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Biomedical subjects

Tom A Elasy

Publications and source records attributed to Tom A Elasy.

At least 19 recordsLinked to original sources
PubMed2006

A randomized controlled trial to prevent glycemic relapse in longitudinal diabetes care: study protocol (NCT00362193).

BACKGROUND: Diabetes is a common disease with self-management a key aspect of care. Large prospective trials have shown that maintaining glycated hemoglobin less than 7% greatly reduces complications but translating this level of control into everyday clinical practice can be difficult. Intensive improvement programs are successful in attaining control in patients with type 2 diabetes, however, many patients experience glycemic relapse once returned to routine care. This early relapse is, in part, due to decreased adherence in self-management behaviors. OBJECTIVE: This paper describes the design of the Glycemic Relapse Prevention study. The purpose of this study is to determine the optimal frequency of maintenance intervention needed to prevent glycemic relapse. The primary endpoint is glycemic relapse, which is defined as glycated hemoglobin greater than 8% and an increase of 1% from baseline. METHODS: The intervention consists of telephonic contact by a nurse practitioner with a referral to a dietitian if indicated. This intervention was designed to provide early identification of self-care problems, understanding the rationale behind the self-care lapse and problem solve to find a negotiated solution. A total of 164 patients were randomized to routine care (least intensive), routine care with phone contact every three months (moderate intensity) or routine care with phone contact every month (most intensive). CONCLUSION: The baseline patient characteristics are similar across the treatment arms. Intervention fidelity analysis showed excellent reproducibility. This study will provide insight into the important but poorly understood area of glycemic relapse prevention.

Journal Article↗
PubMed2006

Improving blood pressure control through provider education, provider alerts, and patient education: a cluster randomized trial.

BACKGROUND: Inadequate blood pressure control is a persistent gap in quality care. OBJECTIVE: To evaluate provider and patient interventions to improve blood pressure control. DESIGN: Cluster randomized, controlled trial. SETTING: 2 hospital-based and 8 community-based clinics in the Veterans Affairs Tennessee Valley Healthcare System. PATIENTS: 1341 veterans with essential hypertension cared for by 182 providers. Eligible patients had 2 or more blood pressure measurements greater than 140/90 mm Hg in a 6-month period and were taking a single antihypertensive agent. INTERVENTION: Providers who cared for eligible patients were randomly assigned to receive an e-mail with a Web-based link to the Seventh Report of the Joint National Committee on the Prevention, Detection, Evaluation and Treatment of High Blood Pressure (JNC 7) guidelines (provider education); provider education and a patient-specific hypertension computerized alert (provider education and alert); or provider education, hypertension alert, and patient education, in which patients were sent a letter advocating drug adherence, lifestyle modification, and conversations with providers (patient education). MEASUREMENTS: Proportion of patients with a systolic blood pressure less than 140 mm Hg at 6 months; intensification of antihypertensive medication. RESULTS: Mean baseline blood pressure was 157/83 mm Hg with no differences between groups (P = 0.105). Six-month follow-up data were available for 975 patients (73%). Patients of providers who were randomly assigned to the patient education group had better blood pressure control (138/75 mm Hg) than those in the provider education and alert or provider education alone groups (146/76 mm Hg and 145/78 mm Hg, respectively). More patients in the patient education group had a systolic blood pressure of 140 mm Hg or less compared with those in the provider education or provider education and alert groups (adjusted relative risk for the patient education group compared with the provider education alone group, 1.31 [95% CI, 1.06 to 1.62]; P = 0.012). LIMITATIONS: Follow-up blood pressure measurements were missing for 27% of study patients. The study could not detect a mechanism by which patient education improved blood pressure control. CONCLUSIONS: A multifactorial intervention including patient education improved blood pressure control compared with provider education alone.

Adult↗
PubMed2006

Patient understanding of food labels: the role of literacy and numeracy.

