Selected by Daphne Plaut, MLS, Librarian, Center for Health Research

From the Northwest:
Web-based weight management programs in an integrated health care setting: A randomized, controlled trial.
Rothert K, Strecher VJ, Doyle LA, Caplan WM, Joyce JS, Jimison HB, Karm LM, Mims AD, Roth MA. Obes Res 2006 Feb;14(2):266-72.

objective: To assess the efficacy of a Web-based tailored behavioral weight management program compared with Web-based information-only weight management materials.
research methods and procedures: Participants, 2862 eligible overweight and obese (BMI = 27 to 40 kg/m²) members from four regions of Kaiser Permanente's integrated health care delivery system, were randomized to receive either a tailored expert system or information-only Web-based weight management materials. Weight change and program satisfaction were assessed by self-report through an Internet-based survey at three- and six-month follow-up periods.
results: Significantly greater weight loss at follow-up was found among participants assigned to the tailored expert system than among those assigned to the information-only condition. Subjects in the tailored expert system lost a mean of 3 ± 0.3% of their baseline weight, whereas subjects in the information-only condition lost a mean of 1.2 ± 0.4% (p < 0.0004). Participants were also more likely to report that the tailored expert system was personally relevant, helpful, and easy to understand. Notably, 36% of enrollees were African American, with enrollment rates higher than the general proportion of African Americans in any of the study regions.
discussion: The results of this large, randomized control trial show the potential benefit of the Web-based tailored expert system for weight management compared with a Web-based information-only weight management program.

Reprinted with permission. Copyright 2006, NAASO.

From the Northwest:
Treatment escalation and rise in HbA_1c following successful initial metformin therapy.
Nichols GA, Alexander CM, Girman CJ, Kamal-Bahl SJ, Brown JB. Diabetes Care 2006 Mar;29(3):504-9.

objective: To describe secondary failure of initial metformin therapy in patients who achieved initial HbA_1c (A1C) <8% and to identify predictors of failure.
research design and methods: We identified 1288 patients who achieved A1C <8% within one year of initiating metformin as their first-ever antihyperglycemic drug. Subjects were followed until they added/switched antihyperglycemics, they terminated Health Plan membership, or December 31, 2004. We defined secondary failure using two separate but overlapping approaches: 1) addition/switch to another antihyperglycemic drug or 2) first A1C measurement >8% after at least six months on metformin.
results: The best A1C achieved within one year of metformin initiation was the most powerful predictor of avoiding secondary failure. Approximately 50% of subjects whose best A1C was 7-7.9% added/switched antihyperglycemic drugs within 36 months, whereas it took >60 months for those in the 6-6.9% A1C category to reach a 50% failure rate. Those who achieved an A1C <6% did not reach a 50% rate of adding/switching drugs until 84 months. For the alternative secondary failure outcome, about half of those whose best A1C was 7.0-7.9% reached an A1C >8% within 24 months. Only approximately 25% of subjects in the 6-6.9% category failed by 48 months, and >80% of subjects in the <6% category remained below 8% through 60 months.
conclusions: Whether defined by adding/switching to another drug or by reaching an A1C of 8%, secondary failure is inversely associated with the reduction of A1C achieved within the first year of metformin monotherapy.

Copyright © 2006 American Diabetes Association. From Diabetes Care, Vol 29, 2006;504-9. Reprinted with permission from The American Diabetes Association.

From Southern California:
Spirometry is related to perinatal outcomes in pregnant women with asthma.
Schatz M, Dombrowski MP, Wise R, Momirova V, Landon M, Mabie W, Newman RB, Rouse DJ, Lindheimer M, Miodovnik M, Caritis SN, Leveno KJ, Meis P, Wapner RJ, Paul RH, O'Sullivan MJ, Varner MW, Thurnau GR, Conway DL; National Institute of Child Health and Human Development Maternal-Fetal Medicine Units Network; National Heart, Lung, and Blood Institute. Am J Obstet Gynecol 2006 Jan;194(1):120-6.

