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Thompson JH, Davis MM, Leo MC, Schneider JL, Smith DH, Petrik AF, Castillo M, Younger B, Coronado GD. Participatory Research to Advance Colon Cancer Prevention (PROMPT): Study protocol for a pragmatic trial. Contemp Clin Trials 2018; 67:11-15. [PMID: 29408304 PMCID: PMC5903679 DOI: 10.1016/j.cct.2018.02.001] [Citation(s) in RCA: 15] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/06/2017] [Revised: 01/18/2018] [Accepted: 02/01/2018] [Indexed: 12/13/2022]
Abstract
BACKGROUND Colon cancer is the second leading cause of cancer deaths in the United States. The Participatory Research to Advance Colon Cancer Prevention (PROMPT) study is a collaboration between two research institutions and a federally qualified health center (FQHC). The study seeks to raise colon cancer screening rates using a direct-mail fecal immunochemical testing (FIT) and reminder program in an FQHC serving a predominantly Latino population in California. METHODS PROMPT is a pragmatic trial enrolling 16 clinics. The study will test automated and live prompts (i.e., alerts, reminders) to a direct-mail FIT program in two phases. In Phase I, we tailored and defined intervention components for the pilot using a community-based participatory research approach called boot camp translation. We then plan to conduct a three-arm patient-randomized comparative effectiveness trial in two pilot clinics to compare 1) automated prompts, 2) live prompts, and 3) a combination of automated plus live prompts to alert and remind patients to complete screening. In Phase II, the adapted best practice intervention will be spread to additional clinics within the FQHC (estimated population 27,000) and assessed for effectiveness. Patient and staff interviews will be conducted to explore receptivity to the program and identify barriers to implementation. DISCUSSION This pragmatic trial applies innovative approaches to engage diverse stakeholders and will test the effectiveness and spread of a direct-mail plus reminder program. If successful, the program will provide a model for a cost-effective method to raise colon cancer screening rates among Latino patients receiving care in FQHCs. TRIAL REGISTRATION National Clinical Trial (NCT) Identifier NCT03167125.
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Affiliation(s)
- Jamie H Thompson
- The Center for Health Research, Kaiser Permanente Northwest, 3800 N. Interstate Avenue, Portland, Oregon 97227, USA.
| | - Melinda M Davis
- Oregon Rural Practice-based Research Network (ORPRN), Oregon Health & Science University, 3181 S.W. Sam Jackson Park Road, Portland, Oregon 97239, USA.
| | - Michael C Leo
- The Center for Health Research, Kaiser Permanente Northwest, 3800 N. Interstate Avenue, Portland, Oregon 97227, USA.
| | - Jennifer L Schneider
- The Center for Health Research, Kaiser Permanente Northwest, 3800 N. Interstate Avenue, Portland, Oregon 97227, USA.
| | - David H Smith
- The Center for Health Research, Kaiser Permanente Northwest, 3800 N. Interstate Avenue, Portland, Oregon 97227, USA.
| | - Amanda F Petrik
- The Center for Health Research, Kaiser Permanente Northwest, 3800 N. Interstate Avenue, Portland, Oregon 97227, USA.
| | | | | | - Gloria D Coronado
- The Center for Health Research, Kaiser Permanente Northwest, 3800 N. Interstate Avenue, Portland, Oregon 97227, USA.
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Kraft SA, Schneider JL, Leo MC, Kauffman TL, Davis JV, Porter KM, McMullen CK, Wilfond BS, Goddard KAB. Patient actions and reactions after receiving negative results from expanded carrier screening. Clin Genet 2018; 93:962-971. [PMID: 29293279 DOI: 10.1111/cge.13206] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/01/2017] [Revised: 12/05/2017] [Accepted: 12/27/2017] [Indexed: 02/04/2023]
Abstract
With the expansion of carrier screening to general preconception and prenatal patient populations, most patients will receive negative results, which we define as indicating <25% risk of having a child with a genetic condition. Because there is limited experience with expanded carrier screening, it is important to understand how receiving negative results affects patients, especially as providers, payers, and policymakers consider whether to offer it. In this mixed-methods study, we asked preconception patients enrolled in the NextGen study about their expectations and experiences receiving negative expanded carrier screening results. Participants completed surveys at study enrollment (n = 110 women, 51 male partners), after receiving carrier results (n = 100 women, 38 male partners), after receiving secondary findings (n = 98 women, 36 male partners), and 6 months after receiving results (n = 95 women, 28 male partners). We also interviewed a subset of participants 12 to 24 months after receiving results (n = 24 women, 12 male partners). We found minimal negative emotional impact and privacy concerns, increased confidence in reproductive plans, and few changes to health behaviors, although some patients made health decisions based on misunderstandings of their results. These findings suggest that expanded carrier screening causes minimal psychosocial harms, but systems are needed to reduce the risk of misinterpreting results.
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Affiliation(s)
- S A Kraft
- Treuman Katz Center for Pediatric Bioethics, Seattle Children's Hospital and Research Institute, Seattle, Washington.,Division of Bioethics, Department of Pediatrics, University of Washington School of Medicine, Seattle, Washington
| | - J L Schneider
- Center for Health Research, Kaiser Permanente Northwest, Portland, Oregon
| | - M C Leo
- Center for Health Research, Kaiser Permanente Northwest, Portland, Oregon
| | - T L Kauffman
- Center for Health Research, Kaiser Permanente Northwest, Portland, Oregon
| | - J V Davis
- Center for Health Research, Kaiser Permanente Northwest, Portland, Oregon
| | - K M Porter
- Treuman Katz Center for Pediatric Bioethics, Seattle Children's Hospital and Research Institute, Seattle, Washington
| | - C K McMullen
- Center for Health Research, Kaiser Permanente Northwest, Portland, Oregon
| | - B S Wilfond
- Treuman Katz Center for Pediatric Bioethics, Seattle Children's Hospital and Research Institute, Seattle, Washington.,Division of Bioethics, Department of Pediatrics, University of Washington School of Medicine, Seattle, Washington
| | - K A B Goddard
- Center for Health Research, Kaiser Permanente Northwest, Portland, Oregon
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Churchill SS, Leo MC, Brennan EM, Sellmaier C, Kendall J, Houck GM. Longitudinal Impact of a Randomized Clinical Trial to Improve Family Function, Reduce Maternal Stress and Improve Child Outcomes in Families of Children with ADHD. Matern Child Health J 2018; 22:1172-1182. [PMID: 29476416 DOI: 10.1007/s10995-018-2502-5] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/20/2023]
Abstract
Objective Evaluate the efficacy of a 12 month nursing case-management intervention over a period of 18 months, 6 months after the end of intervention, for families of children attention deficit hyperactivity disorder (ADHD). Methods Mother and child dyads were enrolled to participate in a randomized controlled clinical trial. Children were 4-18 years old. Data were collected at baseline, 6, 12, and 18 months or 6 months after the termination of direct intervention. Longitudinal analyses, using generalized estimating equations, were conducted to assess change in study outcomes relating to family function, maternal stress, and child behavior over the 18 month period. Results Compared to control families, some family function outcomes were moderately improved in the intervention group. In particular, intervention families demonstrated substantial improvement in implementing family behavior controls (p value = 0.038) and improvement in family satisfaction (not statistically significant p = 0.062). Although there was improvement in the overall family function measure there was not a statistically significant difference between groups. Maternal stress and child behavior outcomes were not significantly different between control and intervention groups by the end of the intervention. Conclusions for Practice Addressing ADHD is complex and requires the assessment of comorbidities that might exacerbate negative behavior. Our findings support the latest American Academy of Pediatrics guidelines to use behavioral therapy as the first line of treatment in young children. Nursing case-management interventions that provide direct family education and improve family function, especially with respect to providing structure and behavior control, may complement and facilitate behavioral therapy for treatment of ADHD and improving child behavior.
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Affiliation(s)
- Shervin S Churchill
- Family and Child Nursing, University of Washington, Seattle, WA, 98195-7266, USA. .,School of Nursing and Health Studies, University of Washington Bothell, Bothell, WA, 98011, USA.
| | - Michael C Leo
- Center for Health Research, Kaiser Permanente Northwest, Portland, OR, USA
| | - Eileen M Brennan
- School of Social Work, Portland State University, Portland, OR, USA
| | - Claudia Sellmaier
- Social Work and Criminal Justice, University of Washington-Tacoma, Tacoma, WA, 98402, USA
| | - Judy Kendall
- Cascadia Behavioral Health Care, Portland, OR, USA
| | - Gail M Houck
- Family and Child Nursing, University of Washington, Seattle, WA, 98195-7266, USA
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Leo MC, Francisco M, Jenkins C, Weinmann S. Abstract P3-08-05: Validation of a nomogram for predicting recurrence among women with ductal carcinoma in situ and breast conserving surgery in an integrated health care system. Cancer Res 2018. [DOI: 10.1158/1538-7445.sabcs17-p3-08-05] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Abstract
Current management of ductal carcinoma in situ (DCIS) most often entails removing the lesion by breast-conserving surgery. Quantifying the risk of a patient's ipsilateral breast event (IBE) recurrence, either invasive cancer or DCIS, after breast conserving surgery remains a clinical concern. The aim of this study was to validate the Memorial Sloan-Kettering Cancer Center (MSKCC) nomogram to predict IBE recurrence in patients from our institution.
Patients and Methods
We retrospectively identified 608 patients in the Kaiser Permanente Northwest integrated healthcare system with a diagnosis of DCIS who had undergone local excision from 1990 through 2007. We assessed the performance of the MSKCC nomogram for predicting IBE recurrence using measures of discrimination (how well risk scores separate those with and without the event) and calibration (agreement between predicted and observed risk). We calculated Harrell's C and R2D to provide estimates of discrimination. We calculated the calibration slope by performing a Cox regression using the prognostic index (PI; predicted log relative hazard based on the original Cox coefficients), with a slope not significantly different from 1 indicating no difference in discrimination from the development sample. We also examined discrimination by comparing the KM curves of 4 risk groups and in a Cox regression as a predictor, which were created using Cox's method (4 groups using the 16th, 50th, & 84th percentiles), as no risk groups were defined in the MSKCC development study. We examined whether there was model misfit by testing each predictor in a Cox regression with an offset of the PI. Finally, we assessed calibration by plotting the observed rates and associated 95% CIs against the predicted probabilities for groups based on 4 risk groups and octiles.
Results
The median follow-up time for the KPNW cohort was 125 months. The 10-year IBE recurrence rate was 9.5%, 95% CI [7.0%, 13.0%). Harrell's C was .70, which is comparable to what has been found in other validation studies. The PI accounted for 22% of variation in time (R2D =.22, 95% CI [.08, .38]). The test of the calibration slope provided no support that discrimination in this sample differs from the development study (LR χ2(1)=0.21, p=.65). An examination of the Kaplan-Meier curves among the risk groups showed good separation of the high risk group compared to the others, but little separation between the lowest two risk groups. None of the predictors demonstrated evidence for differential weighting from the MSKCC coefficients (p values ranged from .08 to .97). Calibration was good for the lowest, low, and moderate risk groups, but there was underprediction in the high risk group. When examining calibration using octiles, we found a similar pattern to that of other validation studies in which the highest octile had the furthest departure from perfect agreement.
Conclusion
The MSKCC nomogram for predicting IBE recurrence in patients with DCIS who were treated with local excision have some utility, and our results are consistent with other validation efforts. However, there is much potential to further increase the prediction of recurrence beyond what is possible with the MSKCC nomogram.
Citation Format: Leo MC, Francisco M, Jenkins C, Weinmann S. Validation of a nomogram for predicting recurrence among women with ductal carcinoma in situ and breast conserving surgery in an integrated health care system [abstract]. In: Proceedings of the 2017 San Antonio Breast Cancer Symposium; 2017 Dec 5-9; San Antonio, TX. Philadelphia (PA): AACR; Cancer Res 2018;78(4 Suppl):Abstract nr P3-08-05.
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Affiliation(s)
- MC Leo
- Kaiser Permanente Center for Health Research, Portland, OR
| | - M Francisco
- Kaiser Permanente Center for Health Research, Portland, OR
| | - C Jenkins
- Kaiser Permanente Center for Health Research, Portland, OR
| | - S Weinmann
- Kaiser Permanente Center for Health Research, Portland, OR
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Dickerson JF, Lynch FL, Leo MC, DeBar LL, Pearson J, Clarke GN. Cost-effectiveness of Cognitive Behavioral Therapy for Depressed Youth Declining Antidepressants. Pediatrics 2018; 141:peds.2017-1969. [PMID: 29351965 PMCID: PMC5810604 DOI: 10.1542/peds.2017-1969] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 11/22/2017] [Indexed: 11/24/2022] Open
Abstract
BACKGROUND AND OBJECTIVES Adolescents with depression identified in primary care settings often have limited treatment options beyond antidepressant (AD) therapy. We assessed the cost-effectiveness of a brief cognitive behavioral therapy (CBT) program among depressed adolescents who declined or quickly stopped using ADs. METHODS A total of 212 youth with depression were randomly assigned to treatment as usual (TAU) or TAU plus brief individual CBT. Clinical outcomes included depression-free days (DFDs) and estimated quality-adjusted life-years (QALYs). Costs were adjusted to 2008 US dollars. Incremental cost-effectiveness ratios (ICERs) comparing CBT to TAU were calculated over 12- and 24-month follow-up periods. RESULTS Youth randomly assigned to CBT had 26.8 more DFDs (P = .044) and 0.067 more QALYs (P = .044) on average compared with TAU over 12 months. Total costs were $4976 less (P = .025) by the end of the 24-month follow-up among youth randomly assigned to CBT. Total costs per DFD were -$51 (ICER = -$51; 95% confidence interval [CI]: -$394 to $9) at 12 months and -$115 (ICER = -$115; 95% CI: -$1090 to -$6) at 24 months. Total costs per QALY were -$20 282 (ICER = -$20 282; 95% CI: -$156 741 to $3617) at 12 months and -$45 792 (ICER = -$45 792; 95% CI: -$440 991 to -$2731) at 24 months. CONCLUSIONS Brief primary care CBT among youth declining AD therapy is cost-effective by widely accepted standards in depression treatment. CBT becomes dominant over TAU over time, as revealed by a statistically significant cost offset at the end of the 2-year follow-up.
