14th Annual HMO Research Network Conference
Abstracts from the HMO Research Network
With this issue we include abstracts from the 2008 14th Annual HMO Research Network Conference, held in Minneapolis, MN, that focused on “Partnerships in Translation: Advancing Research and Clinical Care.”
From Henry Ford Health System; University Hospitals of Cleveland and Case Comprehensive Cancer Center; Case Western Reserve University; Virginia Commonwealth University School of Medicine
The content of physician-patient discussions during routine health maintenance exams
Background: Little is known about the content of routine health maintenance exams (HMEs) delivered by primary care physicians (PCP) in today’s busy primary care practices. We describe the frequency of patient-physician cancer screening discussions amidst the competing demands of other preventive services during routine HMEs to understand HME content in the real world of primary care.
Methods: We use direct observation of PCP-patient interactions during HMEs to examine discussions around breast, colorectal (CRC), cervical, lung, and prostate cancer screening and other lifestyle topics. Visits represent the first 103 visits completed in an NIH-funded study using in-office observations, audio-recordings, and patient surveys to study CRC screening recommendations. Physician participants (n = 34) are general internists or family physicians practicing in a large integrated delivery system in southeast Michigan with patient-specific electronic medical record prompts for evidence-based cancer screening. Patient participants were aged 50 to 80 years who scheduled an HME with a participating physician and were due for CRC screening (ie, no colonoscopy or barium enema within ten years, flexible sigmoidoscopy within five years or fecal occult blood testing (FOBT) within 12 months).
Results: CRC screening was mentioned in 96% of observed HMEs. Among visits by women (n = 74), 85% mentioned breast and 51% cervical cancer screening. Among visits by men (n = 29), 72% mentioned prostate cancer screening. Lung cancer screening was mentioned in 15% of visits. The physician initiated these discussions more than 80% of the time, with the exception of lung cancer screening (53%). Colonoscopy was overwhelmingly the procedure recommended for CRC screening (82%), followed by FOBT (37%) and others (4%). Other topics frequently discussed were exercise (88%), cholesterol (81%), smoking (68%), blood pressure (65%), and diet (65%). Although these discussions were usually initiated by physicians, patients were relatively more likely to initiate discussions around weight (41%) and diet (35%).
Conclusions: In this study of patients due for CRC screening, discussions did occur and specific recommendations frequently were made for CRC screening. Other cancer screening and preventive issues were discussed, but less frequently. PCPs are uniquely positioned to impact the delivery of these preventive measures and seem to be successfully striving to meet guidelines, particularly those for CRC screening.
From the Center for Health Research; Arizona State University; Southern Arizona Veterans Administration Health Care System; City of Hope Medical Center; Kaiser Permanente Northern California; and Kaiser Permanente Northwest.
Fatigue and sleep quality of persons with ostomies: gender differences
Background: Some colorectal cancer (CRC) patients require a permanent ostomy (a surgically created opening on the exterior of the abdomen that allows feces to be eliminated from the body). An ostomy can create psychosocial distress and affect body image, sense of self, and sexual functioning. Few studies have examined health-related quality of life (HR-QOL) relevant to disturbed sleep of CRC survivors with ostomies; moreover, no studies have examined gender differences of ostomates on quality of sleep and fatigue.
Methods: HR-QOL was examined in this cross-sectional study of long-term (>5 years) CRC survivors with ostomies, who receive care at Kaiser Permanente health systems in California, Oregon, Washington, and Hawaii. Participants completed the City of Hope QOL Ostomy questionnaire, which includes demographic and scaled items and narrative comments for greatest challenges associated with having an ostomy. Two items, “fatigue” and “sleep disruption” (scale from 1 to 10), served as dependent variables. Age, ethnicity, education, partnered status, body mass index (BMI), and time since surgery were included in models. Data were analyzed using t-tests and ordinal logistic regression modeling with significance set at p < 0.05.
Results: Women (n = 118) compared to men (n = 168) were less likely to be partnered (25% vs 55%, p < 0.0001). There were no differences for age, ethnicity, education, BMI, or time since surgery. Regression modeling for fatigue showed women to have lower HR-QOL compared with men (0.65 decrease, p < 0.01), adjusted for time since surgery (modest positive association, p < 0.05). Regression modeling for sleep disruption also showed women to have poorer HR-QOL (0.57 decrease, p < 0.01), adjusted for age (modest positive association, p < 0.001). CRC surgical controls without ostomy showed no significant gender difference for either HR-QOL item. Qualitative narrative comments suggest sleep disruption is associated with fear or actual leakage during hours of sleep.
