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Permanente
Abstracts
Abstracts
of articles authored or coauthored by Permanente clinicians.
Relation
between hospital primary angioplasty volume and mortality for patients
with acute MI treated with primary angioplasty vs thrombolytic therapy
Magid DJ, Calonge
BN, Rumsfeld JS, et al. JAMA 2000 Dec 27;284(24):3131-8.
to
article >> | pdf
>>
Effectiveness
and economic impact associated with a program for outpatient management
of acute deep vein thrombosis in a group model health maintenance organization
Tillman DJ, Charland SL, Witt DM. Arch Intern Med 2000 Oct 23;160(19):2926-32.
to
article >> | pdf
>>
Early
discharge of infected patients through appropriate antibiotic use
Eron LJ, Passos S. Arch Intern Med 2001 Jan 8;161(1):61-5.
to
article >> | pdf
>>
Type
2 diabetes: incremental medical care costs during the eight years preceding
diagnosis
Nichols GA, Glauber HS, Brown JB. Diabetes Care 2000 Nov;23(11):1654-9.
to
article >> | pdf
>>
Screening
travelers for hepatitis A antibodies: an observational cost-comparison
study of vaccine use
Lee KK, Beyer-Blodget JB. West J Med 2000 Nov;173(5):325-9.
to
article >> | pdf
>>
Prevalence
of headaches in football players
Sallis RE, Jones K. Med Sci Sports Exerc 2000 Nov;32(11):1820-4.
to
article >> | pdf
>>
The
relative importance of gestational gain and maternal characteristics associated
with the risk of becoming overweight after pregnancy
Gunderson EP, Abrams B, Selvin S. Int J Obes Relat Metab Disord 2000
Dec;24(12):1660-8.
to
article >> | pdf
>>
SNAP-II
and SNAPPE-II: Simplified newborn illness severity and mortality risk
scores
Richardson DK, Corcoran JD, Escobar GJ, Lee SK. J Pediatr 2001 Jan;138(1):92-100.
to
article >> | pdf
>>
Vaccines
and otitis media
Black S, Shinefield H. Pediatr Ann 2000 Oct;29(10):648-5
to
article >> | pdf
>>
Effect
of physician and patient gender concordance on patient satisfaction and
preventive care practices
Schmittdiel J, Grumbach K, Selby JV, Quesenberry CP
Jr. J Gen Intern Med 2000 Nov;15(11):761-9.
to
article >> | pdf
>>
Health
and loyalty promotion visits for new enrollees: results of a randomized
controlled trial
Thompson M, Gee S, Larson P, Kotz K, Northrop L. Patient Educ Couns 2001
Jan 1;42(1):53-65.
to
article >> | pdf
>>
Permanente
Abstracts
Abstracts
of articles authored or coauthored by Permanente clinicians.
Relation
between hospital primary angioplasty volume and mortality for patients
with acute MI treated with primary angioplasty vs thrombolytic therapy
Magid
DJ, Calonge BN, Rumsfeld JS, et al. JAMA 2000 Dec 27;284(24):3131-8.
context:
Institutional experience with primary angioplasty has been suggested as
a factor in selecting a reperfusion strategy for patients with acute myocardial
infarction (AMI). However, no large studies have directly compared outcomes
of primary angioplasty vs thrombolytic therapy as a function of institutional
experience.
objective: To compare outcomes among patients with AMI who were treated
with primary angioplasty vs thrombolytic therapy at hospitals with different
volumes of primary angioplasty.
design: Retrospective cohort.
setting: A total of 446 acute care hospitals with 112 classified as
low volume (16 procedures), 223 as intermediate volume (17-48 procedures),
and 111 as high volume (49 procedures) based on their annual primary angioplasty
volume.
patients: A total of 62,299 patients with AMI treated with primary
angioplasty or thrombolytic therapy from June 1, 1994, through July 31,
1999.
main outcome measure: In-hospital mortality.
results: Mortality was lower among patients who received primary angioplasty
compared with those who received thrombolysis at hospitals with intermediate
volumes (4.5% vs 5.9%; P < .001) and high volumes (3.4% vs 5.4%; P
< .001) of primary angioplasty. At low-volume hospitals, there was
no significant difference in mortality between patients treated with primary
angioplasty vs those treated with thrombolysis (6.2% vs 5.9%; P = .58).
