Abstracts
of Articles Authored or Coauthored by Permanente Clinicians
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Selected
by Daphne Plaut, MLS, Librarian, Center for Health Research
From
the Northwest:
Teen
reach: outcomes from a randomized, controlled trial of a tobacco reduction
program for teens seen in primary medical care.
Hollis
JF, Polen MR, Whitlock EP, et al. Pediatrics 2005 Apr;115(4):981-9.
objective:
To test the long-term efficacy of brief counseling plus a computer-based
tobacco intervention for teens being seen for routine medical care.
methods: Both smoking and nonsmoking teens, 14 to 17 years of age,
who were being seen for routine visits were eligible for this two-arm
controlled trial. Staff members approached teens in waiting rooms of
seven large pediatric and family practice departments within a group-practice
health maintenance organization. Of 3747 teens invited at 1 visits,
2526 (67%) consented and were randomized to tobacco intervention or
brief dietary advice. The tobacco intervention was individually tailored
on the basis of smoking status and stage of change. It included a 30-second
clinician advice message, a ten-minute interactive computer program,
a five-minute motivational interview, and up to two ten-minute telephone
or in-person booster sessions. The control intervention was a five-minute
motivational intervention to promote increased consumption of fruits
and vegetables. Follow-up smoking status was assessed after one and
two years.
results: Abstinence rates after two years were significantly higher
for the tobacco intervention arm, relative to the control group, in
the combined sample of baseline smokers and nonsmokers (odds ratio [OR]:
1.23; 95% confidence interval [CI]: 1.03-1.47). Treatment effects were
particularly strong among baseline self-described smokers (OR: 2.42;
95% CI: 1.40-4.16) but were not significant for baseline nonsmokers
(OR: 1.25; 95% CI: 0.97-1.61) or for those who had "experimented"
in the past month at baseline (OR: 0.95; 95% CI: 0.45-1.98).
conclusions: Brief, computer-assisted, tobacco intervention during
routine medical care increased the smoking cessation rate among self-described
smokers but was less effective in preventing smoking onset.
From
Southern California:
Randomized trial of endoscopic versus open vein harvest for coronary
artery bypass grafting: six-month patency rates.
Mar;129(3):496-503.
objective:
We sought to compare the six-month angiographic patency rates of greater
saphenous veins removed during coronary artery bypass grafting with
the endoscopic vein harvest or open vein harvest techniques.
methods: Two hundred patients undergoing nonemergency on-pump coronary
artery bypass grafting were prospectively randomized to either endoscopic
vein harvest or open vein harvest. Follow-up angiography of all vein
grafts was scheduled at six months. Graft patency and disease grades
were assigned independently by two interventional cardiologists. Leg
wound healing was evaluated at discharge, one month, and six months
for evidence of complications.
results: There were three conversions from endoscopic vein harvest
to open vein harvest because of vein factors. Leg wound complications
were significantly lower in the endoscopic vein harvest group (7.4%
vs 19.4%, p = .014). On multivariable analysis, endoscopic vein harvest
emerged as the only factor affecting wound complications (odds ratio,
0.33). Three deaths (two perioperative and one late) occurred in the
endoscopic vein harvest group that were unrelated to vein graft closure.
Twenty-four and 29 patients in the endoscopic vein harvest and open
vein harvest cohorts, respectively, refused the follow-up six-month
angiography. Therefore a total of 144 angiograms (73 endoscopic vein
harvests and 71 open vein harvests) and 336 vein grafts (166 endoscopic
vein harvests and 170 open vein harvests) were available for analysis.
The overall occlusion rates at six months were 21.7% for endoscopic
vein harvest and 17.6% for open vein harvest. Additionally, there was
evidence of significant disease (>50% stenosis) in 10.2% and 12.4%
of endoscopic vein harvest and open vein harvest grafts, respectively.
