From Northern
California:
Chronic
kidney disease and the risks of death, cardiovascular events, and hospitalization.
Go
AS, Chertow GM, Fan D, McCulloch CE, Hsu CY. N Engl J Med 2004 Sep 23;351(13):1296-305.
background:
End-stage renal disease substantially increases the risks of death,
cardiovascular disease, and use of specialized health care, but the
effects of less severe kidney dysfunction on these outcomes are less
well defined.
methods:
We estimated the longitudinal glomerular filtration rate (GFR) among
1,120,295 adults within a large, integrated system of health care delivery
in whom serum creatinine had been measured between 1996 and 2000 and
who had not undergone dialysis or kidney transplantation. We examined
the multivariable association between the estimated GFR and the risks
of death, cardiovascular events, and hospitalization.
results:
The median follow-up was 2.84 years, the mean age was 52 years, and
55% of the group were women. After adjustment, the risk of death increased
as the GFR decreased below 60 mL per minute per 1.73 m2 of body-surface
area: the adjusted hazard ratio for death was 1.2 with an estimated
GFR of 45 to 59 mL per minute per 1.73 m2 (95% confidence interval,
1.1 to 1.2), 1.8 with an estimated GFR of 30 to 44 mL per minute per
1.73 m2 (95% confidence interval, 1.7 to 1.9), 3.2 with an estimated
GFR of 15 to 29 mL per minute per 1.73 m2 (95% confidence interval,
3.1 to 3.4), and 5.9 with an estimated GFR of less than 15 mL per minute
per 1.73 m2 (95% confidence interval, 5.4 to 6.5). The adjusted hazard
ratio for cardiovascular events also increased inversely with the estimated
GFR: 1.4 (95% confidence interval, 1.4 to 1.5), 2.0 (95% confidence
interval, 1.9 to 2.1), 2.8 (95% confidence interval, 2.6 to 2.9), and
3.4 (95% confidence interval, 3.1 to 3.8), respectively. The adjusted
risk of hospitalization with a reduced estimated GFR followed a similar
pattern.
conclusions:
An independent, graded association was observed between a reduced estimated
GFR and the risk of death, cardiovascular events, and hospitalization
in a large, community-based population. These findings highlight the
clinical and public health importance of chronic renal insufficiency.
Copyright
2004 Massachusetts Medical Society. All rights reserved. Available at:
http://content.nejm.org/cgi/content/full/351/13/1296.
From the
Northwest:
How
to design computerized alerts to safe prescribing practices.
Feldstein
A, Simon SR, Schneider J, et al. Jt Comm J Qual Saf 2004 Nov;30(11):602-13.
background:
Medication errors and preventable adverse drug events are common,
and about half of medication errors occur during medication ordering.
This study was designed to develop and evaluate medication safety alerts
and processes for educating prescribers about the alerts.
methods:
At Kaiser Permanente Northwest, a group-model health maintenance
organization where prescribers have used computerized order entry since
1996, qualitative interviews were conducted with 20 primary care prescribers.
results:
Prescribers considered alerts helpful for providing prescribing and
preventive health information. More than half the interviewees stated
that it would be unwise to let clinicians control or avoid safety alerts.
Common frustrations were 1) being delayed by the alert, 2) having difficulty
interpreting the alert, and 3) receiving the same alert repeatedly.
Most prescribers preferred small-group educational sessions tied to
existing meetings and having local physicians conduct education sessions.
discussion:
The findings were used to design a strategy for introducing and
promoting the interventions, modifying the alert text and tools, and
focusing the education on how clinicians could use the alerts effectively.
Available
at: www.jcrinc.com/subscribers/journal.asp?durki=32.
clinical
implication: Our findings are especially important when viewed
within the context of the increasing pressure for health care providers
to implement computerized physician order entry with clinical decision
support systems. These systems must maximize the usability, safety,
and efficacy of interfaces and applications for clinicians to fulfill
their purpose of reducing medical errors and improving patient safety.
Health care decision-makers must be concerned not only with obtaining
the most up-to-date technology but also with supporting clinicians
in their use of the technology in patient care. AF
From Northern
California
Barriers
to hospice care and referrals: survey of physicians' knowledge, attitudes,
and perceptions in a health maintenance organization.
