case subject, matched on sex, age, and index date). Subjects were sampled from the Northern California Kaiser Permanente Diabetes Registry, a well-characterized, ethnically diverse diabetic population from Kaiser Permanente Medical Care Program, Northern California Region. MI events were ascertained during a 2-year observation period (1998-1999). Separate conditional logistic regression models were specified to assess antibiotic exposure history (cephalosporins only, penicillins only, macrolides only, quinolones only, sulfonamides only, tetracyclines only, as well as more than one, any, or no antibiotic) for three nested windows before the index date (0-6 months, 0-12 months, 0-24 months), facilitating assessment of whether the potential effect was dependent on the timing of the exposure.A total of 1,401 MI case subjects were observed. Odds ratios were calculated in models adjusted for age, sex, race, education attainment, time since diabetes diagnosis, diabetes type and treatment, use of diet and exercise, total cholesterol, HDL cholesterol, triglyceride levels, hypertension, elevated urinary albumin excretion, serum creatinine, BMI, and smoking. We found no evidence of a protective effect of any of these therapeutic classes of antibiotics during any of the three time frames.Our study does not support the hypothesis that use of antibiotics has a protective effect for prevention of coronary heart disease in diabetic patients.

    View details for PubMedID 12832320

  • Patient choice - A Randomized controlled trial of provider selection JOURNAL OF GENERAL INTERNAL MEDICINE Hsu, J., Schmittdiel, J., Krupat, E., Stein, T., Thom, D., Fireman, B., Selby, J. 2003; 18 (5): 319–25


    To evaluate the impact of an intervention designed to help patients choose a new primary care provider (PCP) compared with the usual method of assigning patients to a new PCP.Randomized controlled trial conducted between November 1998 and June 2000.Provision of telephone or web-based provider-specific information to aid in the selection of a provider.Medical center within a large HMO.One thousand and ninety patients who were >/=30 years old, whose previous PCP had retired and who responded to a mailed questionnaire 1 year after linkage with a new PCP.The questionnaire assessed perceptions of choice, satisfaction, trust, and retention of the PCP. During the intervention period, 85% of subjects obtained a new PCP. Intervention subjects were more likely to perceive that they chose their PCP (78% vs 22%; P <.001), to retain their PCP at 1 year (93% vs 69%; P <.001), and to report greater overall satisfaction with the PCP (67% vs 57%; P <.01), compared to control subjects who were assigned to a PCP. The intervention subjects also reported greater trust in their PCP on most measures, but these differences did not remain statistically significant after adjustments for patient age, gender, ethnicity, education, and health status.Encouraging patients to choose their PCP can result in mutually beneficial outcomes for both patients and providers, such as greater overall satisfaction and duration of the relationship. Further research is needed to identify the types of information most useful in making this choice and to understand the relevant underlying patient expectations.

    View details for DOI 10.1046/j.1525-1497.2003.20145.x

    View details for Web of Science ID 000183363500001

    View details for PubMedID 12795729

    View details for PubMedCentralID PMC1494866

  • C-reactive protein, Helicobacter pylori, Chlamydia pneumoniae, cytomegalovirus and risk for myocardial infarction ANNALS OF EPIDEMIOLOGY Witherell, H. L., Smith, K. L., Friedman, G. D., Ley, C., Thom, D. H., Orentreich, N., Vogelman, J. H., Parsonnet, J. 2003; 13 (3): 170-177


    C-reactive protein (CRP), Chlamydia pneumonia, Helicobacter pylori, and cytomegalovirus (CMV) have each been associated with atherosclerosis. We assessed how infection and CRP related to risk for subsequent myocardial infarction (MI).Using a nested case-control design, we assessed how these factors independently and jointly affected risk for myocardial infarction (MI). Cases of first MI (N = 121) were identified from among participants in a multiphasic health check-up cohort. Controls without MI (N = 204) were matched to cases by gender, age, race, and date of serum collection. Sera collected at enrollment were tested for antibodies to infection and for CRP.In multivariate analysis (mean follow-up of 5.1 years), CRP was associated with MI only in subjects older than 51 years (p = 0.004). Although H. pylori infection increased risk for MI, this association was modest (OR = 1.90, 95% CI = 0.97-3.71) and was not evident in non-smokers or when adjusted for education. No association between C. pneumoniae or cytomegalovirus and MI was observed, nor was the association between CRP and MI explained by these infections.Elevated CRP is a risk factor for subsequent MI in older individuals. The relationship between Hp and MI may be due to confounding or co-linearity with socioeconomic status.

    View details for Web of Science ID 000181526000004

    View details for PubMedID 12604160

  • Proceedings of the National Institute of Diabetes and Digestive and Kidney Diseases International Symposium on Epidemiologic Issues in Urinary Incontinence in Women. American journal of obstetrics and gynecology Brown, J. S., Nyberg, L. M., Kusek, J. W., Burgio, K. L., Diokno, A. C., Foldspang, A. n., Fultz, N. H., Herzog, A. R., Hunskaar, S. n., Milsom, I. n., Nygaard, I. n., Subak, L. L., Thom, D. H. 2003; 188 (6): S77–88


    The Epidemiologic Issues in Urinary Incontinence: Current Databases and Future Collaborations Symposium included an international group of 29 investigators from 10 countries. The purpose of the symposium was to discuss the current understanding and knowledge gaps of prevalence, incidence, associated risk factors, and treatment outcomes for incontinence in women. During the symposium, investigators identified existing large databases and ongoing studies that provide substantive information on specific incontinence research questions. The investigators were able to form an international collaborative research working group and identify potential collaborative projects to further research on the epidemiology of urinary incontinence and bladder dysfunction.

    View details for PubMedID 12825024

  • Unmet expectations for care and patient-physician relationship JOURNAL OF GENERAL INTERNAL MEDICINE Bell, R. A., Kravitz, R. L., Thom, D., Krupat, E., Azari, R. 2002; 17 (11): 817–24


    To profile patients likely to have unmet expectations for care, examine the effects of such expectations, and investigate how physicians' responses to patients' requests affect the development of unfulfilled expectations.Patient and physician questionnaires were administered before and after outpatient visits. A follow-up telephone survey was administered 2 weeks post visit.The offices of 45 family practice, internal medicine, and cardiology physicians.Nine hundred nine adults reporting a health problem or concern.Before their visits, patients rated their general health and trust in the index physician. After the visit, patients reported upon 8 types of unmet expectations and any request they made. Two weeks thereafter, patients rated their visit satisfaction, improvement, and intention to adhere to the physician's advice. They also reported any postvisit health system contacts. Overall, 11.6% of patients reported >/=1 unmet expectation. Visits in which a patient held an unmet expectation were rated by physicians as less satisfying and more effortful. At follow-up, patients who perceived an unmet expectation for care also reported less satisfaction with their visits, less improvement, and weaker intentions to adhere. Patients with an unmet expectation related to clinical resource allocation had more postvisit health system contacts. Unmet expectations were typically reported by a patient whose request for a resource was not fulfilled.Unmet expectations adversely affect patients and physicians alike. Physicians' nonfulfillment of patients' requests plays a significant role in patients' beliefs that their physicians did not meet their expectations for care.