By means of ordinal hierarchic logistic regression, endoscopic vein
harvest was not found to be a risk factor for vein graft occlusion or
disease (odds ratio, 1.15). Significant predictors were congestive heart
failure (odds ratio, 2.87), graft to the diagonal artery territory (odds
ratio, 1.76), larger vein conduit size (odds ratio, 1.32), and graft
flow (odds ratio, 0.90).
conclusion: Endoscopic vein harvest reduces leg wound complications
compared with open vein harvest without compromising the six-month patency
rate. The overall patency rate depends on target and vein-related variables
and patient characteristics rather than the method of vein harvesting.
From
Colorado:
Telepharmacy
in a health maintenance organization.
Stubbings
T, Miller C, Humphries TL, Nelson KM, Helling DK. Am J Health Syst Pharm
2005 Feb 15;62(4):406-10.
purpose:
A telepharmacy service in a health maintenance organization is described.
summary: Kaiser Permanente Colorado Region's clinical pharmacy call
center (CPCC) was established in 1996 after an audit showed that the
third most common type of call to the regional call center involved
questions about drug therapy. The service was developed through collaboration
among the pharmacy department, the medical group, and the Health Plan
to care for patients with medication-related questions. CPCC pharmacists
work closely with the physicians, nurses, and service associates of
the regional call center; primary care physicians; and other Pharmacy
Department members. The CPCC team answers approximately 1200 telephone
calls daily, including calls from new members regarding their transition
into the Health Plan, calls about medications for patients recently
discharged from outside hospitals, questions about medication-related
news releases, and general drug therapy questions. CPCC pharmacists
collaborate with physicians to care for patients with allergic rhinitis
and to complete projects that improve the quality and cost-effectiveness
of drug therapy regimens. Many of CPCC's interactions are entered into
an electronic medical record. CPCC has helped over 40,000 new members
with their transition into the Health Plan since January 2000, and significant
cost savings have resulted.
conclusion: CPCC has used telephonic, electronic, and other means
of communication in an effort to reduce costs and improve the quality
of care.
From
the Mid-Atlantic States:
Comparison
of office visit and nurse advice hotline data for syndromic surveillance--Baltimore-Washington,
DC, metropolitan area, 2002.
Henry
JV, Magruder S, Snyder M. MMWR Morb Mortal Wkly Rep 2004 Sep 24;53 Suppl:112-6.
introduction:
Kaiser Permanente of the Mid-Atlantic States (KPMAS) is collaborating
with the Electronic Surveillance System for Early Notification of Community-Based
Epidemics II (ESSENCE II) program to understand how managed-care data
can be effectively used for syndromic surveillance.
objectives: This study examined whether KPMAS nurse advice hotline
data would be able to predict the syndrome diagnoses made during subsequent
KPMAS office visits.
methods: All nurse advice hotline calls during 2002 that were linked
to an outpatient office visit were identified. By using International
Classification of Diseases, Ninth Revision (ICD-9) codes, outpatient
visits were categorized into seven ESSENCE II syndrome groups (coma,
gastrointestinal, respiratory, neurologic, hemorrhagic, infectious dermatologic,
and fever). Nurse advice hotline calls were categorized into ESSENCE
II syndrome groups on the basis of the advice guidelines assigned. For
each syndrome group, the sensitivity, specificity, and positive predictive
value of hotline calls were calculated by using office visits as a diagnostic
standard. For matching syndrome call-visit pairs, the lag (ie, the number
of hours that elapsed between the date and time the patient spoke to
an advice nurse and the date and time the patient made an office visit)
was calculated.
results: Of all syndrome groups, the sensitivity of hotline calls
for respiratory syndrome was highest (74.7%), followed by hotline calls
for gastrointestinal syndrome (72.0%). The specificity of all nurse
advice syndrome groups ranged from 88.9% to 99.9%. The mean lag between
hotline calls and office visits ranged from 8.3 to 50 hours, depending
on the syndrome group.
conclusions: The timeliness of hotline data capture compared with
office visit data capture, as well as the sensitivity and specificity
of hotline calls for detecting respiratory and gastrointestinal syndromes,
indicate that KPMAS nurse advice hotline data can be used to predict
KPMAS syndromic outpatient office visits.
clinical
implication: The anthrax attacks in 2001 highlighted the serious
shortcomings of the US public health infrastructure. Improving surveillance
to detect epidemics requires the cooperation of primary care providers
who are the first responders to both naturally occurring and bioterror
outbreaks in the community. However, public health reporting is often
a provider's last priority, secondary to the care of individual patients.
