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Gassiep I, Grey V, Thean LJ, Farquhar D, Clark JE, Ariotti L, Graham R, Jennison AV, Bergh H, Anuradha S, Dyer W, James C, Huang A, Putt E, Pakeerathan V, Griffin PM, Harris PNA. Expanding the Geographic Boundaries of Melioidosis in Queensland, Australia. Am J Trop Med Hyg 2023; 108:1215-1219. [PMID: 37160276 PMCID: PMC10540097 DOI: 10.4269/ajtmh.23-0002] [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] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/01/2023] [Accepted: 03/23/2023] [Indexed: 05/11/2023] Open
Abstract
Melioidosis is an infectious disease caused by the bacterium Burkholderia pseudomallei. Although this environmental organism is endemic in certain regions of Australia, it is not considered endemic in Southern Queensland, where the last case was reported 21 years ago. We report a climate change-associated outbreak of melioidosis occurring during two La Niña events in a region previously considered nonendemic for B. pseudomallei. During a 15-month period, 14 cases of locally acquired melioidosis were identified. Twelve patients were adults (> 50 years), with diabetes mellitus the most common risk factor in 6 of 12 patients (50%). Eleven patients (79%) had direct exposure to floodwaters or the flooded environment. This study suggests an association between climate change and an increased incidence of melioidosis. In addition, this is the first report of environmental sampling and whole-genome analysis to prove endemicity and local acquisition in this region.
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Affiliation(s)
- Ian Gassiep
- University of Queensland Centre for Clinical Research, Royal Brisbane and Woman’s Hospital, Herston, Queensland, Australia
- Mater Hospital Brisbane, South Brisbane, Queensland, Australia
- Pathology Queensland, Royal Brisbane and Women’s Hospital, Brisbane, Queensland, Australia
| | - Victoria Grey
- Mater Hospital Brisbane, South Brisbane, Queensland, Australia
| | - Li Jun Thean
- Queensland Children’s Hospital, South Brisbane, Queensland, Australia
| | - Drew Farquhar
- Sunshine Coast University Hospital, Birtinya, Queensland, Australia
| | - Julia E. Clark
- Queensland Children’s Hospital, South Brisbane, Queensland, Australia
| | - Lawrence Ariotti
- Public Health Microbiology, Forensic and Scientific Services, Queensland Health, Brisbane, Queensland, Australia
| | - Rikki Graham
- Public Health Microbiology, Forensic and Scientific Services, Queensland Health, Brisbane, Queensland, Australia
| | - Amy V. Jennison
- Public Health Microbiology, Forensic and Scientific Services, Queensland Health, Brisbane, Queensland, Australia
| | - Haakon Bergh
- Pathology Queensland, Royal Brisbane and Women’s Hospital, Brisbane, Queensland, Australia
| | | | - Wendy Dyer
- Metro South Public Health Unit, Brisbane, Queensland, Australia
| | - Christian James
- Metro South Public Health Unit, Brisbane, Queensland, Australia
| | - Andrea Huang
- Bundaberg Hospital, Bundaberg, Queensland, Australia
| | - Elise Putt
- Bundaberg Hospital, Bundaberg, Queensland, Australia
| | | | - Paul M. Griffin
- Mater Hospital Brisbane, South Brisbane, Queensland, Australia
- Faculty of Medicine, University of Queensland, Brisbane, Queensland, Australia
| | - Patrick N. A. Harris
- University of Queensland Centre for Clinical Research, Royal Brisbane and Woman’s Hospital, Herston, Queensland, Australia
- Pathology Queensland, Royal Brisbane and Women’s Hospital, Brisbane, Queensland, Australia
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Thomas T, Dyer W, Adams A, Grant R, Schmittdiel J. Address Changes Are Associated With Unmet Glycemic Targets: Opportunities to Improve Processes and Outcomes of Care Among People With Type 2 Diabetes. Perm J 2022; 26:1-10. [DOI: 10.7812/tpp/21.144] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Affiliation(s)
- Tainayah Thomas
- Division of Research, Kaiser Permanente Northern California, Oakland, CA, USA
| | - Wendy Dyer
- Division of Research, Kaiser Permanente Northern California, Oakland, CA, USA
| | - Alyce Adams
- Division of Research, Kaiser Permanente Northern California, Oakland, CA, USA
- Stanford University, School of Medicine, Department of Epidemiology and Population Health, Stanford, CA, USA
| | - Richard Grant
- Division of Research, Kaiser Permanente Northern California, Oakland, CA, USA
| | - Julie Schmittdiel
- Division of Research, Kaiser Permanente Northern California, Oakland, CA, USA
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Schroeder EB, Neugebauer R, Reynolds K, Schmittdiel JA, Loes L, Dyer W, Pimentel N, Desai JR, Vazquez-Benitez G, Ho PM, Anderson JP, O’Connor PJ. Association of Cardiovascular Outcomes and Mortality With Sustained Long-Acting Insulin Only vs Long-Acting Plus Short-Acting Insulin Treatment. JAMA Netw Open 2021; 4:e2126605. [PMID: 34559229 PMCID: PMC8463942 DOI: 10.1001/jamanetworkopen.2021.26605] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/09/2023] Open
Abstract
IMPORTANCE Cardiovascular events and mortality are the principal causes of excess mortality and health care costs for people with type 2 diabetes. No large studies have specifically compared long-acting insulin alone with long-acting plus short-acting insulin with regard to cardiovascular outcomes. OBJECTIVE To compare cardiovascular events and mortality in adults with type 2 diabetes receiving long-acting insulin who do or do not add short-acting insulin. DESIGN, SETTING, AND PARTICIPANTS This retrospective cohort study emulated a randomized experiment in which adults with type 2 diabetes who experienced a qualifying glycated hemoglobin A1c (HbA1c) level of 6.8% to 8.5% with long-acting insulin were randomized to continuing treatment with long-acting insulin (LA group) or adding short-acting insulin within 1 year of the qualifying HbA1c level (LA plus SA group). Retrospective data in 4 integrated health care delivery systems from the Health Care Systems Research Network from January 1, 2005, to December 31, 2013, were used. Analysis used inverse probability weighting estimation with Super Learner for propensity score estimation. Analyses took place from April 1, 2018, to June 30, 2019. EXPOSURES Long-acting insulin alone or with added short-acting insulin within 1 year from the qualifying HbA1c level. MAIN OUTCOMES AND MEASURES Mortality, cardiovascular mortality, acute myocardial infarction, stroke, and hospitalization for heart failure. RESULTS Among 57 278 individuals (39 279 with data on cardiovascular mortality) with a mean (SD) age of 60.6 (11.5) years, 53.6% men, 43.5% non-Hispanic White individuals, and 4 years of follow-up (median follow-up of 11 [interquartile range, 5-20] calendar quarters), the LA plus SA group was associated with increased all-cause mortality compared with the LA group (hazard ratio, 1.27; 95% CI, 1.05-1.49) and a decreased risk of acute myocardial infarction (hazard ratio, 0.89; 95% CI, 0.81-0.97). Treatment with long-acting plus short-acting insulin was not associated with increased risks of congestive heart failure, stroke, or cardiovascular mortality. CONCLUSIONS AND RELEVANCE Findings of this retrospective cohort study suggested an increased risk of all-cause mortality and a decreased risk of acute myocardial infarction for the LA plus SA group compared with the LA group. Given the lack of an increase in major cardiovascular events or cardiovascular mortality, the increased all-cause mortality with long-acting plus short-acting insulin may be explained by noncardiovascular events or unmeasured confounding.
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Affiliation(s)
- Emily B. Schroeder
- Kaiser Permanente Colorado Institute for Health Research, Aurora
- Parkview Health, Fort Wayne, Indiana
| | - Romain Neugebauer
- Division of Research, Kaiser Permanente Northern California, Oakland
| | - Kristi Reynolds
- Department of Research and Evaluation, Kaiser Permanente Southern California, Pasadena
| | | | - Linda Loes
- HealthPartners Institute, Minneapolis, Minnesota
| | - Wendy Dyer
- Division of Research, Kaiser Permanente Northern California, Oakland
| | - Noel Pimentel
- Division of Research, Kaiser Permanente Northern California, Oakland
| | - Jay R. Desai
- HealthPartners Institute, Minneapolis, Minnesota
- Minnesota Department of Health, St Paul
| | | | - P. Michael Ho
- Rocky Mountain Regional Veterans Affairs and University of Colorado (Anschutz) Medical Center, Denver
| | | | - Patrick J. O’Connor
- HealthPartners Institute, Minneapolis, Minnesota
- HealthPartners Center for Chronic Care Innovation, Minneapolis, Minnesota
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Gong C, Dyer W, Yassin M, Neugebauer R, Karter AJ, Schmittdiel JA. The effect of mail order pharmacy outreach on older patients with diabetes. J Am Geriatr Soc 2021; 69:2028-2030. [PMID: 33769551 PMCID: PMC8273092 DOI: 10.1111/jgs.17124] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/16/2021] [Revised: 02/20/2021] [Accepted: 02/27/2021] [Indexed: 11/28/2022]
Affiliation(s)
- Chelsea Gong
- Department of Medicine, Kaiser Permanente Oakland Medical Center, Oakland, California, USA
| | - Wendy Dyer
- Division of Research, Kaiser Permanente Northern California, Oakland, California, USA
| | - Maher Yassin
- Division of Research, Kaiser Permanente Northern California, Oakland, California, USA
| | - Romain Neugebauer
- Division of Research, Kaiser Permanente Northern California, Oakland, California, USA
| | - Andrew J Karter
- Division of Research, Kaiser Permanente Northern California, Oakland, California, USA
| | - Julie A Schmittdiel
- Division of Research, Kaiser Permanente Northern California, Oakland, California, USA
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Hwong AR, Schmittdiel J, Schillinger D, Newcomer JW, Essock S, Zhu Z, Dyer W, Young-Wolff KC, Mangurian C. Smoking cessation treatment for individuals with comorbid diabetes and serious mental illness in an integrated health care delivery system. Addict Behav 2021; 114:106697. [PMID: 33129613 DOI: 10.1016/j.addbeh.2020.106697] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/13/2020] [Revised: 08/11/2020] [Accepted: 09/29/2020] [Indexed: 10/23/2022]
Abstract
INTRODUCTION Smoking is a significant modifiable risk factor for mortality for persons with serious mental illness (SMI), who have a life expectancy 15-20 years shorter than the general population. Individuals with SMI and comorbid diabetes who are smokers face an even higher risk of cardiovascular complications and early death. Yet despite high rates of smoking among people with SMI, tobacco cessation interventions have not been broadly offered to this population. METHODS We conducted a retrospective cohort study using electronic health records from 2014 in a large integrated care delivery system to examine whether use of smoking cessation pharmacotherapy among smokers with type 2 diabetes varies by serious mental illness (SMI) diagnosis. We analyzed smoking cessation medication prescription fills among adult smokers with diabetes, comparing those with SMI (N = 634) and without SMI (N = 18,021). Risk ratios were adjusted for age, gender, race, urban area type, and medical facility. RESULTS Of the SMI group, 19.09% filled at least one smoking cessation prescription compared to 9.73% of the non-SMI group (adjusted risk ratio 1.80 [95% CI 1.52-2.13]; p < .001). For the SMI group, primary care providers wrote 80.24% of prescriptions, while psychiatrists wrote 8.81% of prescriptions. CONCLUSIONS These findings offer an example of a delivery system with higher uptake of smoking cessation pharmacotherapy among people with SMI than without SMI, and highlight the opportunity to provide more smoking cessation interventions in mental health care settings.