Brickner
L, Scannell K, Marquet S, Ackerson L. J Palliat Med 2004 Jun;7(3):411-8.
introduction:
Many proponents of hospice care believe that this service is underutilized.
objective:
To determine physicians' perceptions of hospice utilization and of their
own hospice referral pattern; their perceived and actual knowledge of
appropriate hospice referral diagnoses; and perceived barriers to hospice
referral.
methods: Surveys for anonymous response were distributed to 125
physicians in two internal medicine departments of a large not-for-profit
health maintenance organization (HMO). Of these 125 physicians, 89%
responded, including 91 staff physicians and 20 residents.
results: Of the 111 physician-respondents, 78% reported their belief
that hospice care was underutilized; 84% were unable to identify appropriate
hospice diagnoses; and 12% were aware of the "National Hospice
Organization Medical Guidelines for Determining Prognosis in Selected
Non-Cancer Diseases." Difficulty of predicting death to within
six months was cited by 37% as the foremost barrier to hospice referral.
In addition, 28% expressed concern that patients or families would interpret
hospice referral as a cost-saving measure; 11% of respondents had been
accused of using hospice referral for this purpose.
conclusion:
Our study--the first major survey of physician attitudes and practices
regarding hospice utilization in an HMO setting--showed that barriers
to hospice referral are similar to those in non-HMO settings; physicians
have difficulty predicting life expectancy and lack knowledge of patient
eligibility guidelines. Physician concern that patients or their family
members would construe hospice referral as a cost-saving technique may
be a barrier particularly troublesome in an HMO setting.
clinical
implication: Our study is the first major survey of physician
attitudes and practices influencing hospice referrals within an HMO
setting. Although our physicians reported experiencing some of the
same concerns and barriers to hospice referral as reported from non-HMO
settings, we also newly report a concern that patients or their families
may construe hospice referral as a cost-saving measure. This may be
a particularly troublesome barrier to overcome in an HMO setting.
LB
From Colorado:
Predicting
declines in physical function in persons with multiple chronic medical
conditions: what we can learn from the medical
problem list.
Bayliss
EA, Bayliss MS, Ware JE Jr, Steiner JF. Health Qual Life Outcomes 2004
Sep 7;2(1):47.
background:
Primary care physicians are caring for increasing numbers of persons
with comorbid chronic illness. Longitudinal information on health outcomes
associated with specific chronic conditions may be particularly relevant
in caring for these populations. Our objective was to assess the effect
of certain comorbid conditions on physical well-being over time in a
population of persons with chronic medical conditions; and to compare
these effects to that of hypertension alone.
methods:
We conducted a secondary analysis of four-year longitudinal data from
the Medical Outcomes Study. A heterogeneous population of 1574 patients
with either hypertension alone (referent) or one or more of the following
conditions: diabetes, coronary artery disease, congestive heart failure,
respiratory illness, musculoskeletal conditions and/or depression were
recruited from primary and specialty (endocrinology, cardiology or mental
health) practices within HMO and fee-for-service settings in three US
cities. We measured categorical change (worse vs same/better) in the
SF-36(R) Health Survey physical component summary score (PCS) over four
years. We used logistic regression analysis to determine significant
differences in longitudinal change in PCS between patients with hypertension
alone and those with other comorbid conditions and linear regression
analysis to assess the contribution of the explanatory variables.
results:
Specific diagnoses of CHF, diabetes and/or chronic respiratory disease;
or four or more chronic conditions, were predictive of a clinically
significant decline in PCS.
conclusions:
Clinical recognition of these specific chronic conditions or four
or more of a list of chronic conditions may provide an opportunity for
proactive clinical decision making to maximize physical functioning
in these populations.
©
2004 Bayliss et al; licensee BioMed Central Ltd. Available at: www.hqlo.com/content/2/1/47.
From Southern
California:
Variability
of symptoms in mild persistent asthma: baseline data from the MIAMI
study.
