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Getahun D, Nash R, Flanders WD, Baird TC, Becerra-Culqui TA, Cromwell L, Hunkeler E, Lash TL, Millman A, Quinn VP, Robinson B, Roblin D, Silverberg MJ, Safer J, Slovis J, Tangpricha V, Goodman M. Cross-sex Hormones and Acute Cardiovascular Events in Transgender Persons: A Cohort Study. Ann Intern Med 2018; 169:205-213. [PMID: 29987313 PMCID: PMC6636681 DOI: 10.7326/m17-2785] [Citation(s) in RCA: 244] [Impact Index Per Article: 40.7] [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: 12/11/2022] Open
Abstract
BACKGROUND Venous thromboembolism (VTE), ischemic stroke, and myocardial infarction in transgender persons may be related to hormone use. OBJECTIVE To examine the incidence of these events in a cohort of transgender persons. DESIGN Electronic medical record-based cohort study of transgender members of integrated health care systems who had an index date (first evidence of transgender status) from 2006 through 2014. Ten male and 10 female cisgender enrollees were matched to each transgender participant by year of birth, race/ethnicity, study site, and index date enrollment. SETTING Kaiser Permanente in Georgia and northern and southern California. PATIENTS 2842 transfeminine and 2118 transmasculine members with a mean follow-up of 4.0 and 3.6 years, respectively, matched to 48 686 cisgender men and 48 775 cisgender women. MEASUREMENTS VTE, ischemic stroke, and myocardial infarction events ascertained from diagnostic codes through the end of 2016 in transgender and reference cohorts. RESULTS Transfeminine participants had a higher incidence of VTE, with 2- and 8-year risk differences of 4.1 (95% CI, 1.6 to 6.7) and 16.7 (CI, 6.4 to 27.5) per 1000 persons relative to cisgender men and 3.4 (CI, 1.1 to 5.6) and 13.7 (CI, 4.1 to 22.7) relative to cisgender women. The overall analyses for ischemic stroke and myocardial infarction demonstrated similar incidence across groups. More pronounced differences for VTE and ischemic stroke were observed among transfeminine participants who initiated hormone therapy during follow-up. The evidence was insufficient to allow conclusions regarding risk among transmasculine participants. LIMITATION Inability to determine which transgender members received hormones elsewhere. CONCLUSION The patterns of increases in VTE and ischemic stroke rates among transfeminine persons are not consistent with those observed in cisgender women. These results may indicate the need for long-term vigilance in identifying vascular side effects of cross-sex estrogen. PRIMARY FUNDING SOURCE Patient-Centered Outcomes Research Institute and Eunice Kennedy Shriver National Institute of Child Health and Human Development.
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Affiliation(s)
- Darios Getahun
- Kaiser Permanente Southern California, Pasadena, California (D.G., T.A.B., V.P.Q.)
| | - Rebecca Nash
- Emory University, Atlanta, Georgia (R.N., W.D.F., T.L.L., M.G.)
| | - W Dana Flanders
- Emory University, Atlanta, Georgia (R.N., W.D.F., T.L.L., M.G.)
| | - Tisha C Baird
- Kaiser Permanente Los Angeles Medical Center, Los Angeles, California (T.C.B.)
| | | | - Lee Cromwell
- Kaiser Permanente Georgia, Atlanta, Georgia (L.C., B.R.)
| | - Enid Hunkeler
- Kaiser Permanente Northern California, Oakland, California (E.H., A.M., M.J.S., J.S.)
| | - Timothy L Lash
- Emory University, Atlanta, Georgia (R.N., W.D.F., T.L.L., M.G.)
| | - Andrea Millman
- Kaiser Permanente Northern California, Oakland, California (E.H., A.M., M.J.S., J.S.)
| | - Virginia P Quinn
- Kaiser Permanente Southern California, Pasadena, California (D.G., T.A.B., V.P.Q.)
| | | | - Douglas Roblin
- Kaiser Permanente Mid-Atlantic States, Rockville, Maryland (D.R.)
| | - Michael J Silverberg
- Kaiser Permanente Northern California, Oakland, California (E.H., A.M., M.J.S., J.S.)
| | - Joshua Safer
- Icahn School of Medicine at Mount Sinai, New York, New York (J.S.)
| | - Jennifer Slovis
- Kaiser Permanente Northern California, Oakland, California (E.H., A.M., M.J.S., J.S.)
| | - Vin Tangpricha
- Emory University School of Medicine and Atlanta VA Medical Center, Atlanta, Georgia (V.T.)
| | - Michael Goodman
- Emory University, Atlanta, Georgia (R.N., W.D.F., T.L.L., M.G.)
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Owen-Smith AA, Gerth J, Sineath RC, Barzilay J, Becerra-Culqui TA, Getahun D, Giammattei S, Hunkeler E, Lash TL, Millman A, Nash R, Quinn VP, Robinson B, Roblin D, Sanchez T, Silverberg MJ, Tangpricha V, Valentine C, Winter S, Woodyatt C, Song Y, Goodman M. Association Between Gender Confirmation Treatments and Perceived Gender Congruence, Body Image Satisfaction, and Mental Health in a Cohort of Transgender Individuals. J Sex Med 2018; 15:591-600. [PMID: 29463478 DOI: 10.1016/j.jsxm.2018.01.017] [Citation(s) in RCA: 87] [Impact Index Per Article: 14.5] [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: 12/01/2017] [Revised: 01/19/2018] [Accepted: 01/29/2018] [Indexed: 02/06/2023]
Abstract
BACKGROUND Transgender individuals sometimes seek gender confirmation treatments (GCT), including hormone therapy (HT) and/or surgical change of the chest and genitalia ("top" and "bottom" gender confirmation surgeries). These treatments may ameliorate distress resulting from the incongruence between one's physical appearance and gender identity. AIM The aim was to examine the degree to which individuals' body-gender congruence, body image satisfaction, depression, and anxiety differed by GCT groups in cohorts of transmasculine (TM) and transfeminine (TF) individuals. METHODS The Study of Transition, Outcomes, and Gender is a cohort study of transgender individuals recruited from 3 health plans located in Georgia, Northern California, and Southern California; cohort members were recruited to complete a survey between 2015-2017. Participants were asked about: history of GCT; body-gender congruence; body image satisfaction; depression; and anxiety. Participants were categorized as having received: (1) no GCT to date; (2) HT only; (3) top surgery; (4) partial bottom surgery; and (5) definitive bottom surgery. OUTCOMES Outcomes of interest included body-gender congruence, body image satisfaction, depression, and anxiety. RESULTS Of the 2,136 individuals invited to participate, 697 subjects (33%) completed the survey, including 347 TM and 350 TF individuals. The proportion of participants with low body-gender congruence scores was significantly higher in the "no treatment" group (prevalence ratio [PR] = 3.96, 95% CI 2.72-5.75) compared to the definitive bottom surgery group. The PR for depression comparing participants who reported no treatment relative to those who had definitive surgery was 1.94 (95% CI 1.42-2.66); the corresponding PR for anxiety was 4.33 (95% CI 1.83-10.54). CLINICAL TRANSLATION Withholding or delaying GCT until depression or anxiety have been treated may not be the optimal treatment course given the benefits of reduced levels of distress after undergoing these interventions. CONCLUSIONS Strengths include the well-defined sampling frame, which allowed correcting for non-response, a sample with approximately equal numbers of TF and TM participants, and the ability to combine data on HT and gender confirmation surgeries. Limitations include the cross-sectional design and the fact that participants may not be representative of the transgender population in the United States. Body-gender congruence and body image satisfaction were higher, and depression and anxiety were lower among individuals who had more extensive GCT compared to those who received less treatment or no treatment at all. Owen-Smith AA, Gerth J, Sineath RC, et al. Association Between Gender Confirmation Treatments and Perceived Gender Congruence, Body Image Satisfaction and Mental Health in a Cohort Of Transgender Individuals. J Sex Med 2018;15:591-600.
