Biomedical subjects

Amy M Kilbourne

Publications and source records attributed to Amy M Kilbourne.

32 records · Page 2Linked to original sources

PubMed2004

Racial differences in the impact of irritable bowel syndrome on health-related quality of life.

GOALS: To compare the impact of irritable bowel syndrome (IBS) on health related quality of life (HRQOI) for non-white and white IBS patients. BACKGROUND: There are no reported data evaluating the HRQOL of non-white persons with IBS. STUDY: SF-36 scores are compared between non-white IBS patients (n = 166), white IBS patients (n = 707), the general US population, and patients with selected chronic diseases. RESULTS: Of the n = 166 non-white IBS patients included for analysis, 66 (40%) described themselves as African-American, 56 (34%) as Hispanic, 25 (15%) as Asian-American, 2 (1%) as Native American and the remaining 17 (10%) as "other." Compared with white IBS patients, non-white IBS patients reported similar decrements in their HRQOL after controlling for age, gender, income and education level. On all 8 SF-36 scales, non-white IBS patients had significantly worse HRQOL compared with the general US population, (P < 0.001). Compared with GERD patients, non-white IBS patients scored significantly lower on all SF-36 scales (P < 0.001) except physical functioning. Similarly, non-white IBS patients had significantly worse HRQOL on selected SF-36 scales compared with diabetes mellitus and ESRD patients. Non-white IBS patients had significantly better emotional well-being than depressed patients, (P < 0.001). CONCLUSIONS: Non-white IBS patients experience impairment in vitality, role limitations-physical, and bodily pain. Yet overall, non-white IBS patients report similar HRQOL to white IBS patients. These data provide the first detailed evaluation of the impact of IBS on HRQOL in non-white IBS patients.

Adult↗

PubMed2004

Translating evidence-based depression management services to community-based primary care practices.

Randomized controlled trials have demonstrated the efficacy and cost-effectiveness of using treatment models for major depression in primary care settings. Nonetheless, translating these models into enduring changes in routine primary care has proved difficult. Various health system and organizational barriers prevent the integration of these models into primary care settings. This article discusses barriers to introducing and sustaining evidence-based depression management services in community-based primary care practices and suggests organizational and financial solutions based on the Robert Wood Johnson Foundation Depression in Primary Care Program. It focuses on strategies to improve depression care in medical settings based on adaptations of the chronic care model and discusses the challenges of implementing evidence-based depression care given the structural, financial, and cultural separation between mental health and general medical care.

Community Health Services↗

PubMed2004

Burden of general medical conditions among individuals with bipolar disorder.

OBJECTIVE: Treatment of coexisting medical comorbidities may reduce the risk of adverse outcomes among patients with bipolar disorder. We determined the prevalence of general medical conditions in a population-based sample of patients diagnosed with bipolar disorder in the Veterans Administration (VA). METHODS: We conducted a cross-sectional study of patients (n = 4310) diagnosed with bipolar disorder in fiscal year 2001 receiving care at VA facilities located within the mid-Atlantic region. General medical conditions were assessed using ICD-9 codes, and we compared the prevalence of each condition in our bipolar sample with national data on the VA patient population. RESULTS: The mean age was 53 (SD = 13), 10% were women, and 12% African-American. The mean age of the VA national patient population was higher (58 years). The most prevalent conditions among patients with bipolar disorder included cardiovascular (e.g. hypertension, 35%), endocrine (e.g. hyperlipidemia, 23%; diabetes, 17%), and alcohol use disorder (25%). When compared with national data, the prevalence of diabetes was higher in the bipolar cohort than in the national cohort (17.2% versus 15.6%; p = 0.0035). Hepatitis C was more common in the bipolar group than the national cohort (5.9% versus 1.1%; p < 0.001). Lower back pain (15.4% versus 10.6%; p < 0.0001) and pulmonary conditions (e.g. COPD: 10.6% versus 9.4%; p = 0.005) were also more prevalent among the bipolar cohort than the VA national cohort. CONCLUSIONS: Individuals with bipolar disorder possess a substantial burden of general medical comorbidity, and are occurring at an earlier age than in the general VA patient population, suggesting the need for earlier detection and treatment for patients with bipolar disorder.

Aged↗

PubMed2004

Are physician-derived disease severity indices associated with health-related quality of life in patients with end-stage liver disease?

