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Biomedical subjects

James M Gill

Publications and source records attributed to James M Gill.

At least 37 records · Page 2Linked to original sources
PubMed2003

Diagnosis of systemic lupus erythematosus.

Systemic lupus erythematosus is a multisystem inflammatory disease that is often difficult to diagnose. Before the diagnosis can be established, four of 11 clinical and laboratory criteria must be met. Antinuclear antibody titer is the primary laboratory test used to diagnose systemic lupus erythematosus. Because of the low prevalence of the disease in primary care populations, the antinuclear antibody titer has a low predictive value in patients without typical clinical symptoms. Therefore, as specified by the American College of Rheumatology, this titer should be obtained only in patients with unexplained involvement of two or more organ systems. Patients with an antinuclear antibody titer of 1:40 and characteristic multiorgan system involvement can be diagnosed with systemic lupus erythematosus without additional testing; however, patients with an antibody titer of 1:40 who fail to meet full clinical criteria should undergo additional testing, including tests for antibody to double-stranded DNA antigen and antibody to Sm nuclear antigen. While an antinuclear antibody titer of less than 1:40 usually rules out systemic lupus erythematosus, patients with persistent, characteristic multisystem involvement may be evaluated for possible antinuclear antibody-negative disease.

Algorithms↗
PubMed2003

Continuity of care and recognition of diabetes, hypertension, and hypercholesterolemia.

BACKGROUND: Continuity of care has been shown to have a variety of health benefits, but the effect of continuity of care on recognition of common chronic diseases has been underinvestigated. OBJECTIVE: To examine the relationship between continuity of care and the recognition of 3 prevalent chronic diseases: diabetes, hypertension, and hypercholesterolemia. METHODS: We analyzed data from the third National Health and Nutrition Examination Survey, a nationally representative sample of 18 162 adult noninstitutionalized residents of the United States collected from 1988 through 1994. We examined the proportion of unrecognized disease among all individuals with diabetes, hypertension, and hypercholesterolemia according to self-reported level of continuity of care. We used logistic regression to control for possible confounders, including number of disease risk factors. RESULTS: Among persons with diabetes, in adjusted models, those with a usual provider of care had a lower likelihood of having unrecognized disease (odds ratio, 0.30; 95% confidence interval, 0.10-0.95) than those with no usual site or provider of care. Unrecognized hypertension had an unadjusted relationship with level of continuity of care, but continuity of care was not a significant predictor after possible confounders were adjusted for. Unrecognized hypercholesterolemia was not predicted by level of continuity of care. CONCLUSIONS: Continuity of care has some benefits in terms of recognizing chronic disease, although benefits appear to be disease specific. More research needs to be conducted to elucidate the complex relationship between continuity and disease recognition.

Adolescent↗
PubMed2003

Prevention and treatment of osteoporosis in primary care offices.

OBJECTIVES: To examine the use of medications for prevention and treatment of osteoporosis and testing for osteoporosis for postmenopausal women in primary care offices. METHOD: This cross-sectional survey study uses electronic medical records data over a 1-year period (January-December 2000) of women >/=55 years of age, either with (n = 31) or without (n = 782) a diagnosis of osteoporosis, who were active patients of two family practice and three gynecology offices in Delaware (n = 813). It presents documented use of medications for prevention or treatment of osteoporosis (estrogens, bisphosphonates, raloxifene, calcitonin, or calcium) and receipt of bone mineral density (BMD) testing. RESULTS: Of women without osteoporosis, 27.4% were taking prescription osteoporosis-related medications, and 32.9% were taking prescription medications or calcium supplements or both. Women were less likely to be taking these medications if they were >70 years of age (adjusted odds ratio [OR] = 0.42, p < 0.01) or were patients of gynecologists (adjusted OR = 0.48, p < 0.01). They were not more likely to take medications if they had risk factors for osteoporosis. Of women with osteoporosis, 58.1% were taking prescription osteoporosis-related medications, and 61.3% were taking prescription medications or calcium or both. BMD testing was done for 34% of all women and was not more likely for those with risk factors. CONCLUSIONS: In family medicine and gynecology offices, most postmenopausal women do not take preventive medications or get testing for osteoporosis. Even among those with known osteoporosis, many do not take medications for treatment of their osteoporosis.

