Beyond the Great Recession: Was the Foreclosure Crisis Harmful to the Health of Individuals With Diabetes?

The housing foreclosure crisis was harmful to the financial well-being of many households. In the present study, we investigated the health effects of the housing foreclosure crisis on glycemic control within a population of patients with diabetes. We hypothesized that an increase in the neighborhood foreclosure rate could worsen glycemic control by activating stressors such as higher neighborhood crime, lower housing prices, and erosion of neighborhood social cohesion. To test this, we linked public foreclosure records at the census-block level with clinical records from 2006 to 2009 of patients with diabetes. We specified individual fixed-effects models and controlled for individual time-invariant confounders and area-level time-varying confounders, including housing prices and unemployment rate, to estimate the effect of the foreclosure rate per census-block group on glycated hemoglobin. We found no statistically significant relationship between changes in the neighborhood foreclosure rate per block group in the prior year and changes in glycated hemoglobin. There is no evidence that increased foreclosure rates worsened glycemic control in this continuously insured population with diabetes. More research is needed to inform our knowledge of the role of insurance and health-care delivery systems in protecting the health of diabetic patients during times of economic stress.

Police-Recorded Crime and Perceived Stress among Patients with Type 2 Diabetes: the Diabetes Study of Northern California (DISTANCE)

While stress has been linked to poor health outcomes, little is known about the impact of objective measures of neighborhood crime on stress in patients with chronic disease. Using the Kaiser Permanente Diabetes Study of Northern California (DISTANCE), we examined associations between police-recorded crime (2005-2007) and stress (Perceived Stress Scale-4) in four large Northern California cities (Oakland, Sacramento, San Francisco, and San Jose). We performed stratified analysis by gender and race/ethnicity using generalized linear regression models. In our study sample (n = 3188, mean age 59, range 30-77), 10 % reported high stress. In adjusted analyses, higher neighborhood all crimes rate was associated with modest increase in high stress for African-American (OR = 1.10; 95 % CI 1.02-1.22) and Latina women (OR = 1.36; 95 % CI 1.10-1.67) and property crime showed similar associations with stress for these groups of women. Visible crime was associated with stress only for Latina women (OR = 1.43; 95 % CI 1.14-1.78). We found no association between crime and stress among men or other racial/ethnic groups of women. High crime levels may disproportionately impact health among certain subpopulations. Studies using additional measures of stress are necessary to differentiate the health impact of crime-related stress from other forms of stressors among individuals living with diabetes.

Changes in Medication Use After Dementia Diagnosis in an Observational Cohort of Individuals with Diabetes Mellitus

OBJECTIVES

To assess changes in medication use after a diagnosis of dementia in individuals with type 2 diabetes mellitus.

DESIGN

Difference-in-differences analysis of changes in the number of dispensed chronic medications between individuals with and without newly diagnosed dementia.

SETTING

Integrated healthcare delivery system, Kaiser Permanente Northern California.

PARTICIPANTS

Individuals aged 50 and older without prevalent dementia with type 2 diabetes mellitus enrolled in a baseline survey. During 5 years of follow-up, 193 individuals with a new diagnosis of dementia were identified, and risk-set sampling was used to randomly select five reference subjects per case matched on 5-year age categories and sex (965 matched participants), resulting in an analytical sample of 1,158.

MEASUREMENTS

The exposure was new diagnosis of dementia. The primary outcome was change in number of current chronic medications (total, cardiovascular (blood pressure and lipid control), diabetes mellitus) at three times: 1 year before index date (preindex date), date of diagnosis of dementia or matched reference date (index date), and up to 1 year after index date or end of follow-up if censored before 1 year (postindex date).

RESULTS

After adjustment, the number of chronic medications and the subset of cardiovascular medications declined after a dementia diagnosis in the overall cohort and in age-, sex-, and time-matched reference individuals, but the decline was significantly greater in the group with dementia (0.71 medications fewer than the reference group, P = .02). The number of diabetes mellitus medications declined in both groups, but the declines were not statistically different (0.18 medications fewer than the reference group, P = .008).