BACKGROUND: Comprehension of food labels can be important for patients, including those with chronic illness, to help follow dietary recommendations. Patient comprehension of food labels was examined, along with the relationship of comprehension to their underlying literacy and numeracy skills. METHODS: From June 2004 to April 2005, a cross-sectional study of 200 primary care patients was performed. A 24-item measure of food label comprehension was administered. Literacy was measured with the Rapid Estimate of Adult Literacy in Medicine (REALM), and numeracy with the Wide Range Achievement Test, third edition (WRAT-3). RESULTS: Most patients (89%) reported using food labels. While 75% of patients reported at least a high school education and 77% had 9th-grade literacy skills, only 37% had 9th-grade math skills. On average, patients answered 69% (standard deviation, 21%) of the food-label questions correctly. Common reasons for incorrect responses included misapplication of the serving size, confusion due to extraneous material on the food label, and incorrect calculations. For example, only 37% of patients could calculate the number of carbohydrates consumed from a 20-ounce bottle of soda that contained 2.5 servings. Higher comprehension of food labels was significantly correlated (all p values were less than 0.001) with higher income (rho=0.39), education (rho=0.49), literacy (rho=0.52), and numeracy (rho=0.67). CONCLUSIONS: Patients demonstrated deficits in understanding nutrition labels. Poor label comprehension was highly correlated with low-level literacy and numeracy skills, but even patients with higher literacy could have difficulties interpreting labels. Providers need to consider patients' literacy and numeracy when providing dietary recommendations. Opportunities may exist for the U.S. Food and Drug Administration to promote changes to make food labels more comprehensible.

Adult↗
PubMed2006

Parent perceptions of caring for adolescents with type 2 diabetes.

OBJECTIVE: No studies have been performed to examine parent perceptions of caring for adolescents with type 2 diabetes. In this qualitative study, we examined parent perceptions of barriers and strategies to address barriers to self-care in adolescents with type 2 diabetes. RESEARCH DESIGN AND METHODS: Families of adolescents with type 2 diabetes were recruited from a pediatric diabetes clinic. Focus groups were used to elicit parent experiences and perceptions of diabetes management of their adolescents with type 2 diabetes. Questions concerning barriers to self-care behaviors were asked by trained group facilitators. Transcripts were coded into themes by three reviewers. Qualitative analyses were conducted using NVIVO software. RESULTS: Between 2003 and 2005, six focus groups were conducted with a total of 27 parents or guardians. Parents identified many barriers to and practical strategies for positive adolescent self-management. Five domains that influence self-management were identified: the role of others with diabetes, parenting skills, perceived lack of normalcy, environment, and adolescent development. Parents identified many barriers to dietary and exercise habits that were unique to the circumstances of adolescents with type 2 diabetes. CONCLUSIONS: Parents identified many barriers to self-management that may be unique to adolescents with type 2 diabetes. The importance of others and environmental influences in the self-management behavior of adolescents with type 2 was evident. Interventions that are designed to improve self-management should include components that address multiple influences such as peers, school professionals, parents, siblings, and/or family systems.

Adolescent↗
PubMed2006

Hypertension prevalence awareness, treatment and control in North Nashville.

North Nashville is a largely African-American community known to suffer from increased cardiovascular mortality compared with whites in the same area of Davidson County. The burden of hypertension, a well-known risk factor for cardiovascular death, has not been fully described for this population. To quantify the prevalence, awareness, treatment and control of hypertension in the North Nashville community, we screened 132 patients aged 18 and older at the 2005 Juneteenth festival on Jefferson Street. We compared our results to data for African-Americans from the most recent NHANES survey. Compared to the national survey, our study population had a higher prevalence of hypertension (52.3 percent versus 33.5 percent) and lower awareness (68.1 percent versus 73.9 percent), treatment (46.4 percent versus 63.0 percent) and control of hypertension (13.0 percent versus 28.1 percent) despite comparable age. This study adds to a growing literature on the racial and geographic disparities in health status in the Unites States and cautions that data from national surveys may not be representative of individual communities.

Adult↗
PubMed2004

A three-part intervention to change the use of hormone replacement therapy in response to new evidence.

