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Steiner JF, Ross C, Stiefel M, Mosen D, Banegas MP, Wall AE, Martin C, Kelly TS, Paolino AR, Zeng C. Association between changes in loneliness identified through screening and changes in depression or anxiety in older adults. J Am Geriatr Soc 2022; 70:3458-3468. [PMID: 36053977 DOI: 10.1111/jgs.18012] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/07/2022] [Revised: 07/09/2022] [Accepted: 07/21/2022] [Indexed: 12/24/2022]
Abstract
BACKGROUND Changes in loneliness are associated with corresponding changes in depression, anxiety, and general health in population surveys, but few studies have assessed these associations through repeated screening in clinical settings. METHODS Retrospective cohort study among individuals ≥age 65 in an integrated health care system who completed loneliness screening before two annual wellness visits, separated by a mean of 12.9 (SD 2.0) months, between 2013 and 2018. Their responses identified four subgroups: individuals who were persistently lonely; not lonely; experienced an increase (recently lonely); or decrease (previously lonely) in loneliness. Loneliness was assessed with a single item. Depression was assessed with the Patient Health Questionnaire-2. Anxiety was assessed with the Generalized Anxiety Disorder-2. Fair/poor general health was assessed by a single item. Linear mixed effects models assessed changes in outcomes after covariate adjustment. RESULTS The cohort comprised 24,666 individuals (19.2% of older adults in the system). Mean age was 73.7 years (SD 6.4); 54.6% were female, and 11.6% were members of racial and ethnic minority groups. Of these individuals, 1936 (7.8%) were persistently lonely, 1687 (6.8%) were recently lonely, 1551 (6.3%) were previously lonely, and 19,492 (79.0%) were not lonely at either time point. After adjustment for sociodemographic, clinical and social variables, recent loneliness was associated with increases in depression (adjusted odds ratio [aOR] 1.76, 95% confidence interval [CI] 1.41-2.19) and anxiety (aOR 1.67, 95% CI 1.32-2.10). Previous loneliness was associated with decreases in depression (aOR, 0.46, 95% CI 0.36-0.58) and anxiety (aOR 0.69, 95% CI 0.54-0.90). Changes in loneliness were not associated with changes in general health. CONCLUSIONS Changes in loneliness identified through screening were associated with corresponding changes in depression and anxiety. These findings support the potential value of identifying social risk factors in clinical settings among older adults.
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Affiliation(s)
- John F Steiner
- Institute for Health Research, Kaiser Permanente Colorado, Denver, Colorado, USA
| | - Colleen Ross
- Institute for Health Research, Kaiser Permanente Colorado, Denver, Colorado, USA
| | - Matthew Stiefel
- Social Health Practice, Kaiser Permanente, Oakland, California, USA
| | - David Mosen
- Center for Health Research, Kaiser Permanente Northwest, Portland, Oregon, USA
| | - Matthew P Banegas
- Center for Health Research, Kaiser Permanente Northwest, Portland, Oregon, USA.,Department of Radiation Medicine and Applied Sciences, University of California, San Diego, California, USA
| | - Alena E Wall
- Social Health Practice, Kaiser Permanente, Oakland, California, USA
| | - Cally Martin
- Social Health Practice, Kaiser Permanente, Oakland, California, USA
| | - Tammy S Kelly
- Quality, Risk & Patient Safety Department, Kaiser Permanente Colorado, Denver, Colorado, USA
| | - Andrea R Paolino
- Institute for Health Research, Kaiser Permanente Colorado, Denver, Colorado, USA
| | - Chan Zeng
- Institute for Health Research, Kaiser Permanente Colorado, Denver, Colorado, USA
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Tzoulaki I, Castagné R, Boulangé CL, Karaman I, Chekmeneva E, Evangelou E, Ebbels TMD, Kaluarachchi MR, Chadeau-Hyam M, Mosen D, Dehghan A, Moayyeri A, Ferreira DLS, Guo X, Rotter JI, Taylor KD, Kavousi M, de Vries PS, Lehne B, Loh M, Hofman A, Nicholson JK, Chambers J, Gieger C, Holmes E, Tracy R, Kooner J, Greenland P, Franco OH, Herrington D, Lindon JC, Elliott P. Serum metabolic signatures of coronary and carotid atherosclerosis and subsequent cardiovascular disease. Eur Heart J 2019; 40:2883-2896. [PMID: 31102408 PMCID: PMC7963131 DOI: 10.1093/eurheartj/ehz235] [Citation(s) in RCA: 96] [Impact Index Per Article: 19.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/22/2018] [Revised: 11/21/2018] [Accepted: 05/13/2019] [Indexed: 12/31/2022] Open
Abstract
AIMS To characterize serum metabolic signatures associated with atherosclerosis in the coronary or carotid arteries and subsequently their association with incident cardiovascular disease (CVD). METHODS AND RESULTS We used untargeted one-dimensional (1D) serum metabolic profiling by proton nuclear magnetic resonance spectroscopy (1H NMR) among 3867 participants from the Multi-Ethnic Study of Atherosclerosis (MESA), with replication among 3569 participants from the Rotterdam and LOLIPOP studies. Atherosclerosis was assessed by coronary artery calcium (CAC) and carotid intima-media thickness (IMT). We used multivariable linear regression to evaluate associations between NMR features and atherosclerosis accounting for multiplicity of comparisons. We then examined associations between metabolites associated with atherosclerosis and incident CVD available in MESA and Rotterdam and explored molecular networks through bioinformatics analyses. Overall, 30 1H NMR measured metabolites were associated with CAC and/or IMT, P = 1.3 × 10-14 to 1.0 × 10-6 (discovery) and P = 5.6 × 10-10 to 1.1 × 10-2 (replication). These associations were substantially attenuated after adjustment for conventional cardiovascular risk factors. Metabolites associated with atherosclerosis revealed disturbances in lipid and carbohydrate metabolism, branched chain, and aromatic amino acid metabolism, as well as oxidative stress and inflammatory pathways. Analyses of incident CVD events showed inverse associations with creatine, creatinine, and phenylalanine, and direct associations with mannose, acetaminophen-glucuronide, and lactate as well as apolipoprotein B (P < 0.05). CONCLUSION Metabolites associated with atherosclerosis were largely consistent between the two vascular beds (coronary and carotid arteries) and predominantly tag pathways that overlap with the known cardiovascular risk factors. We present an integrated systems network that highlights a series of inter-connected pathways underlying atherosclerosis.