Zeiger
RS, Baker JW, Kaplan MS, et al. Respir Med 2004 Sep;98(9):898-905.
objective:
To describe the variability of the asthma phenotype in patients
with mild persistent asthma enrolled in the Mild Asthma Montelukast
versus Inhaled Corticosteroid (MIAMI) study.
methods:
The variability of asthma rescue-free days, asthma symptoms, albuterol
use, medical resource use, and exercise limitations among patients with
documented mild persistent asthma was compared between the month before
study enrollment and the last two weeks of the run-in period.
results:
Patients eligible for randomization (n = 400), aged 15-85 years, exhibited
symptoms (mean ±SD) 3.6 ± 1.3 days/week, beta-agonist use
3.5 ± 1.3 days/week, and normal FEV1 (94.0 ± 9.9% predicted)
during the last two weeks of the run-in period. In the year before enrollment,
medical intervention for asthma flares was common: 38.5% made office
visits, 15.8% had oral corticosteroids, and 8.3% required emergency
room or hospitalized care. In the month before enrollment, 11.8% experienced
daily symptoms, and 28.3% had limitations of normal activity. Patients
with daily symptoms in the month before study enrollment, compared with
those having less-than-daily symptoms, experienced fewer rescue-free
days (p = 0.024) and had more days per week with symptoms (p = 0.008)
and requiring albuterol (p = 0.048) during the run-in; FEV1 was similar
for both groups (93.1% vs 94.2% predicted, respectively).
conclusion:
Patients with mild persistent asthma reported a substantial disease
burden in the year before enrollment. The asthma burden experienced
by these patients both before and during the run-in period was of sufficient
severity to support the recommendation that mild persistent asthma should
be managed with daily controller therapy.
Reprinted
from Respiratory Medicine, 98(9), Zeiger RS, Baker JW, Kaplan MS, Pearlman
DS, Schatz M, Bird S, Hustad C, Edelman J; MIAMI Study Research Group,
Variability of symptoms in mild persistent asthma: baseline data from
the MIAMI study, 898-905, Copyright 2004, with permission from Elsevier.
clinical
implication: National guidelines classify persistent asthma severity
into mild, moderate, and severe categories. In this study almost 12%
of the patients classified as mild persistent during the run-in would
have been classified as moderate persistent because of daily symptoms
in the month prior to run-in. Moreover, asthma burden was evident
in mild persistent asthmatics during the year prior to enrollment;
nearly 16% had exacerbations requiring oral corticosteroids and 8%
experienced ER visits or hospitalizations. We conclude that the clinical
course of asthma can be variable even among the mildest of persistent
asthmatics and mild persistent asthma is associated with clinical
and utilization burdens. Strongly consider treating mild persistent
asthmatics with daily controller medication for better control and
prevention of consequences. RZ
From the
Northwest:
Patient
satisfaction and disease specific quality of life after uterine artery
embolization.
Smith
WJ, Upton E, Shuster EJ, Klein AJ, Schwartz ML. Am J Obstet Gynecol
2004 Jun;190(6):1697-703; discussion 1703-6.
objectives:
This study was undertaken to evaluate changes in fibroid specific symptom
severity and health-related quality of life (HRQOL) after uterine artery
embolization (UAE) and to consider the impact of these changes on satisfaction
with the procedure.
study
design: A validated, fibroid specific, symptom, and HRQOL questionnaire
was mailed to 80 women who had undergone UAE from 1998 through 2002.
Pre- and postprocedure symptom severity and HRQOL scores were obtained.
The primary outcome measure was change in fibroid symptoms and HRQOL
after UAE. Secondary outcomes included objective measures of patient
satisfaction, and the decrease in uterine volume after UAE.
results:
Questionnaires were completed by 64 women (80.0%) at a mean of 32.1
months from UAE (range: 57.5-6 months). After UAE, mean uterine volume
decreased by 26.3% (95% CI 19.6-33.0), and 17 of 79 women (21.5%) underwent
an additional procedure after a mean of 18.6 months. Symptom severity
scores decreased by a mean of 35.2% (95% CI 29.3-41.1) and HRQOL scores
increased by a mean of 35.7% (95% CI 28.9-42.4). Satisfaction with UAE
was correlated with the change in symptom severity and HRQL scores (p
< .0001 and p = .0004, respectively) and the decrease in uterine
volume after UAE (p = .0196).
conclusion:
Women who undergo UAE have a significant decrease in symptom severity
and increase in HRQOL, associated with high levels of satisfaction with
the procedure, even when subsequent therapies are pursued.
Reprinted
from The American Journal of Obstetrics and Gynecology, 190(6), Smith
WJ, Upton E, Shuster EJ, Klein AJ, Schwartz ML, Patient satisfaction
and disease specific quality of life after uterine artery embolization,
1697-1703, discussion 1703-6. Copyright 2004, with permission from Elsevier
Inc.
clinical
implication: "Uterine artery embolization (UAE) offers an
alternative management strategy for symptoms associated with uterine
fibroids. UAE results in a significantly improved quality of life
and high rates of satisfaction in women choosing this procedure. Although
up to 20% of women who have UAE may ultimately undergo a subsequent
surgery to control recurrent or persistent symptoms, even this group
of women express satisfaction in having an alternative to the more
traditional options of hysterectomy and myomectomy." –WS
From the
Northwest:
The
incidence of congestive heart failure in Type 2 diabetes: an update.
