Dulin, M. F., L. F. Hatcher, et al. (2006). "Policosanol is ineffective in the treatment of hypercholesterolemia: a randomized controlled trial." Am J Clin Nutr 84(6): 1543-1548.

BACKGROUND: Policosanol is one of the fastest growing over-the-counter supplements sold in the United States. The use of policosanol to treat elevated cholesterol is based on clinical trials conducted in Cuba, which showed sugar cane-derived policosanol to be similar in efficacy to statins. Recent studies have challenged these findings, but there have been no trials conducted in North America that have examined the ability of sugar cane-derived policosanol to lower cholesterol. OBJECTIVES: This study investigated the efficacy of sugar cane-derived policosanol in healthy adults with mild hypercholesterolemia. The primary outcome was the percentage change in LDL cholesterol after 8 wk of therapy. Secondary outcome measures included changes in total cholesterol, HDL cholesterol, triacylglycerols, C-reactive protein, and nuclear magnetic resonance-determined lipoprotein profile. Dietary habits, weight, and blood pressure were also monitored. DESIGN: Ambulatory, community-dwelling healthy adults with mild hypercholesterolemia (n = 40) were assigned to receive oral policosanol (20 mg) or placebo once daily for 8 wk. This was a double-blind, randomized controlled trial conducted from January through August 2005. RESULTS: No significant differences in the change in LDL cholesterol were observed between the placebo (n = 20) and policosanol (n = 20) groups. Also, no significant changes in secondary outcome measures, including total cholesterol, HDL cholesterol, triacylglycerol, C-reactive protein, and nuclear magnetic resonance spectroscopy-determined profiles were observed. Policosanol was well tolerated, and no significant adverse events were noted. CONCLUSION: Policosanol does not alter the serum lipid profile over an 8-wk period in adults with mild hypercholesterolemia.

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Dulin, M. K., K. E. Olive, et al. (2006). "The financial value of services provided by a rural community health fair." J Health Care Poor Underserved 17(4): 821-829.

There has been little discussion in the literature regarding the financial value of the services provided to the participants in health fairs. This article examines the financial value of preventive services provided through a community health fair in an economically depressed area of southwest Virginia. Current Procedural Terminology codes were assigned to the services provided in order to estimate costs participants might incur for such services. An average 50-year-old man would have paid up to $320 to obtain commonly recommended preventive services available free at the fair. An average 50-year-old woman would have paid up to $495. Overall, more than $58,000 in services were provided through the health fair. This community health fair provided preventive services that many participants otherwise might have found to be cost-prohibitive.

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Dulin, M. F., T. P. Kennard, et al. (2008). "Management of cervical lymphadenitis in children." Am Fam Physician 78(9): 1097-1098.

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Hirsch, M. A., M. Dulin, et al. (2009). "Exercise for management and treatment of Parkinson disease." Am Fam Physician 79(12): 1043.

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Dulin, M. F., T. M. Ludden, et al. (2010). "Using Geographic Information Systems (GIS) to understand a community's primary care needs." J Am Board Fam Med 23(1): 13-21.

INTRODUCTION: A key element for reducing health care costs and improving community health is increased access to primary care and preventative health services. Geographic information systems (GIS) have the potential to assess patterns of health care utilization and community-level attributes to identify geographic regions most in need of primary care access. METHODS: GIS, analytical hierarchy process, and multiattribute assessment and evaluation techniques were used to examine attributes describing primary care need and identify areas that would benefit from increased access to primary care services. Attributes were identified by a collaborative partnership working within a practice-based research network using tenets of community-based participatory research. Maps were created based on socioeconomic status, population density, insurance status, and emergency department and primary care safety-net utilization. RESULTS: Individual and composite maps identified areas in our community with the greatest need for increased access to primary care services. CONCLUSIONS: Applying GIS to commonly available community- and patient-level data can rapidly identify areas most in need of increased access to primary care services. We have termed this a Multiple Attribute Primary Care Targeting Strategy. This model can be used to plan health services delivery as well as to target and evaluate interventions designed to improve health care access.

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Dulin, M. F., T. M. Ludden, et al. (2010). "Geographic Information Systems (GIS) demonstrating primary care needs for a transitioning Hispanic community." J Am Board Fam Med 23(1): 109-120.

