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Abstracts
Abstracts
of Articles Authored or Coauthored by Permanente Physicians |
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by Daphne Plaut, MLS, Librarian, Center for Health Research
From
Northern and Southern California
Alcohol
drinking and risk of hospitalization for heart failure with and
without associated coronary artery disease.
Klatsky
AL, Chartier D, Udaltsova N, et al. Am J Cardiol 2005 Aug 1;96(3):346-51.
Myocardial
damage from heavy alcohol intake can cause the heart failure (HF)
syndrome, but the relation of lighter alcohol intake to HF has rarely
been studied. We examined the risk of HF hospitalization among 126,236
subjects who supplied data about alcohol during health examinations
from 1978 to 1985. Among 2594 subjects who were subsequently hospitalized
for HF, record review established an association between coronary
artery disease (CAD) and HF (CAD-HF) in 1559 patients. Among the
remaining 1035 subjects who had HF (non-CAD-HF), we attempted determination
of preponderant etiologic and contributory factors. Analyses used
Cox models that were controlled for seven covariates, with usual
alcohol intake studied categorically compared with that in subjects
who did not drink alcohol. Heavier drinkers (3 drinks/day) but not
light to moderate drinkers had increased risk of non-CAD-HF; eg,
relative risk for subjects who reported 6 drinks/day was 1.7 (95%
confidence interval 1.1 to 2.6). This association of non-CAD-HF
with heavy drinking was limited to subsets with cardiomyopathy or
of unclear preponderant etiology. Alcohol drinking was inversely
related to risk of CAD-HF (eg, at 1 to 2 drinks/day, relative risk
0.6, 95% confidence interval 0.5 to 0.7), with consistency across
subgroups of age, gender, ethnicity, education, smoking status,
interval to diagnosis, and presence or absence of baseline heart
disease or systemic hypertension. Moderate drinking was inversely
related to non-CAD-HF only in subjects who had diabetes mellitus
(n = 252). In conclusion, heavy, but not light, alcohol drinking
is associated with increased risk of non-CAD-HF and that apparent
protection by alcohol drinking against CAD-HF risk provides confirmation
of a protective effect of alcohol against CAD.
Reprinted
from American Journal of Cardiology, V96(3), Klatsky AL, Chartier
D, Udaltsova N, Gronningen S, Brar S, Friedman GD, Lundstrom RJ,
Alcohol drinking and risk of hospitalization for heart failure with
and without associated coronary artery disease, 346-51, Copyright
2005, with permission from Excerpta Medica, Inc.
clinical
implication: Confusion about the role of lighter alcohol drinking
in the heart failure (HF) syndrome exists because heavy intake
can cause heart muscle damage while light-moderate intake protects
against coronary artery disease (CAD). In this study of risk of
HF hospitalization in a large population, separate analyses were
done for 1559 persons with HF associated with CAD and 1035 persons
with HF from non-CAD causes. Heavy, but not light, alcohol drinking
was associated with increased risk of non-CAD-HF, while alcohol
drinking appeared protective against CAD-HF risk. Thus, prohibition
of light drinking is not warranted in most patients at HF risk.
AK
From
Northern California
Clinical
outcomes and cost-effectiveness of strategies for managing people
at high risk for diabetes.
Eddy
DM, Schlessinger L, Kahn R. Ann Intern Med 2005 Aug 16;143(4):251-64.
background:
Lifestyle modification can forestall diabetes in high-risk people,
but the long-term cost-effectiveness is uncertain.
objective: To estimate the effects of the lifestyle modification
program used in the Diabetes Prevention Program (DPP) on health
and economic outcomes.
design: Cost-effectiveness analysis using the Archimedes model.
data sources: Published basic and epidemiologic studies, clinical
trials, and Kaiser Permanente administrative data.
target population: Adults at high risk for diabetes (body
mass index >24 kg/m2, fasting plasma glucose level
of 5.2725 to 6.9375 mmol/L [95 to 125 mg/dL], two-hour glucose tolerance
test result of 7.77 to 11.0445 mmol/L [140 to 199 mg/dL]).
time horizon: 5 to 30 years.
perspective: Patient, health plan, and societal.
interventions: No prevention, DPP's lifestyle modification
program, lifestyle modification begun after a person develops diabetes,
and metformin.
measurements:
Diagnosis and complications of diabetes.