Nichols
GA, Gullion CM, Koro CE, Ephross SA, Brown JB. Diabetes Care 2004 Aug;27(8):1879-84.
objective:
The aims of this study were to update previous estimates of the congestive
heart failure (CHF) incidence rate in patients with Type 2 diabetes,
compare it with an age- and sex-matched nondiabetic group, and describe
risk factors for developing CHF in diabetic patients over six years
of follow-up.
research
design and methods: We performed a retrospective cohort study of
8231 patients with Type 2 diabetes and 8845 nondiabetic patients of
similar age and sex who did not have CHF as of 1 January 1997, following
them for up to 72 months to estimate the CHF incidence rate. In the
diabetic cohort, we constructed a Cox regression model to identify risk
factors for CHF development.
results:
Patients with diabetes were much more likely to develop CHF than patients
without diabetes (incidence rate 30.9 vs 12.4 cases per 1000 person-years,
rate ratio 2.5, 95% CI 2.3-2.7). The difference in CHF development rates
between persons with and without diabetes was much greater in younger
age-groups. In addition to age and ischemic heart disease, poorer glycemic
control (hazard ratio 1.32 per percentage point of HbA1c)
and greater BMI (1.12 per 2.5 units of BMI) were important predictors
of CHF development.
conclusions:
The CHF incidence rate in Type 2 diabetes may be much greater than
previously believed. Our multivariate results emphasize the importance
of controlling modifiable risk factors for CHF, namely hyperglycemia,
elevated blood pressure, and obesity. Younger patients may benefit most
from risk factor modification.
Copyright
©2004 American Diabetes Association. From Diabetes Care, Vol 27,
2004;1879-84. Reprinted with permission from The American Diabetes Association.
clinical
implication: CHF appears to be more common in Type 2 diabetes
than previously published estimates would suggest. Elevated HbA1c
and blood pressure along with obesity predicted greater CHF incidence.
Therefore, controlling these modifiable risk factors should benefit
the patient at risk for heart failure. In addition, the difference
in CHF risk between patients with and without diabetes is greatest
in younger age groups, so younger diabetes patients may benefit most
from risk factor modification. GN
From Northern
California:
Physical
activity and changes in weight and waist circumference in midlife women:
findings from the Study of Women's Health Across the Nation.
Sternfeld
B, Wang H, Quesenberry CP Jr, et al. Am J Epidemiol 2004 Nov 1;160(9):912-22.
Controversy
exists regarding the extent to which age, menopausal status, and/or
lifestyle behaviors account for the increased weight, fat mass, and
central adiposity experienced by midlife women. To address this question,
the authors longitudinally examined the relations of aging, menopausal
status, and physical activity to weight and waist circumference in 3064
racially/ethnically diverse women aged 42-52 years at baseline who were
participating in the Study of Women's Health Across the Nation (SWAN),
an observational study of the menopausal transition. Over three years
of follow-up (1996-1997 to 1999-2000), mean weight increased by 2.1
kg (standard deviation (SD), 4.8) or 3.0% (SD, 6.5) and mean waist circumference
increased by 2.2 cm (SD, 5.4) or 2.8% (SD, 6.3). Change in menopausal
status was not associated with weight gain or significantly associated
with increases in waist circumference. A one-unit increase in reported
level of sports/exercise (on a scale of 1-5) was longitudinally related
to decreases of 0.32 kg in weight (p < 0.0001) and 0.10 cm in waist
circumference (not significant). Similar inverse relations were observed
for daily routine physical activity (biking and walking for transportation
and less television viewing). These findings suggest that, although
midlife women tend to experience increases in weight and waist circumference
over time, maintaining or increasing participation in regular physical
activity contributes to prevention or attenuation of those gains.
