Biomedical subjects

Janice C Zgibor

Publications and source records attributed to Janice C Zgibor.

15 recordsLinked to original sources

PubMed2006

Developing and validating a diabetes database in a large health system.

BACKGROUND: One component of clinical information systems is a registry of patients. Registries allow providers to identify gaps in care at the population level. Registries also allow for rapid cycle continuous quality improvement, targeted practice change and improved outcomes. Most registries are built based on membership with an insurer or other selection criteria. Little, if any data exist on registries representing demographically heterogeneous populations. METHODS: Administrative and clinical data for the period 1/1/2000-12/30/03 were examined. In total, 46,082,941 lab reports, 233,292,544 medical records, and 9,351,415 medical record abstracts, representing approximately 2 million unique patients were searched. The diabetes source population was identified by presence of any one of the following criteria: ICD-9 code 250 (diabetes) for inpatient, emergency room or outpatient visits; any hemoglobin A1c result; blood glucose >200mg/dl; or diabetes medication. A diagnosis of diabetes was verified by trained chart reviewers on a sample of patients. Single indicators and combinations were examined to determine optimal identification of these cases. RESULTS: In two separate validation studies, using two or more indicators or outpatient diagnosis maximized positive predictive value (PPV) (96 and 97%) and sensitivity (99 and 100%) and identified 55,807 individuals. When all patients with a single indicator of outpatient diagnosis (which had the highest single PPV of 94 and 95%) were included together with those having >or=2 indicators, the final sample size was 65,725. CONCLUSION: Two or more indicators or an out-patient-diagnosis identifies a sizeable and unselective diabetes database which can be used to track processes and outcomes.

Databases, Factual↗

PubMed2006

Influences on screening for chronic diabetes complications in type 1 diabetes.

Screening for the long-term complications of diabetes is a critical component of diabetes management; however, evidence demonstrates that screening rates in diabetes populations are suboptimal. Our objective was to determine the use and predictors of optimal screening behavior, defined as receiving a fasting lipid test, dilated eye exam, spot urine test, foot examination, blood pressure reading, and hemoglobin A1c (HbA1c) in the previous year in a representative cohort of subjects with type 1 diabetes. Data are from the Pittsburgh Epidemiology of Diabetes Complications Study, a prospective cohort study of subjects with childhood onset type 1 diabetes. Data from 325 participants who responded to a survey during 1999-2001 were included in analyses. Reported screening rates were as follows: 87.9% had at least one HbA1c measurement in the past year, 63% had a foot exam, 73.3% had a spot urine test, 81.9% had a dilated eye exam, 93.5% had a blood pressure reading and 68.7% received a fasting lipid profile. Within this group, 37.7% of subjects reported undergoing all five tests (optimal screening). Independent correlates of optimal screening were receiving care from a specialist provider (odds ratio [OR] = 2.4; 95% confidence interval [CI]: 1.4-4.1) and blood glucose monitoring at least weekly (OR = 2.6; 95% CI: 1.1-6.2). These findings indicate that a large proportion of persons with type 1 diabetes are not being screened at the optimal level. Our data indicate that efforts to rectify this should focus on men and those who do not monitor blood glucose, and should involve primary care practitioners.

Adult↗

PubMed2006

Deficiencies of cardiovascular risk prediction models for type 1 diabetes.

OBJECTIVE: Cardiovascular risk prediction models are available for the general population (Framingham) and for type 2 diabetes (U.K. Prospective Diabetes Study [UKPDS] Risk Engine) but may not be appropriate in type 1 diabetes, as risk factors including younger age at diabetes onset and presence of diabetes complications are not considered. Therefore, our objective was to examine the accuracy of Framingham and UKPDS models for predicting coronary heart disease (CHD) in a type 1 diabetic cohort. RESEARCH DESIGN AND METHODS: Ten-year follow-up data from the Pittsburgh Epidemiology of Diabetes Complications (EDC) study, a prospective cohort study of 658 subjects with childhood-onset type 1 diabetes diagnosed between 1950 and 1980 first seen in 1986-1988, were analyzed. EDC study data were used to calculate the 10-year probability of CHD (fatal CHD, nonfatal myocardial infarction, or Q-waves) applying to the Framingham and UKPDS equations. RESULTS: Mean age at CHD onset was 39 years. When fatal/nonfatal myocardial infarction and CHD death were modeled, both the UKPDS and Framingham models showed significant lack of calibration (P < 0.0001) but moderate discrimination (0.76 UKPDS, 0.77 Framingham men, and 0.88 Framingham women). Both the UKPDS and Framingham models underestimated probability of events in highest risk deciles. CONCLUSIONS: Currently available CHD models poorly predict events in type 1 diabetes. Future research should focus on determining the risk factors accounting for the lack of fit and developing prediction models specific to this high-risk group.