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Cassidy K, Dyer W, Biddle P, Brandon T, McClelland N, Ridley L. Making space for mental health care within the penal estate. Health Place 2020; 62:102295. [PMID: 32479371 DOI: 10.1016/j.healthplace.2020.102295] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/30/2019] [Revised: 02/03/2020] [Accepted: 02/06/2020] [Indexed: 11/19/2022]
Affiliation(s)
- Kathryn Cassidy
- Department of Geography and Environmental Sciences, Northumbria University, Ellison Place, Newcastle-upon-Tyne, NE1 8ST, UK.
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Marshall CJ, Rodriguez HP, Dyer W, Schmittdiel JA. Racial and Ethnic Disparities in Diabetes Care Quality among Women of Reproductive Age in an Integrated Delivery System. Womens Health Issues 2020; 30:191-199. [PMID: 32340896 DOI: 10.1016/j.whi.2020.03.003] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/28/2019] [Revised: 03/12/2020] [Accepted: 03/13/2020] [Indexed: 01/24/2023]
Abstract
BACKGROUND Diabetes is increasingly prevalent among women of reproductive age, yet little is known about quality of diabetes care for this population at increased risk of diabetes complications and poor maternal and infant health outcomes. Previous studies have identified racial/ethnic disparities in diabetes care, but patterns among women of reproductive age have not been examined. METHODS This retrospective cohort study analyzed 2016 data from Kaiser Permanente Northern California, a large integrated delivery system. Outcomes were quality of diabetes care measures-glycemic testing, glycemic control, and medication adherence-among women ages 18 to 44 with type 1 or type 2 diabetes (N = 9,923). Poisson regression was used to estimate the association between patient race/ethnicity and each outcome, adjusting for other patient characteristics and health care use. RESULTS In this cohort, 83% of participants had type 2 diabetes; 31% and 36% of women with type 2 and type 1 diabetes, respectively, had poor glycemic control (hemoglobin A1c of ≥9%), and approximately one-third of women with type 2 diabetes exhibited nonadherence to diabetes medications. Compared with non-Hispanic White women with type 2 diabetes, non-Hispanic Black women (adjusted risk ratio, 1.2; 95% confidence interval, 1.1-1.3) and Hispanic women (adjusted risk ratio, 1.2; 95% confidence interval, 1.1-1.3) were more likely to have poor control. Findings among women with type 1 diabetes were similar. CONCLUSIONS Our findings indicate opportunities to decrease disparities and improve quality of diabetes care for reproductive-aged women. Elucidating the contributing factors to poor glycemic control and medication adherence in this population, particularly among Black, Hispanic, and Asian women, should be a high research and practice priority.
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Affiliation(s)
- Cassondra J Marshall
- School of Public Health, University of California, Berkeley, Berkeley, California.
| | - Hector P Rodriguez
- School of Public Health, University of California, Berkeley, Berkeley, California
| | - Wendy Dyer
- Division of Research, Kaiser Permanente Northern California, Oakland, California
| | - Julie A Schmittdiel
- Division of Research, Kaiser Permanente Northern California, Oakland, California
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Neugebauer R, Schroeder EB, Reynolds K, Schmittdiel JA, Loes L, Dyer W, Desai JR, Vazquez-Benitez G, Ho PM, Anderson JP, Pimentel N, O’Connor PJ. Comparison of Mortality and Major Cardiovascular Events Among Adults With Type 2 Diabetes Using Human vs Analogue Insulins. JAMA Netw Open 2020; 3:e1918554. [PMID: 31977057 PMCID: PMC6991251 DOI: 10.1001/jamanetworkopen.2019.18554] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/01/2019] [Accepted: 10/15/2019] [Indexed: 12/25/2022] Open
Abstract
Importance The comparative cardiovascular safety of analogue and human insulins in adults with type 2 diabetes who initiate insulin therapy in usual care settings has not been carefully evaluated using machine learning and other rigorous analytic methods. Objective To examine the association of analogue vs human insulin use with mortality and major cardiovascular events. Design, Setting, and Participants This retrospective cohort study included 127 600 adults aged 21 to 89 years with type 2 diabetes at 4 health care delivery systems who initiated insulin therapy from January 1, 2000, through December 31, 2013. Machine learning and rigorous inference methods with time-varying exposures were used to evaluate associations of continuous exposure to analogue vs human insulins with mortality and major cardiovascular events. Data were analyzed from September 1, 2017, through June 30, 2018. Exposures On the index date (first insulin dispensing), participants were classified as using analogue insulin with or without human insulin or human insulin only. Main Outcomes and Measures Overall mortality, mortality due to cardiovascular disease (CVD), myocardial infarction (MI), stroke or cerebrovascular accident (CVA), and hospitalization for congestive heart failure (CHF) were evaluated. Marginal structural modeling (MSM) with inverse probability weighting was used to compare event-free survival in separate per-protocol analyses. Adjusted and unadjusted hazard ratios and cumulative risk differences were based on logistic MSM parameterizations for counterfactual hazards. Propensity scores were estimated using a data-adaptive approach (machine learning) based on 3 nested covariate adjustment sets. Sensitivity analyses were conducted to address potential residual confounding from unmeasured differences in risk factors across delivery systems. Results The 127 600 participants (mean [SD] age, 59.4 [12.6] years; 68 588 men [53.8%]; mean [SD] body mass index, 32.3 [7.1]) had a median follow-up of 4 quarters (interquartile range, 3-9 quarters) and experienced 5464 deaths overall (4.3%), 1729 MIs (1.4%), 1301 CVAs (1.0%), and 3082 CHF hospitalizations (2.4%). There were no differences in adjusted hazard ratios for continuous analogue vs human insulin exposure during 10 quarters for overall mortality (1.15; 95% CI, 0.97-1.34), CVD mortality (1.26; 95% CI, 0.86-1.66), MI (1.11; 95% CI, 0.77-1.45), CVA (1.30; 95% CI, 0.81-1.78), or CHF hospitalization (0.93; 95% CI, 0.75-1.11). Conclusions and Relevance Insulin-naive adults with type 2 diabetes who initiate and continue treatment with human vs analogue insulins had similar observed rates of major cardiovascular events, CVD mortality, and overall mortality.
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Affiliation(s)
- Romain Neugebauer
- Division of Research, Kaiser Permanente Northern California, Oakland
| | | | - Kristi Reynolds
- Department of Research and Evaluation, Kaiser Permanente Southern California, Pasadena
| | | | - Linda Loes
- HealthPartners Institute, Minneapolis, Minnesota
| | - Wendy Dyer
- Division of Research, Kaiser Permanente Northern California, Oakland
| | - Jay R. Desai
- HealthPartners Institute, Minneapolis, Minnesota
| | | | - P. Michael Ho
- Rocky Mountain Regional Veterans Affairs and University of Colorado (Anschutz) Medical Center, Denver
| | | | - Noel Pimentel
- Division of Research, Kaiser Permanente Northern California, Oakland
| | - Patrick J. O’Connor
- HealthPartners Institute, Minneapolis, Minnesota
- HealthPartners Center for Chronic Care Innovation, Minneapolis, Minnesota
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Adams AS, Schmittdiel JA, Altschuler A, Bayliss EA, Neugebauer R, Ma L, Dyer W, Clark J, Cook B, Willyoung D, Jaffe M, Young JD, Kim E, Boggs JM, Prosser L, Wittenberg E, Callaghan B, Shainline M, Hippler RM, Grant RW. Automated symptom and treatment side effect monitoring for improved quality of life among adults with diabetic peripheral neuropathy in primary care: a pragmatic, cluster, randomized, controlled trial. Diabet Med 2019; 36:52-61. [PMID: 30343489 PMCID: PMC7236318 DOI: 10.1111/dme.13840] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [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] [Accepted: 10/18/2018] [Indexed: 01/19/2023]
Abstract
AIMS To evaluate the effectiveness of automated symptom and side effect monitoring on quality of life among individuals with symptomatic diabetic peripheral neuropathy. METHODS We conducted a pragmatic, cluster randomized controlled trial (July 2014 to July 2016) within a large healthcare system. We randomized 1834 primary care physicians and prospectively recruited from their lists 1270 individuals with neuropathy who were newly prescribed medications for their symptoms. Intervention participants received automated telephone-based symptom and side effect monitoring with physician feedback over 6 months. The control group received usual care plus three non-interactive diabetes educational calls. Our primary outcomes were quality of life (EQ-5D) and select symptoms (e.g. pain) measured 4-8 weeks after starting medication and again 8 months after baseline. Process outcomes included receiving a clinically effective dose and communication between individuals with neuropathy and their primary care provider over 12 months. Interviewers collecting outcome data were blinded to intervention assignment. RESULTS Some 1252 participants completed the baseline measures [mean age (sd): 67 (11.7), 53% female, 57% white, 8% Asian, 13% black, 20% Hispanic]. In total, 1179 participants (93%) completed follow-up (619 control, 560 intervention). Quality of life scores (intervention: 0.658 ± 0.094; control: 0.653 ± 0.092) and symptom severity were similar at baseline. The intervention had no effect on primary [EQ-5D: -0.002 (95% CI -0.01, 0.01), P = 0.623; pain: 0.295 (-0.75, 1.34), P = 0.579; sleep disruption: 0.342 (-0.18, 0.86), P = 0.196; lower extremity functioning: -0.079 (-1.27, 1.11), P = 0.896; depression: -0.462 (-1.24, 0.32); P = 0.247] or process outcomes. CONCLUSIONS Automated telephone monitoring and feedback alone were not effective at improving quality of life or symptoms for people with symptomatic diabetic peripheral neuropathy. TRIAL REGISTRATION ClinicalTrials.gov (NCT02056431).