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Affiliation(s)
- Ashli A Owen-Smith
- Department of Health Management and Policy, School of Public Health, Georgia State University, Atlanta, GA; Center for Clinical and Outcomes Research, Kaiser Permanente Georgia, Atlanta, GA.
| | - Joseph Gerth
- Department of Epidemiology, Rollins School of Public Health, Emory University, Atlanta, GA
| | | | - Joshua Barzilay
- Center for Clinical and Outcomes Research, Kaiser Permanente Georgia, Atlanta, GA
| | - Tracy A Becerra-Culqui
- Department of Research and Evaluation, Kaiser Permanente Southern California, Pasadena, CA
| | - Darios Getahun
- Department of Research and Evaluation, Kaiser Permanente Southern California, Pasadena, CA
| | - Shawn Giammattei
- Rockway Institute, Alliant International University, San Francisco, CA
| | - Enid Hunkeler
- Emeritus, Division of Research, Kaiser Permanente Northern California, Oakland, CA
| | - Timothy L Lash
- Department of Epidemiology, Rollins School of Public Health, Emory University, Atlanta, GA
| | - Andrea Millman
- Division of Research, Kaiser Permanente Northern California, Oakland, CA
| | - Rebecca Nash
- Department of Epidemiology, Rollins School of Public Health, Emory University, Atlanta, GA
| | - Virginia P Quinn
- Emeritus, Department of Research and Evaluation, Kaiser Permanente Southern California, Pasadena, CA
| | - Brandi Robinson
- Center for Clinical and Outcomes Research, Kaiser Permanente Georgia, Atlanta, GA
| | - Douglas Roblin
- Mid-Atlantic Permanente Research Institute, Kaiser Permanente Mid-Atlantic States, Rockville, MD
| | - Travis Sanchez
- Department of Epidemiology, Rollins School of Public Health, Emory University, Atlanta, GA
| | | | - Vin Tangpricha
- School of Medicine, Emory University, Atlanta, GA; Atlanta US Department of Veterans Affairs Medical Center, Atlanta, GA
| | - Cadence Valentine
- Department of Research and Evaluation, Kaiser Permanente Southern California, Pasadena, CA
| | - Savannah Winter
- Center for Clinical and Outcomes Research, Kaiser Permanente Georgia, Atlanta, GA
| | - Cory Woodyatt
- Department of Epidemiology, Rollins School of Public Health, Emory University, Atlanta, GA
| | - Yongjia Song
- Department of Epidemiology, Rollins School of Public Health, Emory University, Atlanta, GA
| | - Michael Goodman
- Department of Epidemiology, Rollins School of Public Health, Emory University, Atlanta, GA
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Quinn VP, Nash R, Hunkeler E, Contreras R, Cromwell L, Becerra-Culqui TA, Getahun D, Giammattei S, Lash TL, Millman A, Robinson B, Roblin D, Silverberg MJ, Slovis J, Tangpricha V, Tolsma D, Valentine C, Ward K, Winter S, Goodman M. Cohort profile: Study of Transition, Outcomes and Gender (STRONG) to assess health status of transgender people. BMJ Open 2017; 7:e018121. [PMID: 29284718 PMCID: PMC5770907 DOI: 10.1136/bmjopen-2017-018121] [Citation(s) in RCA: 87] [Impact Index Per Article: 12.4] [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] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/20/2022] Open
Abstract
PURPOSE The Study of Transition, Outcomes and Gender (STRONG) was initiated to assess the health status of transgender people in general and following gender-affirming treatments at Kaiser Permanente health plans in Georgia, Northern California and Southern California. The objectives of this communication are to describe methods of cohort ascertainment and data collection and to characterise the study population. PARTICIPANTS A stepwise methodology involving computerised searches of electronic medical records and free-text validation of eligibility and gender identity was used to identify a cohort of 6456 members with first evidence of transgender status (index date) between 2006 and 2014. The cohort included 3475 (54%) transfeminine (TF), 2892 (45%) transmasculine (TM) and 89 (1%) members whose natal sex and gender identity remained undetermined from the records. The cohort was matched to 127 608 enrollees with no transgender evidence (63 825 women and 63 783 men) on year of birth, race/ethnicity, study site and membership year of the index date. Cohort follow-up extends through the end of 2016. FINDINGS TO DATE About 58% of TF and 52% of TM cohort members received hormonal therapy at Kaiser Permanente. Chest surgery was more common among TM participants (12% vs 0.3%). The proportions of transgender participants who underwent genital reconstruction surgeries were similar (4%-5%) in the two transgender groups. Results indicate that there are sufficient numbers of events in the TF and TM cohorts to further examine mental health status, cardiovascular events, diabetes, HIV and most common cancers. FUTURE PLANS STRONG is well positioned to fill existing knowledge gaps through comparisons of transgender and reference populations and through analyses of health status before and after gender affirmation treatment. Analyses will include incidence of cardiovascular disease, mental health, HIV and diabetes, as well as changes in laboratory-based endpoints (eg, polycythemia and bone density), overall and in relation to gender affirmation therapy.
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Affiliation(s)
- Virginia P Quinn
- Department of Research & Evaluation, Kaiser Permanente Southern California, Pasadena, California, USA
| | - Rebecca Nash
- Department of Epidemiology, Rollins School of Public Health, Emory University, Atlanta, Georgia, USA
| | - Enid Hunkeler
- Division of Research, Kaiser Permanente Northern California (emerita), Oakland, California, USA
| | - Richard Contreras
- Department of Research & Evaluation, Kaiser Permanente Southern California, Pasadena, California, USA
| | - Lee Cromwell
- Center for Clinical and Outcomes Research, Kaiser Permanente Georgia, Atlanta, Georgia, USA
| | - Tracy A Becerra-Culqui
- Department of Research & Evaluation, Kaiser Permanente Southern California, Pasadena, California, USA
| | - Darios Getahun
- Department of Research & Evaluation, Kaiser Permanente Southern California, Pasadena, California, USA
| | - Shawn Giammattei
- The Rockway Institute, Alliant International University, San Francisco, California, USA
| | - Timothy L Lash
- Department of Epidemiology, Rollins School of Public Health, Emory University, Atlanta, Georgia, USA
| | - Andrea Millman
- Division of Research, Kaiser Permanente Northern California, Oakland, California, USA
| | - Brandi Robinson
- Center for Clinical and Outcomes Research, Kaiser Permanente Georgia, Atlanta, Georgia, USA
| | - Douglas Roblin
- School of Public Health, Georgia State University, Atlanta, Georgia, USA
| | - Michael J Silverberg
- Division of Research, Kaiser Permanente Northern California, Oakland, California, USA
| | - Jennifer Slovis
- The Permanente Medical Group, Kaiser Permanente Northern California, Oakland, California, USA
| | - Vin Tangpricha
- Emory University School of Medicine, Atlanta, Georgia, USA
- The Atlanta VA Medical Center, Atlanta, Georgia, USA
| | - Dennis Tolsma
- Center for Clinical and Outcomes Research, Kaiser Permanente Georgia, Atlanta, Georgia, USA
| | - Cadence Valentine
- Department of Research & Evaluation, Kaiser Permanente Southern California, Pasadena, California, USA
| | - Kevin Ward
- Department of Epidemiology, Rollins School of Public Health, Emory University, Atlanta, Georgia, USA
| | - Savannah Winter
- Center for Clinical and Outcomes Research, Kaiser Permanente Georgia, Atlanta, Georgia, USA
| | - Michael Goodman
- Department of Epidemiology, Rollins School of Public Health, Emory University, Atlanta, Georgia, USA
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Silverberg MJ, Nash R, Becerra-Culqui TA, Cromwell L, Getahun D, Hunkeler E, Lash TL, Millman A, Quinn VP, Robinson B, Roblin D, Slovis J, Tangpricha V, Goodman M. Cohort study of cancer risk among insured transgender people. Ann Epidemiol 2017; 27:499-501. [DOI: 10.1016/j.annepidem.2017.07.007] [Citation(s) in RCA: 19] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/11/2017] [Accepted: 07/14/2017] [Indexed: 10/19/2022]
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Owen-Smith AA, Woodyatt C, Sineath RC, Hunkeler E, Barnwell LT, Graham A, Goodman M. A Qualitative Exploration of Perceived Health Issues Among Transgender Individuals in Atlanta and San Francisco. J Patient Cent Res Rev 2016. [DOI: 10.17294/2330-0698.1335] [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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Owen-Smith AA, Woodyatt C, Sineath RC, Hunkeler E, Barnwell LT, Graham A, Goodman M. Perceptions of Barriers to and Facilitators of Participation in Transgender Health Research. J Patient Cent Res Rev 2016. [DOI: 10.17294/2330-0698.1336] [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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Roblin DW, Goodman M, Cromwell L, Schild L, Hunkeler E, Quinn V, Robinson B, Braun H, Nash R, Gerth J, Barzilay J, Tangpricha V. A Novel Method for Estimating Transgender Status Using EMR Data. J Patient Cent Res Rev 2016. [DOI: 10.17294/2330-0698.1399] [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: 11/04/2022] Open