CONCLUSIONS

Use of cardiometabolic medications fell after a diagnosis of dementia, as recommended in national guidelines.

Is a reduction in distance to nearest supermarket associated with BMI change among type 2 diabetes patients?

We examined whether residing within 2 miles of a new supermarket opening was longitudinally associated with a change in body mass index (BMI). We identified 12 new supermarkets that opened between 2009 and 2010 in 8 neighborhoods. Using the Kaiser Permanente Northern California Diabetes Registry, we identified members with type 2 diabetes residing continuously in any of these neighborhoods 12 months prior to the first supermarket opening until 10 months following the opening of the last supermarket. Exposure was defined as a reduction (yes/no) in travel distance to the nearest supermarket as a result of a new supermarket opening. First difference regression models were used to estimate the impact of reduced supermarket distance on BMI, adjusting for longitudinal changes in patient and neighborhood characteristics. Among patients in the exposed group, new supermarket openings reduced travel distance to the nearest supermarket by 0.7 miles on average. However, reduced distance to nearest supermarket was not associated with BMI changes. Overall, we found no evidence that reduced supermarket distance was associated with reduced levels of obesity for residents with type 2 diabetes.

Associations of perceived neighborhood safety and crime with cardiometabolic risk factors among a population with type 2 diabetes

Little is known about how neighborhood crime may relate to health in diabetes patients. We examined associations between individuals' perceptions of neighborhood safety or violent crime and stress, physical activity, body mass index (BMI) or hemoglobin A1c (HbA1c) in a sample (n=721) of adults (mean age:63) with diabetes. Self-reported neighborhood safety, violent crime, physical activity, and stress were collected and linked to clinical measures of BMI and HbA1c. Approximately 54% and 15% of patients reported neighborhood safety concerns and violent crimes, respectively. Any neighborhood safety concerns (β=1.14, 95% C.I. 0.04-2.24) and violent crime (β=2.04, 95% C.I. 0.34-3.73) were associated with BMI in adjusted analysis. Any violent crime was associated with class II-III obesity (BMI≥35) (OR=1.34, 95% C.I.: 1.02, 1.75). There were no significant associations between neighborhood safety concerns or violent crime with stress, physical activity, or HbA1c. Neighborhood safety is associated with BMI and obesity. Further studies, including longitudinal designs, are needed to study how people with diabetes may be influenced by a sense of poor personal safety in their neighborhoods.

Multiple primary melanomas among 16,570 patients with melanoma diagnosed at Kaiser Permanente Northern California, 1996 to 2011

BACKGROUND

Published rates of cutaneous multiple primary melanoma (MPM) vary widely.

OBJECTIVE

We examined incidence of and risk factors associated with MPMs among Kaiser Permanente Northern California members.

METHODS

We estimated MPM incidence among 16,570 patients with melanoma from 1996 through 2011. We compared characteristics between patients with MPMs and single primary melanomas and estimated crude and adjusted hazard ratios of MPMs using Cox models.

RESULTS

In all, 15,448 patients had a single melanoma and 1122 had MPMs. Patients with MPMs were older and more often male, non-Hispanic white, and partnered. Subsequent primary melanomas were diagnosed after a mean of 3.83 (SD 3.61, median 2.82) years and were more likely in situ and thinner than initial tumors. The risk of a subsequent melanoma decreased from 2% in the first year after diagnosis to a stable approximately 1% rate through 15 years of follow-up.

LIMITATIONS

We lacked data on some known melanoma risk factors and had small numbers of non-white patients and certain tumor subtypes.

CONCLUSIONS

The risk of MPMs, although highest in the first year after diagnosis, remains stable thereafter. Those at highest risk of MPMs are older, male, white, and partnered. Clinicians should be aware of the rate of MPMs and recognize high-risk subgroups.