Adult↗

PubMed2006

Translating the chronic care model into the community: results from a randomized controlled trial of a multifaceted diabetes care intervention.

OBJECTIVE: To determine whether using the chronic care model (CCM) in an underserved community leads to improved clinical and behavioral outcomes for people with diabetes. RESEARCH DESIGN AND METHODS: This multilevel, cluster-design, randomized controlled trial examined the effectiveness of a CCM-based intervention in an underserved urban community. Eleven primary care practices, along with their patients, were randomized to three groups: CCM intervention (n = 30 patients), provider education only (PROV group) (n = 38), and usual care (UC group) (n = 51). RESULTS: A marked decline in HbA(1c) was observed in the CCM group (-0.6%, P = 0.008) but not in the other groups. The magnitude of the association remained strong after adjustment for clustering (P = 0.01). The same pattern was observed for a decline in non-HDL cholesterol and for the proportion of participants who self-monitor blood glucose in the CCM group (non-HDL cholesterol: -10.4 mg/dl, P = 0.24; self-monitor blood glucose: +22.2%, P < 0.0001), with statistically significant between-group differences in improvement (non-HDL cholesterol: P = 0.05; self-monitor blood glucose: P = 0.03) after adjustment. The CCM group also showed improvement in HDL cholesterol (+5.5 mg/dl, P = 0.0004), diabetes knowledge test scores (+6.7%, P = 0.07), and empowerment scores (+2, P = 0.02). CONCLUSIONS: These results suggest that implementing the CCM in the community is effective in improving clinical and behavioral outcomes in patients with diabetes.

Aged↗

PubMed2005

Late diabetes complications and non-dipping phenomenon in patients with Type 1 diabetes.

BACKGROUND: Cardiovascular autonomic neuropathy (CAN) has been thought to underlie the loss of normal nocturnal blood pressure dipping, which is associated with a higher risk for nephropathy in Type 1 diabetes. Previous analyses also suggest however that nephropathy is a major predictor of subsequent CAN. OBJECTIVE: To investigate links between non-dipping phenomenon (NDP) and complications, particularly CAN and nephropathy. METHODS: 24-h ambulatory blood pressure monitoring was performed on 61 consecutively recruited subjects (mean age: 38.5+/-8.1, mean duration: 29.5+/-8.2 years) from the Pittsburgh Epidemiology of Diabetes Complications cohort (658 subjects with childhood onset Type 1 diabetes diagnosed between 1950 and 80). NDP was diagnosed if nocturnal fall of both systolic and diastolic blood pressure was <10% of the average daytime blood pressure. CAN was detected by abnormal ( 20 microg/min) albumin excretion rate (AER) in at least two of three timed urines. RESULTS: Non-dippers (n=17) had greater LDLc (p=0.012) and AER (p=0.052) and a higher frequency of nephropathy (OR=3.6, 95% CI=1.0-12.6) and proliferative retinopathy (OR=5.1, 95% CI=1.3-20.3) compared to the 44 dippers. CAN and NDP were not associated. In multivariate analyses, adjusting for CAN, proteinuria was significantly related to NDP (OR=3.6, 95% CI=1.0-12.6), an association that further modeling suggests was related to interactions between nephropathy, LDLc and hypertension. CONCLUSIONS: These data suggest a strong link between NDP and proteinuria which is independent of CAN and may be modified by LDLc and hypertension.

Adult↗

PubMed2005

Has control of hypercholesterolemia and hypertension in type 1 diabetes improved over time?

