From
Southern California:
Effectiveness
of a home-based palliative care program for end-of-life
Brumley RD, Enguidanos S, Cherin DA. J Palliat Med. 2003 Oct;6(5):715-24.
context:
Despite the widespread recognition of the need for new models of care
to better serve patients at the end-of-life, little evidence exists
documenting the effectiveness of these models.
objective: To evaluate the effectiveness of a palliative program
for end-of-life care.
design: A comparison group study was conducted between March
1999 and August 2000 comparing subjects enrolled in a palliative care
intervention to those receiving usual care.
setting: Home Health Department at Kaiser Permanente, TriCentral
Service Area.
subjects: During the course of the two-year study, 558 subjects
were enrolled. A subgroup of 300 patients who had died during the course
of the study was selected for analysis; 161 were enrolled in the Palliative
Care Program and 139 in the comparison group.
intervention: The Kaiser Permanente Palliative Care Project is a
multidisciplinary care management approach for home-based end-of-life
care and treatment. The program is designed to facilitate the transition
from acute to palliative care during the last 12 months of life with
the goal of improving quality of life through the provision of symptom
control and pain relief, emotional and spiritual support, and patient
education.
main outcome measures: Medical service use and satisfaction with
services.
results: Palliative care patients had increased satisfaction
with services at 60 days after enrollment and significantly fewer emergency
department visits, hospital days, skilled nursing facility days, and
physician visits than those in the comparison group. Those enrolled
in palliative care averaged a 45% decrease in costs as compared to usual
care patients.
conclusion: Through integrating palliative care into curative care
practices earlier in the disease trajectory, chronically ill patients
nearing the end of life report improved satisfaction with care and demonstrate
less acute care use resulting in lower costs of care. In addition, patients
enrolled in the palliative care program were more likely to die at home
than comparison group patients.
From
Colorado:
Implementing
practical interventions to support chronic illness self-management
Glasgow RE, Davis CL, Funnell MM, Beck A. Jt Comm J Qual Saf.
2003 Nov;29(11):563-74.
background:
Self-management support (SMS) is the area of disease management least
often implemented and most challenging to integrate into usual care.
This article outlines a model of SMS applicable across different chronic
illnesses and health care systems, presents recommendations for assisting
health care professionals and practice teams to make changes, and provides
tips and lessons learned. Strategies can be applied across a wide range
of conditions and settings by health educators, care managers, quality
improvement specialists, researchers, program evaluators, and clinician
leaders. Successful SMS programs involve changes at multiple levels:
patient-clinician interactions; office environment changes; and health
system, policy, and environmental supports.
patient-clinician interaction level: Self-management by patients
is not optional but inevitable because clinicians are present for only
a fraction of the patient's life, and nearly all outcomes are mediated
through patient behavior. Clinicians who believe they are in control
or responsible for a patient's well-being are less able to adopt an
approach that acknowledges the central role of the patient in his or
her care.
summary and conclusions: Self-management should be an integral
part of primary care, an ongoing iterative process, and patient centered;
use collaborative goal setting and decision making; and include problem
solving, outreach, and systematic follow-up.
© Joint Commission Resources: Joint Commission Journal on Quality
and Safety. Oakbrook Terrace, IL: Joint Commission on Accreditation
of Healthcare Organizations, 2003, p 563-74. Reprinted with permission.
| clinical
implication: This article discusses how to achieve patient self-management
at each of three levels: patient-clinician interactions, the office
environment, and the systems/policy/environmental level. There are
established evidence-based self-management principles that work
for both chronic illness management and prevention. Specific applications
need to be tailored to each clinical setting. The organizations
that are most successful in achieving self-management use approaches
that are multilevel, patient-centered, proactive, and population-base;
plan patient visits and follow-up contacts; create prompts and reminders
for both patients and clinicians; and distribute responsibilities
for self-management support across all team members. --RG |
From
the Northwest:
Complications
in young adults with early-onset type 2 diabetes: losing the relative
protection of youth
Hillier TA, Pedula KL. Diabetes Care. 2003 Nov;26(11):2999-3005.