objective: The purpose of this study was to test the hypothesis that maternal asthma symptoms and pulmonary function are related to adverse perinatal outcomes.
study design: Asthmatic patients were recruited from the 16 centers of the Maternal Fetal Medicine Units. Forced expiratory volume in one second was obtained at enrollment and at monthly study visits, and the frequency of asthma symptoms was assessed from enrollment to delivery. Perinatal data were obtained at postpartum chart reviews.
results: The final cohort included 2123 participants with asthma. After adjustment for demographic characteristics, smoking, acute asthmatic episodes, and oral corticosteroid use, significant relationships were demonstrated between gestational hypertension and preterm birth and lower maternal gestational forced expiratory volume in one second. The data did not show any significant independent relationship between asthma symptom frequency and perinatal outcomes.
conclusion: Lower pulmonary function during pregnancy is associated with increased gestational hypertension and prematurity in the pregnancies of women with asthma, which may be due to inadequate asthma control or factors that are associated with increased asthma severity.

Reprinted from American Journal of Obstetrics and Gynecology, 194(1), Schatz M, Dombrowski MP, Wise R, et al; National Institute of Child Health and Human Development Maternal-Fetal Medicine Units Network; National Heart, Lung, and Blood Institute, Spirometry is related to perinatal outcomes in pregnant women with asthma, 120-6, Copyright 2006, with permission from Elsevier.

From Northern California:
Short-term outcomes of infants born at 35 and 36 weeks gestation: we need to ask more questions.
Escobar GJ, Clark RH, Greene JD. Semin Perinatol 2006 Feb;30(1):28-33.

background: Newborns who are 35 to 36 weeks gestation comprise 7.0% of all live births and 58.3% of all premature infants in the United States. They have been studied much less than very low birth weight infants.
objective: To examine available data permitting quantification of short-term hospital outcomes among infants born at 35 and 36 weeks gestation.
design: Review of existing published data and, where possible, re-analysis of existing databases or retrospective cohort analyses.
setting: Multiple hospitals and neonatal intensive care units in the United States and England.
patients: Premature infant cohorts with infants whose dates of birth ranged from 1/1/98 through 6/30/04.
main outcome measures: 1) Death, 2) respiratory distress requiring some degree of inhospital respiratory support during the birth hospitalization, and 3) rehospitalization following discharge home after the birth hospitalization.
results: Newborns born at 35 and 36 weeks gestation experienced considerable mortality and morbidity. Approximately 8% required supplemental oxygen support for at least one hour, almost three times the rate found in infants born at 37 weeks. Among 35 to 36 week newborns who progressed to respiratory failure and who survived to six hours of age and did not have major congenital anomalies, the mortality rate was 0.8%. Following discharge from the birth hospitalization, 35 to 36 week infants were much more likely to be rehospitalized than term infants, and this increase was evident both within 14 days as well as within 15 to 182 days after discharge. In addition, late preterm infants experienced multiple therapies, few of which have been formally evaluated for safety or efficacy in this gestational age group.
conclusions: Greater attention needs to be paid to the management of late preterm infants. In addition, it is important to conduct formal evaluations of the therapies and follow-up strategies employed in caring for these infants.

Reprinted from Seminars in Perinatology, 30(1), Escobar GJ, Clark RH, Greene JD, Short-term outcomes of infants born at 35 and 36 weeks gestation: we need to ask more questions, 28-33, Copyright 2006, with permission from Elsevier.

From Colorado:
Outcomes of a multifaceted physical activity regimen as part of a diabetes self-management intervention.
King DK, Estabrooks PA, Strycker LA, Toobert DJ, Bull SS, Glasgow RE. Ann Behav Med 2006 Apr;31(2):128-37.

background: Physical activity (PA) is important for management of diabetes, yet practical interventions that achieve sustained behavior change are rare.
purpose: The goals of this research were to evaluate the effectiveness of a multifaceted PA intervention for people with type 2 diabetes that emphasized participant choice in activity selection. Baseline activity patterns were examined to determine whether they predicted changes in PA at two months.
methods: Three hundred thirty-five participants were recruited from 42 primary care physicians and then randomized to either a computer-assisted, tailored self-management intervention (n = 174) or health risk appraisal with feedback control (n = 161). Primary outcome measures included the Community Healthy Activities Model Program for Seniors Questionnaire, diet, and psychosocial assessments at baseline and two months.
results: For 301 participants who completed the two-month follow-up, the intervention significantly improved all PA (p < .01) and moderate PA (metabolic equivalents >3.0, p < 01) relative to controls. Baseline cluster analyses grouped participant activity patterns into three categories. At two months, cluster assignment differentially predicted change in calories expended in moderate, rote, sport, and lifestyle PA.
conclusions: A computer-assisted, multifaceted approach to PA demonstrated improvement after two months. The results suggest that individuals are capable of adjusting their activity patterns to maximize their PA.