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Affiliation(s)
- Ioanna Tzoulaki
- Department of Epidemiology and Biostatistics, School of Public Health, Imperial College London, Norfolk Place, London, UK
- MRC-PHE Centre for Environment and Health, School of Public Health, Imperial College London, Norfolk Place, London, UK
- Department of Hygiene and Epidemiology, University of Ioannina Medical School, University Campus Road 455 00, Ioannina, Greece
- Dementia Research Institute, Imperial College London, Norfolk Place, London, UK
| | - Raphaële Castagné
- Department of Epidemiology and Biostatistics, School of Public Health, Imperial College London, Norfolk Place, London, UK
- LEASP, UMR 1027, Inserm-Université Toulousse III Paul Sabatier, Toulousse, France
| | - Claire L Boulangé
- Metabometrix Ltd, Imperial Incubator, Bessemer Building, Prince Consort Road, London, UK
- Division of Computational and Systems Medicine, Department of Surgery and Cancer, Imperial College London, South Kensington Campus, London, UK
| | - Ibrahim Karaman
- Department of Epidemiology and Biostatistics, School of Public Health, Imperial College London, Norfolk Place, London, UK
- MRC-PHE Centre for Environment and Health, School of Public Health, Imperial College London, Norfolk Place, London, UK
- Dementia Research Institute, Imperial College London, Norfolk Place, London, UK
| | - Elena Chekmeneva
- Division of Computational and Systems Medicine, Department of Surgery and Cancer, Imperial College London, South Kensington Campus, London, UK
| | - Evangelos Evangelou
- Department of Epidemiology and Biostatistics, School of Public Health, Imperial College London, Norfolk Place, London, UK
- MRC-PHE Centre for Environment and Health, School of Public Health, Imperial College London, Norfolk Place, London, UK
- Department of Hygiene and Epidemiology, University of Ioannina Medical School, University Campus Road 455 00, Ioannina, Greece
| | - Timothy M D Ebbels
- Division of Computational and Systems Medicine, Department of Surgery and Cancer, Imperial College London, South Kensington Campus, London, UK
| | - Manuja R Kaluarachchi
- Metabometrix Ltd, Imperial Incubator, Bessemer Building, Prince Consort Road, London, UK
- Division of Computational and Systems Medicine, Department of Surgery and Cancer, Imperial College London, South Kensington Campus, London, UK
| | - Marc Chadeau-Hyam
- Department of Epidemiology and Biostatistics, School of Public Health, Imperial College London, Norfolk Place, London, UK
- MRC-PHE Centre for Environment and Health, School of Public Health, Imperial College London, Norfolk Place, London, UK
| | - David Mosen
- Department of Epidemiology and Biostatistics, School of Public Health, Imperial College London, Norfolk Place, London, UK
- MRC-PHE Centre for Environment and Health, School of Public Health, Imperial College London, Norfolk Place, London, UK
| | - Abbas Dehghan
- Department of Epidemiology and Biostatistics, School of Public Health, Imperial College London, Norfolk Place, London, UK
- MRC-PHE Centre for Environment and Health, School of Public Health, Imperial College London, Norfolk Place, London, UK
- Dementia Research Institute, Imperial College London, Norfolk Place, London, UK
| | - Alireza Moayyeri
- Farr Institute of Health Informatics Research, University College London Institute of Health Informatics, 222 Euston Road, London, UK
| | - Diana L Santos Ferreira
- MRC Integrative Epidemiology Unit, School of Social and Community Medicine, University of Bristol, Oakfield House, Oakfiled Grove, Bristol, UK
| | - Xiuqing Guo
- Department of Pediatrics, Institute for Translational Genomics and Population Sciences, Los Angeles Biomedical Research Institute at Harbor-UCLA Medical Center, 1000 W Carson St, Torrance, CA, USA
- Department of Medicine, Institute for Translational Genomics and Population Sciences, Los Angeles Biomedical Research Institute at Harbor-UCLA Medical Center, 1000 W Carson St, Torrance, CA, USA
| | - Jerome I Rotter
- Department of Pediatrics, Institute for Translational Genomics and Population Sciences, Los Angeles Biomedical Research Institute at Harbor-UCLA Medical Center, 1000 W Carson St, Torrance, CA, USA
- Department of Medicine, Institute for Translational Genomics and Population Sciences, Los Angeles Biomedical Research Institute at Harbor-UCLA Medical Center, 1000 W Carson St, Torrance, CA, USA
| | - Kent D Taylor
- Department of Pediatrics, Institute for Translational Genomics and Population Sciences, Los Angeles Biomedical Research Institute at Harbor-UCLA Medical Center, 1000 W Carson St, Torrance, CA, USA
- Department of Medicine, Institute for Translational Genomics and Population Sciences, Los Angeles Biomedical Research Institute at Harbor-UCLA Medical Center, 1000 W Carson St, Torrance, CA, USA
| | - Maryam Kavousi
- Department of Epidemiology, Erasmus University Medical Center, University Medical Center Rotterdam, CA Rotterdam, the Netherlands
| | - Paul S de Vries
- Department of Epidemiology, Erasmus University Medical Center, University Medical Center Rotterdam, CA Rotterdam, the Netherlands
- Department of Epidemiology, Human Genetics, and Environmental Sciences, Human Genetics Center, School of Public Health, The University of Texas Health Science Center at Houston, 1200 Pressler Street, Houston, TX, USA
| | - Benjamin Lehne
- Department of Epidemiology and Biostatistics, School of Public Health, Imperial College London, Norfolk Place, London, UK
| | - Marie Loh
- Department of Epidemiology and Biostatistics, School of Public Health, Imperial College London, Norfolk Place, London, UK
| | - Albert Hofman
- Department of Epidemiology, Erasmus University Medical Center, University Medical Center Rotterdam, CA Rotterdam, the Netherlands
- Department of Epidemiology, Harvard T.H. Chan School of Public Health, 677 Huntington Avenue, Boston, MA, USA
| | - Jeremy K Nicholson
- Metabometrix Ltd, Imperial Incubator, Bessemer Building, Prince Consort Road, London, UK
- Division of Computational and Systems Medicine, Department of Surgery and Cancer, Imperial College London, South Kensington Campus, London, UK
| | - John Chambers
- Department of Epidemiology and Biostatistics, School of Public Health, Imperial College London, Norfolk Place, London, UK
- London North West Healthcare NHS Trust, Northwick Park Hospital, Watford Rd, Harrow, UK
