Biomedical subjects

Jonathan Betz Brown

Publications and source records attributed to Jonathan Betz Brown.

5 recordsLinked to original sources

PubMed2004

Longitudinal follow-up and outcomes among a population with chronic kidney disease in a large managed care organization.

BACKGROUND: Chronic kidney disease is the primary cause of end-stage renal disease in the United States. The purpose of this study was to understand the natural history of chronic kidney disease with regard to progression to renal replacement therapy (transplant or dialysis) and death in a representative patient population. METHODS: In 1996 we identified 27 998 patients in our health plan who had estimated glomerular filtration rates of less than 90 mL/min per 1.73 m(2) on 2 separate measurements at least 90 days apart. We followed up patients from the index date of the first glomerular filtration rates of less than 90 mL/min per 1.73 m(2) until renal replacement therapy, death, disenrollment from the health plan, or June 30, 2001. We extracted from the computerized medical records the prevalence of the following comorbidities at the index date and end point: hypertension, diabetes mellitus, coronary artery disease, congestive heart failure, hyperlipidemia, and renal anemia. RESULTS: Our data showed that the rate of renal replacement therapy over the 5-year observation period was 1.1%, 1.3%, and 19.9%, respectively, for the National Kidney Foundation Kidney Disease Outcomes Quality Initiative (K/DOQI) stages 2, 3, and 4, but that the mortality rate was 19.5%, 24.3%, and 45.7%. Thus, death was far more common than dialysis at all stages. In addition, congestive heart failure, coronary artery disease, diabetes, and anemia were more prevalent in the patients who died but hypertension prevalence was similar across all stages. CONCLUSION: Our data suggest that efforts to reduce mortality in this population should be focused on treatment and prevention of coronary artery disease, congestive heart failure, diabetes mellitus, and anemia.

Adult↗

PubMed2004

Cost of medical care for chronic kidney disease and comorbidity among enrollees in a large HMO population.

Chronic kidney disease (CKD) afflicts up to 20 million people in the United States, but little is known about their health care costs. The authors analyzed costs and resource use associated with CKD by using National Kidney Foundation staging definitions. Patients insured through a large health maintenance organization with a laboratory finding of CKD (defined as estimated GFR between 15 and 90 ml/min per 1.73 m(2) in 1996 followed by a second GFR below 90 at the next creatinine measurement occurring at least 90 d later) were followed from 1996 for up to 66 mo. The final cohort included 13,796 persons with CKD and their age- and gender-matched controls; 1741 in stage 2; 11,278 in stage 3; and 777 in stage 4. Depending on stage, cases had 1.9 to 2.5 times more prescriptions, 1.3 to 1.9 times more outpatient visits, were 1.6 to 2.2 times more likely to have had an inpatient stay, and had 1.8 to 3.1 more stays than did controls. Total per patient follow-up costs were [$total, (95% CI) cases and controls, respectively] $38,764 (95% CI, 37,033 to $40,496) and $16,212 (95% CI, $15,644 to $16,780) in stage 2; $33,144 (95% CI, $32,578 to $33,709) and $18,964 (95% CI, $18,730 to $19,197) in stage 3; and $41,928 (95% CI, $39,354 to $44,501) and $19,106 (95% CI, $18,212 to $20,000) in stage 4. Cases with no CKD-related comorbidities had costs double that of controls with no CKD-related comorbidities, and comorbidities related to CKD were more costly to manage than CKD alone. Future research in this area could be usefully directed toward analyzing the clinical and economic consequences of better managing or preventing comorbidities in patients with CKD.

Aged↗

PubMed2003

Diabetic retinopathy: contemporary prevalence in a well-controlled population.

