Presentation of Selected Research Projects
University of Wisconsin Department of Family Medicine
2014 Summer Student Research and Clinical Assistantship Program
DFM Faculty Meeting - August 20, 2014
4:30-4:45
Gregory Lines
(Hunter)
Improving treatment completion rates for latent tuberculosis infection: a review of two treatment
4:45-5:00
Saamia Masoom
(Hanrahan & Hahn)
Life course predictors of asthma risks in a large clinical population: age, sex, and BMI
5:00-5-15
Lizzie Maxwell
(Barrett)
Self-reported mental health predicts incidence of acute respiratory infection
The SSRCA is designed to pair UW medical students and UW-DFM faculty who have mutual interests in
research. The goals of the program are:
(1) to provide medical students with an early exposure to family medicine,
(2) to provide students with an early exposure to clinical research and medicine in a variety
of primary care settings, and
(3) to stimulate and support research by Wisconsin family physicians and DFM faculty.
The overall intent is to attract students into careers in family practice, in both community and academic
settings, which may include research as a significant focus through their own initiatives or through
participation in practice-based research networks such as WREN.
2014 SSRCA Faculty Mentors
Ildi Martonffy, Paul Hunter, Sarah Bleything, Sarina Schrager Larry Hanrahan, David Hahn, Ann
Evensen, Dennis Baumgardner, Tiffany Mullen, Kristen H. Reynolds, Randy Brown, Bruce Barrett,
Kevin Thao, Aleksandra Zgierska
ABSTRACTS
Negative Pap Smear, Positive HPV: What Does It Mean?
Sarina Schrager MD, Lindsey Anderson
Background: Persistent high-risk human papilloma virus (HPV) infection (HPV subtypes 16, 18, 31, 33, and 45)
has been shown to be a prerequisite for the development of cervical cancer. Specifically, infection with HPV
subtype 16 has been correlated with a 61% regression rate in women with CIN II whereas infection with other
subtypes or no HPV infection shows a regression rate of 89.5% (Discacciati MG et al. 2014). Methods: This
retrospective study looked at the colposcopy results of women in the University of Wisconsin health system who
had a negative pap smear and tested positive for HPV between November, 2012 and April, 2014. The colposcopy
results were then characterized by other possible contributing factors, including previous abnormal pap smears,
HPV subtype, and smoking status. Results: This study showed that only 6 of the 56 women meeting the
negative pap smear with positive HPV test criteria had an abnormal colposcopy, and only 2 of these women were
referred for further treatment. To find these two women, it took 29 biopsies and 30 endocervical curettages
(ECC), with 23 and 28 of those coming back normal, respectively. Infection with HPV 16 in this population was
the highest at 80.4% compared to 17.9% for HPV 18 infection. In addition, the women who had abnormal
colposcopies were 47% more likely to have had an abnormal pap smear in the past than those who had normal
colposcopies. Conclusions: Referring women to colposcopy who have tested positive for HPV 16 or 18 with a
negative pap smear results in a large number of unproductive biopsies and ECCs, with a low detection of women
needing further follow up (2 of 56 or 3.6%). Further characterization as to timing of the abnormal pap smear in
relation to the current tests and a larger study are needed to determine the validity of using previous pap smear
status as a qualifier for colposcopy referrals in HPV positive/cytology negative women in the future.
Meditation for Chronic Low Back Pain in Patients Prescribed Opioids: A Cost Analysis
Aleksandra Zgierska, MD PhD; James Ircink, BS
Background: The US health care system is the most expensive in the world yet trails other countries in measures
of quality and efficiency. Chronic low back pain (CLBP), a pervasive and disabling condition, imposes a
significant economic burden on the patient and health care system. CLBP often requires opioid therapy, which is
costly and can cause adverse effects, including addiction and overdose. Alternative safe treatment strategies that
improve health outcomes in patients with CLBP while reducing costs and harm related to prescribed opioids are
warranted. Mindfulness meditation is a treatment that could fulfill this aim. However, evidence on meditation for
opioid-treated CLBP is limited and costs are yet to be estimated. Methods: 35 adults with CLBP, treated with
daily opioids (>= 30mg of morphine-equivalent dose/day) were randomized to (i) standard of care or (ii) 8-week
long meditation course + standard of care. Participant-reported medication, health care utilization, and
productivity costs as well as quality of life measures were assessed at baseline, 8 weeks, and 26 weeks. Statistical
cost-benefit analyses pending. Results: The total 6-month baseline cost per subject (not yet including medication
cost) was $9503 (95% CI: $5662-$13344). Meditation-efficacy analysis results pending. Conclusions: The opioidtreated CLBP patient population is costly.
