of Articles Authored or Coauthored by Permanente Clinicians |
by Louise Williams, PhD, Center for Health Research
Ethnic and racial differences in diabetes care: the insulin resistance
DE, Zaccaro DJ, Karter AJ, Selby JV, Saad M, Goff DC Jr. Diabetes Care
Diabetes and its complications disproportionately affect African Americans
and Hispanics. Complications could be prevented with appropriate medical
care. We compared five processes of care and three outcomes of care among
African Americans, Hispanics, and non-Hispanic whites.
research and design methods: We used data from the Insulin Resistance
Atherosclerosis Study (1993-1998) of participants with known diabetes.
African Americans and Hispanics were compared with non-Hispanic whites
from the same region. Five process measures (treatment of diabetes, hypertension,
hyperlipidemia, albuminuria, and coronary artery disease) and three outcome
measures (control of diabetes, hypertension, and hyperlipidemia) were
Comparison groups were similar in baseline characteristics. African Americans
and Hispanics were equally likely as their non-Hispanic white comparison
group to receive treatment for diabetes, hypertension, hyperlipidemia,
albuminuria, and coronary artery disease, although treatment rates for
hyperlipidemia and albuminuria were poor for all groups. African Americans
were more likely to have poorly controlled diabetes (HbA1c
>8.0%: OR 2.23, 95% CI 1.26-3.94). Both African Americans and Hispanics
were significantly more likely to have borderline or poorly controlled
hypertension than non-Hispanic whites (blood pressure >130-140/85-90
or >140/90 mmHg: African American/non-Hispanic white OR 3.22, 95% CI
1.57-6.59; Hispanic/non-Hispanic white 3.14, 1.35-7.3).
The rates of treatment for diabetes and associated comorbidities are similar
across all three ethnic groups. Few individuals in any ethnic group received
treatment for hyperlipidemia and albuminuria. Ethnic disparities exist
in control of diabetes and hypertension. Programs should be tested to
improve overall quality of care and eliminate these disparities.
© 2003 American Diabetes Association. From Diabetes Care, Vol 26,
2003;1040-46. Reprinted with permission from The American Diabetes Association.
Slow response to loss of glycemic control in type 2 diabetes mellitus
JB, Nichols GA. Am J Manag Care 2003 Mar;9(3):213-7.
To achieve glycemic control in type 2 diabetes mellitus, the American
Diabetes Association (ADA) recommends intensification of glucose-lowering
therapy when the glycosylated hemoglobin (HbA1c) level exceeds
objective: To study glycemic control before and after initiation
of secondary antihyperglycemic therapy to better understand the pace and
patterns of therapeutic failure and clinical responses to failure.
design: A retrospective, population-based observational study.
and methods: From a 12-year-old diabetes registry of members of Kaiser
Permanente Northwest, a large group-model HMO, we tracked the glycemic
control histories of all 570 registrants who, in 1998, added metformin
therapy to sulphonylurea monotherapy.
The last HbA1c level before metformin use averaged 9.4%. Metabolic
decompensation accelerated over time. Patients typically spent numerous
months at and had several measurements of HbA1c >8.0% before
a final glycemic spike to >9.0%. Persons experiencing more gradual
failure accumulated greater glycemic burdens before changing therapy.
The level of HbA1c that seemed to trigger glucose-lowering
action was 9.0% or higher, not 8.0% as recommended by the ADA. A substantial
hyperglycemic peak preceded change in therapy even in this relatively
tightly controlled population with type 2 diabetes mellitus. Earlier therapeutic
changes, but not more frequent testing, would prevent the glycemic excursions
we observed. Low mean HbA1c levels in populations do not necessarily
indicate that loss of glycemic control is being rapidly addressed for
most patients. More research is needed to estimate the impact of these
peaks on current well-being and future complications.
implication: KP and KPNW have some of the highest HEDIS scores in
the nation for quality of diabetes care. We were therefore surprised
to discover that, looking backward from new metformin prescriptions,
most members reached HbA1c levels well above 9.0% before
starting the drug. Sizable glycemic burden can accumulate when we do
not react quickly to failures of antihyperglycemic therapies. Now that
our members with diabetes are living longer--thanks to aggressive cardiovascular
disease prevention and treatment--glycemic excursions have more time
to cause harm in the form of serious renal, retinal, and neuropathic
disease. Just measuring the HbA1c is not enough. JB
Evaluation of a nurse-care management system to improve outcomes in patients
with complicated diabetes
CB, Miller NH, Reilly KR, et al. Diabetes Care 2003 Apr;26(4):1058-63.