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Affiliation(s)
- Alyce S. Adams
- Kaiser Permanente Division of Research, Oakland, CA, USA
| | | | | | - Elizabeth A. Bayliss
- Kaiser Permanente Colorado Institute for Health Research, Denver, CO, USA
- University of Colorado School of Medicine, Denver, CO, USA
| | | | - Lin Ma
- Kaiser Permanente Division of Research, Oakland, CA, USA
| | - Wendy Dyer
- Kaiser Permanente Division of Research, Oakland, CA, USA
| | - Joel Clark
- Kaiser Permanente Division of Research, Oakland, CA, USA
| | - Bonieta Cook
- Kaiser Permanente Division of Research, Oakland, CA, USA
| | | | - Marc Jaffe
- Kaiser Permanente South San Francisco Medical Center, South San Francisco, CA, USA
| | | | - Eileen Kim
- Kaiser Permanente Oakland Medical Center, Oakland, CA, USA
| | - Jennifer M. Boggs
- Kaiser Permanente Colorado Institute for Health Research, Denver, CO, USA
| | - Lisa Prosser
- University of Michigan School of Public Health, Ann Arbor, MI, USA
| | | | - Brian Callaghan
- University of Michigan, Michigan Medicine, Neurology Clinic, Ann Arbor, MI, USA
| | - Michael Shainline
- Kaiser Permanente Colorado Institute for Health Research, Denver, CO, USA
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Biddle P, Dyer W, Hand R, Strinati C. Reflections on a project to prevent suicide and self-harm among prisoners identified as high risk in two prisons in Northern England. Health Justice 2018; 6:22. [PMID: 30511204 PMCID: PMC6755593 DOI: 10.1186/s40352-018-0080-7] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 05/29/2018] [Accepted: 11/13/2018] [Indexed: 06/03/2023]
Abstract
BACKGROUND This article critically explores the implementation and evaluation of a project designed, delivered and evaluated by frontline staff to improve prison responses to prisoner suicide and self-harm. We begin by evidencing the need for the project and detail its content, delivery and attempts at evaluation. We draw on the reflections of the three practitioners most closely involved in its development, delivery and review in order to explore lessons learned for future staff-led projects including those aimed at tackling prison suicide and self-harm. RESULTS Findings from staff reflections suggest that the development, implementation and evaluation of the project were influenced by a combination of issues around: project focus, communication and professional relationships, the institutional environment, funding and time, roll-out and evaluation, and the need for a 'champion' role. CONCLUSIONS There is limited evidence that the project left a modest positive legacy in terms of impact. A more substantial legacy of the project is provided in terms of actionable learning points for future projects of this nature.
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Affiliation(s)
- Paul Biddle
- Department of Social Sciences, Northumbria University, Newcastle upon Tyne, NE1 8ST UK
| | - Wendy Dyer
- Department of Social Sciences, Northumbria University, Newcastle upon Tyne, NE1 8ST UK
| | - Richard Hand
- Tees Esk & Wear Valley NHS Foundation Trust, Roseberry Park Hospital, Middlesbrough, TS4 3AF UK
| | - Charlitta Strinati
- Tees Esk & Wear Valley NHS Foundation Trust, Roseberry Park Hospital, Middlesbrough, TS4 3AF UK
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Horton MC, Dyer W, Tennant A, Wright NMJ. Assessing the predictability of self-harm in a high-risk adult prisoner population: a prospective cohort study. Health Justice 2018; 6:18. [PMID: 30242541 PMCID: PMC6755554 DOI: 10.1186/s40352-018-0076-3] [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] [Grants] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Received: 05/30/2018] [Accepted: 09/06/2018] [Indexed: 06/08/2023]
Abstract
BACKGROUND Prisoners are at increased risk of self-harm and when either intent is expressed, or an act of self-harm carried out, prisoners in the UK are subject to self-harm/suicide monitoring (referred to as "open ACCT" monitoring). However, there is a paucity of validated instruments to identify risk of self-harm in prisoner populations. In response to the need to support prison staff to determine who is at increased risk of self-harm or repeat self-harm, the aim of this study was to determine whether any pre-existing, standardised instruments could usefully identify future self-harm events in prisoners undergoing ACCT monitoring. METHODS A multi-stage prospective cohort study was conducted, where the Prison Screening Questionnaire (PriSnQuest), a modified Borderline Symptom List-23 (BSL-23), Self-Harm Inventory (SHI), Patient Health Questionnaire-9 (PHQ-9) and Clinical Outcomes in Routine Evaluation - Outcome Measure (CORE-OM) instruments were administered to prisoners aged 18 and above, who were judged to be at an increased risk of self-harm (on open ACCT monitoring) during the recruitment phase. A 6-month follow-up determined self-harm occurrence since baseline, and Area-Under-the-Curve (AUC) analysis examined the ability of the instruments to predict future self-harm. RESULTS Prison records established that 29.1% self-harmed during the follow up period, involving a total of 423 self-harm events reported from 126 individuals, followed up for 66,789 prisoner days (median 167 days; IQR 71-207.5 days). This translated to an 'event incidence' of 6.33 per 1000 prisoner days of those who had been placed upon an ACCT, or 'prisoner incidence' of 1.89 per 1000 days, with considerable variation for both gender and participating prisons. None of the summary scores derived from the selected instruments showed a meaningful ability to predict self-harm, however, exploratory logistic regression analysis of individual background and instrument items revealed gender-specific item sets which were statistically significant in predicting future self-harm. CONCLUSIONS Prospective self-harm was not predicted by any of the pre-existing instruments that were under consideration. Exploratory logistic regression analysis did reveal gender-specific item sets, producing predictive algorithms which were statistically significant in predicting future self-harm; however, the operational functionality of these item sets may be limited.
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Affiliation(s)
- Mike C. Horton
- Section of Rehabilitation Medicine, Leeds Institute of Rheumatic and Musculoskeletal Medicine, Faculty of Medicine and Health, University of Leeds, D Floor, Martin Wing, LGI, LS1 3EX, Leeds, UK
| | - Wendy Dyer
- School of Arts and Social Sciences, Northumbria University, Lipman Building Room 216, Newcastle Upon Tyne, NE1 8ST UK
| | - Alan Tennant
- Swiss Paraplegic Research, Guido A. Zäch-Strasse 4, 6207 Nottwil, Switzerland
| | - Nat M. J. Wright
- Clinical Research Director Transform Research Alliance, Visiting Associate Professor Leeds University, Spectrum Community Health CIC, One Navigation Walk, Hebble Wharf, Wakefield, WF1 5RH UK
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Nichols GA, Raebel MA, Dyer W, Schmittdiel JA. The Effect of Age and Comorbidities on the Association Between the Medicare STAR Oral Antihyperglycemic Adherence Metric and Glycemic Control. J Manag Care Spec Pharm 2018; 24:856-861. [PMID: 30156449 PMCID: PMC10398005 DOI: 10.18553/jmcp.2018.24.9.856] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
BACKGROUND The Medicare STAR program for Medicare Advantage Plans that include drug benefits provides monetary incentives for health plans to achieve good adherence to oral antihyperglycemic (OAH) agents but does not account for differential case mix that could affect the ability of health plans to achieve the required quality metrics. OBJECTIVE To determine whether OAH adherence varies by age and comorbidities among patients aged 65 years or older and the extent to which adherence affects glycemic control across age and comorbidity strata. METHODS We studied 54,480 patients with diabetes aged > 65 years from the Colorado, Northwest, and Northern California regions of Kaiser Permanente who received OAH agents but not insulin in 2010. We calculated adherence using the proportion of days covered (PDC) method. Per the STAR program, hemoglobin A1c < 8% defined good glycemic control. We also defined poor control as A1c > 9%. We used modified Poisson regression to identify predictors of adherence and to determine its effects on A1c across age and comorbidity strata, adjusting for sociodemographics and medication-related variables. RESULTS The risk of being adherent to OAH declined moderately with an increasing number of comorbidities (risk ratio [RR] = 0.99, 95% CI = 0.98-1.00 for 1 comorbidity and RR = 0.90, 95% CI = 0.88-0.91 for 4 or more comorbidities). Adherence to OAH agents was associated with a 0%-3% increased risk of A1c < 8% across age and comorbidity categories, as well as a large decreased risk (RR = 0.55-0.73) of A1c > 9% for patients aged < 80 years or with < 3 comorbidities. CONCLUSIONS Among patients with diabetes aged > 65 years, having multiple comorbidities affects adherence. Adherence reduces the risk of poor A1c control among patients aged 65-79 years or with 2 or fewer comorbidities. Our results suggest that health plan case mix minimally influenced the Medicare STAR OAH adherence metric, but it may affect glycemic control quality measures, especially if a HEDIS-like measure of poor control were adopted. DISCLOSURES This study was supported by grant number 1R21DK103146-01A1 from the National Institute of Diabetes and Digestive and Kidney Disorders. Nichols currently receives grant funding from Boehringer-Ingelheim, Sanofi, Amarin Pharma, and Janssen Pharmaceuticals for other unrelated research projects. The other authors declare no conflicts of interest. This study was presented at the American Diabetes Association's 77th Scientific Sessions; June 9-13, 2017; San Diego, CA.