Adjusting for differences in demographic, medical history, clinical presentation,
treatment, and hospital characteristics did not significantly alter these
findings.
conclusions: In this study, patients with AMI treated at hospitals
with high or intermediate volumes of primary angioplasty had lower mortality
with primary angioplasty than with thrombolysis, whereas patients with
AMI treated at hospitals with low angioplasty volumes had similar mortality
outcomes with primary angioplasty or thrombolysis.
Copyright 2000, American Medical Association.
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list of abstracts >>
Effectiveness
and economic impact associated with a program for outpatient management
of acute deep vein thrombosis in a group model health maintenance organization
Tillman DJ, Charland SL, Witt DM. Arch Intern Med 2000 Oct 23;160(19):2926-32.
background:
Controlled clinical trials have demonstrated that outpatient administration
of low-molecular-weight heparin to patients with acute deep vein thrombosis
(DVT) provides safety and efficacy equivalent to that of traditional inpatient
therapy with unfractionated heparin. Whether favorable results reported
in controlled clinical trials are achievable in clinical practice is an
important consideration.
methods: Appropriate patients with objectively diagnosed DVT were
treated as outpatients with low-molecular-weight heparin and warfarin
sodium according to an approved guideline. The primary end point for analysis
consisted of objectively diagnosed symptomatic recurrent thromboembolism
or major bleeding within a 90-day evaluation period. The incremental cost
incurred by the organization while using the outpatient DVT treatment
guideline was determined. Incremental cost savings of the outpatient DVT
treatment program were determined based on the cost that would have accrued
had the patient been admitted to the hospital for treatment with unfractionated
heparin.
results: We enrolled 391 patients (91.4%) in the outpatient DVT treatment
program. Of these, 373 (95.4%) completed 90 days of therapy without reaching
the primary end point. The percentage of patients reaching the primary
outcome measure (4.6%) fell within the range of patients enrolled in controlled
clinical trials (3.5%-9.4%). During the two-year program evaluation, total
cost savings of $1,108,587 were realized.
conclusions: Outpatient treatment of acute DVT can be managed safely
and effectively in clinical practice. The potential savings associated
with outpatient DVT treatment are substantial.
Copyright 2000, American Medical Association.
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list of abstracts >>
Early
discharge of infected patients through appropriate antibiotic use
Eron LJ, Passos S. Arch Intern Med 2001 Jan 8;161(1):61-5.
background:
Patients with infections are usually discharged from the hospital with
antibiotics when afebrile and clinically improved.
objectives: To compare outcomes of early vs conventionally discharged
patients and to examine the role of antibiotic use in the discharge process.
methods: One hundred eleven patients hospitalized with cellulitis,
community-acquired pneumonia, or pyelonephritis (urinary tract infection)
discharged from the hospital early in their clinical course before defervescence
by an infectious diseases hospitalist (LJE) were compared in a case-controlled
study with 112 patients discharged from the hospital according to conventional
standards of care by internal medicine (IM) hospitalists. Patients were
matched for age, sex, diagnosis, and comorbidities. Outcomes were determined
for average lengths of stay, readmission to the hospital within 30 days
with the same diagnosis, satisfaction with their discharge program, and
time to return to their normal activities of daily living.
results: Patients cared for by the infectious diseases hospitalist
had a shorter average length of stay (mean difference, 1.7 days), no readmissions,
higher satisfaction scores, and a shorter time to return to their activities
of daily living, compared with those cared for by the IM hospitalists.
Analysis of the antibiotics that patients were discharged with revealed
that the infectious diseases hospitalist used outpatient parenteral antibiotic
therapy more frequently than IM hospitalists in the treatment of cellulitis,
and switched from intravenous to oral antibiotics sooner than IM hospitalists
for patients with community-acquired pneumonia and urinary tract infection.
conclusions: The infectious diseases hospitalist discharged patients
from the hospital earlier than the IM hospitalists by more efficient use
of antibiotics. The earlier discharge did not adversely affect outcomes.
Copyright 2001, American Medical Association.
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list of abstracts >>
Type
2 diabetes: incremental medical care costs during the eight years preceding
diagnosis
Nichols GA, Glauber HS, Brown JB. Diabetes Care 2000 Nov;23(11):1654-9.
objective:
To describe and analyze medical care costs for the eight years preceding
a diagnosis of type 2 diabetes.
research design and meathods: From electronic records of a large group-model
health maintenance organization (HMO), we ascertained the medical care
costs preceding diagnosis for all members with type 2 diabetes who were
newly diagnosed between 1988 and 1995. To isolate incremental costs (costs
caused by the future diagnosis of diabetes), we subtracted the costs of
individually age- and sex-matched HMO members without impending diabetes
from the costs of members who were destined to receive this diagnosis.