BACKGROUND: Hispanics are the largest and fastest growing minority group in the United States. Charlotte, NC, had the 4th fastest growing Hispanic community in the nation between 1990 to 2000. Gaining understanding of the patterns of health care use for this changing population is a key step toward designing improved primary care access and community health. METHODS: The Multiple Attribute Primary Care Targeting Strategy process was applied to key patient- and community-level attributes describing the Charlotte Hispanic community. Maps were created based on socioeconomic status, population density, insurance status, and use of the emergency department as a primary care safety net. Each of these variables was weighed and added to create a single composite map. RESULTS: Individual attribute maps and the composite map identified geographic locations where Hispanic community members would most benefit from increased access to primary care services. CONCLUSIONS: Using the Multiple Attribute Primary Care Targeting Strategy process we were able to identify geographic areas within our community where many Hispanic immigrants face barriers to accessing appropriate primary care services. These areas can subsequently be targeted for interventions that improve access to primary care and reduce emergency department use. The geospatial model created through this process can be monitored over time to determine the effectiveness of these interventions.

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Tapp, H. and M. Dulin (2010). "The science of primary health-care improvement: potential and use of community-based participatory research by practice-based research networks for translation of research into practice." Exp Biol Med (Maywood) 235(3): 290-299.

There is a need for new approaches to supplement the existing methods of taking research from bench to bedside and from bedside to practice. Community-based participatory research (CBPR) is an emerging model of research that enhances ongoing clinical research by involving key stakeholders, including community members and patients. A practice-based research network (PBRN) is a group of primary care practices devoted principally not only to the primary care of patients, but also with a mission to investigate questions related to community-based practice and to improve the quality of primary care. Traditionally, PBRN research has not included patients or community members, while CBPR has excluded health providers as key stakeholders. Typical overlap topics of PBRN and CBPR research are health-care disparities, prevention, chronic disease management and mental health. The inclusion of CBPR within a PBRN has been identified as an important next step with the potential to significantly enhance the research process. This review focuses on bringing together the ideals of CBPR and PBRNs in order to tackle intractable problems such as disparities in health-care access and outcomes and translate these results into practice. Specifically, the CBPR PBRN approach can: (1) guide the research process so that studies more closely match the needs of all stakeholders (including providers, patients and community members); (2) assist in the development of the research protocol and identification of research methodologies so that the study is more amenable to participants; (3) facilitate recruitment of research participants; (4) enrich the data collection and analysis; and (5) allow rapid translation of results from the study back into clinical practice and the community. Once these mechanisms have been clearly elucidated, their widespread adoption will positively impact overall health at both a local and national level.

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Dulin, M. F., H. Tapp, et al. (2011). "A community based participatory approach to improving health in a Hispanic population." Implement Sci 6: 38.

BACKGROUND: The Charlotte-Mecklenburg region has one of the fastest growing Hispanic communities in the country. This population has experienced disparities in health outcomes and diminished ability to access healthcare services. This city is home to an established practice-based research network (PBRN) that includes community representatives, health services researchers, and primary care providers. The aims of this project are: to use key principles of community-based participatory research (CBPR) within a practice-based research network (PBRN) to identify a single disease or condition that negatively affects the Charlotte Hispanic community; to develop a community-based intervention that positively impacts the chosen condition and improves overall community health; and to disseminate findings to all stakeholders. METHODS/DESIGN: This project is designed as CBPR. The CBPR process creates new social networks and connections between participants that can potentially alter patterns of healthcare utilization and other health-related behaviors. The first step is the development of equitable partnerships between community representatives, providers, and researchers. This process is central to the CBPR process and will occur at three levels - community members trained as researchers and outreach workers, a community advisory board (CAB), and a community forum. Qualitative data on health issues facing the community - and possible solutions - will be collected at all three levels through focus groups, key informant interviews and surveys. The CAB will meet monthly to guide the project and oversee data collection, data analysis, participant recruitment, implementation of the community forum, and intervention deployment. The selection of the health condition and framework for the intervention will occur at the level of a community-wide forum. Outcomes of the study will be measured using indicators developed by the participants as well as geospatial modeling. On completion, this study will: determine the feasibility of the CBPR process to design interventions; demonstrate the feasibility of geographic models to monitor CBPR-derived interventions; and further establish mechanisms for implementation of the CBPR framework within a PBRN.