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Affiliation(s)
- Gregory A Nichols
- 1 Kaiser Permanente Northwest Center for Health Research, Portland, Oregon
| | - Marsha A Raebel
- 2 Kaiser Permanente Colorado Institute for Health Research, Denver
| | - Wendy Dyer
- 3 Kaiser Permanente Northern California Division of Research, Oakland
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Mangurian C, Schillinger D, Newcomer JW, Vittinghoff E, Essock S, Zhu Z, Dyer W, Schmittdiel J. Diabetes Screening among Antipsychotic-Treated Adults with Severe Mental Illness in an Integrated Delivery System: A Retrospective Cohort Study. J Gen Intern Med 2018; 33:79-86. [PMID: 29090381 PMCID: PMC5756176 DOI: 10.1007/s11606-017-4205-9] [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] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/01/2017] [Revised: 09/22/2017] [Accepted: 10/04/2017] [Indexed: 11/25/2022]
Abstract
BACKGROUND Severe mental illness (SMI) is associated with increased risk for type 2 diabetes, partly due to adverse metabolic effects of antipsychotic medications. In public health care settings, annual screening rates are 30%. We measured adherence to national diabetes screening guidelines for patients taking antipsychotic medications. OBJECTIVE To estimate diabetes screening prevalence among patients with SMI within an integrated health care system, and to assess characteristics associated with lack of screening. DESIGN Retrospective cohort study. PARTICIPANTS Antipsychotic-treated adults with SMI. We excluded participants with known diabetes. MAIN MEASURES Primary outcome was screening via fasting glucose test or hemoglobin A1c during a 1-year period. KEY RESULTS In 2014, 16,754 patients with SMI diagnoses were receiving antipsychotics. Seventy-four percent of these patients' providers ordered diabetes screening tests that year, but only 55% (9247/16,754) received screening. When the observation time frame was extended to 2 years, 73% (12,250/16,754) were screened. Adjusting for sex and race/ethnicity, young adults (aged 18-29 years) were less likely to receive screening than older age groups [adjusted RR (aRR) 1.23-1.57, p < 0.0001]. Compared to whites, screening was more common for Asians (aRR 1.141, 95% CI 1.089-1.195, p < 0.0001), less common for blacks (aRR 0.946, 95% CI 0.898-0.997, p < 0.0375), and no different for Hispanics (aRR 1.030, 95% CI 0.988-1.074, p = 0.165). Smokers were less likely to be screened than non-smokers (aRR 0.93, 95% CI 0.89-0.97, p < 0.0008). Utilization of either mental health or primary care services increased the likelihood of screening. CONCLUSIONS While almost three-fourths of adults with SMI taking antipsychotic medications received a lab order for diabetes screening, only 55% received screening within a 12-month period. Young adults and smokers were less likely to be screened, despite their disproportionate metabolic risk. Future studies should assess the barriers and facilitators with regard to diabetes screening in this vulnerable population at the patient, provider, and system levels.
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Affiliation(s)
- Christina Mangurian
- Department of Psychiatry, University of California San Francisco (UCSF) Weill Institute of Neurosciences, San Francisco, CA, USA. .,UCSF Center for Vulnerable Populations at Zuckerberg San Francisco General Hospital, San Francisco, CA, USA.
| | - Dean Schillinger
- UCSF Center for Vulnerable Populations at Zuckerberg San Francisco General Hospital, San Francisco, CA, USA.,UCSF Division of General Internal Medicine at Zuckerberg San Francisco General Hospital, San Francisco, CA, USA
| | - John W Newcomer
- Charles E. Schmidt College of Medicine at Florida Atlantic University, Boca Raton, FL, USA
| | - Eric Vittinghoff
- UCSF Department of Epidemiology and Biostatistics, San Francisco, CA, USA
| | - Susan Essock
- Columbia University Department of Psychiatry and the New York State Psychiatric Institute, New York, NY, USA
| | - Zheng Zhu
- Kaiser Permanente Northern California Division of Research, Oakland, CA, USA
| | - Wendy Dyer
- Kaiser Permanente Northern California Division of Research, Oakland, CA, USA
| | - Julie Schmittdiel
- Kaiser Permanente Northern California Division of Research, Oakland, CA, USA
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Abstract
In recent years, both realism and complexity have begun to have methodological influence in social research. Yet for the most part, these have existed separately and have had limited impact on empirical research. In this article, we develop a theoretical argument for complex realism, grounded in an ontology of probability, that may be operationalised to demonstrate the reality of social change at a micro- and meso-level. We apply our conception of complex realism to an example using the method of longitudinal case–based cluster analysis to analyse the trajectories over time of male and female prisoners aged 18 and above who were at risk of self-harm.
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Affiliation(s)
| | - Wendy Dyer
- Northumbria University, Newcastle upon Tyne, UK
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15
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Raebel MA, Dyer W, Nichols GA, Goodrich GK, Schmittdiel JA. Relationships between Medication Adherence and Cardiovascular Disease Risk Factor Control in Elderly Patients with Diabetes. Pharmacotherapy 2017; 37:1204-1214. [PMID: 28752555 PMCID: PMC5647232 DOI: 10.1002/phar.1994] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.0] [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] [Indexed: 11/12/2022]
Abstract
BACKGROUND The Centers for Medicare and Medicaid Services (CMS) Medicare Star program provides incentives to health plans when their patients with diabetes meet adherence targets to angiotensin-converting enzyme inhibitors/angiotensin II receptor blockers (ACEIs/ARBs) and statins. While a link between adherence and cardiovascular risk factor control is established, most studies included young patients with few comorbidities. Whether the Star adherence target is associated with reduced blood pressure or low-density lipoprotein cholesterol (LDL-C) in complex older patients is not well understood. OBJECTIVES Determine correlates of adherence and examine the effect of meeting Star adherence targets on blood pressure and LDL-C in the Medicare-aged diabetes population. DESIGN AND SUBJECTS Retrospective cohort study of 129,040 patients with diabetes aged 65 or older. MEASURES Adherence estimated using proportion of days covered target ≥ 0.8; blood pressure < 140/90 mg Hg; LDL-C < 100 mg/dl. Modified Poisson regression used to assess relationships. RESULTS Adherence differed little across elderly age groups. Compared to no comorbidity, high comorbidity (≥ 4) was associated with lower ACEI/ARB (risk ratio [RR] 0.88 [95% confidence interval (CI) 0.87-0.89]) or statin (RR 0.91 [0.90-0.92]) adherence. ACEI/ARB adherence was not associated with blood pressure < 140/90 mm Hg in patients ≥ 85 years (RR 1.01 [0.96-1.07]) or with multiple comorbidities (e.g., 3: RR 1.04 [0.99-1.08]). Statin adherence and LDL-C < 100 mg/dl were associated in all elderly age groups (e.g., ≥ 85: RR 1.13 [1.09-1.16]) and comorbidity levels (e.g., ≥ 4: RR 1.13 [1.12-1.15]). CONCLUSIONS Adherence to ACEI/ARB is not linked with reduced blood pressure in patients with diabetes who are at least 85 years or with multiple comorbidities.
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Affiliation(s)
- Marsha A. Raebel
- Kaiser Permanente Colorado Institute for Health Research, Denver, Colorado, USA
- University of Colorado Skaggs School of Pharmacy and Pharmaceutical Sciences, Aurora, Colorado, USA
| | - Wendy Dyer
- Division of Research, Kaiser Permanente Northern California, Oakland, California, USA
| | - Gregory A. Nichols
- Center for Health Research, Kaiser Permanente Northwest, Portland, Oregon, USA
| | - Glenn K. Goodrich
- Kaiser Permanente Colorado Institute for Health Research, Denver, Colorado, USA
| | - Julie A. Schmittdiel
- Division of Research, Kaiser Permanente Northern California, Oakland, California, USA
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Schmittdiel JA, Dlott R, Young JD, Rothmann MB, Dyer W, Adams AS. The Delivery Science Rapid Analysis Program: A Research and Operational Partnership at Kaiser Permanente Northern California. Learn Health Syst 2017; 1. [PMID: 29152588 PMCID: PMC5687292 DOI: 10.1002/lrh2.10035] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.3] [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: 11/12/2022] Open
Abstract
Introduction Health care researchers and delivery system leaders share a common mission to improve health care quality and outcomes. However, differing timelines, incentives, and priorities are often a barrier to research and operational partnerships. In addition, few funding mechanisms exist to generate and solicit analytic questions that are of interest to both research and to operations within health care settings, and provide rapid results that can be used to improve practice and outcomes. Methods The Delivery Science Rapid Analysis Program (RAP) was formed in 2013 within the Kaiser Permanente Northern California Division of Research, sponsored by The Permanente Medical Group. A steering committee consisting of both researchers and clinical leaders solicits and reviews proposals for rapid analytic projects that will use existing data and are feasible within 6 months and with up to $30,000 (approximately 25%–50% full‐time equivalent) of programmer/analyst effort. Review criteria include the importance of the analytic question for both research and operations, and the potential for the project to have a significant impact on care delivery within 12 months of completion. Results The RAP funded 5 research and operational analytic projects between 2013 and 2017. These projects spanned a wide range of clinical areas, including lupus, pediatric obesity, diabetes, e‐cigarette use, and hypertension. The hypertension RAP project, which focused on optimizing thiazide prescribing in Black/African American patients with hypertension, led to new insights that inform an equitable care quality metric designed to reduce blood pressure control disparities throughout the Kaiser Permanente Northern California region. Conclusions Programs that actively encourage research and operational analytic partnerships have significant potential to improve care, enhance research collaborations, and contribute to the building and sustaining of learning health systems.