How Doctors Birth: How our experiences shape our practice
Carly Kruse, MSc, Ildi Martonffy, MD
Background: Birthing stories are personal narratives that provide a space for women to share experiences. Much
research has been done analyzing thematic norms presented in birth stories to improve healthcare practices and
patient experiences. However, very little data has been collected on how physicians’ own birthing stories shape
the ways they provide care. One study that successfully captures how personal experiences inform the choices of
physicians is Dr. Ken Murray’s “How Doctors Die: It’s not like the rest of us, but it should be”. Murray’s study
investigates why physicians often choose less interventional supportive care when faced with a terminal illness,
and how that is different from the choice of their patients. How Doctors Birth aims to explore similar
discrepancies in delivery preferences by listening to the powerful birth stories of physicians themselves.
Methods: Physicians’ birthing narratives were obtained from 30 minute in-person interviews. These stories were
coupled with quantitative survey data consisting of information on medical training and family development
history. Female Family Medicine physicians and Obstetricians who have received training in labor and delivery
were recruited. Survey data was analyzed for correlations between medical training experiences, family
development trajectories, and delivery interventions. Data was also analyzed for common breastfeeding practices
and perceptions. Content and thematic analysis of interviews was conducted to elicit associations between
physician’s birthing experiences and the care they provide. Results: Quantitative data assessing the way doctors
birth demonstrates similar averages to those across the Nation and in Wisconsin. Analyses are still in progress,
but suggest that doctors birth in similar ways to other non-physician women. Physicians experiences throughout
pregnancy have changed their scope of practice in three major ways: increased empathy for patients, increased
awareness of social pressure put on women to parent or birth in a particular way, and increased advocacy efforts
for patient empowerment. Prenatal counseling, labor support, breastfeeding counseling, and pediatric care all
changed as a result of personal birthing experiences. Conclusions: Personal experiences construct the way
physicians approach and counsel patients. Therefore, further research must address the following questions: How
successful are physicians with leveraging empathy to address empowerment? How do we teach non-parents in
medical training all that doctors have garnered from personal experiences?
Self-reported mental health predicts incidence of acute respiratory infection
Lizzie Maxwell, Bruce Barrett, Roger Brown, Tola Ewers, Joe Chase
Background: Poor mental health conditions, including stress and depression, have been recognized as risk
factors for the development of acute respiratory infection (ARI). Despite research investigating specific
conditions, very few studies have considered the role of general mental health in ARI occurrence. The aim of this
analysis is to determine if overall mental health, as assessed by the mental component of the Short Form 12
Health Survey (SF-12), predicts incidence of ARI. Methods: Data utilized for this analysis came from the
MEPARI and MEPARI-2 randomized controlled trials. A Spearman rank-order correlation was run on the SF-12
Mental completed by participants at baseline, and ARI incidence as defined by the Jackson-criteria for respiratory
infection. Multivariate statistical analysis is yet to be performed. Results: Initial findings from the Spearman
rank-order correlation include a significant correlation between the mental component of SF-12 (MCS-12) and
incidence of ARI (p=0.045). Conclusions: Self-reported overall mental health, as measured by the SF-12, predicts
incidence of ARI. Lower mental health-related quality of life is associated with greater ARI occurrence.
Improving treatment completion rates for latent tuberculosis infection: a review of two
treatment regimens at a community health center
Gregory Lines, MPH, Paul Hunter, MD, Sarah Bleything, PA
Background: Prophylactic treatment of latent tuberculosis infection (LTBI) is necessary for preventing active TB
and controlling the spread of tuberculosis in low-incidence settings. Treatment is often limited by poor
completion rates. Isoniazid (INH) and Rifapentine (RPT) directly observed for 12 weekly doses has been found to
be as efficacious as 9 months daily Isoniazid (INH) treatment for preventing the development of active
tuberculosis. Methods: A retrospective chart review was conducted at a community health center serving a lowincome and predominantly Hispanic population. Treatment completion among patients accepting 12 weekly
doses of INH/RPT directly observed was compared to patients accepting 9 months of daily INH during 2012 and
2013 (n=139). Results: Among patients who agreed to treatment, INH/RPT directly observed therapy (DOT) was
associated with higher completion rates (OR 3.06; 95% CI, 1.23-7.62; P=0.016) when compared to INH only.