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Affiliation(s)
| | - Frances L. Lynch
- Kaiser Permanente Center for Health Research, Portland, Oregon; and
| | - Michael C. Leo
- Kaiser Permanente Center for Health Research, Portland, Oregon; and
| | - Lynn L. DeBar
- Kaiser Permanente Washington Health Research Institute, Seattle, Washington
| | - John Pearson
- Kaiser Permanente Center for Health Research, Portland, Oregon; and
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Rieckmann T, Muench J, McBurnie MA, Leo MC, Crawford P, Ford D, Stubbs J, O'Cleirigh C, Mayer KH, Fiscella K, Wright N, Doe-Simkins M, Cuddeback M, Salisbury-Afshar E, Nelson C. Medication-assisted treatment for substance use disorders within a national community health center research network. Subst Abus 2018; 37:625-634. [PMID: 27218678 DOI: 10.1080/08897077.2016.1189477] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/12/2023]
Abstract
BACKGROUND The Affordable Care Act increases access to treatment services for people who suffer from substance use disorders (SUDs), including alcohol use disorders (AUDs) and opioid use disorders (OUDs). This increased access to treatment has broad implications for delivering health services and creates a dramatic need for transformation in clinical care, service lines, and collaborative care models. Medication-assisted treatments (MAT) are effective for helping SUD patients reach better outcomes. This article uses electronic health record (EHR) data to examine the prevalence of EHR-documented SUDs, patient characteristics, and patterns of MAT prescribing and screening for patients within the Community Health Applied Research Network (CHARN), a national network of 17 community health centers that facilitates patient-centered outcomes research among underserved populations. METHODS Hierarchical generalized linear models examined patient characteristics, SUD occurrence rates, MAT prescription, and human immunodeficiency virus (HIV) and hepatitis virus C screening for patients with AUDs or OUDs. Results: Among 572,582 CHARN adult patients, 16,947 (3.0%) had a documented AUD diagnosis and 6,080 (1.1%) an OUD diagnosis. Alcohol MAT prescriptions were documented for 547 AUD patients (3.2%) and opioid MAT for 1,764 OUD patients (29.0%). Among OUD patients, opioid MAT was significantly associated with HIV screening (odds ratio [OR] = 1.31, P < .001) in OUD patients, as was alcohol MAT among AUD patients (OR = 1.30, P = .013). CONCLUSIONS These findings suggest that effective opioid and alcohol MAT may be substantially underprescribed among safety-net patients identified as having OUDs or AUDs.
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Affiliation(s)
- Traci Rieckmann
- a School of Medicine, Oregon Health and Science University (OHSU) , Portland , Oregon , USA.,b School of Public Health, Oregon Health and Science University (OHSU) , Portland , Oregon , USA
| | - John Muench
- c Department of Family Medicine , Oregon Health and Science University Richmond Clinic , Portland , Oregon , USA
| | - Mary Ann McBurnie
- d Oregon Community Health Information Network (OCHIN) , Portland , Oregon , USA
| | - Michael C Leo
- e Community Health Applied Research Network (CHARN) Data Coordinating Center , Portland , Oregon , USA
| | - Phillip Crawford
- e Community Health Applied Research Network (CHARN) Data Coordinating Center , Portland , Oregon , USA
| | - Daren Ford
- b School of Public Health, Oregon Health and Science University (OHSU) , Portland , Oregon , USA
| | - Jennifer Stubbs
- b School of Public Health, Oregon Health and Science University (OHSU) , Portland , Oregon , USA
| | - Conall O'Cleirigh
- f Fenway Health, Harvard Medical School, and Massachusetts General Hospital , Boston , Massachusetts , USA
| | - Kenneth H Mayer
- f Fenway Health, Harvard Medical School, and Massachusetts General Hospital , Boston , Massachusetts , USA
| | - Kevin Fiscella
- g Departments of Family Medicine and Public Health Sciences , University of Rochester Medical Center , Rochester , New York , USA
| | - Nicole Wright
- h Association of Asian Pacific Community Health Organizations , Oakland , California , USA
| | - Maya Doe-Simkins
- i Alliance of Chicago Community Health Services , Chicago , Illinois , USA
| | - Matthew Cuddeback
- i Alliance of Chicago Community Health Services , Chicago , Illinois , USA
| | | | - Christine Nelson
- d Oregon Community Health Information Network (OCHIN) , Portland , Oregon , USA
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Naleway AL, Henninger ML, Waiwaiole LA, Mosen DM, Leo MC, Pihlstrom DJ. Dental provider practices and perceptions regarding adolescent vaccination. J Public Health Dent 2017; 78:159-164. [PMID: 29114884 DOI: 10.1111/jphd.12256] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/17/2017] [Revised: 10/03/2017] [Accepted: 10/06/2017] [Indexed: 01/01/2023]
Abstract
OBJECTIVE To assess dental providers' clinical practices and perceptions regarding adolescent vaccinations. METHODS We surveyed 234 dental providers in an integrated health care setting in Portland, Oregon, in March-April 2015. We assessed participants' knowledge of adolescent vaccines, barriers to recommending vaccines, and their perceived role in the promotion of vaccination and preventive medical care. RESULTS Over 80 percent of respondents correctly identified influenza, tetanus-diphtheria-acellular pertussis, and human papillomavirus as vaccinations recommended for adolescents; 60 percent correctly identified meningococcal conjugate. Forty-four percent of providers reported previously discussing vaccination with their adolescent patients. Lack of knowledge (66 percent), uncertainty about whether patients would accept recommendations (62 percent), and lack of time (61 percent) were commonly reported barriers. While few providers expressed personal concerns about the safety (13 percent) and effectiveness (10 percent) of adolescent vaccines, most believed parents had concerns about safety (70 percent) and effectiveness (60 percent). Although 80 percent endorsed the premise that providers should discuss preventive medical care with their patients, only 54 percent said they should discuss vaccinations specifically. CONCLUSIONS Dental providers reported several barriers to recommending vaccines. While comfortable with discussing preventive medical care in general, providers are less comfortable making vaccine recommendations to their patients. Vaccine recommendations are not a traditional practice among dental providers and may require additional education and communication tools.
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Affiliation(s)
- Allison L Naleway
- Center for Health Research, Kaiser Permanente Northwest, Portland, OR
| | | | - Lisa A Waiwaiole
- Center for Health Research, Kaiser Permanente Northwest, Portland, OR
| | - David M Mosen
- Center for Health Research, Kaiser Permanente Northwest, Portland, OR
| | - Michael C Leo
- Center for Health Research, Kaiser Permanente Northwest, Portland, OR
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Akhabue E, Rittner SS, Carroll JE, Crawford PM, Dant L, Laws R, Leo MC, Puro J, Persell SD. Implications of American College of Cardiology/American Heart Association (ACC/AHA) Cholesterol Guidelines on Statin Underutilization for Prevention of Cardiovascular Disease in Diabetes Mellitus Among Several US Networks of Community Health Centers. J Am Heart Assoc 2017; 6:JAHA.117.005627. [PMID: 28673901 PMCID: PMC5586289 DOI: 10.1161/jaha.117.005627] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/02/2023]
Abstract
Background Little is known about statin underutilization among diabetes mellitus patients cared for in community health centers, which tend to serve socioeconomically disadvantaged populations. Implications of the American College of Cardiology/American Heart Association (ACC/AHA) guidelines on preexisting gaps in statin treatment in this population are unclear. Methods and Results We included 32 440 adults (45% male, 63% nonwhite, 29% uninsured/Medicaid) aged 40 to 75 years with diabetes mellitus who received care within 16 community health center groups in 11 states in the Community Health Applied Research Network during 2013. Statin prescribing was analyzed as a function of concordance with the National Cholesterol Education Program Adult Treatment Panel 2001 and ACC/AHA 2013 guidelines. More patients’ treatments were concordant with the ACC/AHA (52.8%) versus the National Cholesterol Education Program Adult Treatment Panel (36.2%) guideline. Female sex was associated with lower concordance for both (odds ratio [OR] 0.90, CI 0.85‐0.94; and OR 0.84, CI 0.80‐0.88, respectively). Being insured, an Asian/Pacific Islander, or primarily Spanish speaking were associated with greater concordance for both guidelines: 35.5% (11 526/32 440) were concordant with neither guideline, the majority (79.7%) having no statin prescribed; 28.2% (9168/32 440) were concordant with ACC/AHA but not the National Cholesterol Education Program Adult Treatment Panel. 8.7% of these patients had a low‐density lipoprotein cholesterol >160 mg/dL despite having a moderate‐ or high‐intensity statin prescribed. And 11.6% (3772/32 440) were concordant with the National Cholesterol Education Program Adult Treatment Panel but not with ACC/AHA. Most of these patients had a low‐density lipoprotein cholesterol between 70 and 99 mg/dL with no or a low‐intensity statin prescribed. Conclusions Opportunities exist to improve cholesterol management in diabetes mellitus patients in community health centers. Addressing care gaps could improve cardiovascular disease prevention in this high‐risk population.
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Affiliation(s)
- Ehimare Akhabue
- Division of Cardiology, Feinberg School of Medicine, Northwestern University, Chicago, IL
| | | | | | | | | | - Reesa Laws
- Kaiser Permanente Center for Health Research, Portland, OR
| | - Michael C Leo
- Kaiser Permanente Center for Health Research, Portland, OR
| | | | - Stephen D Persell
- Division of General Internal Medicine and Geriatrics, Center for Primary Care Innovation, Feinberg School of Medicine, Northwestern University, Chicago, IL
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Kauffman TL, Irving SA, Leo MC, Gilmore MJ, Himes P, McMullen CK, Morris E, Schneider J, Wilfond BS, Goddard KAB. The NextGen Study: patient motivation for participation in genome sequencing for carrier status. Mol Genet Genomic Med 2017; 5:508-515. [PMID: 28944234 PMCID: PMC5606895 DOI: 10.1002/mgg3.306] [Citation(s) in RCA: 19] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/17/2017] [Revised: 05/15/2017] [Accepted: 05/22/2017] [Indexed: 11/18/2022] Open
Abstract
Background While translational genomic sequencing research is increasing, few studies have been limited to healthy individuals; most have focused on patients with a disease or a strong family history of a disorder. The limited studies that have included healthy individuals have focused on the disclosure of medically actionable secondary results, rather than carrier status, to assess reproductive risks. To address this important gap, we conducted the NextGen study, which focuses on carrier status and medically actionable secondary findings in a population of women planning a pregnancy. Methods We assessed 310 participants’ motivations for receiving genome sequencing for expanded carrier screening and experiences with familial genetic conditions that may relate to study participation. Results Most participants reported that obtaining general health information from genome sequencing was their primary motivator, even though they were recruited to join a study to learn more about carrier status. Forty‐two percent of enrolled women became pregnant prior to obtaining sequencing results. Conclusion Genomic carrier testing may need to be offered to women prior to active pregnancy efforts to be useful for reproductive planning.
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Affiliation(s)
- Tia L Kauffman
- Center for Health ResearchKaiser Permanente NorthwestPortlandOregon
| | | | - Michael C Leo
- Center for Health ResearchKaiser Permanente NorthwestPortlandOregon
| | - Marian J Gilmore
- Department of Medical GeneticsKaiser Permanente NorthwestPortlandOregon
| | - Patricia Himes
- Department of Medical GeneticsKaiser Permanente NorthwestPortlandOregon
| | | | - Elissa Morris
- Center for Health ResearchKaiser Permanente NorthwestPortlandOregon
| | | | - Benjamin S Wilfond
- Department of PediatricsTreuman Katz Center for Pediatric BioethicsSeattle Children's Hospital and Research InstituteUniversity of Washington School of MedicineSeattleWashington
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Kwan ML, Leo MC, Lee VS, Danforth KN, Weinmann S, O'Keeffe-Rosetti MC, Yi D, Wendel CS, Bulkley JE, Hornbrook MC, Krouse RS, Gilbert SM, McMullen CK. Predictors of urinary diversion choice in patients with bladder cancer in integrated care settings. J Clin Oncol 2017. [DOI: 10.1200/jco.2017.35.15_suppl.4543] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Abstract
4543 Background: Annually over 10,000 people with bladder cancer in the US have cystectomy surgery with urinary diversion (UD). While ileal conduit (IC) is most common, neobladder (NB) and continent pouch (CP) are options to retain urinary continence. Few studies in community settings have examined patient and clinician factors associated with UD choice. Methods: Eligible patients were age ≥21 with a cystectomy and UD for bladder cancer from 1/2010 to 6/2015 in 3 West coast Kaiser Permanente regions. Data were obtained from the EHR and chart review.We useda mixed effects logistic regression model with surgeon as a random effect, and region as a fixed effect, to identify patient factors associated with UD choice (IC vs NB/CP). We also examined whether surgeon factors were associated with UD choice above and beyond patient factors. Results: Among 1063 patients, 80% had an IC. IC patients were older (mean age 72 vs. 62), more likely female (24% vs. 16%), more likely diagnosed with AJCC stage III/IV (41% vs. 28%), and had higher Charlson comorbidity score (median 4 vs. 3) than NB/CP patients. Surgeons accounted for a sizable portion of the variability in UD choice (ICC = .26). The model with patient factors showed good fit (AUC = .93, Hosmer-Lemeshow test p = .22). Including surgeon factors (annual cystectomy volume, specialty training, clinical tenure) did not improve model fit (p = .32). Female sex, eGFR < 45, 4+ comorbidities, and stage III/IV tumors were associated with higher odds of receiving an IC vs. NB/CP (Table). Conclusions: Patient factors predict much of the variability in UD choice. The high ICC indicates that surgeons also contribute to this process, but surgeon factors we examined were not uniquely associated with IC. Future studies should explore more nuanced surgeon factors, such as how UD choice is shaped by personal beliefs about UD and likely outcomes. [Table: see text]
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Affiliation(s)
- Marilyn L. Kwan
- Division of Research, Kaiser Permanente Northern California, Oakland, CA
| | - Michael C Leo
- Center for Health Research, Kaiser Permanente Northwest, Portland, OR
| | - Valerie S. Lee
- Division of Research, Kaiser Permanente Northern California, Oakland, CA
| | | | - Sheila Weinmann
- Center for Health Research, Kaiser Permanente Northwest, Portland, OR
| | | | - David Yi
- Kaiser Permanente Southern California Department of Research and Evaluation, Pasadena, CA
| | | | - Joanna E. Bulkley
- The Center for Health Research, Kaiser Permanente Northwest, Portland, OR
| | - Mark C. Hornbrook
- Center for Health Research, Kaiser Permanente Northwest, Portland, OR
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Gilbert SM, Leo MC, Wendel C, Krouse RS, Grant M, Danforth KN, Kwan ML, Harrison T, Bulkley JE, McMullen CK. Decision dissonance/alignment scale to promote patient-centered decisions about urinary diversion with cystectomy for bladder cancer. J Clin Oncol 2017. [DOI: 10.1200/jco.2017.35.15_suppl.e16010] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Abstract
e16010 Background: The choice of urinary diversion (UD) with cystectomy is an opportunity to provide preference-driven care. We adapted a decision dissonance scale to measure concordance of patient goals with choice of ileal conduit (IC) vs. neobladder (NB) UD. Methods: With patient and clinician input, we identified 6 IC- and 4 NB-aligned goals, each rated on an 11-point scale (0 = not at all important to 10 = very important). Kaiser Permanente members rated the importance of these goals in a comprehensive survey mailed 6 months post-op (71% response rate (269/381)). Excluding respondents (n=93) with contraindications to NB and missing data on goals, we examined structural validity with principal axis factor analysis and convergent validity using correlations with other decision-making measures. Results: Items aligned to IC vs. NB factored separately as hypothesized (Table 1). NB patients prioritized (p<.05) NB-aligned goals (M=8.8, SD=1.8) over NB-dissonant goals (M=4.3, SD=2.4). IC patients’ alignment (M=5.4, SD=2.7) and dissonance (M=5.6, SD=2.1) ratings were similar. Dissonance was negatively correlated with informed decision-making (r=-.27) and satisfaction with care (r=-.21), and positively correlated with decision regret (r=.28) (each p<.01), but not correlated with shared decision making or decision style preference. Alignment was not significantly correlated with decision-making measures. Conclusions: Our measure distinguished patient values that could guide shared decision-making about UD choice. Patients who chose a NB had strong preferences for maintaining body integrity and function. [Table: see text]
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Affiliation(s)
| | - Michael C Leo
- Center for Health Research, Kaiser Permanente Northwest, Portland, OR
| | | | | | | | | | - Marilyn L. Kwan
- Division of Research, Kaiser Permanente Northern California, Oakland, CA
| | | | - Joanna E Bulkley
- Center for Health Research, Kaiser Permanente Northwest, Portland, OR
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Kauffman TL, Wilfond BS, Jarvik GP, Leo MC, Lynch FL, Reiss JA, Richards CS, McMullen C, Nickerson D, Dorschner MO, Goddard KAB. Design of a randomized controlled trial for genomic carrier screening in healthy patients seeking preconception genetic testing. Contemp Clin Trials 2017; 53:100-105. [PMID: 27940182 PMCID: PMC5274557 DOI: 10.1016/j.cct.2016.12.007] [Citation(s) in RCA: 24] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/08/2016] [Revised: 11/30/2016] [Accepted: 12/03/2016] [Indexed: 11/30/2022]
Abstract
Population-based carrier screening is limited to well-studied or high-impact genetic conditions for which the benefits may outweigh the associated harms and costs. As the cost of genome sequencing declines and availability increases, the balance of risks and benefits may change for a much larger number of genetic conditions, including medically actionable additional findings. We designed an RCT to evaluate genomic clinical sequencing for women and partners considering a pregnancy. All results are placed into the medical record for use by healthcare providers. Through quantitative and qualitative measures, including baseline and post result disclosure surveys, post result disclosure interviews, 1-2year follow-up interviews, and team journaling, we are obtaining data about the clinical and personal utility of genomic carrier screening in this population. Key outcomes include the number of reportable carrier and additional findings, and the comparative cost, utilization, and psychosocial impacts of usual care vs. genomic carrier screening. As the study progresses, we will compare the costs of genome sequencing and usual care as well as the cost of screening, pattern of use of genetic or mental health counseling services, number of outpatient visits, and total healthcare costs. This project includes novel investigation into human reactions and responses from would-be parents who are learning information that could both affect a future pregnancy and their own health.