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Affiliation(s)
- Julie A Schmittdiel
- Division of Research, Kaiser Permanente Northern California, Oakland, California, USA
| | - Rick Dlott
- The Permanente Medical Group, Oakland, California, USA
| | | | | | - Wendy Dyer
- Division of Research, Kaiser Permanente Northern California, Oakland, California, USA
| | - Alyce S Adams
- Division of Research, Kaiser Permanente Northern California, Oakland, California, USA
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Marshall C, Adams S, Dyer W, Schmittdiel J. Opportunities to Reduce Diabetes Risk in Women of Reproductive Age: Assessment and Treatment of Prediabetes within a Large Integrated Delivery System. Womens Health Issues 2017; 27:666-672. [PMID: 28694019 DOI: 10.1016/j.whi.2017.06.001] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/18/2016] [Revised: 05/31/2017] [Accepted: 06/02/2017] [Indexed: 02/03/2023]
Abstract
BACKGROUND Preventing diabetes before pregnancy may be important to improve maternal and infant outcomes. Although the preconception period is a crucial time to focus on chronic disease prevention, little is known about preventive services for reproductive-aged women at risk of developing diabetes. METHODS Using electronic health record data from patients at Kaiser Permanente Northern California, we identified 21,965 nonpregnant women aged 18 to 44 with incident prediabetes (PDM; fasting plasma glucose [FPG] = 100-125 or glycated hemoglobin A1c = 5.7%-6.4%) between 2007 and 2010. We looked for evidence of a "clinical response" to PDM in the 6 months after laboratory testing, defined as retesting of blood glucose levels, referral or attendance to health education, diagnosis of PDM, metformin initiation, or a clinical note of discussion of PDM. Multilevel models were used to examine the relationship between patient characteristics and clinical response, and to assess provider-level variation. RESULTS Fewer than one-half of women had a documented clinical response to the PDM-range laboratory result. Women with higher FPG values and body mass indexes were more likely to have a PDM diagnosis (FPG 120-125 vs. 100-119: OR, 1.96; 95% CI, 1.78-2.17; body mass index, 30-34 kg/m2 vs. <25 kg/m2: OR, 1.30; 95% CI, 1.13-1.48) and have 'PDM' recorded in the notes (FPG 120-125 vs. 100-119: OR, 1.15; 95% CI, 1.06-1.26; body mass index: 30-34 kg/m2 vs. <25 kg/m2: OR, 1.58; 95% CI, 1.44-1.74). Provider-level variation was modest, except for metformin initiation (intraclass correlation coefficient, 0.8; p < .01). CONCLUSIONS Low clinical response to PDM among women of reproductive age suggests there are missed opportunities for diabetes prevention among this vulnerable population.
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Affiliation(s)
- Cassondra Marshall
- Division of Research, Kaiser Permanente Northern California, Oakland, California, USA.
| | - Sara Adams
- Division of Research, Kaiser Permanente Northern California, Oakland, California, USA
| | - Wendy Dyer
- Division of Research, Kaiser Permanente Northern California, Oakland, California, USA
| | - Julie Schmittdiel
- Division of Research, Kaiser Permanente Northern California, Oakland, California, USA
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Adams AS, Bayliss EA, Schmittdiel JA, Altschuler A, Dyer W, Neugebauer R, Jaffe M, Young JD, Kim E, Grant RW. The Diabetes Telephone Study: Design and challenges of a pragmatic cluster randomized trial to improve diabetic peripheral neuropathy treatment. Clin Trials 2016; 13:286-93. [PMID: 27034455 PMCID: PMC7261503 DOI: 10.1177/1740774516631530] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.5] [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] [Indexed: 01/29/2023]
Abstract
BACKGROUND Challenges to effective pharmacologic management of symptomatic diabetic peripheral neuropathy include the limited effectiveness of available medicines, frequent side effects, and the need for ongoing symptom assessment and treatment titration for maximal effectiveness. We present here the rationale and implementation challenges of the Diabetes Telephone Study, a randomized trial designed to improve medication treatment, titration, and quality of life among patients with symptomatic diabetic peripheral neuropathy. METHODS We implemented a pragmatic cluster randomized controlled trial to test the effectiveness of an automated interactive voice response tool designed to provide physicians with real-time patient-reported data about responses to newly prescribed diabetic peripheral neuropathy medicines. A total of 1834 primary care physicians treating patients in the diabetes registry at Kaiser Permanente Northern California were randomized into the intervention or control arm. In September 2014, we began identification and recruitment of patients assigned to physicians in the intervention group who receive three brief interactive calls every 2 months after a medication is prescribed to alleviate diabetic peripheral neuropathy symptoms. These calls provide patients with the opportunity to report on symptoms, side effects, self-titration of medication dose and overall satisfaction with treatment. We plan to compare changes in self-reported quality of life between the intervention group and patients in the control group who receive three non-interactive automated educational phone calls. RESULTS Successful implementation of this clinical trial required robust stakeholder engagement to help tailor the intervention and to address pragmatic concerns such as provider time constraints. As of 27 October 2015, we had screened 2078 patients, 1447 of whom were eligible for participation. We consented and enrolled 1206 or 83% of those eligible. Among those enrolled, 53% are women and the mean age is 67 (standard deviation = 12) years. The racial ethnic make-up is 56% White, 8% Asian, 13% Black or African American, and 19% Hispanic or Latino. CONCLUSION Innovative strategies are needed to guide improvements in healthcare delivery for patients with symptomatic diabetic peripheral neuropathy. This trial aims to assess whether real-time collection and clinical feedback of patient treatment experiences can reduce patient symptom burden. Implementation of a clinical trial closely involving clinical care required researchers to partner with clinicians. If successful, this intervention provides a critical information feedback loop that would optimize diabetic peripheral neuropathy medication titration through widely available interactive voice response technology.
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Affiliation(s)
- Alyce S Adams
- Division of Research, Kaiser Permanente, Oakland, CA, USA
| | | | | | | | - Wendy Dyer
- Division of Research, Kaiser Permanente, Oakland, CA, USA
| | | | - Marc Jaffe
- South San Francisco Medical Center, Kaiser Permanente, South San Francisco, CA, USA
| | - Joseph D Young
- Oakland Medical Center, Kaiser Permanente, Oakland, CA, USA
| | - Eileen Kim
- Oakland Medical Center, Kaiser Permanente, Oakland, CA, USA
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Schmittdiel JA, Raebel MA, Dyer W, Xu S, Goodrich GK, Schroeder EB, Segal JB, O' Connor PJ, Nichols GA, Lawrence JM, Kirchner HL, Karter AJ, Lafata JE, Butler MG, Steiner JF. Prescription medication burden in patients with newly diagnosed diabetes: a SUrveillance, PREvention, and ManagEment of Diabetes Mellitus (SUPREME-DM) study. J Am Pharm Assoc (2003) 2015; 54:374-82. [PMID: 24860866 DOI: 10.1331/japha.2014.13195] [Citation(s) in RCA: 19] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022]
Abstract
OBJECTIVE To understand the burden of medication use for patients with newly diagnosed diabetes both before and after diabetes diagnosis and to identify subpopulations of patients with newly diagnosed diabetes who face a relatively high drug burden. DESIGN Retrospective cohort study. SETTING 11 integrated health systems in the United States. PARTICIPANTS 196,654 insured adults 20 years of age or older newly diagnosed with type 1 or type 2 diabetes from January 2005 through December 2009. MAIN OUTCOME MEASURES Number of unique therapeutic classes of drugs dispensed in the 12 months before and 12 months after diagnosis of diabetes in five categories: overall, antihypertensive agents, antihyperlipidemic agents, mental health agents, and antihyperglycemic agents (in the postdiagnosis period only). RESULTS The mean number of drug classes used by newly diagnosed patients with diabetes is high before diagnosis (5.0) and increases significantly afterward (6.6). Of this increase, 81% is due to antihyperglycemic initiation and increased use of medications to control hypertension and lipid levels. Multivariate analyses showed that overall drug burden after diabetes diagnosis was higher in women, older, white, and obese patients, as well as among those with higher glycosylated hemoglobin concentrations and comorbidity levels (significant for all comparisons). The overall number of drug classes used by newly diagnosed patients with diabetes after diagnosis decreased slightly but significantly between 2005 and 2009. CONCLUSION Patients newly diagnosed with diabetes face a substantially increased burden of medications used to control diabetes and other comorbidities. This study shows an increased focus on cardiovascular disease risk factor control after diagnosis of diabetes. However, total drug burden may be slightly decreasing over time.