We also compared these prediagnosis costs with the first three years of
postdiagnosis costs.
results: An economic burden from impending diabetes is apparent for
at least eight years before diagnosis, beginning with costs for outpatient
and pharmacy services. Diabetes-associated incremental costs (costs of
type 2 diabetic patients minus matched costs of nondiabetic patients)
averaged $1205 per type 2 diabetic patient per year during the first eight
prediagnostic years, including $1913 each year for the three years preceding
diagnosis. In the year immediately preceding diagnosis, incremental costs
were equivalent to those observed in the second and third years after
diagnosis.
conclusions: Incremental costs of diabetes begin at least eight
years before diagnosis and grow at an accelerating rate as diagnosis approaches
and immediately after diagnosis. These incremental costs span the full
range of medical services. Furthermore, the majority of these costs are
for conditions not normally associated with diabetes or its complications.
To
list of abstracts >>
Screening
travelers for hepatitis A antibodies: an observational cost-comparison
study of vaccine use
Lee KK, Beyer-Blodget JB. West J Med 2000 Nov;173(5):325-9.
objectives:
To measure the seroprevalence of antibodies to hepatitis A virus (anti-HAV)
in a health plan population of travelers and to determine whether prevaccination
screening for anti-HAV can reduce unnecessary vaccination and thus promote
the most effective, economic use of hepatitis A vaccine.
design: Observational, cost-comparison study.
setting: Central injection clinic of a health maintenance organization
medical center.
subjects: Five hundred twenty-seven adults who denied having previous
hepatitis A or vaccination.
main outcome measures: Subgroups with the greatest prevalence of anti-HAV
seen between June 1995 and April 1996 for immunizations before traveling
to nonindustrialized countries. Relative costs of their screening and
immunization.
results: The presence of anti-HAV precluded the need for vaccination
in 148 subjects (28.1%). The highest prevalence of anti-HAV (82.7%) was
found in subjects born in nonindustrialized countries (62/75), in subjects
who had previously traveled to areas of endemic hepatitis A (32.1% [135/420]),
and in subjects born before 1945 (29.2% [92/315]). Costs of screening
and vaccinating travelers were cheapest if prevaccination antibody sera
testing was limited to subjects born in nonindustrialized countries and
those born before 1945.
conclusions: Prevaccination screening of travelers for hepatitis A
can be done selectively on the basis of age and country of origin. This
strategy could lead to a more economic use of the vaccine and clinic resources.
To
list of abstracts >>
Prevalence
of headaches in football players
Sallis RE, Jones K. Med Sci Sports Exerc 2000 Nov;32(11):1820-4.
background:
Football coaches and team physicians rely heavily on players' reports
of symptoms in deciding whether a player may return to the game after
sustaining head trauma. The decision is made difficult by the wide variety
of associated symptoms, some of which (eg, headache is among the most
common) may or may not be associated with serious head injury. More information
is needed about the clinical significance of football-related headache.
methods: To assess the frequency of headache associated with playing
football, we analyzed responses to our questionnaire asking about incidence,
frequency, and outcome of football-related headache from 443 football
players (320 from college, 123 from high school).
results: Eighty-five percent of respondents reported previous headache
related to hitting in football. Asked specifically about their most recent
game, 21% of respondents reported having had headache during that game.
Of players who had headache, only 19% informed the team physician, trainer,
or coach, and only 6% were removed from the game. Twenty-seven percent
of respondents reported previous diagnosis of cerebral concussion by medical
personnel. Defensive backs (25%), defensive linemen (19%), and offensive
linemen (18%) were most likely to have headache, related to hitting.
conclusions: Our data confirm that posttraumatic headache is commonly
associated with football participation and often goes unreported. Given
that the most serious complications of head injuries (eg, second-impact
syndrome) occur infrequently, headache as an isolated symptom lacks specificity
in predicting such complications in football players. Therefore, unless
it persists or is accompanied by additional symptoms, headache alone may
not reliably suggest the need to remove players from the game.