Sternfeld
B, Wang H, Quesenberry CP Jr, Abrams B, Everson-Rose SA, Greendale GA,
Matthews KA, Torrens JI, Sowers M, Physical activity and changes in
weight and waist circumference in midlife women: findings from the Study
of Women's Health Across the Nation, American Journal of Epidemiology,
2004, 160(9), 912-22, by permission of Oxford University Press.
clinical
implication: This study examined the changes in weight and waist
circumference over a three-year period of a racially/ethnically diverse
cohort of initially pre- or early perimenopausal women. Although the
mean weight and waist circumference of the cohort increased with time,
the changes in weight and waist circumference in those who transitioned
to a later stage of the menopause were no different than those in
women who remained in the pre- or early perimenopause. A higher level
of physical activity was associated with less weight gain and central
adiposity, independently of the aging (time) effect. BS
From Northern
California:
Causes
and demographic, medical, lifestyle and psychosocial predictors of premature
mortality: the CARDIA study.
Iribarren
C, Jacobs DR, Kiefe CI, et al. Soc Sci Med 2005 Feb;60(3):471-82.
We examined
the 16-year mortality experience among participants in the baseline
examination (1985-86) of the Coronary Artery Risk Development in Young
Adults (CARDIA) Study, a US cohort of 5115 urban adults initially 18-30
years old and balanced by sex and race (black and whites) in the USA.
We observed 127 deaths (annual mortality of 0.15%). Compared to white
women, the rate ratio (95% confidence interval) of all-cause mortality
was 9.3 (4.4, 19.4) among black men, 5.3 (2.5, 11.4) among white men
and 2.7 (1.2, 6.1) among black women. The predominant causes of death,
which also differed greatly by sex-race, were AIDS (28% of deaths),
homicide (16%), unintentional injury (10%), suicide (7%), cancer (7%)
and coronary disease (7%). The significant baseline predictors of all-cause
mortality in multivariate analysis were male sex, black race, diabetes,
self-reported liver and kidney disease, current cigarette smoking and
low social support. Two other factors, self-reported thyroid disease
and high hostility, were significant predictors in analyses adjusted
for age, sex and race. In conclusion, we found striking differences
in the rates and underlying cause of death across sex-race groups and
several independent predictors of young adult mortality that have major
implications for preventive medicine and social policies.
Reprinted
from Social Science and Medicine, Vol 60, Iribarren C, Jacobs DR, Kiefe
CI, Lewis CE, Matthews KA, Roseman JM, Hulley SB, Causes and demographic,
medical, lifestyle and psychosocial predictors of premature mortality:
the CARDIA study, 471-82, Copyright 2005, with permission from Elsevier.
clinical
implication: This paper describes 16-year mortality in the Coronary
Artery Risk Development in Young Adults (CARDIA) cohort, which included
the KP Oakland Division of Research as one of four centers. CARDIA
enrolled 5115 black and white adults aged 18 to 30 years. Among 127
deaths, compared to white women, black men, white men and black women
were 9, 5, and 3 times more likely to die. Predominant causes of death,
which also differed greatly by sex-race, were AIDS (28% of deaths),
homicide (16%), unintentional injury (10%), suicide (7%), cancer (7%)
and coronary disease (7%). Factors independently predictive of mortality
were male sex, black race, diabetes, self-reported liver andkidney
disease, cigarette smoking and low social support. CI
From Northern
California:
Computer-aided
detection in diagnostic mammography: detection of clinically unsuspected
cancers.
Butler
SA, Gabbay RJ, Kass DA, Siedler DE, O'shaughnessy KF, Castellino RA.
AJR Am J Roentgenol 2004 Nov;183(5):1511-5.
objective:
We had two objectives: to determine the percentage of women presenting
with clinical findings whose diagnostic mammogram led to detection of
a breast cancer at a site distant from the original clinical complaint
and to assess the performance of computer-aided detection (CAD) on diagnostic
mammography.
materials
and methods: Three institutions contributed consecutive cases in
which a mammogram was obtained to evaluate a clinical finding, after
which a histologic diagnosis of breast cancer was made. Clinical data
and the mammograms were reviewed to determine the nature of the clinical
findings and to document the location and characteristics of 212 biopsy-proven
cancers in 197 patients who met the study criteria. Standard four-view
breast mammograms were then analyzed by a CAD system.
results:
The most common clinical finding was a palpable mass (90%, 177/197),
with nipple discharge (5%, 9/197), focal tenderness or pain (2%, 5/197),
and miscellaneous complaints (3%, 6/197) also noted. Two separate cancers
were found in 7.6% (15/197) of the cases. In another 7.6% (15/197) of
the cases, the single diagnosed cancer was not at the location of the
specific clinical finding. The CAD system correctly marked 87% (26/30)
of those cancers that were clinically unsuspected (ie, not at the location
of the clinical finding).
conclusion:
Breast cancers occurred at locations other than the site of the
presenting clinical finding in 15% (30/197) of patients undergoing diagnostic
mammography in whom a cancer was detected. CAD identified 87% of these
incidentally detected cancers and may therefore be useful as a detection
aid to the radiologist when interpreting diagnostic mammograms.