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McWilliams, A., H. Tapp, et al. (2011). "Cost analysis of the use of emergency departments for primary care services in Charlotte, North Carolina." North Carolina medical journal 72(4): 265-271.

BACKGROUND: Patients often inappropriately seek emergency services for ambulatory care-sensitive conditions (ACSCs). The unnecessary use of emergency departments (EDs) is an expensive burden on hospitals and payers. Here, we identify factors influencing ED visits for ACSCs and analyze the costs of such visits for EDs and primary care clinics. METHODS: Age, race, sex, and insurance data from 2007 for 3 primary care safety net clinics and 4 EDs in Charlotte, North Carolina, were analyzed using the New York University (NYU) algorithm to identify ACSC diagnoses. Cost analyses used hospital charge data and net margins as surrogates for payer and hospital system costs. RESULTS: A total of 113,730 (59.4%) of 191,622 ED visits were for ACSCs. Factors that increased the number of ACSC-related visits included lack of insurance coverage; receipt of Medicaid insurance; age of less than 2 years; African American, Hispanic, or Native American race or ethnicity; and female sex. Charges in the EDs were 320%-728% higher than those in the primary care clinics, allowing for a potential savings of 69%-86% had ACSCs been treated in primary care clinics instead of in EDs. LIMITATIONS: The NYU algorithm may have inherent weaknesses in the categorization of ACSC-related visits and the accuracy of cost assignment, especially for vulnerable patients, such as those with comorbidities or those aged less than 2 years. CONCLUSION: The majority of conditions treated during outpatient ED visits are treatable in primary care clinics or even preventable. Some groups are at higher risk for inappropriate use of EDs. Solutions to this complex problem will require payers and hospital systems to design and invest in novel targeted interventions.

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Tapp, H., L. Hebert, et al. (2011). "Comparative effectiveness of asthma interventions within a practice based research network." BMC Health Serv Res 11: 188.

BACKGROUND: Asthma is a chronic lung disease that affects more than 23 million people in the United States, including 7 million children. Asthma is a difficult to manage chronic condition associated with disparities in health outcomes, poor medical compliance, and high healthcare costs. The research network coordinating this project includes hospitals, urgent care centers, and outpatient clinics within Carolinas Healthcare System that share a common electronic medical record and billing system allowing for rapid collection of clinical and demographic data. This study investigates the impact of three interventions on clinical outcomes for patients with asthma. Interventions are: an integrated approach to care that incorporates asthma management based on the chronic care model; a shared decision making intervention for asthma patients in underserved or disadvantaged populations; and a school based care approach that examines the efficacy of school-based programs to impact asthma outcomes including effectiveness of linkages between schools and the healthcare providers. METHODS/DESIGN: This study will include 95 Practices, 171 schools, and over 30,000 asthmatic patients. Five groups (A-E) will be evaluated to determine the effectiveness of three interventions. Group A is the usual care control group without electronic medical record (EMR). Group B practices are a second control group that has an EMR with decision support, asthma action plans, and population reports at baseline. A time delay design during year one converts practices in Group B to group C after receiving the integrated approach to care intervention. Four practices within Group C will receive the shared decision making intervention (and become group D). Group E will receive a school based care intervention through case management within the schools. A centralized database will be created with the goal of facilitating comparative effectiveness research on asthma outcomes specifically for this study. Patient and community level analysis will include results from patient surveys, focus groups, and asthma patient density mapping. Community variables such as income and housing density will be mapped for comparison. Outcomes to be measured are reduced hospitalizations and emergency department visits; improved adherence to medication; improved quality of life; reduced school absenteeism; improved self-efficacy and improved school performance. DISCUSSION: Identifying new mechanisms that improve the delivery of asthma care is an important step towards advancing patient outcomes, avoiding preventable Emergency Department visits and hospitalizations, while simultaneously reducing overall healthcare costs.

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Steuerwald M., T. H., Martin A., Serbert M., Taylor Y., Kuhn L., Dulin M., (2012). "Care Coordination for Patients With Diabetes in Primary Care: Goal Setting by Patients is Associated With Improved A1c Outcomes." New Orleans, North American Primary Care Research Group Annual Meeting 2012.