When providers routinely use electronic medical record systems to
document patient care, the process of reporting can be automated--Information
can be transmitted to health departments in near real time without
interfering with the provider's ability to care for patients. JH
From
Northern California:
Use
of dietary supplements by female seniors in a large Northern California
health plan.
Gordon
NP, Schaffer DM. BMC Geriatr 2005 Feb 9;5(1):4.
background:
Women aged 65 years are high utilizers of prescription and over-the-counter
medications, and many of these women are also taking dietary supplements.
Dietary supplement use by older women is a concern because of possible
side effects and drug-supplement interactions. The primary aim of this
study was to provide a comprehensive picture of dietary supplement use
among older women in a large health plan in Northern California, USA,
to raise awareness among health care providers and pharmacists about
the need for implementing structural and educational interventions to
minimize adverse consequences of self-directed supplement use. A secondary
aim was to raise awareness about how the focus on use of herbals and
megavitamins that has occurred in most surveys of complementary and
alternative therapy use results in a significant underestimate of the
proportion of older women who are using all types of dietary supplements
for the same purposes.
methods: We used data about use of different vitamin/mineral (VM)
supplements and nonvitamin, nonmineral (NVNM) supplements, including
herbals, from a 1999 general health survey mailed to a random sample
of adult members of a large Northern California health plan to estimate
prevalence of and characteristics associated with supplement use among
women aged 65-84 (n = 3109).
results: Based on weighted data, 84% had in the past 12 months used
>1 dietary supplement, 82% a VM, 59% a supplement other than just
multivitamin or calcium, 32% an NVNM, and 25% an herbal. Compared to
white, nonHispanic women, African Americans and Latinas were significantly
less likely to use VM and NVNM supplements and Asian/Pacific Islanders
were less likely to use NVNM supplements. Higher education was strongly
associated with use of an NVNM supplement. Prevalence did not differ
by number of prescription medications taken. Among white, nonHispanic
women, multiple logistic regression models showed that college education,
good health, belief that health practices have at least a moderate effect
on health, and having arthritis or depression significantly increased
likelihood of NVNM use, while having diabetes decreased likelihood.
conclusions: An extremely high proportion of older women are using
dietary supplements other than multivitamins and calcium, many in combination
with multiple prescription medications. Increased resources should be
devoted to helping clinicians, pharmacists, supplement vendors, and
consumers become more aware of the safety, effectiveness, and potential
side effects of dietary supplements.
clinical
implication: Our finding that nearly 60% of older women in this
population were using dietary supplements other than multivitamins
and calcium underscores the importance of clinicians and pharmacists
routinely and nonjudgmentally querying patients about use of any dietary
supplements and other traditional remedies (ie, not just asking about
herbal supplement use) when assessing health problems. Supplements
may potentially interact with medicines and the supplement itself
may be the source of symptomatic complaints. Clinicians and pharmacists
can now easily obtain information on many commonly used supplements
from the Natural Medicines Database, Natural Standard, or Desktop
Guide to Alternative Medicine available on PKC. Patients can be referred
to the Drug Encyclopedia in the Get Health Advice section of the KP
member Web site. NG
From
Northern California:
Development
of overweight associated with childbearing depends on smoking habit:
The Coronary Artery Risk Development in Young Adults (CARDIA) Study.