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list of abstracts >>
The
relative importance of gestational gain and maternal characteristics associated
with the risk of becoming overweight after pregnancy
Gunderson EP, Abrams B, Selvin S. Int J Obes Relat Metab Disord 2000
Dec;24(12):1660-8.
objectives:
To assess the relationships between gestational gain, race/ethnicity,
reproductive history, age, education and the risk of becoming overweight
after
pregnancy.
study design: Prospective cohort study of adult women from four race/ethnicity
groups who had two consecutive births between 1980 and 1990 at the University
of California, San Francisco (UCSF).
measurements: Height and pregravid weights for each pregnancy were
self-reported. Women were classified as overweight or not overweight according
to the Institute of Medicine (IOM) criteria for pregnancy. Gestational
gain was defined as the difference between the pregravid weight and the
last weight before delivery of the first study pregnancy.
subjects: 1300 healthy women aged 18-41 years who had a singleton,
full-term, live birth (index or first study pregnancy) followed by a second
birth. Self-reported pregravid weights and heights were used to calculate
body mass index (BMI). Women with a pregravid BMI below 26.0 kg/m2 before
the index pregnancy were classified as not overweight (n = 1128). Overweight
status following the index pregnancy was based on pregravid BMI for the
second pregnancy.
results: Seventy-two women (6.4%) became overweight following the
index pregnancy. Statistically significant independent predictors of the
risk of becoming overweight included: maternal age 24-30 vs above 30 years,
high gestational gain, short interval from menarche to first ever birth
(< 8 years), and young age at menarche (< 12 years). The risk of
becoming overweight was increased 2.5-3 times for each of these risk factors.
Whites were 4.5 times more likely to become overweight than Asians, but
blacks and Hispanics did not appear to differ from whites. Parity, time
interval, smoking habit, education, marital status and other factors were
not associated with the risk of becoming overweight.
conclusions: These findings suggest that young age at menarche, maternal
age and short time from menarche to first ever birth may be as important
as high gestational weight gain in determining the risk of becoming overweight
after pregnancy.
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list of abstracts >>
SNAP-II
and SNAPPE-II: Simplified newborn illness severity and mortality risk
scores
Richardson DK, Corcoran JD, Escobar GJ, Lee SK. J Pediatr 2001 Jan;138(1):92-100.
objectives:
Illness severity scores for newborns are complex and restricted by birth
weight and have dated validations and calibrations. We developed and validated
simplified neonatal illness severity and mortality risk scores. The primary
outcome was in-hospital mortality.
study design: Thirty neonatal intensive care units in Canada, California,
and New England collected data on all admissions during the mid 1990s;
patients moribund at birth or discharged to normal newborn care in <24
hours were excluded. Starting with the 34 data elements of the Score for
Neonatal Acute Physiology (SNAP), we derived the most parsimonious logistic
model for in-hospital mortality using 10,819 randomly selected Canadian
cases. SNAP-II includes six physiologic items; to this are added points
for birth weight, low Apgar score, and small for gestational age to create
a nine-item SNAP-Perinatal Extension-II (SNAPPE-II). We validated SNAPPE-II
on the remaining 14,610 cases and optimized the calibration.
results: In all birth weights, SNAPPE-II had excellent discrimination
and goodness of fit. Area under the receiver operator characteristic curve
was .91 ± 0.01. Goodness of fit (Hosmer-Lemeshow) was 0.90.
conclusions: SNAP-II and SNAPPE-II are empirically validated illness
severity and mortality risk scores for newborn intensive care. They are
simple, accurate, and robust across populations.
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list of abstracts >>
Vaccines
and otitis media
Black S, Shinefield H. Pediatr Ann 2000 Oct;29(10):648-51.
context:
Otitis media is one of the most common infectious diseases in children
and causes approximately 24.5 million doctor visits each year, according
to a 1990 survey of office practices in the United States by the Center
for Disease Control (CDC). Otitis media was the most frequent cause of
an office visit for children under 15 years old and particularly affects
one and two year olds. In a sample of 2807 children, 38% of the positive
bacterial cultures of middle ear fluids contained Streptococcus pneumoniae.
In recent years, treating otitis media has become more difficult because
of antibiotic resistant strains of the bacteria. Pneumococcal polysaccharide
vaccines have been available for decades, but they had not been used to
prevent otitis media because they do not induce immune responses for most
serotypes in children under two years old.
objectives: This study examined conjugate vaccines against the
pneumococcus, which used the same technology as Haemophilus influenzae
type b (Hib) conjugate vaccines that successfully induced immune responses
and protected young children. Multiple serotypes of pneumococci are responsible
for invasive disease and otitis media, therefore the vaccines contain
conjugates for multiple serotypes to protect against the majority of disease.