Absorptiometry, Photon↗
PubMed2003

Does having an outpatient visit after hospital discharge reduce the likelihood of readmission?

OBJECTIVE: To determine whether or not having an outpatient visit after hospital discharge is associated with a lower likelihood of readmission for a statewide Medicaid population. DESIGN AND SETTING: A case-control study in the Delaware Medicaid program over a two-year period (7/1/93-6/30/95). PARTICIPANTS: 3,846 continuously enrolled patients aged 0-64 years who were hospitalized and were readmitted within 90 days (cases = 641) or not readmitted within 90 days (controls = 3,205). Subgroups included those readmitted for the same diagnosis (N = 720), for ambulatory care sensitive conditions (N = 906), or both (N = 276). MAIN OUTCOME MEASURE: Likelihood of readmission within 90 days of discharge. RESULTS: Readmission was significantly more likely when an outpatient visit was made after hospital discharge, both before and after controlling for demographic variables and case mix (adjusted odds ratio = 1.47, 95% confidence interval = 1.20-1.80). When readmission for the same diagnosis was examined, having an outpatient visit was associated with an increased likelihood of readmission before but not after controlling for demographics and case mix (adjusted odds ratio = 1.11, 95% confidence interval = 0.67-1.86). The same was for those admitted for ambulatory care sensitive conditions (adjusted odds ratio = 1.16, 95% confidence interval = 0.74-1.85) and for those readmitted for the same ambulatory care sensitive condition (adjusted odds ratio = 1.53, 95% confidence interval = 0.54-4.29). CONCLUSIONS: This study fails to demonstrate that outpatient visits after hospital discharge are associated with fewer readmissions for nonelderly Medicaid patients. This suggests that it may not be appropriate to use hospital readmission rates as an indicator of the quality of outpatient care.

Adolescent↗
PubMed2003

Treatment of hypercholesterolemia in patients with diabetes at a family practice office.

BACKGROUND: Patients with diabetes have an increased risk of developing coronary heart disease (CHD) and therefore need optimal management of hypercholesterolemia. Previous studies have shown that management of these patients remains suboptimal. OBJECTIVE: Our study aimed to determine the extent to which patients with diabetes in a family practice setting in Delaware are being managed according to national guidelines for the management of hypercholesterolemia. METHODS: Using a retrospective medical chart review, we identified all active patients with diabetes in a family practice office. We determined the percentage of patients who had a low-density lipoprotein (LDL) documented in their chart and the percentage of patients who received LDL screening within the past year. We then stratified the sample into three different categories of LDL level (< 100 mg/dl, 100-129 mg/dl, and > or = 130 mg/dl) and determined the percentage of patients who were on lipid-lowering therapy within each stratum. RESULTS: According to the medical record review, 80.30% of the active patients with diabetes had an LDL recorded in their chart. Of the patients with diabetes, 57.99% had an LDL measurement taken within the past year. Of this group, 41.03% had an LDL < 100 mg/dl, 31.41% had an LDL between 100 and 129 mg/dl, and 25.00% had an LDL > or = 130 mg/dl. Of the total number of patients with an LDL < 100 mg/dl, 53.93% were on lipid-lowering agents, while 38.18% of the patients with an LDL > or = 130 mg/dl were on lipid-lowering agents. Of the patients with an LDL measurement taken in the past year, 67.19% of those with an LDL < 100 mg/dl were on lipid-lowering medications, while 43.59% of patients with an LDL > or = 130 mg/dl were on lipid-lowering medications. CONCLUSIONS: In a Delaware family practice office, the screening rate for hyperlipidemia in patients with diabetes is similar to that found in other studies, but still leaves room for improvement. Lipid control rates are somewhat better than the rates reported in previous studies, but they are still not optimal. While many of the patients requiring lipid-lowering therapy are on these medications, a substantial minority has an LDL of < 100 mg/dl without being on medications. Although these findings may reflect patient preference to defer medications, it suggests that there is room for improvement with medical therapy.