CD8+ lymphocyte intratumoral infiltration as a stage-independent predictor of Merkel cell carcinoma survival: a population-based study

OBJECTIVES

Intratumoral CD8+ lymphocytes (IT-CD8s) have shown promise as a prognostic indicator for Merkel cell carcinoma (MCC). We tested whether IT-CD8s predict survival among a population-based MCC cohort.

METHODS

One hundred thirty-seven MCC cases that had not previously been analyzed for IT-CD8s were studied.

RESULTS

Three-year MCC-specific survival rates were 56%, 72%, and 100% for patients with absent (n = 46), low (n = 85), and moderate or strong (n = 6) IT-CD8s, respectively. Increased IT-CD8s were associated with improved MCC-specific survival in a multivariate competing risk-regression analysis including stage, age, and sex (hazard ratio [HR] = 0.5; 95% confidence interval [CI] = 0.3-0.9). Although a similar trend was observed for overall survival, statistical significance was not reached (HR = 0.8; 95% CI = 0.6-1.0), likely because of the high rate of non-MCC deaths among older patients.

CONCLUSIONS

This study of prospectively captured MCC cases supports the concept that cellular immunity is important in MCC outcome and that CD8+ lymphocyte infiltration adds prognostic information to conventional staging.

Effect of host, tumor, diagnostic, and treatment variables on outcomes in a large cohort with Merkel cell carcinoma

IMPORTANCE

Merkel cell carcinoma (MCC) is a rare, aggressive, neuroendocrine-derived skin cancer with high rates of recurrence and associated mortality. Few published studies have used comprehensive patient data and long-term follow-up to examine factors that predict MCC outcomes.

OBJECTIVE

To characterize MCC in a large defined-population cohort and analyze predictors of disease recurrence and survival.

SETTING, DESIGN, AND PARTICIPANTS

Retrospective cohort study of 218 patients with MCC from the cancer registry of Kaiser Permanente Northern California, a large integrated health care delivery system. Patients were diagnosed as having MCC and followed up from January 1, 1995, through December 31, 2009. We examined host (age, sex, race, and immunosuppression), tumor (anatomic site, size, and extent), diagnostic (results of imaging and pathologic nodal evaluation), and treatment (surgery, radiation therapy, and chemotherapy) variables for their association with MCC outcomes.

EXPOSURE

Host, tumor, diagnostic, and treatment factors.

MAIN OUTCOMES AND MEASURES

Recurrence (locoregional and distant) of MCC and patient survival (overall and MCC specific).

RESULTS

We estimated adjusted hazard ratios (AHRs) and 95% CIs for outcomes using Cox proportional hazards regression models. After adjustment for host, tumor, diagnostic, and treatment variables, tumor extent (categorized as local, regional, and distant) remained significantly associated with all outcomes. Immunosuppression was associated with higher MCC-specific mortality (AHR, 4.9 [95% CI, 1.7-14.4]), and an unknown primary site was associated with a lower risk for distant metastasis (0.1 [0.0-0.7]) and improved survival (0.4 [0.2-0.9]). Pathological nodal evaluation was associated with a lower risk for metastasis (AHR, 0.2 [95% CI, 0.0-1.0]) and improved survival. Radiation treatment was associated with a decreased risk for locoregional recurrence (AHR, 0.3 [95% CI, 0.1-0.6]), whereas chemotherapy was not associated with any alteration in outcomes.

CONCLUSIONS AND RELEVANCE

Tumor site and extent, results of pathologic nodal evaluation, and the presence of radiation treatment were associated with MCC recurrence. Immunosuppression, tumor extent, and results of pathologic nodal evaluation were associated with MCC-specific survival, whereas chemotherapy was not associated with any outcomes. Our findings may help to inform diagnostic and therapeutic management of MCCs.

The effect of bariatric surgery on psychiatric course among patients with bipolar disorder

OBJECTIVE

Bariatric surgery is the most effective therapy for severe obesity. People with bipolar disorder have increased risk of obesity, yet are sometimes considered ineligible for bariatric surgery due to their bipolar disorder diagnosis. This study aimed to determine if bariatric surgery alters psychiatric course among stable patients with bipolar disorder.