| | - Christian Gieger
- German Research Centre for Environmental Health, Helmholtz Zentrum München, Ingolstädter Landstraße 1, D Neuherberg, Germany
| | - Elaine Holmes
- Metabometrix Ltd, Imperial Incubator, Bessemer Building, Prince Consort Road, London, UK
- Division of Computational and Systems Medicine, Department of Surgery and Cancer, Imperial College London, South Kensington Campus, London, UK
| | - Russell Tracy
- M.D. College of Medicine University of Vermont, The Robert Larner, Given Medical Bldg, E-126, 89 Beaumont Ave, Burlington, VT, USA
| | - Jaspal Kooner
- Department of Epidemiology, Harvard T.H. Chan School of Public Health, 677 Huntington Avenue, Boston, MA, USA
- National Heart & Lung Institute, Faculty of Medicine, Imperial College London, Guy Scadding Building, Dovehouse St, Chelsea, London, UK
| | - Philip Greenland
- Department of Preventive Medicine, Northwestern University, Feinberg School of Medicine, 680 North Lake Shore Drive, Suite, 1400, Chicago, IL, USA
| | - Oscar H Franco
- Department of Medicine, Institute for Translational Genomics and Population Sciences, Los Angeles Biomedical Research Institute at Harbor-UCLA Medical Center, 1000 W Carson St, Torrance, CA, USA
- Institute of Social and Preventive Medicine (ISPM), University of Bern, Mittelstrasse 43, Bern, Switzerland
| | - David Herrington
- Section on Cardiovascular Medicine, Department of Internal Medicine, Wake Forest University School of Medicine, Medical Center Boulevard, Winston-Salem, NC, USA
| | - John C Lindon
- Metabometrix Ltd, Imperial Incubator, Bessemer Building, Prince Consort Road, London, UK
- Division of Computational and Systems Medicine, Department of Surgery and Cancer, Imperial College London, South Kensington Campus, London, UK
| | - Paul Elliott
- Department of Epidemiology and Biostatistics, School of Public Health, Imperial College London, Norfolk Place, London, UK
- MRC-PHE Centre for Environment and Health, School of Public Health, Imperial College London, Norfolk Place, London, UK
- Dementia Research Institute, Imperial College London, Norfolk Place, London, UK
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Banegas MP, Dickerson JF, Friedman NL, Mosen D, Ender AX, Chang TR, Runge TA, Hornbrook MC. Evaluation of a Novel Financial Navigator Pilot to Address Patient Concerns about Medical Care Costs. Perm J 2019; 23:18-084. [PMID: 30939267 DOI: 10.7812/tpp/18-084] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/24/2022]
Abstract
CONTEXT Interventions are required that address patients' medically related financial needs. OBJECTIVE To evaluate a Financial Navigator pilot addressing patients' concerns/needs regarding medical care costs in an integrated health care system. METHODS Adults (aged ≥ 18 years) enrolled at Kaiser Permanente Northwest, who had a concern/need about medical care costs and received care in 1 of 3 clinical departments at the intervention or comparison clinic were recruited between August 1, 2016, and October 31, 2016. Baseline and 30-day follow-up participant surveys were administered to assess medical and nonmedical socioeconomic needs, satisfaction with medical care, and satisfaction with assistance with cost concerns. Physicians at both clinics were invited to complete a survey on medical care costs. We assessed participant characteristics and survey responses using descriptive statistics and 30-day change in satisfaction measures using multivariable linear regression models. RESULTS Eighty-five intervention and 51 comparison participants completed the baseline survey. At baseline, intervention participants reported transportation (52.9%), housing (38.2%), and social isolation (32.4%) needs; comparison participants identified employment (33.3%), food (33.3%), and housing (33.3%) needs. Intervention participants reported higher satisfaction with care (p = 0.01) and higher satisfaction with cost concerns assistance (p = 0.01) vs comparison participants at 30-day follow-up, controlling for baseline responses. Although most physicians (80%) reported discussing medical care costs with their patients, only 18% reported knowing about their patients' financial well-being. CONCLUSION We demonstrated the promise of a novel Financial Navigator pilot intervention to address medical care cost concerns and needs, and underscored the prevalence of nonmedical social needs in an economically vulnerable population.
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Affiliation(s)
- Matthew P Banegas
- Kaiser Permanente Center for Health Research, Portland, OR.,Kaiser Permanente Northwest, Portland, OR
| | - John F Dickerson
- Kaiser Permanente Center for Health Research, Portland, OR.,Kaiser Permanente Northwest, Portland, OR
| | - Nicole L Friedman
- Kaiser Permanente Center for Health Research, Portland, OR.,Kaiser Permanente Northwest, Portland, OR
| | - David Mosen
- Kaiser Permanente Center for Health Research, Portland, OR.,Kaiser Permanente Northwest, Portland, OR
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Ramraj R, Garcia A, Mosen D, Waiwaiole L, Smith N. Utility of Fecal Calprotectin in Evaluation of Chronic Gastrointestinal Symptoms in Primary Care. Clin Pediatr (Phila) 2018; 57:1058-1063. [PMID: 29192504 DOI: 10.1177/0009922817744607] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.5] [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] [Indexed: 01/26/2023]
Abstract
Fecal calprotectin (FC) is a marker of intestinal inflammation. Data are limited on utility of routine FC testing in pediatric primary care. Participants 0 to 18 years old who had an FC test in the years 2010-2014 were retrospectively identified. Those with less than a year of follow-up or a prior diagnosis of inflammatory bowel disease (IBD) were excluded. In all, 84% (689/822) had normal FC; no participant with normal FC was diagnosed with IBD in the subsequent 12 months. Also, 16% (133/822) had elevated FC, and 31% of those (42/133) were diagnosed with IBD. FC values for IBD and non-IBD groups were 1084 µg/g (interquartile range [IQR] = 514.4-2000) and 27.05 µg/g (IQR = 15.6-62.6; P < .001), respectively. Abdominal pain was the primary indication. In this cohort, sensitivity of FC for IBD is 100%, and specificity is 88%. The FC test can be an excellent tool in the primary care setting to exclude IBD and avoid unnecessary referrals and colonoscopies.