Reprinted
with permission from the American Journal of Roentgenology.
May
3-5, 2004 Dearborn, MI
Evaluating Care Delivery
From HMO
Research Network Member: Fallon Health Care
Identifying
Patients with Peripheral Arterial Disease in the Primary Care Setting.
Doubeni
CA, Yood RA, Emani S, Gurwitz JH.
objective:
To assess the yield from screening for peripheral arterial disease (PAD)
in primary care settings.
study
design: Cross-sectional study
methods:
Study subjects were patients receiving care from a multispecialty group
practice in Massachusetts between July 2002 and July 2003, who were
aged 70 years, or aged 50-69 with a diagnosis of diabetes mellitus,
dyslipidemia, hypertension and/or smoking based on information derived
from administrative databases. Participants completed a telephone interview
to ascertain their medical history. We excluded patients with a prior
diagnosis of PAD and/or coronary heart disease. The ankle-brachial index
(ABI) was measured at the time of a scheduled primary care office visit.
PAD was diagnosed if one or both legs had an ABI of 0.90. We also assessed
the time spent in performing ABI testing in a convenience sample of
the study participants.
results:
ABI testing was performed on 717 patients, of whom 54 (7.5%, 95% confidence
interval: 5.6%, 9.4%) were diagnosed with PAD. Among 359 patients aged
70 years, 45 (12.5%) were diagnosed with PAD. Nine (2.5%) of 358 patients
aged 50-69 years were diagnosed with PAD. The average total time (n
= 52) for ABI testing was 13.8 (SD: ±3.3) minutes. Patients aged
70 years required more time for ABI testing compared to those aged 50-69
(mean: 15.0 vs 13.0 minutes, p = 0.04).
conclusions:
PAD is common among patients in the primary care setting who are not
already known to have atherosclerotic disease. More ambulatory care
resources are required to identify PAD in younger patients compared
to older patients.
From HMO
Research Network Member: Harvard Pilgrim Health Care
Cluster-Randomized
Controlled Trial of Three Different Interventions to Improve Antihypertensive
Prescribing in Primary Care.
Simon
SR, Majumdar SR, Kleinman KP, et al.
background:
Academic detailing, also called educational outreach, has been shown
to improve individual physicians' prescribing practices but is perceived
to be costly and labor-intensive and, as a result, is not widely used.
Therefore, we compared traditional one-on-one individual academic detailing
(IAD) with group academic detailing (GAD), and compared them with mailed
guidelines dissemination (MG) within one large managed care organization
to improve the use of antihypertensive medications in primary care.
methods:
We conducted a cluster-randomized controlled trial, allocating three
practice sites to IAD (n = 235 prescribers and 2478 patients), three
to GAD (n = 227 and 2352), and three to MG (n = 319 and 3575). The goal
of the intervention was to increase the use of diuretics and beta-blockers
(DIUR-BB), the guideline-recommended first-line agents. The IAD intervention
consisted of a single physician visit following established principles
of academic detailing; the GAD intervention was a single group session
incorporating those principles, also led by a trained physician.
results:
At baseline, sociodemographic characteristics and rates of prescribing
DIUR-BB among newly diagnosed and treated patients with hypertension
were almost identical in the three experimental groups: IAD = 57.6%,
GAD = 59.1, and MG = 57.6. In the nine-month period following the intervention,
rates of DIUR-BB use increased by 21.7% in IAD, 22.3% in GAD, and 10.8%
in MG. As compared with MG patients, DIUR-BB use among patients with
newly diagnosed hypertension was more likely in both IAD (OR 1.40; 95%
CI, 1.07-1.84) and GAD (OR 1.30; 95% CI, 0.89-1.90), controlling for
physician-level clustering. The effects of IAD and GAD were of similar
magnitude. There was no apparent effect of the intervention on rates
of switching patients previously treated with medications other than
DIUR-BB to the guideline-recommended agents.
conclusion:
Both IAD and GAD improve antihypertensive prescribing over and above
the dissemination of guidelines. If GAD is confirmed to be as effective
and less expensive than IAD, it may represent a more attractive option
for improving practice.
