From
the Northwest:
Computerized health information and
the demand for medical care
Wagner TH, Jimison HB. Value Health 2003; 6(1):29-39.
objective:
Consumer health information, once the domain of books and booklets,
has become increasingly digitized and available on the Internet. This
study assessed the effect of using computerized health information on
consumers' demand for medical care.
methods: The dependent variable was self-reported number of visits
to the doctor in the past year. The key independent variable was the
use of computerized health information, which was treated as endogenous.
We tested the effect of using computerized health information on physician
visits using ordinary least squares, instrumental variables, fixed effects,
and fixed-effects instrumental variables models. The instrumental variables
included exposure to the Healthwise Communities Project, a community-wide
health information intervention; computer ownership; and Internet access.
Random households in three cities were mailed questionnaires before
and after the Healthwise Communities Project. In total, 5909 surveys
were collected for a response rate of 54%.
results:
In both the bivariate and the multivariate analyses, the use of computerized
health information was not associated with self-reported entry into
care or number of visits. The instrumental variables models also found
no differences, with the exception that the probability of entering
care was significantly greater with the two-stage conditional logit
model (p < .05).
conclusions: Although providing people with health information is
intuitively appealing, we found little evidence of an association between
using a computer for health information and self-reported medical visits
in the past year. This study used overall self-reported utilizations
as the dependent variable, and more research is needed to determine
whether health information affects the health production function in
other important ways, such as the location of care, the timing of getting
care, or the intensity of treatment.
Reprinted with permission from Blackwell Publishing Ltd.
From
Northern California:
Safety and efficacy of the seven-valent
pneumococcal conjugate vaccine: evidence from Northern California
Black S, Shinefield H. Eur J Pediatr 2002; 161 Suppl 2:S127-31.
Pneumococcal
disease remains a significant cause of morbidity among young children.
A large-scale efficacy trial in the Northern California Kaiser Permanente
system (the KP trial) demonstrated that a seven-valent conjugate vaccine
(PCV) is safe and immunogenic in young children and effective in preventing
both invasive pneumococcal disease caused by vaccine serotypes (97.4%
efficacy) and episodes of otitis media (7.0% efficacy). Since the publication
of the results of the KP trial in 2000, we have performed an additional
analysis on the safety, immunogenicity, and efficacy of the vaccine
in low birth weight (LBW) and preterm (PT) infants, and have examined
the efficacy of the vaccine during one year of wide-scale post-licensure
use. The vaccine was at least as immunogenic in LBW and PT infants as
in normal-weight, full-term infants and was 100% effective, although
the LBW and PT infants had higher rates of adverse events such as redness
and swelling. LBW and PT infants receiving pneumococcal vaccine also
had higher rates of adverse events, such as hives, than those receiving
control meningococcal vaccine, but these reactions were not severe.
When the PCV was used in the general population, the efficacy remained
high and there was no corresponding increase in disease caused by nonvaccine
serotypes. There was also evidence that vaccine administration led to
herd immunity. Febrile illness was the only adverse event seen more
frequently after vaccine administration than during a control period.
conclusion: The seven-valent conjugate vaccine is safe and effective
for use in the general population.
Reprinted with permission from Springer-Verlag. http://link.springer.de
From
Southern California:
Acute diverticulitis in the young
adult is not "virulent"
Schweitzer
J, Casillas RA, Collins JC. Am Surg 2002; 68(12):1044-7.
Acute
diverticulitis historically has been considered rare before the age
of 40 but "virulent" when it does occur and frequently requiring
emergency operation. Recent experience suggests that the demographics
and management of this disease are changing. Outcomes at Kaiser Permanente
Los Angeles Medical Center were reviewed. Between January 1997 and July
2001, 261 patients were discharged with the diagnosis of acute diverticulitis;
46 or 18% of these were aged 40. Patients' mean age was 35, 76% were
men, 65% were Latino, and 72% were obese (body mass index 30 kg/m2).
An operation at initial presentation was performed on 35% (16/46) patients.
Only 19% of these (3/16) had a correct preoperative diagnosis. The 30
patients who were treated nonoperatively all were managed successfully;
one required a percutaneous drain. Given the apparent increasing frequency
of acute diverticulitis in young adults and the high success rate of
initial nonoperative management, surgeons should consider this diagnosis
in selected patients who present with abdominal symptoms. Knowledge
of typical clinical features and judicious use of computed tomography
may decrease the number of unnecessary emergency operations in young
adults with acute diverticulitis. Our data do not support a "virulent"
label for this disease in the young.
From
Southern California:
Fate of the anterior cruciate ligament-injured
knee
Fithian DC, Paxton LW, Goltz DH. Orthop Clin North Am 2002; 33(4):621-36,
v.
Most patients
with anterior cruciate ligament (ACL) injuries do well with activities
of daily living even after follow-up in the range of five to 15 years.