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Sineath RC, Woodyatt C, Sanchez T, Giammattei S, Gillespie T, Hunkeler E, Owen-Smith A, Quinn VP, Roblin D, Stephenson R, Sullivan PS, Tangpricha V, Goodman M. Determinants of and Barriers to Hormonal and Surgical Treatment Receipt Among Transgender People. Transgend Health 2016; 1:129-136. [PMID: 27689139 PMCID: PMC5012371 DOI: 10.1089/trgh.2016.0013] [Citation(s) in RCA: 37] [Impact Index Per Article: 4.6] [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] [Indexed: 02/01/2023] Open
Abstract
Purpose: Medical gender confirmation therapy (GCT) plays an important role in transgender health; however, its prevalence and determinants constitute an area of uncertainty. Methods: Data for this cross-sectional study were obtained from an online survey distributed from October 2012 through the end of 2013 among persons who visited the social media sites of a transgender education and social networking meeting. Eligible respondents (n=280) were persons whose gender identity was different from their sex assigned at birth and who responded to questions about previously received or planned hormonal therapy (HT), chest reconstruction, or genital surgery. Multivariable logistic regression models examined how receipt and plans to receive different GCT types were associated with participants' characteristics and gender identity. Results: The respective percentages of ever and current HT were 58% and 47% for transwomen and 63% and 57% for transmen. Genital surgery was reported by 11 participants; all transwomen. Relative to transmen, transwomen were thrice more likely to report plans to undergo genital surgery. By contrast, transmen were more than 10 times as likely as transwomen to have had or planned chest surgery. Older participants and those who were in a committed relationship were less likely to plan future GCT. Having health insurance was not associated with GCT receipt. Treatment cost was named as the main problem by 23% of transwomen and 29% of transmen. Accessing a qualified healthcare provider for transgender-related care was listed as the primary reason for not receiving surgery by 41% of transmen and 2% of transwomen. Conclusions: Prevalence of GCT differed across subgroups of participants and was lower than corresponding estimates reported elsewhere. The variability of results may reflect differences in recruitment procedures and response rates; however, it is also possible that it may be driven by geographic, socioeconomic, and health-related heterogeneity of the transgender population.
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Affiliation(s)
- R Craig Sineath
- Rollins School of Public Health, Emory University, Atlanta, Georgia.; School of Medicine, Emory University, Atlanta, Georgia
| | - Cory Woodyatt
- Rollins School of Public Health, Emory University , Atlanta, Georgia
| | - Travis Sanchez
- Rollins School of Public Health, Emory University , Atlanta, Georgia
| | - Shawn Giammattei
- The Rockway Institute, Alliant International University , San Francisco, California
| | - Theresa Gillespie
- School of Medicine, Emory University, Atlanta, Georgia.; Atlanta VA Medical Center, Decatur, Georgia
| | - Enid Hunkeler
- Division of Research, Kaiser Permanente, Oakland, California
| | - Ashli Owen-Smith
- School of Public Health, Georgia State University , Atlanta, Georgia
| | | | - Douglas Roblin
- School of Public Health, Georgia State University , Atlanta, Georgia
| | | | | | - Vin Tangpricha
- School of Medicine, Emory University, Atlanta, Georgia.; Atlanta VA Medical Center, Decatur, Georgia
| | - Michael Goodman
- Rollins School of Public Health, Emory University , Atlanta, Georgia
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Roblin D, Barzilay J, Tolsma D, Robinson B, Schild L, Cromwell L, Braun H, Nash R, Gerth J, Hunkeler E, Quinn VP, Tangpricha V, Goodman M. A novel method for estimating transgender status using electronic medical records. Ann Epidemiol 2016; 26:198-203. [PMID: 26907539 PMCID: PMC4772142 DOI: 10.1016/j.annepidem.2016.01.004] [Citation(s) in RCA: 47] [Impact Index Per Article: 5.9] [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: 10/20/2015] [Revised: 12/30/2015] [Accepted: 01/06/2016] [Indexed: 01/27/2023]
Abstract
PURPOSE We describe a novel algorithm for identifying transgender people and determining their male-to-female (MTF) or female-to-male (FTM) identity in electronic medical records of an integrated health system. METHODS A computer program scanned Kaiser Permanente Georgia electronic medical records from January 2006 through December 2014 for relevant diagnostic codes, and presence of specific keywords (e.g., "transgender" or "transsexual") in clinical notes. Eligibility was verified by review of de-identified text strings containing targeted keywords, and if needed, by an additional in-depth review of records. Once transgender status was confirmed, FTM or MTF identity was assessed using a second program and another round of text string reviews. RESULTS Of 813,737 members, 271 were identified as possibly transgender: 137 through keywords only, 25 through diagnostic codes only, and 109 through both codes and keywords. Of these individuals, 185 (68%, 95% confidence interval [CI]: 62%-74%) were confirmed as definitely transgender. The proportions (95% CIs) of definite transgender status among persons identified via keywords, diagnostic codes, and both were 45% (37%-54%), 56% (35%-75%), and 100% (96%-100%). Of the 185 definitely transgender people, 99 (54%, 95% CI: 46%-61%) were MTF, 84 (45%, 95% CI: 38%-53%) were FTM. For two persons, gender identity remained unknown. Prevalence of transgender people (per 100,000 members) was 4.4 (95% CI: 2.6-7.4) in 2006 and 38.7 (95% CI: 32.4-46.2) in 2014. CONCLUSIONS The proposed method of identifying candidates for transgender health studies is low cost and relatively efficient. It can be applied in other similar health care systems.
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Affiliation(s)
- Douglas Roblin
- School of Public Health, Georgia State University, Atlanta; Center for Clinical and Outcomes Research, Kaiser Permanente Georgia, Atlanta
| | - Joshua Barzilay
- Center for Clinical and Outcomes Research, Kaiser Permanente Georgia, Atlanta
| | - Dennis Tolsma
- Center for Clinical and Outcomes Research, Kaiser Permanente Georgia, Atlanta
| | - Brandi Robinson
- Center for Clinical and Outcomes Research, Kaiser Permanente Georgia, Atlanta
| | - Laura Schild
- Center for Clinical and Outcomes Research, Kaiser Permanente Georgia, Atlanta
| | - Lee Cromwell
- Center for Clinical and Outcomes Research, Kaiser Permanente Georgia, Atlanta
| | - Hayley Braun
- Rollins School of Public Health, Emory University, Atlanta, GA
| | - Rebecca Nash
- Rollins School of Public Health, Emory University, Atlanta, GA
| | | | - Enid Hunkeler
- Division of Research, Kaiser Permanente, Oakland, CA
| | | | - Vin Tangpricha
- Emory University, School of Medicine, Atlanta, GA; The Atlanta VA Medical Center, Atlanta, GA
| | - Michael Goodman
- Rollins School of Public Health, Emory University, Atlanta, GA.
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Roblin D, Barzilay J, Tolsma D, Robinson B, Schild L, Cromwell L, Braun H, Nash R, Gerth J, Hunkeler E, Quinn VP, Tangpricha V, Goodman M. A novel method for estimating transgender status using electronic medical records. Ann Epidemiol 2016. [PMID: 26907539 DOI: 10.1016/j.annepidem.2016.01.004.] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
PURPOSE We describe a novel algorithm for identifying transgender people and determining their male-to-female (MTF) or female-to-male (FTM) identity in electronic medical records of an integrated health system. METHODS A computer program scanned Kaiser Permanente Georgia electronic medical records from January 2006 through December 2014 for relevant diagnostic codes, and presence of specific keywords (e.g., "transgender" or "transsexual") in clinical notes. Eligibility was verified by review of de-identified text strings containing targeted keywords, and if needed, by an additional in-depth review of records. Once transgender status was confirmed, FTM or MTF identity was assessed using a second program and another round of text string reviews. RESULTS Of 813,737 members, 271 were identified as possibly transgender: 137 through keywords only, 25 through diagnostic codes only, and 109 through both codes and keywords. Of these individuals, 185 (68%, 95% confidence interval [CI]: 62%-74%) were confirmed as definitely transgender. The proportions (95% CIs) of definite transgender status among persons identified via keywords, diagnostic codes, and both were 45% (37%-54%), 56% (35%-75%), and 100% (96%-100%). Of the 185 definitely transgender people, 99 (54%, 95% CI: 46%-61%) were MTF, 84 (45%, 95% CI: 38%-53%) were FTM. For two persons, gender identity remained unknown. Prevalence of transgender people (per 100,000 members) was 4.4 (95% CI: 2.6-7.4) in 2006 and 38.7 (95% CI: 32.4-46.2) in 2014. CONCLUSIONS The proposed method of identifying candidates for transgender health studies is low cost and relatively efficient. It can be applied in other similar health care systems.
