Center for Health Research
Center for Health Research
News Article | May 21, 2017
Pressures on primary care doctors to move away from opioid pain management are increasing, but practitioners need practical, evidence-based information on how to employ multidisciplinary pain care successfully in everyday clinical practice. A senior investigator for Kaiser Permanente, speaking at the American Pain Society Annual Scientific Conference, believes wider use of practical clinical trials and more emphasis on patient self-management are key solutions for achieving wider use of multidisciplinary pain care to improve patient function and help lower use and misuse of opioids. While the national death toll from opioid overdoses is staggering, Lynn DeBar, PhD, senior investigator, Kaiser Permanente Center for Health Research said that a small minority of pain patients are represented in the mortality data. "Given the justified apprehensions of primary care doctors to continue prescribing opioids, the central question focuses on what can we do in primary care to help improve function for pain patients," said DeBar. DeBar said the benefits of multidisciplinary pain care, which employs non-pharmacologic treatments, have been well documented in peer-reviewed studies but it still is not widely available due largely to inadequate insurance coverage. "Medicare and other health insurance providers need value-based care metrics and outcomes, and more studies are needed to help implement evidence-based multimodal pain care with attention to feasibility and sustainability in everyday clinical practice," DeBar explained. Widespread gaps in evidence-based knowledge about pain management underscore the need to conduct practical clinical trials designed to meet the needs of clinicians and answer their questions. Such trials are of increasing interest to the National Institutes of Health who are ramping up efforts to support pragmatic trial initiatives. "Practical clinical trials can bridge the gap between research and clinical care," said DeBar. "Traditional randomized clinical trials are slow and expensive, and results often cannot be implemented easily in clinical practice. Findings can be difficult to translate into the real world because treatments are given to carefully selected populations in ideal conditions." DeBar said practical clinical trials are designed to improve practice and policy and take place in settings where routine medical care occurs. They seek answers to real-world clinical questions and are designed to test what will work in everyday care. Also, practical clinical trials study diverse populations using broadly inclusive eligibility criteria. The NIH Health Care Systems Research Collaboratory, is spearheading execution of pragmatic clinical trials in pain management by partnering with health systems and physician groups. "Engaging health systems, provider and patients as partners in pragmatic research accelerates realistic integration of research, policy and practice," said DeBar. She reported that Kaiser Permanente is organizing a practical clinical trial in pain management involving 851 patients in the Portland, Ore. area. DeBar also spoke about the benefits of adopting alternative treatment approaches, such as virtual reality and patient-to-patient reinforcement methods. "Remote interventions with cognitive behavioral therapies are proving effective and so are new smart phone apps that allow patients to transmit real-time information about their pain," said DeBar. "Also, more attention should be given to patient-driven models of support, similar to programs like Weight Watchers, which empower patients to take more active roles in managing their care."
News Article | May 9, 2017
The U.S. Preventive Services Task Force (USPSTF) recommends against screening for thyroid cancer in adults without any signs or symptoms. The report appears in the May 9 issue of JAMA. This is a D recommendation, indicating that there is moderate or high certainty that screening has no net benefit or that the harms outweigh the benefits. The incidence of thyroid cancer detection has increased by 4.5 percent per year over the last 10 years, faster than for any other cancer; however, the mortality rate from thyroid cancer has not changed substantially, despite the increase in diagnoses. In 2013, the incidence rate of thyroid cancer in the United States was 15.3 cases per 100,000 persons. Most cases of thyroid cancer have a good prognosis; the 5-year survival rate for thyroid cancer overall is 98.1 percent. To update its 1996 recommendation, the USPSTF reviewed the evidence on the benefits and harms of screening for thyroid cancer in asymptomatic adults, the diagnostic accuracy of screening (including by neck palpation and ultrasound), and the benefits and harms of treatment of screen-detected thyroid cancer. The USPSTF is an independent, volunteer panel of experts that makes recommendations about the effectiveness of specific preventive care services such as screenings, counseling services, and preventive medications. The USPSTF found inadequate evidence to estimate the accuracy of neck palpation or ultrasound as a screening test for thyroid cancer in asymptomatic persons. The USPSTF found inadequate direct evidence to determine whether screening for thyroid cancer in asymptomatic persons using neck palpation or ultrasound improves health outcomes. However, the USPSTF determined