OBJECTIVES: Model for end-stage liver disease (MELD) score is now often used as an overall indicator of health status for patients with end-stage liver disease. However, there are no data evaluating the associations between MELD scores and patient reports of health-related quality of life (HRQOL). METHODS: Two hundred-three patients with end-stage liver disease completed a disease-targeted HRQOL instrument (the LDQOL 1.0). Patients also rated the severity of their liver disease and reported number of disability days attributed to their liver disease in the preceding month. MELD and Child Turcott Pugh (CTP) scores were calculated for all patients. Associations of MELD and CTP scores with patient-derived outcomes were estimated. RESULTS: The mean MELD and CTP scores were 12 and 7, respectively, indicating mild severity of liver disease. HRQOL of patients was generally poor, with the mean SF-36 physical and mental component summary scores of 35 and 40. Seventy percent of patients rated their liver disease symptoms as moderate to severe. Similarly, 70% reported being disabled from their liver disease. MELD was associated with physical functioning scale and the physical component summary (PCS) score in patients with end-stage liver disease. In contrast, CTP score was significantly associated with physical functioning, role limitations due to physical health problems, PCS score, effects of liver disease, sexual functioning, and sexual problems. Both MELD and CTP scores correlated with self-rated severity of liver disease symptoms but not with self-reported disability days. CONCLUSIONS: Despite objectively mild liver disease, the subjective HRQOL of this cohort was severely impaired. CTP score was more closely associated with patient-reported estimates of HRQOL than the MELD score. CTP or disease-specific HRQOL instruments may compliment MELD by providing insights into outcomes of importance to patients with low risk of mortality.

Adult↗

PubMed2004

Concurrent psychiatric diagnoses by age and race among persons with bipolar disorder.

The authors characterized concurrent psychiatric diagnoses among patients with a diagnosis of bipolar disorder who were in routine care by using administrative data from a Department of Veterans Affairs facility. Of 813 patients who had a diagnosis of bipolar disorder in 2000, 21 percent were older (>/=60 years) whites, and 2 percent were older African Americans. Older African Americans were the most likely to have a diagnosis of schizophrenia documented in the medical record compared with younger African Americans, older whites, and younger whites (67 percent, 34 percent, 38 percent, and 27 percent, respectively). The results suggest that older African-American patients with bipolar disorder are more likely to receive diagnoses of mutually exclusive conditions, such as schizophrenia, and thus appear to have an elevated risk of their illness being underrecognized or misdiagnosed and receiving inappropriate treatment.

Aged↗

PubMed2003

Differences in symptom expression in older HIV-positive patients: The Veterans Aging Cohort 3 Site Study and HIV Cost and Service Utilization Study experience.

Symptom recognition is critical for patient care but has been little studied in older HIV-infected individuals. The authors examined differences in symptom expression between younger (younger than age 50 years) and older (older than age 50 years) HIV-infected individuals. The authors analyzed data from two cross-sectional studies of HIV-infected individuals: 2864 individuals from the HIV Cost and Service Utilization Study (HCSUS) and 881 individuals from the Veterans Aging Cohort 3 Site Study (VACS 3). The authors compared the prevalence of eight symptoms common to both studies and 10 symptoms examined only in the VACS 3 population, stratified by age and race. Disease severity was assessed by CD4 count and 18 HIV-related diseases reported. Multivariate logistic regression models were used to account for demographics and severity differences. VACS 3 versus HCSUS participants were more likely nonwhite and older. In unadjusted comparisons, older nonwhites were less likely to report experiencing symptoms than younger whites. They reported the fewest total number of symptoms and the fewest individual symptoms common to both studies (headache, fever, nausea/vomiting, and diarrhea) or in the VACS 3 only (dizziness, sleeping difficulty, fatigue, rashes, bloating, and myalgias/arthalgias). Multivariate regression estimates suggest older age predicts a greater likelihood of reporting peripheral neuropathy, weight loss, or hair loss, but a lower likelihood of reporting headaches, depressed mood, white oral patches, or diarrhea. Nonwhites appeared less likely to report symptoms. Age is a determinant of reporting certain symptoms in HIV disease but may be masked or accentuated by other factors such as race.

Adult↗

PubMed2003

Underdiagnosis of depression in HIV: who are we missing?

