Abstracts
of Articles Authored or Coauthored by Permanente Physicians |
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Selected by Daphne Plaut, MLS, Librarian, Center for Health Research
From
Southern California:
Hormone
use and cognitive performance in women of advanced age.
Buckwalter
JG, Crooks VC, Robins SB, Petitti DB. J Am Geriatr Soc 2004 Feb;52(2):182-6.
objectives:
To explore the association between hormone replacement therapy (HRT)
and cognitive performance in a group of elderly women (75) using a battery
of well-standardized neuropsychological instruments.
design: Equivalent samples from existing cohort.
setting: Health care provider organization.
participants:
All women enrolled were participants in an ongoing study of the association
between HRT and the prevalence and incidence of dementia. Prescription
records were used to establish HRT status. Fifty-eight users and 47
nonusers of HRT participated in this substudy.
measurements:
Given previous reports that HRT has a positive effect on verbal memory,
the California Verbal Learning Test and the Logical Memory Test were
used as primary outcomes. A range of validated tests that assess other
cognitive domains was also included.
results:
There were no significant differences between users and nonusers of
HRT on any cognitive measures.
conclusion:
Given equivalent groups of users and nonusers of HRT no support was
found for the hypothesis that use of HRT improves cognitive performance
in older women.
From
Southern California:
Diabetes
mellitus and cognitive performance in older women.
Crooks
VC, Buckwalter JG, Petitti DB. Ann Epidemiol 2003 Oct;13(9):613-9.
purpose:
This cross-sectional study sought to identify diabetes accurately in
a study population of 3681 women age 75 and older and
to determine the association of diabetes with cognitive performance.
methods:
A previously validated test, the Telephone Interview of Cognitive Screening-Modified
(TICSm) was given to assess cognitive status. A diabetes case identification
database, medical record review and self-report were used to determine
diabetes cases. Four hundred eighty-nine (13.3%) of the women in the
study were classified with diabetes and 3192 without diabetes.
results:
T-tests and linear regression analyses determined that diabetic women
had a mean TICSm score 1.4 points lower (ie more impaired) than nondiabetic
women. Using linear regression to adjust for age, education, and vascular
disease, diabetic women showed a 1.1 lower score on the TICSm. Similar
adjustments were made for potential confounding variables such as depression,
hormone replacement therapy (HRT), high body weight, smoking, alcohol
use and exercise, and diabetics again showed a 1.0 lower score.
conclusion: This study, which utilizes highly rigorous case identification
methodology, provides further evidence that diabetes is associated with
significantly worse cognitive performance in the elderly.
Reprinted
from Annals of Epidemiology, 13(9), Crooks VC, Buckwalter JG, Petitti
DB, Diabetes mellitus and cognitive performance in older women, 613-9,
Copyright 2003, with permission from Elsevier.
clinical
implication: In this large cross-sectional
study, we have confirmed the association of diminished cognitive performance
with diabetes in elderly females. It is important for clinicians to
be aware that, in addition to its more well-known complications, diabetes
mellitus may increase the risk of cognitive decline. This condition
can greatly hamper the ability of patients to follow their treatment
regimen and can further inhibit their normal daily function. --VC
From
Northern California:
Cohort
study of exposure to environmental tobacco smoke and risk of first ischemic
stroke and transient ischemic attack.
Iribarren
C, Darbinian J, Klatsky AL, Friedman GD. Neuroepidemiology 2004 Jan-Apr;23(1-2):38-44.
The independent
effect of exposure to environmental tobacco smoke (ETS; passive smoking)
on the risk of stroke is not well established. We performed a cohort
study among 27,698 lifelong nonsmokers with no prior history of stroke,
62% women, aged 30-85 years at enrollment (1979-1985). Self-reported
ETS exposure at home and outside home (in hours/week) and stroke risk
factors were collected at a health plan in San Francisco and Oakland.
Follow-up for hospitalization and death was available through the end
of 2000 (median = 16 years). In multivariate analysis adjusting for
age, race/ethnicity, educational attainment, marital status, hypertension,
diabetes and serum total cholesterol, ETS exposure at home of 20 hours
or more/week (in relation to <1 hours/week) was associated with a
1.29-fold (95% CI 0.75-2.20) and a 1.50-fold (95% CI 1.07-2.09) increased
risk of first ischemic stroke among men and women, respectively. No
significant associations were found between ETS exposure outside home
and ischemic stroke or between exposure to ETS at home or out of home
and the risk of transient ischemic attack. Although potentially important
confounders (such as dietary habits) were not included in the analysis,
high-level ETS exposure at home was independently associated with increased
risk of first ischemic stroke among never-smoking women.