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Affiliation(s)
- Ramya Ramraj
- 1 Kaiser Permanente Northwest, Portland, OR, USA.,2 Oregon Health & Science University, Portland, OR, USA
| | - Amy Garcia
- 2 Oregon Health & Science University, Portland, OR, USA
| | - David Mosen
- 3 Kaiser Permanente Center for Health Research, Portland, OR, USA
| | - Lisa Waiwaiole
- 3 Kaiser Permanente Center for Health Research, Portland, OR, USA
| | - Ning Smith
- 3 Kaiser Permanente Center for Health Research, Portland, OR, USA
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5
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Mosen D, Glauber H, Stoneburner A, Feldstein A, Fortmann S. Assessing the Association Between Exercise Status and Poor Glycemic Control. J Patient Cent Res Rev 2017. [DOI: 10.17294/2330-0698.1499] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [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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Luk LJ, Mosen D, MacArthur CJ, Grosz AH. Implementation of a Pediatric Posttonsillectomy Pain Protocol in a Large Group Practice. Otolaryngol Head Neck Surg 2016; 154:720-4. [DOI: 10.1177/0194599815627810] [Citation(s) in RCA: 28] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/21/2015] [Accepted: 12/30/2015] [Indexed: 12/31/2022]
Abstract
Objective In response to the increased risk of respiratory failure and death after tonsillectomy related to codeine use, Kaiser Permanente Northwest restricted use of opioids in patients <7 years old via electronic health record (EHR). However, opioids could be prescribed at physician discretion by overriding the EHR. This study aims to examine protocol compliance in a large group practice using EHR order sets and complication rates as compared with historical data. Study Design Case series with chart review. Setting Ambulatory care within a health maintenance organization. Subjects and Methods Procedural codes were used to identify children <7 years old who underwent tonsillectomy or adenotonsillectomy approximately 1.5 years before and after implementation of EHR protocol (n = 437). Primary outcome was opioid pain prescriptions received by patients. Secondary outcomes were emergency or urgent care utilization, postoperative bleeding, nausea, vomiting, dehydration, death, and reasons for prescribing opioid pain medication after EHR protocol implementation. Chi-square analysis and Fischer’s exact testing were used to compare differences in event rates. Results Implementation of an age-based narcotic protocol significantly decreased physician narcotic prescribing from 82.2% to 15.4% ( P < .0001). The most common reason for narcotic prescription after the intervention was the report of inadequate pain control by phone call (35%). There was no significant difference in rate of emergency or urgent care utilization between pre- and postimplementation groups (4% vs 6%, P = .29). Conclusions Implementation of an age-based narcotic restriction for posttonsillectomy patients using an EHR order set is an effective and safe way to influence physician prescription practices.
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Affiliation(s)
- Lauren J. Luk
- Division of Pediatric Otolaryngology, Department of Otolaryngology–Head and Neck Surgery, Oregon Health and Science University, Portland, Oregon, USA
| | - David Mosen
- Kaiser Permanente Center for Health Research, Portland, Oregon, USA
| | - Carol J. MacArthur
- Division of Pediatric Otolaryngology, Department of Otolaryngology–Head and Neck Surgery, Oregon Health and Science University, Portland, Oregon, USA
| | - Anna H. Grosz
- Department of Otolaryngology–Head and Neck Surgery, Kaiser Permanente Northwest, Clackamas, Oregon, USA
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Abstract
CONTEXT The dental setting represents an unrealized opportunity to increase adherence to preventive services and improve health outcomes. OBJECTIVE To compare adherence to a subset of Healthcare Effectiveness Data and Information Set (HEDIS) measures among a population that received dental care with a population that did not receive dental care. DESIGN Using a retrospective cohort design, we identified 5216 adults who received regular dental care and 5216 persons who did not. The groups were matched on propensity scores, were followed for 3 years, and retained medical and dental benefits. Receipt of dental care was defined as 1 or more dental visits in each 12-month period. MAIN OUTCOME MEASURES Outcome measures were assessed in a subpopulation that qualified for 1 of 5 HEDIS denominator groups (dental = 4184 patients; nondental = 3871 patients). They included 3 preventive measures (cervical, colorectal, and breast cancer screening), 4 chronic disease management services (hemoglobin A1c and low-density lipoprotein cholesterol testing, and nephropathy and retinopathy screening among the diabetes mellitus [DM] population), and 4 health outcome measures (poor glycemic control, low-density lipoprotein cholesterol control, blood pressure control in the DM population, and blood pressure control in the hypertensive population). RESULTS Dental care was associated with higher adherence to all three cancer screening measures, one of four disease management services (higher retinopathy screening), and three of four health outcomes (better glycemic control in the DM population and better blood pressure control in the DM and hypertensive populations). CONCLUSIONS Dental care was associated with improved adherence to 7 of 11 HEDIS measures.
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Affiliation(s)
- David Mosen
- Senior Program Evaluation Consultant and Affiliate Investigator at The Center for Health Research in Portland, OR.
| | - Dan Pihlstrom
- Associate Director for Evidence-Based Care and Oral Health Research for Permanente Dental Associates in Portland, OR.
| | - John Snyder
- CEO and Dental Director for Permanente Dental Associates in Portland, OR.
| | - Ning Smith
- Biostatistician and Investigator for The Center for Health Research in Portland, OR.
| | - Elizabeth Shuster
- Research Analyst for The Center for Health Research in Portland, OR.
| | - Kristal Rust
- Statistical Research Analyst for The Center for Health Research in Portland, OR.