From Southern California:
Screening of EEG referrals by neurologists leads to improved health care resource utilization.
Gurbani NS, Gurbani SG, Mittal M, McGuckin JS, Tin SN, Tehrani K, Chayasirisobhon S. Clin EEG Neurosci 2006 Jan;37(1):30-3.

The objective of this study was to determine if screening by a neurologist of all non-neurologist electroencephalogram (EEG) referrals prior to approval reduces the number of inappropriate requests. This retrospective survey included 600 consecutive EEG requisitions referred to the Anaheim Kaiser Permanente Neurodiagnostic Laboratory to rule out epilepsy. Patients with established epilepsy referred for a repeat EEG for management issues were excluded. Three groups of EEG referrals were analyzed. Each group consisted of 200 EEGs (100 pediatric and 100 adult EEGs). The first group was referred directly by non-neurologists, the second group was referred by non-neurologists with scrutiny by a neurologist, and the third group was referred by a neurologist directly. In the pediatric group, the ratio of abnormal EEG vs normal EEG was 1:3.35 in the first group, 1:0.69 in the second group and 1:0.33 in the third group. In the adult group, the ratio of abnormal EEGs vs normal EEGs was 1:2.23 in the first group, 1:0.82 in the second group and 1:0.45 in the third group. In the combined pediatric and adult groups, the ratio of abnormal EEG vs normal EEG was 1:2.70 in the first group, 1:0.75 in the second group and 1:0.39 in the third group. There was a significant difference between the results of the EEGs ordered by non-neurologists directly versus non-neurologists with scrutiny (p = .334, c-square test). Scrutiny by a neurologist of EEG referrals from non-neurologists led to a reduction in the number of normal EEG results. This suggests that inappropriate EEG requests for nonepileptic patients that yield normal EEG results are significantly reduced with scrutiny. This can help reduce the indiscriminate overuse of EEGs by non-neurologists thereby leading to better utilization of health care resources.

From Northern California:
Outcomes of a disease-management program for patients with recent osteoporotic fracture.
Che M, Ettinger B, Liang J, Pressman AR, Johnston J. Osteoporos Int 2006;17(6):847-54.

introduction: The purpose of this study was to evaluate outcomes of a disease-management program designed to increase rates of bone-mineral-density (BMD) testing and initiation of osteoporosis medication among patients with a recent osteoporotic fracture.
study design: We identified 744 consecutive patients aged 55 years who were seen at either of two of 14 Kaiser Permanente medical facilities in Northern California (KPNC) after sustaining a fracture of the hip, spine, wrist, or humerus between April 2003 and May 2004. These patients were invited to participate in a study of the Fragile Fracture Management Program, whose protocol used fracture-risk assessment tools to determine treatment recommendations. Postfracture care of study participants was compared with usual postfracture care received by osteoporotic-fracture patients at 12 other KPNC facilities.
results: Of the 744 patients who were invited to participate in the study, 293 (39%) agreed to participate, and 169 (23%) completed the evaluation. Of these 169 patients (127 women, 42 men), 65 (51%) of the women and seven (17%) of the men qualified for drug treatment; of these 72 patients, six (86%) of the men and 41 (63%) of the women accepted the offered treatment. At the two study locations, rates of care (BMD testing or prescribing osteoporosis medication) were about twice as high as rates of usual postfracture care observed at 12 other medical centers in KPNC.
conclusions: Compared with patients who received usual care for osteoporotic fracture, patients participating in a postfracture disease management program had substantially higher rates of medical attention given for osteoporosis; however, the overall yield of the program was low. This low uptake rate was related to factors not previously appreciated: many patients refused participation in the program; a high proportion of younger women--and men of all ages--did not qualify for treatment; and treatment was refused by one in three study-qualified women and by one in seven study-qualified men. Additional efforts are needed to overcome patient barriers to improved osteoporosis evaluation, treatment, and participation in postfracture programs.

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