    View details for DOI 10.1046/j.1525-1497.2002.10319.x

    View details for Web of Science ID 000179196900001

    View details for PubMedID 12406352

    View details for PubMedCentralID PMC1495125

  • Patient trust in the physician: relationship to patient requests. Family practice Thom, D. H., Kravitz, R. L., Bell, R. A., Krupat, E., Azari, R. 2002; 19 (5): 476-83


    Patient trust is a key component of the patient-physician relationship. A previous qualitative study has suggested that a low level of trust is associated with unfulfilled requests.Our aim was to test the hypothesis that patients with a low level of trust will be more likely to report that requested or needed services were not provided during an office visit.An observational study was carried out of office visits by 732 patients of 45 physicians (16 family physicians, 18 general internists and 11 cardiologists), within two managed care settings. Participants were consecutive, English-speaking patients, age 18 and older who had a significant health concern. Visit questionnaires were completed by 68% of patients known to be eligible. Post-visit measures included services requested (information, examination, prescription, test or referral); services provided; and requested or needed services not provided during the visit. Measures at 2-week follow-up included patient satisfaction, intended adherence to advice, interval contacts with the health system and symptom improvement.After adjustment for patient and physician characteristics, patient trust in the physician was not associated with the likelihood that a service was requested or provided during the visit, with the exception that prescription of a new medication was more frequent among patients with higher trust. In contrast, patients with low trust prior to the visit consistently were more likely to report that a needed or requested service was not provided (P < 0.001 for all services). Patients with a low level of trust were less satisfied with their care (P < 0.001), were less likely to intend to follow the doctor's advice (P < 0.001) and were less likely to report symptom improvement at 2 weeks (P = 0.03).Patients with a lower level of trust in their physician are more likely to report that requested or needed services are not provided. Understanding this relationship may lead to better ways of responding to patient requests that preserve or enhance patient trust, leading to better outcomes.

    View details for PubMedID 12356698

  • Risk of sudden versus nonsudden cardiac death in patients with coronary artery disease AMERICAN HEART JOURNAL Every, N., Hallstrom, A., McDonald, K. M., Parsons, L., Thom, D., Weaver, D., Hlatky, M. A. 2002; 144 (3): 390-396


    Patients at high risk of sudden cardiac death, yet at low risk of nonsudden death, might be ideal candidates for antiarrhythmic drugs or devices. Most previous studies of prognostic markers for sudden cardiac death have ignored the competitive risk of nonsudden cardiac death. The goal of the present study was to evaluate the ability of clinical factors to distinguish the risks of sudden and nonsudden cardiac death.We identified all deaths during a 3.3-year follow-up of 30,680 patients discharged alive after admission to the cardiac care unit of a Seattle hospital. Detailed chart reviews were conducted on 1093 subsequent out-of-hospital sudden deaths, 973 nonsudden cardiac deaths, and 442 randomly selected control patients.Patients who died in follow-up (suddenly or nonsuddenly) were significantly different for many clinical factors from control patients. In contrast, patients with sudden cardiac death were insignificantly different for most clinical characteristics from patients with nonsudden cardiac death. The mode of death was 20% to 30% less likely to be sudden in women, patients who had angioplasty or bypass surgery, and patients prescribed beta-blockers. The mode of death was 20% to 30% more likely to be sudden in patients with heart failure, frequent ventricular ectopy, or a discharge diagnosis of acute myocardial infarction. A multivariable model had only modest predictive capacity for mode of death (c-index of 0.62).Standard clinical evaluation is much better at predicting overall risk of death than at predicting the mode of death as sudden or nonsudden.

    View details for DOI 10.1067/mhj.2002.125495

    View details for Web of Science ID 000178086800005

    View details for PubMedID 12228774

  • Pelvic organ prolapse surgery in the United States, 1997 AMERICAN JOURNAL OF OBSTETRICS AND GYNECOLOGY Brown, J. S., Waetjen, L. E., Subak, L. L., Thom, D. H., Van den Eeden, S., Vittinghoff, E. 2002; 186 (4): 712-716


    Our purpose was to describe the prevalence, regional rates and demographic characteristics, morbidity, and mortality of pelvic organ prolapse surgeries in the United States.We used data from the 1997 National Hospital Discharge Survey and the 1997 National Census to calculate rates of pelvic organ prolapse surgeries by age, race, and regional trends.In 1997, 225,964 women underwent surgery for prolapse (22.7 per 10,000 women). The mean age of these women was 54.6 years (+/-15.2). The South had the highest rate of surgery (29.3 per 10,000) and the Northeast had the lowest (16.1 per 10,000). The surgery rate for whites (19.6 per 10,000) was 3 times greater than that for African Americans (6.4 per 10,000). Although 16% of surgeries had complications, mortality was rare (0.03%).Pelvic organ prolapse surgery is common. Regional and racial differences in rates of surgery may reflect physician practice, patient preferences, and gynecologic care utilization.