objective:
To determine whether adults diagnosed with type 2 diabetes from age
18 to 44 years more aggressively develop clinical complications after
diagnosis than adults diagnosed at 45 years of age.
research design and methods: We compared outcomes among 7844
adults in a health maintenance organization who were newly diagnosed
with type 2 diabetes between 1996 and 1998. We abstracted clinical data
from electronic medical, laboratory, and pharmacy records. To adjust
for length of follow-up and sex, we used proportional hazards models
to compare incident complication rates through 2001 between onset groups
(mean follow-up 3.9 years). To adjust for the increasing prevalence
of macrovascular disease with advancing age, onset groups were matched
by age and sex to control subjects without diabetes for macrovascular
outcomes.
results: Adults with early-onset type 2 diabetes were 80% more likely
to begin insulin therapy than those with usual-onset type 2 diabetes
(hazards ratio [HR] 1.8, 95% CI 1.5-2.0), despite a similar average
time to requiring insulin (approximately 2.2 years). Although the combined
risk of microvascular complications did not differ overall, microalbuminuria
was more likely in early-onset type 2 diabetes than usual-onset type
2 diabetes (HR 1.2, 95% CI 1.1-1.4). The hazard of any macrovascular
complication in early-onset type 2 diabetic patients compared with control
subjects was twice as high in usual-onset type 2 diabetic patients compared
with control subjects (HR 7.9 vs 3.8, respectively). Myocardial infarction
(MI) was the most common macrovascular complication, and the hazard
of developing an MI in early-onset type 2 diabetic patients was 14-fold
higher than in control subjects (HR 14.0, 95% CI 6.2-31.4). In contrast,
adults with usual-onset type 2 diabetes had less than four times the
risk of developing an MI compared with control subjects (HR 3.7, p <
0.001).
conclusions: Early-onset type 2 diabetes appears to be a more
aggressive disease from a cardiovascular standpoint. Although the absolute
rate of cardiovascular disease (CVD) is higher in older adults, young
adults with early-onset type 2 diabetes have a much higher risk of CVD
relative to age-matched control subjects.
Copyright © 2003 American Diabetes Association. From Diabetes
Care, Vol 26, 2003;2999-3005. Reprinted with permission from The American
Diabetes Association.
From
the Northwest:
Screening
rarely screened women: time-to-service and 24-month outcomes of tailored
interventions
Valanis B, Whitlock EE, Mullooly J, et al. Prev Med. 2003 Nov;37(5):442-50.
background:
Managed care organizations and others reaching out to underscreened
women seek strategies to encourage mammogram and Pap screening.
methods: Female HMO members aged 50-69 years and overdue for
a mammogram and a Pap test (n = 501) were followed for 24 months after
interventions began. An Outreach intervention (tailored letters and
motivational telephone interviews), an Inreach intervention (motivational
interview delivered in clinics), and a Combined Inreach/Outreach intervention
were compared to Usual Care at 24 months. Logistic regression and Cox
hazard models examined predictors of obtaining screening services and
time-to-service, respectively.
results: Compared with Usual Care, the odds of Outreach women aged
50-64 obtaining a mammogram (OR = 2.06; 95% CI = 1.59-5.29), a Pap test
(OR = 1.97; 95% CI = 1.12-3.53), or both (OR = 2.53; 95% CI = 1.40-4.63)
remained significantly increased at 24 months. The average time-to-service
for Outreach women was reduced by four months. Outreach effects persisted
despite intensive, ongoing health plan efforts to improve screening
of all women.
conclusions: This brief, tailored outreach intervention was an effective
strategy for encouraging cervical and breast cancer screening among
women overdue for both screening services. It also shortened time-to-service,
an important benefit for early detection and treatment. Alternative
strategies are needed for women who remain unscreened.