OBJECTIVE: To determine the sociodemographic and service delivery correlates of depression underdiagnosis in HIV. DESIGN: Cross-sectional survey. PATIENTS/PARTICIPANTS: National probability sample of HIV-infected persons in care in the contiguous United States who have available medical record data. MEASUREMENTS AND MAIN RESULTS: We interviewed patients using the Composite International Diagnostic Interview (CIDI) survey from the Mental Health Supplement. Patients also provided information regarding demographics, socioeconomic status, and HIV disease severity. We extracted patient medical record data between July 1995 and December 1997, and we defined depression underdiagnosis as a diagnosis of major depressive disorder based on the CIDI and no recorded depression diagnosis by their principal health care provider in their medical records between July 1995 and December 1997. Of the 1140 HIV Cost and Services Utilization Study patients with medical record data who completed the CIDI, 448 (37%) had CIDI-defined major depression, and of these, 203 (45%) did not have a diagnosis of depression documented in their medical record. Multiple logistic regression analysis revealed that patients who had less than a high school education (P <.05) were less likely to have their depression documented in the medical record compared to those with at least a college education. Patients with Medicare insurance coverage compared to those with private health insurance (P <.01) and those with >or=3 outpatient visits (P <.05) compared to <3 visits were less likely to have their depression diagnosis missed by providers. CONCLUSIONS: Our results suggest that providers should be more attentive to diagnosing comorbid depression in HIV-infected patients.

Adolescent↗

PubMed2002

Clinical importance of HIV and depressive symptoms among veterans with HIV infection.

OBJECTIVE: To compare the clinical importance (association with illness severity and survival) of depressive and HIV symptoms among veterans with HIV infection. DESIGN: Cross-sectional study; survival analysis. SETTING: Infectious Disease Clinics at 3 VA Medical Centers. PARTICIPANTS: HIV-infected patients (N = 881) and their health care providers from June 1999 through July 2000. MEASUREMENTS AND MAIN RESULTS: Depressive symptoms were assessed using the 10-item Centers for Epidemiologic Studies Depression Scale (CES-D). Patient baseline survey included an HIV Symptom Index measuring the frequency and bother of 20 common symptoms. Providers were surveyed on patients' illness severity, and survival data were obtained from VA death records. Of 881 patients, 46% had significant depressive symptoms (CES-D >/=10). Increasing depression symptom severity was associated with increasing HIV symptom frequency (P <.001) and bother (P <.001). Multiple regression results revealed that having moderate or severe depressive symptoms was not associated with provider-reported illness severity or survival. However, HIV symptoms were significantly associated with provider-reported illness severity (P <.01) and survival (P =.05), after adjusting for moderate and severe depressive symptoms, CD4 cell count/mm3, viral load, age, race, and antiretroviral use. CONCLUSIONS: Depression, while common in this sample, was not associated with illness severity or mortality after adjusting for HIV symptoms. HIV symptoms are associated with severity of illness and survival regardless of patients' severity of depressive symptoms. This suggests that equal medical consideration should be given to HIV symptoms presented by HIV-infected patients regardless of their depression status, rather than automatically attributing medical complaints to depression.

Adult↗

PubMed2002

Hospital care for low-risk patients with acute, nonvariceal upper GI hemorrhage: a comparison of neighboring community and tertiary care centers.

OBJECTIVES: The proportion of patients admitted to the hospital with acute upper GI hemorrhage (UGIH) who are at low risk for adverse outcomes may be substantial. The process of care for this low risk population likely varies across practice settings but has not been extensively studied. Use of the Rockall Risk score, a simple validated scoring index that predicts outcomes in UGIH, may help to identify these low risk patients. METHODS: We evaluated and compared the incidence of low risk UGIH admissions, adverse outcomes, and level of healthcare resource use in a community hospital (SMH) and a neighboring tertiary care university hospital (CHS). Cases of UGIH were identified from administrative databases during 1997 and 1998. Medical record data were abstracted in a standardized manner. Cases were defined as low risk on the basis of Rockall risk scores of < or = 2. RESULTS: The low risk study groups consisted of 49 of 187 (26%) SMH cases and 53/175 (30%) CHS cases (p = 0.40). Rebleeding was uncommon (6% at SMH; 4% at CHS) (p = 0.64). No deaths occurred; 71% at SMH versus 49% at CHS were admitted to a monitored bed (p = 0.04); and 92% at SMH versus 57% at CHS were prescribed i.v. H2 blockers for the acute bleeding event (p < 0.001). Low risk patients had a mean hospital length of stay of 3.3 + 2.4 days at SMH versus 2.6 + 2.1 days at CHS (p = 0.15). CONCLUSIONS: In this study, the proportion of acute, low risk, nonvariceal, upper GI hemorrhage admissions to neighboring community and tertiary care medical centers was high, whereas adverse clinical outcomes in this group of patients was low. Use of healthcare resources seemed to be greater in the community hospital. This observed variation in the process of care for populations with similar disease severity and outcomes suggests an opportunity for evidence-based interventions aimed at improving the efficiency of care.