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Affiliation(s)
- Douglas Roblin
- School of Public Health, Georgia State University, Atlanta; Center for Clinical and Outcomes Research, Kaiser Permanente Georgia, Atlanta
| | - Joshua Barzilay
- Center for Clinical and Outcomes Research, Kaiser Permanente Georgia, Atlanta
| | - Dennis Tolsma
- Center for Clinical and Outcomes Research, Kaiser Permanente Georgia, Atlanta
| | - Brandi Robinson
- Center for Clinical and Outcomes Research, Kaiser Permanente Georgia, Atlanta
| | - Laura Schild
- Center for Clinical and Outcomes Research, Kaiser Permanente Georgia, Atlanta
| | - Lee Cromwell
- Center for Clinical and Outcomes Research, Kaiser Permanente Georgia, Atlanta
| | - Hayley Braun
- Rollins School of Public Health, Emory University, Atlanta, GA
| | - Rebecca Nash
- Rollins School of Public Health, Emory University, Atlanta, GA
| | | | - Enid Hunkeler
- Division of Research, Kaiser Permanente, Oakland, CA
| | | | - Vin Tangpricha
- Emory University, School of Medicine, Atlanta, GA; The Atlanta VA Medical Center, Atlanta, GA
| | - Michael Goodman
- Rollins School of Public Health, Emory University, Atlanta, GA.
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Quinn VP, Becerra TA, Gillespie T, Hunkeler E, Baird T, Baisch NM, Owen-Smith A, Roblin D, Stephenson R, Tangpricha V, Valentine C, Goodman M. Embedding Patients, Providers, and Community Stakeholders in Research to Improve Transgender Health. J Patient Cent Res Rev 2015. [DOI: 10.17294/2330-0698.1137] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [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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Abstract
OBJECTIVES To evaluate demographic and clinical predictors of suicide attempt and suicide death in a population-based sample of people treated for bipolar disorder (BD). METHODS Computerized records were used to identify 32,360 individuals treated for BD at two large prepaid health plans. Suicide attempts were identified using computerized records of outpatient visit diagnoses and hospital discharge diagnoses. Suicide deaths were identified using state death certificate data. RESULTS Overall event rates were 1.06 per 1,000 person-years for suicide death, 5.6 per 1,000 person-years for suicide attempt leading to hospitalization, and 13.9 per 1,000 person-years for suicide attempt not leading to hospitalization. Men had a significantly lower rate of suicide attempt [hazard ratio (HR) 0.68, 95% confidence interval (CI) 0.56-0.83] but a higher rate of suicide death (HR 2.70, 95% CI 1.69-4.31). Suicide attempts were significantly more frequent among younger patients, but suicide deaths did not vary significantly by age. Substance use comorbidity was significantly related to risk of suicide attempt (HR 2.53, 95% CI 2.07-3.09) but not to risk of suicide death (HR 1.02, 95% CI 0.54-1.93). Comorbid anxiety disorder was associated with significantly higher risk of both suicide attempt (HR 1.40, 95% CI 1.14-1.72) and suicide death (HR 1.81, 95% CI 1.09-2.99). CONCLUSIONS Among people treated for BD, risk of suicide death is significantly related to male sex and comorbid anxiety disorder. The predictors of suicide death differ markedly from predictors of suicide attempt.
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Affiliation(s)
- Gregory E Simon
- Center for Health Studies, Group Health Cooperative, Seattle, WA 98101, USA.
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Kinchen KS, Lee J, Fireman B, Hunkeler E, Nehemiah JL, Curtice TG. The Prevalence, Burden, and Treatment of Urinary Incontinence among Women in a Managed Care Plan. J Womens Health (Larchmt) 2007; 16:415-22. [PMID: 17439386 DOI: 10.1089/jwh.2006.0122] [Citation(s) in RCA: 27] [Impact Index Per Article: 1.6] [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: 11/12/2022] Open
Abstract
OBJECTIVE Urinary incontinence (UI) symptoms are common among women, yet only a small proportion of women with incontinence receive a diagnosis and treatment. We used survey and utilization data to determine the prevalence, burden, and treatment use for incontinence among women at Kaiser Permanente in Northern California. METHODS In 2002, we surveyed 6726 female health plan members about health issues, including incontinence. We assessed type and bothersomeness of incontinence symptoms in the previous 7 days. For survey respondents and a 10% sample of female plan members (n = 108,825), we assessed use from 1997 to 2003. RESULTS The survey response rate was 49.7% (3344 of 6726); 44% of respondents reported incontinence symptoms in the previous 7 days, with over half of these women reporting that these symptoms bothered them. Fifteen percent of women with incontinence symptoms had a diagnosis consistent with incontinence in the previous 5 years. One third of the women reporting current bothersome incontinence and 14 or more incontinence episodes in the last 7 days had a diagnosis consistent with incontinence in the previous 5 years. Among women who had received medical or surgical treatment for incontinence in the previous 5 years, approximately half currently report being bothered by their symptoms. CONCLUSIONS Prevalence of bothersome incontinence symptoms among females in a prepaid health plan is high. However, only a small proportion of these women received a diagnosis or treatment for incontinence symptoms in the last 5 years. Efforts to improve the detection and treatment of bothersome incontinence symptoms are needed.
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Affiliation(s)
- Kraig S Kinchen
- Outcomes Research, Eli Lilly and Company, Indianapolis, Indiana 46285, USA
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Unützer J, Tang L, Oishi S, Katon W, Williams JW, Hunkeler E, Hendrie H, Lin EHB, Levine S, Grypma L, Steffens DC, Fields J, Langston C. Reducing Suicidal Ideation in Depressed Older Primary Care Patients. J Am Geriatr Soc 2006; 54:1550-6. [PMID: 17038073 DOI: 10.1111/j.1532-5415.2006.00882.x] [Citation(s) in RCA: 125] [Impact Index Per Article: 6.9] [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: 12/01/2022]
Abstract
OBJECTIVES To determine the effect of a primary care-based collaborative care program for depression on suicidal ideation in older adults. DESIGN Randomized, controlled trial. SETTING Eighteen diverse primary care clinics. PARTICIPANTS One thousand eight hundred one adults aged 60 and older with major depression or dysthymia. INTERVENTION Participants randomized to collaborative care had access to a depression care manager who supported antidepressant medication management prescribed by their primary care physician and offered a course of Problem Solving Treatment in Primary Care for 12 months. Participants in the control arm received care as usual. MEASUREMENTS Participants had independent assessments of depression and suicidal ideation at baseline and 3, 6, 12, 18, and 24 months. Depression was assessed using the Structured Clinical Interview for the Diagnostic and Statistical Manual of Mental Disorders, 4th Edition (SCID). Suicidal ideation was determined using the SCID and the Hopkins Symptoms Checklist. RESULTS At baseline, 139 (15.3%) intervention subjects and 119 (13.3%) controls reported thoughts of suicide. Intervention subjects had significantly lower rates of suicidal ideation than controls at 6 months (7.5% vs 12.1%) and 12 months (9.8% vs 15.5%) and even after intervention resources were no longer available at 18 months (8.0% vs 13.3%) and 24 months (10.1% vs 13.9%). There were no completed suicides in either group. Information on suicide attempts or hospitalization for suicidal ideation was not available. CONCLUSION Primary care-based collaborative care programs for depression represent one strategy to reduce suicidal ideation and potentially the risk of suicide in older primary care patients.