    View details for DOI 10.1067/mob.2002.121897

    View details for Web of Science ID 000175545300018

    View details for PubMedID 11967496

  • Request fulfillment in office practice - Antecedents and relationship to outcomes MEDICAL CARE Kravitz, R. L., Bell, R. A., Azari, R., Krupat, E., Kelly-Reif, S., Thom, D. 2002; 40 (1): 38–51


    Patients communicate their desires and expectations largely by making requests. However, the antecedents and consequences of request fulfillment have received limited attention.To describe patient and physician characteristics associated with request fulfillment and to understand the consequences of request fulfillment and nonfulfillment on visit evaluations by patients and physicians, self-reported health care use, and health outcomes.Data were gathered from patient and physician surveys administered at several points before and after problem-driven outpatient visits.The study was carried out in the office practices of 45 family practice, internal medicine, and cardiology physicians working either in a large multispecialty group practice or in a group-model health maintenance organization.Data were collected at the index visit from 909 patients (cooperation rate, 68%; net response rate, 32%). A telephone follow-up survey was administered to 887 (98%) of these patients 2 weeks after the visit.Before the visit, patients provided ratings of their health concerns, physical functioning, role limitations, general health perceptions, and trust in the index physician. After the visit, patients reported on any request that they made, physician responses to these requests, and their satisfaction with care. At the 2-week follow-up evaluation, patients again reported on satisfaction, health concerns, health status, and self-reported postvisit health care use.Patients reported making at least one request in 84% of encounters; requests for medical information, examination, and tests or procedures were most common. Four-fifths of patients who made at least one request reported complete fulfillment of all requests. Perceived request fulfillment was significantly lower among patients with relatively low pr-visit trust in the treating physician. Higher request fulfillment was predictive of more positive patient evaluations of care. Visits in which requests could not be completely fulfilled were rated by physicians as more demanding and less satisfying. Request fulfillment was also positively associated with fewer health concerns and greater symptom improvement at follow up. Nonfulfillment of patient requests did not predict postvisit health care use.Request fulfillment affects patient and physician satisfaction and perceptions of health outcomes. New approaches that efficiently recognize and respond to patient requests are needed.

    View details for DOI 10.1097/00005650-200201000-00006

    View details for Web of Science ID 000173011000006

    View details for PubMedID 11748425

  • When physicians and patients think alike: Patient-centered beliefs and their impact on satisfaction and trust JOURNAL OF FAMILY PRACTICE Krupat, E., Bell, R. A., Kravitz, R. L., Thom, D., Azari, R. 2001; 50 (12): 1057–62


    Our goal was to identify physician and patient characteristics associated with patient-centered beliefs about the sharing of information and power, and to determine how these beliefs and the congruence of beliefs between patients and physicians affect patients' evaluations.Physicians completed a scale assessing their beliefs about sharing information and power, and provided demographic information. A sample of their patients filled out the same scale and made evaluations of their physicians before and after a target visit.Physicians and patients in a large multispecialty group practice and a group model health maintenance organization were included. Forty-five physicians in internal medicine, family practice, and cardiology participated, as well as 909 of their patients who had a significant concern.Trust in the physician was measured previsit, and visit satisfaction and physician endorsement were measured immediately postvisit.Among patients, patient-centered beliefs (a preference for information and control) were associated with being women, white, younger, more educated, and having a higher income; among physicians these beliefs were unrelated to sex, ethnicity, or experience. The patients of patient-centered physicians were no more trusting or endorsing of their physicians, and they were not more satisfied with the target visit. However, patients whose beliefs were congruent with their physicians' beliefs were more likely to trust and endorse their physicians, even though they were not more satisfied with the target visit.The extent of congruence between physicians' and patients' beliefs plays an important role in determining how patients evaluate their physicians, although satisfaction with a specific visit and overall trust may be determined differently.

    View details for Web of Science ID 000172660100009

    View details for PubMedID 11742607

  • Cost of pelvic organ prolapse surgery in the United States OBSTETRICS AND GYNECOLOGY Subak, L. L., Waetjen, L. E., Van den Eeden, S., Thom, D. H., Vittinghoff, E., Brown, J. S. 2001; 98 (4): 646-651


    To estimate the annual direct cost to society of pelvic organ prolapse operations in the United States.We multiplied the number of pelvic organ prolapse operations identified in the 1997 National Hospital Discharge Survey by national average Medicare reimbursement for physician services and hospitalizations. Although this reimbursement does not estimate the actual cost, it is a proxy for cost, which estimates what society pays for the procedures.In 1997, direct costs of pelvic organ prolapse surgery were 1012 million dollars (95% confidence interval [CI] 775 dollars, 1251 million), including 494 dollars million (49%) for vaginal hysterectomy, 279 million dollars (28%) for cystocele and rectocele repair, and 135 million dollars (13%) for abdominal hysterectomy. Physician services accounted for 29% (298 million dollars) of total costs, and hospitalization accounted for 71% (714 million dollars). Twenty-one percent of pelvic organ prolapse operations included urinary incontinence procedures (218 million dollars). If all operations were reimbursed by non-Medicare sources, the annual estimated cost would increase by 52% to 1543 million dollars.The annual direct costs of operations for pelvic organ prolapse are substantial.

    View details for Web of Science ID 000171374400021

    View details for PubMedID 11576582

  • Antibiotic use and occlusive stroke: weighing a negative result. The American journal of medicine Thom, D. H. 2001; 111 (5): 409-11

    View details for PubMedID 11583648

  • Unsaid but not forgotten - Patients' unvoiced desires in office visits ARCHIVES OF INTERNAL MEDICINE Bell, R. A., Kravitz, R. L., Thom, D., Krupat, E., Azari, R. 2001; 161 (16): 1977–84


    To examine patient, physician, and health care system characteristics associated with unvoiced desires for action, as well as the consequences of these unspoken requests.Patient surveys were administered before, immediately after, and 2 weeks after outpatient visits in the practices of 45 family practice, internal medicine, and cardiology physicians working in a multispecialty group practice or group model health maintenance organization. Data were collected at the index visit from 909 patients, of whom 97.6% were surveyed 2 weeks after the outpatient visit. Before the visit, patients rated their trust in the physician, health concerns, and health status. After the visit, patients reported on various types of unexpressed desires and rated their visit satisfaction. At follow-up, patients rated their satisfaction, health concerns, and health status, and also described their postvisit health care use. Evaluations of the visit were also obtained from physicians.Approximately 9% of the patients had 1 or more unvoiced desire(s). Desires for referrals (16.5% of desiring patients) and physical therapy (8.2%) were least likely to be communicated. Patients with unexpressed desires tended to be young, undereducated, and unmarried and were less likely to trust their physician. Patients with unvoiced desires evaluated the physician and visit less positively; these encounters were evaluated by physicians as requiring more effort. Holding an unvoiced desire was associated with less symptom improvement, but did not affect postvisit health care use.Patients' unvoiced needs affect patients' and physicians' visit evaluations and patients' subjective perceptions of improvement. Implications of these findings for clinical practice are examined.

