Seeking connections-the beginning of a complex and important story.
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Chorionic Gonadotropin↗
Biomedical subjects
J B Brown
Publications and source records attributed to J B Brown.
Health care costs associated with escalation of drug treatment in type 2 diabetes mellitus.
The cost of different intensities of therapy in HMO patients with type 2 diabetes mellitus was studied. Health care utilization data from 1995 were obtained for 12,200 registrants from the Kaiser Permanente Northwest Diabetes Registry who had type 2 diabetes mellitus. The data were used to determine costs associated with the escalation of antidiabetic therapies in persons with type 2 diabetes mellitus. The total annual costs (in 1993 dollars) associated with no drug therapy, a sulfonylurea only, metformin, a sulfonylurea plus insulin, and insulin alone were $4400, $4187, $4838, $8856, and $7365, respectively. Per patient total costs were higher for patients who had received antidiabetic therapy in 1995 or previously than for those who had not ($5303 versus $4365) and for patients who had received insulin therapy than for those who had not ($7379 versus $4117). Macrovascular complications accounted for 62-89% of the cost associated with inpatient treatment of diabetes-related complications. The total cost of treating patients with type 2 diabetes mellitus at an HMO increased as antidiabetic therapies escalated.
Aged↗
Body mass index and future healthcare costs: a retrospective cohort study.
OBJECTIVE: To assess the relationship between body mass index (BMI) and future healthcare costs. RESEARCH METHODS AND PROCEDURES: We undertook a retrospective cohort study of the relationship between obesity and future healthcare costs at Kaiser Permanente Northwest Division, a large health maintenance organization in Portland, Oregon. Study subjects (n = 1286) consisted of persons who responded to a 1990 health survey that was mailed to a random sample of adult Kaiser Permanente Northwest Division members who were 35 to 64 years of age; had a BMI > or = 20 kg/m(2) (based on self-reported height and weight); did not smoke cigarettes; and did not have a history of coronary heart disease, stroke, human immunodeficiency virus, or cancer. Subjects were stratified according to their BMI in 1990 (20 to 24.9, 25 to 29.9, and > or = 30 kg/m(2); n = 545, 474, and 367, respectively). We then tallied their costs (in 1998 US dollars) for all inpatient care, outpatient services, and prescription drugs over a 9-year period (1990 through 1998). RESULTS: For persons with BMIs of 20 to 24.9 kg/m(2), mean (+/-SE) annual costs of prescription drugs, outpatient services, inpatient care, and all medical care averaged $261 (+/-18), $848 (+/-59), $532 (+/-85), and $1631 (+/-120), respectively, over the study period. Cost ratios (95% confidence intervals) for persons with BMIs of 25 to 29.9 kg/m(2) and > or = 30 kg/m(2), respectively, were 1.37 (1.12 to 1.66) and 2.05 (1.62 to 2.55) for prescription drugs, 0.96 (0.83 to 1.13) and 1.14 (0.97 to 1.37) for outpatient services, 1.20 (0.81 to 1.86) and 1.38 (0.91 to 2.14) for inpatient care, and 1.10 (0.91 to 1.35) and 1.36 (1.11 to 1.68) for all medical care. DISCUSSION: Future healthcare costs are higher for persons who are overweight, especially those with BMIs > or = 30 kg/m(2).
Adult↗
Patient-centered communication scoring method report on nine coded interviews.
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Canada↗
Congestive heart failure in type 2 diabetes: prevalence, incidence, and risk factors.
OBJECTIVE: To estimate the prevalence and incidence of congestive heart failure (CHF) in populations with and without type 2 diabetes and to identify risk factors for diabetes-associated CHF. RESEARCH DESIGN AND METHODS: We searched the inpatient and outpatient electronic medical records of 9,591 individuals diagnosed with type 2 diabetes before 1 January 1997 and those of an age- and sex-matched control group without diabetes for a diagnosis of CHF. Among those without a baseline diagnosis of CHF, we searched forward for 30 months for incident cases of CHF. We constructed multiple logistic regression models to identify risk factors for both prevalent and incident CHF. RESULTS: CHF was prevalent in 11.8% (n = 1,131) of diabetic subjects and 4.5% (n = 435) of control subjects at baseline. We observed incident cases of CHF in 7.7% of diabetic subjects free of CHF at baseline (650 of 8,460) and in 3.4% of control subjects (314 of 9,156). In diabetic subjects, age, diabetes duration, insulin use, ischemic heart disease, and elevated serum creatinine were independent risk factors for both prevalent and incident CHF. Better glycemic control at baseline, and improved glycemic and blood pressure control at follow-up predicted the development of CHF. CONCLUSIONS: Despite controlling for age, duration of diabetes, presence of ischemic heart disease, and presence of hypertension, insulin use was associated with both prevalent and incident CHF. Why insulin use and better glycemic control both at baseline and follow-up independently predicted CHF deserves further study.