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Affiliation(s)
- Jürgen Unützer
- Department of Psychiatry, School of Medicine, University of Washington, Seattle, Washington 98195, USA.
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Gum AM, Areán PA, Hunkeler E, Tang L, Katon W, Hitchcock P, Steffens DC, Dickens J, Unützer J. Depression treatment preferences in older primary care patients. Gerontologist 2006; 46:14-22. [PMID: 16452280 DOI: 10.1093/geront/46.1.14] [Citation(s) in RCA: 169] [Impact Index Per Article: 9.4] [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: 11/13/2022] Open
Abstract
PURPOSE For depressed older primary care patients, this study aimed to examine (a) characteristics associated with depression treatment preferences; (b) predictors of receiving preferred treatment; and (c) whether receiving preferred treatment predicted satisfaction and depression outcomes. DESIGN AND METHODS Data are from 1,602 depressed older primary care patients who participated in a multisite, randomized clinical trial comparing usual care to collaborative care, which offered medication and counseling for up to 12 months. Baseline assessment included demographics, depression, health information, prior depression treatment, potential barriers, and treatment preferences (medication, counseling). At 12 months, services received, satisfaction, and depression outcomes were assessed. RESULTS More patients preferred counseling (57%) than medication (43%). Previous experience with a treatment type was the strongest predictor of preference. In addition, medication preference was predicted by male gender and diagnosis of major depression (vs dysthymia). The collaborative care model greatly improved access to preferred treatment, especially for counseling (74% vs 33% in usual care). Receipt of preferred treatment did not predict satisfaction or depression outcomes; these outcomes were most strongly impacted by treatment condition. IMPLICATIONS Many depressed older primary care patients desire counseling, which is infrequently available in usual primary care. Discussion of treatment preferences should include an assessment of prior treatment experiences. A collaborative care model that increases collaboration between primary care and mental health professionals can increase access to preferred treatment. If preferred treatment is not available, collaborative care still results in good satisfaction and depression outcomes.
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Affiliation(s)
- Amber M Gum
- Department of Aging and Mental Health, University of South Florida, 13301 Bruce B. Downs Blvd., MHC 1400, Tampa, FL 33612, USA.
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Katon WJ, Schoenbaum M, Fan MY, Callahan CM, Williams J, Hunkeler E, Harpole L, Zhou XHA, Langston C, Unützer J. Cost-effectiveness of Improving Primary Care Treatment of Late-Life Depression. ACTA ACUST UNITED AC 2005; 62:1313-20. [PMID: 16330719 DOI: 10.1001/archpsyc.62.12.1313] [Citation(s) in RCA: 150] [Impact Index Per Article: 7.9] [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: 11/14/2022]
Abstract
CONTEXT Depression is a leading cause of functional impairment in elderly individuals and is associated with high medical costs, but there are large gaps in quality of treatment in primary care. OBJECTIVE To determine the incremental cost-effectiveness of the Improving Mood Promoting Access to Collaborative Treatment (IMPACT) collaborative care management program for late-life depression. DESIGN Randomized controlled trial with recruitment from July 1999 to August 2001. SETTING Eighteen primary care clinics from 8 health care organizations in 5 states. PARTICIPANTS A total of 1801 patients 60 years or older with major depression (17%), dysthymic disorder (30%), or both (53%). INTERVENTION Patients were randomly assigned to the IMPACT intervention (n = 906) or to usual primary care (n = 895). Intervention patients were provided access to a depression care manager supervised by a psychiatrist and primary care physician. Depression care managers offered education, support of antidepressant medications prescribed in primary care, and problem-solving treatment in primary care (a brief psychotherapy). MAIN OUTCOME MEASURES Total outpatient costs, depression-free days, and quality-adjusted life-years. RESULTS Relative to usual care, intervention patients experienced 107 (95% confidence interval [CI], 86 to 128) more depression-free days over 24 months. Total outpatient costs were USD $295 (95% CI, -$525 to $1115) higher during this period. The incremental outpatient cost per depression-free day was USD $2.76 (95% CI, -$4.95 to $10.47) and incremental outpatient costs per quality-adjusted life-year ranged from USD $2519 (95% CI, -$4517 to $9554) to USD $5037 (95% CI, -$9034 to $19 108). Results of a bootstrap analysis suggested a 25% probability that the IMPACT intervention was "dominant" (ie, lower costs and greater effectiveness). CONCLUSIONS The IMPACT intervention is a high-value investment for older adults; it is associated with high clinical benefits at a low increment in health care costs.
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Affiliation(s)
- Wayne J Katon
- Department of Psychiatry and Behavioral Sciences, University of Washington School of Medicine, 1959 Pacific Street, Seattle, WA 98195, USA.
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Areán PA, Ayalon L, Hunkeler E, Lin EHB, Tang L, Harpole L, Hendrie H, Williams JW, Unützer J. Improving depression care for older, minority patients in primary care. Med Care 2005; 43:381-90. [PMID: 15778641 DOI: 10.1097/01.mlr.0000156852.09920.b1] [Citation(s) in RCA: 154] [Impact Index Per Article: 8.1] [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: 12/26/2022]
Abstract
OBJECTIVE Few older minorities receive adequate treatment of depression in primary care. This study examines whether a collaborative care model for depression in primary care is as effective in older minorities as it is in nonminority elderly patients in improving depression treatment and outcomes. STUDY DESIGN A multisite randomized clinical trial of 1801 older adults comparing collaborative care for depression with treatment as usual in primary care. Twelve percent of the sample were black (n = 222), 8% were Latino (n = 138), and 3% (n = 53) were from other minority groups. We compared the 3 largest ethnic groups (non-Latino white, black, and Latino) on depression severity, quality of life, and mental health service use at baseline, 3, 6, and 12 months after randomization to collaborative care or usual care. PRINCIPAL FINDINGS Compared with care as usual, collaborative care significantly improved rates and outcomes of depression care in older adults from ethnic minority groups and in older whites. At 12 months, intervention patients from ethnic minorities (blacks and Latinos) had significantly greater rates of depression care for both antidepressant medication and psychotherapy, lower depression severity, and less health-related functional impairment than usual care participants (64%, 95% confidence interval [CI] 55-72 versus 45%, CI 36-55, P = 0.003 for antidepressant medication; 37%, CI 28-47 versus 13%, CI 6-19, P = 0.002 for psychotherapy; mean = 0.9, CI 0.8-1.1 versus mean = 1.4, CI 1.3-1.5, P < 0.001 for depression severity, range 0-4; mean = 3.7, CI 3.2-4.1, versus mean = 4.7, CI 4.3-5.1, P < 0.0001 for functional impairment, range 0-10). CONCLUSIONS Collaborative Care is significantly more effective than usual care for depressed older adults, regardless of their ethnicity. Intervention effects in ethnic minority participants were similar to those observed in whites.
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Affiliation(s)
- Patricia A Areán
- Department of Psychiatry, University of California, San Francisco, California 94143, USA.
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18
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Areán PA, Ayalon L, Hunkeler E, Lin EHB, Tang L, Harpole L, Hendrie H, Williams JW, Unützer J. Improving depression care for older, minority patients in primary care. Med Care 2005. [PMID: 15778641 DOI: 10.1097/01.mlr.0000156852.09920] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 03/30/2023]
Abstract
OBJECTIVE Few older minorities receive adequate treatment of depression in primary care. This study examines whether a collaborative care model for depression in primary care is as effective in older minorities as it is in nonminority elderly patients in improving depression treatment and outcomes. STUDY DESIGN A multisite randomized clinical trial of 1801 older adults comparing collaborative care for depression with treatment as usual in primary care. Twelve percent of the sample were black (n = 222), 8% were Latino (n = 138), and 3% (n = 53) were from other minority groups. We compared the 3 largest ethnic groups (non-Latino white, black, and Latino) on depression severity, quality of life, and mental health service use at baseline, 3, 6, and 12 months after randomization to collaborative care or usual care. PRINCIPAL FINDINGS Compared with care as usual, collaborative care significantly improved rates and outcomes of depression care in older adults from ethnic minority groups and in older whites. At 12 months, intervention patients from ethnic minorities (blacks and Latinos) had significantly greater rates of depression care for both antidepressant medication and psychotherapy, lower depression severity, and less health-related functional impairment than usual care participants (64%, 95% confidence interval [CI] 55-72 versus 45%, CI 36-55, P = 0.003 for antidepressant medication; 37%, CI 28-47 versus 13%, CI 6-19, P = 0.002 for psychotherapy; mean = 0.9, CI 0.8-1.1 versus mean = 1.4, CI 1.3-1.5, P < 0.001 for depression severity, range 0-4; mean = 3.7, CI 3.2-4.1, versus mean = 4.7, CI 4.3-5.1, P < 0.0001 for functional impairment, range 0-10). CONCLUSIONS Collaborative Care is significantly more effective than usual care for depressed older adults, regardless of their ethnicity. Intervention effects in ethnic minority participants were similar to those observed in whites.