This study evaluated the efficacy of a nurse-care management system designed
to improve outcomes in patients with complicated diabetes.
research and design methods: In this randomized controlled trial
that took place at Kaiser Permanente Medical Center in Santa Clara, CA,
169 patients with longstanding diabetes, one or more major medical comorbid
conditions, and HbA1c >10% received a special intervention
(n = 84) or usual medical care (n = 85) for one year. Patients met with
a nurse-care manager to establish individual outcome goals, attended group
sessions once a week for up to four weeks, and received telephone calls
to manage medications and self-care activities. HbA1c, LDL,
HDL, and total cholesterol, triglycerides, fasting glucose, systolic and
diastolic blood pressure, BMI, and psychosocial factors were measured
at baseline and one year later. Annualized physician visits were determined
for the year before and during the study.
results: At one year, the mean reductions in HbA1c,
total cholesterol, and LDL cholesterol were significantly greater for
the intervention group compared with the usual care group. Significantly
more patients in the intervention group met the goals for HbA1c
(<7.5%) than patients in usual care (42.6 vs 24.6%, P < 0.03, chi(2)).
There were no significant differences in any of the psychosocial variables
or in physician visits.
conclusions: A nurse-care management program can significantly improve
some medical outcomes in patients with complicated diabetes without increasing
Copyright © 2003 American Diabetes Association. From Diabetes
Care, Vol 26, 2003;1058-63. Reprinted with permission from The American
Inhaled corticosteroids and allergy specialty care reduce emergency hospital
use for asthma
M, Cook EF, Nakahiro R, Petitti D. J Allergy Clin Immunol 2003 Mar;111(3):503-8.
The interrelationships between optimal inhaled corticosteroid (IC) therapy,
allergy specialist care, and reduced emergency hospital care for asthma
have not been well defined.
objective: We sought to evaluate the independent effectiveness
of various levels of IC dispensing and allergy specialist care in reducing
subsequent emergency asthma hospital use.
methods: Asthmatic patients (n = 9608) aged three to 64 years were
identified from an electronic database of a large health maintenance organization.
The outcome was any year 2000 asthma hospitalization or emergency department
visit. The main predictors were at least one allergy department visit
and the number of IC canisters dispensed in 1999. Analyses were adjusted
for age, sex, insurance type, and asthma severity (1999 emergency asthma
hospital use, beta-agonist use, and oral corticosteroid use).
results: Dispensing of seven or more canisters of ICs (odds ratio
[OR], 0.64; 95% CI, 0.43-0.94) and allergy care (OR, 0.73; 95% CI, 0.55-0.97)
were associated with reduced subsequent emergency asthma hospital use.
More patients with allergy specialist care than those without such care
received seven or more dispensations of ICs (24.7% vs 8.3%, P < .001).
When seven or more dispensations of ICs and allergy specialist care were
simultaneously included in an adjusted model, both ICs (OR, 0.68; 95%
CI, 0.46-1.00) and allergy care (OR, 0.77; 95% CI, 0.58-1.02) were independently
associated with a lower risk of year 2000 emergency asthma hospital care,
although significance was borderline.
conclusion: Allergy care reduces emergency hospital use for asthma
by increasing use of ICs but probably also has an independent effect.
from Journal of Allergy and Clinical Immunology, Vol 111, Schatz M, Cook
EF, Nakahiro R, Petitti D, Inhaled corticosteroids and allergy specialty
care reduce emergency hospital use for asthma, 503-8, Copyright 2003,
with permission from Elsevier.
implication: I believe there are two important practical lessons
in this article. The first is that inhaled steroids can be shown to
reduce emergency hospital care requirements for asthma, but only if
patients take them regularly. The second is that referral of patients
with more severe asthma to allergists can improve their outcomes, probably
above and beyond the effects of optimal inhaled steroid therapy. MS
Irritable bowel syndrome, health care use, and costs: a US managed care
GF, Wilson A, Knight K, et al. Am J Gastroenterol 2003 Mar;98(3):600-7.