METHODS

A matched cohort study (2006-2009) with mean follow-up of 2.17 years was conducted within Kaiser Permanente Northern California, a group practice integrated health services delivery organization that provides medical and psychiatric care to 3.3 million people. Participants were 144 severely obese patients with bipolar disorder who underwent bariatric surgery, and 1,440 control patients with bipolar disorder, matched for gender, medical center, and contemporaneous health plan membership. Controls met referral criteria for bariatric surgery. Hazard ratio for psychiatric hospitalization, and change in rate of outpatient psychiatric utilization from baseline to Years 1 and 2, were compared between groups.

RESULTS

A total of 13 bariatric surgery patients (9.0%) and 153 unexposed to surgery (10.6%) had psychiatric hospitalization during follow-up. In multivariate Cox models adjusting for potential confounding factors, the hazard ratio of psychiatric hospitalization associated with bariatric surgery was 1.03 [95% confidence interval (CI): 0.83-1.23]. In fully saturated multivariate general linear models, change in outpatient psychiatric utilization was not significantly different for surgery patients versus controls, from baseline to Year 1 (-0.4 visits/year, 95% CI: -0.5 to 0.4) or baseline to Year 2 (0.4 visits/year, 95% CI: -0.1 to 1.0).

CONCLUSIONS

Bariatric surgery did not affect psychiatric course among stable patients with bipolar disorder. The results of this study suggest that patients with bipolar disorder who have been evaluated as stable can be considered for bariatric surgery.

HbA1c and risk of severe hypoglycemia in type 2 diabetes: the Diabetes and Aging Study

OBJECTIVE

We examined the association between HbA1c level and self-reported severe hypoglycemia in patients with type 2 diabetes.

RESEARCH DESIGN AND METHODS

Type 2 diabetic patients in a large, integrated healthcare system, who were 30-77 years of age and treated with glucose-lowering therapy, were asked about severe hypoglycemia requiring assistance in the year prior to the Diabetes Study of Northern California survey conducted in 2005-2006 (62% response rate). The main exposure of interest was the last HbA1c level collected in the year preceding the observation period. Poisson regression models adjusted for selected demographic and clinical variables were specified to evaluate the relative risk (RR) of severe hypoglycemia across HbA1c levels. We also tested whether the HbA1c-hypoglycemia association differed across potential effect modifiers (age, diabetes duration, and category of diabetes medication).

RESULTS

Among 9,094 eligible survey respondents (mean age 59.5 ± 9.8 years, mean HbA1c 7.5 ± 1.5%), 985 (10.8%) reported experiencing severe hypoglycemia. Across HbA1c levels, rates of hypoglycemia were 9.3-13.8%. Compared with those with HbA1c of 7-7.9%, the RR of hypoglycemia was 1.25 (95% CI 0.99-1.57), 1.01 (0.87-1.18), 0.99 (0.82-1.20), and 1.16 (0.97-1.38) among those with HbA1c <6, 6-6.9, 8-8.9, and ≥9%, respectively, in a fully adjusted model. Age, diabetes duration, and category of diabetes medication did not significantly modify the HbA1c-hypoglycemia relationship.

CONCLUSIONS

Severe hypoglycemia was common among patients with type 2 diabetes across all levels of glycemic control. Risk tended to be higher in patients with either near-normal glycemia or very poor glycemic control.

Obesity and the food environment: income and ethnicity differences among people with diabetes: the Diabetes Study of Northern California (DISTANCE)

OBJECTIVE

It is unknown whether any association between neighborhood food environment and obesity varies according to individual income and/or race/ethnicity. The objectives of this study were to test whether there was an association between food environments and obesity among adults with diabetes and whether this relationship differed according to individual income or race/ethnicity.

RESEARCH DESIGN AND METHODS

Subjects (n = 16,057) were participants in the Diabetes Study of Northern California survey. Kernel density estimation was used to create a food environment score for each individual's residence address that reflected the mix of healthful and unhealthful food vendors nearby. Logistic regression models estimated the association between the modeled food environment and obesity, controlling for confounders, and testing for interactions between food environment and race/ethnicity and income.