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Lin MW, Zhu Z, Dyer W, Schmittdiel JA, Adams AS. Medicaid Expansion and the Affordable Care Act: Data From the First Year of Enrollment at Kaiser Permanente Northern California. J Patient Cent Res Rev 2015. [DOI: 10.17294/2330-0698.1152] [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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Schmittdiel J, Raebel M, Dyer W, Steiner J, Goodrich G, Karter A, Nichols G. Medicare Star excludes diabetes patients with poor CVD risk factor control. Am J Manag Care 2014; 20:e573-e581. [PMID: 25741874 PMCID: PMC4641517] [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] [Subscribe] [Scholar Register] [Indexed: 06/04/2023]
Abstract
OBJECTIVES CMS recently added medication adherence to antihypertensives, antihyperlipidemics, and oral antihyperglycemics to its Medicare Star quality measures. These CMS metrics exclude patients with <2 medication fills (ie, "early nonadherence") and patients concurrently taking insulin. This study examined the proportion of patients with diabetes prescribed cardiovascular disease (CVD) medications excluded from Star adherence metrics and assessed the relationship of both Star-defined adherence and exclusion from Star metrics with CVD risk factor control. STUDY DESIGN Cross-sectional, population-based analysis of 129,040 patients with diabetes aged ≥65 years in 2010 from 3 Kaiser Permanente regions. METHODS We estimated adjusted risk ratios to assess the relationship between achieving Star adherence and being excluded from Star adherence metrics, with CVD risk factor control (glycated hemoglobin [A1C]<8.0%, low-density lipoprotein cholesterol [LDL-C]<100 mg/dL, and systolic blood pressure [SBP]<130 mm Hg) in patients with diabetes. RESULTS Star metrics excluded 27% of patients with diabetes prescribed oral medications. Star-defined nonadherence was negatively associated with CVD risk factor control (risk ratio [RR], 0.95, 0.84, 0.96 for A1C, LDL-C, and SBP control, respectively; P<.001). Exclusion from Star metrics due to early nonadherence was also strongly associated with poor control (RR, 0.83, 0.56, 0.87 for A1C, LDL-C, and SBP control, respectively; P<.001). Exclusion for insulin use was negatively associated with A1C control (RR, 0.78; P<.0001). CONCLUSIONS Medicare Star adherence measures underestimate the prevalence of medication nonadherence in diabetes and exclude patients at high risk for poor CVD outcomes. Up to 3 million elderly patients with diabetes may be excluded from these measures nationally. Quality measures designed to encourage effective medication use should focus on all patients treated for CVD risk.
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Schmittdiel JA, Steiner JF, Adams AS, Dyer W, Beals J, Henderson WG, Desai J, Morales LS, Nichols GA, Lawrence JM, Waitzfelder B, Butler MG, Pathak RD, Hamman RF, Manson SM. Diabetes care and outcomes for American Indians and Alaska natives in commercial integrated delivery systems: a SUrveillance, PREvention, and ManagEment of Diabetes Mellitus (SUPREME-DM) Study. BMJ Open Diabetes Res Care 2014; 2:e000043. [PMID: 25452877 PMCID: PMC4246918 DOI: 10.1136/bmjdrc-2014-000043] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/14/2014] [Revised: 09/23/2014] [Accepted: 10/14/2014] [Indexed: 11/03/2022] Open
Abstract
OBJECTIVE To compare cardiovascular disease risk factor testing rates and intermediate outcomes of care between American Indian/Alaska Native (AI/AN) patients with diabetes and non-Hispanic Caucasians enrolled in nine commercial integrated delivery systems in the USA. RESEARCH DESIGN AND METHODS We used modified Poisson regression models to compare the annual testing rates and risk factor control levels for glycated haemoglobin (HbA1c), low-density lipoprotein cholesterol (LDL-C), and systolic blood pressure (SBP); number of unique diabetes drug classes; insulin use; and oral diabetes drug medication adherence between insured AI/AN and non-Hispanic white adults with diabetes aged ≥18 in 2011. RESULTS 5831 AI/AN patients (1.8% of the cohort) met inclusion criteria. After adjusting for age, gender, comorbidities, insulin use, and geocoded socioeconomic status, AI/AN patients had similar rates of annual HbA1c, LDL-C, and SBP testing, and LDL-C and SBP control, compared with non-Hispanic Caucasians. However, AI/AN patients were significantly more likely to have HbA1c >9% (>74.9 mmol/mol; RR=1.47, 95% CI 1.38 to 1.58), and significantly less likely to adhere to their oral diabetes medications (RR=0.90, 95% CI 0.88 to 0.93) compared with non-Hispanic Caucasians. CONCLUSIONS AI/AN patients in commercial integrated delivery systems have similar blood pressure and cholesterol testing and control, but significantly lower rates of HbA1c control and diabetes medication adherence, compared with non-Hispanic Caucasians. As more AI/ANs move to urban and suburban settings, clinicians and health plans should focus on addressing disparities in diabetes care and outcomes in this population.
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Affiliation(s)
- Julie A Schmittdiel
- Division of Research , Kaiser Permanente Northern California , Oakland, California , USA
| | - John F Steiner
- Institute for Health Research, Kaiser Permanente Colorado , Denver, Colorado , USA
| | - Alyce S Adams
- Division of Research , Kaiser Permanente Northern California , Oakland, California , USA
| | - Wendy Dyer
- Division of Research , Kaiser Permanente Northern California , Oakland, California , USA
| | - Janette Beals
- Centers for American Indian and Alaska Native Health, Colorado School of Public Health, University of Colorado Denver , Denver, Colorado , USA
| | - William G Henderson
- Centers for American Indian and Alaska Native Health, Colorado School of Public Health, University of Colorado Denver , Denver, Colorado , USA
| | - Jay Desai
- HealthPartners Institute for Education and Research , Minneapolis, Minnesota , USA
| | - Leo S Morales
- Group Health Research Institute , Seattle, Washington , USA
| | - Gregory A Nichols
- Kaiser Permanente Center for Health Research , Portland, Oregon , USA
| | - Jean M Lawrence
- Department of Research & Evaluation , Kaiser Permanente Southern California , Pasadena, California , USA
| | | | - Melissa G Butler
- Kaiser Permanente Georgia Center for Health Research-Southeast , Atlanta , Georgia , USA
| | | | - Richard F Hamman
- Centers for American Indian and Alaska Native Health, Colorado School of Public Health, University of Colorado Denver , Denver, Colorado , USA
| | - Spero M Manson
- Centers for American Indian and Alaska Native Health, Colorado School of Public Health, University of Colorado Denver , Denver, Colorado , USA
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Horton M, Wright N, Dyer W, Wright-Hughes A, Farrin A, Mohammed Z, Smith J, Heyes T, Gilbody S, Tennant A. Assessing the risk of self-harm in an adult offender population: an incidence cohort study. Health Technol Assess 2014; 18:1-151, vii-viii. [PMID: 25348581 DOI: 10.3310/hta18640] [Citation(s) in RCA: 9] [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] [Subscribe] [Scholar Register] [Indexed: 11/22/2022] Open
Abstract
BACKGROUND Self-harm is common among prisoners, particularly female prisoners. In 2007, concerned about the rising incidence, the prison service introduced a care-planning system called Assessment, Care in Custody, and Teamwork (ACCT). To date, it does not incorporate a standardised diagnostic test to estimate the risk of future self-harm. OBJECTIVE To identify potential screening instruments, or items from those instruments, to predict the risk of self-harm among prisoners. PARTICIPANTS Prisoners who had been assigned to an ACCT during the recruitment period. DESIGN A multistage prospective cohort study. Following a pilot study, instruments were administered to prisoners by interview at baseline, and followed up for 6 months (or until point of release if this was sooner) to ascertain self-harm status. Instruments were assessed for unidimensionality, scalability (Mokken) and quantitative structure (Rasch). Area under the curve (AUC) analysis was used to examine the ability of instruments and/or their items to predict future self-harm. Cox proportional hazards regression models were used to examine the multivariate predictive ability of the scales and various sociodemographic and sentencing factors. SETTING Three prisons (including one women's prison) in northern England. MAIN OUTCOME MEASURES A set of standardised questionnaires, including the Prison Screening Questionnaire (PriSnQuest), Revised Borderline Symptom List-23 (frequency-based responses) (BSL-23-F), Self-Harm Inventory (SHI), Patient Health Questionnaire (PHQ-9) and the Clinical Outcomes in Routine Evaluation - Outcome Measure (CORE-OM), together with sociodemographic and sentencing data. RESULTS In total, 450 prisoners consented to participate in the study, of whom 26% were female. The mean age of participants was 31.2 years. Over half of male prisoners recruited were on remand, compared with just over one-fifth (22.6%) of female prisoners. The average tariff of those sentenced was 41 months, of which 14.7 months, on average, had been served. Just over one-third of ACCTs had been initiated because of a known self-harm event, and over one-quarter (27.8%) of participants self-harmed during the follow-up period. Thus, almost half (46.7%) of those entered into the study were reported to have self-harmed, either from their index ACCT, or subsequently, or both. Cutting was the most frequent behaviour (51%). All screening instruments showed some evidence of unidimensionality, and four out of five showed scaling criteria consistent with ordinal scaling, so verifying the validity of the cut points. However, many showed gender bias and failure to fit the Rasch measurement model. While a resolution was made in most cases, both ordinal raw scores and latent interval scale estimates failed to show predictive value when applied within AUC analysis (0.491-0.566) or adjusted Cox proportional hazards models. However, good predictive values were shown for gender-specific sets of items, thus providing easily applied screening indexes. CONCLUSIONS While four out of five potential screening instruments were found to have acceptable psychometric properties within this setting, their predictive validity of all instruments was poor under AUC analysis. Gender-specific item sets were put together to form two screening indexes with formative indicators which gave reasonable AUC values, particularly so for females. The indexes provide identification of low-medium-high risk of self-harm, and so may help to inform potential care pathways and decisions to sign prisoners off from the ACCT. Future work should concentrate on refining a set of predictive screening items among different offender populations and investigating the time point at which this set of items should be administered. Future work may also look at the different magnitudes of risk as indicators for care pathways. FUNDING The National Institute for Health Research Health Technology Assessment programme.