Reprinted from Preventive Medicine, 37(5), Valanis B, Whitlock EE,
Mullooly J, et al. Screening rarely screened women: time-to-service
and 24-month outcomes of tailored interventions, p 442-50, Copyright
2003, with permission from Elsevier.
From
Northern California:
Reproductive
health counseling at pregnancy testing: a pilot study
Boise R, Petersen R, Curtis KM, et al. Contraception. 2003 Nov;68(5):377-83.
objectives:
To pilot brief reproductive health counseling for women obtaining
pregnancy testing in a managed-care setting who did not desire pregnancy.
methods: Women received counseling, access to contraception and
a booster call at two weeks. Changes in contraceptive behavior were
evaluated.
results: Of 85 women who completed counseling, 58 (68%) completed
follow-up. Participants reported that counseling was useful at baseline
(94%) and follow-up (83%). The staff found the intervention important
(100%) and implementation feasible (100%). Forty-one percent of participants
improved their use of contraception (from no use or from less effective
use to more effective use). Twenty-nine percent continued highly effective
use and 9% recessed from highly effective use. Of 22 participants with
risk of sexually transmitted disease, three (14%) began using condoms
consistently, while one (5%) continued using condoms consistently.
conclusions: Counseling at pregnancy testing was well accepted by
the staff and participants. Observed behavioral changes suggest that
this intervention may be effective in increasing effective use of contraception.
Reprinted with permission from Contraception, 68(5), Boise R, Petersen
R, Curtis KM, et al, Reproductive health counseling at pregnancy testing:
a pilot study, p 377-83, Copyright 2003, with permission from Elsevier.
From
the Northwest:
Older
women with fractures: patients falling through the cracks of guideline-recommended
osteoporosis screening and treatment
Feldstein AC, Nichols GA, Elmer PJ, Smith DH, Aickin M, Herson
M. J Bone Joint Surg Am. 2003 Dec;85-A(12):2294-302.
background:
Many older patients with fractures are not managed in accordance with
evidence-based clinical guidelines for osteoporosis. Guidelines recommend
that these patients receive treatment for clinically apparent osteoporosis
or have bone mineral density measurements followed by treatment when
appropriate. This cohort study was conducted to further characterize
the gap between guidelines and actual practice with regard to bone mineral
density measurement and treatment of older women after a fracture. Our
purpose was to aid in the design of more effective future interventions.
methods: We identified female members of a not-for-profit group-model
health maintenance organization who were 50 years of age or older and
who had a diagnosis of a new fracture as defined in the study. We used
administrative databases and the clinical electronic medical records
to obtain data on demographics, diagnoses, drugs dispensed by the pharmacy,
and the measurement of bone mineral density.
results: The study population included 3812 women with an average
age of 71.3 years. Fewer than 12% of the women had a diagnosis of osteoporosis
prior to the index fracture; 10.7% had an increased risk for secondary
osteoporosis and 38.8%, for falls because of a diagnosis or medication.
It was found that 46.4% of the study population had been managed as
specified by clinical guidelines. The patients who had been managed
as specified by the guidelines were younger and less likely to have
the risk factor of a weight of <127 lb (58 kg), a hip fracture, or
a wrist fracture. They were also more likely to be taking steroids on
a chronic basis and to have had a vertebral fracture. The percentage
of women who had measurement of bone mineral density increased during
the study period, from 1.3% in 1998 to 10.2% in 2001. Of the patients
receiving treatment for osteoporosis, 73.6% adhered to the treatment
regimen.
conclusions: Adherence to guidelines for evaluation and treatment
for osteoporosis after a patient sustained a fracture did not improve
between 1998 and 2001 despite the promulgation of evidence-based guidelines.
Methods to enhance education and facilitate processes of care will be
necessary to reduce this gap. It may be fruitful to target high-risk
subgroups for tailored interventions for prevention of refracture.