that the magnitude of benefit can be bounded as no greater than small, based on the relative rarity of thyroid cancer, the apparent lack of difference in outcomes between patients who are treated vs only monitored (i.e., for the most common tumor types), and the observational evidence demonstrating no change in mortality over time after introduction of a population-based screening program. The USPSTF found inadequate direct evidence to assess the harms of screening for thyroid cancer in asymptomatic persons. The USPSTF found adequate evidence to bound the magnitude of the overall harms of screening and treatment as at least moderate, based on adequate evidence of serious harms of treatment of thyroid cancer and evidence that overdiagnosis and overtreatment are likely consequences of screening. The USPSTF concludes with moderate certainty that screening for thyroid cancer in asymptomatic persons results in harms that outweigh the benefits. Editor's Note: Please see the article for additional information, including other authors, author contributions and affiliations, financial disclosures, funding and support, etc. Note: More information about the U.S. Preventive Services Task Force, its process, and its recommendations can be found on the newsroom page of its website. To place an electronic embedded link to this report in your story This link will be live at the embargo time: http://jamanetwork. Screening for Thyroid Cancer Updated Evidence Report and Systematic Review for the US Preventive Services Task Force Jennifer S. Lin, M.D., M.C.R., Kaiser Permanente Center for Health Research, Portland, Ore., and colleagues Editorial: How to Look for Thyroid Cancer Anne R. Cappola, M.D., Sc.M., University of Pennsylvania, Philadelphia; Associate Editor, JAMA Editorial: Cancer Screening, Overdiagnosis, and Regulatory Capture H. Gilbert Welch, M.D., M.P.H., Dartmouth Institute of Health Policy and Clinical Practice, Geisel School of Medicine, Hanover, N.H. Editorial: The USPSTF Recommendation on Thyroid Cancer Screening Louise Davies, M.D., M.S., Department of Veterans Affairs Medical Center, White River Junction, Vt., and Luc G. T. Morris, M.D., M.Sc., Memorial Sloan Kettering Cancer Center, New York Editorial: Striving for Clarity About the Best Approach to Thyroid Cancer Screening and Treatment Julie Ann Sosa, M.D., M.A., Duke University Medical Center, Durham, N.C., and colleagues
News Article | April 21, 2016
"He's basically looking for ... anything that would be out of the ordinary. A bag. A particular weapon. People acting erratic," says Aguirre, who suffers from post-traumatic stress disorder after three tours of duty in Iraq and one in Afghanistan. At the cash register, Aguirre says "Block," and the dog places himself perpendicular to his master, creating a buffer to anyone who might approach. Before Munger, a simple outing like this would have been terrifying, if not impossible. "He's put faith back into my way of looking at society," Aguirre says. But do the comfort and security this lovable dog provides come at the expense of true healing from PTSD? Is Munger merely preventing Aguirre from confronting his demons? Since 2002, the U.S. Department of Veterans Affairs has paid veterinary bills to veterans with guide or service dogs for physical disabilities. Now, the agency is in the midst of a $12 million study to gauge the efficacy and costs of using dogs to help those who suffer from post-traumatic stress. Four years in, that research has been plagued by problems. Only about 50 dogs have been placed with veterans, and critics question whether the protocol itself is flawed—with the dogs being trained to do things that could reinforce fears. Others worry the animals could become a substitute for the hard work that comes with therapy. "You will have the veterans go to more places with the dogs and do more things than they would otherwise do. But they are reliant on the dog, not on their knowledge of ... whether really they are afraid of a ghost," said Dr. Edna Foa, director of the Center for Treatment and Study of Anxiety at the University of Pennsylvania Perelman School of Medicine. More than 350,000 veterans of the Iraq and Afghanistan wars have sought help from the VA for PTSD. Yet the agency is authorized to pay only for "evidence-based" therapies such as cognitive processing and prolonged exposure, which involve having veterans confront and analyze traumatic events. In 2010, Congress permitted the VA to study alternative treatments for PTSD, including the therapeutic use of animals. The study began in late 2011 in Tampa, Florida, with three nonprofits contracted to provide up to 200 service dogs for veterans, who would be compared against a control group that did not receive dogs. The effort soon ran into trouble. The VA cut off two of the three dog vendors following biting incidents involving participants' children. The final contract was terminated in August 2012 amid allegations of lax veterinary care and placement of dogs "with known aggressive behavior," according to VA records. By then, only 17 dogs had been placed. During the next year and a half, the study protocol was revamped to exclude veterans with children under age 10. It also dropped the no-dog control in favor of a group that would receive less-specialized "emotional support dogs" whose "sole function is to provide comfort." Critics of the study object most strongly to the tasks