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Muller D, Logan J, Dorr D, Mosen D. The effectiveness of a secure email reminder system for colorectal cancer screening. AMIA Annu Symp Proc 2009; 2009:457-461. [PMID: 20351899 PMCID: PMC2815450] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 05/29/2023]
Abstract
This study looks at the effectiveness of using a secure email system linked to an electronic health record to send reminders to patients in an effort to increase colorectal cancer (CRC) screening rates; 1397 subjects were randomized to receive usual care, a letter reminder or an email reminder which invited patients to pick up a fecal occult blood test at the lab for CRC screening. The number of completed CRC screenings was tallied after a 3 month study period. Rates of CRC screening in the 3 groups were 7.8% in the usual care group, 23.6% in the letter reminder group and 22.7% in the email group. Significant statistical difference was seen between usual care group and letter reminders (p<0.0005) and between usual care and email reminders (p<0.0005) but not between the letter reminders and the email reminders (p=7.11). Email reminders are as effective as letter reminders in increasing CRC screening rates.
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Affiliation(s)
- David Muller
- Department of Family Medicine, Northwest Permanente, Portland, OR, USA
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9
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Schatz M, Zeiger RS, Mosen D, Vollmer WM. Asthma-specific quality of life and subsequent asthma emergency hospital care. Am J Manag Care 2008; 14:206-211. [PMID: 18402513] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 05/26/2023]
Abstract
OBJECTIVE To identify an optimal cut-point score on the Mini-Asthma Quality of Life Questionnaire (mini-AQLQ) to predict subsequent asthma exacerbations, and to determine the additional risk conferred by a prior history of acute episodes. STUDY DESIGN Cross-sectional survey linked to administrative records. METHODS A total of 1006 HMO patients with active asthma completed surveys that included the mini-AQLQ and prior-year history of acute episodes. Surveys were linked to administrative data that captured asthma emergency department and hospital care (emergency hospital care) for the year after the survey. Optimal mini-AQLQ cut-point scores were determined by stepwise logistic regression analyses using subsequentyear asthma emergency hospital care as the outcome and various mini-AQLQ cut-points as the predictors. Predictive properties of the 2 risk factors (mini-AQLQ cut-points and prior acute episodes) were determined. RESULTS A mini-AQLQ cut-point of 4.7 was most significantly associated with subsequent exacerbations in patients without a history of prior acute episodes. The presence of either a mini-AQLQ score <4.7 or a history of prior acute episodes provided high sensitivity (90.4%) and identified a group nearly 6 times more likely to require emergency hospital care than patients with neither risk factor. The presence of both risk factors provided high specificity (79.2%) and resulted in a risk ratio of 9.5 compared with the absence of both risk factors. CONCLUSION Asthma-specific quality of life and a history of acute episodes can be used together to identify patients with clinically meaningful higher and lower risks of subsequent acute exacerbations.
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Affiliation(s)
- Michael Schatz
- Department of Allergy, Kaiser-Permanente Medical Center, 7060 Clairemont Mesa Blvd, San Diego, CA 92111, USA.
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10
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Vollmer WM, Kirshner M, Peters D, Drane A, Stibolt T, Hickey T, Tom GI, Buist AS, O'Connor EA, Frazier EA, Mosen D. Use and impact of an automated telephone outreach system for asthma in a managed care setting. Am J Manag Care 2006; 12:725-33. [PMID: 17149995] [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: 05/12/2023]
Abstract
OBJECTIVE To test the ability of an automated telephone outreach intervention to reduce acute healthcare utilization and improve quality of life among adult asthma patients in a large managed care organization. STUDY DESIGN Randomized clinical trial. METHODS Patients with persistent asthma were randomly assigned to telephone outreach (automated = 3389, live caller = 192) or usual care (n = 3367). Intervention participants received 3 outreach calls over a 10-month period. The intervention provided brief, supportive information and flagged individuals with poor asthma control for follow-up by a provider. A survey was mailed to 792 intervention participants and 236 providers after the intervention. Additional feedback was obtained as part of the final intervention contact. RESULTS The intent-to-treat analysis found no significant differences between the intervention and usual-care groups for medication use, healthcare utilization, asthma control, or quality of life. Post hoc analyses found that, compared with the control group, individuals who actually participated in the intervention were significantly more likely to use inhaled steroids and to have had a routine medical visit for asthma during the follow-up period and less likely to use short-acting beta-agonists. They also reported higher satisfaction with their asthma care and better asthma-specific quality of life. Of surveyed providers, 59% stated the program helped them to clinically manage their asthma patients and 70% thought the program should be continued. CONCLUSIONS This study did not find improved health outcomes in the primary analyses. The intervention was well accepted by providers, however, and the individuals who participated in the calls appeared to have benefited from them. These findings suggest that further studies of automated telephone outreach interventions seem warranted.
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Affiliation(s)
- William M Vollmer
- Center for Health Research, Kaiser Permanente Northwest, Portland, OR 97227, USA.
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11
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Schatz M, Mosen D, Kosinski M, Vollmer WM, O'Connor E, Cook EF, Zeiger RS. Validation of the asthma impact survey, a brief asthma-specific quality of life tool. Qual Life Res 2006; 16:345-55. [PMID: 17033905 DOI: 10.1007/s11136-006-9103-2] [Citation(s) in RCA: 20] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 07/24/2006] [Indexed: 11/29/2022]
Abstract
BACKGROUND The Asthma Impact Survey (AIS-6) is a new six question asthma outcome tool for which information on validity has not been published. OBJECTIVE To provide validation for the AIS-6 as a brief asthma-specific quality of life tool. METHODS Surveys were sent to a random sample of members of a large managed care organization who were at least 35 years of age and in the two-year period preceding the survey had either (1) at least one documented asthma-related medical encounter, or (2) at least a 6 months supply of asthma medication dispensed. In addition to the AIS-6, the survey included a validated quality of life tool [the mini-Asthma Quality of Life Questionnaire (AQLQ)]; a validated asthma control questionnaire [the Asthma Therapy Assessment Questionnaire (ATAQ)]; a validated symptom severity scale (AOMS); and information regarding demographics, co-morbidities, asthma severity, and asthma management. The results of the AIS-6 were compared to the results of the other tools by means of correlation and factor analysis. Independent predictors of AIS-6 and AQLQ scores were determined by multiple stepwise linear regression analyses. RESULTS AIS-6 scores were significantly related to female sex, educational level, income, smoking, body mass index (BMI), COPD, steroid use, and hospitalization history in bivariate analyses. The AIS-6 score significantly correlated (r = - 0.84, p < 0.0001) with the AQLQ total score and loaded on the three factors (activity, symptoms, and concern/bother) reflected by the survey information and on which the AQLQ also loaded. Significant but somewhat smaller correlations were found between the AIS-6 and the ATAQ (r = 0.70, p < 0.0001) and the AOMS (r = 0.55, p < 0.0001). Independent predictors were the same for the AIS-6 and AQLQ and included oral steroid use, COPD history, BMI, female sex, educational level, and hospitalization in the past year. CONCLUSION These data support the validity of the short six-question AIS-6 as an asthma-specific quality of life tool.