results
of base-case analysis: Compared with no prevention program,
the DPP lifestyle program would reduce a high-risk person's 30-year
chances of getting diabetes from about 72% to 61%, the chances of
a serious complication from about 38% to 30%, and the chances of
dying of a complication of diabetes from about 13.5% to 11.2%. Metformin
would deliver about one third the long-term health benefits achievable
by immediate lifestyle modification. Compared with not implementing
any prevention program, the expected 30-year cost/quality-adjusted
life-year (QALY) of the DPP lifestyle intervention from the health
plan's perspective would be about 143,000 dollars. From a societal
perspective, the cost/QALY of the lifestyle intervention compared
with doing nothing would be about 62,600 dollars. Either using metformin
or delaying the lifestyle intervention until after a person develops
diabetes would be more cost-effective, costing about $35,400 or
$24,500 per QALY gained, respectively, compared with no program.
Compared with delaying the lifestyle program until after diabetes
is diagnosed, the marginal cost-effectiveness of beginning the DPP
lifestyle program immediately would be about $201,800.
results
of sensitivity analysis: Variability and uncertainty deriving
from the structure of the model were tested by comparing the model's
results with the results of real clinical trials of diabetes and
its complications. The most critical element of uncertainty is the
effectiveness of the lifestyle program, as expressed by the 95%
CI of the DPP study. The most important potentially controllable
factor is the cost of the lifestyle program. Compared with no program,
lifestyle modification for high-risk people can be made cost-saving
over 30 years if the annual cost of the intervention can be reduced
to about $100.
limitations:
Results depend on the accuracy of the model.
conclusions:
Lifestyle modification is likely to have important effects on the
morbidity and mortality of diabetes and should be recommended to
all high-risk people. The program used in the DPP study may be too
expensive for health plans or a national program to implement. Less
expensive methods are needed to achieve the degree of weight loss
seen in the DPP.
clinical
implication: Lifestyle modification with weight loss and exercise
are important ways to reduce the risk of developing diabetes and
its complications in high-risk people. They should be strongly
encouraged. The particular lifestyle modification program implemented
in the Diabetes Prevention Program was very expensive and is unlikely
to be cost-effective in most settings. Less expensive ways to
help people lose weight need to be found and implemented. DE
From
The Northwest
Higher medical care costs accompany impaired fasting glucose.
Nichols
GA, Brown JB. Diabetes Care 2005 Sep;28(9):2223-9.
objective:
The purpose of this study was to estimate medical costs associated
with elevated fasting plasma glucose (FPG) and to determine whether
costs differed for patients who met the 2003 ( mg/dL) versus the
1997 (110 mg/dL) American Diabetes Association (ADA) cut point for
impaired fasting glucose.
research
design and methods: We identified 28,335 patients with two or
more FPG test results of at least 100 mg/dL between 1 January 1994
and 31 December 2003. Those with evidence of diabetes before the
second test were excluded. We categorized patients into two stages
of abnormal glucose (100-109 mg/dL and 110-125 mg/dL) and matched
each of these subjects to a patient with a normal FPG test (<100
mg/dL) on age, sex, and year of FPG test. All subjects were followed
until an FPG test qualified them for a higher stage, dispensing
of an anti-hyperglycemic drug, health plan termination, or 31 December
2003.
results:
Adjusted annual costs were $4357 among patients with normal FPG,
$4580 among stage 1 patients, and $4960 among stage 2 patients (p
< 0.001, all comparisons). After removing patients with normal
FPG tests whose condition progressed to a higher stage or diabetes,
costs in the normal FPG stage were $3799. Patients in both stages
1 and 2 had more cardiovascular comorbidities than patients with
normal FPG.
conclusions:
Our results demonstrate that abnormal glucose metabolism is associated
with higher medical care costs. Much of the excess cost was attributable
to concurrent cardiovascular disease. The 2003 ADA cut point identifies
a group of patients with greater costs and comorbidity than normoglycemic
patients but with lower costs and less comorbidity than patients
with FPG above the 1997 cut point.
Copyright
© 2005 American Diabetes Association from Diabetes Care, Vol
28, 2005; 2223-9. Reprinted with permission from The American Diabetes
Association.
clinical
implication: Our primary finding was that medical costs among
patients with elevated fasting glucose were higher than among
patients with normal glucose. However, the cost differential was
not nearly as great as between those with and without diabetes.
Thus, successful diet and exercise modifications that have been
shown to delay or prevent diabetes should result in cost savings.