From
Northern California:
Hot
tub use during pregnancy and the risk of miscarriage
Li DK, Janevic T, Odouli R, Liu L. Am J Epidemiol. 2003 Nov 15;158(10):931-7.
To examine
whether hot tub or whirlpool bath use during pregnancy increases the
risk of miscarriage, the authors conducted a 1996-1998 population-based
prospective cohort study at the Kaiser Permanente Medical Care Program
in Oakland, California. Of 2729 eligible women, 1063 completed the interview.
Miscarriage before 20 weeks of gestation was ascertained for all participants.
Information on hot tub or whirlpool bath use was obtained during an
in-person interview conducted early in the pregnancy. A Cox proportional
hazards model was used to estimate the hazard ratio after adjustment
for potential confounders. Compared with nonuse, use of a hot tub or
whirlpool bath after conception was associated with a twofold increased
risk of miscarriage (adjusted hazard ratio (aHR) = 2.0, 95% confidence
interval: 1.3, 3.1). The risk seemed to increase with increasing frequency
of use (aHR = 1.7 for less than once a week, aHR = 2.0 for once a week,
and aHR = 2.7 for more than once a week) and with use during early gestation
(aHR = 2.3 for initial use within the first four weeks of the last menstrual
period and aHR = 1.5 for initial use after four weeks of the last menstrual
period). Findings suggest an association between use of a hot tub or
whirlpool bath during early pregnancy and the risk of miscarriage.
Li DK, Janevic T, Odouli R, Liu L, Hot tub use during pregnancy and
the risk of miscarriage, American Journal of Epidemiology 2003, 158(10),
p 931-7, by permission of Oxford University Press.
| clinical
implication: For women (1) who are pregnant, (2) who are planning
on being pregnant, and (3) who are sexually active, though not "planning"
a pregnancy, they should stop using hot tub or Whirlpool bath during
first trimester to reduce their risk of miscarriage. However, they
may want to consider to stop using hot tub or Whirlpool bath throughout
the pregnancy because there have been reports that hyperthermia
in pregnancy increases the risk of certain birth defects. Use of
regular bath tub did not increase the risk of miscarriage in our
study. --DL |
From
Northern California:
Nonvitamin,
nonmineral supplement use over a 12-month period by adult members of
a large health maintenance organization
Schaffer DM, Gordon NP, Jensen CD, Avins AL. J Am Diet Assoc.
2003 Nov;103(11):1500-5.
objective:
National survey data show an increase in the prevalence of nonvitamin,
nonmineral (NVNM) supplement use among adults over the past ten years.
Concern over this trend is based in part on reports of potential drug-supplement
interactions. The type and prevalence of supplement use by demographic
and behavior characteristics were examined among members of a large
group model health plan, including those with selected health conditions.
design: Data on the use of herbal medicines and dietary supplements
among survey respondents were analyzed. Questions employed a checklist
for six specific NVNM supplements with optional write-ins.
subjects/setting: A stratified random sample of 15,985 adult
members of a large group model health maintenance organization in northern
California, who were respondents to a 1999 general health survey.
statistical analyses performed: Analyses were conducted with poststratification
weighted data to reflect the actual age, gender, and geographic distribution
of the adult membership from which the sample was drawn.
results: An estimated 32.7% of adult health plan members used at
least one NVNM supplement. The most frequently used herbs were Echinacea
(14.7%) and Gingko biloba (10.9%). Use of all NVNM supplements was highest
among females, 45 to 64 years of age, whites, college graduates, and
among those with selected health conditions.
applications: Dietetics professionals need to uniformly screen
clients for dietary supplement use and provide accurate information
and appropriate referrals to users.
Reprinted with permission from the Journal of the American Dietetic
Association, 103(11), Schaffer DM, Gordon NP, Jensen CD, Avins AL, Nonvitamin,
nonmineral supplement use over a 12-month period by adult members of
a large health maintenance organization, p 1500-5, Copyright 2003, with
permission from the American Dietetic Association.