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Affiliation(s)
- Mike Horton
- Academic Department of Rehabilitation Medicine, Leeds Institute of Rheumatic and Musculoskeletal Medicine, University of Leeds, Leeds, UK
| | - Nat Wright
- HMP Leeds Health Care Department, Leeds, UK
| | - Wendy Dyer
- Department of Sociology and Criminology, University of Durham, , UK
| | - Alex Wright-Hughes
- Clinical Trials Research Unit, Leeds Institute of Clinical Trials Research, University of Leeds, Leeds, UK
| | - Amanda Farrin
- Clinical Trials Research Unit, Leeds Institute of Clinical Trials Research, University of Leeds, Leeds, UK
| | | | - Jamie Smith
- North East Offender Health Commissioning Unit, Durham University Science Park, County Durham, UK
| | - Tom Heyes
- Brampton Primary Care Medical Centre, Rotherham, UK
| | - Simon Gilbody
- Department of Health Sciences, University of York, York, UK
| | - Alan Tennant
- Academic Department of Rehabilitation Medicine, Leeds Institute of Rheumatic and Musculoskeletal Medicine, University of Leeds, Leeds, UK
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Schmittdiel JA, Dyer W, Uratsu C, Magid DJ, O'Connor PJ, Beck A, Butler M, Ho MP, Vazquez-Benitez G, Adams AS. Initial persistence with antihypertensive therapies is associated with depression treatment persistence, but not depression. J Clin Hypertens (Greenwich) 2014; 16:412-7. [PMID: 24716533 PMCID: PMC4061252 DOI: 10.1111/jch.12300] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/03/2014] [Revised: 01/28/2014] [Accepted: 02/02/2014] [Indexed: 11/29/2022]
Abstract
The purpose of this study was to examine the relationship between the presence of clinical depression and persistence to drug therapy treatment for depression with early nonpersistence to antihypertensive therapies in a large, diverse cohort of newly treated hypertension patients. Using a hypertension registry at Kaiser Permanente Northern California, the authors conducted a retrospective cohort study of 44,167 adults (18 years and older) with hypertension who were new users of antihypertensive therapy in 2008. We used multivariate logistic regression analysis to model the relationships between the presence of clinical depression and early nonpersistence (defined as failing to refill the first prescription within 90 days after the end of the first fill days' supply) to antihypertensive therapies, controlling for sociodemographic and clinical risk factors. Within the group of 1484 patients who had evidence of clinical depression in the 12 months prior to the initiation of antihypertensive therapy, the authors examined the relationship between drug therapy treatment for depression and 6-month persistence with antidepressant therapy with early nonpersistence with antihypertensive therapies. No association was found between the presence of clinical depression and early nonpersistence to antihypertensive therapies after adjustment for individual demographic and clinical characteristics and neighborhood-level socioeconomic status. However, among the subset of 1484 patients with documented evidence of clinical depression in the 12 months prior to the initiation of antihypertensive therapy, being prescribed and persistence with antidepressant therapy was strongly associated with lower odds of early nonpersistence to antihypertensive medications (odds ratio, 0.64; confidence interval, 0.42-0.96). In an integrated delivery system, the authors found that treatment for depression was associated with higher levels of antihypertensive persistence. Improving quality of depression care in patients with comorbid hypertension may be an important strategy in decreasing cardiovascular disease risk in these patients.
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Adams AS, Uratsu C, Dyer W, Magid D, O'Connor P, Beck A, Butler M, Ho PM, Schmittdiel JA. Health system factors and antihypertensive adherence in a racially and ethnically diverse cohort of new users. JAMA Intern Med 2013; 173:54-61. [PMID: 23229831 PMCID: PMC5105889 DOI: 10.1001/2013.jamainternmed.955] [Citation(s) in RCA: 46] [Impact Index Per Article: 4.2] [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] [Indexed: 01/22/2023]
Abstract
BACKGROUND The purpose of this study was to identify potential health system solutions to suboptimal use of antihypertensive therapy in a diverse cohort of patients initiating treatment. METHODS Using a hypertension registry at Kaiser Permanente Northern California, we conducted a retrospective cohort study of 44 167 adults (age, ≥18 years) with hypertension who were new users of antihypertensive therapy in 2008. We used multivariate logistic regression analysis to model the relationships between race/ethnicity, specific health system factors, and early nonpersistence (failing to refill the first prescription within 90 days) and nonadherence (<80% of days covered during the 12 months following the start of treatment), respectively, controlling for sociodemographic and clinical risk factors. RESULTS More than 30% of patients were early nonpersistent and 1 in 5 were nonadherent to therapy. Nonwhites were more likely to exhibit both types of suboptimal medication-taking behavior compared with whites. In logistic regression models adjusted for sociodemographic, clinical, and health system factors, nonwhite race was associated with early nonpersistence (black: odds ratio, 1.56 [95% CI, 1.43-1.70]; Asian: 1.40 [1.29-1.51]; Hispanic: 1.46 [1.35-1.57]) and nonadherence (black: 1.55 [1.37-1.77]; Asian: 1.13 [1.00-1.28]; Hispanic: 1.46 [1.31-1.63]). The likelihood of early nonpersistence varied between Asians and Hispanics by choice of first-line therapy. In addition, racial and ethnic differences in nonadherence were appreciably attenuated when medication co-payment and mail-order pharmacy use were accounted for in the models. CONCLUSIONS Racial/ethnic differences in medication-taking behavior occur early in the course of treatment. However, health system strategies designed to reduce patient co-payments, ease access to medications, and optimize the choice of initial therapy may be effective tools in narrowing persistent gaps in the use of these and other clinically effective therapies.
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Affiliation(s)
- Alyce S Adams
- Kaiser Permanente Division of Research, Oakland, CA 94612, USA.
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26
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Selby JV, Schmittdiel JA, Fireman B, Jaffe M, Ransom LJ, Dyer W, Uratsu CS, Reed ME, Kerr EA, Hsu J. Improving treatment intensification to reduce cardiovascular disease risk: a cluster randomized trial. BMC Health Serv Res 2012; 12:183. [PMID: 22747998 PMCID: PMC3438122 DOI: 10.1186/1472-6963-12-183] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/12/2012] [Accepted: 07/02/2012] [Indexed: 11/17/2022] Open
Abstract
Background Blood pressure, lipid, and glycemic control are essential for reducing cardiovascular disease (CVD) risk. Many health care systems have successfully shifted aspects of chronic disease management, including population-based outreach programs designed to address CVD risk factor control, to non-physicians. The purpose of this study is to evaluate provision of new information to non-physician outreach teams on need for treatment intensification in patients with increased CVD risk. Methods Cluster randomized trial (July 1-December 31, 2008) in Kaiser Permanente Northern California registry of members with diabetes mellitus, prior CVD diagnoses and/or chronic kidney disease who were high-priority for treatment intensification: blood pressure ≥ 140 mmHg systolic, LDL-cholesterol ≥ 130 mg/dl, or hemoglobin A1c ≥ 9%; adherent to current medications; no recent treatment intensification). Randomization units were medical center-based outreach teams (4 intervention; 4 control). For intervention teams, priority flags for intensification were added monthly to the registry database with recommended next pharmacotherapeutic steps for each eligible patient. Control teams used the same database without this information. Outcomes included 3-month rates of treatment intensification and risk factor levels during follow-up. Results Baseline risk factor control rates were high (82-90%). In eligible patients, the intervention was associated with significantly greater 3-month intensification rates for blood pressure (34.1 vs. 30.6%) and LDL-cholesterol (28.0 vs 22.7%), but not A1c. No effects on risk factors were observed at 3 months or 12 months follow-up. Intervention teams initiated outreach for only 45-47% of high-priority patients, but also for 27-30% of lower-priority patients. Teams reported difficulties adapting prior outreach strategies to incorporate the new information. Conclusions Information enhancement did not improve risk factor control compared to existing outreach strategies at control centers. Familiarity with prior, relatively successful strategies likely reduced uptake of the innovation and its potential for success at intervention centers. Trial registration ClinicalTrials.gov Identifier NCT00517686
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Affiliation(s)
- Joe V Selby
- Patient-Centered Outcomes Research Institute, Washington, DC, USA
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Mohamed A, Koundinya R, Junius F, Dyer W, Yong A, Ho J, Kritharides L, Freedman B, dos Remedios C. CD Antibody Microarrays as an Objective Tool to Differentiate between Inflammatory Conditions of Coronary Arteries. Heart Lung Circ 2009. [DOI: 10.1016/j.hlc.2009.05.248] [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: 11/15/2022]
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Abstract
OVERVIEW LPNs may be able to help fill some of the gaps caused by the nursing shortage, but little research has been conducted on the demographic characteristics of LPNs, their education and scope of practice, and the demand for their services, all of which vary from state to state. In 2002 and 2003, the authors conducted a comprehensive national study, Supply, Demand, and Use of Licensed Practical Nurses, and have summarized that study's findings in this article. They found that RNs and LPNs are similar in age and tend to have similar numbers of children, but that racial and ethnic minorities, particularly African Americans, and those who are single, widowed, divorced, or separated are better represented among LPNs. Expanding LPN educational programs might draw more people into nursing. Some LPNs would like to become RNs, so expanding LPN-to-RN "ladder" programs could also be beneficial. LPNs can't replace RNs entirely, but they could perform much of the work now performed by RNs. While long-term care facilities already depend heavily on LPNs, hospitals could benefit from employing more LPNs. The authors make several specific policy recommendations to improve the education and employment of LPNs.
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Affiliation(s)
- Jean Ann Seago
- School of Nursing, University of California, San Francisco, USA.