    View details for DOI 10.1001/archinte.161.16.1977

    View details for Web of Science ID 000170816200004

    View details for PubMedID 11525700

  • Physician behaviors that predict patient trust. The Journal of family practice Thom, D. H. 2001; 50 (4): 323-8


    The goal for this study was to assess the relative strength of the association between physician behaviors and patient trust. STUDY DESIGN AND POPULATION: Patients (N=414) enrolled from 20 community-based family practices rated 18 physician behaviors and completed the Trust in Physician Scale immediately after their visits. Trust was also measured at 1 and 6 months after the visit. The association between physician behaviors and trust was examined in regard to patient sex, age, and length of relationship with the physician.All behaviors were significantly associated with trust (P<.0001), with Pearson correlation coefficients (r) ranging from 0.46 to 0.64. Being comforting and caring, demonstrating competency, encouraging and answering questions, and explaining were associated with trust among all groups. However, referring to a specialist if needed was strongly associated with trust only among women (r=0.61), more established patients (r=0.62), and younger patients (r=0.63). The behaviors least important for trust were gentleness during the examination, discussing options/asking opinions, looking in the eye, and treating as an equal.Caring and comfort, technical competency, and communication are the physician behaviors most strongly associated with patient trust. Further research is needed to test the hypothesis that changes in identified physician behaviors can lead to changes in the level of patient trust.

    View details for PubMedID 11300984

  • Opioids for chronic nonmalignant pain - Attitudes and practices of primary care physicians in the UCSF/Stanford Collaborative Research Network 26th Annual North-American-Primary-Care-Research-Group Meeting Potter, M., Schafer, S., Gonzalez-Mendez, E., Gjeltema, K., Lopez, A., Wu, J., Pedrin, R., Cozen, M., Wilson, R., Thom, D., Croughan-Minihane, M. DOWDEN HEALTH MEDIA. 2001: 145–51


    We hoped to determine the attitudes and practices of primary care physicians regarding the use of opioids to treat chronic nonmalignant pain (CNMP). We also examined the factors associated with the willingness to prescribe opioids for CNMP.A survey was mailed to primary care physicians in the University of California, San Francisco/Stanford Collaborative Research Network. This survey contained questions regarding treatment in response to 3 case vignettes, the use of opioids for CNMP in general, and the demographic characteristics of the physicians.Among 230 physicians surveyed, 161 (70%) responded. Two percent of the respondents were never willing to prescribe schedule III opioids (eg, acetaminophen with codeine) as needed for patients with CNMP that persisted unchanged after exhaustive evaluation and attempts at treatment. Thirty-five percent were never willing to prescribe schedule II opioids (eg, sustained-release morphine) on an around-the-clock schedule for these patients. The most significant predictor of willingness to prescribe opioids for patients with CNMP was a lower level of concern about physical dependence, tolerance, and addiction.Primary care physicians are willing to prescribe schedule III opioids as needed, but many are unwilling to use schedule II opioids around the clock for CNMP. Individual prescribing practices vary widely among primary care physicians. Concerns about physical dependence, tolerance, and addiction are barriers to the prescription of opioids by primary care physicians for patients with CNMP.

    View details for Web of Science ID 000166923400011

    View details for PubMedID 11219563

  • Re: "Differences in socioeconomic status and survival among white and black men with prostate cancer" - Reply AMERICAN JOURNAL OF EPIDEMIOLOGY Robbins, A. S., Whittemore, A. S., Thom, D. H. 2000; 152 (5): 494-494
  • Hysterectomy and urinary incontinence: a systematic review LANCET Brown, J. S., Sawaya, G., Thom, D. H., Grady, D. 2000; 356 (9229): 535–39


    Serious complications after hysterectomy are estimated to occur in around six women per 10,000 hysterectomies in the USA. We did a systematic review of evidence that hysterectomy is associated with urinary incontinence.We identified English-language and non-English-language articles registered on MEDLINE from January, 1966, to December, 1997, did manual review of references, and consulted specialists. We identified 45 articles reporting on the association of urinary incontinence and hysterectomy. We selected reports that presented original data on development of incontinence in women who underwent hysterectomy compared with those who did not. Results were abstracted by two independent reviewers and summarised with a random-effects model.12 papers met our selection criteria--eight cross-sectional studies, two prospective cohort studies, one case-control study, and one randomised controlled trial. The summary estimate was consistent with increased odds for incontinence in women with hysterectomy. Because incontinence might not develop for many years after hysterectomy, we stratified the findings by age at assessment of incontinence. Among women who were 60 years or older, the summary odds ratio for urinary incontinence was increased by 60% (1.6 [95% CI 1.4-1.8]) but odds were not increased for women younger than 60 years.When women are counselled about sequelae of hysterectomy, practitioners should discuss the possibility of an increased likelihood of incontinence in later life.

    View details for DOI 10.1016/S0140-6736(00)02577-0

    View details for Web of Science ID 000088820800009

    View details for PubMedID 10950229

  • Training physicians to increase patient trust. Journal of evaluation in clinical practice Thom, D. H. 2000; 6 (3): 245-53


    Patient trust in the physician is an important aspect of the patient-physician relationship that has recently become a focus of interest, in part due to the rise of managed care in the US healthcare system. In a previous study, we identified physician behaviours reported by patients as important to establishing their trust in the physician. The current study attempted to modify these behaviours via a short training programme and thereby to increase patient trust and improve associated outcomes. After baseline measurements, 10 physicians were randomized to the intervention group and 10 remained as a control group. While intervention physicians showed a net improvement in 16 of 19 specific patient-reported behaviours when compared to control physicians, these differences were not statistically significant. There was also no significant difference in patient trust, patient satisfaction, continuity, self-reported adherence, number of referrals or number of diagnostic tests ordered. This short training course in a group of self-selected physicians was not a sufficiently strong intervention to achieve the desired effect. Suggestions are given for designing a stronger training intervention.

    View details for PubMedID 11083035

  • Differences in socioeconomic status and survival among white and black men with prostate cancer AMERICAN JOURNAL OF EPIDEMIOLOGY Robbins, A. S., Whittemore, A. S., Thom, D. H. 2000; 151 (4): 409-416


    After diagnosis with prostate cancer, Black men in the United States have poorer survival than White men, even after controlling for differences in cancer stage. The extent to which these racial survival differences are due to biologic versus non-biologic factors is unclear, and it has been hypothesized that differences associated with socioeconomic status (SES) might account for much of the observed survival difference. The authors examined this hypothesis in a cohort study, using cancer registry and US Census data for White and Black men with incident prostate cancer (n = 23,334) who resided in 1,005 census tracts in the San Francisco Bay Area during 1973-1993. Separate analyses were conducted using two endpoints: death from prostate cancer and death from other causes. For each endpoint, death rate ratios (Blacks vs. Whites) were computed for men diagnosed at ages <65 years and at ages > or =65 years. These data suggest that differences associated with SES do not explain why Black men die from prostate cancer at a higher rate when compared with White men with this condition. However, among men with prostate cancer, SES-associated differences appear to explain almost all of the racial difference in risk of death from other causes.