Age Distribution↗
[Screening for violence against women. Validation and feasibility studies of a French screening tool].
OBJECTIVE: To replicate, in a Francophone community, our prior work determining the reliability and validity of the full Woman Abuse Screening Tool (WAST) and a two-item version (WAST-Short). DESIGN: Questionnaires completed by abused and nonabused women. SETTING: Two women's shelters in Francophone communities in Ontario and Quebec and participants' homes or workplaces. PARTICIPANTS: A convenience sample of 25 abused women currently residing in two women's shelters and a convenience sample of 21 women who reported they were not abused. MAIN OUTCOME MEASURES: Women's responses to French versions of the WAST, the Abuse Risk Inventory (ARI), and comfort in answering the questions were compared. Also, the reliability and validity of French versions of WAST and WAST-Short were assessed. RESULTS: Abused (n = 23) and not abused (n = 21) women were demographically similar. A strong single-factor structure that accounted for 81% of total variance in the French WAST items was identified. The French WAST was found to be highly reliable with a coefficient alpha of .95 and demonstrated construct and discriminant validity. The WAST-Short correctly classified all the nonabused women and 78.7% of the abused women. The abused women reported feeling less comfortable responding to the WAST questions than the nonabused women. CONCLUSION: The French version of the WAST demonstrated good reliability and validity and discriminated between known samples of abused and nonabused women. Even though the French WAST-Short did not perform as well as the English version, results of this study support further evaluation of the WAST for screening women in Francophone or bilingual family practice settings.
Adult↗
Making decisions about cancer screening when the guidelines are unclear or conflicting.
OBJECTIVE: Our purpose was to determine the factors involved in the cancer screening decisions of family physicians in situations where the clinical practice guidelines are unclear or conflicting as opposed to when they are clear and uncontroversial. STUDY DESIGN: We analyzed discussions with focus groups using a constant comparative approach. POPULATION: A total of 73 family physicians in active practice participated in 10 focus groups (1 urban group and 1 rural group in each of 5 Canadian provinces). OUTCOME MEASURES: Our main outcome measures were participants' perceptions regarding cancer screening when the guidelines were unclear or conflicting. RESULTS: We propose a model of the determinants of cancer screening decision making with regard to unclear and conflicting guidelines. This model is rooted in the physician-patient relationship, and is an interactive process influenced by patient factors (anxiety, expectations, and family history) and physician factors (perception of guidelines, clinical practice experience, influence of colleagues, distinction between the screening styles of specialists and family physicians, and the amount of time and financial costs involved in performing the maneuver). CONCLUSIONS: Our model is unique, because it is embedded in the physician-patient relationship. Ultimately, a modified model could be used to design interventions to assist with the implementation of preventive services guidelines.
Adult↗
Following depression in primary care: do family practice physicians ask about depression at different rates than internal medicine physicians?
OBJECTIVE: To determine whether the chronically or recurrently depressed patients of family practice and internal medicine physicians differed in the proportion reporting that their primary care physician asked them about depression symptoms. DESIGN: A cross-sectional observational study of chronically or recurrently depressed survey respondents who identified a family practice or internal medicine physician as their primary care provider. SETTING: A large not-for-profit group-model health maintenance organization in the northwestern United States, with a population representative of its service area. PATIENTS: Health maintenance organization members (n= 1161) with ongoing or recurring depression or dysthymia who responded to a 1993 survey and who identified either a family practice or internal medicine physician as their primary care provider. MAIN OUTCOME MEASURE: Patients' self-report of their primary care physician asking them: (1) whether they had been feeling sad, blue, or depressed; (2) to fill out a questionnaire about their mood or feelings; and (3) whether they had been thinking about death or suicide. RESULTS: Chronically or recurrently depressed patients of family practice physicians were more likely to report that their physician asked them about depressive symptoms than were patients of internal medicine physicians (34.0% vs 27.3%) (P=.02). This finding persisted in a multivariate analysis. CONCLUSION: Family practice physicians may be more attentive to depressive disorders than internal medicine physicians.