Reprinted
with permission from S Karger AG, Basel.
clinical
implication: The independent effect
of passive smoking on the risk of stroke is not well established. Although
potentially important confounders (such as dietary habits) were not
included in the analysis, a high self-reported level of passive smoking
at home (20 hours per week or more) was independently and significantly
associated with a 1.5-fold increased risk of first ischemic stroke among
never-smoking women. A consistent but weaker association was seen in
men. --CI
From
Northern California:
A
post-licensure evaluation of the safety of inactivated hepatitis A vaccine
(VAQTA, Merck) in children and adults.
Black
S, Shinefield H, Hansen J, Lewis E, Su L, Coplan P. Vaccine 2004 Jan
26;22(5-6):766-72.
background:
Hepatitis A is a major cause of epidemic hepatitis in the US. In pre-licensure
trials, inactivated hepatitis A vaccine (HAV, VAQTA, Merck) was shown
to be generally well tolerated and effective in inducing immunity to
hepatitis A infection in adults and children over two years of age.
Following the licensure of this vaccine, we began a Phase IV safety
evaluation in adults and in children over two years of age.
methods:
Safety was assessed by comparing the rates of diagnoses in clinic, emergency
and hospital utilization. From April 1997 to December 1998, rates of
diagnoses within 30 days for the clinic and emergency setting and 60
days for hospitalization were compared with unexposed follow-up time
in the same individuals both before receipt of vaccine and after the
60 days interval post-vaccination.
results:
There were a total of approximately 2000 comparisons between the risk
and "before" or "after" period. Among them, 106
were found to have statistically significant differences in rates (30
elevated, 76 lowered). Among children/adolescents (2-17 years old),
in the hospitalization category, the only statistically significant
elevated risk found was "elective procedures," as compared
with both "before" and "after" periods. In the outpatient
visit category for children and adolescents, elevated risks were found
for consultation/general medicine/exam when compared with both "before"
and "after" periods, and ganglion and viral warts when compared
with either "before" or "after" period. Among adults
(18 year-old), in the outpatient visit category, a statistically significant
elevated relative risk was seen for diarrhea/gastroenteritis for both
"before" and "after" periods. There were additionally
17 diagnostic categories that showed a statistically significantly elevated
relative risk compared with either "before" or "after"
period. Except for diarrhea/gastroenteritis, the other eight events
were elevated only in one comparison (either "before" or "after").
These eight elevated relative risks might be explained by chance resulting
from multiple comparison or seasonal variations. There were no serious
adverse events judged by the investigator to be associated with HAV.
conclusion:
In this large Phase IV evaluation of the safety of HAV, the vaccine
appeared to be generally well tolerated. These data support the continued
routine use of HAV for vaccination in children and adults.
Reprinted
from Vaccine, 22(5-6), Black S, Shinefield H, Hansen J, Lewis E, Su
L, Coplan P, A post-licensure evaluation of the safety of inactivated
hepatitis A vaccine (VAQTA, Merck) in children and adults, 766-72, Copyright
2004, with permission from Elsevier.
clinical
implication: The hepatitis A vaccine
was evaluated for safety in children and adults by Northern California
Kaiser Permanente. In this large postmarketing evaluation of the vaccine,
no safety concerns were identified. Hepatitis A vaccine is currently
recommended for routine use in states, such as California, with high
endemicity. --SB
From
Northern California:
High
rates of co-occurrence of hypertension, elevated low-density lipoprotein
cholesterol, and diabetes mellitus in a large managed care population.
Selby
JV, Peng T, Karter AJ, et al. Am J Manag Care 2004 Feb;10(2 Pt 2):163-70.
objective:
To examine prevalence and co-occurrence of diabetes mellitus (DM), hypertension
(HT), and elevated low-density lipoprotein cholesterol (dyslipidemia,
or DL) in a managed care population.
study
design: Period prevalence study.