    View details for Web of Science ID 000085474800010

    View details for PubMedID 10695600

  • Further validation and reliability testing of the Trust in Physician Scale. The Stanford Trust Study Physicians. Medical care Thom, D. H., Ribisl, K. M., Stewart, A. L., Luke, D. A. 1999; 37 (5): 510-7


    To further validate and assess the reliability and validity of the Trust in Physician Scale.Consecutive adult patients (n = 414) from 20 community-based, primary care practices were enrolled in a prospective, 6-month study. At enrollment, subjects completed the 11-item Trust in Physician Scale plus measures of demographics, preferences for care, and satisfaction with care received from the physician. Continuity, satisfaction with care, and self-reported adherence to treatment were measured at 6 months. Reliability, construct validity, and predictive validity were assessed using correlation coefficients and analysis of variance techniques.The Trust in Physician Scale showed high internal consistency (Cronbach's alpha = .89) and good 1-month test-retest reliability (intraclass correlation coefficient = .77). As expected, trust increased with the length of the relationship and was higher among patients who actively chose their physician, who preferred more physician involvement, and who expected their physician to care for a larger proportion of their problems (P < 0.001 for all associations). Baseline trust predicted continuity with the physician, self-reported adherence to medication, and satisfaction at 6 months after adjustment for gender, age, education, length of the relationship, active choice of the physician, and preferences for care. After additional adjustment for baseline satisfaction with physician care, trust remained a significant predictor of continuity, adherence, and satisfaction.The Trust in Physician Scale has desirable psychometric characteristics and demonstrates construct and predictive validity. It appears to be related to, but still distinct from, patient satisfaction with the physician and, thus, provides a valuable additional measure for assessment of the quality of the patient-physician relationship.

    View details for PubMedID 10335753

  • An intervention to increase patients' trust in their physicians ACADEMIC MEDICINE Thom, D. H., Bloch, D. A., Segal, E. S. 1999; 74 (2): 195-198


    To investigate the effect of a one-day workshop in which physicians were taught trust-building behaviors on their patients' levels of trust and on outcomes of care.In 1994, the study recruited 20 community-based family physicians and enrolled 412 consecutive adult patients from those physicians' practices. Ten of the physicians (the intervention group) were randomly assigned to receive a one-day training course in building and maintaining patients' trust. Outcomes were patients' trust in their physicians, patients' and physicians' satisfaction with the office visit, continuity in the patient-physician relationship, patients' adherence to their treatment plans, and the numbers of diagnostic tests and referrals.Physicians and patients in the intervention and control groups were similar in demographic and other data. There was no significant difference in any outcome. Although their overall ratings were not statistically significantly different, the patients of physicians in the intervention group reported more positive physician behaviors than did the patients of physicians in the control group.The trust-building workshop had no measurable effect on patients' trust or on outcomes hypothesized to be related to trust.

    View details for Web of Science ID 000078705800028

    View details for PubMedID 10065061

  • Research interests of physicians in two practice-based primary care research networks. The Western journal of medicine Croughan-Minihane, M. S., Thom, D. H., Petitti, D. B. 1999; 170 (1): 19-24


    Regional practice-based network research has grown significantly in the past 15 years. Previous studies have reported on characteristics of physicians who participate in network research, but little is known about the specific a priori research interests of practicing physicians. Knowledge of such interests could be useful in planning network research studies. We conducted a mail survey to assess the research interests of primary care physicians in two contiguous research networks at the University of California at San Francisco (UCSF) and at Stanford University. Among 120 respondents from the UCSF Collaborative Research Network and 85 from the Stanford Ambulatory Research Network, the most common topics of interest were disease prevention, communication and compliance, and managed care. Among specific conditions, heart disease, hypertension, and respiratory infection were of interest to the majority of respondents. Topics not of interest to network members were obstetrics, diagnostic procedures, alcoholism, drug abuse, tuberculosis, male genito-urinary problems, occupational hazards, domestic violence, and AIDS and HIV. Identification of network physician research interests can help focus research and recruitment efforts on topics of interest and provide estimates of participation levels for planning studies and preparing funding applications for research networks.

    View details for PubMedID 9926731

    View details for PubMedCentralID PMC1305430

  • Reproductive and hormonal risk factors for urinary incontinence in later life: A review of the clinical and epidemiologic literature JOURNAL OF THE AMERICAN GERIATRICS SOCIETY Thom, D. H., Brown, J. S. 1998; 46 (11): 1411-1417


    To review and integrate the current literature on the role of reproductive factors in the development of urinary incontinence in later life.An extensive literature review using Medline and Science Citation Index for the period 1966 through 1997 was undertaken to identify published studies of the association between parturition events, hysterectomy, menopause, estrogen therapy, and later urinary incontinence.Vaginal delivery is an established risk factor for both transient postpartum incontinence and the development of incontinence in later life. Several studies have found evidence of nerve and muscle damage that provide a physiologic basis for this association. Prospective studies of incontinence after hysterectomy have generally found no increased risk in the first few years. In contrast, cross-sectional epidemiologic studies have consistently found an increased risk many years after hysterectomy. Although menopause is often considered a risk factor for urinary incontinence, epidemiological studies have generally not found an increase in the prevalence of incontinence in the perimenopausal period. Oral estrogen replacement therapy seems to have little short-term clinical benefit in regard to incontinence and is associated consistently with increased risk of incontinence in women aged 60 years and older in epidemiologic studies.This review provides a framework for further investigation of the complex relationships between reproductive risk factors and urinary incontinence. Integration of physiologic, clinical, and epidemiologic studies is needed to address the compelling health care issue of urinary incontinence. Suggestions are made for further areas of research.