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Affiliation(s)
- Tia L Kauffman
- Center for Health Research, Kaiser Permanente Northwest, 3800 North Interstate Avenue, Portland, OR 97227, USA.
| | - Benjamin S Wilfond
- Treuman Katz Center for Pediatric Bioethics, Seattle Children's Research Institute, Department of Pediatrics, University of Washington School of Medicine, 1900 Ninth Ave, Rm 683, Seattle, WA, 98105, USA
| | - Gail P Jarvik
- Department of Medicine, Division of Medical Genetics, University of Washington, Box 357720, Seattle, WA 98195, USA; Department of Genome Sciences, University of Washington, Box 357720, Seattle, WA 98195, USA
| | - Michael C Leo
- Center for Health Research, Kaiser Permanente Northwest, 3800 North Interstate Avenue, Portland, OR 97227, USA
| | - Frances L Lynch
- Center for Health Research, Kaiser Permanente Northwest, 3800 North Interstate Avenue, Portland, OR 97227, USA
| | - Jacob A Reiss
- Center for Health Research, Kaiser Permanente Northwest, 3800 North Interstate Avenue, Portland, OR 97227, USA
| | - C Sue Richards
- Knight Diagnostic Laboratories, Oregon Health & Science University, 3181 SW Sam Jackson Park Road, Mail Code MP350, Portland, OR, 97239, USA
| | - Carmit McMullen
- Center for Health Research, Kaiser Permanente Northwest, 3800 North Interstate Avenue, Portland, OR 97227, USA
| | - Deborah Nickerson
- Department of Genome Sciences, University of Washington, Box 357720, Seattle, WA 98195, USA
| | - Michael O Dorschner
- Department of Pathology, University of Washington, Box 357655, 1959 NE Pacific St., Seattle, WA, 98195, USA
| | - Katrina A B Goddard
- Center for Health Research, Kaiser Permanente Northwest, 3800 North Interstate Avenue, Portland, OR 97227, USA
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Korngiebel DM, McMullen CK, Amendola LM, Berg JS, Davis JV, Gilmore MJ, Harding CO, Himes P, Jarvik GP, Kauffman TL, Kennedy KA, Simpson DK, Leo MC, Lynch FL, Quigley DI, Reiss JA, Richards CS, Rope AF, Schneider JL, Goddard KAB, Wilfond BS. Generating a taxonomy for genetic conditions relevant to reproductive planning. Am J Med Genet A 2016; 170:565-73. [PMID: 26889673 DOI: 10.1002/ajmg.a.37513] [Citation(s) in RCA: 23] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/09/2015] [Accepted: 10/22/2015] [Indexed: 01/20/2023]
Abstract
As genome or exome sequencing (hereafter genome-scale sequencing) becomes more integrated into standard care, carrier testing is an important possible application. Carrier testing using genome-scale sequencing can identify a large number of conditions, but choosing which conditions/genes to evaluate as well as which results to disclose can be complicated. Carrier testing generally occurs in the context of reproductive decision-making and involves patient values in a way that other types of genetic testing may not. The Kaiser Permanente Clinical Sequencing Exploratory Research program is conducting a randomized clinical trial of preconception carrier testing that allows participants to select their preferences for results from among broad descriptive categories rather than selecting individual conditions. This paper describes (1) the criteria developed by the research team, the return of results committee (RORC), and stakeholders for defining the categories; (2) the process of refining the categories based on input from patient focus groups and validation through a patient survey; and (3) how the RORC then assigned specific gene-condition pairs to taxonomy categories being piloted in the trial. The development of four categories (serious, moderate/mild, unpredictable, late onset) for sharing results allows patients to select results based on their values without separately deciding their interest in knowing their carrier status for hundreds of conditions. A fifth category, lifespan limiting, was always shared. The lessons learned may be applicable in other results disclosure situations, such as incidental findings.
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Affiliation(s)
- Diane M Korngiebel
- Department of Biomedical Informatics and Medical Education, University of Washington, Seattle, Washington
| | - Carmit K McMullen
- Kaiser Permanente Northwest Center for Health Research, Portland, Oregon
| | - Laura M Amendola
- Division of Medical Genetics, Department of Medicine, University of Washington, Seattle, Washington
| | - Jonathan S Berg
- Department of Genetics, University of North Carolina Chapel Hill, Chapel Hill, North Carolina
| | - James V Davis
- Kaiser Permanente Northwest Center for Health Research, Portland, Oregon
| | - Marian J Gilmore
- Department of Medical Genetics, Kaiser Permanente Northwest, Portland, Oregon
| | - Cary O Harding
- Molecular and Medical Genetics, Oregon Health and Science University, Portland, Oregon
| | - Patricia Himes
- Department of Medical Genetics, Kaiser Permanente Northwest, Portland, Oregon
| | - Gail P Jarvik
- Division of Medical Genetics, Department of Medicine, University of Washington, Seattle, Washington
| | - Tia L Kauffman
- Kaiser Permanente Northwest Center for Health Research, Portland, Oregon
| | - Kathleen A Kennedy
- Department of Perinatal Services, Kaiser Permanente Northwest, Portland, Oregon
| | | | - Michael C Leo
- Kaiser Permanente Northwest Center for Health Research, Portland, Oregon
| | - Frances L Lynch
- Kaiser Permanente Northwest Center for Health Research, Portland, Oregon
| | - Denise I Quigley
- Kaiser Permanente Northwest Center for Health Research, Portland, Oregon
| | - Jacob A Reiss
- Kaiser Permanente Northwest Center for Health Research, Portland, Oregon
| | - C Sue Richards
- Molecular and Medical Genetics, Oregon Health and Science University, Portland, Oregon
| | - Alan F Rope
- Department of Medical Genetics, Kaiser Permanente Northwest, Portland, Oregon
| | | | | | - Benjamin S Wilfond
- Treuman Katz Center for Pediatrics Bioethics, Seattle Children's Research Institute, Seattle, Washington.,Division of Bioethics, Department of Pediatrics, University of Washington, Seattle, Washington
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Vesco KK, Leo MC, Karanja N, Gillman MW, McEvoy CT, King JC, Eckhardt CL, Smith KS, Perrin N, Stevens VJ. One-year postpartum outcomes following a weight management intervention in pregnant women with obesity. Obesity (Silver Spring) 2016; 24:2042-9. [PMID: 27670399 PMCID: PMC5084910 DOI: 10.1002/oby.21597] [Citation(s) in RCA: 49] [Impact Index Per Article: 6.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/31/2015] [Revised: 05/03/2016] [Accepted: 05/16/2016] [Indexed: 11/08/2022]
Abstract
OBJECTIVE This analysis was focused on 1-year maternal and infant follow-up of a randomized trial that tested a weight management intervention conducted during pregnancy. METHODS One hundred fourteen women with obesity (mean BMI 36.7 kg/m(2) ) were randomly assigned at a mean of 15 weeks gestation to a weight management intervention or usual care control condition. The intervention ended at delivery and resulted in less gestational weight gain and a lower proportion of large-for-gestational-age newborns among intervention compared with control participants. The primary outcome at 12 months postpartum was maternal weight. Secondary outcomes included infant weight-for-age and weight-for-length z-scores. RESULTS At 1 year, mothers in the intervention group weighed 96.3 ± 18.6 kg and those in the control group 99.7 ± 19.2 kg. There was no significant difference between groups in change in weight from randomization to 1 year postpartum (b = -0.47, 95% CI: -4.03 to 3.08). There was a significant main effect of group for infant weight-for-age z-scores (b = -0.40, 95% CI: -0.75 to -0.05) but not infant weight-for-length z-scores (b = -0.20, 95% CI: -0.59 to 0.20). CONCLUSIONS A gestational weight management intervention did not influence maternal weight or infant weight-for-length at 1 year postpartum. Future studies may be warranted to determine whether extending prenatal interventions into the postpartum period would be beneficial for maternal and infant outcomes.
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Affiliation(s)
- Kimberly K Vesco
- Center for Health Research, Kaiser Permanente Northwest, Portland, Oregon, USA.
- Department of Obstetrics & Gynecology, Kaiser Permanente Northwest, Portland, Oregon, USA.
| | - Michael C Leo
- Center for Health Research, Kaiser Permanente Northwest, Portland, Oregon, USA
| | - Njeri Karanja
- Center for Health Research, Kaiser Permanente Northwest, Portland, Oregon, USA
| | - Matthew W Gillman
- Obesity Prevention Program, Harvard Medical School/Harvard Pilgrim Health Care Institute, Boston, Massachusetts, USA
| | - Cindy T McEvoy
- Obesity Prevention Program, Oregon Health & Science University, Portland, Oregon, USA
| | - Janet C King
- Pediatric and Child Health Research Program, Children's Hospital Oakland Research Institute, Oakland, California, USA
| | - Cara L Eckhardt
- School of Community Health, Portland State University, Portland, Oregon, USA
| | - K Sabina Smith
- Center for Health Research, Kaiser Permanente Northwest, Portland, Oregon, USA
| | - Nancy Perrin
- Center for Health Research, Kaiser Permanente Northwest, Portland, Oregon, USA
| | - Victor J Stevens
- Center for Health Research, Kaiser Permanente Northwest, Portland, Oregon, USA
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Fellows JL, Mularski RA, Leo MC, Bentz CJ, Waiwaiole LA, Francisco MC, Funkhouser K, Stoney CM. Referring Hospitalized Smokers to Outpatient Quit Services: A Randomized Trial. Am J Prev Med 2016; 51:609-19. [PMID: 27647061 PMCID: PMC5031367 DOI: 10.1016/j.amepre.2016.06.014] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/09/2015] [Revised: 05/27/2016] [Accepted: 06/17/2016] [Indexed: 01/02/2023]
Abstract
INTRODUCTION Linking outpatient cessation services to bedside counseling for hospitalized smokers can improve long-run quit rates. Adding an assisted referral (AR) offer to a tobacco treatment specialist consult service fits the team approach to care in U.S. hospitals. DESIGN A two-arm patient-randomized trial tested the effectiveness of adding an AR offer to outpatient smoking-cessation services and interactive voice recognition (AR+IVR) follow-up to a usual care (UC) tobacco-cessation consult for hospitalized smokers. SETTING/PARTICIPANTS Over 24 months (November 2011-November 2013), 898 hospitalized adult smokers interested in quitting smoking were recruited from three large hospitals in the Portland, Oregon, area: an integrated group model HMO (n=622), a community hospital (n=195), and an academic health center (n=81). INTERVENTION Tobacco treatment specialists identified smokers and provided an intensive bedside tobacco use assessment and cessation consultation (UC). AR+IVR recipients also received proactive ARs to available outpatient counseling programs and medications, and linked patients to a tailored IVR telephone follow-up system. MAIN OUTCOME MEASURES The primary outcome was self-reported 30-day abstinence at 6-month follow-up. Secondary outcomes included self-reported and continuous abstinence and biochemically confirmed 7-day abstinence at 6 months. Follow-up was completed in September 2014; data were analyzed in 2015. RESULTS A total of 597 and 301 hospitalized smokers were randomized to AR+IVR and UC, respectively. AR+IVR and UC recipients received 19.3 and 17.0 minutes of bedside counseling (p=0.372), respectively. Most (58%) AR+IVR patients accepted referrals for counseling, 43% accepted medications, and 28% accepted both. Self-reported 30-day abstinence for AR+IVR (17.9%) and UC (17.3%) were not statistically significant (p=0.569). Differences in 7-day, continuous, and biochemically confirmed abstinence by treatment group also were insignificant, overall and adjusting for site. CONCLUSIONS Adding an AR to outpatient counseling and medications did not increase cigarette abstinence at 6 months compared to UC alone.
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Affiliation(s)
| | | | - Michael C Leo
- Kaiser Permanente Center for Health Research, Portland, Oregon
| | - Charles J Bentz
- Tobacco Cessation and Prevention, Legacy Health System, Portland, Oregon
| | | | | | | | - Catherine M Stoney
- Division of Cardiovascular Sciences, National Heart, Lung, and Blood Institute, NIH, Bethesda, Maryland
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Abstract
Little information is available on how to help families manage common negative sequelae of attention deficit/hyperactivity disorder (ADHD). This article is a report of the extent to which a theoretical formulation of child behavior, maternal distress, and family conflict was explained by data obtained from a community sample of families with children and adolescents with ADHD. Structural equation modeling was used to test the theoretical model. The primary variables of interest were (a) child behavior problems, (b) maternal distress, and (c) family conflict. The results suggest that maternal distress may mediate the relationship between child behavior problems and family conflict, indicating the critical importance of mothers in ADHD families and the need to provide them with additional support.