the VA is requiring of the dogs—sweeping the perimeter of a room before a veteran enters, for example, or protecting the veteran by "blocking." "Isn't that saying that al-Qaida could be behind the shower curtain? That's supporting paranoid, pathological thinking," said Meg Daley Olmert, author of a book on how contact with a dog can create a sense of well-being. Olmert is chief research adviser for Warrior Canine Connection, a Maryland-based nonprofit that uses veterans to train service dogs for their fellows. The group's leaders say dogs should be trained to pick up on cues from PTSD sufferers and then provide the appropriate support, such as learning to wake someone up during a nightmare or detecting when a veteran is anxious, and interacting in a way that helps calm him. The VA's training protocol "reinforces the cognitive distortions that accompany PTSD," said Robert Koffman, a retired Navy psychiatrist and chief medical officer for Warrior Canine Connection. Rick Yount, executive director of the nonprofit, questioned whether the study had perhaps even been set up to fail so that the VA wouldn't have to pick up the tab for veterinary bills for psychiatric service dogs. Already the VA is on the hook for upward of $1.4 million a year to cover bills for service dogs for physical disabilities. Michael Fallon, the VA's chief veterinary medical officer, said the insinuation that money is the researchers' chief concern is "ludicrous." As for the training guidelines, he said the list of commands was developed during more than a year of consultation with mental-health experts, service dog providers and veterans. They help get veterans "out into the community and integrated more into the public life," he said. One dog trainer agreed, in part. David Cantara heads North Carolina-based Patriot Rovers, which trained Aguirre's dog and is not connected to the VA's study. While Cantara is opposed to using dogs to sweep rooms, he said the blocking command is one of the most vital to his veterans. "They startle very quickly. And knowing that they have that dog there, guarding their six as it were ... they're not in this constant hyper vigilant state," he said. The debate has highlighted an overall lack of standards in the service dog industry. Currently, the VA will only pay benefits for service dogs trained by an organization accredited by Assistance Dogs International, and that group is only now developing its own guidelines for the use of dogs for veterans with combat-related PTSD. Only one of the vendors supplying dogs for the VA study is ADI-accredited, and none has prior experience training animals for veterans with PTSD. Sheila O'Brien, chair of the steering committee drafting ADI's guidelines, said the group is studying other tasks in lieu of blocking and sweeping. Despite all the criticism, the VA's study, set to conclude in 2018, is chugging along—with more than 100 of an eventual 220 veterans enrolled, about half paired with dogs. Fallon said the only recent glitch was a vendor error that shipped out service dog vests for some support dogs, which don't have the same public access rights under the Americans with Disabilities Act. In November, the Kaiser Permanente Northwest Center for Health Research released the results of a study involving 78 veterans with PTSD. It found that those with animals had better overall mental health, less substance abuse and higher ratings on their interpersonal relationships. Researchers said, however, that "differences cannot be directly attributed to service dogs" and that more study is needed. U.S. Rep. Ron DeSantis recently introduced a bill that would take $10 million from the VA's budget to immediately begin pairing service dogs with post-9/11 veterans for whom traditional PTSD treatments hadn't worked. During a subcommittee hearing last week, Rory Diamond, executive director of the group K9s for Warriors, said the VA had "fumbled" its study, and that veterans can't afford to wait. As far as Joe Aguirre is concerned, the question of whether these dogs help has been answered. "I honestly feel without Munger in my life right now, I probably wouldn't be alive," he said of the dog named in honor of Spc. Joshua Munger of Maysville, Missouri, killed by an improvised explosive device near Baghdad in 2005. Patriot Rovers names all its support dogs after fallen service members. "It makes me feel like I've got a bond, knowing that he, like any other soldier that you have a bond with, would take a bullet for you. Would watch your back—and your front." Whatever the potential costs of providing these animals, Aguirre added, it's "nickels and dimes compared to the service we provided to our country." In this Thursday, April 14, 2016 photo, from left, Veterans Affairs Department Office of Research and Development Chief Veterinary Medical Officer Dr. Michael Fallon, K9s for Warriors Executive Directory Rory Diamond, military veteran Cole Lyle, who suffers with PTSD, accompanied by his dog Kaya, and Steve Feldman, Human Animal Bond Research Initiative (HARBI) Foundation Executive Director, are sworn-in on Capitol Hill in Washington, prior to testifying at the House National Security subcommittee hearing on "Connecting Veterans with PTSD with Service Dogs." (AP Photo/Pablo Martinez Monsivais) Explore further: Researcher examines impact of service dogs on returning vets
News Article | December 20, 2016