RESULTS

The authors found that more healthful food environments were associated with lower obesity in the highest income groups (incomes 301-600% and >600% of U.S. poverty line) among whites, Latinos, and Asians. The association was negative, but smaller and not statistically significant, among high-income blacks. On the contrary, a more healthful food environment was associated with higher obesity among participants in the lowest-income group (<100% poverty threshold), which was statistically significant for black participants in this income category.

CONCLUSIONS

These findings suggest that the availability of healthful food environments may have different health implications when financial resources are severely constrained.

Neighborhood deprivation and change in BMI among adults with type 2 diabetes: the Diabetes Study of Northern California (DISTANCE)

OBJECTIVE

To compare associations between neighborhood deprivation and measures of BMI change among adults with type 2 diabetes.

RESEARCH DESIGN AND METHODS

Using data from the Kaiser Permanente Diabetes Study of Northern California (DISTANCE) survey, we estimated the association between neighborhood deprivation and two measures of BMI change over 3 years: 1) a continuous measure and 2) a categorical measure of clinically substantive BMI loss or gain (≥7% of baseline BMI) versus stable BMI. The sample included 13,609 adults.

RESULTS

On average, there was little change in BMI (-0.12, SD 3.07); 17.0 and 16.1% had clinically substantive BMI loss or gain, respectively, at follow-up. There was a positive association between neighborhood deprivation and BMI change for adults in the most versus least-deprived quartile of neighborhood deprivation (β = 0.22, P = 0.02) in adjusted models. In addition, relative to the least-deprived quartile (Q1), adults in more-deprived quartiles of neighborhood deprivation were more likely to experience either substantive BMI loss (Q2 relative risk ratio 1.19, 95% CI 1.00-1.41; Q3 1.20, 1.02-1.42; Q4 1.30, 1.08-1.55) or gain (Q2 1.25, 1.04-1.49; Q3 1.24, 1.04-1.49; Q4 1.45, 1.20-1.75).

CONCLUSIONS

Greater neighborhood deprivation was positively associated with BMI change among adults with diabetes as well as with clinically substantive BMI loss or gain. Findings stress the importance of allowing for simultaneous associations with both gain and loss in future longitudinal studies of neighborhood deprivation and weight change, which may be particularly true for studies of patients with diabetes for whom both weight loss and gain have health implications.

Communication and medication refill adherence: the Diabetes Study of Northern California

BACKGROUND

Poor medication refill adherence contributes to poor cardiometabolic control and diabetes outcomes. Studies linking communication between patients and health care providers to adherence often use self-reported adherence and have not explored differences across communication domains or therapeutic indications.

METHODS

To investigate associations between patient communication ratings and cardiometabolic medication refill adherence, we conducted a cross-sectional analysis of 9377 patients in the Diabetes Study of Northern California (DISTANCE), a race-stratified, random sample of Kaiser Permanente survey respondents. Eligible participants received 1 or more oral hypoglycemic, lipid-lowering, or antihypertensive medication in the 12 months preceding the survey. Communication was measured with a 4-item Consumer Assessment of Healthcare Providers and Systems Survey (CAHPS) score and 4 items from the Trust in Physicians and Interpersonal Processes of Care instruments. Poor adherence was classified as greater than a 20% continuous medication gap for ongoing medication therapies. Using modified least squares regression, we calculated differences in poor adherence prevalence for a 10-point decrease in CAHPS score and compared higher vs lower communication ratings on other items, adjusting for necessary sociodemographic and medical confounders derived from a directed acyclic graph.

RESULTS

In this cohort, 30% had poor cardiometabolic medication refill adherence. For each 10-point decrease in CAHPS score, the adjusted prevalence of poor adherence increased by 0.9% (P=.01). Compared with patients offering higher ratings, patients who gave health care providers lower ratings for involving patients in decisions, understanding patients' problems with treatment, and eliciting confidence and trust were more likely to have poor adherence, with absolute differences of 4% (P=.04), 5% (P=.02), and 6% (P=.03), respectively. Associations between communication and adherence were somewhat larger for hypoglycemic medications than for other medications.