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Affiliation(s)
- Judy Kendall
- School of Nursing, Oregon Health & Science University
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67
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Amendola LM, Jarvik GP, Leo MC, McLaughlin HM, Akkari Y, Amaral MD, Berg JS, Biswas S, Bowling KM, Conlin LK, Cooper GM, Dorschner MO, Dulik MC, Ghazani AA, Ghosh R, Green RC, Hart R, Horton C, Johnston JJ, Lebo MS, Milosavljevic A, Ou J, Pak CM, Patel RY, Punj S, Richards CS, Salama J, Strande NT, Yang Y, Plon SE, Biesecker LG, Rehm HL. Performance of ACMG-AMP Variant-Interpretation Guidelines among Nine Laboratories in the Clinical Sequencing Exploratory Research Consortium. Am J Hum Genet 2016; 98:1067-1076. [PMID: 27181684 DOI: 10.1016/j.ajhg.2016.03.024] [Citation(s) in RCA: 311] [Impact Index Per Article: 38.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/21/2015] [Accepted: 03/22/2016] [Indexed: 02/06/2023] Open
Abstract
Evaluating the pathogenicity of a variant is challenging given the plethora of types of genetic evidence that laboratories consider. Deciding how to weigh each type of evidence is difficult, and standards have been needed. In 2015, the American College of Medical Genetics and Genomics (ACMG) and the Association for Molecular Pathology (AMP) published guidelines for the assessment of variants in genes associated with Mendelian diseases. Nine molecular diagnostic laboratories involved in the Clinical Sequencing Exploratory Research (CSER) consortium piloted these guidelines on 99 variants spanning all categories (pathogenic, likely pathogenic, uncertain significance, likely benign, and benign). Nine variants were distributed to all laboratories, and the remaining 90 were evaluated by three laboratories. The laboratories classified each variant by using both the laboratory's own method and the ACMG-AMP criteria. The agreement between the two methods used within laboratories was high (K-alpha = 0.91) with 79% concordance. However, there was only 34% concordance for either classification system across laboratories. After consensus discussions and detailed review of the ACMG-AMP criteria, concordance increased to 71%. Causes of initial discordance in ACMG-AMP classifications were identified, and recommendations on clarification and increased specification of the ACMG-AMP criteria were made. In summary, although an initial pilot of the ACMG-AMP guidelines did not lead to increased concordance in variant interpretation, comparing variant interpretations to identify differences and having a common framework to facilitate resolution of those differences were beneficial for improving agreement, allowing iterative movement toward increased reporting consistency for variants in genes associated with monogenic disease.
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Affiliation(s)
- Laura M Amendola
- Division of Medical Genetics, Department of Medicine, University of Washington, Seattle, WA 98195, USA
| | - Gail P Jarvik
- Division of Medical Genetics, Department of Medicine, University of Washington, Seattle, WA 98195, USA.
| | - Michael C Leo
- Center for Health Research, Kaiser Permanente, Portland, OR 97227, USA
| | - Heather M McLaughlin
- Laboratory for Molecular Medicine, Partners HealthCare Personalized Medicine, Cambridge, MA 02139, USA
| | - Yassmine Akkari
- Department of Molecular and Medical Genetics, Oregon Health and Science University, Portland, OR 97239, USA
| | | | - Jonathan S Berg
- Department of Genetics, University of North Carolina, Chapel Hill, NC 27599, USA
| | - Sawona Biswas
- Division of Human Genetics, Department of Pediatrics, Children's Hospital of Philadelphia, Philadelphia, PA 19104, USA
| | - Kevin M Bowling
- HudsonAlpha Institute for Biotechnology, Huntsville, AL 35806, USA
| | - Laura K Conlin
- Division of Human Genetics, Department of Pediatrics, Children's Hospital of Philadelphia, Philadelphia, PA 19104, USA
| | - Greg M Cooper
- HudsonAlpha Institute for Biotechnology, Huntsville, AL 35806, USA
| | - Michael O Dorschner
- Center for Precision Diagnostics, Department of Pathology, University of Washington, Seattle, WA 98195, USA
| | - Matthew C Dulik
- Department of Pathology and Laboratory Medicine, Children's Hospital of Philadelphia, Philadelphia, PA 19104, USA
| | - Arezou A Ghazani
- Department of Medical Oncology, Dana-Farber Cancer Institute, Boston, MA 02215, USA
| | | | - Robert C Green
- Laboratory for Molecular Medicine, Partners HealthCare Personalized Medicine, Cambridge, MA 02139, USA; Brigham and Women's Hospital and Harvard Medical School, Cambridge, MA 02115, USA; Broad Institute of MIT and Harvard, Cambridge, MA 02142, USA
| | - Ragan Hart
- Division of Medical Genetics, Department of Medicine, University of Washington, Seattle, WA 98195, USA
| | - Carrie Horton
- Clinical Diagnostics, Ambry Genetics, Aliso Viejo, CA 92656, USA
| | - Jennifer J Johnston
- Intramural Research Program, National Human Genome Research Institute, NIH, Bethesda, MD 20892, USA
| | - Matthew S Lebo
- Laboratory for Molecular Medicine, Partners HealthCare Personalized Medicine, Cambridge, MA 02139, USA; Brigham and Women's Hospital and Harvard Medical School, Cambridge, MA 02115, USA
| | | | - Jeffrey Ou
- Division of Medical Genetics, Department of Medicine, University of Washington, Seattle, WA 98195, USA
| | - Christine M Pak
- Department of Molecular and Medical Genetics, Oregon Health and Science University, Portland, OR 97239, USA
| | | | - Sumit Punj
- Department of Molecular and Medical Genetics, Oregon Health and Science University, Portland, OR 97239, USA
| | - Carolyn Sue Richards
- Department of Molecular and Medical Genetics, Oregon Health and Science University, Portland, OR 97239, USA
| | - Joseph Salama
- Division of Medical Genetics, Department of Medicine, University of Washington, Seattle, WA 98195, USA
| | - Natasha T Strande
- Department of Genetics, University of North Carolina, Chapel Hill, NC 27599, USA
| | - Yaping Yang
- Baylor College of Medicine, Houston, TX 77030, USA
| | | | - Leslie G Biesecker
- Intramural Research Program, National Human Genome Research Institute, NIH, Bethesda, MD 20892, USA
| | - Heidi L Rehm
- Laboratory for Molecular Medicine, Partners HealthCare Personalized Medicine, Cambridge, MA 02139, USA; Brigham and Women's Hospital and Harvard Medical School, Cambridge, MA 02115, USA; Broad Institute of MIT and Harvard, Cambridge, MA 02142, USA.
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Clarke G, DeBar LL, Pearson JA, Dickerson JF, Lynch FL, Gullion CM, Leo MC. Cognitive Behavioral Therapy in Primary Care for Youth Declining Antidepressants: A Randomized Trial. Pediatrics 2016; 137:e20151851. [PMID: 27244782 PMCID: PMC4845864 DOI: 10.1542/peds.2015-1851] [Citation(s) in RCA: 24] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 02/02/2016] [Indexed: 11/24/2022] Open
Abstract
BACKGROUND AND OBJECTIVE Health care providers have few alternatives for youth depression other than antidepressants. We examined whether brief cognitive behavioral therapy (CBT) is a viable alternative in primary care. METHODS A total of 212 adolescents aged 12 to 18 with major depression who had recently declined or quickly discontinued new antidepressant treatment were randomized to self-selected treatment as usual (TAU) control condition or TAU plus brief individual CBT. Blinded evaluators followed youth for 2 years. The primary outcome was time to major depression diagnostic recovery. RESULTS CBT was superior to the control condition on the primary outcome of time to diagnostic recovery from major depression, with number needed to treat from 4 to 10 across follow-up. A similar CBT advantage was found for time to depression diagnosis response, with number needed to treat of 5 to 50 across time points. We observed a significant advantage for CBT on many secondary outcomes over the first year of follow-up but not the second year. Cohen's d effect sizes for significant continuous measures ranged from 0.28 to 0.44, in the small to medium effect range. Most TAU health care services did not differ across conditions, except for psychiatric hospitalizations, which occurred at a significantly higher rate in the control condition through the first year of follow-up. CONCLUSIONS Observed results were consistent with recent meta-analyses of CBT for youth depression. The initial year of CBT superiority imparted an important clinical benefit and may reduce the risk of future recurrent depression episodes.
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Affiliation(s)
- Gregory Clarke
- Kaiser Permanente Center for Health Research, Portland Oregon
| | - Lynn L DeBar
- Kaiser Permanente Center for Health Research, Portland Oregon
| | - John A Pearson
- Kaiser Permanente Center for Health Research, Portland Oregon
| | | | - Frances L Lynch
- Kaiser Permanente Center for Health Research, Portland Oregon
| | | | - Michael C Leo
- Kaiser Permanente Center for Health Research, Portland Oregon
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Yarborough BJH, Leo MC, Yarborough MT, Stumbo S, Janoff SL, Perrin NA, Green CA. Improvement in Body Image, Perceived Health, and Health-Related Self-Efficacy Among People With Serious Mental Illness: The STRIDE Study. Psychiatr Serv 2016; 67:296-301. [PMID: 26522674 PMCID: PMC7104613 DOI: 10.1176/appi.ps.201400535] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Abstract
OBJECTIVE The authors examined secondary outcomes of STRIDE, a randomized controlled trial that tested a weight-loss and lifestyle intervention for individuals taking antipsychotic medications. METHODS Hierarchical linear regression was used to explore the effects of the intervention and weight change at follow-up (six, 12, and 24 months) on body image, perceived health, and health-related self-efficacy. RESULTS Participants were 200 adults who were overweight and taking antipsychotic agents. Weight change × study arm interaction was associated with significant improvement in body image from baseline to six months. From baseline to 12 months, body image scores of intervention participants improved by 1.7 points more compared with scores of control participants; greater weight loss was associated with more improvement. Between baseline and 24 months, greater weight loss was associated with improvements in body image, perceived health, and health-related self-efficacy. CONCLUSIONS Participation in STRIDE improved body image, and losing weight improved perceived health and health-related self-efficacy.
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Affiliation(s)
- Bobbi Jo H Yarborough
- The authors are with the Center for Health Research, Kaiser Permanente Northwest, Portland, Oregon (e-mail: )
| | - Michael C Leo
- The authors are with the Center for Health Research, Kaiser Permanente Northwest, Portland, Oregon (e-mail: )
| | - Micah T Yarborough
- The authors are with the Center for Health Research, Kaiser Permanente Northwest, Portland, Oregon (e-mail: )
| | - Scott Stumbo
- The authors are with the Center for Health Research, Kaiser Permanente Northwest, Portland, Oregon (e-mail: )
| | - Shannon L Janoff
- The authors are with the Center for Health Research, Kaiser Permanente Northwest, Portland, Oregon (e-mail: )
| | - Nancy A Perrin
- The authors are with the Center for Health Research, Kaiser Permanente Northwest, Portland, Oregon (e-mail: )
| | - Carla A Green
- The authors are with the Center for Health Research, Kaiser Permanente Northwest, Portland, Oregon (e-mail: )
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70
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Leo MC, McMullen C, Wilfond BS, Lynch FL, Reiss JA, Gilmore MJ, Himes P, Kauffman TL, Davis JV, Jarvik GP, Berg JS, Harding C, Kennedy KA, Simpson DK, Quigley DI, Richards CS, Rope AF, Goddard KAB. Patients' ratings of genetic conditions validate a taxonomy to simplify decisions about preconception carrier screening via genome sequencing. Am J Med Genet A 2016; 170:574-82. [PMID: 26792268 DOI: 10.1002/ajmg.a.37477] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/10/2015] [Accepted: 10/28/2015] [Indexed: 12/27/2022]
Abstract
Advances in genome sequencing and gene discovery have created opportunities to efficiently assess more genetic conditions than ever before. Given the large number of conditions that can be screened, the implementation of expanded carrier screening using genome sequencing will require practical methods of simplifying decisions about the conditions for which patients want to be screened. One method to simplify decision making is to generate a taxonomy based on expert judgment. However, expert perceptions of condition attributes used to classify these conditions may differ from those used by patients. To understand whether expert and patient perceptions differ, we asked women who had received preconception genetic carrier screening in the last 3 years to fill out a survey to rate the attributes (predictability, controllability, visibility, and severity) of several autosomal recessive or X-linked genetic conditions. These conditions were classified into one of five taxonomy categories developed by subject experts (significantly shortened lifespan, serious medical problems, mild medical problems, unpredictable medical outcomes, and adult-onset conditions). A total of 193 women provided 739 usable ratings across 20 conditions. The mean ratings and correlations demonstrated that participants made distinctions across both attributes and categories. Aggregated mean attribute ratings across categories demonstrated logical consistency between the key features of each attribute and category, although participants perceived little difference between the mild and serious categories. This study provides empirical evidence for the validity of our proposed taxonomy, which will simplify patient decisions for results they would like to receive from preconception carrier screening via genome sequencing.
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Affiliation(s)
- Michael C Leo
- Kaiser Permanente Center for Health Research, Portland, Oregon
| | - Carmit McMullen
- Kaiser Permanente Center for Health Research, Portland, Oregon
| | | | - Frances L Lynch
- Kaiser Permanente Center for Health Research, Portland, Oregon
| | - Jacob A Reiss
- Kaiser Permanente Center for Health Research, Portland, Oregon
| | - Marian J Gilmore
- Department of Medical Genetics, Kaiser Permanente Northwest, Portland, Oregon
| | - Patricia Himes
- Department of Medical Genetics, Kaiser Permanente Northwest, Portland, Oregon
| | - Tia L Kauffman
- Kaiser Permanente Center for Health Research, Portland, Oregon
| | - James V Davis
- Kaiser Permanente Center for Health Research, Portland, Oregon
| | | | - Jonathan S Berg
- The University of North Carolina at Chapel Hill, Chapel Hill, North Carolina
| | - Cary Harding
- Department of Molecular and Medical Genetics, Oregon Health & Science University, Portland, Oregon
| | - Kathleen A Kennedy
- Department of Medical Genetics, Kaiser Permanente Northwest, Portland, Oregon
| | | | - Denise I Quigley
- Department of Medical Genetics, Kaiser Permanente Northwest, Portland, Oregon
| | - C Sue Richards
- Department of Molecular and Medical Genetics, Oregon Health & Science University, Portland, Oregon
| | - Alan F Rope
- Department of Medical Genetics, Kaiser Permanente Northwest, Portland, Oregon
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McMullen CK, Danforth KN, Kwan ML, Bulkley JE, O'Keeffe-Rosetti MC, Weinmann S, Krouse RS, Hornbrook MC, Grant M, Leo MC, Gilbert SM. Recovery challenges faced by bladder cancer survivors after recent cystectomy and urinary diversion. J Clin Oncol 2016. [DOI: 10.1200/jco.2016.34.3_suppl.90] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Abstract
90 Background: Bladder cancer patients who are treated with cystectomy (bladder removal) and urinary diversion (bladder replacement) experience high rates of complications and hospital readmissions, and have substantial supportive care needs. Patient-reported priorities for improving early-phase survivorship care are lacking. Methods: On the basis of focus groups and in-depth interviews with 32 bladder cancer survivors about post-operative challenges, we developed a structured question listing 16 early survivorship challenges. We asked respondents to indicate which challenges had been difficult to manage at home. The item was part of a survey mailed to members of three Kaiser Permanente regions who had undergone cystectomy and urinary diversion for bladder cancer approximately 6 months previously (N = 197). Eligible patients were identified through health plan databases and chart review. Results: The response rate to the survey was 65%. Respondents reported an average of 3 challenges. The most commonly reported challenges pertained to coordination of medical care (69%), such as confusion about follow-up care, problems obtaining medical and ostomy supplies, knowing what complications to look for and who to notify if they occur, receiving home health care, or obtaining prompt medical advice. Other problems were caring for the urinary diversion (53%); dealing with urine leaks and incontinence (49%); problems with balance, vision, and dexterity (32%); difficulty managing emotions (23%); and management of lymphedema (11%) or incisional or parastomal hernias (7%). Conclusions: More than two thirds of bladder cancer survivors who had recently undergone cystectomy and urinary diversion struggled with medical care coordination. Managing self-care, complications, and emotional well-being after this major surgery can be difficult for patients, who must also navigate a variety of supportive services, such as medical follow-up with multiple departments and providers, home health services, and wound or ostomy care. A more formal approach to discharge and better communication among patients and providers will help improve early survivorship care for this group.