From
Southern California:
Restenosis
in intervened coronaries with hyperhomocysteinemia (RICH)
Kojoglanian SA, Jorgensen MB, Wolde-Tsadik G, Burchette RJ, Aharonian
VJ. Am Heart J. 2003 Dec;146(6):1077-81.
background:
Controversy exists regarding the contribution made by elevated serum
homocysteine levels in raising the risk of restenosis after percutaneous
coronary interventions. The objective of this study was to determine
whether elevated homocysteine levels increase the risk of restenosis.
methods: Two hundred and two consecutive patients undergoing percutaneous
coronary intervention with stents on previously nonintervened native
coronary arteries were eligible for enrollment in the study. Before
the percutaneous coronary intervention, a fasting serum homocysteine
level was drawn. Patients were followed-up by their primary cardiologists
for recurrence of symptoms. Those patients who had a recurrence of anginal
symptoms consistent with clinical restenosis were referred for a repeat
angiogram. All other patients were followed-up medically. The homocysteine
levels of the patients who had repeat angiography for recurrent symptoms
were compared to those who were followed-up medically.
results: Age, stent length, stent diameter, and homocysteine
levels were all associated with an increased risk of restenosis in the
univariate analysis. In the multiple logistic regression model, the
only variable that remained significant in relation to an increased
risk of restenosis was homocysteine. There was a significant difference
in the mean homocysteine levels between the restenosis group (13.7 micromol/L)
and those without restenosis (9.6 micromol/L; p < .0001). A homocysteine
level 11.1 micromol/L was identified as the best threshold for an increased
risk of restenosis with a sensitivity of 75.0% and specificity of 76.9%
(OR 6.5, CI 2.3-18.6; p = .0004).
conclusion: This study demonstrates that elevated homocysteine levels
strongly correlate with an increased risk of restenosis.
Reprinted from American Heart Journal 146(6), Kojoglanian SA, Jorgensen
MB, Wolde-Tsadik G, Burchette RJ, Aharonian VJ, Restenosis in Intervened
Coronaries with Hyperhomocysteinemia (RICH), p 1077-81, Copyright 2003,
with permission from Elsevier.
From
Northern California:
Dietary
intake of n-3, n-6 fatty acids and fish: relationship with hostility
in young adults--the CARDIA study
Iribarren C, Markovitz JH, Jacobs DR Jr, Schreiner PJ, Daviglus
M, Hibbeln JR. Eur J Clin Nutr. 2004 Jan;58(1):24-31.
background:
Hostility has been shown to predict both the development and manifestation
of coronary disease. Examining the inter-relation of dietary intake
of fish and of polyunsaturated (n-3 and n-6) essential fatty acids with
hostility may provide additional insights into the cardioprotective
effect of dietary fish and polyunsaturated fatty acids.
objective: To examine the association of dietary n-3, n-6 fatty
acids and fish with level of hostility in a sample of 3581 urban white
and black young adults.
design: Cross-sectional observational study as part of an ongoing
cohort study. A dietary assessment in 1992-1993 and measurement of hostility
and other covariates in 1990-1991 were used in the analysis.
results: The multivariate odds ratios of scoring in the upper quartile
of hostility (adjusting for age, sex, race, field center, educational
attainment, marital status, body mass index, smoking, alcohol consumption
and physical activity) associated with one standard deviation increase
in docosahexaenoic acid (DHA, 22:6) intake was 0.90 (95% CI = 0.82-0.98;
p = 0.02). Consumption of any fish rich in n-3 fatty acids, compared
to no consumption, was also independently associated with lower odds
of high hostility (OR = 0.82; 95% CI = 0.69-0.97; p = 0.02).
conclusions: These results suggest that high dietary intake of DHA
and consumption of fish rich in n-3 fatty acids may be related to lower
likelihood of high hostility in young adulthood. The association between
dietary n-3 fatty acids and hostile personality merits further research.
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