CONCLUSIONS

Poor communication ratings were independently associated with objectively measured inadequate cardiometabolic medication refill adherence, particularly for oral hypoglycemic medications. Future studies should investigate whether improving communication skills among clinicians with poorer patient communication ratings could improve their patients' cardiometabolic medication refill adherence and outcomes.

HIV infection status, immunodeficiency, and the incidence of non-melanoma skin cancer

Background The incidence of non-melanoma skin cancers (NMSCs), including basal cell (BCC) or squamous cell carcinoma (SCC), is not well documented among HIV-positive (HIV(+)) individuals. Methods We identified 6560 HIV(+) and 36 821 HIV-negative (HIV(-)) non-Hispanic white adults who were enrolled and followed up in Kaiser Permanente Northern California from 1996 to 2008. The first biopsy-proven NMSCs diagnosed during follow-up were identified from pathology records. Poisson models estimated rate ratios that compared HIV(+) (overall and stratified by recent CD4 T-cell counts and serum HIV RNA levels) with HIV(-) subjects and were adjusted for age, sex, smoking history, obesity diagnosis history, and census-based household income. Sensitivity analyses were adjusted for outpatient visits (ie, a proxy for screening). All statistical tests were two-sided. Results The NMSC incidence rate was 1426 and 766 per 100 000 person-years for HIV(+) and HIV(-) individuals, respectively, which corresponds with an adjusted rate ratio of 2.1 (95% confidence interval [CI] = 1.9 to 2.3). Similarly, the adjusted rate ratio for HIV(+) vs HIV(-) subjects was 2.6 (95% CI = 2.1 to 3.2) for SCCs, and it was 2.1 (95% CI = 1.8 to 2.3) for BCCs. There was a statistically significant trend of higher rate ratios with lower recent CD4 counts among HIV(+) subjects compared with HIV(-) subjects for SCCs (P trend < .001). Adjustment for number of outpatient visits did not affect the results. Conclusion HIV(+) subjects had a twofold higher incidence rate of NMSCs compared with HIV(-) subjects. SCCs but not BCCs were associated with immunodeficiency.

Validation of a large basal cell carcinoma registry

BACKGROUND

The epidemiological study of basal cell carcinomas (BCCs) is difficult because BCCs lack distinct disease codes and are excluded from most cancer registries.

OBJECTIVE

To develop and validate a large BCC registry based on electronically assigned Systematized Nomenclature of Medicine (SNOMED) codes and text-string searches of electronic pathology reports from Kaiser Permanente Northern California.

METHODS AND MATERIALS

Potential BCCs were identified from electronic pathology reports (n=39,026) in 2005 and were reviewed by a dermatologist who assigned case/non-case status (gold-standard). A subset of the records (n=9,428) was independently reviewed by a second dermatologist to ascertain reliability of case assignment. In addition, a subset of excluded electronic pathology reports from 2005 (n=2,700) was reviewed to determine whether inclusion criteria had missed potential BCCs. We calculated the positive predictive value (PPV) of 3 different algorithms for identifying BCCs from electronic pathology data.

RESULTS

BCC-specific SNOMED codes had the highest PPV for identifying BCCs, 0.992 (95 percent CI: 0.991-0.993). Inter-rater reliability for case assignment was high (kappa=0.92, 95 percent CI: 0.91-0.93). Standardized incidence rates were consistent with previously published rates in the United States.

CONCLUSIONS

We created and validated a large BCC registry to serve as a unique resource for studying BCCs.

Antihypertensive drugs and lip cancer in non-Hispanic whites

BACKGROUND

In screening pharmaceuticals for possible carcinogenic effects we noted an association between lip cancer risk and the photosensitizing antihypertensive drugs hydrochlorothiazide and nifedipine. In this study, we further characterized the risk of lip cancer associated with these and other commonly used antihypertensive drugs.