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Affiliation(s)
- Patricia A Areán
- Department of Psychiatry, University of California, San Francisco, California 94143, USA.
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Noël PH, Williams JW, Unützer J, Worchel J, Lee S, Cornell J, Katon W, Harpole LH, Hunkeler E. Depression and comorbid illness in elderly primary care patients: impact on multiple domains of health status and well-being. Ann Fam Med 2004; 2:555-62. [PMID: 15576541 PMCID: PMC1466751 DOI: 10.1370/afm.143] [Citation(s) in RCA: 167] [Impact Index Per Article: 8.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/09/2022] Open
Abstract
PURPOSE Our objective was to examine the relative association of depression severity and chronicity, other comorbid psychiatric conditions, and coexisting medical illnesses with multiple domains of health status among primary care patients with clinical depression. METHODS We collected cross-sectional data as part of a treatment effectiveness trial that was conducted in 8 diverse health care organizations. Patients aged 60 years and older (N = 1,801) who met diagnostic criteria for major depression or dysthymia participated in a baseline survey. A survey instrument included questions on sociodemographic characteristics, depression severity and chronicity, neuroticism, and the presence of 11 common chronic medical illnesses, as well as questions screening for panic disorder and posttraumatic stress disorder. Measures of 4 general health indicators (physical and mental component scales of the SF-12, Sheehan Disability Index, and global quality of life) were included. We conducted separate mixed-effect regression linear models predicting each of the 4 general health indicators. RESULTS Depression severity was significantly associated with all 4 indicators of general health after controlling for sociodemographic differences, other psychological dysfunction, and the presence of 11 chronic medical conditions. Although study participants had an average of 3.8 chronic medical illnesses, depression severity made larger independent contributions to 3 of the 4 general health indicators (mental functional status, disability, and quality of life) than the medical comorbidities. CONCLUSIONS Recognition and treatment of depression has the potential to improve functioning and quality of life in spite of the presence of other medical comorbidities.
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Affiliation(s)
- Polly Hitchcock Noël
- VERDICT, an HSR&D Center of Excellence, South Texas Veterans Health Care System, 7400 Merton Minter Blvd (11C6), San Antonio, TX 78229-4404, USA.
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Williams JW, Katon W, Lin EHB, Nöel PH, Worchel J, Cornell J, Harpole L, Fultz BA, Hunkeler E, Mika VS, Unützer J. The effectiveness of depression care management on diabetes-related outcomes in older patients. Ann Intern Med 2004; 140:1015-24. [PMID: 15197019 DOI: 10.7326/0003-4819-140-12-200406150-00012] [Citation(s) in RCA: 182] [Impact Index Per Article: 9.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/22/2022] Open
Abstract
BACKGROUND Depression frequently occurs in combination with diabetes mellitus, adversely affecting the course of illness. OBJECTIVE To determine whether enhancing care for depression improves affective and diabetic outcomes in older adults with diabetes and depression. DESIGN Preplanned subgroup analysis of the Improving Mood-Promoting Access to Collaborative Treatment (IMPACT) randomized, controlled trial. SETTING 18 primary care clinics from 8 health care organizations in 5 states. PATIENTS 1801 patients 60 years of age or older with depression; 417 had coexisting diabetes mellitus. INTERVENTION A care manager offered education, problem-solving treatment, or support for antidepressant management by the patient's primary care physician; diabetes care was not specifically enhanced. MEASUREMENTS Assessments at baseline and at 3, 6, and 12 months for depression, functional impairment, and diabetes self-care behaviors. Hemoglobin A(1c) levels were obtained for 293 patients at baseline and at 6 and 12 months. RESULTS At 12 months, diabetic patients who were assigned to intervention had less severe depression (range, 0 to 4 on a checklist of 20 depression items; between-group difference, -0.43 [95% CI, -0.57 to -0.29]; P < 0.001) and greater improvement in overall functioning (range, 0 [none] to 10 [unable to perform activities]; between-group difference, -0.89 [CI, -1.46 to -0.32]) than did participants who received usual care. In the intervention group, weekly exercise days increased (between-group difference, 0.50 day [CI, 0.12 to 0.89 day]; P = 0.001); other self-care behaviors were not affected. At baseline, mean (+/-SD) hemoglobin A1c levels were 7.28% +/- 1.43%; follow-up values were unaffected by the intervention (P > 0.2). LIMITATIONS Because patients had good glycemic control at baseline, power to detect small but clinically important improvements in glycemic control was limited. CONCLUSIONS Collaborative care improves affective and functional status in older patients with depression and diabetes; however, among patients with good glycemic control, such care minimally affects diabetes-specific outcomes.
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Affiliation(s)
- John W Williams
- Center for Health Services Research in Primary Care, Durham Veterans Affairs Medical Center, and Duke University School of Medicine, Durham, North Carolina 27705, USA
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Lin EHB, Katon W, Von Korff M, Tang L, Williams JW, Kroenke K, Hunkeler E, Harpole L, Hegel M, Arean P, Hoffing M, Della Penna R, Langston C, Unützer J. Effect of improving depression care on pain and functional outcomes among older adults with arthritis: a randomized controlled trial. JAMA 2003; 290:2428-9. [PMID: 14612479 DOI: 10.1001/jama.290.18.2428] [Citation(s) in RCA: 387] [Impact Index Per Article: 18.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/14/2022]
Abstract
CONTEXT Depression and arthritis are disabling and common health problems in late life. Depression is also a risk factor for poor health outcomes among arthritis patients. OBJECTIVE To determine whether enhancing care for depression improves pain and functional outcomes in older adults with depression and arthritis. DESIGN, SETTING, AND PARTICIPANTS Preplanned subgroup analyses of Improving Mood-Promoting Access to Collaborative Treatment (IMPACT), a randomized controlled trial of 1801 depressed older adults (> or =60 years), which was performed at 18 primary care clinics from 8 health care organizations in 5 states across the United States from July 1999 to August 2001. A total of 1001 (56%) reported coexisting arthritis at baseline. INTERVENTION Antidepressant medications and/or 6 to 8 sessions of psychotherapy (Problem-Solving Treatment in Primary Care). MAIN OUTCOME MEASURES Depression, pain intensity (scale of 0 to 10), interference with daily activities due to arthritis (scale of 0 to 10), general health status, and overall quality-of-life outcomes assessed at baseline, 3, 6, and 12 months. RESULTS In addition to reduction in depressive symptoms, the intervention group compared with the usual care group at 12 months had lower mean (SE) scores for pain intensity (5.62 [0.16] vs 6.15 [0.16]; between-group difference, -0.53; 95% confidence interval [CI], -0.92 to -0.14; P =.009), interference with daily activities due to arthritis (4.40 [0.18] vs 4.99 [0.17]; between-group difference, -0.59; 95% CI, -1.00 to -0.19; P =.004), and interference with daily activities due to pain (2.92 [0.07] vs 3.17 [0.07]; between-group difference, -0.26; 95% CI, -0.41 to -0.10; P =.002). Overall health and quality of life were also enhanced among intervention patients relative to control patients at 12 months. CONCLUSIONS In a large and diverse population of older adults with arthritis (mostly osteoarthritis) and comorbid depression, benefits of improved depression care extended beyond reduced depressive symptoms and included decreased pain as well as improved functional status and quality of life.
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Affiliation(s)
- Elizabeth H B Lin
- Center for Health Studies, Group Health Cooperative, Seattle, Wash 98101, USA.