Female sex (OR 2.75; 95% CI, 1.22-6.18; P=0.014) was also a statistically significant predictor of treatment
completion. Overall completion rates among those agreeing to treatment were 77.8% (35/45) for INH/RPT
combined therapy and 52.1% (49/94) for INH monotherapy. Among those initiating treatment, completion rates
were 100% (35/35) for INH/RPT combined therapy and 73.1% (49/67) for INH monotherapy. Conclusions: High
completion rates for LTBI prophylaxis can be achieved at a community health center using directly observed
INH/RPT combination therapy. Greater success treating with INH/RPT may be attributed to DOT strategy,
shorter treatment regimen and fewer pills overall.
Disease-Management and Financial Implications of the Addition of a Health
Coach/Nutritionist in Two Family Medicine Clinics
Dennis Baumgardner MD, Kristin Magliocco, Tiffany Mullen DO, Kristen Reynolds MD
Background: 80% of healthcare spending is attributed to chronic disease. Maintenance of chronic disease depends
on medication adherence and lifestyle changes, and the majority of patients have not met their disease
maintenance goals. Self-management support in the form of health coaching has been shown to improve clinical
outcomes for patients with chronic disease. Since clinicians’ time is limited, other personnel can serve as health
coaches to work with patients on lifestyle changes. This study will examine the impact of a dual-trained
Nutritionist/Health Coach, and justify that the model is economically beneficial for patients in the Aurora
Accountable Care Network. Methods: Patients diagnosed with chronic diseases or obesity will be referred to the
Nutritionist/Health Coach by clinicians in two family medicine clinics. A retrospective chart review will allow
comparison of clinical outcomes one year before and after the initial intervention for all patients, and comparison
of billing data two years before and after for AACN patients only. Results: The study is ongoing. 12 patients are
enrolled and preliminary data indicate that chronic disease is fairly well-controlled, although all patients are
obese. Discussion: Current limitations of the study include low enrollment and variable follow-up. Additionally,
encounters with the Nutritionist/Health Coach must be paid for out-of-pocket, which creates bias towards those
who can afford it and are highly motivated. The study is still ongoing, but potential impact is promising.
Life course predictors of asthma risks in a large clinical population: age, sex, and BMI
Saamia Masoom, Aman Tandias, Jarjieh Fang, Dr. David Hahn, Dr. Theresa Guilbert, Dr. Yingqi Zhao,
and Dr. Larry Hanrahan
Background: Current literature indicates the existence of a significant association between asthma prevalence and
body mass index (BMI), with a dose-dependency between BMI and asthma control. These associations are
modified by sex, possibly due to interactions between sex hormones and immune factors or underlying
inflammation linked to both asthma and obesity. Studies indicate a stronger association in pediatric males and
adult females. Methods: We examined cross-sectional data in the University of Wisconsin Electronic Health
Record Public Health Information Exchange (UW eHealth – PHINEX) database for 298,847 patients with at least
two encounters at the UW Departments of Family Medicine, Internal Medicine, and Pediatrics clinics from 20072012. Prevalence of asthma and uncontrolled asthma were calculated after stratification by age group, sex, and
BMI category. Results: 40,011 patients had asthma (prevalence 13.4%), and 6554 had uncontrolled asthma (16.4%
of patients with asthma). Asthma prevalence was higher in obese pediatric males (25.7% [95% CI 23.7, 27.7])
compared to obese pediatric females (19.2% [17.2, 21.2]) and higher in obese adult females of reproductive age
(22.6% [21.8, 23.4]) compared to obese males of the same age (15.4% [14.6, 16.2]). Odds ratios of the association
between obesity and asthma were similar (~1.5) for pediatric males and females but were significantly greater for
adult pre-, peri-, and post-menopausal females (respectively 1.8 [1.7,1.9]; 2.1 [1.9,2.2]; 2.0 [1.8, 2.1]) than for males
of corresponding age (respectively 1.4 [1.2, 1.5]; 1.5 [1.3, 1.7]; 1.4 [1.2, 1.5]). Similar but statistically non-significant
patterns were observed for uncontrolled asthma. Conclusion: These data suggest an effect of age and sex on the
association between asthma and obesity in a large, clinical data set, supporting previous data implicating an effect
of female sex hormones and obesity on asthma prevalence.