Cross-Sectional Studies↗
Computer models of diabetes: almost ready for prime time.
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Computer Simulation↗
The global diabetes model: user friendly version 3.0.
The attributes of Release 3.0 of the user friendly version (UFV) of the global diabetes model (GDM) are described and documented in detail. The GDM is a continuous, stochastic microsimulation model of type 2 diabetes. Suitable for predicting the medical futures of both individuals with diabetes and representative diabetic populations, the GDM predicts medical events (complications of diabetes), survival, utilities, and medical care costs. Incidence rate functions for microvascular and macrovascular complications are based on a combination of published studies and analyses of data describing diabetic members of Kaiser Permanente Northwest Region, a non-profit group-model health maintenance organization. Active risk factors include average blood glucose (HbAlc), systolic blood pressure (SBP), low density lipoprotein cholesterol (LDL), high density lipoprotein cholesterol (HDL), triglycerides, smoking status, and use of prophylactic aspirin. Events predicted include diabetic eye disease, diabetic nephropathy, peripheral neuropathy amputation, myocardial infarction, stroke, peripheral artery disease, congestive heart failure, coronary artery surgery, coronary angioplasty, and death.
Age Factors↗
The Mt. Hood challenge: cross-testing two diabetes simulation models.
Starting from identical patients with type 2 diabetes, we compared the 20-year predictions of two computer simulation models, a 1998 version of the IMIB model and version 2.17 of the Global Diabetes Model (GDM). Primary measures of outcome were 20-year cumulative rates of: survival, first (incident) acute myocardial infarction (AMI), first stroke, proliferative diabetic retinopathy (PDR), macro-albuminuria (gross proteinuria, or GPR), and amputation. Standardized test patients were newly diagnosed males aged 45 or 75, with high and low levels of glycated hemoglobin (HbA(1c)), systolic blood pressure (SBP), and serum lipids. Both models generated realistic results and appropriate responses to changes in risk factors. Compared with the GDM, the IMIB model predicted much higher rates of mortality and AMI, and fewer strokes. These differences can be explained by differences in model architecture (Markov vs. microsimulation), different evidence bases for cardiovascular prediction (Framingham Heart Study cohort vs. Kaiser Permanente patients), and isolated versus interdependent prediction of cardiovascular events. Compared with IMIB, GDM predicted much higher lifetime costs, because of lower mortality and the use of a different costing method. It is feasible to cross-validate and explicate dissimilar diabetes simulation models using standardized patients. The wide differences in the model results that we observed demonstrate the need for cross-validation. We propose to hold a second 'Mt Hood Challenge' in 2001 and invite all diabetes modelers to attend.
Albuminuria↗
Breast cancer patients' experiences of patient-doctor communication: a working relationship.
The traumas of diagnosis and treatment for breast cancer are well researched and generally addressed in care. While women with breast cancer continue to identify the need for better communication with physicians, studies to date have not investigated how the process of communication between physicians and women with breast cancer actually unfolds. This phenomenological study therefore explored how women with breast cancer experience patient-physician communication to gain a greater understanding of effective approaches. Interviews of a purposeful sample of 11 women within 6 months of initial diagnosis or recurrence of breast cancer were audiotaped, transcribed verbatim and analyzed using inductive interpretation. Themes and patterns of positive and negative experiences emerged. All experiences began with the woman's feeling of vulnerability. In positive experiences, information sharing and relationship building were inextricably linked components of a working relationship which was at the same time affective, behavioural and instrumental. This experience, in turn, influenced the woman's experience of control and mastery of the illness experience, and their experience of learning to live with breast cancer. Findings illuminate the importance of comprehensively patient-centred, working relationships. Several specific techniques to enhance effective communication are identified.
Adult↗
The influence of older patient-physician communication on health and health-related outcomes.