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Unützer J, Katon W, Callahan CM, Williams JW, Hunkeler E, Harpole L, Hoffing M, Della Penna RD, Noel PH, Lin EHB, Tang L, Oishi S. Depression treatment in a sample of 1,801 depressed older adults in primary care. J Am Geriatr Soc 2003; 51:505-14. [PMID: 12657070 DOI: 10.1046/j.1532-5415.2003.51159.x] [Citation(s) in RCA: 155] [Impact Index Per Article: 7.4] [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: 11/20/2022]
Abstract
OBJECTIVES To examine rates and predictors of lifetime and recent depression treatment in a sample of 1,801 depressed older primary care patients DESIGN Cross sectional survey data collected from 1999 to 2001 as part of a treatment effectiveness trial. SETTING Eighteen primary care clinics belonging to eight organizations in five states. PARTICIPANTS One thousand eight hundred one clinic users aged 60 and older who met diagnostic criteria for major depression or dysthymia. MEASUREMENTS Lifetime depression treatment was defined as ever having received a prescription medication, counseling, or psychotherapy for depression. Potentially effective recent depression treatment was defined as 2 or more months of antidepressant medications or four or more sessions of counseling or psychotherapy for depression in the past 3 months. RESULTS The mean age +/- standard deviation was 71.2 +/- 7.5; 65% of subjects were women. Twenty-three percent of the sample came from ethnic minority groups (12% were African American, 8% were Latino, and 3% belonged to other ethnic minorities). The median household income was $23,000. Most study participants (83%) reported depressive symptoms for 2 or more years, and most (71%) reported two or more prior depressive episodes. About 65% reported any lifetime depression treatment, and 46% reported some depression treatment in the past 3 months, although only 29% reported potentially effective recent depression treatment. Most of the treatment provided consisted of antidepressant medications, with newer antidepressants such as selective serotonin reuptake inhibitors constituting the majority (78%) of antidepressants used. Most participants indicated a preference for counseling or psychotherapy over antidepressant medications, but only 8% had received such treatment in the past 3 months, and only 1% reported four or more sessions of counseling. Men, African Americans, Latinos, those without two or more prior episodes of depression, and those who preferred counseling to antidepressant medications reported significantly lower rates of depression care. CONCLUSION The findings suggest that there is considerable opportunity to improve care for older adults with depression. Particular efforts should be focused on improving access to depression care for older men, African Americans, Latinos, and patients who prefer treatments other than antidepressants.
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Affiliation(s)
- Jürgen Unützer
- Center for Health Services Research, UCLA Neuropsychiatric Institute, Los Angeles, California 90024, USA.
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Pearson B, Katz SE, Soucie V, Hunkeler E, Meresman J, Rooney T, Amick BC. Evidence-based care for depression in Maine: dissemination of the Kaiser Permanente Nurse Telecare Program. Psychiatr Q 2003; 74:91-102. [PMID: 12602791 DOI: 10.1023/a:1021149923867] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/12/2022]
Abstract
This paper describes the program model, implementation and preliminary results from a dissemination of a nurse case management program for treating depression in primary care. The program design was modeled after the Kaiser Permanente Nurse TeleCare program, which in a randomized clinical trial had previously demonstrated significant improvement in depression outcomes and patient satisfaction over usual care. As illustrated in this pilot by patient outcomes measured using the Hamilton Depression Rating Scale, the SF-12 Mental Health Composite Score, and the Work Role, Household and Leisure Time Functioning, the authors believe that it is possible to implement successful interventions in smaller primary care practices in community-based settings.
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Affiliation(s)
- Brian Pearson
- Maine Health Information Center, P.O. Box 360, Manchester, Maine 04351, USA.
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Unützer J, Katon W, Callahan CM, Williams JW, Hunkeler E, Harpole L, Hoffing M, Della Penna RD, Noël PH, Lin EHB, Areán PA, Hegel MT, Tang L, Belin TR, Oishi S, Langston C. Collaborative care management of late-life depression in the primary care setting: a randomized controlled trial. JAMA 2002; 288:2836-45. [PMID: 12472325 DOI: 10.1001/jama.288.22.2836] [Citation(s) in RCA: 1461] [Impact Index Per Article: 66.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/14/2022]
Abstract
CONTEXT Few depressed older adults receive effective treatment in primary care settings. OBJECTIVE To determine the effectiveness of the Improving Mood-Promoting Access to Collaborative Treatment (IMPACT) collaborative care management program for late-life depression. DESIGN Randomized controlled trial with recruitment from July 1999 to August 2001. SETTING Eighteen primary care clinics from 8 health care organizations in 5 states. PARTICIPANTS A total of 1801 patients aged 60 years or older with major depression (17%), dysthymic disorder (30%), or both (53%). INTERVENTION Patients were randomly assigned to the IMPACT intervention (n = 906) or to usual care (n = 895). Intervention patients had access for up to 12 months to a depression care manager who was supervised by a psychiatrist and a primary care expert and who offered education, care management, and support of antidepressant management by the patient's primary care physician or a brief psychotherapy for depression, Problem Solving Treatment in Primary Care. MAIN OUTCOME MEASURES Assessments at baseline and at 3, 6, and 12 months for depression, depression treatments, satisfaction with care, functional impairment, and quality of life. RESULTS At 12 months, 45% of intervention patients had a 50% or greater reduction in depressive symptoms from baseline compared with 19% of usual care participants (odds ratio [OR], 3.45; 95% confidence interval [CI], 2.71-4.38; P<.001). Intervention patients also experienced greater rates of depression treatment (OR, 2.98; 95% CI, 2.34-3.79; P<.001), more satisfaction with depression care (OR, 3.38; 95% CI, 2.66-4.30; P<.001), lower depression severity (range, 0-4; between-group difference, -0.4; 95% CI, -0.46 to -0.33; P<.001), less functional impairment (range, 0-10; between-group difference, -0.91; 95% CI, -1.19 to -0.64; P<.001), and greater quality of life (range, 0-10; between-group difference, 0.56; 95% CI, 0.32-0.79; P<.001) than participants assigned to the usual care group. CONCLUSION The IMPACT collaborative care model appears to be feasible and significantly more effective than usual care for depression in a wide range of primary care practices.
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Affiliation(s)
- Jürgen Unützer
- Center for Health Services Research, UCLA Neuropsychiatric Institute, 10920 Wilshire Blvd, Suite 300, Los Angeles, CA 90024, USA.
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McCaw B, Bauer HM, Berman WH, Mooney L, Holmberg M, Hunkeler E. Women referred for on-site domestic violence services in a managed care organization. Women Health 2002; 35:23-40. [PMID: 12201508 DOI: 10.1300/j013v35n02_02] [Citation(s) in RCA: 11] [Impact Index Per Article: 0.5] [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: 11/18/2022]
Abstract
BACKGROUND Limited data about victims of domestic violence in health care settings hinder development of appropriate services. A comprehensive program was established in a managed care organization to increase identification and referral of domestically abused female patients. METHODS Female victims of domestic abuse were referred to a trained social worker for further assessment. Information about the women was obtained from clinical consultation forms; initial interviews conducted by social workers; a survey administered to a convenience sample of women seen by the program; and medical chart review. RESULTS Of 265 women who agreed to a domestic violence referral, 177 (67%) were contacted for further evaluation. The study sample was ethnically diverse and included female victims seen for routine care, women who had been assaulted, women who had depression, and women with various somatic symptoms. Responses from 51 of the 177 women showed the most cited reasons for accepting referral were unhappiness with current situation, wanting to leave or change the situation, concern about children who witnessed abuse, and the suggestion by a health care practitioner that the patient's symptoms could be related to the abuse. Most reported having symptoms of depression in the previous year. CONCLUSIONS Comprehensive programs in the health care setting can increase identification of victims of domestic abuse. This descriptive report provides a greater understanding of victims of domestic abuse, their presentation in the medical setting, their motivation for accepting referral, and issues which affect their recovery. Links between health care and community resources are necessary for effective intervention.
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Affiliation(s)
- Brigid McCaw
- Department of Internal Medicine, Kaiser Permanente Medical Center, Richmond, CA 94801-2565, USA.
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Kelsey J, Vodoor M, Hunkeler E, Zarr M, Mason J. The management of depression: the implications for managed care--roundtable discussion: Part 1. Manag Care Interface 2001; Suppl B:12-8. [PMID: 11183020] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 02/19/2023]
Abstract
Depression affects not only the patient and the provider, but the employer as well. Up to 25% of all women experience major depressive disorder, compared with perhaps as many as 12% of all men. It is highly prevalent in patients with other acute and chronic disease. On October 4, 1999, a panel of managed care medical directors, pharmacy directors, clinicians, researchers, and health economists was convened in San Diego to discuss the optimal treatment of the disorder. This roundtable discussion is presented in three parts. The first portion lays the clinical foundation for the management of this critical disorder.