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Affiliation(s)
| | | | - Marilyn L Kwan
- Division of Research, Kaiser Permanente Northern California, Oakland, CA
| | - Joanna E Bulkley
- Center for Health Research, Kaiser Permanente Northwest, Portland, OR
| | | | - Sheila Weinmann
- Center for Health Research, Kaiser Permanente Northwest, Portland, OR
| | | | - Mark C. Hornbrook
- Center for Health Research, Kaiser Permanente Northwest, Portland, OR
| | | | - Michael C Leo
- Center for Health Research, Kaiser Permanente Northwest, Portland, OR
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Glass AG, Leo MC, Haddad Z, Yousefi K, du Plessis M, Chen C, Choeurng V, Abdollah F, Robbins B, Ra S, Richert-Boe KE, Buerki C, Pearson K, Davicioni E, Weinmann S. Validation of a Genomic Classifier for Predicting Post-Prostatectomy Recurrence in a Community Based Health Care Setting. J Urol 2015; 195:1748-53. [PMID: 26626216 DOI: 10.1016/j.juro.2015.11.044] [Citation(s) in RCA: 29] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 11/11/2015] [Indexed: 10/22/2022]
Abstract
PURPOSE We determined the value of Decipher®, a genomic classifier, to predict prostate cancer outcomes among patients after prostatectomy in a community health care setting. MATERIALS AND METHODS We examined the experience of 224 men treated with radical prostatectomy from 1997 to 2009 at Kaiser Permanente Northwest, a large prepaid health plan in Portland, Oregon. Study subjects had aggressive prostate cancer with at least 1 of several criteria such as preoperative prostate specific antigen 20 ng/ml or greater, pathological Gleason score 8 or greater, stage pT3 disease or positive surgical margins at prostatectomy. The primary end point was clinical recurrence or metastasis after surgery evaluated using a time dependent c-index. Secondary end points were biochemical recurrence and salvage treatment failure. We compared the performance of Decipher alone to the widely used CAPRA-S (Cancer of the Prostate Risk Assessment Post-Surgical) score, and assessed the independent contributions of Decipher, CAPRA-S and their combination for the prediction of recurrence and treatment failure. RESULTS Of the 224 patients treated 12 experienced clinical recurrence, 68 had biochemical recurrence and 34 experienced salvage treatment failure. At 10 years after prostatectomy the recurrence rate was 2.6% among patients with low Decipher scores but 13.6% among those with high Decipher scores (p=0.02). When CAPRA-S and Decipher scores were considered together, the discrimination accuracy of the ROC curve was increased by 0.11 compared to the CAPRA-S score alone (combined c-index 0.84 at 10 years after radical prostatectomy) for clinical recurrence. CONCLUSIONS Decipher improves our ability to predict clinical recurrence in prostate cancer and adds precision to conventional pathological prognostic measures.
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Affiliation(s)
- Andrew G Glass
- Center for Health Research, Kaiser Permanente Northwest, Portland, Oregon.
| | - Michael C Leo
- Center for Health Research, Kaiser Permanente Northwest, Portland, Oregon
| | - Zaid Haddad
- GenomeDx Biosciences, Vancouver, British Columbia, Canada
| | - Kasra Yousefi
- GenomeDx Biosciences, Vancouver, British Columbia, Canada
| | | | - Chuhe Chen
- Center for Health Research, Kaiser Permanente Northwest, Portland, Oregon
| | | | - Firas Abdollah
- Vattikuti Urology Institute, Henry Ford Hospital, Detroit, Michigan
| | - Bruce Robbins
- San Diego Pathologists Medical Group, San Diego, California
| | - Seong Ra
- San Diego Pathologists Medical Group, San Diego, California
| | | | | | - Kathy Pearson
- Center for Health Research, Kaiser Permanente Northwest, Portland, Oregon
| | - Elai Davicioni
- GenomeDx Biosciences, Vancouver, British Columbia, Canada
| | - Sheila Weinmann
- Center for Health Research, Kaiser Permanente Northwest, Portland, Oregon
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Green CA, Yarborough BJH, Leo MC, Stumbo SP, Perrin NA, Nichols GA, Stevens VJ. Weight maintenance following the STRIDE lifestyle intervention for individuals taking antipsychotic medications. Obesity (Silver Spring) 2015; 23:1995-2001. [PMID: 26334929 PMCID: PMC4586363 DOI: 10.1002/oby.21205] [Citation(s) in RCA: 18] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/06/2015] [Accepted: 06/09/2015] [Indexed: 11/10/2022]
Abstract
OBJECTIVE Individuals taking antipsychotic medications have increased risk of obesity-related early morbidity/mortality. This report presents weight maintenance results from a successful weight loss and behavioral lifestyle change program developed for people taking antipsychotic medications. METHODS STRIDE was a two-arm randomized controlled trial. Intervention participants attended weekly group meetings for 6 months, then monthly group meetings for 6 months. Assessments were completed at baseline and at 6, 12, and 24 months. RESULTS At 24 months, intervention participants lost 3.7% of baseline weight and control participants 2.1%, a non-significant difference. Fasting glucose results followed a similar pattern. There was a statistically significant difference, however, for fasting insulin-the intervention group's levels decreased between the end of the intensive intervention (at 6 months) and 24 months (10.1-7.91 μU/mL); control participants' levels increased (11.66 to 12.92 μU/mL) during this period. There were also fewer medical hospitalizations among intervention participants (5.7%) than controls (21.1%; χ(2) = 8.47, P = 0.004) during the 12- to 24-month post-intervention maintenance period. CONCLUSIONS Weight change differences between arms diminished following the intervention period, though fasting insulin levels continued to improve. Reduced hospitalizations suggest that weight loss, even with regain, may have long-term positive benefits for people taking antipsychotic medications and may reduce costs.
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Affiliation(s)
- Carla A Green
- Center for Health Research, Kaiser Permanente Northwest, Portland, Oregon, USA
| | | | - Michael C Leo
- Center for Health Research, Kaiser Permanente Northwest, Portland, Oregon, USA
| | - Scott P Stumbo
- Center for Health Research, Kaiser Permanente Northwest, Portland, Oregon, USA
| | - Nancy A Perrin
- Center for Health Research, Kaiser Permanente Northwest, Portland, Oregon, USA
| | - Gregory A Nichols
- Center for Health Research, Kaiser Permanente Northwest, Portland, Oregon, USA
| | - Victor J Stevens
- Center for Health Research, Kaiser Permanente Northwest, Portland, Oregon, USA
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Abstract
Research on symptom distress experienced by patients with end-stage liver disease at the end of life is limited. The aims of the study were to describe presence, frequency, severity, and distress of symptoms in patients with end-stage liver disease toward the end of life and to describe the variability in psychological and physical symptom distress between and within patients over time. This study used a prospective, longitudinal descriptive design. Data were collected from 20 patients once a month for up to 6 months. Participants completed the Memorial Symptom Assessment Scale, which reports a total score, a Global Distress Index score, and a psychological and a physical distress score. Patients reported lack of energy, pain, difficulty sleeping, and feeling drowsy as the most frequent, severe, and distressing symptoms. Global Distress Index mean scores (measured on a 1-4 scale) ranged from 2.6 to 2.9 across time. There was notable variability in psychological and physical distress scores between and within patients across time. Gaining knowledge about the prevalent symptoms experienced by patients with end-stage liver disease and the trajectory of these symptoms is crucial for designing interventions that optimize well-being in patients with end-stage liver disease as they are approaching death.
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Affiliation(s)
- Lissi Hansen
- Oregon Health & Science University, School of Nursing, SN-ORD, 3455 S.W. US Veterans Hospital Rd., Portland, Oregon 97239-2941, Phone: 503-418-3357, Fax: 503-494-7783
| | - Michael C. Leo
- Kaiser Permanente Center for Health Research, 3800 N. Interstate Ave Portland, OR 97227, Phone: 503-528-3909, Fax
| | - Michael F. Chang
- Portland Veterans Affairs Medical Center, 3710 SW U.S. Veterans Hospital Rd., Portland, OR 97239, Phone: 503-220-8262 ext. 54482, Fax: 503-220-3426
| | - Atif Zaman
- Oregon Health & Science University, 3181 S.W. Sam Jackson Park Rd., MC L461, Portland, Oregon 97239-3098, Phone: 503-494-8071, Fax: 503-494-8776
| | - Willscott Naugler
- Oregon Health & Science University, 3181 S.W. Sam Jackson Park Rd., MC L461, Portland, Oregon 97239-3098, Phone: 503-713-3069, Fax: 503-494-8776
| | - Jonathan Schwartz
- Montefiore Medical Center, Albert Einstein College of Medicine, 111 East 210th Street, Bronx NY 10467, Phone: 503 351-6691, Fax
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Green CA, Yarborough BJH, Leo MC, Yarborough MT, Stumbo SP, Janoff SL, Perrin NA, Nichols GA, Stevens VJ. The STRIDE weight loss and lifestyle intervention for individuals taking antipsychotic medications: a randomized trial. Am J Psychiatry 2015; 172:71-81. [PMID: 25219423 PMCID: PMC4282602 DOI: 10.1176/appi.ajp.2014.14020173] [Citation(s) in RCA: 129] [Impact Index Per Article: 14.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Abstract
OBJECTIVES The STRIDE study assessed whether a lifestyle intervention, tailored for individuals with serious mental illnesses, reduced weight and diabetes risk. The authors hypothesized that the STRIDE intervention would be more effective than usual care in reducing weight and improving glucose metabolism. METHOD The study design was a multisite, parallel two-arm randomized controlled trial in community settings and an integrated health plan. Participants who met inclusion criteria were ≥18 years old, were taking antipsychotic agents for ≥30 days, and had a body mass index ≥27. Exclusions were significant cognitive impairment, pregnancy/breastfeeding, recent psychiatric hospitalization, bariatric surgery, cancer, heart attack, or stroke. The intervention emphasized moderate caloric reduction, the DASH (Dietary Approaches to Stop Hypertension) diet, and physical activity. Blinded staff collected data at baseline, 6 months, and 12 months. RESULTS Participants (men, N=56; women, N=144; mean age=47.2 years [SD=10.6]) were randomly assigned to usual care (N=96) or a 6-month weekly group intervention plus six monthly maintenance sessions (N=104). A total of 181 participants (90.5%) completed 6-month assessments, and 170 (85%) completed 12-month assessments, without differential attrition. Participants attended 14.5 of 24 sessions over 6 months. Intent-to-treat analyses revealed that intervention participants lost 4.4 kg more than control participants from baseline to 6 months (95% CI=-6.96 kg to -1.78 kg) and 2.6 kg more than control participants from baseline to 12 months (95% CI=-5.14 kg to -0.07 kg). At 12 months, fasting glucose levels in the control group had increased from 106.0 mg/dL to 109.5 mg/dL and decreased in the intervention group from 106.3 mg/dL to 100.4 mg/dL. No serious adverse events were study-related; medical hospitalizations were reduced in the intervention group (6.7%) compared with the control group (18.8%). CONCLUSIONS Individuals taking antipsychotic medications can lose weight and improve fasting glucose levels. Increasing reach of the intervention is an important future step.
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76
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Vesco KK, Karanja N, King JC, Gillman MW, Leo MC, Perrin N, McEvoy CT, Eckhardt CL, Smith KS, Stevens VJ. Efficacy of a group-based dietary intervention for limiting gestational weight gain among obese women: a randomized trial. Obesity (Silver Spring) 2014; 22:1989-96. [PMID: 25164259 PMCID: PMC4407817 DOI: 10.1002/oby.20831] [Citation(s) in RCA: 88] [Impact Index Per Article: 8.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/12/2014] [Revised: 06/12/2014] [Accepted: 06/14/2014] [Indexed: 11/08/2022]
Abstract
OBJECTIVE Observational studies suggest that minimal gestational weight gain (GWG) may optimize pregnancy outcomes for obese women. This trial tested the efficacy of a group-based weight management intervention for limiting GWG among obese women. METHODS One hundred and fourteen obese women (BMI [mean ± SD] 36.7 ± 4.9 kg/m(2) ) were randomized between 7 and 21 weeks' (14.9 ± 2.6) gestation to intervention (n = 56) or usual care control conditions (n = 58). The intervention included individualized calorie goals, advice to maintain weight within 3% of randomization and follow the Dietary Approaches to Stop Hypertension dietary pattern without sodium restriction, and attendance at weekly group meetings until delivery. Control participants received one-time dietary advice. Our three main outcomes were maternal weight change from randomization to 2 weeks postpartum and from randomization to 34 weeks gestation, and newborn large-for-gestational age (birth weight >90th percentile, LGA). RESULTS Intervention participants gained less weight from randomization to 34 weeks gestation (5.0 vs. 8.4 kg, mean difference = -3.4 kg, 95% CI [-5.1-1.8]), and from randomization to 2 weeks postpartum (-2.6 vs. +1.2 kg, mean difference = -3.8 kg, 95% CI [-5.9-1.7]). They also had a lower proportion of LGA babies (9 vs. 26%, odds ratio = 0.28, 95% CI [0.09-0.84]). CONCLUSIONS The intervention resulted in lower GWG and lower prevalence of LGA newborns.
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Affiliation(s)
- Kimberly K. Vesco
- Center for Health Research, Kaiser Permanente, Northwest, 3800 N. Interstate Avenue, Portland, OR, 97227, USA
- Department of Obstetrics & Gynecology, Kaiser Permanente, Northwest, 500 NE Multnomah Street, Portland, OR 97232
| | - Njeri Karanja
- Center for Health Research, Kaiser Permanente, Northwest, 3800 N. Interstate Avenue, Portland, OR, 97227, USA
| | - Janet C. King
- Children’s Hospital Oakland Research Institute, 5700 Martin Luther King Jr Way, Oakland, CA, 94609, USA
| | - Matthew W. Gillman
- Obesity Prevention Program, Harvard Medical School/Harvard Pilgrim Health Care Institute, 133 Brookline Avenue, 6th Floor, Boston, MA, 02215, USA
| | - Michael C. Leo
- Center for Health Research, Kaiser Permanente, Northwest, 3800 N. Interstate Avenue, Portland, OR, 97227, USA
| | - Nancy Perrin
- Center for Health Research, Kaiser Permanente, Northwest, 3800 N. Interstate Avenue, Portland, OR, 97227, USA
| | - Cindy T. McEvoy
- Oregon Health & Science University, 700 Southwest Campus Drive, Portland, OR, 97239, USA
| | - Cara L. Eckhardt
- School of Community Health, Portland State University, 506 SW Mill Street, Suite 450, Portland, OR, 97201, USA
| | - K. Sabina Smith
- Center for Health Research, Kaiser Permanente, Northwest, 3800 N. Interstate Avenue, Portland, OR, 97227, USA
| | - Victor J. Stevens
- Center for Health Research, Kaiser Permanente, Northwest, 3800 N. Interstate Avenue, Portland, OR, 97227, USA
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Abstract
Objective: To determine the validity of adult body weights and heights recorded in electronic medical records (EMRs) in the course of routine medical care. Background: EMRs allow the potential use of data collected in the course of routine medical care for a variety of research applications in many fields including epidemiology and comparative effectiveness studies. However, researchers familiar with carefully controlled measurement protocols typically used in clinical trials may question the validity of data collected in the course of routine clinical care. Methods: Weights and heights collected during a research project that focused on weight gain during pregnancy were compared to weight and height measurements coincidently recorded in the research participant’s medical records. For weight measures (N=102), data recorded within ±14 days were compared, and for height measures (N=114), data recorded within ±5 years were compared. We assessed agreement between medical and research measurements using the concordance and intraclass correlation coefficients, and Bland and Altman’s limits of agreement. Findings: The mean research and medical record weight measurements were 99.3 kg and 99.2 kg, respectively. The concordance and intraclass correlation coefficients for weight had similar estimates of .999 and 95 percent confidence intervals [.998, .999]. The 95 percent limits of agreement were −1.5 kg and +1.7 kg. The mean research and medical height measurements were 1.646 m and 1.654 m, respectively, and the concordance and intraclass correlation coefficients for height were .941 and .942, respectively. The 95 percent limits of agreement were −.031 m and +.047 m. Conclusions: For pregnant women, body weights documented in the medical record are exchangeable with body weights recorded in a research setting. Height measurements recorded in the medical records were not in as close agreement as weights, but concordance between medical record and research height measurements are high enough to allow them to be used epidemiological and comparative effectiveness research.