We performed an evaluation of patient symptoms, health care use, and costs
to define the burden of illness of irritable bowel syndrome (IBS) and
the relation to the severity of abdominal pain/discomfort in a large health
methods: All 6500 adult health maintenance organization members who
had undergone flexible sigmoidoscopy in the year 2000 were mailed a questionnaire
that elicited Rome I symptom criteria and severity ratings for abdominal
pain/discomfort. Multiple health care use measures were obtained from
various administrative databases. IBS patients were compared with a control
group of non-IBS subjects, and analyses were adjusted for age and sex.
results: We received 2613 (40.2%) responses. Compared with non-IBS
subjects over two years, IBS patients had more outpatient visits (medical,
surgery, and emergency, p < 0.05), were hospitalized more often (p
< 0.05), and had more total outpatient prescriptions (p < 0.05)
and IBS-related prescriptions (p < 0.05). Over one year, total costs
were 51% higher in IBS patients, who also had higher costs for outpatient
visits, drugs, and radiology and laboratory tests (p < 0.05). Total
costs were increased by 35%, 52%, and 59% in IBS patients with mild, moderate,
and severe symptoms of abdominal pain/discomfort compared with non-IBS
subjects (p < 0.05).
conclusions: Using Rome I symptom criteria, we found that IBS is associated
with a broad pattern of increased health care use and costs. The severity
of abdominal pain/discomfort is a significant predictor of health care
use and costs for patients with IBS compared with non-IBS subjects.
Reprinted from American Journal of Gastroenterology, Vol 98, Longstreth
GF, Wilson A, Knight K, et al, Irritable bowel syndrome, health care use,
and costs: a US managed care perspective, 600-7, Copyright 2003, with
permission from American College of Gastroenterology.
implication: Although IBS has long been regarded by many physicians
as unimportant, recent research has revealed it causes an adverse effect
on quality of life as great as that of common organic diseases. This
study emphasizes the high direct medical costs attributable to this
chronic disorder. These "high utilizers" may have contributing
psychosocial issues, and they seek care for multiple functional somatic
syndromes. They are even predisposed to undergo surgery, including cholecystectomy
and hysterectomy. Therefore, minimizing costs while satisfying patients
demands a lot from practitioners. Management of IBS in most patients
should comprise a symptom-based diagnosis, limited testing, explanation,
reassurance, attention to psychosocial issues and symptom-directed treatment.
Evaluation of the clinical and economic impact of a brand name-to-generic
warfarin sodium conversion program
DM, Tillman DJ, Evans CM, Plotkin TV, Sadler MA. Pharmacotherapy 2003
Substitution of generic warfarin initially was discouraged because of
concerns regarding therapeutic failure or toxicity. Although subsequent
research with AB-rated (ie, bioequivalent) warfarin did not confirm initial
concerns, the issue is not settled for all clinicians.
objectives: We sought to provide additional information regarding
the clinical and economic impact of warfarin conversion by analyzing a
real-life sample of patients receiving long-term anticoagulation therapy
who were switched from brand name to generic warfarin.
Patients who had been taking warfarin for at least 180 days and had received
uninterrupted oral anticoagulation 90 days before and 90 days after switching
to generic warfarin were included. The switch date was based on the first
time generic warfarin was dispensed from our pharmacies. The primary end
point was the calculated amount of time each patient's international normalized
ratio (INR) values were within the patient-specific target INR range in
the 90 days before and after the switch. Data regarding adverse events
and medical resource utilization were also collected. Pharmacoeconomic
analyses were performed.
The analysis included 2299 patients. The overall difference in calculated
time INR values were below (22.6% before vs 26.1% after switch, p <
0.0001) and within (65.9% before vs 63.3% after switch, p = 0.0002) the
therapeutic INR range was statistically but not clinically significant.
Only 28.0% of patients experienced a change in therapeutic INR control
of 10% or less, 33.1% experienced INR control that improved by greater
than 10%, and 38.9% experienced INR control that worsened by more than
10%. The difference in total treatment costs associated with brand name
and generic warfarin was 3128 dollars/100 patient-years in favor of the
generic product. Sensitivity analyses revealed that cost savings associated
with warfarin conversion in this health care system were highly dependent
on the difference between warfarin costs and cost of treating anticoagulation-related
Most of these patients were successfully switched from brand name to generic
warfarin. However, supplemental INR monitoring is warranted when one warfarin
product is substituted for another to allow timely detection of those
patients who experience significant changes in anticoagulation response.
implication: Our study demonstrates that even though global measures
of anticoagulant control (eg, mean INR) show minimal differences, a
substantial number (72.0%) of patients will experience greater than
a 10% change in therapeutic INR control following the switch to generic
warfarin. Accordingly, we recommend that patients should utilize a single
warfarin product whenever possible. Furthermore, clinicians should err
on the side of caution and additional INR monitoring should occur in
the days and weeks following substitution of one warfarin product for
another to allow timely detection of those patients who experience significant
changes in anticoagulant response. DW
A survey of herbal use in children with attention-deficit-hyperactivity
disorder or depression
S, Crismon ML, Baumgartner J. Pharmacotherapy 2003 Feb;23(2):222-30.