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Vodoor M, Southwell YP, Grubin M, Wert S, Kang-Cipolla L, Denes A, Evans S, Mason J, Zarr M, Osborn L, Kenney J, Hunkeler E, Waugh W, Bull S. The management of depression: the implications for managed care--roundtable discussion: Part 3. Manag Care Interface 2001; Suppl B:26-32. [PMID: 11183022] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 02/19/2023]
Abstract
From the standpoint of managed care, the rising cost of depression can be addressed in multiple ways. In the final portion of the roundtable discussion, the faculty discuss not only disease management programs for depression, but other initiatives health plans (including at the pharmacy level) are undertaking to address the rising costs associated with depression. They also discuss the effect of mental health coverage "parity" laws, which can be expected to drive costs even higher.
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Hilton ME, Maisto SA, Conigliaro J, McNiel M, Kraemer K, Kelley ME, Conigliaro R, Samet JH, Larson MJ, Savetsky J, Winter M, Sullivan LM, Saitz R, Weisner C, Mertens J, Parthasarathy S, Moore C, Hunkeler E, Hu TW, Selby J, Stout RL, Zywiak W, Rubin A, Zwick W, Shepard D. Improving Alcoholism Treatment Across the Spectrum of Services. Alcohol Clin Exp Res 2001. [DOI: 10.1111/j.1530-0277.2001.tb02137.x] [Citation(s) in RCA: 24] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/01/2022]
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Hilton ME, Maisto SA, Conigliaro J, McNiel M, Kraemer K, Kelley ME, Conigliaro R, Samet JH, Larson MJ, Savetsky J, Winter M, Sullivan LM, Saitz R, Weisner C, Mertens J, Parthasarathy S, Moore C, Hunkeler E, Hu TW, Selby J, Stout RL, Zywiak W, Rubin A, Zwick W, Shepard D. Improving alcoholism treatment across the spectrum of services. Alcohol Clin Exp Res 2001; 25:128-35. [PMID: 11198708] [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: 02/19/2023]
Abstract
This article represents the proceedings of a symposium at the 2000 RSA Meeting in Denver, Colorado. The chair was Michael E. Hilton. The presentations were (1) The effects of brief advice and motivational enhancement on alcohol use and related variables in primary care, by Stephen A. Maisto, Joseph Conigliaro, Melissa McNiel, Kevin Kraemer, Mary E. Kelley, and Rosemarie Conigliaro; (2) Enhanced linkage of alcohol dependent persons to primary medical care: A randomized controlled trial of a multidisciplinary health evaluation in a detoxification unit, by Jeffrey H. Samet, Mary Jo Larson, Jacqueline Savetsky, Michael Winter, Lisa M. Sullivan, and Richard Saitz; (3) Cost-effectiveness of day hospital versus traditional alcohol and drug outpatient treatment in a health maintenance organization: Randomized and self-selected samples, by Constance Weisner, Jennifer Mertens, Sujaya Parthasarathy, Charles Moore, Enid Hunkeler, Teh-Wei Hu, and Joe Selby; and (4) Case monitoring for alcoholics: One year clinical and health cost effects, by Robert L. Stout, William Zywiak, Amy Rubin, William Zwick, Mary Jo Larson, and Don Shepard.
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Affiliation(s)
- M E Hilton
- NIAAA, Division of Clinical/Prevention Research, Rockville, Maryland, USA.
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Alexander M, Tekawa I, Hunkeler E, Fireman B, Rowell R, Selby JV, Massie BM, Cooper W. Evaluating hypertension control in a managed care setting. Arch Intern Med 1999; 159:2673-7. [PMID: 10597757 DOI: 10.1001/archinte.159.22.2673] [Citation(s) in RCA: 76] [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] [Subscribe] [Scholar Register] [Indexed: 11/14/2022]
Abstract
BACKGROUND We conducted a retrospective cohort study on a random sample of adult patients with hypertension in a large health maintenance organization to assess the feasibility of documenting blood pressure (BP) control and to compare different measures for defining BP control. METHODS Three criteria for BP control were assessed: systolic BP less than 140 mm Hg; diastolic BP less than 90 mm Hg; and combined BP control, with systolic BP less than 140 mm Hg and diastolic BP less than 90 mm Hg. Four methods of assessing hypertension control by the above criteria were examined: proportion of patients with BP under control at 75% and 50% or more of their office visits; the mean of all pressures during the study period; and the BP from the last visit during the study period. RESULTS The proportion of patients meeting each criterion for control was similar whether we used the mean BP for all visits, the last recorded BP, or control at 50% or more of visits. Control rates were substantially lower when the more stringent assessment, 75% of visits, was used. The proportion of patients with combined BP control at 75% or more of their visits was half that of the other methods. CONCLUSIONS In this health maintenance organization population, results with the use of the simplest approach, the last BP measurement recorded, were similar to results with the mean BP. Our findings indicate that evaluation of BP control in a large health maintenance organization will find substantial room for improvement, and clinicians should be encouraged to be more aggressive in their management of hypertension, especially with regard to the systolic BP, which until recent years has been underemphasized.
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Affiliation(s)
- M Alexander
- Division of Research, Kaiser Permanente Medical Care Program, Northern California Region, Oakland 94611-5714, USA.
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Affiliation(s)
- A T McLellan
- Center for Addiction Studies, Department of Psychiatry, University of Pennsylvania 19104, USA.
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Tallmer J, Scherwitz L, Chesney M, Hecker M, Hunkeler E, Serwitz J, Hughes G. Selection, training, and quality control of Type A interviewers in a prospective study of young adults. J Behav Med 1990; 13:449-66. [PMID: 2273523 DOI: 10.1007/bf00844831] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.1] [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] [Indexed: 12/31/2022]
Abstract
This paper describes Type A/B interviewer selection, training, and quality control results in a prospective study of coronary artery risk development in young adults (CARDIA). Interviewer behaviors from 152 CARDIA structured interviews were audited and compared with 747 Western Collaborative Group Study (WCGS) interviews and 577 Multiple Risk Factor Intervention Trial (MRFIT) interviews. The results show success in modeling the CARDIA interviewer behaviors on those of the WCGS. CARDIA interviews were very similar to WCGS interviews for interview length, number of questions asked, and speed of speaking; they were similar to MRFIT interviews in latency of asking questions. CARDIA interviewer behaviors remained fairly consistent over the four time periods. Comparing the clinics, there were regional differences in latency of asking and speed of speaking, with the Southern clinic having a longer asking latency and speaking more slowly. There were differences between individual interviewers in most characteristics, particularly those that were more free to vary. The study provides procedures and guidelines designed to maintain quality control of the structured interview process.
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Affiliation(s)
- J Tallmer
- University of California, San Francisco 94143
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Hughes GH, Cutter G, Donahue R, Friedman GD, Hulley S, Hunkeler E, Jacobs DR, Liu K, Orden S, Pirie P. Recruitment in the Coronary Artery Disease Risk Development in Young Adults (Cardia) Study. Control Clin Trials 1987; 8:68S-73S. [PMID: 3440391 DOI: 10.1016/0197-2456(87)90008-0] [Citation(s) in RCA: 188] [Impact Index Per Article: 5.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 01/05/2023]
Abstract
Coronary Artery Disease Risk Development in Young Adults (CARDIA) is a longitudinal study designed to trace the development of risk factors for coronary heart disease in 5100 individuals 18-30 years old. The study will compare, by cross-sectional and longitudinal analyses, trends and processes involved in risk factor development by sex, race, age, and other sociodemographic characteristics. Participants for the approximately 4 1/2-hour baseline examination were randomly selected and recruited by telephone from census tracts in Minneapolis and Chicago, by telephone exchanges within the Birmingham city limit, and from lists of the Kaiser-Permanente Health Plan membership in Oakland and Berkeley. A major issue was the desirability of sampling approximately equal numbers by age, race, sex, and education as compared with sampling numbers representative of the population base. The recruitment goal of 5100 was achieved on schedule.
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