Adult↗
PubMed2002

Benefits of a mobile, point-of-care anticoagulation therapy management program.

BACKGROUND: Current guidelines recommend anticoagulation therapy for a number of medical conditions, but this therapy also has the potential for serious complications, particularly bleeding complications. Maintenance of anticoagulation within a narrow therapeutic window usually entails frequent monitoring with a blood test called the international normalized ratio (INR). Anticoagulation therapy management (ATM) clinics lead to improvements in quality of care, in terms of improved INR control and reduced complications. This study examined the impact of a mobile multisite, office-based ATM program that operated in seven cardiology offices in all three counties in Delaware. ATM PROGRAM: The ATM program was managed by a trained nurse who rotated among all seven offices. Patients made office visits to the nurse and received patient education, point-of-care INR testing, and medication adjustment based on a physician-approved algorithm. METHODS: This retrospective cohort study compared INR levels in the year before (May 1998-Apr 1999) and the year after (Aug 1999-Jul 2000) the start of the ATM program. RESULTS: From the year before to the year after implementation of the ATM program, the percentage of in-range INRs increased from 40.7% to 58.5% (p < 0.001). The percentage in the modified target range also increased (50.0% to 62.9%, p < 0.001). DISCUSSION: This study demonstrates the positive impact of a statewide office-based ATM program. If similar programs could be implemented in other networks of specialty offices or primary care offices, they could have a significant benefit to quality of care for patients who require anticoagulation therapy.

Adolescent↗
PubMed2002

Does continuity between prenatal and well-child care improve childhood immunizations?

BACKGROUND AND OBJECTIVES: Continuity of care has been associated with positive health benefits, but the benefit of continuity for the maternal-child unit has not been studied. This study determined whether continuity from prenatal to pediatric care is associated with higher immunization rates for low-income children in Delaware. METHODS: This retrospective cohort study included 187 women who received prenatal care in one of four clinics (predominantly family practice) over a 2-year period. Each maternal-child pair was defined as having provider continuity (same provider for prenatal and pediatric care), clinic continuity (same clinic but different provider), or no continuity (different clinic). We measured the association between continuity and completion of immunizations by 7 months of age and by 12 months of age. RESULTS: Provider continuity was significantly associated with a higher immunization rate both at 7 and 12 months of age. After controlling for age, gender, ethnicity, insurance, birth order, and language, this association persisted at 7 months but lost statistical significance at 12 months. Those with clinic continuity were not significantly different than those with no continuity for any outcomes. CONCLUSIONS: For low-income persons in Delaware, provider continuity for the maternal-child unit is associated with higher completion rates for early childhood immunizations.

Adult↗
PubMed2002

Guideline for diagnosis of primary hemochromatosis.

We hope that this guideline will increase awareness among clinicians that PH is much more common than previously suspected and will provide a standardized diagnostic approach to persons with symptoms and signs suggestive of PH.

Algorithms↗
PubMedDate not supplied

Should we screen for hemochromatosis? An examination of evidence of downstream effects on morbidity and mortality.