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Affiliation(s)
- Michael Schatz
- Department of Allergy, Kaiser Permanente Medical Center, San Diego, CA 92111, USA.
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Schatz M, Zeiger RS, Vollmer WM, Mosen D, Mendoza G, Apter AJ, Stibolt TB, Leong A, Johnson MS, Cook EF. The controller-to-total asthma medication ratio is associated with patient-centered as well as utilization outcomes. Chest 2006; 130:43-50. [PMID: 16840381 DOI: 10.1378/chest.130.1.43] [Citation(s) in RCA: 97] [Impact Index Per Article: 5.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/01/2022] Open
Abstract
BACKGROUND The ratio of controller medication to total asthma medications has been related to asthma utilization outcomes, but its relationship to patient-centered outcomes has not been explored. METHODS Surveys that included validated asthma quality-of-life, control, and symptom severity tools were completed by a random sample of 2,250 health maintenance organization members aged 18 to 56 years who had persistent asthma. Linked computerized pharmacy data provided dispensing information on beta-agonist canisters and asthma controller medication. The ratio was calculated as the number of controller medications dispensed during the year of the survey divided by the total number medications (ie, inhaled beta-agonist plus controller medications) dispensed. The relationships of the optimal ratio cutoff to patient-centered outcomes and to subsequent acute asthma exacerbations were determined. RESULTS Mean asthma quality-of-life, asthma control, and symptom severity scale scores were significantly (p < 0.0001) more favorable in patients with ratios of > or = 0.5. After adjusting for demographic characteristics, patients with ratios of > or = 0.5 were significantly less likely to have adverse results regarding asthma quality of life (odds ratio [OR], 0.65; 95% confidence interval [CI], 0.52 to 0.80), asthma control (OR, 0.62; 95% CI, 0.50 to 0.77), and symptom severity (OR, 0.53; 95% CI, 0.43 to 0.65), and were also less likely to experience subsequent asthma hospitalizations or emergency department visits (OR, 0.44; 95% CI, 0.26 to 0.74) than patients with lower ratios. CONCLUSION A higher controller medication/total asthma medication ratio is associated with better patient-centered asthma outcomes as well as with reduced emergency hospital utilization. This adds further support to the use of the medication ratio as an asthma quality-of-care measure.
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Affiliation(s)
- Michael Schatz
- Department of Allergy, Kaiser-Permanente Medical Center Program, 7060 Clairemont Mesa Blvd, San Diego, CA 92111, USA.
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Schatz M, Zeiger RS, Vollmer WM, Mosen D, Apter AJ, Stibolt TB, Leong A, Johnson MS, Mendoza G, Cook EF. Development and validation of a medication intensity scale derived from computerized pharmacy data that predicts emergency hospital utilization for persistent asthma. Am J Manag Care 2006; 12:478-84. [PMID: 16886890] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 05/11/2023]
Abstract
OBJECTIVE To validate a risk stratification scheme using computerized pharmacy data to predict emergency hospital utilization for persistent asthma. STUDY DESIGN Retrospective cohort. METHODS The development sample consisted of 1079 HMO members aged 18 to 56 years with persistent asthma. The scale used medication cut-points as predictors for next-year emergency hospital utilization in a stepwise logistic regression model. Prediction properties were evaluated in a validation sample of 24 370 patients aged 18 to 56 years in a separate persistent-asthma database. RESULTS Increasing use of beta-agonists (odds ratio [OR] of 2.2 for 5-13 vs 0-4 canisters; OR of 2.4 for >13 vs 5-13 canisters) and oral corticosteroids (OR of 2.6 for >2 vs 0-2 dispensing events) in the first year independently predicted emergency hospital utilization in the second year. Assigning 1 point for exceeding each of the above 3 medication thresholds led to a 4-level medication intensity scale that was significantly (P <.0001) related to validated measures of asthma symptom severity, asthma control, and asthma quality of life in the development sample. In the validation sample, this scheme identified a high-risk group that was 6 times more likely than the low-risk group to require subsequent emergency hospital care, with overall sensitivity of 65% and specificity of 54%. This scale did not perform as well as a scale based on both baseline emergency hospital care and pharmacy data. CONCLUSION This simple risk stratification scheme can be used for populations with persistent asthma for whom computerized pharmacy data, but not computerized prior utilization data, are available.
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Affiliation(s)
- Michael Schatz
- Kaiser Permanente Medical Center, 7060 Clairemont Mesa Blvd, San Diego, CA 92111, USA.