Most can participate in some sports activity if they are inclined to
do so, but most will have some limitations in vigorous sports, and only
a few will be entirely asymptomatic. The challenge to the clinician
is to understand and predict how ACL deficiency in a given patient will
affect that patients' life and activities. In counseling patients about
treatment after an ACL injury, the clinician can use knee ligament arthrometry
measurements and pre-injury sports activity to estimate the risk of
injury over the next five to ten years. Meniscus, chondral, and sub-chondral
injuries are not uncommon, but rarely require surgical intervention
in the early phase of ACL deficiency. The prevalence of clinically significant
meniscal damage increases with time, and is associated with increasing
disability, surgery, and arthrosis in high-risk patients. Ligament reconstruction
has not been shown to prevent arthrosis, but in prospective studies
it appears to reduce the risk of subsequent meniscal injury, improve
passive anteroposterior knee motion limits, and facilitate return to
high-level sporting activities.
Reprinted from Orthopedic Clinics of North America, V33(4), Fithian
DC, Paxton LW, Goltz DH, p 621-36, v. Copyright 2002, with permission
from Elsevier.
clinical
implication: ACL injury results in knee instability that can lead
to recurrent injury, surgery, and potentially, arthritis. It is important
for first-line care providers to consider the possibility of ACL injury
when a patient presents with a knee injury. Pathologic anterior knee
laxity can be documented with a careful examination by an experienced
knee specialist. In counseling patients about treatment after an ACL
injury, the clinician can use knee ligament arthrometry measurements
and pre-injury sports activity to estimate the risk of injury over
the next five to ten years. DF
From
the Northwest:
Understanding changes in primary care clinicians' satisfaction
from depression care activities during adoption of selective serotonin
reuptake inhibitors
Shye D, Brown JB, Mullooly JP, Nichols GA. Am J Manag Care 2002; 8(11):963-74.
objectives:
To describe how primary care clinicians' perceptions about depression
care as a clinical activity changed during the adoption of selective
serotonin reuptake inhibitors (SSRIs) in their health maintenance organization
(HMO).
study
design: Prospective study of change in primary care clinicians'
level of satisfaction from depression care activities from Time 1 (mid-1993)
to Time 2 (early 1995).
methods:
Study subjects were internal medicine and family practice physicians,
physician assistants, and nurse practitioners (n = 196) in a large,
not-for-profit group-model HMO. We modeled level of satisfaction from
depression care activities at Time 2 as a function of changes in depression-care-related
attitudes and perceptions over the study period, controlling for Time
1 level of satisfaction and personal and professional characteristics.
results:
Overall satisfaction showed a small, statistically significant improvement
over the study period. Time 2 satisfaction was a function of improved
perceptions about the feasibility of primary care treatment of depression,
which in turn were related to improved perceptions about the effectiveness
of drug treatment. The relevance of clinicians' perceptions about their
own depression care skills declined concomitantly.
conclusions:
The adoption of SSRIs in the HMO was associated with improvement in
primary care clinicians' perceptions about their ability to successfully
treat depression (especially using pharmacology) and in their overall
satisfaction from depression care activities. Future research should
address whether reliance on SSRIs replaces the use of other depression
treatment modalities, and if so, how this reliance affects patient outcomes
and satisfaction and overall health care costs.
From
Ohio:
The impact of a health education
program targeting patients with high visit rates in a managed care organization
Dally DL, Dahar W, Scott A, Roblin D, Khoury AT. Am J Health Promot
2002; 17(2):101-11.
purpose:
To determine if a mailed health promotion program reduced outpatient
visits while improving health status.
design: Randomized controlled trial.
setting: A midsized, group practice model, managed care organization
in Ohio.
subjects: Members invited (n = 3214) were high utilizers, 18 to
64 years old, with hypertension, diabetes, or arthritis (or all). A
total of 886 members agreed to participate, and 593 members returned
the initial questionnaires. The 593 members were randomized to the following
groups: 99 into arthritis treatment and 100 into arthritis control,
94 into blood pressure treatment and 92 into blood pressure control,
and 104 into diabetes treatment and 104 into diabetes control.
measures: Outpatient utilization, health status, and self-efficacy
were followed over 30 months.
interventions: Health risk appraisal questionnaires were mailed
to treatment and control groups before randomization and at one year.
The treatment group received three additional condition-specific (arthritis,
diabetes, or hypertension) questionnaires and a health information handbook.
The treatment group also received written health education materials
and an individualized feedback letter after each returned questionnaire.