OBJECTIVE: To determine the extent to which patients' awareness, treatment, and control of hypertension and hypercholesterolemia have changed over time and to examine factors associated with awareness and treatment in a type 1 diabetes population. RESEARCH DESIGN AND METHODS: Data from six examinations conducted over 10 years from the Pittsburgh Epidemiology of Diabetes Complications Study, a prospective study of subjects with childhood-onset (<17 years of age) type 1 diabetes diagnosed between 1950 and 1980 and followed since 1986, were analyzed. Hypertension and hypercholesterolemia were defined according to the concurrent Joint National Committee and National Cholesterol Education Program Adult Treatment Panel criteria, respectively. RESULTS: Results demonstrated that awareness of both conditions has improved; however, control is not optimal (e.g., only 32.1 and 28% of those with hypertension in 1986-1988 and 1996-1998 were controlled, while for hypercholesterolemia, the rates were 0 and 5.5%, respectively). Stratified by age-group (18-29, 30-39, and >40 years), the youngest subjects with hypercholesterolemia were least likely to be treated and controlled to goal levels. Older age and physician contact were correlates of awareness and treatment of hypertension at baseline, while presence of renal or coronary complications was also associated with awareness and treatment of both hypertension and hypercholesterolemia at the 10-year follow-up. CONCLUSIONS: There is a considerable treatment gap, particularly for hypercholesterolemia. Improved treatment of both hypertension and hypercholesterolemia are clearly needed, particularly hypercholesterolemia in younger age-groups who have not yet experienced long-term complications.

Adult↗

PubMed2004

ACE inhibitors and calcium channel blockers: patterns of use and associations with mortality in type 1 diabetes.

OBJECTIVE: To determine the frequency of ACE-I and Calcium channel blockers (CCB) use in type 1 diabetes (T1D), and associations of these medications with mortality. RESEARCH DESIGN AND METHODS: Data from the Pittsburgh Epidemiology of Diabetes Complications (EDC) Study, a 10-year follow up of childhood onset T1D, were used to document ACE-I and CCB use. Use in subjects who died during follow up was compared to gender, age, duration (+/-5 years), hypertension, and renal status matched living controls. RESULTS: ACE-I use increased from baseline (1986-1988) to 10 years later (1996-1998) for those with hypertension (20.8-65.8%), and microalbuminuria (2.3-31.5%). However, the majority of patients with microalbuminuria were not on ACE-I at 10 years. CCB use was 2.1% at baseline, increased to 10.4% at 8 years, and fell to 9.5% at 10 years. An increased risk of mortality was apparent for those not treated with either ACE-I or CCB when controlling for cardiovascular status and age (hazard ratio (HR) 2.6, 95% CI 1.1-6.3), while ACE-I use alone was protective (HR=0.26, 0.08-0.79). CCB use with or without ACE-I was not related to mortality status. CONCLUSIONS: This data suggests that ACE-I use is not optimal, but more favorably associated with decreased mortality than CCB use.

Adult↗

PubMed2002

Barriers to blood glucose monitoring in a multiethnic community.

OBJECTIVE: We studied a multiethnic community to determine factors associated with blood glucose monitoring (BGM) and to determine the independent association between barriers to diabetes care and BGM. RESEARCH DESIGN AND METHODS: A total of 323 participants (35.6% European, 32.2% Maori, and 32.2% Pacific Islander) from the South Auckland Diabetes Project (free of major complications by self-report) completed a qualitative survey to determine barriers to diabetes care. Five barriers to diabetes care categories were generated including internal psychological (self efficacy/health beliefs), external psychological (psychosocial environment), internal physical (comorbidities/side effects of treatment), external physical (finance/access to care), and educational (knowledge of diabetes/services) barriers. RESULTS: Characteristics associated with BGM greater than or equal to twice weekly were female sex, HbA(1c) >8%, higher diabetes knowledge scores, and insulin use. Multivariate analyses demonstrated that those reporting external physical barriers (OR 0.47, 95% CI 0.26-0.84), external psychological barriers (0.55, 0.30-1.0), and internal psychological barriers (0.56, 0.32-1.0) were less likely to perform BGM independent of ethnicity, insulin use, age, sex, diabetes knowledge, and glycemic control. Further multivariate analyses demonstrated that those reporting external physical barriers, particularly related to personal finance, were less likely to perform BGM. CONCLUSIONS: These data demonstrate that patient-reported barriers to diabetes care are associated with BGM, particularly in relation to financial, psychosocial, and self-efficacy issues. Understanding these barriers and overcoming them within the context of the patient's ethnic environment may lead to increased participation in self-care.

Attitude to Health↗

PubMed2002

Influence of health care providers on the development of diabetes complications: long-term follow-up from the Pittsburgh Epidemiology of Diabetes Complications Study.