    View details for Web of Science ID 000076784000012

    View details for PubMedID 9809764

  • Variation in estimates of urinary incontinence prevalence in the community: Effects of differences in definition, population characteristics, and study type JOURNAL OF THE AMERICAN GERIATRICS SOCIETY Thom, D. 1998; 46 (4): 473–80


    Prevalence estimates for urinary incontinence among community-dwelling adults vary from 2 to 55%. A review of the literature was undertaken to investigate the degree to which differences in definitions of incontinence, age, and gender of the populations studied, response rates, measurement techniques, or location could explain differences in reported prevalences.A literature search was conducted to locate all studies published in English reporting the prevalence of urinary incontinence in a population-based sample of adults.Information was abstracted for study size, response rate, type of survey, definition of urinary incontinence, and prevalence of incontinence by age group and gender. Prevalence by type of incontinence was also abstracted where available. Stratification was used to obtain prevalence estimates specific for age, gender, and frequency of incontinence. Data were examined for associations between prevalence and survey type, response rate, year, and location of survey.A total of 21 studies met inclusion criteria. Stratification of reported prevalence by frequency, gender, and age substantially reduced the variation in prevalence estimates. For older women, the estimated prevalence of urinary incontinence ranged from 17 to 55% (median = 35%, pooled mean = 34%), and for daily incontinence it ranged from 3 to 17% (median = 14%, pooled mean = 12%). For older men, incontinence prevalence was estimated to be 11 to 34% (median = 17%, pooled mean = 22%), and 2 to 11% reported daily incontinence (median = 4%, pooled mean = 5%). Within studies, the prevalence of any incontinence was 1.3 to 2.0 times greater for older women than for older men. Among middle-aged and younger adults, prevalence of incontinence ranged from 12 to 42% (median = 28%, pooled mean = 25%) for women and from 3 to 5% (median = 4%, pooled mean = 5%) for men. The ratio of prevalence of any incontinence for women to men in this age group ranged from 4.1 to 4.5. Stress incontinence predominated in younger women, whereas urge and mixed incontinence predominated in older women. There was a tendency for studies using in-person interviews to report higher prevalences.An accurate estimate of the prevalence of urinary incontinence depends on specifying the definition of incontinence and the age and gender groups of interest.

    View details for DOI 10.1111/j.1532-5415.1998.tb02469.x

    View details for Web of Science ID 000072973100012

    View details for PubMedID 9560071

  • Use and accuracy of state death certificates for classification of sudden cardiac deaths in high-risk populations AMERICAN HEART JOURNAL Every, N. R., Parsons, L., Hlatky, M. A., McDonald, K. M., Thom, D., Hallstrom, A. P., Martin, J. S., Weaver, W. D. 1997; 134 (6): 1129-1132


    In a large cohort of patients with known or suspected coronary disease, we evaluated the characteristics of 407 patients who died after hospital discharge and tested whether the state death certificate can be used to classify deaths as sudden cardiac versus nonsudden. Compared with a paramedic classification system based on heart rhythm, the death certificate-based classification resulted in a sensitivity that ranged from 78% to 85% and a specificity that ranged from 25% to 58%. We conclude that the death certificate can be used to identify cases of sudden cardiac death in patients at high risk; however, there is a substantial rate of false-positive sudden death classification.

    View details for Web of Science ID 000071254500020

    View details for PubMedID 9424075

  • Evaluation of parturition and other reproductive variables as risk factors for urinary incontinence in later life OBSTETRICS AND GYNECOLOGY Thom, D. H., VANDENEEDEN, S. K., Brown, J. S. 1997; 90 (6): 983-989


    To assess specific parturition and reproductive variables as potential risk factors for urinary incontinence in later life.A mail survey was conducted with a random sample of 1922 women members of a large health maintenance organization. Multivariate analysis was used to estimate the independent association between parturition factors, hysterectomy, hormone use, and incontinence.Completed surveys were returned by 939 women (49%), 682 of whom reported at least one episode of incontinence in the past 12 months or ever having been treated for incontinence. On univariate analysis, women with incontinence were more likely to be white and heavier and to have had a hysterectomy before age 45, at least one live birth, a postdate (at least 42 weeks' gestation) birth, a labor lasting longer than 24 hours, and exposure to oxytocin. The risk of incontinence increased significantly with the number of exposures to oxytocin. In a multivariate model including age, there was a significant association between incontinence and white race (odds ratio [OR] 1.8, 95% confidence interval [CI] 1.2, 2.8), body mass (OR for fourth quartile 3.0, 95% CI 1.8, 5.0), estrogen replacement (OR 1.9, 95% CI 1.3, 2.8) and oxytocin (OR 1.9, 95% CI 1.0, 3.6). Parity was also associated with incontinence (P < .05).This study supports previous findings of a positive association between urinary incontinence and body mass, parity, and use of estrogen. In addition, we found a significant independent association between exposure to oxytocin during labor and incontinence in later life.

    View details for Web of Science ID A1997YH88500026

    View details for PubMedID 9397116

  • Effects of a self-administered previsit questionnaire to enhance awareness of patients' concerns in primary care JOURNAL OF GENERAL INTERNAL MEDICINE Hornberger, J., Thom, D., MaCurdy, T. 1997; 12 (10): 597-606


    To determine if a self-administered previsit questionnaire designed to increase awareness of patients' concerns alters the visit duration, content of the discussion, and patient and physician satisfaction.A balanced, two-arm trial in which physicians were randomized.Two primary-care clinics affiliated with a university hospital.Ten physicians and 201 continuity-care patients.In intervention visits, patients completed a previsit questionnaire asking about the desire for medical information, psychosocial assistance, therapeutic listening, general health advice, and biomedical treatment. Physicians reviewed questionnaires with patients during the visit.We used audiotapes of encounters to quantify the duration of the encounter and measured the number and type of diagnoses discussed in the visit, and patient and physician satisfaction with the encounter. Intervention visits were 34% longer (increase of 6.8 minutes; 95% confidence interval [CI] 0.4, 13.2) than control visits with most of the additional time spent in discussion of biomedical diagnoses (3.35 minutes; 95% CI 0.00, 6.72) and in the performance of the physical examination (2.7 minutes; 95% CI 0.5, 4.9). The number of diagnoses discussed per visit was 30% higher in intervention visits (increase of 1.7 diagnoses per visit; 95% CI 0.3, 3.2), but patients' satisfaction with these visits tended to be lower.Using a previsit questionnaire to increase awareness of the patients' concerns may entail a trade-off between conflicting goals: trying to respond to patient concerns while not significantly increasing the cost per visit. A future challenge is to develop and refine techniques with sufficient efficacy to justify the expense of implementing the intervention and the longer visit needed to respond adequately to patients' concerns.