patients
and methods: The study population included all adults (age >
20 years) who had been members of Kaiser Permanente, Northern California,
for at least four months on December 31, 2001 (n = 2.1 million). Criteria
from the Joint National Committee on Prevention, Detection, Evaluation,
and Treatment of Hypertension, the Third Report of the National Cholesterol
Education Program Expert Panel on Detection, Evaluation, and Treatment
of High Blood Cholesterol in Adults, and the Northern California Kaiser
Permanente Diabetes Registry were applied to computerized databases
for an 18-month period to identify HT, DL, and DM, respectively. Because
screening for these conditions is incomplete, we applied age- and sex-specific
prevalence estimates from the Third National Health and Nutrition Examination
Survey to simulate full ascertainment.
results:
Unadjusted prevalence rates of HT, DL, and DM were 23.8%, 17.6%, and
6.6%, respectively. More than 50% of persons with either HT or DL also
had at least one other condition. Of all persons with DM, 74% had HT,
73% had DL, and 56% had both. Under full ascertainment, prevalence increased
to 27.6%, 35.6%, and 8.7% for HT, DL, and DM, respectively, and co-occurrence
increased further.
conclusion:
HT, DL, and DM co-occur in most affected individuals. To avoid fragmentation
of care, disease management strategies should aim to manage these conditions
within the same programs.
clinical
implications: This paper presents the extraordinary rates at which
hypertension, elevated LDL cholesterol level, and diabetes mellitus
co-occur in general populations. Of all patients with dyslipidemia 47%
also have hypertension, whereas 56% of those with hypertension also
have dyslipidemia. Of persons with diabetes, more than 90% have either
hypertension or dyslipidemia, and more than 60% have both conditions.
In light of this overlap and the high risk for cardiovascular disease
when two or more conditions are present, population programs addressing
any of these conditions should be planned and implemented to address
all three. --JS
From Southern California:
Use
of inhaled steroids by pregnant asthmatic women does not reduce intrauterine
growth.
Namazy
J, Schatz M, Long L, et al. J Allergy Clin Immunol 2004 Mar;113(3):427-32.
background:
Inhaled steroids are recommended for the treatment of persistent asthma
during pregnancy, but their potential effects on intrauterine growth
have been inadequately evaluated.
objective:
The purpose of this study was to evaluate the association between maternal
use of specific inhaled steroids and inhaled steroid dose during pregnancy
and the incidence of infants who are small for gestational age (SGA)
and mean birth weight.
methods:
Pregnant asthmatic women being treated with inhaled steroids were enrolled
in the study before delivery by their managing allergists. Information
regarding the specific inhaled steroid and daily dose used, requirement
for oral steroids, occurrence of acute asthmatic episodes, maternal
race, birth weight, gestational age, and congenital malformations was
obtained for each patient. SGA was defined through use of a published
normative sample of American births.
results:
A total of 474 women were enrolled in the study; of the 451 enrolled
participants whose pregnancy ended in a singleton live birth, 396 (88%)
completed the study. The incidence of infants with low birth weight,
preterm births, and congenital malformations in this cohort was not
greater than expected in the general population. The incidence of SGA
was 7.1% (95% CI, 5.0% to 10.1%). No significant relationships between
specific inhaled steroid or dose of inhaled steroid used and either
SGA or mean birth weight were observed.
conclusion:
These data suggest that the use of inhaled steroids by pregnant asthmatic
women does not reduce intrauterine growth and supports the recommendation
that inhaled steroids should be used in the management of persistent
asthma during pregnancy.
Reprinted
from Journal of Allergy and Clinical Immunology, 113(3), Namazy J, Schatz
M, Long L, et al, Use of inhaled steroids by pregnant asthmatic women
does not reduce intrauterine growth, 427-32, Copyright 2004, with permission
from American Academy of Allergy, Asthma and Immunology.
clinical
implication: Prior studies suggest that
uncontrolled asthma during pregnancy may be associated with adverse
maternal and infant outcomes. However, previously described adverse
effects of oral corticosteroids on intrauterine growth and of some inhaled
steroids on growth in children raised the possibility of an adverse
effect of inhaled corticosteroids on fetal growth. These data suggest
that currently used inhaled corticosteroids do not reduce intrauterine
growth. This study thus supports current recommendations that inhaled
corticosteroids should be considered preferred
controller therapy for pregnant patients with persistent asthma. --MS
From
Northern California:
Incidence
and prevalence of uveitis in Northern California; the Northern California
Epidemiology of Uveitis Study.