To examine whether herbal medicines were given to children or adolescents
receiving care for attention-deficit-hyperactivity disorder or depression.
Between October 2000 and July 2001, a 23-item questionnaire was administered
in five community mental health centers in Texas. Parents or primary caregivers
of children who received a psychiatric assessment were sought for participation.
One hundred seventeen caregivers completed a questionnaire. The main outcome
measure was primary caregivers' self-report of the use of herbal therapy
in their children.
The lifetime prevalence of herbal therapy in patients was 20% (23 patients).
Eighteen patients (15%) had taken herbal medicines during the past year.
Recommendations from a friend or relative resulted in the administration
of herbal medicines by 61% of 23 caregivers. Herbal medicines were given
most frequently for a behavioral condition, with ginkgo biloba, echinacea,
and St John's wort most prevalent. Almost 83% of caregivers gave herbal
medicines alone, whereas 13% gave herbal medicines with prescription drugs.
Most caregivers (78%) supervised the administration of herbal therapy
in their children; the children's psychiatrists (70%), pediatricians (56%),
or pharmacists (74%) typically were not aware of the use.
Most caregivers supervised herbal therapy in their children, without communication
with a health professional. A need exists for better communication between
health professionals and caregivers regarding the use of herbal therapy.
implication: Important practice lesson: Parents of children with
psychiatric disorders may be administering herbal remedies to their
children without supervision of a physician or pharmacist. It is important
for health care providers to inquire about the use of herbals in their
Tobacco use patterns and attitudes among teens being seen for routine
JF, Polen MR, Lichtenstein E, Whitlock EP. Am J Health Promot 2003 Mar-Apr;17(4):231-9.
To describe the tobacco-related attitudes, behaviors, and needs of smoking
and nonsmoking teens being seen for routine pediatric care and to identify
predictors of tobacco use.
design: Cross-sectional survey of adolescent primary care patients
who completed self-administered questionnaires in medical office waiting
rooms while waiting for routine care visits.
setting: A group-practice HMO in the Pacific Northwest.
subjects: A sample of 2526 teenagers, ages 14 to 17, who consented
to receive health promotion interventions as a part of a randomized trial
in seven pediatric and family practice offices.
A 38-item questionnaire assessed tobacco use history, attitudes, quit
attempts, and stage of acquisition or cessation along with gender, age,
race/ethnicity, body mass index, educational plans, frequency of exercise,
attempts to lose weight, and depressed mood.
Sixty-seven percent of teens approached (2526 of 3747) consented to complete
a questionnaire and receive tobacco- or diet-related interventions as
a part of their medical visit. About 23% of teen patients reported smoking
at least one cigarette in the last month, although only 14% described
themselves as current "smokers." Most current smokers (84%)
smoked at least 20 days in the last month. Logistic regression predictors
of smoking included older age, Native American ethnicity, lower educational
aspirations, lower body mass index, smoking among half or more friends,
smokers at home, and a positive depression screen. Among ever-regular
smokers, most were in the action (28%), preparation (21%), or contemplation
(22%) readiness to quit smoking stages, and 77% of current smokers had
made one or more serious quit attempts in the last year.
Most teens in these medical facilities consented to receive tobacco and
diet interventions, and most self-described current smokers were contemplating
or preparing to quit. Medical visits provide attractive opportunities
for tobacco intervention, but messages should be tailored based on the
patient's tobacco status and stage of acquisition or cessation.
implication: One in four teens smokes, but few report receiving
prevention or cessation assistance from clinicians. Most teens in this
study were open to brief counseling during visits, and 71% of those
who smoked were interested in quitting. Almost half were either trying
to quit or preparing to quit within a month. Teens were more likely
to admit they smoked (23% vs 14%) if asked "Have you smoked a cigarette
within the last 30 days?" than if asked "Do you currently
smoke?" Clinicians should attempt to determine how likely teens
are to start or quit smoking, and tailor their messages accordingly.
full contents list >>