BACKGROUND: Population-based hemochromatosis screening has been suggested with the rationale that identification and treatment of subclinical disease would decrease morbidity and mortality due to hemochromatosis. OBJECTIVE: To examine the prevalence of elevated serum transferrin saturation levels and the burden of illness of hemochromatosis in terms of ambulatory visits, hospitalizations, and death in the United States. PARTICIPANTS AND METHODS: Four nationally representative data sets were used for the analysis of the prevalence of hemochromatosis as well as ambulatory care, hospitalizations, and deaths related to hemochromatosis. Participants included men and nonpregnant women aged 18 years and older in the Third National Health and Nutrition Examination Survey (1988-1994) and the 1996, 1997, and 1998 National Ambulatory Care Survey, National Hospital Discharge Survey, and Underlying Cause-of-Death Mortality Files. The data sets were based on single measurements of serum transferrin saturation levels, serum ferritin levels, and healthcare provider-recorded diagnoses according to the International Classification of Diseases, Ninth Revision, Clinical Modification, code for hemochromatosis. RESULTS: The prevalence of elevated serum transferrin saturation levels ranged from 1% to 6%. When an elevated serum transferrin saturation level of 55% is combined with an elevated serum ferritin level, the prevalence decreases from 1.9% to 0.65%. The proportion of diagnosed hemochromatosis utilization out of total ambulatory visits, hospitalizations, and deaths is stable across the measures and the 3 years of data ranging from 0.01% to 0.03%. When white men were examined separately, the relationships remained the same as those among the general population of adults. CONCLUSIONS: Although a substantial proportion of adults whose condition is not currently diagnosed would be identified in a population-based screening program for subclinical hemochromatosis, diagnosed morbidity or mortality owing to hemochromatosis is considerably lower than would be expected. Recommendations for screening programs may need to be revisited.

Adolescent↗
PubMedDate not supplied

Quality of outpatient care for diabetes mellitus in a national electronic health record network.

This retrospective cohort study examined quality of care for diabetes in a large national network of electronic health record users. Of 10572 patients with diabetes included in the study, 55% had at least 2 hemoglobin A1c (HbA1c) tests, 95% had at least 1 systolic and diastolic blood pressure test, and 52% had at least 1 low-density lipoprotein (LDL) cholesterol test over a 1-year period. Of those tested, 41% had an HbA1c<7.0, 28% had a blood pressure<130/80 mm Hg, and 44% had an LDL cholesterol level<100 mg/dL. Of those not adequately controlled, 99% were prescribed hypoglycemic medications, 85% were prescribed antihypertensive medications, and 71% were prescribed lipid-lowering medications. These results suggest that there is significant room for improvement in testing and control of risk factors for persons with diabetes and that the electronic health record has a significant potential for conducting practice-based quality-of-care studies across large numbers of outpatient practices.

Ambulatory Care↗
PubMedDate not supplied

Impact of provider continuity on quality of care for persons with diabetes mellitus.

BACKGROUND: Many patients with diabetes fail to receive recommended monitoring tests. One reason might be inadequate continuity of care. This study examined the association between provider continuity and completion of monitoring tests for patients with diabetes mellitus. METHODS: A cross-sectional analysis was conducted on claims data from a private national health plan for 1 year (January 1, 1999, through December 31, 1999). Participants had a diagnosis of diabetes mellitus and at least 2 outpatient visits during the study year (N = 1,795). The association was measured between continuity of care with an individual provider and completion of 3 diabetes monitoring tests: a glycosylated hemoglobin test, a lipid profile, and an eye examination. RESULTS: Eighty-one percent of patients had a glycosylated hemoglobin test, 66% had a lipid profile, and 28% had an eye examination during the study year. After controlling for demographics, number of diabetes visits, case mix, and diabetes complications, provider continuity was not significantly associated with the receipt of a glycosylated hemoglobin test (odds ratio [OR] = 0.61, 95% confidence interval [CI], 0.32-1.16), a lipid profile (OR = 0.97, 95% CI, 0.57-1.64) or an eye examination (OR = 0.60, 95% CI, 0.30-1.19). When continuity was measured only among primary care providers, there was no significant association for receipt of a glycosylated hemoglobin test (OR = 0.73, 95% CI, 0.41-1.33), a lipid profile (OR = 0.88, 95% CI, 0.53-1.47) or an eye examination (OR = 0.70, 95% CI, 0.35-1.36). CONCLUSIONS: This study found no association between provider continuity and completion of diabetes monitoring tests in a national privately insured population. Whereas continuity might benefit other aspects of health care, it does not appear to benefit improved monitoring for diabetes.

Adult↗
PubMedDate not supplied

Elevated serum transferrin saturation and mortality.