    View details for Web of Science ID A1997YA45700002

    View details for PubMedID 9346455

    View details for PubMedCentralID PMC1497170

  • Medically recognized urinary incontinence and risks of hospitalization, nursing home admission and mortality AGE AND AGEING Thom, D. H., Haan, M. N., VandenEeden, S. K. 1997; 26 (5): 367–74


    this study examined the association between medically recognized urinary incontinence and risk of several disease conditions, hospitalization, nursing home admission and and abstraction of medical records and computerized data bases from 5986 members, aged 65 years and older, of a large health maintenance organization in northern California.there was an increased risk of newly recognized urinary incontinence following a diagnosis of Parkinson's disease, dementia, stroke, depression and congestive heart failure in both men and women, after adjustment for age and cohort. The risk of hospitalization was 30% higher in women following the diagnosis of incontinence [relative risk (RR) = 1.3, 95% confidence interval (CI) = 1.2-1.5] and 50% higher in men (RR = 1.5, 95% CI = 1.3-1.6) after adjustment for age, cohort and co-morbid conditions. The adjusted risk of admission to a nursing facility was 2.0 times greater for incontinent women (95% CI = 1.7-2.4) and 3.2 times greater for incontinent men (95% CI = 2.7-3.8). In contrast, the adjusted risk of mortality was only slightly greater for women (RR = 1.1; 95% CI = 0.99-1.3) and men (RR= 1.2; 95% CI= 1.1-1.4).urinary incontinence increases the risk of hospitalization and substantially increases the risk of admission to a nursing home, independently of age, gender and the presence of other disease conditions, but has little effect on total mortality.

    View details for DOI 10.1093/ageing/26.5.367

    View details for Web of Science ID A1997XZ09600007

    View details for PubMedID 9351481

  • Patient-physician trust: An exploratory study JOURNAL OF FAMILY PRACTICE Thom, D. H., Campbell, B. 1997; 44 (2): 169–76


    Patients' trust in their physicians has recently become a focus of concern, largely owing to the rise of managed care, yet the subject remains largely unstudied. We undertook a qualitative research study of patients' self-reported experiences with trust in a physician to gain further understanding of the components of trust in the context of the patient-physician relationship.Twenty-nine patients participants, aged 26 to 72, were recruited from three diverse practice sites. Four focus groups, each lasting 1.5 to 2 hours, were conducted to explore patients' experiences with trust. Focus groups were audio-recorded, transcribed, and coded by four readers, using principles of grounded theory.The resulting consensus codes were grouped into seven categories of physician behavior, two of which related primarily to technical competence (thoroughness in evaluation and providing appropriate and effective treatment) and five of which were interpersonal (understanding patient's individual experience, expressing caring, communicating clearly and completely, building partnership/sharing power and honesty/respect for patient). Two additional categories were predisposing factors and structural/staffing factors. Each major category had multiple subcategories. Specific examples from each major category are provided.These nine categories of physician behavior encompassed the trust experiences related by the 29 patients. These categories and the specific examples provided by patients provide insights into the process of trust formation and suggest ways in which physicians could be more effective in building and maintaining trust.

    View details for Web of Science ID A1997WH21000007

    View details for PubMedID 9040520


    View details for Web of Science ID A1995QZ28000053

    View details for PubMedID 7748416

  • Respiratory infection with Chlamydia pneumoniae in middle-aged and older adult outpatients. European journal of clinical microbiology & infectious diseases : official publication of the European Society of Clinical Microbiology Thom, D. H., Grayston, J. T., Campbell, L. A., Kuo, C. C., Diwan, V. K., Wang, S. P. 1994; 13 (10): 785-92


    This study was undertaken to characterize the epidemiology and clinical presentation of infection with Chlamydia pneumoniae in a population composed primarily of middle-aged and older adults. Pharyngeal swabs and acute and convalescent phase sera were obtained from outpatients presenting with signs and symptoms of an acute respiratory infection. Sera were examined using the micro-immunofluorescence (MIF) test to detect antibody to Chlamydia pneumoniae and complement fixation tests to detect Mycoplasma pneumoniae, influenza A virus, influenza B virus, respiratory syncytial virus and adenovirus. Pharyngeal swab specimens were cultured for Chlamydia pneumoniae and tested for Chlamydia pneumoniae by the polymerase chain reaction (PCR). A total of 743 patients with a mean age of 40.5 +/- 16.1 years were enrolled in the study. Twenty-one patients were serologically positive for acute Chlamydia pneumoniae infection in the MIF test. PCR was positive in 15 of the 20 serologically positive patients tested. Acute Chlamydia pneumoniae infection was identified in 3% (2/76) of subjects with pneumonia, 5% (12/247) of those with bronchitis, 5% (3/61) of those with sinusitis only and 2% (2/103) of those with pharyngitis only. Of the 21 patients with Chlamydia pneumoniae infection, seven (mean age of 33 years) had an antibody pattern suggesting a primary infection while 14 (mean age of 54 years) had a reinfection pattern. Patients with reinfection had milder disease than those with primary infection. PCR testing in the current study confirms the previously proposed serologic criteria of acute Chlamydia pneumoniae infection.

    View details for PubMedID 7889946

  • Lower respiratory tract infection with Chlamydia pneumoniae. Archives of family medicine Thom, D. 1994; 3 (9): 828-32


    Chlamydia pneumoniae, also known as TWAR, is a common respiratory pathogen that can cause pneumonia, bronchitis, sinusitis, and pharyngitis. The clinical similarities between C pneumoniae infection and infection with other respiratory pathogens together with the lack, until recently, of readily available diagnostic tests for C pneumoniae have hindered its recognition and treatment in the outpatient setting. In this report, three patients with acute C pneumoniae infection from the Acute Respiratory Disease Study at the University of Washington are described, and the microbiologic characteristics, epidemiologic characteristics, clinical presentations, diagnosis, and treatment of acute C pneumoniae infection are considered.

    View details for PubMedID 7987518



    To evaluate the association between prior infection with Chlamydia pneumoniae, as measured by IgG antibody, and coronary artery disease.A population-based, case-control study.Group Health Cooperative of Puget Sound, a Seattle-based health maintenance organization.Men 55 years of age and younger and women 65 years of age and younger. Cases (n = 171) were members of Group Health Cooperative undergoing diagnostic coronary angiography who had at least one coronary artery lesion occupying 50% or more of the luminal diameter. The population controls (n = 120) were Group Health Cooperative members without known coronary heart disease.The adjusted odds ratio (OR) for coronary artery disease associated with prior C pneumoniae infection as measured by the presence of IgG antibody.After adjusting for age, gender, and calendar quarter of blood drawing, the OR for coronary artery disease associated with the presence of antibody was 2.6 (95% confidence interval, 1.4 to 4.8). The association was limited to cigarette smokers, in whom the OR was 3.5 (95% confidence interval, 1.7 to 7.0). Among never-smokers, the OR was 0.8 (95% confidence interval, 0.3 to 1.9). When cases and controls were restricted to those assayed concurrently, the adjusted OR (smokers and nonsmokers combined) was 4.2 (95% confidence interval, 1.8 to 10.0). Adjustment for serum cholesterol, hypertension, alcohol use, diabetes, and socioeconomic status did not change these results. Only a week association was found when cases were compared with 63 subjects whose angiographic results were normal (OR, 1.2; 95% confidence interval, 0.6 to 2.2).These results generally support the previously reported association between C pneumoniae infection and coronary heart disease. However, caution should be used in interpreting the basis for this association.