The control group received condition-specific written health education
materials and reimbursement for exercise equipment or fitness club membership
after returning the one-year end of the study questionnaire.
results: Changes in visit rates were disease specific. Parameter
estimates were calculated from a Poisson regression model. For intervention
vs controls, the arthritis group decreased visits 4.84 per 30 months
(p < 0.00), the diabetes group had no significant change, and the
hypertension group increased visits 2.89 per 30 months (p < 0.05),
the overall health status improved significantly (-6.5 vs 2.3, p <
0.01) for the arthritis group but showed no significant change for the
other two groups, and coronary artery disease and cancer risk scores
did not change significantly for any group individually. Overall self-efficacy
for intervention group completers improved by -8.6 points (p < 0.03)
for the arthritis group, and the other groups showed no significant
change.
conclusions: This study demonstrated that in a population of 18
to 64 years with chronic conditions, mailed health promotion programs
might only benefit people with certain conditions.
Reprinted with permission from the American Journal of Health Promotion.
clinical
implication: This study indicates that health promotion programs
mailed to 18-64-year-old members of Medical Care Organizations reduces
visit rates while improving functionality and health status of high-utilizing
persons with only certain diagnoses. Further research is needed to
determine the effect of mailed health promotion programs on additional
medical outcomes, such as hospitalizations and emergency departments,
or in determining which conditions benefit from these mailings. DD
From
Northern California/Northwest:
Bone loss predicts subsequent cognitive
decline in older women: the study of osteoporotic fractures
Lui LY, Stone K, Cauley JA, Hillier T, Yaffe K. J Am Geriatr Soc 2003;
51(1):38-43.
objectives:
To determine whether the rate of bone loss predicts subsequent cognitive
decline independently of baseline bone mass and whether apolipoprotein
E (ApoE) genotype explains the association.
design: A prospective cohort study.
setting: Clinical centers in Baltimore, MD; Minneapolis, MN; Pittsburgh,
PA; and Portland, OR.
participants: Four thousand four hundred sixty-two women aged 70
and older (mean = 75.8) participating in the Study of Osteoporotic Fractures.
measurements: Total hipbone mineral density (BMD) was measured two
and six years after enrollment (mean follow-up = 3.5 years), and expressed
as annualized percentage rate of bone change. A modified Mini-Mental
State Examination (mMMSE) was administered at six and ten years (mean
follow-up = 4.5 years) and defined cognitive decline as a decline of
three or more points on repeat mMMSE score. ApoE genotype information
was available on 883 women.
results: Cognitive decline occurred in 12% of the women with the
least bone loss (by quartile), 14% in the second, 16% in the third,
and 20% in those with the greatest bone loss. After adjustment for age,
education, stroke, functional status, estrogen use, body mass index,
and smoking, the results were similar. Those who lost the most BMD were
almost 40% more likely than women in the lowest quartile to develop
cognitive decline in the multivariate model (odds ratio (OR) = 1.4,
95% confidence interval (CI) = 1.1-1.8). A similar association between
hipbone loss and cognitive decline was observed in the multivariate
model further adjusting for ApoE e4 (OR = 1.5, 95% CI = 0.8-2.7).
conclusions: Women with more rapid hipbone loss were more likely
to develop cognitive decline than those who had lower rate of loss (or
who gained bone mass). Differences in functional status, estrogen use,
and ApoE did not explain this association. Further investigation is
needed to determine the mechanisms that link osteoporosis and cognitive
decline.
Reprinted with permission from Blackwell Publishing Ltd.
From
Northern California:
Prevalence of and reasons for preoperative
tobacco use
Shannon-Cain J, Webster SF, Cain BS. AANA J 2002 Feb;70(1):33-40.
Smoking
cigarettes has an impact on all aspects of the perioperative anesthetic.
It is not known whether patients are typically educated regarding these
effects. Eighty-one patients completed a questionnaire concerning smoking
behavior in the 24 hours before surgery. Variables measured were smoking
history, tobacco addiction, and preoperative education. Chi-square analysis
was used. Of 81 participants, 66 (81%) smoked tobacco within 24 hours
of surgery. Thirty-seven patients received no instructions to stop smoking,
and only two patients abstained on their own. Of the 44 patients counseled
not to smoke, 12 abstained from tobacco before operation. Thus, with
counseling, the cessation rate was approximately five times greater
(chi 2 = 7.0, p = .008). A second correlation was seen when the patients
were informed about tobacco's risks related to anesthesia. The smoking
rate decreased from 15% to 4%, a four-fold decrease (chi 2 = 15.3, p
= .0001). The results indicate patients who smoke are not routinely
informed of the risks of tobacco use or the benefits of abstinence before
surgery. Counseling has a positive impact on the patient's smoking behavior
in the 24 hours preceding surgery. Anesthesia providers and surgeons
have a renewed obligation to instruct patients not to smoke before surgery.
clinical
implication: The most important practical lesson in the article
for the Primary Care Provider is that your patient's risk of anesthetic
complications is significantly affected if he or she continues to
smoke into the preoperative period. We should strongly advise them
to abstain from smoking especially in that time range. This recommendation
can statistically reduce patients' perioperative tobacco abuse. SW
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