BACKGROUND: A large proportion of US adults have elevated transferrin saturation, an indicator of a predisposition for iron overload. The purpose of this study was to evaluate the relationship between elevated serum transferrin saturation and mortality. METHODS: This cohort study was conducted using data from the First Health and Nutrition Examination Survey 1 (1971-1974) (NHANES I) merged with the NHANES I Epidemiologic Followup Study (1992) (N = 10,714). We used SUDAAN and appropriate weights to make population estimates for the adult US population (aged 25 to 74 years at baseline). All-cause mortality was evaluated in relation to serum transferrin saturation of greater than 45%, greater than 50%, greater than 55%, and greater than 60% using Cox proportional hazards regression. RESULTS: In a Cox proportional hazards model controlling for potential confounders, including comorbid diseases, smoking, and cholesterol, all-cause mortality is significantly greater for persons with a serum transferrin saturation of more than 55%, compared with those with saturations below this cutoff (hazards ratio [HR] = 1.60, 95% confidence interval [CI], 1.17-2.21). No one who died had hemochromatosis as any of the 20 listed causes of death. Many of the underlying causes of death for persons with serum transferrin saturation levels of more than 55% are common causes of death in the general population, although these persons were more likely to have died of cirrhosis and diabetes, a finding consistent with iron overload. CONCLUSIONS: In this nationally representative cohort of adults, those with elevated serum transferrin saturation, more than 2% of the adult US population, were at increased risk for all-cause mortality.

Adult↗
PubMedDate not supplied

Transferrin saturation, dietary iron intake, and risk of cancer.

PURPOSE: Transferrin saturation of more than 60% has been identified as a cancer risk factor. It is unclear whether dietary iron intake increases the risk of cancer among individuals with transferrin saturation of less than 60%. The purpose of this study was to examine the association of dietary iron intake and the risk of cancer among adults with increased transferrin saturation. METHODS: Analysis of a cohort study, the National Health and Nutrition Examination Survey I Epidemiologic Follow-Up Study, was performed. US adults (aged 25 to 74 years at baseline) were followed up from baseline in 1971-1974 to 1992 (N = 6,309). RESULTS: A total of 7.3% of the US population had a serum transferrin saturation of more than 45% at baseline. Intake of dietary iron was essentially uncorrelated with transferrin saturation (r = 0.04). Compared with individuals who had normal serum transferrin saturation and low dietary iron intake, individuals whose serum transferrin saturation was more than 45% and who had high dietary iron intake also had an increased adjusted relative risk of cancer (2.24; 95% confidence interval [CI], 1.02-4.89). Increased risk was not found for individuals with a transferrin saturation of more than 45% but a normal dietary iron intake (hazard ratio, 1.02; 95% CI, 0.69-1.49). Transferrin saturation levels could be set as low as 41%, and the individuals with high transferrin saturation and high dietary iron intake would still have an increased adjusted relative risk of cancer (hazard ratio, 2.00; 95% CI, 1.04-3.82). CONCLUSIONS: Among persons with increased transferrin saturation, a daily intake of dietary iron more than 18 mg is associated with an increased risk of cancer. Future research might focus on the benefits of dietary changes in those individuals with increased serum transferrin saturation.

Adult↗
PubMedDate not supplied

Accuracy of screening for diabetic retinopathy by family physicians.

BACKGROUND: We wanted to examine the accuracy of family physicians' screening for diabetic retinopathy using standardized criteria and a nonmydriatic ophthalmoscope. METHODS: Eleven family physicians assessed 28 standardized patients with diabetes mellitus using the PanOptic ophthalmoscope. Their assessments of whether the patients required referral to an ophthalmologist were compared with the reference standard of retinal diagrams. RESULTS: The mean sensitivity for the family physicians was 87% (95% confidence interval [CI], 83%-91%) with a specificity of 57% (95% CI, 46%-68%). Overall agreement was moderate, with a mean kappa = .43 (95% CI, 0.39%-0.47%). CONCLUSIONS: Using standardized criteria and a nonmydriatic ophthalmoscope, family physicians were fairly accurate in screening patients for diabetic retinopathy. Whereas this technique is not sufficiently accurate to replace routine referral for all patients with diabetes, it can be used to improve care for those patients who fail to get routine eye screenings.

Diabetic Retinopathy↗