    View details for Web of Science ID A1992JA16500025

    View details for PubMedID 1608116



    Our purpose was to evaluate the association between spontaneous abortion and subsequent adverse birth outcomes.Washington State birth certificate records for 1984 to 1987 were used to examine the association between spontaneous abortion and adverse outcomes in the subsequent live birth. Adverse birth outcomes were examined for women with one spontaneous abortion before the index pregnancy (n = 2146) and for women with three or more prior spontaneous abortions and no other prior pregnancies (n = 638); compared with women with no prior spontaneous abortions (n = 3099). Logistic regression was used to estimate the relative risk associated with prior spontaneous abortion of each adverse outcome.Women with three or more prior spontaneous abortions were at higher risk for delivery at less than 37 weeks' gestation (relative risk 1.5, 95% confidence interval 1.1 to 2.1), placenta previa (relative risk 6.0, 95% confidence interval 1.6 to 22.2), having membranes ruptured greater than 24 hours (relative risk 1.8, 95% confidence interval 1.2 to 2.9), breech presentation (relative risk 2.4, 95% confidence interval 1.6 to 3.6), and having an infant with a congenital malformation (relative risk 1.8, 95% confidence interval 1.1 to 3.0).These findings suggest that common causes may underlie recurrent spontaneous abortion and certain adverse birth outcomes. They may also help guide clinical management of pregnancies in women with a history of recurrent spontaneous abortions.

    View details for Web of Science ID A1992HA45100027

    View details for PubMedID 1733179

  • Chlamydia pneumoniae strain TWAR antibody and angiographically demonstrated coronary artery disease. Arteriosclerosis and thrombosis : a journal of vascular biology Thom, D. H., Wang, S. P., Grayston, J. T., Siscovick, D. S., Stewart, D. K., Kronmal, R. A., Weiss, N. S. 1991; 11 (3): 547-51


    A recent case-control study from Finland reported a strong association between high antibody titers to Chlamydia pneumoniae, strain TWAR, and both chronic coronary heart disease and acute myocardial infarction. The current case-control study investigated the relation between C. pneumoniae immunoglobulin G antibody titers and angiographically diagnosed coronary artery disease. Cases (n = 461) were angiography patients with at least one coronary artery lesion occupying at least 50% of the luminal diameter. Controls (n = 95) were angiography patients with no demonstrable coronary artery disease. After standardization for age and gender, the geometric mean antibody titer was higher for cases than for controls (30.0 versus 24.0, p = 0.04). The estimated risk of coronary artery disease, adjusted for age and gender, was greater among subjects with high (greater than or equal to 1:64) antibody titers than among subjects with low (less than or equal to 1:8) antibody titers (relative risk, 2.0; 95% confidence interval, 1.0-4.0). The risk associated with a high antibody titer was particularly great for coronary artery disease with five or more lesions (relative risk, 2.8; 95% confidence interval, 1.2-7.0). The results of this cross-sectional study support an association between infection with C. pneumoniae and coronary artery disease.

    View details for PubMedID 2029495

  • Chlamydia pneumoniae strain TWAR, Mycoplasma pneumoniae, and viral infections in acute respiratory disease in a university student health clinic population. American journal of epidemiology Thom, D. H., Grayston, J. T., Wang, S. P., Kuo, C. C., Altman, J. 1990; 132 (2): 248-56


    Clinical and serologic data were collected on 667 University of Washington students who presented to the David Hall Student Health Center between 1983 and 1987 with acute respiratory disease. Sera were tested for evidence of acute or past infections with Chlamydia pneumoniae strain TWAR, Chlamydia trachomatis, Mycoplasma pneumoniae, influenza A virus, influenza B virus, adenovirus, and respiratory syncytial virus. Pharyngeal swab specimens were cultured for C. pneumoniae and C. trachomatis, but not for the other agents. Evidence of acute infection with C. pneumoniae was found in 20 patients and evidence of an acute infection with M. pneumoniae in 29 patients. C. pneumoniae was associated with 9% and M. pneumoniae with 11% of 149 pneumonias diagnosed clinically, and with 20% and 22%, respectively, of the 59 pneumonias confirmed on chest radiograph. There was no evidence of seasonality in C. pneumoniae or M. pneumoniae infections. Compared with patients with M. pneumoniae, patients with C. pneumoniae were less likely to have a temperature greater than 37.8 degrees C (10% vs. 34%), but were more likely to present with a sore throat (80% vs. 52%) or hoarseness (30% vs. 3%). The mean number of days from onset of symptoms until enrollment was longer in patients with C. pneumoniae infections than in those with M. pneumoniae (12.8 vs. 7.9 days), or those with a viral infection (12.8 vs. 7.3 days), suggesting a more gradual onset of disease caused by C. pneumoniae.

    View details for PubMedID 2372005

  • A new respiratory tract pathogen: Chlamydia pneumoniae strain TWAR. The Journal of infectious diseases Grayston, J. T., Campbell, L. A., Kuo, C. C., Mordhorst, C. H., Saikku, P., Thom, D. H., Wang, S. P. 1990; 161 (4): 618-25


    Chlamydia pneumoniae strain TWAR, the new third species of Chlamydia, is a common cause of pneumonia and other acute respiratory tract infections. About 10% of hospitalized and outpatient pneumonia cases have been associated with TWAR infection. TWAR is among the four or five most commonly identified causes of all pneumonia. Most TWAR infections are mild or asymptomatic, but occasionally severe pneumonia with death has been observed. Laboratory diagnosis is not generally available. Vigorous treatment with tetracycline or erythromycin is recommended. Both epidemic and endemic infections have been described in North America and the Nordic Countries. Population prevalence antibody studies suggest that TWAR infection is wide-spread throughout the world, that nearly everyone is infected and reinfected during their life-time, and that infection is common in all ages except those less than 5 years in temperate zone countries. The infection is transmitted from person to person, apparently with a long incubation period.

    View details for PubMedID 2181028