We also identified a subset of patients with apparently normal
FPG who progressed to IFG or diabetes. These patients, although
their FPG was normal, were substantially costlier than their counterparts
who did not progress to defined levels of abnormal glucose. GN
From
Colorado
Comparison
of syndromic surveillance and a sentinel provider system in detecting
an influenza outbreak--Denver, Colorado, 2003.
Ritzwoller
DP, Kleinman K, Palen T, et al. MMWR Morb Mortal Wkly Rep 2005 Aug
26;54 Suppl:151-6.
introduction:
Syndromic surveillance systems can be useful in detecting naturally
occurring illness.
objectives:
Syndromic surveillance performance was assessed to identify an early
and severe influenza A outbreak in Denver in 2003.
methods:
During October 1, 2003-January 31, 2004, syndromic surveillance
signals generated for detecting clusters of influenza-like illness
(ILI) were compared with ILI activity identified through a sentinel
provider system and with reports of laboratory-confirmed influenza.
The syndromic surveillance and sentinel provider systems identified
ILI activity based on ambulatory-care visits to Kaiser Permanente
Colorado. The syndromic surveillance system counted a visit as ILI
if the provider recorded any in a list of 30 respiratory diagnoses
plus fever. The sentinel provider system required the provider to
select "influenza" or "ILI."
results:
Laboratory-confirmed influenza cases, syndromic surveillance ILI
episodes, and sentinel provider reports of patient visits for ILI
all increased substantially during the week ending November 8, 2003.
A greater absolute increase in syndromic surveillance episodes was
observed than in sentinel provider reports, suggesting that sentinel
clinicians failed to code certain cases of influenza. During the
week ending December 6, when reports of laboratory-confirmed cases
peaked, the number of sentinel provider reports exceeded the number
of syndromic surveillance episodes, possibly because clinicians
diagnosed influenza without documenting fever.
conclusion:
Syndromic surveillance performed as well as the sentinel provider
system, particularly when clinicians were advised to be alert to
influenza, suggesting that syndromic surveillance can be useful
for detecting clusters of respiratory illness in various settings.
From
Northern California
Comparison
of glyburide and insulin for the management of gestational diabetes
in a large managed care organization.
Jacobson
GF, Ramos GA, Ching JY, Kirby RS, Ferrara A, Field DR. Am J Obstet
Gynecol 2005 Jul;193(1):118-24.
objective:
This study was undertaken to compare the use of glyburide with insulin
for the treatment of gestational diabetes mellitus (GDM) unresponsive
to diet therapy.
study
design: A retrospective study was performed among women with
singleton pregnancies who had GDM diagnosed, with fasting plasma
glucose 140 mg/dL or less on glucose tolerance testing, between
12 and 34 weeks who failed diet therapy from 1999 to 2002. We identified
584 women and compared those treated with insulin between 1999 and
2000 with women treated with glyburide between 2001 and 2002. Maternal
and neonatal outcomes and complications were assessed. Statistical
methods included univariate analyses and multivariable logistic
regression.
results:
In 1999 through 2000, 268 women had GDM diagnosed and were treated
with insulin; in 2001 through 2002, 316 women had GDM diagnosed
of which 236 (75%) received glyburide. The two groups were similar
with regard to age, nulliparity, and historical GDM risk factors;
however, women in the insulin group had a higher mean body mass
index (31.9 vs 30.6 kg/m 2, p = .04), a greater proportion identified
themselves as white (43%, 28%, p < .001) and fewer as Asian (24%,
37%, p = .001), and they had a significantly higher mean fasting
on glucose tolerance test (105.4 vs 102.4 mg/dL, p = .005) compared
with the glyburide group. There were no significant differences
in birth weight (3599 ± 650 g vs 3661 ± 629 g, p = .3),
macrosomia (24%, 25%, p = .7), or cesarean delivery (35%, 39%, p
= .4). Women in the glyburide group had a higher incidence of preeclampsia
(12%, 6%, p = .02), and neonates in the glyburide group were more
likely to receive phototherapy (9%, 5%, p < .05), and less likely
to be admitted to the neonatal intensive care unit (NICU) (15%,
24%, p = .008) though they had a longer NICU length of stay (4.3
± 9.6 vs 8.0 ± 10.1, p = .002). Posttreatment glycemic
control data were available for 122 women treated with insulin and
137 women treated with glyburide. More women in the glyburide group
achieved mean fasting and postprandial goals (86%, 63%, p < .001).