METHODS

In a comprehensive medical care program, we evaluated prescriptions dispensed and cancer occurrence from August 1, 1994, to February 29, 2008. We identified 712 patients with lip cancer (cases) and 22,904 comparison individuals (controls) matched for age, sex, and cohort year of entry in the susceptible group, non-Hispanic whites. We determined use, at least 2 years before diagnosis or control index date, of the commonly prescribed diuretics hydrochlorothiazide and hydrochlorothiazide combined with triamterene, the angiotensin-converting enzyme inhibitor lisinopril, the calcium channel blocker nifedipine, and the β-adrenergic blocker atenolol, the only nonphotosensitizer agent studied. We analyzed the use of each drug exclusively and regardless of use of the others, and focused on duration of use. Conditional logistic regression was used for analysis of matched case-control sets, with control for cigarette smoking.

RESULTS

At least a 5-year supply of a drug yielded the following odds ratios (95% CIs), respectively, compared with no use: hydrochlorothiazide, 4.22 (2.82-6.31); hydrochlorothiazide-triamterene, 2.82 (1.74-4.55); lisinopril, 1.42 (0.95-2.13); nifedipine, 2.50 (1.29-4.84); and atenolol, 1.93 (1.29-2.91). When the other drugs were excluded, the odds ratio for atenolol was reduced to 0.54 (0.07-4.08).

CONCLUSION

These data support an increased risk of lip cancer in non-Hispanic whites receiving treatment for hypertension with long-term use of photosensitizing drugs.

Place matters: neighborhood deprivation and cardiometabolic risk factors in the Diabetes Study of Northern California (DISTANCE)

While neighborhood deprivation is associated with prevalence of chronic diseases, it is not well understood whether neighborhood deprivation is also associated with cardiometabolic risk factors among adults with chronic disease. Subjects (n = 19,804) from the Diabetes Study of Northern California (DISTANCE) cohort study, an ethnically-stratified, random sample of members of Kaiser Permanente Northern California (KPNC), an integrated managed care consortium, with type 2 diabetes who completed a survey between 2005 and 2007 and who lived in a 19 county study area were included in the analyses. We estimated the association between a validated neighborhood deprivation index (NDI) and four cardiometabolic risk factors: body mass index (BMI = kg/m2), glycosylated hemoglobin (A1c), low density lipoproteins (LDL) and systolic blood pressure (SBP) using multi-level models. Outcomes were modeled in their continuous form and as binary indicators of poor control (severe obesity: BMI ≥35, poor glycemic control: A1c ≥9%, hypercholesterolemia: LDL ≥130 mg/dL, and hypertension: SBP ≥140 mmHg). BMI, A1c and SBP increased monotonically across quartiles of NDI (p < 0.001 in each case); however, LDL was significantly associated with NDI only when comparing the most to the least deprived quartile. NDI remained significantly associated with BMI and A1c after adjusting for individual level factors including income and education. A linear trend (p < 0.001) was observed in the relative risk ratios for dichotomous indicators of severe obesity, poor glycemic control, and 2 or more poorly controlled cardiometabolic risk factors across NDI quartile. In adjusted models, higher levels of neighborhood deprivation were positively associated with indicators of cardiometabolic risk among adults with diabetes, suggesting that neighborhood level deprivation may influence individual outcomes. However, longitudinal data are needed to test the causal direction of these relationships.

Predictors of patient satisfaction with Mohs surgery: analysis of preoperative, intraoperative, and postoperative factors in a prospective cohort

OBJECTIVE

To identify preoperative, intraoperative, and postoperative variables that predict higher short- and long-term patient satisfaction with Mohs surgery.

DESIGN

Prospective cohort study.

SETTING

A university-based dermatology practice and the affiliated Veterans Affairs medical center dermatology clinic.

PATIENTS

A total of 339 consecutive patients treated with Mohs surgery in 1999 and 2000.