Effective patient-physician communication significantly influences health outcomes of older patients. For example, concordance between patient and physician expectations and patient participation in the decision-making process affects older patients. Communication is also linked to patient recall, adherence, and satisfaction. Furthermore, communication impacts emotional and physical outcomes of older patients, although evidence of improved physical outcomes remains under-investigated in this population. Dimensions of communication, such as continuity of relationship, seem to be important in decreasing hospitalization of older patients. This article explores the link between communication and health care outcomes in the older population.
Aged↗
Controlled trials of CQI and academic detailing to implement a clinical practice guideline for depression.
BACKGROUND: The release of the Agency for Health Care Policy and Research (AHCPR)'s Guideline for the Detection and Treatment of Depression in Primary Care created an opportunity to evaluate under naturalistic conditions the effectiveness of two clinical practice guideline implementation methods: continuous quality improvement (CQI) and academic detailing. A study conducted in 1993-1994 at Kaiser Permanente Northwest Division, a large, not-for-profit prepaid group practice (group-model) HMO, tested the hypotheses that each method would increase the number of members receiving depression treatment and would relieve depressive symptoms. METHODS: Two trials were conducted simultaneously among adult primary care physicians, physician assistants, and nurse practitioners, using the same guideline document, measurement methods, and one-year follow-up period. The academic detailing trial was randomized at the clinician level. CQI was assigned to one of the setting's two geographic areas. To account for intraclinician correlation, both trials were evaluated using generalized equations analysis. RESULTS: Most of the CQI team's recommendations were not implemented. Academic detailing increased treatment rates, but--in a cohort of patients with probable chronic depressive disorder--it failed to improve symptoms and reduced measures of overall functional status. CONCLUSIONS: New organizational structures may be necessary before CQI teams and academic detailing can substantially change complex processes such as the primary care of depression. New research and treatment guidelines are needed to improve the management of persons with chronic or recurring major depressive disorder.
Adult↗
Case-control study of 10 years of comprehensive diabetes care.
OBJECTIVE: To describe the long-term clinical impact of a comprehensive management program instituted throughout a health system for members with diabetes mellitus. DESIGN: 10 year case-control evaluation. SETTING: Kaiser Permanente Northwest, Portland, OR. PARTICIPANTS: Members of the health maintenance organization between 1987 and 1996; members with diabetes were compared with equal numbers of members without diabetes. The number of participants with diabetes ranged from 5331 in 1987 to 13,099 in 1996. MAIN OUTCOME MEASURES: Number in diabetes register, mortality, change in comorbidity, rates of uptake of preventive health measures, use of pharmaceuticals, levels of risk factors, hospital days per thousand per year, emergency room visits per thousand per year. RESULTS: The prevalence of diabetes identified in this population rose from 2.54% (7,895/310,819) in 1987 to 3.66% (14,741/402,754) in 1996, and the mean (SEM) age of members at the time of diagnosis fell slightly from 62.9 (+/- 0.21) years to 62.0 (+/- 0.13) years (P < 0.05). By 1996, 10,885 of the 13,099 (83% +/- 0.3%) of members with diabetes had an annual laboratory test to assess glycemic control, the annual screening rate for retinopathy was 67.6% (+/- 0.4%), the rate of uptake of influenza immunizations was 60.2% (7,886/13,099) and the screening rate for nephropathy was 43% (5,698/13,099) (+/- 0.49%). The use of home glucose testing increased from 32.4% (1721/5331) of members with diabetes to 53.0% (6,942/12,099); the use of lipid lowering drugs increased from 3.5% (187/55,331) to 19.8% (2,594/13,099). The use of angiotensin converting enzyme inhibitors increased from 8.5% to 34.8% of members with diabetes. Mean blood pressure decreased from 144/82 mm Hg (+/- 0.8/0.4) to 138/79 mm Hg (+/- 0.3/0.15), and mean total cholesterol concentrations dropped from 243 mg/dL (+/- 4.2) to 215 mg/dL (+/- 0.6). By 1996, 56.4% (7,388/1,3099) (+/- 0.5%) of members on the diabetes register had good to excellent glycemic control (HbA1c < 8%). Mortality decreased from 4.8% (256/5331) (+/- 0.3%) to 3.6% (472/13,099) (+/- 0.2%) among members with diabetes, this was a more rapid decrease than was observed among those without diabetes (P < 0.01). The annual ratio of visits to the emergency room by members with diabetes to members without fell from 2.5 to 1.8, and the ratio for the number of days spent in acute care in the hospital dropped from 3.6 to 2.5. CONCLUSIONS: This centrally organized program based in a primary care setting and utilizing a register of patients with diabetes was associated with substantial improvements in the process and outcomes of care in a large population of health maintenance organization members with diabetes.