These findings remained significant in logistic regression analysis.
conclusion:
In a large managed care organization, glyburide was at least as
effective as insulin in achieving glycemic control and similar birth
weights in women with GDM who failed diet therapy. The increased
risk of preeclampsia and phototherapy in the glyburide group warrant
further study.
Reprinted
from American Journal of Obstetrics and Gynecology, V193(1), Jacobson
GF, Ramos GA, Ching JY, Kirby RS, Ferrara A, Field DR, Comparison
of glyburide and insulin for the management of gestational diabetes
in a large managed care organization, 118-24, Copyright 2005, with
permission from Elsevier.
clinical
implication: Our study showed that glyburide is a reasonable
alternative to insulin for the treatment of gestational diabetics
who fail diet therapy. We successfully demonstrated this in a
large clinical setting. It is important that these women receive
all the other standard prenatal, intrapartum, and postpartum care
that would have been provided if they were on insulin, including
frequency of visits, counseling, and antepartum surveillance.
GJ
From
Colorado
Radiation
exposure to the hands from mini C-arm fluoroscopy.
Singer
G. J Hand Surg [Am] 2005 Jul;30(4):795-7.
purpose:
To quantify the level of radiation exposure to the hands of
hand surgeons using intraoperative mini C-arm fluoroscopy and to
compare the actual level of exposure with predicted levels and acceptable
limits.
methods:
Five hand surgeons were given ring dosimeters to measure radiation
exposure to their hands during surgery of the finger, hand, and
wrist. A total of 81 rings were analyzed. After the clinical study
a phantom was used to measure scatter at close range from the mini
C-arm.
results:
Surgeons' hands were exposed to an average ±SD of 20 ±
12.3 mrem/case. For comparison a chest x-ray results in approximately
20 mrem exposure to the patient. Radiation exposure for the group
of hand surgeons ranged from 5 to 80 mrem. Surgeons used an average
of 51 ± 36.9 seconds of fluoroscopy time per case. Exposure
time for the group ranged from 6 to 170 seconds. The radiation scatter
rate decreases precipitously outside the beam or beyond the radius
of the intensifier. An average exposure to the hands of 20 mrem/case
suggests that surgeons' hands must be entering the beam and getting
direct exposure.
conclusions:
Hand surgeons work close to the beam and as a result their hands
potentially are exposed to a nontrivial amount of radiation. We
recommend that surgeons who use the mini C-arm use precautions to
minimize radiation exposure, particularly to their hands.
Reprinted
from Journal of Hand Surgery [AM], 30(4), Singer G, Radiation exposure
to the hands from mini C-arm fluoroscopy, 795-7, Copyright 2005,
with permission from American Society for Surgery of the Hand.
clinical
implication: The mini C-arm fluoroscope is being used increasingly
in trauma clinics, emergency rooms and operating rooms. This study
provides both clinical data and experimental scatter data to quantify
exposure for the health care worker operating the machine. Results
show that although exposure is low relative to allowable levels,
they are higher than might be expected. Scatter to the operator's
torso appears to be small, but radiation from direct exposure
to the operator's hand is higher than expected. In addition to
other measures to minimize radiation exposure, one should specifically
avoid putting ones' hand directly in the beam when operating the
fluoroscope. GS
From
Southern California
Obesity
and perioperative morbidity in total hip and total knee arthroplasty
patients.
Namba
RS, Paxton L, Fithian DC, Stone ML. J Arthroplasty 2005 Oct;20(7
Suppl 3):46-50.
The
incidence of obesity in 1071 total hip arthroplasty (THA) patients
and 1813 total knee arthroplasty (TKA) patients and its effect on
perioperative morbidity were evaluated prospectively. Fifty-two
percent of TKA and 36% of THA patients were obese (body mass index
30). The obese patients were significantly younger, with a higher
proportion of obese TKA patients being women. Higher rates of diabetes
and hypertension were found in obese patients. Higher postoperative
infection rates were observed in patients with body mass index 35
or higher. The odds ratio was 6.7 times higher risk for infection
in obese TKA patients and 4.2 times higher for obese THA patients.
The increased risk of infection in obese patients undergoing total
joint arthroplasty must be realized by both the patient and surgeon.
Reprinted
from Journal of Arthroplasty, V20(7 suppl 3), Namba RS, Paxton L,
Fithian DC, Stone ML, Obesity and perioperative morbidity in total
hip and total knee arthorplasty patients, 46-50, Copyright 2005,
with permission from Elsevier.