MAIN OUTCOME MEASURES

Short-term satisfaction at 1 week and long-term satisfaction at 1 year. We used directed acyclic graphs to determine appropriate confounding adjustment for preoperative, intraoperative, and postoperative variables that influence satisfaction with Mohs surgery in logistic regression models.

RESULTS

Better preoperative skin-related quality of life (measured using Skindex) and more intraoperative Mohs stages were the most salient predictors of higher short- and long-term satisfaction; these odds ratios (ORs) were 2.33 (95% CI, 1.01-5.35) and 5.19 (1.66-16.29), respectively, for preoperative skin-related quality of life and 7.06 (2.02-24.67) and 5.30 (1.24-22.64), respectively, for more intraoperative Mohs stages. Patients not bothered by postoperative bleeding were more likely to be satisfied short term (OR, 2.25; 95% CI, 1.25-4.05), as were those who considered themselves involved in decision making about their treatment (3.05; 1.52-6.10). Higher long-term satisfaction with Mohs surgery was observed among patients who were married (2.36; 1.10-5.09).

CONCLUSIONS

Higher short- and long-term satisfaction with Mohs surgery is predicted by better preoperative skin-related quality of life and by more intraoperative Mohs stages. The effect of postoperative variables wanes over time, suggesting that factors influencing satisfaction can vary depending on the time frame when satisfaction is measured. Our results may help clinicians identify patients who are at higher risk of dissatisfaction following Mohs surgery.

Supplement use and risk of cutaneous squamous cell carcinoma

BACKGROUND

Laboratory and epidemiologic studies suggest that certain dietary supplements may alter risk of cutaneous squamous cell carcinoma (SCC).

OBJECTIVE

We sought to examine the association between supplement use and SCC risk.

METHODS

Cases (n = 415) were defined as Kaiser Permanente Northern California members with a pathology-verified SCC in 2004 and control subjects (n = 415) were age-, sex-, and race-matched members with no history of skin cancer. Supplement use and SCC risk factors were ascertained by questionnaire. Associations of SCC with use of multivitamins; vitamins A, C, D, and E; and grape seed extract were estimated as odds ratios and 95% confidence intervals using conditional logistic regression. Models were adjusted for SCC risk factors and other supplement use.

RESULTS

Grape seed extract users had a significantly decreased risk of cutaneous SCC (adjusted odds ratio 0.26, confidence interval 0.08-0.89, P = .031). Multivitamin use was associated with a borderline significant reduction in SCC risk (adjusted odds ratio 0.71, confidence interval 0.51-1.00, P = .049). Use of vitamins A, C, D, and E was not associated with SCC risk.

LIMITATIONS

The data may be prone to recall and selection bias because of the case-control design. No information was obtained on dose or duration of supplement use.

CONCLUSIONS

Use of grape seed extract may be associated with a decreased risk of cutaneous SCC. The other supplements included in our study did not reveal clear associations with SCC risk.

Association of tea consumption and cutaneous squamous cell carcinoma

Laboratory and epidemiologic studies suggest a protective effect of tea consumption on risk of cutaneous squamous cell carcinoma (SCC). We designed a case-control study to examine the association between putative protective exposures, including tea consumption, and SCC risk using a large health maintenance organization population. Cases (n=415) were defined as Kaiser Permanente Northern California (KPNC) members with a pathology-verified SCC in 2004 and controls (n=415) were age-, gender-, and race-matched members with no previous history of skin cancer. Tea consumption and SCC risk factors were ascertained by questionnaire. Odds ratios (OR) and 95% confidence intervals (CI) were calculated using conditional logistic regression to estimate the association of SCC with regular use, as well as dose and duration of tea consumption. Risk factor adjusted models included education, smoking, hair and eye color, skin type, family history of skin cancer, and history of freckling, sunburns, sun exposure, and tanning bed use. Adjusted analyses showed no reduction in SCC risk with regular consumption of tea (OR=1.11, 95% CI: 0.81-1.54). Examining duration, dose, and combined duration and dose exposure variables did not alter findings. We found no evidence that tea consumption was associated with cutaneous SCC risk.