Gunderson
EP, Quesenberry CP Jr, Lewis CE, et al. Obes Res 2004 Dec;12(12):2041-53.
objective:
To prospectively evaluate whether childbearing leads to development
of overweight in women and to evaluate the role of other known risk
factors.
research methods and procedures: A prospective, multicenter observational
study, the Coronary Artery Risk Development in Young Adults (CARDIA)
Study from 1986 to 1996, examined subjects at baseline and in follow-up
years two, five, seven, and ten. Included were 998 (328 black and 670
white) nulliparous women, age 18-30 years, who were not overweight at
baseline. Relative odds for incident overweight (BMI 25 kg/m2) associated
with parity change (0, 1, or 2+) and risk factors were estimated using
discrete-time survival models adjusted for baseline and time-dependent
covariates.
results: Parity change-association with development of overweight
depended on smoking habit (interaction, p < 0.001). In multivariate
adjusted models, 1 and 2+ births vs 0, respectively, were associated
with increased risk for development of overweight among never smokers
[odds ratio (OR) = 2.66; 95% confidence interval (CI): 1.80, 3.93, and
2.10, 95% CI: 1.24, 3.56] and decreased risk among current smokers (OR
= 0.41; 95% CI: 0.17, 0.96, and 0.36, 95% CI: 0.08, 1.65). Risk was
increased for black vs white race (OR = 3.49; 95% CI: 2.59, 4.69), frequent
weight cycling (OR = 1.45; 95% CI: 1.03, 2.04), and high school education
or less (OR = 2.21; 95% CI: 1.50, 3.26) and was decreased for highest
physical activity quartile (OR = 0.62; 95% CI: 0.43, 0.90).
discussion: Childbearing contributes to development of overweight
in nonsmokers but not in smokers, where development of overweight is
less likely in women who bear children. Race, education, and behaviors
are important factors in development of overweight in young women.
clinical
implication: Smoking during pregnancy is hazardous to maternal
and fetal health, including fetal growth retardation, preterm delivery,
placenta previa and abruptio, and higher perinatal mortality. For
women, the reproductive years are a critical time to implement public
health screening to evaluate excess postpartum weight retention, promote
smoking cessation, and to implement interventions to prevent overweight
and obesity in women. Excess weight gain after pregnancy not only
increases maternal risk for chronic disease in the future, but it
adversely affects maternal and fetal health during subsequent pregnancies.
EG
From
Hawaii:
Safety and efficacy of carotid arteriography in vascular surgery practice.
Schneider
PA, Silva MB Jr, Bohannon WT, et al. J Vasc Surg 2005 Feb;41(2):238-45.
objective:
Carotid arteriography (CA) is an important method of assessing carotid
artery occlusive disease and is the best method of planning for carotid
angioplasty and stent placement (CAS). This study compared the results
of CA performed by vascular surgeons in a contemporary series against
widely recognized interdisciplinary quality standards for this procedure.
Although many vascular surgeons perform CA, there is a paucity of data
about its safety, efficacy, and compliance with quality standards in
vascular practice. The importance of quality CA will likely increase
as CAS emerges to assume a broader clinical role.
method: Carotid arteriograms performed by seven vascular surgeons
at three institutions from September 2000 to May 2004 were reviewed.
These results were compared with quality standards for the performance
of CA.
results: Five hundred three carotid arteriograms were performed
over 45 months. Indications for the procedure were extracranial cerebrovascular
disease (86%), trauma (5%), and other conditions (9%). Indications for
the procedure were appropriate in 100% of patients (as determined by
guidelines document) and exceeded the recommended standard of appropriate
indications in 99%. All procedures successfully provided the information
required, exceeding the threshold of 98% for procedural success. Reversible
neurologic deficits occurred in 0.6% (two transient ischemic attacks
and one stroke) compared with the threshold of 2.5%. A permanent neurologic
deficit occurred in 0.2% (one patient) compared with the published guideline
of 1% after carotid arteriography. Major non-neurologic complications
occurred in 1.2% (six patients), less than the standard of 2.0%.
conclusions: The safety and efficacy of a contemporary series of
CA performed in vascular surgery practice compared favorably with recognized
interdisciplinary quality standards for this procedure. Ensuring safe
and effective CA is likely to support the successful growth of CAS as
a treatment option.