Acute Disease↗

PubMed2002

Response to symptoms among a U.S. national probability sample of adults infected with human immunodeficiency virus.

Previous studies concerning disparities in Human Immunodeficiency Virus (HIV) services use among vulnerable groups did not control for specific clinical need for care such as symptom events. Using the Andersen Behavioral Model of Health Services Use, the authors determined whether minorities, women, and the less educated (vulnerable groups) were less likely to receive care for HIV symptoms. Persons enrolled in the HIV Cost and Services Utilization Study were asked whether they received care for their most bothersome symptom. Surprisingly, minorities and women were no more likely to go without care than other groups. Those with Medicaid, Medicare, private health maintenance organization (HMO) insurance, or no insurance were less likely to receive care for symptoms than those with private-non-HMO insurance. Vulnerable groups were no less likely to use services for HIV-related symptoms when need for care was considered. However, disparities may exist for symptom-specific care among HIV infected persons covered by public or HMO insurance.

Adolescent↗

PubMed2002

Psychiatric symptoms, health services, and HIV risk factors among homeless women.

The authors determined whether psychiatric symptoms and lack of health and/or social services contacts were associated with HIV risk behaviors among a probability sample of homeless women. Women were interviewed regarding socioeconomic indicators, psychiatric symptoms, health and/or social services contacts, and past-year HIV risk behaviors. Overall, 8 percent of the women injected drugs, 64 percent engaged in unprotected sex, and 22 percent traded sex. Multiple logistic regression results revealed that substance abuse was positively associated with injection drug use and trading sex. Homeless women with case managers were less likely to inject drugs. Although barriers to obtaining drug treatment were associated with trading sex, women attending self-help meetings for substance abuse were also more likely to trade sex. Homeless women who are substance abusers are vulnerable to HIV risk behaviors. Risk reduction interventions for homeless women should be implemented through substance abuse and intensive case management programs.

Adolescent↗

PubMedDate not supplied

Prevalence and predictors of HIV testing among a probability sample of homeless women in Los Angeles County.

OBJECTIVES: To describe the prevalence and predictors of HIV testing in a probability cluster sample of urban homeless women. METHODS: Analysis of data from the University of California Los Angeles-RAND Access to Health Care for Homeless Women of Reproductive Age Study, a survey conducted in six waves from January 1997 through November 1997 at shelters and soup kitchens in Los Angeles (LA) County, California. The sampling unit consists of homeless woman-visits, and data were collected using structured face-to-face interviews for which respondents were paid US dollars 10. Each sampling unit was weighted to take into account the frequency with which the respondent used shelters or meal programs. The main outcome measure was receipt of HIV test in the past year. RESULTS: The response rate was 83%, and the final sample size was N=970. Sixty-eight percent of our sample reported receiving an HIV test in the past year, and 1.6% reported ever being diagnosed with HIV. HIV testing in the past year was most strongly associated with pregnancy in the past year (OR 2.99; p<.001) and having a regular source of care (OR 2.13; p<.001). Approximately 25% of homeless women with indications for HIV testing had not been tested in the past year. CONCLUSIONS: The reported HIV seroprevalence of greater than 1% suggests that providers should offer and encourage HIV testing for all homeless women in LA County. Our data, which show a high rate of testing and few statistically significant independent predictors, indicate that this may be what is happening in practice.

AIDS Serodiagnosis↗

PubMedDate not supplied

Diabetes preventive care and non-traumatic lower extremity amputation rates.

Clinical performance monitoring data on processes of care from a 3-year period were used to assess whether preventive foot care was associated with improved health outcomes in diabetes mellitus patients. Preventive foot care as well as sensory and pedal-pulse examinations were associated with reduced rates of Lower extremity amputation. It is believed that an administrative focus, resource direction, and improvement in process monitoring will lead to better patient outcomes. External review measures can be used by administrators and cLinicians to determine trends in quality of care and patient outcomes andto provide feedback on prevention efforts.

Amputation, Surgical↗

PubMedDate not supplied

From silos to bridges: meeting the general health care needs of adults with severe mental illnesses.

Despite their higher burden of chronic general medical disorders, adults with severe mental illnesses have poorer access to and quality of general health care compared to people without mental illnesses. Because a key contributor to this situation is the separation between the mental health care sector (patients' health care home) and the general health care sector, bridges to connect these systems are needed. We discuss obstacles to clinical integration and propose strategies to address them.

Adult↗