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Schatz M, Zeiger RS, Vollmer WM, Mosen D, Apter AJ, Stibolt TB, Leong A, Johnson MS, Mendoza G, Cook EF. Validation of a β-agonist long-term asthma control scale derived from computerized pharmacy data. J Allergy Clin Immunol 2006; 117:995-1000. [PMID: 16675324 DOI: 10.1016/j.jaci.2006.01.053] [Citation(s) in RCA: 87] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/19/2005] [Revised: 01/26/2006] [Accepted: 01/31/2006] [Indexed: 11/24/2022]
Abstract
BACKGROUND Asthma control has been defined clinically by using validated tools, but an asthma control scale using administrative data has not been reported. OBJECTIVE We sought to validate a beta-agonist asthma control scale derived from administrative data. METHODS Surveys that included validated asthma symptom and control tools were completed by a random sample of 2250 health maintenance organization members aged 18 to 56 years with persistent asthma. Linked computerized pharmacy data provided beta-agonist canister and oral corticosteroid dispensings. The proposed 4-level asthma control scale was based on the number of short-acting beta-agonist canisters dispensed in 12 months. Construct validity and predictive validity were assessed. RESULTS For construct validity, factor analysis showed significant loading of the beta-agonist scale on the symptom control factor, and the beta-agonist scale was significantly related to the validated asthma control and symptom scales (r = 0.31, P < .0001). For predictive validity, each progressive level of the proposed beta-agonist control scale was associated with an increased risk of subsequent asthma hospitalizations or emergency department visits and oral corticosteroid use, independent of prior use. CONCLUSION A scale based on the number of beta-agonists dispensed in a 1-year period and derived from administrative data reflects asthma symptom control over that period of time. This scale can help identify patients who are at risk for future acute asthma health care use. CLINICAL IMPLICATIONS This information can be used in population management and by clinicians to assess long-term asthma control and identify patients who need intervention to prevent future morbidity.
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Affiliation(s)
- Michael Schatz
- Department of Allergy (San Diego), Kaiser-Permanente Medical Care Program, Kaiser-Permanente Medical Center, CA 92111, USA.
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Schatz M, Zeiger RS, Mosen D, Apter AJ, Vollmer WM, Stibolt TB, Leong A, Johnson MS, Mendoza G, Cook EF. Improved asthma outcomes from allergy specialist care: a population-based cross-sectional analysis. J Allergy Clin Immunol 2005; 116:1307-13. [PMID: 16337464 DOI: 10.1016/j.jaci.2005.09.027] [Citation(s) in RCA: 65] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/05/2005] [Revised: 08/29/2005] [Accepted: 09/01/2005] [Indexed: 11/29/2022]
Abstract
BACKGROUND Prior studies suggest that allergist care improves asthma outcomes, but many of these studies have methodological shortcomings. OBJECTIVE We sought to compare patient-based and medical utilization outcomes in randomly selected asthmatic patients cared for by allergists versus primary care providers. METHODS A random sample of 3568 patients enrolled in a staff model health maintenance organization who were given diagnoses of persistent asthma completed surveys. Of these participants, 1679 (47.1%) identified a primary care provider as their regular source of asthma care, 884 (24.8%) identified an allergist, 693 (19.4%) reported no regular source of asthma care, and 195 (5.5%) identified a pulmonologist. Validated quality of life, control, severity, patient satisfaction, and self-management knowledge tools and linked administrative data that captured medication use were compared between groups, adjusting for demographics and baseline hospital and corticosteroid use. RESULTS Compared with those followed by primary care providers, patients of allergists reported significantly higher (P < .001) generic physical and asthma-specific quality of life, less asthma control problems, less severe symptoms, higher satisfaction with care, and greater self-management knowledge. Patients of allergists were less likely than patients of primary care providers to require an asthma hospitalization (odds ratio, 0.45) or unscheduled visit (odds ratio, 0.71) and to overuse beta-agonists (odds ratio, 0.47) and were more likely to receive inhaled steroids (odds ratio, 1.81) during their past year. CONCLUSIONS Allergist care is associated with a wide range of improved outcomes in asthmatic patients compared with care provided by primary care providers.
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Abstract
STUDY OBJECTIVE To evaluate the relationship of potential asthma quality-of-care markers to subsequent emergency hospital care. DESIGN Retrospective administrative database analysis. SETTING Managed care organization. PATIENTS Asthmatic patients aged 5 to 56 years of age. INTERVENTIONS None. MEASUREMENTS AND RESULTS Candidate quality measures included one or more or four or more controller medication canisters, a controller/total asthma medication ratio of > or = 0.3 or > or = 0.5, and the dispensing of fewer than six beta-agonist canisters in 2002. Outcome was a 2003 asthma emergency department visit or hospitalization. Multivariable analyses adjusted for age, sex, and year 2002 severity (based on utilization). In the total sample (n = 109,774), one or more controllers (odds ratio, 1.35) and four or more controllers (odds ratio, 1.98) were associated with an increased risk of emergency hospital care, whereas a controller/total asthma medication ratio of > or = 0.5 (odds ratio, 0.73) and the dispensing of fewer than six beta-agonist canisters (odds ratio 0.30) were associated with a decreased risk. After adjustment for baseline severity in the total asthma sample, the controller/total asthma medication ratio (odds ratio, 0.62 to 0.78) and beta-agonist measure (odds ratio, 0.42) were associated with decreased risk, whereas the dispensing of four or more canisters of controller medication was associated with increased risk (odds ratio, 1.33). After stratification by year 2002 beta-agonist use, all of the measures were associated with decreased risk in those who received fewer than six beta-agonist canisters, whereas all of the measures except the medication ratio of > or = 0.5 were associated with increased risk in the cohort who received six or more beta-agonist canisters. CONCLUSION Controller use and beta-agonist use may function as severity indicators in large populations rather than as asthma quality-of-care markers. A medication ratio of > or = 0.5 appeared to function as the best quality-of-care marker in this study.
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Affiliation(s)
- Michael Schatz
- Department of Allergy, Kaiser-Permanente Medical Center, San Diego, Los Angeles, CA 92111, USA.