A new breast cancer model, published today in the Journal of the National Cancer Institute, will help health care providers more accurately predict breast cancer risk in their Hispanic patients. The model, developed by a Kaiser Permanente researcher and his colleagues, is the first to be based exclusively on data from Hispanic women, and will become part of the National Cancer Institute's online tool that helps providers calculate breast cancer risk in individual patients. "Hispanics are the largest racial/ethnic minority group in the U.S., so it's important that the NCI tool include information from these women in determining their risk score. Our model does that because it is based on data from Hispanic women and specifically tailored for them," said Matthew P. Banegas, PhD, MPH, lead author and researcher from the Kaiser Permanente Center for Health Research. NCI's Breast Cancer Risk Assessment Tool asks providers to enter information about the patient's age, race, family history of breast cancer and other risk factors, including: The Breast Cancer Risk Assessment Tool currently includes risk models for non-Hispanic white, African-American and Asian and Pacific Islander women, but no model specific to Hispanic women, and studies show that the tool underestimates breast cancer risk in these women. "Prior studies have shown that Hispanic women born in the U.S. have a higher breast cancer risk than Hispanic women who emigrate here from other countries," said Banegas. "Our model includes data from U.S. and foreign-born women, so providers will be able to more accurately predict risk based on where the woman was born." To build the model, researchers started with data from the San Francisco Bay Area Breast Cancer Study, which included 1,086 Hispanic women who developed breast cancer between 1995 and 2002 and 1,411 women who did not have breast cancer. Nearly 1,000 of the women were born in the United States and 1,500 were born in other countries. The researchers then included breast cancer incidence and mortality data from the California Cancer Registry and NCI's Surveillance, Epidemiology and End Results program. To validate their model, researchers used data from the Women's Health Initiative and the Four-Corners Breast Cancer Study. The new model accurately predicted the number of breast cancers among U.S.-born Hispanic women who participated in the Women's Health Initiative, but slightly overestimated the number of breast cancers among foreign-born Hispanic women in the WHI. "We built the model using data from Hispanic women in California who are mostly of Mexican and Central American descent, so these are the women for whom the model will be most accurate," said Banegas. "As we collect more data on Hispanic women from other regions and countries, we will be able to further refine the model." The new model, like the National Cancer Institute's Breast Cancer Risk Assessment Tool, should not be used for women who already have invasive breast cancer, for women who have an inherited genetic mutation known to cause breast cancer, or for women who received therapeutic radiation of the chest for other types of cancers. This study was supported by the Intramural Research Program of the National Cancer Institute, National Institutes of Health. Other authors include: Esther M. John PhD, MSPH, and Scarlett Lin Gomez, PhD, MPH, Cancer Prevention Institute of California and the Department of Health Research and Policy at the Stanford Cancer Institute; Martha L. Slattery, PhD, MPH, University of Utah Department of Medicine; Mandi Yu, PhD, Division of Cancer Control and Population Sciences, National Cancer Institute; Andrea LaCroix, PhD, Family and Preventive Medicine, University of California, San Diego; David Pee, MPhil, Information Management Services; Rowan T. Chlebowski, MD, PhD, Los Angeles Biomedical Research Institute, Harbor-UCLA Medical Center; Lisa Hines, ScD, Department of Biology, University of Colorado Colorado Springs; Cynthia Thompson, PhD, RD, Mel and Enid Zuckerman College of Public Health, University of Arizona; and Mitchell Gail, MD, PhD, Division of Cancer Epidemiology and Genetics, National Cancer Institute. About the Kaiser Permanente Center for Health Research The Kaiser Permanente Center for Health Research, founded in 1964, is a nonprofit research institution dedicated to advancing knowledge to improve health. It has research sites in Portland, Oregon and Honolulu. Visit kpchr.org for more information. Kaiser Permanente is committed to helping shape the future of health care. We are recognized as one of America's leading health care providers and not-for-profit health plans. Founded in 1945, Kaiser Permanente has a mission to provide high-quality, affordable health care services and to improve the health of our members and the communities we serve. We currently serve more than 10.6 million members in eight states and the District of Columbia. Care for members and patients is focused on their total health and guided by their personal physicians, specialists and team of caregivers. Our expert and caring medical teams are empowered and supported by industry-leading technology advances and tools for health promotion, disease prevention, state-of-the-art care delivery and world-class chronic disease management. Kaiser Permanente is dedicated to care innovations, clinical research, health education and the support of community health. For more information, go to: kp.org/share.