Conclusion: Women CRC survivors with ostomies report more fatigue and sleep disruption that may contribute to poorer HR-QOL compared to their male counterparts. Higher rates of fatigue for women are consistent with gender differences in other health conditions. These findings can provide a foundation for gender-specific ostomy interventions to improve sleep quality.
From Kaiser Permanente Colorado
Patient-centered communication research in integrated delivery systems
Background: Considerable differences exist between the ways in which communication is conceptualized in the academic field of communication studies, on the one hand, and in clinical practice, on the other. Theorists in the field of communication studies have conceptualized communication as 1) mutual and interactive, 2) concerning the establishment of shared meaning, and 3) dyadic in terms of physician-patient consultation.
Methods: A literature-based theoretical review focusing on the academic field of communication studies.
Results: Loosely coupled organizational systems can excel at locale-specific innovation while failing at horizontal coordination and organizational learning. Bureaucratic tendencies of complex organizations are inherently dehumanizing. In integrated health care delivery systems, attaining and maintaining a state of patient-centeredness will require continual vigilance.
Conclusions: Patient-centered communication extends beyond the context of physician-patient interaction to include provider-to-provider communication, health care team coordination, applications of electronic medical records, intraorganizational issues of continuity of care, and interorganizational issues of patient-centered communication policy dissemination. A research agenda about patient-centered communication for integrated delivery system researcher is proposed as a means for systematically improving patient-centered communication.
From the Kaiser Permanente Northwest Center for Health Research
Three-year weight change in diabetes, associated factors, and glycemic control using electronic records
Background/Aims: The importance of weight loss in diabetes mellitus type 2 (DM) is undisputed. Limited community data describe weight change in DM and resulting glycemic and blood pressure control.
Methods: Using electronic medical records, this retrospective cohort study identified patients aged 21-75 years with new DM diagnosed between 1/1/1997 and 12/31/2002. Eligible patients met weight measurement criteria and did not have a condition associated with unintentional weight change (n = 2574). We estimated three-year patient weight trajectories using growth curve analyses, grouped similar trajectories using cluster analysis, compared their characteristics, and used weight trajectory patterns to predict year-four above-goal glycosylated hemoglobin (HbA1c) and blood pressure.
Results:The four weight trajectory groups were “higher stable weight” (n = 418; 16.2%), “lower stable weight” (n = 1542; 59.9%), “weight gain” (n = 300; 11.7%), and “weight loss” (n = 314; 12.2%). Weight losers began regaining weight at about 18 months and by three years were nearly the same mean weight as weight gainers. When compared to gainers, a weight loss pattern was associated with baseline older age, higher income, more frequent obesity, and lower levels of above-goal HbA1c and blood pressure. After adjusting for age, gender, baseline values, and related medication use, those with higher stable or weight gain patterns were more likely to have above-goal HbA1c and blood pressure than losers.
Conclusion: A three-year weight loss pattern after a new diagnosis of DM improved glycemic and blood pressure control in year four despite weight regain. The initial period after diagnosis of diabetes may be a critical time to apply weight loss treatments to improve longer-term risk factor control.
From Kaiser Permanente Southern California
Activities and cognitive functioning in very elderly women
Background: Although not uniformly positive, several studies have suggested that leisure and social activities are associated with higher cognitive functioning in older adults.
Methods: This cross-sectional study examined the influence of social activities on the cognitive functioning of 1436 women who were aged 80 years or older from a health maintenance organization in Southern California. Cognitive functioning was assessed using the Telephone Interview for Cognitive Status modified (TICSm). Ten questions measured which social and leisure activities women participated in in the past few months. Major medical conditions and Instrumental Activities of Daily Living (IADL) were also assessed.
Results: Except for watching television and doing paid volunteer work, all of the TICSm mean scores were higher for women who participated in the other eight activities. When comparing those who scored in the lower versus the higher cognitive functioning groups (ie, <28 score on TICSm), those engaged in hobbies, shopping, movies, crossword puzzles, trips, and unpaid volunteer work had much higher proportions of participants scoring in the higher cognitive group. Those who reported needing help in IADL were less likely to participate in activities and scored lower on TICSm (t-test: all p < 0.001). Older women and those with less education had a reduced likelihood of participating in activities. After adjusting for age, education, medical conditions and IADL, only four activities were significantly and inversely related to lower cognitive scores (p < 0.05). Odds ratios (95% confidence interval [CI]) were as follows: having a hobby, 0.73 (CI 0.57, 0.94); going on a day or overnight trip, 0.58 (CI 0.46, 0.75); doing unpaid volunteer work, 0.69 (CI 0.52, 0.92); and doing crossword puzzles, 0.51 (CI 0.39, 0.67).
Conclusions: These results suggest that some social and leisure activities may help promote cognitive health.