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Tapp, H., S. E. Phillips, et al. (2012). "Multidisciplinary team approach to improved chronic care management for diabetic patients in an urban safety net ambulatory care clinic." J Am Board Fam Med 25(2): 245-246.

Since the care of patients with multiple chronic diseases such as diabetes and depression accounts for the majority of health care costs, effective team approaches to managing such complex care in primary care are needed, particularly since psychosocial and physical disorders coexist. Uncontrolled diabetes is a leading health risk for morbidity, disability and premature mortality with between 18-31% of patients also having undiagnosed or undertreated depression. Here we describe a team driven approach that initially focused on patients with poorly controlled diabetes (A1c > 9) that took place at a family Medicare office. The team included: resident and faculty physicians, a pharmacist, social worker, nurses, behavioral medicine interns, office scheduler, and an information technologist. The team developed immediate integrative care for diabetic patients during routine office visits.

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Dulin, M., Tapp, H., et al. (2012).  "A Transdisciplinary Approach to the Evaluation of Social Determinants of Health in a Hispanic Population." BMC Public Health 2012 12:769.

Individual and community health are adversely impacted by disparities in health outcomes among disadvantaged and vulnerable populations.  Understanding the underlying causes for variation in health outcomes is an essential step towards developing effective interventions to ameliorate inequalities and subsequently improve overall community health.  Working at the neighborhood scale, this study examines multiple social determinants that can cause health disparities including low neighborhood wealth, weak social networks, inadequate public infrastructure, the presence of hazardous materials in or near a neighborhood and the lack of access to primary care services. 

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Dulin, M., Tapp, H. et al. (2012). "Communities Matter: The Relationship Between Neighborhoods and Health." NC Medical Journal 73(5):381-388.

Understanding the link between neighborhood conditions (both physical and social) and health outcomes is an essential step toward ameliorating health disparities in low-income and high-risk minority populations.  This commentary discusses the evidence that the neighborhood is a key social determinant of health and describes tools that can be used to help overcome disparities in community health.

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Tapp, H. et al. (2013). "Evaluating Primary Care Delivery Systems for an Uninsured Hispanic Immigrant Population." Family and Community Health 36(1): 19-33

Hispanic populations experience disparities in health outcomes and health care.  Using participatory methods, we evaluated 4 systems of primary care delivery for an uninsured Hispanic population.  Best practices were determined that could be translated back to the partner clinics and the community.  The assessment included patient service areas, provider discussion groups, patient surveys, calculation of travel distances, and costs.  The following best practices were identified: improved proximity to services, enhanced bilingual services, affordable services, and integrated services.  Researchers and providers not only identified translatable service delivery practices but also laid the foundation for ongoing research partnerships.

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Tapp, H., McWilliams, A. et al (2014). "Patient Engagement and Informed Decision Making Regarding Medical Imaging." NC Medical Journal 75(2):114-116

Misuse and overuse of medical imaging have gained widespread attention due to rising costs, radiation exposure risks, and limited comparative effectiveness evidence.  Involving patients in shared decision making offers an opportunity to more clearly define risks and benefits, thus allowing patients to consider both personal values and the best available evidence.

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Mohanan, S., Tapp, H. et al (2014).  "Obesity and Asthma: Pathophysiology and Implications for Diagnosis and Management in Primary Care." Experimental Biology and Medicine DOI: 10.1177/1535370214525302

The effects of obesity on asthma diagnosis, control, and exacerbation severity are increasingly recognized:  however, the underlying pathophysiology of this association is poorly understood.  Mainstream clinical practice has yet to adopt aggressive management of obesity as a modifiable risk factor in asthma care, as is the case with a risk factor like tobacco or allergen exposure.  This review summarizes the existing data that support the pathophysiologic mechanisms underlying the association between obesity and asthma, as well as the current and future state of treatment for the obese patient with asthma.

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Tapp, H., Kuhn, L. et al (2014) "Adapting Community Based Participatory Research (CBPR) Methods to the Implementation of an Asthma Shared Decision Making Intervention in Ambulatory Practices."  Journal of Asthma 51(4): 380-390

Translating research findings into clinical practice is a major challenge to improve the quality of healthcare delivery.  Shared decision making (SDM) has been shown to be effective and has not yet been widely adopted by health providers. This paper describes the participatory approach used to adapt and implement an evidence-based asthma SDM intervention into primary care practices.

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