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Smith LB, Leo MC, Anderson C, Wright TJ, Weymann KB, Wood LJ. The role of IL-1β and TNF-α signaling in the genesis of cancer treatment related symptoms (CTRS): a study using cytokine receptor-deficient mice. Brain Behav Immun 2014; 38:66-76. [PMID: 24412646 PMCID: PMC3989411 DOI: 10.1016/j.bbi.2013.12.022] [Citation(s) in RCA: 33] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/16/2013] [Revised: 12/19/2013] [Accepted: 12/28/2013] [Indexed: 02/01/2023] Open
Abstract
Cytotoxic chemotherapeutic agents often induce a cluster of cancer treatment related symptoms (CTRS). The purpose of this study was to develop a mouse model of CTRS to examine the role of IL-1β and TNF-α signaling in the genesis of these symptoms. CTRS (change in wheel running activity, food intake, and body weight from baseline) were examined in wild type (WT) mice or mice lacking the TNF-α p55 (type 1) receptor (TNFR1-/-) and/or IL-1β type 1 receptor (IL-1R1-/-) injected with four doses of cyclophosphamide/Adriamycin/5-fluorouracil (CAF) at 20-day intervals. Inflammatory cytokines in blood and tissues were measured using multiplex immunoassays and quantitative RT-PCR. ANOVA was used to examine differences between genotype and/or treatment group. Kaplan-Meier analysis was used to estimate survival rate. CAF rapidly increased IL-1β and TNF-α signaling in WT mice. CAF induced acute CTRS immediately following drug injection which returned to baseline prior to the next CAF dose. Persistent CTRS were evident 3weeks after the 4th CAF dose. Acute but not persistent CTRS were associated with increased levels of IL-7, IL-9, KC, MCP-1, GCSF, and IP-10. This CAF induced inflammatory response was blunted in IL-1R1 deficient mice and absent in IL-1R1/TNFR1-deficient mice. IL-1R1-/- mice showed an identical pattern of CTRS to their WT counterparts. The assessment of CTRS in IL-1R1/TNF-R1-deficient mice was precluded by severe toxicity. Our data suggest that an important function of the IL-1β and TNF-α driven inflammatory cascade is to promote recovery following exposure to cytotoxic agents.
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Affiliation(s)
- Logan B. Smith
- School of Nursing, Oregon Health Science University, Portland, OR, 97239
| | - Michael C. Leo
- Center for Health Research, Kaiser Permanente Northwest, Portland, OR 97227
| | - Caroline Anderson
- School of Nursing, Oregon Health Science University, Portland, OR 97239, United States.
| | - Teresa J. Wright
- School of Nursing, Oregon Health Science University, Portland, OR, 97239
| | | | - Lisa J. Wood
- School of Nursing, Oregon Health Science University, Portland, OR, 97239
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Nguyen-Truong CKY, Leo MC, Lee-Lin F, Gedaly-Duff V, Nail LM, Gregg J, Le TV, Tran T. Adaptation and testing of instruments to measure cervical cancer screening factors among Vietnamese immigrant women. J Transcult Nurs 2014; 26:244-53. [PMID: 24692341 DOI: 10.1177/1043659614524245] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
Abstract
PURPOSE Vietnamese American women diagnosed with cervical cancer are more likely to have advanced cancer than non-Hispanic White women. We sought to (a) develop a culturally sensitive Vietnamese translation of the Revised Susceptibility, Benefits, and Barriers Scale; Cultural Barriers to Screening Inventory; Confidentiality Issues Scale; and Quality of Care from the Health Care System Scale and (b) examine the psychometric properties. DESIGN Cross-sectional study with 201 Vietnamese immigrant women from the Portland, Oregon, metropolitan area. METHOD We used a community-based participatory research approach and the U.S. Census Bureau's team approach to translation. RESULTS Cronbach's alpha ranged from .57 to .91. The incremental fit index ranged from .83 to .88. DISCUSSION AND CONCLUSIONS The instruments demonstrated moderate to strong subscale internal consistency. Further research to assess structural validity is needed. IMPLICATIONS FOR PRACTICE Our approaches to translation and psychometric examination support use of the instruments in Vietnamese immigrant women.
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Affiliation(s)
| | - Michael C Leo
- Kaiser Permanente-Center for Health Research, Portland, OR, USA
| | | | | | | | - Jessica Gregg
- Oregon Health & Science University, Portland, OR, USA
| | - Tuong Vy Le
- Vietnamese Community Member, Portland, OR, USA
| | - Tuyen Tran
- Providence Cancer Center of Providence Health & Services, Portland, OR, USA
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Lee-Lin F, Menon U, Leo MC, Pedhiwala N. Feasibility of a targeted breast health education intervention for Chinese American immigrant women. Oncol Nurs Forum 2014; 40:361-72. [PMID: 23803269 DOI: 10.1188/13.onf.361-372] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
PURPOSE/OBJECTIVES To assess the feasibility and acceptability of a targeted educational intervention to increase mammography screening among Chinese American women. DESIGN One-group pre- and post-test quasiexperimental design. SETTING Metropolitan areas of Portland, OR. SAMPLE 44 foreign-born Chinese American women aged 40 years and older. METHODS Participants who had not had a mammogram within the past 12 months were recruited and enrolled to a targeted breast health educational program. Before starting the group session, participants completed a baseline survey, which was administered again 12 weeks postintervention. MAIN RESEARCH VARIABLES Completion of mammography screening test, movement in stage of readiness, mammography and breast cancer knowledge, perceived susceptibility, perceived benefits, and perceived common and cultural barriers. FINDINGS The study response rate was high (71%). Of the 42 women who completed the study, 21 (50%) had a mammogram postintervention. The top three reasons for not completing a mammogram at the end of the study were no need or no symptom, busy, and reliance on family for assistance. Mean breast cancer susceptibility scores increased significantly at post-test as theorized (t[40] = -2.88, p < 0.01). Participants were more likely to obtain a mammogram when they had been in the United States for 3-15 years. CONCLUSIONS A targeted program that aims to increase breast health knowledge, improve access, and remove barriers may promote mammography screening among Chinese American immigrant women. IMPLICATIONS FOR NURSING This promising intervention now being tested under a randomized, controlled design can be adapted to other Asian subgroups. KNOWLEDGE TRANSLATION Targeted breast health intervention is feasible for improving mammography screening among Chinese immigrant women. Educating these women about early detection is important, as the first sign of breast cancer usually shows on a woman's mammogram before it can be felt or any other symptoms are present. Immigrant women may be too busy to dedicate proper time to self-care behaviors; therefore, making it easier and faster for them to obtain a mammogram may improve the screening rate.
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Affiliation(s)
- Frances Lee-Lin
- School of Nursing, Oregon Health and Science University, Portland, USA.
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81
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Hansen L, Leo MC, Chang MF, Zucker BL, Sasaki A. Pain and self-care behaviours in adult patients with end-stage liver disease: a longitudinal description. J Palliat Care 2014; 30:32-40. [PMID: 24826441 PMCID: PMC4377279] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/03/2023]
Abstract
This prospective descriptive study investigated pain characteristics in 20 outpatients with endstage liver disease (ESLD) who were approaching the end of life, described variability in pain between and within patients, and described the pharmacological and nonpharmacological pain management strategies used. The instruments we utilized were the Brief Pain Inventory (BPI) and the self-care behaviour (SCB) log for pain. Data were collected once a month over a six-month period. BPI severity of, and interference from pain mean scores ranged from 5.52 to 6.03 and 5.36 to 6.64, respectively. The top three pain-relieving behaviours reported by patients were "taking pain medication," "taking a nap," and "asking for help." Pain medication intake-differed between patients who were pursuing a liver transplant and those who were not eligible for one. If we are to effectively improve care for ESLD patients, it is essential that we understand the ways in which these patients experience pain and the pain management strategies they employ.
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Affiliation(s)
- Lissi Hansen
- Oregon Health & Science University, School of Nursing, SN-ORD, 3455 S.W. US Veterans Hospital Rd., Portland, Oregon 97239-2941, Phone: 503 418-3357, Fax: 503 494-7783
| | - Michael C. Leo
- Kaiser Permanente Center for Health Research, 3800 N. Interstate Ave Portland, OR 97227, Phone: 503 528-3909, Fax: 503 273-5136
| | - Michael F. Chang
- Portland Veterans Affairs Medical Center, 3710 SW U.S. Veterans Hospital Rd., Portland, OR 97239, Phone: 503 220-8262 ext. 54482
| | - Betsy L. Zucker
- Portland Veterans Affairs Medical Center, 3710 SW U.S. Veterans Hospital Rd., Portland, OR 97239, Phone: 503 220-8262 ext. 54398, Fax: 503 273-5136
| | - Anna Sasaki
- Portland Veterans Affairs Medical Center and Oregon Health & Science University, Portland Veterans Affairs Medical Center, 3710 SW U.S. Veterans Hospital Rd., Portland, OR 97239, Phone: 503 220-8262, Fax: 503 273-5136
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Green CA, Perrin NA, Leo MC, Janoff SL, Yarborough BJH, Paulson RI. Recovery from serious mental illness: trajectories, characteristics, and the role of mental health care. Psychiatr Serv 2013; 64:1203-10. [PMID: 23999823 PMCID: PMC4330090 DOI: 10.1176/appi.ps.201200545] [Citation(s) in RCA: 39] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Abstract
OBJECTIVE The objective was to identify trajectories of recovery from serious mental illnesses. METHODS A total of 177 members (92 women; 85 men) of a not-for-profit integrated health plan participated in a two-year mixed-methods study of recovery (STARS, the Study of Transitions and Recovery Strategies). Diagnoses included schizophrenia, schizoaffective disorder, bipolar disorder, and affective psychosis. Data sources included self-reported standardized measures, interviewer ratings, qualitative interviews, and health plan data. Recovery was conceptualized as a latent construct, and factor analyses and factor scores were used to calculate recovery trajectories. Individuals with similar trajectories were identified through cluster analyses. RESULTS Four trajectories were identified-two stable (high and low levels of recovery) and two fluctuating (higher and lower). Few demographic or diagnostic factors differentiated clusters at baseline. Discriminant analyses for trajectories found differences in psychiatric symptoms, physical health, satisfaction with mental health clinicians, resources and strains, satisfaction with medications, and mental health service use. Those with higher scores on recovery factors had fewer psychiatric symptoms, better physical health, greater satisfaction with mental health clinicians, fewer strains and greater resources, less service use, better quality of care, and greater satisfaction with medication. Consistent predictors of trajectories included psychiatric symptoms, physical health, resources and strains, and use of psychiatric medications. CONCLUSIONS Having access to good-quality mental health care-defined as including satisfying relationships with clinicians, responsiveness to needs, satisfaction with psychiatric medications, receipt of services at needed levels, support in managing deficits in resources and strains, and care for general medical conditions-may facilitate recovery. Providing such care may improve recovery trajectories.
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Brown JP, Amaechi BT, Bader JD, Gilbert GH, Makhija SK, Lozano-Pineda J, Leo MC, Chen C, Vollmer WM. Visual scoring of non cavitated caries lesions and clinical trial efficiency, testing xylitol in caries-active adults. Community Dent Oral Epidemiol 2013; 42:271-8. [PMID: 24205951 DOI: 10.1111/cdoe.12082] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/15/2013] [Accepted: 10/01/2013] [Indexed: 11/29/2022]
Abstract
OBJECTIVES To better understand the effectiveness of xylitol in caries prevention in adults and to attempt improved clinical trial efficiency. METHODS As part of the Xylitol for Adult Caries Trial (X-ACT), non cavitated and cavitated caries lesions were assessed in subjects who were experiencing the disease. The trial was a test of the effectiveness of 5 g/day of xylitol, consumed by dissolving in the mouth five 1 g lozenges spaced across each day, compared with a sucralose placebo. For this analysis, seeking trial efficiency, 538 subjects aged 21-80, with complete data for four dental examinations, were selected from the 691 randomized into the 3-year trial, conducted at three sites. Acceptable inter- and intra-examiner reliability before and during the trial was quantified using the kappa statistic. RESULTS The mean annualized noncavitated plus cavitated lesion transition scores in coronal and root surfaces, from sound to carious favoured xylitol over placebo, during the three cumulative periods of 12, 24, and 33 months, but these clinically and statistically nonsignificant differences declined in magnitude over time. Restricting the present assessment to those subjects with a higher baseline lifetime caries experience showed possible but inconsistent benefit. CONCLUSIONS There was no clear and clinically relevant preventive effect of xylitol on caries in adults with adequate fluoride exposure when non cavitated plus cavitated lesions were assessed. This conformed to the X-ACT trial result assessing cavitated lesions. Including non cavitated lesion assessment in this full-scale, placebo-controlled, multisite, randomized, double-blinded clinical trial in adults experiencing dental caries did not achieve added trial efficiency or demonstrate practical benefit of xylitol. TRIAL REGISTRATION ClinicalTrials.Gov NCT00393055.