From HMO
Research Network Member: Group Health Permanente
Electronic
Data Collection from Patients on Breast Cancer Risk Factor Information
in a Mammography Setting.
Aiello
E, Taplin S, Reid R, et al.
background:
Information on breast cancer risk factors is important to identifying
high-risk groups who may be eligible for prevention activities, but
the data collection process is time consuming. Data collection currently
occurs at Group Health Cooperative (GHC) using a paper survey at the
time of the mammogram. The project goal was to evaluate patient acceptance
and feasibility of using an electronic questionnaire. We hoped to reduce
the repetitive nature of the questionnaire by prepopulating some answers,
reduce the amount of time needed to complete the questionnaire, and
improve the accuracy of data collected.
methods:
The HIPAA compliant survey software was developed on a Fujitsu Tablet
PC and incorporated prepopulated answers from each woman's previous
survey. We piloted the prototype in one GHC clinic over a three-month
period. One hundred sixty women were randomized to use the electronic
survey (n = 86) or the paper survey (n = 74 controls) and complete an
evaluation form. We compared the distribution of Likert scale responses
between the intervention and control groups, and between age groups
(<60 vs >60 years old).
results:
Overall, 90% of women in the intervention group preferred using the
Tablet compared to the paper questionnaire. Preference for the Tablet
did not differ by age; however, women >60 years did not find the
Tablet as easy to use as women <60 years. Every woman liked seeing
her prepopulated answers; 97% stated that their prepopulated answers
were accurate. The majority (65%) did not think that the Tablet was
very easy to carry throughout their appointment.
conclusion:
Electronic questionnaires are feasible to use in a mammography setting
and are preferred by nearly all women, even older women. Although the
Tablet PC was feasible to use as a prototype, this configuration may
not be suitable for full deployment in a setting where patient mobility
and high volumes are necessary. Clinics elsewhere may have different
technology requirements thus requiring further evaluation of different
hardware and software options.
From HMO
Research Network Member: Henry Ford Health System
Exploring
Racial Differences in Asthma Incidence and Age at Diagnosis.
Joseph
CLM, Havstad SL, Peterson EL, Ownby DR, Johnson CC.
background:
Researchers strive to identify definitive reasons for racial disparities
in asthma morbidity and mortality. It is unclear as to when the disparity
begins, as few studies have explored a racial divergence in asthma incidence.
To do so would require a racially diverse population followed from birth.
Our objective was to examine racial differences in the incidence and
age of onset of asthma among children enrolled in a racially diverse
managed care organization (MCO).
methods:
We obtained all inpatient/outpatient encounters for children born 1992-93,
who were members of a large managed care organization, and who were
continuously enrolled from birth through 12/31/98. Asthma was defined
as any visit assigned the ICD-9 code 493.
results:
Over 6600 children met birthdate criteria, and of those 3562 (53%) met
enrollment criteria. The sample was 30% African American (AA), and 48%
female. Overall cumulative incidence of asthma by age 6-7 years was
18.4% (95% confidence interval (CI) = 17.1-19.7), with an overall mean
age of diagnosis = 2.7 years (standard deviation = 1.7). Cumulative
incidence of asthma for AA children was 22.9% (95% CI = 20.4-25.4) vs
16.5% (95 CI = 15.0-17.9) for non-AA children. A proportional hazards
model revealed that AA were over 30% more likely to have an asthma encounter
by age 1-7 years when compared to non-AA children, hazard ratio = 1.36
(95% CI = 1.16-1.60); p < 0.001. Age at onset of asthma appeared
similar by race; mean age for AA and non-AA = 2.8 years and 2.7 years,
respectively. Adjusting for gender did not change the results; adjusted
hazard ratio = 1.37 (95% CI = 1.17-1.61); p = 0.0014.
conclusion:
In summary, incidence of asthma by age 6-7 years was significantly higher
for AA children vs non-AA children. Our results suggest that racial
differences in asthma may begin very early in childhood. Racially diverse
birth-cohort studies are needed to determine if differences observed
in infancy drive the racial disparities in asthma prevalence and morbidity
we observe later in childhood and adolescence. MCO pharmacy claims and
encounter databases can be valuable tools in exploring these issues.