Gritz
DC, Wong IG. Ophthalmology 2004 Mar;111(3):491-500; discussion 500.
purpose:
To determine the incidence and prevalence of uveitis in a large, well-defined
population in Northern California.
design:
Cross-sectional study using retrospective database and medical record
review.
participants:
A group of 2070 people within six Northern California medical center
communities (n = 731,898) who had a potential diagnosis of uveitis.
methods:
The patient database of a large health maintenance organization (2,805,443
members at time of the study) was searched for all patients who, during
a 12-month period, had the potential diagnosis of uveitis. Detailed
quarterly gender- and age-stratified population data were available.
Medical records of patients who potentially had uveitis and who were
members of the six target communities were reviewed by two uveitis subspecialists
to confirm the diagnosis of uveitis and to establish time of onset.
Demographic and clinical data were gathered for patients meeting the
clinical definition of uveitis. Incidence rates were calculated by using
a dynamic population model. Prevalence rates were based on the mid-study
period population.
main
outcome measures: Presence and date of onset of uveitis.
results:
At midstudy, the population for the six communities was 731,898. During
the target period, 382 new cases of uveitis were diagnosed; 462 cases
of uveitis were diagnosed before the target period. These data yielded
an incidence of 52.4/100,000 person-years and a period prevalence of
115.3/100,000 persons. The incidence and prevalence of disease were
lowest in pediatric age groups and were highest in patients 65 years
or older (p < 0.0001). The prevalence of uveitis was higher in women
than in men (p < 0.001), but the difference in incidence between
men and women was not statistically significant. Comparison between
the group of patients who had onset of uveitis before the target period
(ongoing uveitis) and the entire cohort of uveitis patients showed that
women had a higher prevalence of ongoing uveitis than men and that this
difference was largest in the older age groups (p < 0.001).
conclusion:
In this largest population-based uveitis study in the United States
to date, the incidence of uveitis was approximately three times that
of previous US estimates and increased with the increasing age of patients.
Women had a higher prevalence of uveitis than men, and the largest differences
were in older age groups.
Reprinted
from Ophthalmology, 111(3), Gritz DC, Wong IG, Incidence and prevalence
of uveitis in Northern California; the Northern California Epidemiology
of Uveitis Study, Copyright 2004, with permission from American Academy
of Ophthalmology.
clinical
implications: This study is an important
reassessment of the present epidemiology of uveitis in the diverse population
served by Kaiser Permanente Northern California. The much higher rates
of disease, especially in people over 65 and in women over 65, are of
concern. Uveitis patients are at significant risk of ocular complications
and visual loss. Because of the severity of their disease, uveitis patients
utilize more health care resources, and that could also impact the health
care system, especially with the aging of our population. --DG
Practice Innovations with Results
Abstracts from
the March 2004 KP San Diego Primary Care Access Conference
This
special section includes abstracts taken from the KP Primary Care Access
Conference to highlight innovations in practice so that clinicians can
see what is new, and to create a broadened sense of organizational change,
a vision of the future,
and potential resolutions to current dilemmas. We hope to encourage
others to create trials of their own, guided and encouraged by those
who presented.
From
Hawaii:
Patient
Care Messaging as an Alternative to the Traditional Visit Paradigm
William
E Clevenger, MD
why:
Traditional office visits and the increasing workload related to the
assessment of and action on electronic data overloading frontline doctors.
what:
At the Kaiser Permanente Mililani Clinic, we created a new workflow
and role for our PCPs: One physician daily is relieved of his/her traditional
role and functions as the Patient Care Messaging physician. This "designated
hitter" deals with electronic information, makes phone contact
with patients and deals with overload and walk-in patients in the clinic.
results:
Our experience shows that we create increased opportunities for patient
contact while decreasing the perceived workload and burnout of our staff.
We are averaging five more daily "patient contact opportunities"
than a conventional schedule.
voices:
"Our patients seem positive about the program. When all family
members are working,
they appreciate not having to take time off from work to get medical
advice."
"Doing
something 'different' seems to break up the work week a little. I like
it."
Presented
by William E Clevenger, MD; e-mail: bill.clevenger@kp.org.
From
Ohio and Group Health Cooperative:
Predicting
Appointment Demand
Nicholas
Dreher, MD, Ohio; Mark Spadin, Ohio; Belinda Potts, Ohio; June BlueSpruce,
GHC; Tony Posch, MD, GHC
why:
While the historical adjusted demand approach is valuable for planning
annual staffing, the true demand approach offers potential for determining
historically unmet demand. An accurate demand forecast model impacts
access planning.
what:
There are two demand models: The "historical adjusted demand"
approach uses historical utilization, based on gender/age distribution,
as a starting point, and adjusts for other factors, such as membership
changes, disease burden, and unmet demand. The "true demand"
approach looks at appointments requested, not appointments made.
results:
Although these models have limitations, they still predict better than
"no prediction" at all. The demand model alone won't improve
access--using forecast information to help with access planning will
make a difference.