This study evaluated on a large scale the safety and efficacy of the first
such conjugate vaccine, which has just been licensed in the United States.
participants: The study population of children had a total of 47,392
visits for otitis media and 33,529 episodes of otitis from October 1995
to April 1998. A total of 5160 children had frequent otitis.
results: In more than 37,000 children in Northern California Kaiser
Permanente, the vaccine was 97.4% effective in preventing invasive disease.
The number of otitis media episodes decreased by 7.0%. The effectiveness
of the vaccine against frequent otitis media increased from 9.5 to 22.8%
as the frequency of episodes increased. During the study, 355 children
needed ventilatory tube placement, while vaccinated children were 20.3%
less likely than controls to require such tube placement.
conclusion: With licensure of this heptavalent conjugate vaccine for
routine use in the United States, we anticipate for the annual US birth
cohort of 3.8 million children, that otitis media doctor visits will decrease
by more than 1,000,000 visits and that up to 500,000 fewer children each
year will undergo ventilatory tube placement. However, the impact on the
average child's otitis media experience will be relatively modest.
At present, the ACIP has recommended routine vaccination with pneumococcal
conjugate vaccine for all infants and children under age two as well as
high risk children older than age two. We believe that vaccination of
children over two years of age with frequent otitis media should also
be considered.
To
list of abstracts >>
Effect
of physician and patient gender concordance on patient satisfaction and
preventive care practices
Schmittdiel J, Grumbach K, Selby JV, Quesenberry CP
Jr. J Gen Intern Med 2000 Nov;15(11):761-9.
objective:
To explore the role of the gender of the patient and the gender of the
physician in explaining differences in patient satisfaction and patient-reported
primary care practice.
design: Cross-sectional mailed survey [response rate of 71%].
setting: A large group-model Health Maintenance Organization (HMO)
in northern California.
patients/participants: Random sample of HMO members aged 35 to 85
years with a primary care physician. The respondents (n = 10,205) were
divided into four dyads: female patients of female doctors; male patients
of female doctors; female patients of male doctors; and male patients
of male doctors. Patients were also stratified on the basis of whether
they had chosen their physician or had been assigned.
measurements and main results: Among patients who chose their physician,
females who chose female doctors were the least satisfied of the four
groups of patients for four of five measures of satisfaction. Male patients
of female physicians were the most satisfied. Preventive care and health
promotion practices were comparable for male and female physicians. Female
patients were more likely to have chosen their physician than males, and
were much more likely to have chosen female physicians. These differences
were not seen among patients who had been assigned to their physicians
and were not due to differences in any of the measured aspects of health
values or beliefs.
conclusions: Our study revealed differences in patient satisfaction
related to the gender of the patient and of the physician. While our study
cannot determine the reasons for these differences, the results suggest
that patients who choose their physician may have different expectations,
and the difficulty of fulfilling these expectations may present particular
challenges for female physicians.
Reprinted by permission of Blackwell Science, Inc.
To
list of abstracts >>
Health
and loyalty promotion visits for new enrollees: results of a randomized
controlled trial
Thompson M, Gee S, Larson P, Kotz K, Northrop L. Patient Educ Couns 2001
Jan 1;42(1):53-65.
Managed
care needs effective and efficient ways to orient new members, enhance
trust and loyalty, and offer prevention and self-care education and services.
Recent adult enrollees of Kaiser Permanente (Northern California) were
randomly assigned to one of three intervention conditions (n = 286) (individual
visit with a physician, physician visit plus a visit with a health educator,
a group visit of eight new members led by a physician and health educator)
or a random control group (n = 278). Outcomes were gauged via pre- and
post-visit questionnaires and a 20-minute telephone survey at baseline
and at a six-month follow-up. Compared to controls, attendees of the three
interventions had higher satisfaction, self-rated prevention knowledge,
acceptance of health plan guidelines, and were more likely to plan to
remain in the health plan. Group visit attendees stood out as experiencing
the greatest benefits and were especially likely to report saving a telephone
call or visit to their doctor by using a self-care handbook.
Reprinted from Patient Education and Counseling, Vol 42, Thompson M, Gee
S, Larson P, Kotz K, Northrop L, Health and loyalty promotion visits for
new enrollees: results of a randomized controlled trial, 53-65, Copyright
2001, with permission from Elsevier Science.
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