BACKGROUND: Slow adaptation of new information by providers may result in suboptimal care. OBJECTIVE: To evaluate changes in prescriptions for combination hormone replacement therapy (HRT) after a multicomponent intervention to deliver new information to patients and providers. DESIGN: Quasi-experimental study with multiple baselines. SETTING: Veterans Affairs Tennessee Valley Healthcare System (VA-TVHS). PATIENTS: Female veterans age 50 to 79 years who had a prescription filled at the VA-TVHS for combination HRT between 1 January 2002 and 1 July 2002. MEASUREMENTS: Discontinuation of HRT. INTERVENTION: A 3-part intervention consisted of 1) notifying patients who were using combination HRT of the results of the Women's Health Initiative study (patient education component), 2) sending all providers an e-mail with the Women's Health Initiative study results (provider education component), and 3) placing an electronic alert in each eligible patient's chart (provider care component). The alert asked providers to reevaluate the need for combination HRT. The intervention was implemented at different VA-TVHS sites in a stepwise fashion to differentiate intervention effect from media effect. Study follow-up continued through 31 December 2002. RESULTS: The total rate of discontinuation of combination HRT was 70.3% in 2002. The proportion of discontinuation from time of media release until intervention was 23.3%. After initiation of the intervention, an additional 43% of the original cohort discontinued use of HRT; this percentage represents a 59% relative decrease in HRT use among patients. After adjustment for time, the discontinuation rate per day was 4.9 times higher after the multifacted intervention than after the media release (95% CI, 1.8 to 13.1). LIMITATIONS: A true control group is lacking. CONCLUSION: A multifaceted approach in an integrated health care system with standardized methods of communication is an effective way to implement patient-centered, effective, and timely care with changing medical knowledge.

Aged↗
PubMed2004

Oral contraceptive use and risk of diabetes among Chinese women.

Oral contraceptive (OC) use has been associated with alterations in carbohydrate metabolism. We examined the effect of OC use on the risk of diabetes among Chinese women. A nested case-control study was conducted among 57,130 women screened for diabetes at enrollment for the Shanghai Women's Health Study, a population-based cohort study of Chinese women aged 40-70 years in Shanghai, China. Included in this study were 259 women newly diagnosed with diabetes and 2072 age-matched controls (8 controls per case), randomly selected from women who tested negative for urine glucose. Multivariate-adjusted odds ratios (OR) and 95% confidence intervals (CI) were used to measure the strength of the association between OC use and diabetes risk. Overall, OC use was not associated with the risk of diabetes. Stratified analysis by menopausal status revealed a dose-response relationship between the duration of OC use and the risk of diabetes among premenopausal women (p for trend = 0.02), with a 3.2-fold elevated risk observed among those who used OC longer than 1 year. Risk of diabetes diminished with increasing time since last OC use (p = 0.02). Use of intrauterine devices was associated with a reduced risk of diabetes in both pre- and postmenopausal women (OR = 0.67, CI: 0.48-0.93). These findings suggest that recent use (within 5 years) and continued use (>1 year) of OCs may increase the risk of diabetes among Chinese women. However, the attributable risk for diabetes among OC users in the general population, if confirmed by further studies, appears to be small.

Adult↗
PubMed2004

Improving documentation of patient acuity level using a progress note template.