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Affiliation(s)
- John P Brown
- Dental School, University of Texas Health Science Center at San Antonio, San Antonio, TX, USA
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Yarborough BJH, Leo MC, Stumbo S, Perrin NA, Green CA. STRIDE: a randomized trial of a lifestyle intervention to promote weight loss among individuals taking antipsychotic medications. BMC Psychiatry 2013; 13:238. [PMID: 24074269 PMCID: PMC3907020 DOI: 10.1186/1471-244x-13-238] [Citation(s) in RCA: 24] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/11/2013] [Accepted: 09/24/2013] [Indexed: 11/12/2022] Open
Abstract
BACKGROUND Individuals diagnosed with serious mental illnesses are at increased risk of obesity- and cardiovascular-related morbidity and early mortality. Lifestyle interventions aimed at weight loss, even those adapted to suit the needs of this particular subgroup, have rarely produced clinically meaningful reductions in weight. METHODS/DESIGN The STRIDE study is a multi-site, parallel, two-arm randomized controlled translational trial. Participants were recruited from community mental health clinics and an integrated not-for-profit health system. Participants were randomized either to usual care or to a 12-month intervention that consisted of: 1) weekly group participation for six months covering topics on nutrition, physical activity and lifestyle changes; 2) monthly group participation for an additional six month maintenance period; and 3) individual monthly contacts from intervention group facilitators during the second six month phase. All participants are assessed at baseline, 6, 12, and 24 months post-enrollment. Process and implementation evaluations are included and the study design includes a cost-utility analysis. Participants include 200 individuals with serious mental illness with an average age of 47.1 years, a mean body-mass index of 38.3 kg/m(2) and taking an average of 3.2 psychiatric medications at baseline. Baseline physiological measures included mean blood pressure (SBP/DBP) measurements of 119.2 (SD = 14.7)/79.4 (SD = 10.1); 35% reported a hypertension diagnosis and 11% took antihypertensive medications. Average lipid levels (mg/dL) were: a) triglycerides 188.0 (SD = 138.6), ranged from 43 to 1145; b) LDL 101.4 (SD = 32.9) and ranged from 17 to 185; c) HDL 45.8 (SD = 12.7) and ranged from 22 to 89; and d) total cholesterol 181.6 (SD = 39.7) and ranged from 50 to 324. Average fasting glucose levels were 108.9 (SD = 32.5) and ranged from 24 to 289. Average fasting insulin levels were 13.0 (SD=11.9) and ranged from 2 to 99. DISCUSSION The STRIDE study is based on a modified version of the PREMIER comprehensive lifestyle intervention, DASH diet arm. STRIDE has successfully enrolled 200 individuals with serious mental illness in community-based settings. Baseline characteristics present a population at high risk for obesity-related negative health outcomes and demonstrate the need for evidence-based interventions to reduce these risks. TRIAL REGISTRATION Clinical Trials.gov NCT00790517.
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Affiliation(s)
- Bobbi Jo H Yarborough
- Kaiser Permanente Center for Health Research, 3800 N. Interstate Avenue, Portland, OR 97227, USA
| | - Michael C Leo
- Kaiser Permanente Center for Health Research, 3800 N. Interstate Avenue, Portland, OR 97227, USA
| | - Scott Stumbo
- Kaiser Permanente Center for Health Research, 3800 N. Interstate Avenue, Portland, OR 97227, USA
| | - Nancy A Perrin
- Kaiser Permanente Center for Health Research, 3800 N. Interstate Avenue, Portland, OR 97227, USA
| | - Carla A Green
- Kaiser Permanente Center for Health Research, 3800 N. Interstate Avenue, Portland, OR 97227, USA
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Winters-Stone KM, Dobek J, Nail LM, Bennett JA, Leo MC, Torgrimson-Ojerio B, Luoh SW, Schwartz A. Impact + resistance training improves bone health and body composition in prematurely menopausal breast cancer survivors: a randomized controlled trial. Osteoporos Int 2013; 24:1637-46. [PMID: 22996743 PMCID: PMC3856427 DOI: 10.1007/s00198-012-2143-2] [Citation(s) in RCA: 80] [Impact Index Per Article: 7.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/20/2012] [Accepted: 09/05/2012] [Indexed: 02/07/2023]
Abstract
UNLABELLED Our randomized controlled trial in prematurely menopausal breast cancer survivors showed that impact + resistance training prevented increases in percentage of body fat compared with controls and also improved BMD at the hip and prevented BMD loss at the spine among exercise-trained women who were menopausal for >1 year. INTRODUCTION Cancer treatment-related menopause worsens bone health and body composition in breast cancer survivors (BCS). We investigated whether impact + resistance training could improve bone mineral density (BMD), reduce bone turnover, build muscle, and decrease fat mass in BCS with premature menopause. METHODS We conducted a randomized controlled trial in 71 BCS (mean age, 46.5 years) within 5 years of treatment-related menopause. Women were randomly assigned to one of two groups: (1) impact + resistance training (prevent osteoporosis with impact + resistance (POWIR)) or (2) exercise placebo (FLEX) 3×/week for 1 year. Outcomes were hip and spine BMD (in grams per square centimeter) and body composition (percent body fat (%BF) and lean and fat mass (in kilograms)) by DXA and bone turnover markers (serum osteocalcin (in nanograms per milliliter) and urinary deoxypryrodinoline (in nanomoles per milliliter). RESULTS There were no significant group × time interactions for bone outcomes when using an intent-to-treat approach on the full sample. In analyses restricted to BCS who were menopausal for ≥1 year, POWIR increased BMD at the hip and slowed BMD loss at the spine compared with FLEX (femoral neck-POWIR, 0.004 ± 0.093 g/cm(2) vs. FLEX, -0.010 ± 0.089 g/cm(2); p < 0.01; spine-POWIR, -0.003 ± 0.114 g/cm(2) vs. FLEX, -0.020 ± 0.110 g/cm(2); p = 0.03). POWIR prevented increases in %BF (POWIR, 0.01 % vs. FLEX, 1.3 %; p < 0.04). Women with attendance to POWIR at ≥64 % had better improvements in %BF than women attending less often (p < 0.03). CONCLUSION Impact + resistance training may effectively combat bone loss and worsening body composition from premature menopause in BCS.
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Affiliation(s)
- K M Winters-Stone
- School of Nursing, Oregon Health & Science University, Portland, OR, USA.
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Ritter AV, Bader JD, Leo MC, Preisser JS, Shugars DA, Vollmer WM, Amaechi BT, Holland JC. Tooth-surface-specific effects of xylitol: randomized trial results. J Dent Res 2013; 92:512-7. [PMID: 23589387 DOI: 10.1177/0022034513487211] [Citation(s) in RCA: 29] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022] Open
Abstract
The Xylitol for Adult Caries Trial was a three-year, double-blind, multi-center, randomized clinical trial that evaluated the effectiveness of xylitol vs. placebo lozenges in the prevention of dental caries in caries-active adults. The purpose of this secondary analysis was to investigate whether xylitol lozenges had a differential effect on cumulative caries increments on different tooth surfaces. Participants (ages 21-80 yrs) with at least one follow-up visit (n = 620) were examined at baseline, 12, 24, and 33 months. Negative binomial and zero-inflated negative binomial regression models were used to estimate incidence rate ratios (IRR) for xylitol's differential effect on cumulative caries increments on root and coronal surfaces and, among coronal surfaces, on smooth (buccal and lingual), occlusal, and proximal surfaces. Participants in the xylitol arm developed 40% fewer root caries lesions (0.23 D2FS/year) than those in the placebo arm (0.38 D2FS/year; IRR = 0.60; 95% CI [0.44, 0.81]; p < .001). There was no statistically significant difference between xylitol and control participants in the incidence of smooth-surface caries (p = .100), occlusal-surface caries (p = .408), or proximal-surface caries (p = .159). Among these caries-active adults, xylitol appears to have a caries-preventive effect on root surfaces (ClinicalTrials.gov NCT00393055).
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Affiliation(s)
- A V Ritter
- University of North Carolina, School of Dentistry, 441 Brauer Hall, Chapel Hill, NC 27599-7450, USA
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Cini E, Leo MC, Cecchi M, Agostino E, Pugi A, Rispoli AI, Banfi R. GRP-004 A New Strategy For Monitoring and Identification of Adverse Drug Reactions in Oncology Patients. Eur J Hosp Pharm 2013. [DOI: 10.1136/ejhpharm-2013-000276.004] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/03/2022] Open
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Leo MC, Cini E, Pugi A, Banfi R. GRP-188 Under-Reporting of Adverse Drug Reactions in the Hospital Setting: An Estimate Based on the Analysis of Hospital Discharge Records. Eur J Hosp Pharm 2013. [DOI: 10.1136/ejhpharm-2013-000276.188] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022] Open
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Leo MC, Peterson D, Haas M, LeFebvre R, Bhalerao S. Development and psychometric evaluation of an evidence-based practice questionnaire for a chiropractic curriculum. J Manipulative Physiol Ther 2012. [PMID: 23206964 DOI: 10.1016/j.jmpt.2012.10.011] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Abstract
OBJECTIVE The purposes of this study were to describe the questionnaire development process for evaluating elements of an evidence-based practice (EBP) curriculum in a chiropractic program and to report on initial reliability and validity testing for the EBP knowledge examination component of the questionnaire. METHODS The EBP knowledge test was evaluated with students enrolled in a doctor of chiropractic program in the University of Western States. The initial version was tested with a sample of 374 and a revised version with a sample of 196 students. Item performance and reliability were assessed using item difficulty, item discrimination, and internal consistency. An expert panel assessed face and content validity. RESULTS The first version of the knowledge examination demonstrated a low internal consistency (Kuder-Richardson 20 = 0.55), and a few items had poor item difficulty and discrimination. This resulted in an expansion in the number of items from 20 to 40, as well as a revision of the poorly performing items from the initial version. The Kuder-Richardson 20 of the second version was 0.68; 32 items had item difficulties of between 0.20 and 0.80, and 26 items had item discrimination values of 0.20 or greater. CONCLUSIONS A questionnaire for evaluating a revised EBP-integrated curriculum was developed and evaluated. Psychometric testing of the EBP knowledge component provided some initial evidence for acceptable reliability and validity.
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Affiliation(s)
- Michael C Leo
- Kaiser Permanente Center for Health Research, Portland, OR 97227, USA.
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Abstract
The director of nursing (DON) is an essential member of the top management team in nursing homes and in a key position to improve the quality and value of care. This article describes and examines the roles and responsibilities of DONs as perceived by a convenience sample of current/previous DONs and nursing home administrators (n = 29). Data were collected through in-depth semistructured interviews and analyzed using content analysis and thematic analysis. The findings reveal a broad scope and wide variation in the DON position across settings, with inextricable linkages between clinical care and other aspects of care delivery, such as managing fiscal and human resources (HR). As RN licensure is the only Federal requirement for the DON position, suggesting a clinical focus, the findings highlight a policy-practice gap. Research is needed to address this gap, focusing on the requisite preparation DONs need to effectively and cost-efficiently lead initiatives for quality improvement.
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Affiliation(s)
- Elena O Siegel
- Betty Irene Moore School of Nursing at UC Davis, UC Davis Health System, Sacramento, CA 95817, USA.
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Nguyen-Truong CKY, Lee-Lin F, Leo MC, Gedaly-Duff V, Nail LM, Wang PR, Tran T. A community-based participatory research approach to understanding pap testing adherence among Vietnamese American immigrants. J Obstet Gynecol Neonatal Nurs 2012; 41:E26-40. [PMID: 23030739 DOI: 10.1111/j.1552-6909.2012.01414.x] [Citation(s) in RCA: 18] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022] Open
Abstract
OBJECTIVE To explore factors potentially influencing Pap testing practices among Vietnamese American immigrant women (VIW, foreign-born) and describe their awareness of cervical cancer screening resources in their community. DESIGN Descriptive study guided by the ecological model and community-based participatory research principles. SETTING Portland, Oregon, metropolitan area. PARTICIPANTS Vietnamese American immigrant women (211) who were age 21 and older. METHODS We used descriptive statistics and logistic regression analyses to analyze a self-administered questionnaire that was pretested and translated using a team approach. RESULTS Approximately 74% of VIW who completed the survey reported at least one Pap test, and 69% reported Pap testing history adherent to national guidelines. The factor most strongly associated with Pap testing receipt was suggestion from a friend, followed by longer residency in the United States, lower perceived common barriers, and lower perceived cultural barriers, for example, lack of family support and use of Eastern/Asian medicine. The factor most strongly associated with guideline adherence was having health insurance, followed by a recommendation from a physician or nurse practitioner. Only 11% of VIW knew where to obtain a free or low-cost Pap tests. CONCLUSION Nurses can influence rates of Pap testing among VIW by providing health education through outreach programs targeted at lay health workers and their social networks, identifying at-risk patients such as recently immigrated women, reducing perceived common and cultural barriers to Pap testing, and helping women seek alternative payment options if they lack health insurance. Primary health care providers should be reminded of their essential role in increasing Pap testing adherence.
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Winters-Stone KM, Leo MC, Schwartz A. Exercise effects on hip bone mineral density in older, post-menopausal breast cancer survivors are age dependent. Arch Osteoporos 2012; 7:301-6. [PMID: 23225299 PMCID: PMC3533253 DOI: 10.1007/s11657-012-0071-6] [Citation(s) in RCA: 24] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/20/2012] [Accepted: 02/13/2012] [Indexed: 02/03/2023]
Abstract
UNLABELLED We evaluated whether age moderated the effect of impact + resistance exercise on hip BMD in older post-menopausal breast cancer survivors (BCS). Exercise was more beneficial among younger than older women within our sample, suggesting that much older BCS may require different training programs to improve hip health. PURPOSE Previously, we reported that a program of resistance + impact training stopped bone loss at the spine in older, post-menopausal BCS but had no effect on bone mineral density (BMD) at the hip. Aging may blunt the responsiveness of the hip to mechanical loading, so we conducted a secondary data analysis to evaluate whether age moderated the effect of exercise on hip BMD. METHODS We analyzed data from our randomized, controlled trial in older (≥ 50 years of age at diagnosis), post-menopausal, post-adjuvant treatment BCS (n = 106) comparing women assigned to impact + resistance exercise (POWIR) or to a control program of low-intensity stretching (FLEX). We examined effect modification by age on BMD at three hip sites (greater trochanter, femoral neck, and total hip) using hierarchical linear modeling adjusting for time since diagnosis and use of adjuvant hormone therapy. RESULTS Age moderated the effect of exercise on total hip BMD such that younger women in POWIR were more likely to see a positive net benefit than FLEX compared to older women where there was little difference between groups (p = 0.02). CONCLUSIONS The skeletal response to loading at the hip within post-menopausal BCS diminishes with age. Whether more vigorous exercise programs and/or longer training periods are required to favorably change hip health in older BCS will require future study and careful thought about the risks and benefits of tougher training programs.
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Affiliation(s)
- Kerri M Winters-Stone
- School of Nursing, Oregon Health and Science University, 3455 SW US Veteran's Hospital Rd, Mailcode: SN-ORD, Portland, OR 97239, USA.
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Winters-Stone KM, Dobek J, Bennett JA, Nail LM, Leo MC, Schwartz A. The effect of resistance training on muscle strength and physical function in older, postmenopausal breast cancer survivors: a randomized controlled trial. J Cancer Surviv 2011; 6:189-99. [PMID: 22193780 DOI: 10.1007/s11764-011-0210-x] [Citation(s) in RCA: 122] [Impact Index Per Article: 9.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/25/2011] [Accepted: 11/22/2011] [Indexed: 01/07/2023]
Abstract
INTRODUCTION Older breast cancer survivors (BCS) report more falls and functional limitations than women with no cancer history. Exercise training could reduce risk factors for future falls and disability. METHODS We conducted a randomized, controlled trial in 106 early-stage, postmenopausal BCS who were ≥50 years old at diagnosis and post-treatment. Women were randomly assigned to a 1-year resistance + impact exercise program or a stretching placebo program. Endpoints were one repetition maximum bench press and leg press strength, timed five chair stands, 4 m usual walk speed, timed stance tests, handgrip strength, self-report physical function, and fatigue. We also examined the influence of age, adjuvant hormone therapy use, and exercise adherence on study outcomes. RESULTS Women in the resistance + impact training program significantly improved maximal leg (p <0 .02) and bench (p <0 .02) press strength compared to the stretching group. Women who attended 50% or more of prescribed resistance training sessions had significantly better changes in maximal strength measures compared to less adherent women. CONCLUSIONS Resistance + impact exercise is superior to stretching at improving maximal muscle strength and exercise adherence contributes to the degree of improvement. IMPLICATIONS FOR CANCER SURVIVORS Older BCS can safely engage in resistance exercise that improves lower and upper body strength, thereby reducing a risk factor for falls and future disability. However, the ability of resistance training to shift other indices of fall and disability risk, i.e., balance and function, is unclear. Strategies to promote adherence to resistance training could lead to greater improvements in strength.