OBJECTIVE: To measure the extent to which modern intensified risk factor control has lessened the duration-specific prevalence of diabetic retinopathy and, therefore, has decreased the risk of blindness in Americans with type 2 diabetes. RESEARCH DESIGN AND METHODS: Intensified control of blood glucose and blood pressure has prevented diabetic retinopathy in randomized controlled trials. There is as yet no confirmation that subsequent treatment intensification in the community has had the same result. We identified all 6993 members of a health maintenance organization, Kaiser Permanente Northwest (KPNW), who, in 1997-1998, had dilated retinal examinations and verifiable data of diagnosis of type 2 diabetes. We plotted prevalence by time since diagnosis for background diabetic retinopathy (BDR) and proliferative diabetic retinopathy (PDR) and compared these results to identically derived 1980-1982 results from the Wisconsin Epidemiologic Study of Diabetic Retinopathy (WESDR). We estimated multivariate predictive models. RESULTS: Mean (+/- SD) HbA(1c) in KPNW was 7.84 +/- 1.26% versus 10.37% (standardized) in the WESDR. KPNW blood pressure averaged 138.6 +/- 13.8/79.5 +/- 7.4 mmHg compared with 147.0/79.0 in the WESDR. BDR was much less prevalent in KPNW, but PDR prevalence appeared unchanged. BDR preceded diagnosis in 20.8% of the WESDR subjects but only 2.0% of KPNW subjects. However, in both populations, the first cases of PDR appeared similarly, soon after diagnosis. CONCLUSIONS: Earlier diagnosis and more aggressive control of blood glucose and blood pressure decreased the duration-adjusted prevalence of background, but not of sight-threatening proliferative retinopathy. More population-based research is needed to replicate and explain this unexpected finding. Detecting and treating PDR should not be neglected on the assumption that risk-factor control has minimized its prevalence.

Blood Glucose↗

PubMed2002

Treatment decisions about lumbar herniated disk in a shared decision-making program.

BACKGROUND: An explicit process of collaborative (shared) decision making involving the patient and physician has been recommended for discretionary surgical procedures in which small-area analysis demonstrates high variation not attributable to differences in the patient population in the area. One such example is laminectomy for lumbar herniated disk (HD). An observational study was undertaken to evaluate the impact of an HD videodisk program on patient satisfaction, decision making, and treatment preferences. METHODS: Enrollment occurred in the outpatient offices of surgeons treating Kaiser Permanente (Colorado Region) patients with HD who had indications for surgery. Enrollment took place from May 1993 to December 1995, and follow-up surveys of patients were completed by January 1997. RESULTS: A 6.0% decrease in the undecided group and a 1.3% decrease in the group preferring nonsurgical treatment drove a shift of patients toward laminectomy, from 26.7% to 35.8% (Wilcoxon signed rank test = 349.5, p = .017). Postviewing preference (74.0%) was a better aggregate predictor of the ultimate treatment than previewing preference (70.0%) for laminectomy. DISCUSSION: Viewing the videodisk increased the preference for laminectomy. However, limitations in the data prevented us from determining whether this change in preference was actually reflected in patients' ultimate decisions. The fact that the strongest predictor of choosing surgery was the patient's valuation of his or her condition supports shared decision making, with its emphasis on patient's values. Participation in other videodisk programs has been low; perhaps physicians should ask patients to view these videodisks before their visits.

Adult↗

PubMed2002

Impact of intensified dental care on outcomes in human immunodeficiency virus infection.

This study evaluated the health effects of routine and intensified dental care and disease prevention in persons with human immunodeficiency virus (HIV). We recruited 376 HIV-infected persons ages 19 to 61 with CD4 counts between 100 and 750 into a year-long two-arm randomized controlled trial. Control group subjects (n = 185) received professional dental protective treatment and checkups at baseline, 6 months, and 1 year, plus dental care. Enhanced care patients (n = 191) received bimonthly protective treatment and twice-daily chlorhexidine mouthrinses to treat gingivitis. Active decay, gingivitis, oral pain, impact of oral health on functioning, and global functional status improved in both groups. The mean depth of periodontal pockets decreased 0.18 mm (control group) versus 0.27 mm (enhanced group) (p < 0.04), as did an erythema index (-1.22 versus -1.78, p < 0.01). No effects on acquired immune deficiency syndrome (AIDS)-related complications, symptoms, or mortality were observed. We concluded that access to dental screening, prophylaxis, and repair will significantly improve oral health, functioning, and quality of life in persons with AIDS.

AIDS-Related Opportunistic Infections↗