Contact
Julie Liao; e-mail: julie.liao@kp.org.
From
Southern California:
SCPMG
Web Based Patient Panel System
Andrew
Golden, MD; Waldemar Strubinski
why:
A desktop-based Patient Panel System was limited by single-user only
access and the need for individual, custom installation.
what: The Southern California Region developed a Web-based Patient
Panel System for all 12 of its Medical Center Areas. The database provides
updated panel and demand data, and allows for local entry of supply-side
information, including distribution of the nonpanel provider supply
among the panel providers. The application integrates the regionally
projected demand data with the locally entered supply information, resulting
in panel reports that are downloadable as needed.
results: The new Web-based system allows any user to view or
update data created within his department, facility, Medical Area, or
across the entire SCAL Region, depending on his/her security access
level. A KP-IT programmer controls the system resources. Anyone with
Web access can use the system, eliminating individual installation.
The user
base has more than doubled, and user satisfaction has increased.
Presented
by Andrew Golden, MD; e-mail: andrew.m.golden@kp.org
and Waldemar Strubiski; e-mail: waldemar.w.strubinski@kp.org.
From
Northern California:
Santa
Teresa Access Management
Priya
Smith; William Yee; Maritess Salaysay
why:
The success of an access management process lies in both prospective
and real time management of appointment availability.
what:
The components in this process include:
- Meetings:
the access "team" meets on a regular basis and involves
various individuals from the department;
- Data
analysis: an analyst assigned to Medicine provides prospective and
real time access data to the team;
- Decision
making: the team provides a forum to make adjustments to appointment
supply as needed to help meet access goals;
- Strategic
planning: initiatives to help meet specific access targets such as
75% of appointments booked at first call by the Appointment &
Advice Call Center;
- Performance
evaluation and trending: examine retrospective data to assess access
performance and show improvements and areas for improvement.
results:
The Member Patient Satisfaction scores reflect significant patient satisfaction
with the ability to get an appointment.
Presented by Priya Smith; e-mail: priya.s.smith@kp.org.
From
Hawaii:
Proactive
Linking (Improvements to the Hawaii Region's Exit Linking Program)
Chris
Lutz
why:
A core principle in the Hawaii Region is: "The Key Relationship
for the Member is with His or Her Own Physician."
what:
As a result of the Focus Groups, the Hawaii Region will be piloting
a "proactive linking" program in 2004-2005 that will include
a packet of information for new members with a welcome letter describing
the importance of having a personal doctor; a brochure from the member's
"home clinic" with basic information including how to choose
a primary care physician (PCP); "bio cards" of available PCPs
that include basic information and four to five specific comments from
the patient satisfaction surveys for this physician, as well as a statement
about the physician's "philosophy of medicine"; (see figure
1) and a reply card for the member to indicate a PCP preference.
Subsequently,
the member will receive a welcome and a Healthwise Handbook from
his/her new PCP.
results:
The pilot will be conducted at one Oahu Clinic from July 2004 until
June 2005. If the results are positive, the program will be implemented
regionwide in the second half of 2005.
Presented by Chris Lutz; e-mail: chris.lutz@kp.org.
Figure 1. New bio card
From
Hawaii, the Northwest, and Southern California:
Yardsticks
for Measuring Access
Chris
Lutz; Bill Pfeiffer, MD; Waldo Luciano, MD; Kristina Spahr
why:
The entire program has a great deal of access measures; we wanted to
advance the knowledge of the program by sharing effective practices
from around the region.
what:
All Regions create primary care access reports that fall into seven
broad categories. Standardization and consistency in these reporting
systems would allow more effective utilization.
results:
Operational measures have improved across the board simply with delivering
measures to frontline staff and improving systems to allow for patient-centered
systems.
voices:
"It's good to see where each operation is scoring so that we get
positive reinforcement about what works and so that we know where to
focus on what doesn't. It's great to see the staff respond to their
measures and take ownership for improvement."
For more
information and for examples of all of the measures, please see the
CEC Intranet site: http://kpnet.kp.org/permfed/Education/pcaccess_conference.htm.
Presented
by Chris Lutz; e-mail:
chris.lutz@kp.org.
.
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