Community Health Assessment in the Wausau Hmong Population: Preliminary Survey of
Wausau Hmong Community Leaders
Paj Ntaub Vang, MPH, Kevin Thao, MD, MPH
Background: With the growing Hmong population in Wisconsin, there has not been a community health
assessment to specifically evaluate the health of the Hmong population. We plan to do a mini Survey of the
Health of Wisconsin (SHOW) in the future, but before then it is important to introduce the survey to the Hmong
community leaders with a preliminary mini survey. Methods: Ten Wausau Hmong community leaders are to be
surveyed over the phone with a modified SHOW survey that was translated in Hmong. This serves as an
introduction of the project to the community and as a preliminary trial of the survey. Results: The purpose of
this project is to evaluate the feasibility of the 65-page survey that was used in the miniSHOW project at Lindsay
heights. Thus allowing the capability to compare the Wausau Hmong population to other populations that
SHOW has surveyed. Although we are not finished with this project, we have learned so far that there are some
health concepts that cannot be translated or explained in Hmong, such as DNA and genetics. The concept of
“scales” was also difficult to explain as well. We will use information gleaned from the preliminary surveys to
modify the questions and the administration of future surveys. Conclusion: This project is important for
collecting health information that can be used for future interventions and to provide a health profile of Hmong
in Wisconsin for health care providers and more importantly, for the community.
Dropout Characteristics of Opioid Dependent Offenders in Community-Based Treatments;
Preliminary Findings
Brown, Randall, MD/PhD, Wayne, Shawn, BS
Background: The illicit use of opioid analgesics has become increasingly burdensome upon the legal system.
Treatment of an addicted individual prevents an estimated 63 crimes per year. Interface with the legal system
opportunistically permits referrals for substance abuse treatment. To optimize limited resources, this study aims
to identify individual baseline characteristics associated with dropout amongst participants assigned to different
treatment models. Methods: Opioid offenders, referred from the Dane County Drug Treatment Court, were
randomized to two treatment conditions: (1) suboxone via physician’s office (PO) for 10-months or suboxone via
specialty care at Madison Health Services (MHS) for 3-months followed by 7-months PO. Baseline data pertaining
to drug use and motivation were analyzed according to dropout status within each treatment condition. Results:
53% of participants (n=17) dropped out within the first month. Treatment condition had no significant affect upon
dropout rate. Illicit drug use 14-days prior to participation and heroin use were not found to be prognostic of
dropout status (p=0.36, p=0.91). At MHS (n=8), lower self-reported motivation metrics; including “importance of
treatment” and “seriousness of pending legal problems,” were associated with dropout (p=0.013, p=0.035).
Qualitative reasons for dropout included recidivism, transportation, and access. Conclusions: According to
preliminary findings, motivation has prognostic value for dropout amongst individuals assigned to MHS.
Presumably due to the strict daily dispensing, a lack of baseline motivation leads dropout more precipitously
than individuals assigned to PO. This preliminary finding indentifies offenders for whom specialty care may be
inappropriate and supports the personalization of treatment programs.
Streamlining assessment of resident physician competency in performing the pelvic
examination
Ann Evensen, MD1, Lydia Weyenberg, M2, and Ronald Prince, MS1
Introduction/Objective: Incoming resident physicians (R1s) vary in skill and experience with the pelvic
examination (PE). PE training and competency evaluation is costly and time-consuming. With the new
Accreditation Council for Graduate Medical Education (ACGME) requirements that require many additional
resident competencies be formally evaluated, our residency is interested in streamlining PE training and
evaluation. Methods: From 2009 to 2013, 67 incoming UWSMPH family medicine R1s performed a guided PE on
two gynecological teaching assistants (GTAs). An additional 11 R1s did not have GTA training. Over the next 1-12
months, 72 R1s were observed by faculty as they each performed a minimum of 3 PEs on clinic patients. All PEs
were evaluated with a standardized checklist. Using variables such as R1 gender and scores from individual
items on the GTA and initial faculty standardized evaluations, we developed a logistical regression model to
predict which R1s required more supervision and training in PE skills. Results: Preliminary results show that the
ability of an R1 to successfully locate the cervix and to verbalize PE steps to the patient in advance of performing
the steps predicts the R1’s success in performing subsequent PEs. Further data analysis is ongoing. Conclusion:
We will use results of this modeling to streamline PE training and evaluation for incoming family medicine
residents. This will make evaluation of PE competency in residents more efficient, decreasing financial and
opportunity costs.