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Schatz M, Mosen D, Apter AJ, Zeiger RS, Vollmer WM, Stibolt TB, Leong A, Johnson MS, Mendoza G, Cook EF. Relationships among quality of life, severity, and control measures in asthma: an evaluation using factor analysis. J Allergy Clin Immunol 2005; 115:1049-55. [PMID: 15867865 DOI: 10.1016/j.jaci.2005.02.008] [Citation(s) in RCA: 78] [Impact Index Per Article: 4.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
Abstract
BACKGROUND Validated psychometric tools measuring quality of life, asthma control, and asthma severity have been developed, but their relationships with each other and with other important patient-centered outcomes have not been rigorously assessed. OBJECTIVE To use factor analysis to evaluate the relationships of these validated tools with each other and with other patient-centered outcomes. METHODS Surveys were completed by a random sample of 2854 Health Maintenance Organization members age 18 to 56 years with persistent asthma. Surveys included demographic information; validated tools measuring generic (Short Form-12; SF-12) and asthma-specific (Juniper Mini Asthma Quality of Life Questionnaire; AQLQ) quality of life, asthma control (Asthma Therapy Assessment Questionnaire), and asthma symptom severity (Asthma Outcomes Monitoring System); self-described severity, control, and course over time; and history of acute exacerbations. RESULTS Principal component analysis suggested a 5-factor model that accounted for approximately 59% of the variability. The most prominent rotated factor reflected asthma symptom frequency (19.4% of variability), was measured by the symptom subscale of the AQLQ, and was the only factor significantly related to the Asthma Therapy Assessment Questionnaire, Asthma Outcomes Monitoring System, or the self-reported assessments of severity, control, or course. Other factors included symptom bother (12.1% of variability), reflected by the environment and emotion AQLQ subscales; activity limitation (13.9% of variability), reflected by the activity AQLQ subscale and the SF-12 physical component scale; mental health (8.3% of variability), reflected by the SF-12 mental component scale; and acute exacerbations (5.0% of variability), not measured by any of the validated scales. CONCLUSION Distinct components of patient-reported asthma health status can be identified by factor analysis. Distinct constructs of severity versus control cannot be identified by the use of these tools alone.
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Affiliation(s)
- Michael Schatz
- Department of Allergy, Kaiser-Permanente Medical Center, San Diego, CA 92111, USA.
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Schatz M, Mosen D, Apter AJ, Zeiger RS, Vollmer WM, Stibolt TB, Leong A, Johnson MS, Mendoza G, Cook EF. Relationship of validated psychometric tools to subsequent medical utilization for asthma. J Allergy Clin Immunol 2005; 115:564-70. [PMID: 15753905 DOI: 10.1016/j.jaci.2004.12.005] [Citation(s) in RCA: 23] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
Abstract
BACKGROUND Risk stratification is used to identify patients with asthma at increased risk of experiencing morbidity and resource utilization. Validated psychometric tools are infrequently studied sources of data for this purpose. PURPOSE To evaluate 4 types of validated psychometric tools as predictors for subsequent asthma utilization and determine their clinical usefulness. METHODS Eleven hundred patients with active asthma from a Health Maintenance Organization completed surveys that included demographic information and validated psychometric tools measuring generic quality of life (physical and mental components), asthma-specific quality of life, asthma control, and asthma symptom severity. Survey records were linked to administrative data that captured emergency department and hospital care, short-acting beta-agonist, and oral corticosteroid utilization for the year of and the year following the survey. Relationships of survey variables with subsequent utilization were assessed, adjusting for both baseline demographic and asthma utilization factors. RESULTS Scores of each psychometric tool were significantly related to subsequent utilization in univariate analyses and after adjusting for baseline utilization and demographic risk factors. Patients with higher scale-defined morbidity were as much as 4 times more likely to have subsequent utilization (sensitivity as high as 58%; specificity as high as 78%). Addition of an asthma-specific tool to either demographic or utilization prediction models added sensitivity (as much as 15%) but did not substantially improve the prediction properties of models containing both demographic and utilization predictors. CONCLUSION Validated psychometric tools appear useful for asthma risk stratification in individuals and in populations in which both utilization and demographic predictors are not available.
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Affiliation(s)
- Michael Schatz
- Department of Allergy, Kaiser-Permanente Medical Center, San Diego, Calif 92111, USA.
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Mosen D, Elliott CG, Egger MJ, Mundorff M, Hopkins J, Patterson R, Gardner RM. The Effect of a Computerized Reminder System on the Prevention of Postoperative Venous Thromboembolism. Chest 2004; 125:1635-41. [PMID: 15136370 DOI: 10.1378/chest.125.5.1635] [Citation(s) in RCA: 49] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/01/2022] Open
Abstract
STUDY OBJECTIVE To measure the effect of an altered process of care, directed by a computerized reminder system, on rates of symptomatic postoperative venous thromboembolism. DESIGN Comparisons of preintervention and postintervention measurements. SETTING A university-affiliated community hospital in Utah. PATIENTS Two-thousand seventy-seven consecutive patients who underwent major operations in four surgical divisions between January 1, 1997, and October 31, 1997 (preintervention), and 2,093 consecutive patients who underwent the same procedures between January 1, 1998, and October 31,1998 (postintervention). INTERVENTION A program to prevent venous thromboembolism developed from American College of Chest Physicians guidelines, and an altered work process directed by a computerized reminder system. MEASUREMENTS Rates of symptomatic, objectively confirmed deep vein thrombosis (DVT), pulmonary embolism (PE), and death attributable to venous thromboembolism occurring within 90 days of the date of surgery. RESULTS The preintervention and postintervention cohorts did not differ with respect to age, severity of illness, number of risk factors for venous thromboembolism, or individual risk factors for venous thromboembolism. The overall prophylaxis rate increased from 89.9% before implementation of the computerized reminder system to 95.0% after implementation (p < 0.0001). The combined 90-day rate of symptomatic DVT, PE, and death attributable to PE remained the same (preintervention, 1.0%; postintervention, 1.2%; odds ratio, 1.21; 95% confidence interval, 0.67 to 2.20). Forty of 46 venous thromboembolic complications (87%) occurred despite the delivery of American College of Chest Physicians-recommended measures to prevent venous thromboembolism. CONCLUSIONS Computerized reminder systems combined with altered care procedures increase the rate of prophylaxis against venous thromboembolism without decreasing the rate of symptomatic venous thromboembolism when the baseline rate of prophylaxis is high. A population of surgical patients exists who are resistant to American College of Chest Physicians-recommended prophylactic measures against venous thromboembolism. New strategies are needed to address prophylaxis-resistant venous thromboembolism.
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Affiliation(s)
- David Mosen
- Department of Public Health & Preventive Medicine, Oregon Health & Science University, Portland, OR, USA
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