BACKGROUND: Accurately documenting patient comorbidities and complications improves case-mix representation, coding accuracy, and risk-adjusted mortality estimates for benchmarking. We hypothesized that a progress note template containing comorbidities and complications would improve documentation and teach residents to correctly document comorbidities and complications. STUDY DESIGN: Surgical residents and patients on three inpatient services were followed for a 1-year prospective cohort study. After a 6-month baseline period, a progress note template was developed and implemented for 6 months, and administrative data were retrieved. Residents were given three case examinations assessing documentation knowledge pre- and postintervention, and a satisfaction survey. Demographics, Charlson comorbidity score, ICD-9 codes, template-specific ICD-9 codes, All Patient Refined (APR)-DRG patient severity, DRG relative weight, predicted mortality (University Healthcare Consortium), pre- and postexam scores, and resident satisfaction were collected. RESULTS: No difference in age, gender, race, or Charlson comorbidity score existed between pre- and postintervention patient groups. The length of stay decreased from 5.5 days to 4.8 days (p = 0.013). In the intervention group, total ICD-9 codes, template-specific ICD-9 codes, APR-DRG, DRG weight, and UHC predicted mortality had significant increases. Residents exposed to the progress note template improved their knowledge scores from 52% to 63% (p < 0.001), and 73% agreed that the progress note template was an improvement over handwritten notes. Residents not exposed to the progress note template did not improve their scores. CONCLUSIONS: A progress note template improves documentation of comorbidities and complications, APR-DRG patient severity for benchmarking, and case-mix index, and increases patient-specific predicted mortality. The progress note template also improves surgical residents' documentation knowledge and satisfaction.

Acute Disease↗
PubMed2004

Diabetes patient education: a meta-analysis and meta-regression.

Diabetes education has largely been accepted in diabetes care. The effect of diabetes education on glycemic control and the components of education responsible for such an effect are uncertain. We performed a meta-analysis of randomized controlled trials of diabetes patient education published between 1990 and December 2000 to quantitatively assess and characterize the effect of patient education on glycated hemoglobin (HbA(1c)). Additionally, we used meta-regression to analyze which variables within an education intervention that best explained variance in glycemic control. Twenty-eight educational interventions (n=2439) were included in the analysis. The net glycemic change was 0.320% lower in the intervention group than in the control group. Meta-regression revealed that interventions which included a face-to-face delivery, cognitive reframing teaching method, and exercise content were more likely to improve glycemic control. Those three areas collectively explained 44% of the variance in glycemic control. Current patient education interventions modestly improve glycemic control in adults with diabetes. We highlight three potential components of educational interventions that may predict an increased likelihood of success in ameliorating glycemic control.

Adult↗
PubMed2004

Optimizing combination therapy for type 2 diabetes in adolescents and adults: a case-based approach.

Children and adolescents who are overweight and have additional risk factors (ie, high-risk ethnic group or signs of insulin resistance) should be screened for diabetes every 2 years (strength of recommendation [SOR]: C). Management of type 2 diabetes in all age groups requires a multifactorial approach that addresses not only glycemic control (A1C <7%) but also other cardiovascular risk factors such as hypertension, dyslipidemia, and obesity (SOR: A). Most patients with type 2 diabetes will eventually require combination therapy with 2 or more agents to attain and maintain glycemic control (SOR: A). Combining an insulin secretagogue (ie, sulfonylurea or meglitinide) and an insulin sensitizer (ie, metformin or a glitazone) capitalizes on unique mechanisms of action and results in significant A1C lowering (SOR: C). If a patient is unable to achieve glycemic control on 2 oral agents, insulin therapy is an appropriate consideration and should be added to oral agents (rather than substituted) (SOR: B).

Administration, Oral↗
PubMed2003

Physicians' ability to predict the risk of coronary heart disease.

BACKGROUND: Coronary heart disease (CHD) is the leading cause of death in the United States. Previous research examining physicians ability to estimate cardiovascular risk has shown that physicians' generally overestimate the absolute risk of CHD events. This question has, however, only studied risk prediction for a limited number of patient care scenarios. The aim of this study is to measure the ability of physicians to estimate the risk of CHD events in patients with no previous history of coronary heart disease. METHODS: Twelve primary prevention scenarios with a 5-year risk of CHD events were developed. This questionnaire was surveyed at 3 university teaching hospitals where the participants were a convenience sample of internal medicine residents and fellows or attending physicians in general internal medicine or cardiology. For each scenario, physicians were asked to estimate the baseline 5-year risk of a coronary heart disease event and the revised risk if the patient were to receive lipid-lowering drug therapy. Estimates of the baseline 5-year risk were compared with values calculated from Framingham risk equations. Inaccurate responses were defined as those with a ratio of estimated to actual risk of more than 1.5 or less than 0.67. Physicians' estimates of the relative risk reduction with therapy were considered to be accurate if they were between 25% and 40%. RESULTS: 79 physicians (53 residents, 8 fellows, 18 attending physicians) completed the survey. Only 24% of physicians' risk estimates were accurate. In most cases, physicians overestimated the absolute risk of cardiovascular events without therapy (proportion overestimating ranged from 32-92% for the 12 individual scenarios). Physicians made larger errors in patient scenarios involving patients with high total or LDL cholesterol levels. Physicians' estimates of the relative risk reduction from treatment were more accurate: 43% of estimates were between 25 and 40%. Over 85% of physicians recommended treatment in 10 of 12 scenarios. CONCLUSIONS: Physicians overestimate the absolute risk of CHD events and the potential absolute benefit of drug therapy.