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Seago JA, Spetz J, Chapman S, Dyer W, Grumbach K. NAPNES board of directors position paper regarding supply, demand, and use of licensed practical nurses. J Pract Nurs 2004; 54:4. [PMID: 15460340] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 04/30/2023]
Affiliation(s)
- Jean Ann Seago
- Center for California Health Workforce Studies, University of California, San Francisco, USA
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Kelleher AD, Long C, Holmes EC, Allen RL, Wilson J, Conlon C, Workman C, Shaunak S, Olson K, Goulder P, Brander C, Ogg G, Sullivan JS, Dyer W, Jones I, McMichael AJ, Rowland-Jones S, Phillips RE. Clustered mutations in HIV-1 gag are consistently required for escape from HLA-B27-restricted cytotoxic T lymphocyte responses. J Exp Med 2001; 193:375-86. [PMID: 11157057 PMCID: PMC2195921 DOI: 10.1084/jem.193.3.375] [Citation(s) in RCA: 391] [Impact Index Per Article: 17.0] [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] [Subscribe] [Scholar Register] [Indexed: 12/01/2022] Open
Abstract
The immune response to HIV-1 in patients who carry human histocompatibility leukocyte antigen (HLA)-B27 is characterized by an immunodominant response to an epitope in p24 gag (amino acids 263-272, KRWIILGLNK). Substitution of lysine (K) or glycine (G) for arginine (R) at HIV-1 gag residue 264 (R264K and R264G) results in epitopes that bind to HLA-B27 poorly. We have detected a R264K mutation in four patients carrying HLA-B27. In three of these patients the mutation occurred late, coinciding with disease progression. In another it occurred within 1 yr of infection and was associated with a virus of syncytium-inducing phenotype. In each case, R264K was tightly associated with a leucine to methionine change at residue 268. After the loss of the cytotoxic T lymphocyte (CTL) response to this epitope and in the presence of high viral load, reversion to wild-type sequence was observed. In a fifth patient, a R264G mutation was detected when HIV-1 disease progressed. Its occurrence was associated with a glutamic acid to aspartic acid mutation at residue 260. Phylogenetic analyses indicated that these substitutions emerged under natural selection rather than by genetic drift or linkage. Outgrowth of CTL escape viruses required high viral loads and additional, possibly compensatory, mutations in the gag protein.
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Affiliation(s)
- A D Kelleher
- Medical Research Council Human Immunology Unit, Institute of Molecular Medicine, John Radcliffe Hospital, Headington, Oxford OX3 9DS, United Kingdom.
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31
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Veldhuis LJ, Hall LM, O'Donovan JT, Dyer W, Hall JC. Metabolism-based resistance of a wild mustard (Sinapis arvensis L.) biotype to ethametsulfuron-methyl. J Agric Food Chem 2000; 48:2986-2990. [PMID: 10898653 DOI: 10.1021/jf990752g] [Citation(s) in RCA: 22] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 05/23/2023]
Abstract
Under controlled-environment conditions, ethametsulfuron-methyl doses that inhibited growth by 50% (ED(50)) were >100 and <1 g of active ingredient (ai) ha(-)(1) for ethametsulfuron-methyl-resistant (R) and -susceptible (S) wild mustard, respectively. There were no differences between the two biotypes with regard to absorption and translocation of the herbicide. Three days after treatment, approximately 90, 5, and 2% of the applied [(14)C]ethametsulfuron-methyl was found in the treated leaf, foliage, and roots of each biotype, respectively. Acetolactate synthase extracted from the two biotypes was equally sensitive to both ethametsulfuron-methyl and chlorsulfuron. These results indicate that resistance was not due to differences in the target site, absorption, or translocation. However, ethametsulfuron-methyl was metabolized more rapidly in the R than the S biotype. Approximately 82, 73, 42, 30, and 17% of the recovered radioactivity remained as ethametsulfuron-methyl in R wild mustard 3, 6, 18, 48, and 72 h after treatment, respectively. Conversely, 84, 79, 85, and 73% of the (14)C was ethametsulfuron-methyl in the S biotype 12, 24, 48, and 72 h after treatment, respectively. On the basis of these results, it is proposed that resistance is due to enhanced metabolism of ethametsulfuron-methyl in the R biotype.
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Affiliation(s)
- L J Veldhuis
- Department of Environmental Biology, University of Guelph, Guelph, Ontario, Canada N1G 2W1
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32
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Wilson JD, Ogg GS, Allen RL, Davis C, Shaunak S, Downie J, Dyer W, Workman C, Sullivan S, McMichael AJ, Rowland-Jones SL. Direct visualization of HIV-1-specific cytotoxic T lymphocytes during primary infection. AIDS 2000; 14:225-33. [PMID: 10716497 DOI: 10.1097/00002030-200002180-00003] [Citation(s) in RCA: 126] [Impact Index Per Article: 5.3] [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: 10/27/2022]
Abstract
OBJECTIVE HIV-specific cytotoxic T lymphocytes (CTL) are believed to play an important role in containing viral replication throughout HIV-1 infection. Previous studies have attempted to quantify the HIV-1-specific CTL precursor frequency during primary HIV infection by using limiting dilution analysis, which almost certainly underestimates the true CTL frequency. Here we use a relatively new technique to quantify HIV-specific CD8 T cells in primary HIV infection. METHODS We have used soluble tetrameric complexes of HLA class I molecules complexed with HIV epitope peptides to study the dynamics and frequency of HIV-specific CD8 T cells in relation to plasma viral load in early HIV infection, in three patients with a highly focused HIV-specific CTL response. RESULTS We show that the frequencies of HIV-1-specific CD8 T cells in acute infection are significantly higher than previously documented and can be demonstrated well before full seroconversion. These studies also confirm the immunodominance of the B27-restricted response in HIV infection and demonstrate a close temporal relationship between the numbers of circulating HIV-specific CD8 T cells and viral load. CONCLUSIONS These findings strongly suggest that HIV-1-specific CD8 T cells are responding directly to the level of viral replication in early HIV infection and are a major factor in its control. In addition, the data indicate that immunodominance for CD8 T-cell responses is established in the acute phase of HIV infection.
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Affiliation(s)
- J D Wilson
- Human Immunology Unit, Institute of Molecular Medicine, John Radcliffe Hospital, Headington, Oxford, UK
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Jin X, Demoitie MA, Donahoe SM, Ogg GS, Bonhoeffer S, Kakimoto WM, Gillespie G, Moss PA, Dyer W, Kurilla MG, Riddell SR, Downie J, Sullivan JS, McMichael AJ, Workman C, Nixon DF. High frequency of cytomegalovirus-specific cytotoxic T-effector cells in HLA-A*0201-positive subjects during multiple viral coinfections. J Infect Dis 2000; 181:165-75. [PMID: 10608763 DOI: 10.1086/315201] [Citation(s) in RCA: 53] [Impact Index Per Article: 2.2] [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: 11/03/2022] Open
Abstract
How the cellular immune response copes with diverse antigenic competition is poorly understood. Responses of virus-specific cytotoxic T lymphocytes (CTL) were examined longitudinally in an individual coinfected with human immunodeficiency virus type 1 (HIV-1), Epstein-Barr virus (EBV), and cytomegalovirus (CMV). CTL responses to all 3 viruses were quantified by limiting dilution analysis and staining with HLA-A*0201 tetrameric complexes folded with HIV-1, EBV, and CMV peptides. A predominance of CMV-pp65-specific CTL was found, with a much lower frequency of CTL to HIV-1 Gag and Pol and to EBV-BMLF1 and LMP2. The high frequency of CMV-specific CTL, compared with HIV-1- and EBV-specific CTL, was confirmed in an additional 16 HLA-A*0201-positive virus-coinfected subjects. Therefore, the human immune system can mount CTL responses to multiple viral antigens simultaneously, albeit with different strengths.
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Affiliation(s)
- X Jin
- Aaron Diamond AIDS Research Center, The Rockefeller University, New York, New York, USA
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Kuipers H, Workman C, Dyer W, Geczy A, Sullivan J, Oelrichs R. An HIV-1-infected individual homozygous for the CCR-5 delta32 allele and the SDF-1 3'A allele. AIDS 1999; 13:433-4. [PMID: 10199243 DOI: 10.1097/00002030-199902250-00025] [Citation(s) in RCA: 36] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [What about the content of this article? (0)] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
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Deliyannis G, Jackson DC, Dyer W, Bates J, Coulter A, Harling-McNabb L, Brown LE. Immunopotentiation of humoral and cellular responses to inactivated influenza vaccines by two different adjuvants with potential for human use. Vaccine 1998; 16:2058-68. [PMID: 9796065 DOI: 10.1016/s0264-410x(98)00080-2] [Citation(s) in RCA: 21] [Impact Index Per Article: 0.8] [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: 02/09/2023]
Abstract
Two quite different adjuvants, currently under development for use in humans, have been examined for their effects on the magnitude and type of immunity elicited in response to inactivated influenza vaccine. Immunostimulating complexes (ISCOM adjuvant) contain the saponin ISCOPREP 703, and SPT is an oil-in-water emulsion of squalane, non-ionic block copolymer (L121) and Tween 80. Influenza virus vaccines formulated in either adjuvant were far superior to the non-adjuvanted aqueous vaccine in eliciting antibody and T-cell responses in mice, particularly at lower doses of antigen. In addition, the vaccines containing adjuvant were superior in eliciting protective immunity. One of the shortcomings of the unadjuvanted inactivated influenza vaccine was its inability to elicit a primary proliferative T-cell response. However, after one dose of either adjuvanted vaccine, strong proliferative responses were achieved. We also show that subcutaneous vaccination with inactivated vaccines is capable of modulating the isotype profile of antibody secreting cells generated in the lungs of mice in response to intranasal challenge with live virus. In this system, the isotype of antibody elicited after challenge of mice that had received ISCOM vaccine more closely mimicked that of animals vaccinated with live virus.
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Affiliation(s)
- G Deliyannis
- Department of Microbiology and Immunology, University of Melbourne, Parkville, Australia
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Sullivan JS, Learmont JC, Geczy AF, Dyer W. HIV and AIDS. Nature 1995; 378:10. [PMID: 7477274 DOI: 10.1038/378010d0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/25/2023]
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Dyer W. Remarks on the Extraction of Teeth, with a View to Lessen the Danger of That Operation; and a Description of a New Instrument for Drawing Teeth; Including the Account of an Improved Scarificator. Med Phys J 1799; 1:13-17. [PMID: 30489973 PMCID: PMC5650849] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 10/27/2022]
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