Case-Control Studies↗
Achieving further glycemic control in type 2 diabetes mellitus.
OBJECTIVES: To identify patients with type 2 diabetes mellitus who were in poor glycemic control and therapeutic adjustments that might improve control. DESIGN: Using electronic pharmacy data, we assigned subjects to 1 of 4 therapeutic categories. We then identified patients within each category who did not meet the recommended standard of glycemic control (glycosylated hemoglobin [Hb A(1c)] <0. 08 [<8.0%]) and studied their therapetic regimens for possible improvements. SUBJECTS: The subjects were 5,061 members of a large group-model health maintenance organization who had type 2 diabetes and 12 months of 1997 health plan eligibility. Main outcome measures The dosage of antihyperglycemic agents (sulfonylureas, metformin, and insulin) in relation to glycemic control as measured by the Hb A(1c). RESULTS: A significant number (n = 1,570 [31.0%]) of persons with type 2 diabetes might improve their glycemic control with simple adjustments to their pharmacologic therapy. CONCLUSION: Busy clinicians with heavy workloads can improve their management of diabetes by identifying patients whose glycemic control could be improved through a change in medication or simple adjustment in dosage.
Aged↗
Adapting a national guideline for local use: a comparative case study in a US and an Israeli health maintenance organization.
OBJECTIVES: We compared the way a US and an Israeli health maintenance organization (HMO) used the Fifth Report of the Joint National Committee on Detection, Evaluation, and Treatment of High Blood Pressure (the JNC-V) in developing a hypertension guideline. METHODS: Comparative case study. We describe and contrast the two HMOs, the social contexts in which they function, their motivations for creating a local guideline and their guideline development processes. We then compare the two HMO guidelines with each other and with the JNC-V. Based on this analysis, we offer provisional answers to some key concerns raised by local adaptations of national or international guidelines. These include whether adaptations will reflect local cost-containment concerns in ways that could threaten quality of care, whether guidelines constitute a threat to physician autonomy and the relationship between local adaptations and the evolution of national or international guidelines. RESULTS: The HMO guidelines differed substantially, and in similar ways, from the JNC-V in format, coverage and emphasis of topics. They differed from it minimally, but also in similar ways, in the content of their recommendations. Each HMO guideline 'improvised' on the JNC-V in ways that differed to reflect local needs and objectives but did not significantly distort the original. Quality of care considerations appeared to predominate over cost considerations, and we found no evidence that guidelines threatened physician autonomy. CONCLUSIONS: Local adaptations may function as part of the iterative process through which national or international guidelines evolve in ways more suitable for potential local use.
Evidence-Based Medicine↗
Use of complementary/alternative medicine by breast cancer survivors in Ontario: prevalence and perceptions.
PURPOSE: To determine the prevalence of use of complementary/alternative medicine (CAM) by breast cancer survivors in Ontario, Canada, and to compare the characteristics of CAM users and CAM nonusers. PATIENTS AND METHODS: A questionnaire was mailed to a random sample of Ontario women diagnosed with breast cancer in 1994 or 1995. RESULTS: The response rate was 76.3%. Overall, 66.7% of the respondents reported using CAM, most often in an attempt to boost the immune system. CAM practitioners (most commonly chiropractors, herbalists, acupuncturists, traditional Chinese medicine practitioners, and/or naturopathic practitioners) were visited by 39.4% of the respondents. In addition, 62.0% reported use of CAM products (most frequently vitamins/minerals, herbal medicines, green tea, special foods, and essiac). Almost one half of the respondents informed their physicians of their use of CAM. Multiple logistic regression analysis determined that support group attendance was the only factor significantly associated with CAM use. CONCLUSION: CAM use is common among Canadian breast cancer survivors, many of whom are discussing CAM therapy options with their physicians. Knowledge of CAM therapies is necessary for physicians and other health care practitioners to help patients make informed choices. CAM use may play a role in the positive benefits associated with support group attendance.
Attitude↗