Age Factors↗
PubMed2002

Prominent medical journals often provide insufficient information to assess the validity of studies with negative results.

BACKGROUND: Physicians reading the medical literature attempt to determine whether research studies are valid. However, articles with negative results may not provide sufficient information to allow physicians to properly assess validity. METHODS: We analyzed all original research articles with negative results published in 1997 in the weekly journals BMJ, JAMA, Lancet, and New England Journal of Medicine as well as those published in the 1997 and 1998 issues of the bimonthly Annals of Internal Medicine (N = 234). Our primary objective was to quantify the proportion of studies with negative results that comment on power and present confidence intervals. Secondary outcomes were to quantify the proportion of these studies with a specified effect size and a defined primary outcome. Stratified analyses by study design were also performed. RESULTS: Only 30% of the articles with negative results comment on power. The reporting of power (range: 15%-52%) and confidence intervals (range: 55-81%) varied significantly among journals. Observational studies of etiology/risk factors addressed power less frequently (15%, 95% CI, 8-21%) than did clinical trials (56%, 95% CI, 46-67%, p < 0.001). While 87% of articles with power calculations specified an effect size the authors sought to detect, a minority gave a rationale for the effect size. Only half of the studies with negative results clearly defined a primary outcome. CONCLUSION: Prominent medical journals often provide insufficient information to assess the validity of studies with negative results.

Confidence Intervals↗
PubMed2002

A randomized trial of an intervention to improve self-care behaviors of African-American women with type 2 diabetes: impact on physical activity.

OBJECTIVE: To determine whether a culturally appropriate clinic- and community-based intervention for African-American women with type 2 diabetes will increase moderate-intensity physical activity (PA). RESEARCH DESIGN AND METHODS: In this randomized controlled trial conducted at seven practices in central North Carolina, 200 African-American women, > or =40 years of age with type 2 diabetes, were randomized to one of three treatment conditions: clinic and community (group A), clinic only (group B), or minimal intervention (group C). The clinic-based intervention (groups A and B) consisted of four monthly visits with a nutritionist who provided counseling to enhance PA and dietary intake that was tailored to baseline practices and attitudes; the community-based intervention (group A) consisted of three group sessions and 12 monthly phone calls from a peer counselor and was designed to provide social support and reinforce behavior change goals; and the minimal intervention (group C) consisted of educational pamphlets mailed to participants. The primary study outcome was the comparison of PA levels between groups assessed at 6 and 12 months by accelerometer, which was worn while awake for 7 days. RESULTS: Totals of 175 (88%) and 167 (84%) participants completed PA assessment at 6 and 12 months, respectively. For comparison of PA, the P value for overall group effect was 0.014. Comparing group A with C, the difference in the average adjusted mean for PA was 44.1 kcal/day (95% CI 13.1-75.1, P = 0.0055). Comparing group B with C, the difference in the average adjusted mean was 33.1 kcal/day (95% CI 3.3-62.8, P = 0.029). The intervention was acceptable to participants: 88% were very satisfied with clinic-based counseling to enhance PA, and 86% indicated that the peer counselor's role in the program was important. CONCLUSIONS: The intervention was associated with a modest enhancement of PA and was acceptable to participants.

Adult↗