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Affiliation(s)
- Kerri M Winters-Stone
- School of Nursing, Oregon Health and Science University, 3455 SW US Veteran's Hospital Rd, Mailcode: SN-ORD, Portland, OR 97239, USA.
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Winters-Stone KM, Dobek J, Nail L, Bennett JA, Leo MC, Naik A, Schwartz A. Strength training stops bone loss and builds muscle in postmenopausal breast cancer survivors: a randomized, controlled trial. Breast Cancer Res Treat 2011; 127:447-56. [PMID: 21424279 DOI: 10.1007/s10549-011-1444-z] [Citation(s) in RCA: 139] [Impact Index Per Article: 10.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/24/2011] [Accepted: 03/07/2011] [Indexed: 01/07/2023]
Abstract
Targeted exercise training could reduce risk factors for fracture and obesity-related diseases that increase from breast cancer treatment, but has not been sufficiently tested. We hypothesized that progressive, moderate-intensity resistance + impact training would increase or maintain hip and spine bone mass, lean mass and fat mass and reduce bone turnover compared to controls who participated in a low-intensity, non-weight bearing stretching program. We conducted a randomized, controlled trial in 106 women with early stage breast cancer who were >1 year post-radiation and/or chemotherapy, ≥ 50 years of age at diagnosis and postmenopausal, free from osteoporosis and medications for bone loss, resistance and impact exercise naïve, and cleared to exercise by a physician. Women were randomly assigned to participate in 1 year of thrice-weekly progressive, moderate-intensity resistance + impact (jump) exercise or in a similar frequency and length control program of progressive, low-intensity stretching. Primary endpoints were bone mineral density (BMD; g/cm²) of the hip and spine and whole body bone-free lean and fat mass (kg) determined by DXA and biomarkers of bone turnover-serum osteocalcin (ng/ml) and urinary deoxypyrodiniline cross-links (nmol/mmolCr). Women in the resistance + impact training program preserved BMD at the lumbar spine (0.47 vs. -2.13%; P = 0.001) compared to controls. The resistance + impact group had a smaller increase in osteocalcin (7.0 vs. 27%, P = 0.03) and a larger decrease in deoxypyrodinoline (-49.9 vs. -32.6%, P = 0.06) than controls. Increases in lean mass from resistance + impact training were greatest among women currently taking aromatase inhibitors compared to controls not on this therapy (P = 0.01). Our combined program of resistance + impact exercise reduced risk factors for fracture among postmenopausal breast cancer survivors (BCS) and may be particularly relevant for BCS on aromatase inhibitors (AIs) because of the additional benefit of exercise on muscle mass that could reduce falls.
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Buck T, Pellegrini P, Sauerwein R, Leo MC, Covell DA, Maier T, Machida CA. Elastomeric-ligated vs self-ligating appliances: a pilot study examining microbial colonization and white spot lesion formation after 1 year of orthodontic treatment. Orthodontics (Chic.) 2011; 12:108-121. [PMID: 21935504] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 05/31/2023]
Abstract
AIM To (1) evaluate the use of adenosine triphosphate (ATP)-driven bioluminescence for quantification of total plaque bacteria in orthodontic patients, (2) compare plaque bacteria amounts at the bracket-tooth interface with use of elastomeric-ligated and self-ligating brackets after 1 year of orthodontic treatment, and (3) analyze formation of white spot lesions by photographic evaluation and laser-light fluorescence (DIAGNOdent). METHODS Thirteen subjects had fixed orthodontic appliances placed where lateral incisors were bonded with either elastomeric-ligated or self-ligating brackets. Plaque bacteria were collected from incisor surfaces after 1 year and quantified using plating methods and ATP-driven bioluminescence. White spot lesions were evaluated by photographic and DIAGNOdent determinations. A 2 x 2 x 2 mixed-design ANOVA was conducted to determine differences in plaque retention between elastomeric-ligated and self-ligating brackets. RESULTS ATP-driven bioluminescence values correlated to numbers of total plaque bacteria (r = 0.80). However, unlike findings published in the original pilot study, which described increased plaque retention with elastomeric-ligated brackets at 5 weeks postbonding, there were no significant differences in bacterial numbers or ATP-driven bioluminescence values surrounding the elastomeric-ligated vs self-ligating brackets after 1 year of orthodontic treatment. Based on photographic and DIAGNOdent determinations, white spot lesions were found relatively equally on teeth bonded with either bracket type. DIAGNOdent measurements were found to have moderate sensitivity (0.71) and good specificity (0.88) when compared to white spot lesions determined using photographic evaluation. CONCLUSION ATP-driven bioluminescence can be used as an accurate assessment of total plaque bacteria in orthodontic patients. After 1 year of orthodontic treatment for patients in this pilot study, there appeared to be no differences in retention of plaque bacteria or white spot lesions comparing the bracket types. The use of DIAGNOdent has some limitations, but may prove to be useful to monitor white spot lesions longitudinally.
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Affiliation(s)
- Tyson Buck
- Department of Orthodontics, Oregon Health & Science University, School of Dentistry, Portland, Oregon 97239, USA
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McCarty D, Perrin NA, Green CA, Polen MR, Leo MC, Lynch F. Methadone maintenance and the cost and utilization of health care among individuals dependent on opioids in a commercial health plan. Drug Alcohol Depend 2010; 111:235-40. [PMID: 20627427 PMCID: PMC2950212 DOI: 10.1016/j.drugalcdep.2010.04.018] [Citation(s) in RCA: 31] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/12/2010] [Revised: 04/28/2010] [Accepted: 04/30/2010] [Indexed: 10/19/2022]
Abstract
BACKGROUND Few health plans provide maintenance medication for opioid dependence. This study assessed the cost of treating opioid-dependent members in a commercial health plan and the impacts of methadone maintenance on costs of care. METHODS Individuals with diagnoses of opioid dependence (two or more diagnoses per year) and at least 9 months of health plan eligibility each year were extracted from electronic health records for the years 2000 through 2004 (1,518 individuals and 2,523 observations across the study period-some individuals were in multiple years). Analyses examined the patterns and costs of health care for three groups of patients: (1) one or more methadone visits during the year (n=1,298; 51%); (2) no methadone visits and 0 or 1 visits in the Addiction Medicine Department (n=370; 15%); (3) no methadone visits and 2 or more visits in addiction medicine (n=855; 34%). RESULTS Primary care (86%), emergency department (48%) and inpatient (24%) visits were common. Mean total annual costs to the health plan were $11,200 (2004 dollars) per member per year. The health plan's costs for members receiving methadone maintenance were 50% lower ($7,163) when compared to those with two or more outpatient addiction treatment visits but no methadone ($14,157) and 62% lower than those with one or zero outpatient addiction treatment visits and no methadone treatment ($18,694). CONCLUSIONS Use of opioid maintenance services was associated with lower total costs of care for opioid-dependent members in a commercial health plan.
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Affiliation(s)
- Dennis McCarty
- Oregon Health & Science University, Portland, OR 97239, USA.
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97
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Green CA, Polen MR, Leo MC, Perrin NA, Anderson BM, Weisner CM. Drinking Patterns, Gender and Health II: Predictors of Preventive Service Use. Addict Res Theory 2010; 18:143-159. [PMID: 23814545 PMCID: PMC3694481 DOI: 10.3109/16066350903398494] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/02/2023]
Abstract
BACKGROUND Chronic diseases and injuries are elevated among people with substance use problems/dependence, yet heavier drinkers use fewer routine and preventive health services than non-drinkers and moderate drinkers, while former drinkers and abstainers use more than moderate drinkers. Researchers hypothesize that drinking clusters with attitudes and practices that produce better health among moderate drinkers and that heavy drinkers avoid doctors until becoming ill, subsequently quitting and using more services. Gender differences in alcohol consumption, health-related attitudes, practices, and prevention-services use may affect these relationships. METHODS A stratified random sample of health-plan members (7884; 2995 males, 4889 females) completed a mail survey that was linked to 24 months of health-plan records. Data were used to examine relationships between alcohol use, gender, health-related attitudes/practices, health, and prevention-service use. RESULTS Controlling for attitudes, practices, and health, female lifelong abstainers and former drinkers were less likely to have mammograms; individuals with alcohol use disorders and positive AUDIT scores were less likely to obtain influenza vaccinations. AUDIT-positive women were less likely to undergo colorectal screening than AUDIT-positive men. Consistent predictors of prevention-services use were: self-report of having a primary care provider (positive); disliking visiting the doctor (negative); smoking cigarettes (negative), and higher BMI (negative). CONCLUSIONS When factors associated with drinking are controlled, patterns of alcohol consumption have limited effects on preventive service use. Individuals with stigmatized behaviors (e.g., hazardous/harmful drinking, smoking, or high BMIs) are less likely to receive care. Making care experiences positive and carefully addressing stigmatized health practices could increase preventive service use.
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Affiliation(s)
- Carla A. Green
- Center for Health Research, Kaiser Permanente Northwest, 3800 N. Interstate Avenue, Portland, OR 97227-1110, USA
| | - Michael R. Polen
- Center for Health Research, Kaiser Permanente Northwest, 3800 N. Interstate Avenue, Portland, OR 97227-1110, USA
| | - Michael C. Leo
- Oregon Health & Science University, 3181 S.W. Sam Jackson Park Road, Portland, OR 97239-3098, USA
| | - Nancy A. Perrin
- Center for Health Research, Kaiser Permanente Northwest, 3800 N. Interstate Avenue, Portland, OR 97227-1110, USA
| | - Bradley M. Anderson
- Addiction Medicine Department, Interstate Medical Office East, Kaiser Permanente Northwest, 3550 N. Interstate Avenue, Portland, OR 97227, USA
| | - Constance M. Weisner
- University of California, San Francisco, 401 Parnassus Ave, Box F-0984, San Francisco, CA 94143 and Kaiser Permanente Division of Research, 2000 Broadway, 3rd floor, Oakland, CA 94612, USA
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98
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Green CA, Polen MR, Leo MC, Janoff SL, Anderson BM, Weisner CM, Perrin NA. Drinking Patterns, Gender and Health III: Avoiding vs. Seeking Healthcare. Addict Res Theory 2010; 18:160-180. [PMID: 23795149 PMCID: PMC3686530 DOI: 10.3109/16066350903398502] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/02/2023]
Abstract
BACKGROUND Inability to predict most health services use and costs using demographics and health status suggests that other factors affect use, including attitudes and practices that influence health and willingness to seek care. Alcohol consumption has generated interest because heavy, chronic consumption causes adverse health consequences, acute consumption increases injury, and moderate drinking is linked to better health while hazardous drinking and alcohol-related problems are stigmatized and may affect willingness to seek care. METHODS A stratified random sample of health-plan members completed a mail survey, yielding 7884 respondents (2995 male/4889 female). We linked survey data to 24 months of health-plan records to examine relationships between alcohol use, gender, health-related attitudes, practices, health, and service use. In-depth interviews with a stratified 150-respondent subsample explored individuals' reasons for seeking or avoiding care. RESULTS Quantitative results suggest health-related practices and attitudes predict subsequent service use. Consistent predictors of care were having quit drinking, current at-risk consumption, cigarette smoking, higher BMI, disliking visiting doctors, and strong religious/spiritual beliefs. Qualitative analyses suggest embarrassment and shame are strong motivators for avoiding care. CONCLUSIONS Although models included numerous health, functional status, attitudinal and behavioral predictors, variance explained was similar to previous reports, suggesting more complex relationships than expected. Qualitative analyses suggest several potential predictive factors not typically measured in service-use studies: embarrassment and shame, fear, faith that the body will heal, expectations about likelihood of becoming seriously ill, disliking the care process, the need to understand health problems, and the effects of self-assessments of health-related functional limitations.
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Affiliation(s)
- Carla A. Green
- Center for Health Research, Kaiser Permanente Northwest, 3800 N. Interstate Avenue, Portland, OR 97227-1110, USA
| | - Michael R. Polen
- Center for Health Research, Kaiser Permanente Northwest, 3800 N. Interstate Avenue, Portland, OR 97227-1110, USA
| | - Michael C. Leo
- Oregon Health & Science University, 3181 S.W. Sam Jackson Park Road, Portland, OR 97239-3098, USA
| | - Shannon L. Janoff
- Center for Health Research, Kaiser Permanente Northwest, 3800 N. Interstate Avenue, Portland, OR 97227-1110, USA
| | - Bradley M. Anderson
- Addiction Medicine Department, Interstate Medical Office East, Kaiser Permanente Northwest, 3550 N. Interstate Avenue, Portland, OR 97227, USA
| | - Constance M. Weisner
- University of California, San Francisco, 401 Parnassus Ave, Box F-0984, San Francisco, CA 94143 and Kaiser Permanente Division of Research, 2000 Broadway, 3rd floor, Oakland, CA 94612, USA
| | - Nancy A. Perrin
- Center for Health Research, Kaiser Permanente Northwest, 3800 N. Interstate Avenue, Portland, OR 97227-1110, USA
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Green CA, Perrin NA, Polen MR, Leo MC, Hibbard JH, Tusler M. Development of the Patient Activation Measure for mental health. Adm Policy Ment Health 2009; 37:327-33. [PMID: 19728074 DOI: 10.1007/s10488-009-0239-6] [Citation(s) in RCA: 91] [Impact Index Per Article: 6.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/16/2009] [Accepted: 08/12/2009] [Indexed: 11/28/2022]
Abstract
Our objective was to adapt the physical health Patient Activation Measure (PAM) for use among people with mental health conditions (PAM-MH). Data came from three studies among people with chronic mental health conditions and were combined in Rasch analyses. The PAM-MH's psychometric properties equal those of the original 13-item PAM. Test-retest reliability and concurrent validity were good, and the PAM-MH showed sensitivity to change. The PAM-MH appears to be a reliable and valid measure of patient activation among individuals with mental health problems. It appears to have potential for use in assessing change in activation.
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Affiliation(s)
- Carla A Green
- Center for Health Research, Kaiser Permanente Northwest, 3800 N. Interstate Avenue, Portland, OR 97227-1110, USA.
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100
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Butterworth S, Linden A, McClay W, Leo MC. Effect of motivational interviewing-based health coaching on employees' physical and mental health status. J Occup Health Psychol 2007; 11:358-65. [PMID: 17059299 DOI: 10.1037/1076-8998.11.4.358] [Citation(s) in RCA: 68] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
Abstract
Motivational Interviewing (MI) based health coaching is a relatively new behavioral intervention that has gained popularity in public health because of its ability to address multiple behaviors, health risks, and illness self-management. In this study, 276 employees at a medical center self-selected to participate in either a 3-month health coaching intervention or control group. The treatment group showed significant improvement in both SF-12 physical (p = .035) and mental (p = .0001) health status compared to controls. Because of concerns of selection bias, a matched case-control analysis was also performed, eliciting similar results. These findings suggest that MI-based health coaching is effective in improving both physical and mental health status in an occupational setting.
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Affiliation(s)
- Susan Butterworth
- School of Nursing, Oregon Health & Science University, Portland, Oregon 97239, USA.
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