OBJECTIVE: To quantify total diabetes care received (generalist or specialist) from diagnosis onward and its association with the incidence of diabetes complications in a representative cohort of patients with type 1 diabetes. RESEARCH DESIGN AND METHODS: A total of 429 subjects from the Pittsburgh Epidemiology of Diabetes Complications Study, a prospective follow-up study of childhood-onset type 1 diabetic subjects first seen between 1986 and 1988 (mean age 28 years, mean duration 19 years), followed biennially for up to 10 years were studied. Specialist care was defined as care received from a board-certified endocrinologist, diabetologist, or diabetes clinic and quantified as the percent of diabetes duration spent in specialist care. RESULTS: There was a significant trend for a higher incidence of neuropathy, overt nephropathy, and coronary artery disease with lower use of specialist care. Multivariate analyses controlling for diabetes duration, demographic characteristics, health care practices, and physiological risk factors demonstrated that higher past use of specialist care was found to be significantly protective against the development of overt nephropathy (risk ratio 0.43, 95% CI 0.21-0.88) and neuropathy (0.54, 0.35-0.83) and weakly protective against coronary artery disease (0.65, 0.37-1.1). CONCLUSIONS: A higher proportion of diabetes duration spent in specialist care may result in delayed development of certain diabetes complications independent of other risk factors. This study thus supports the concept that the benefits of specialist care should be available to all patients with type 1 diabetes.

Adult↗

PubMedDate not supplied

Markers of endothelial dysfunction in the prediction of coronary artery disease in type 1 diabetes. The Pittsburgh Epidemiology of Diabetes Complications Study.

Low-density lipoprotein (LDL) oxidation, the immune response it provokes, and lipoprotein subclasses measured by nuclear magnetic resonance (NMR) spectroscopy have explained some of the enhanced coronary artery disease (CAD) risks in Type 1 diabetes. We examined whether cellular adhesion molecules further improve CAD prediction. Participants were identified from the Epidemiology of Diabetes Complications (EDC) cohort, a 10-year prospective study of childhood-onset Type 1 diabetes. Mean age at baseline was 28 years, and diabetes duration was 19 years. CAD incidence was determined by EDC physician-diagnosed angina, confirmed myocardial infarction (MI), stenosis > or =50%, ischemic ECG, or revascularization. Cases were gender, age, and diabetes duration (+/-3 years) matched with the controls. The samples and risk factors used in the analyses were identified from the earliest exam prior to incidence in the cases. Sixty cases and 72 controls (including 43 pairs) had complete information on all covariates. Cox proportional hazard models with backward elimination and conditional logistic regression (for paired analyses) were conducted. Separate analyses were conducted to examine whether E-selectin related differently to soft (ischemic ECG and angina; n=68) or hard (revascularization, MI, and fatal events; n=37) CAD endpoints. Mean E-selectin concentration was elevated among cases (P=.0009) compared to controls. Adjusting for previously established CAD risk factors, E-selectin remained an independent predictor of CAD (HR=1.07, 95% Cl=1.01-1.15). Multivariable models confirmed the importance of E-selectin as a risk factor of soft (HR=1.13, 95% Cl=1.03-1.24; HRs are per standard deviation increase) but not hard CAD. Study results suggest that E-selectin may enhance CAD prediction beyond traditional risk factors or markers of oxidative stress in Type 1 diabetes.

Adult↗

PubMedDate not supplied

Antioxidants and coronary artery disease among individuals with type 1 diabetes: Findings from the Pittsburgh Epidemiology of Diabetes Complications Study.

OBJECTIVE: Oxidative stress has been implicated in the development of diabetes and cardiovascular disease. We evaluated the effect of serum antioxidants and total antioxidant reserve (TAR) on coronary artery disease (CAD) incidence in type 1 diabetes. METHODS: Subjects were identified from the Pittsburgh Epidemiology of Diabetes Complications Study (EDC) cohort, a 10-year prospective study of childhood-onset type 1 diabetes. Mean age at baseline was 28 and diabetes duration 19 years. Coronary artery disease was defined as physician-diagnosed angina, confirmed MI, stenosis >or=50%, ischemic electrocardiogram (ECG), or revascularization. Controls were gender, age, and diabetes duration (+/-3 years) matched with cases. Samples and risk factors used in analyses were identified from the earliest exam prior to incidence in cases (54 cases, 67 controls). RESULTS: None of the antioxidant measures (alpha-tocopherol, gamma-tocopherol, retinol, TAR) showed protection against incident CAD overall. However, a protective effect of alpha-tocopherol against CAD was observed among antioxidant supplement users (HR=0.22, 95% CI=0.10-0.49) and in renal disease (HR=0.46, 95% CI=0.23-0.91). Despite similar alpha-tocopherol concentration, there was no protective effect among nonusers of antioxidant supplements. CONCLUSIONS: High alpha-tocopherol levels among patients with renal disease and in those using vitamin supplements were associated with lower CAD risk in type 1 diabetes. The specificity of these effects merits further investigation.

Adult↗

PubMedDate not supplied

Tracking and improving influenza immunization rates in a high-risk medicare beneficiary population.

Immunization rates for end stage renal disease (ESRD) patients were well below the 80% target set by Healthy People 2000 and Centers for Medicare and Medicaid Services. The authors sought to increase documentation of immunization status, and influenza immunization rates of these patients. A survey was distributed to dialysis facilities to determine immunization practices. Facilities were provided with an immunization toolbox and spreadsheets to document the immunization status of patients. A total of 102 facilities (53%) provided data for three collection periods (1999, 2000, and 2001). Immunization rates for each influenza season increased significantly from 62.1% and 61.4% in 1998-1999 to 80.3% and 80.0% in 2000-2001 (Pennsylvania and Delaware respectively).

Aged↗

PubMedDate not supplied

Improving the quality of diabetes care in primary care practice.

The quality of care delivered to patients with diabetes has an impact on long-term outcomes. The purpose of this quality improvement project was to examine the effect of a Diabetes Disease Management Program (DDMP) on compliance with recommended process measures of care in primary care practice settings. Certified diabetes nurse educators visited five participating primary care practices biweekly for 1 year providing education to physicians and office staff on standards for diabetes management and to patients regarding self-management. Among 208 participants, 85.5% had >2 HbA1cs, 93.6% had lipid profiles, and 100% had foot examinations. Improvements in HbA1c (9.0% to 7.7%) were observed. Implementation of DDMP effectively promotes compliance with care standards in primary care practices.

Adult↗

PubMedDate not supplied

Implementing the chronic care model for improvements in diabetes care and education in a rural primary care practice.

PURPOSE: The purpose of this pilot study was to determine the impact of implementing elements of the chronic care model (CCM; decision support, self-management, and delivery system redesign) on providers' diabetes care practices and patient outcomes in a rural practice setting. METHODS: In this pilot study, 104 patients with type 2 diabetes and 6 providers in a rural primary care practice were involved in an intervention that included a certified diabetes educator (CDE) who educated and supported providers on diabetes management and adherence to the American Diabetes Association (ADA) Standards of Care over the year of the project. The CDE also provided diabetes self-management education (DSME) at the office site for 29 of the 104 patients who received their care in the practice. The following variables were evaluated: provider perceived barriers to care and adherence to ADA standards of care and patient A1C, blood pressure, cholesterol, knowledge, and empowerment levels. RESULTS: Provider adherence to ADA Standards of Care increased significantly across all process measures. Patients who received DSME at point of service in the primary care practice setting gained improvements in knowledge, empowerment, A1C, and high-density lipoprotein cholesterol levels. CONCLUSIONS: Implementing systems to support decision support, self-management education, and delivery system redesign has a positive influence on practices and patient outcomes in outlying rural communities.

Aged↗

PubMedDate not supplied

Deploying the chronic care model to implement and sustain diabetes self-management training programs.

PURPOSE: The purpose of this project was to evaluate the utility of using the 6 elements of the chronic care model (CCM; health system, community, decision support, self-management support, clinical information systems, and delivery system design) to implement and financially sustain an effective diabetes self-management training (DSMT) program. METHODS: The University of Pittsburgh Medical Center (UPMC) uses all elements of the CCM. Partnerships were formed between UPMC and western Pennsylvanian community hospitals and practices; the American Diabetes Association DSMT recognition program provided decision support. A clinical data repository and reorganization of primary care practices aided in supporting DSMT. The following process and patient outcomes were measured: number of recognized programs, reimbursement, patient hemoglobin A1C levels, and the proportion of patients who received DSMT in primary care practices versus hospital-based programs. RESULTS: Using elements of the CCM, the researchers were able to gain administrative support; expand the number of recognized programs from 3 to 21; cover costs through increased reimbursement; reduce hemoglobin A1C levels (P < .0001), and increase the proportion of patients receiving DSMT through delivery in primary care (26.4% suburban; 19.8% urban) versus hospital-based practices (8.3%; P < .0001). CONCLUSIONS: The CCM serves as an effective model for implementing and sustaining DSMT programs.

Chronic Disease↗