News Article | October 26, 2016
A newly published study of people with chronic obstructive pulmonary disease (COPD) concludes that long-term supplemental oxygen treatment results in little or no change in time to death, time to first hospitalizations or significant quality of life improvements for those with moderately low blood oxygen levels. The findings, published in the New England Journal of Medicine on Oct. 27, are based on research examining oxygen treatment outcomes in 738 COPD patients with moderately low blood oxygen levels at 42 clinical centers in the United States. The study began in 2009 and ended in 2015. Patients who received supplemental oxygen over the course of the study showed no significant differences in rate of hospitalizations, time to death after diagnosis, exercise capacity or quality of life when compared to patients who did not receive supplemental oxygen. The results of the study, believed by the investigators to be the largest of its kind to date, show that most people with moderately low blood oxygen levels do not receive the same benefits from long-term oxygen therapy as COPD patients with severely low blood oxygen levels. "The benefits of long-term oxygen supplements for COPD patients with severe oxygen deficiency are clear," says Robert Wise, M.D., professor of medicine in the Johns Hopkins University School of Medicine's Division of Pulmonary and Critical Care Medicine and the paper's corresponding author. "However, it's never been established what benefits, if any, exist for patients with less severe oxygen deficiency." For the study, moderate oxygen deficiency was defined as having a blood oxygen saturation between 89 and 93 percent at rest, or a blood oxygen saturation below 90 percent during a six-minute walk test. A normal blood oxygen saturation level is generally defined as between 94 and 99 percent. Blood oxygen saturation levels are a measure of oxygen-carrying hemoglobin in circulating blood and a marker of lung function, and low levels are a hallmark of people with COPD. To examine the benefits of supplemental oxygen, the researchers studied two types of COPD patients: those who suffered from moderate oxygen deficiency while resting, and those who suffered from moderate oxygen deficiency only during exercise. Some 133 patients had resting oxygen deficiency, 319 had only exercise-induced oxygen deficiency and 268 had both. Participants in each of the two groups were randomly assigned to get supplemental oxygen or no supplemental oxygen at the start of the study, and all visited clinics annually for follow-up examinations that included oxygen levels at rest and exercise, oxygen use, respiratory symptoms and quality of life. All participants also completed telephone interviews biannually and completed mailed questionnaires regarding symptoms and health care use at four and 16 months. Of the 738 total patients studied with moderate oxygen deficiency, 368 received supplemental oxygen, and 370 did not. Wise says the primary outcomes measured -- time to death or time to first hospitalization -- were essentially the same in both groups. The risk of death in the no-oxygen group was 5.7 percent per year, compared to 5.2 percent per year for the oxygen group. Overall, the risk of death or hospitalization was not different between the two treatment groups. The researchers also found no significant differences between the oxygen treatment and non-oxygen treatment groups in all hospitalization rates; COPD exacerbations, defined as sudden worsening of COPD symptoms, such as shortness of breath and phlegm production that lasts for several days; self-reported quality of life; lung function; or measures of walk distance. Even when researchers controlled for variables such as total hours of oxygen use, race, sex and smoking status, no significant differences in the primary outcomes arose, Wise says. "No matter what measure we looked at, it made no apparent difference whether a patient with moderate oxygen deficiency received long-term oxygen treatments or not. I think the evidence is strong and shows that some patients may not need those treatments at all," says Wise. Wise cautioned that "we don't want to imply that everyone with COPD now using oxygen should stop; some individual patients may find that they can do more activities or have more effective exercise training if they use oxygen. Every patient should discuss his or her specific needs with his or her health care provider, but the data show, very clearly, that for many COPD patients with moderately low blood oxygen levels, supplemental oxygen won't help you live any longer or keep you out of the hospital." Supplemental oxygen therapy can be considered burdensome and expensive for many. From 2009 to 2011, Medicare reimbursements for oxygen-related costs for COPD patients exceeded $2 billion per year. Supplemental oxygen therapy requires those using it to carry or cart around heavy and bulky oxygen delivery equipment, sometimes resulting in adverse events, such as tripping over equipment or the start of fires. According to the COPD Foundation, an estimated 24 million people in the U.S. suffer from COPD, and it is the third leading cause of death in the nation. Other authors on this study include Amanda L. Blackford, David Shade, James Tonascia and Alice L. Sternberg of The Johns Hopkins University; Richard K. Albert of the University of Colorado at Denver; Richard Casaburi of the University of California at Los Angeles Medical Center; Allen Cooper Jr. of the Birmingham Veterans Administration Medical Center; Gerard J. Criner of the Lewis Katz School of Medicine at Temple University; Philip Diaz of Ohio State University; Anne L. Fuhlbrigge of Brigham and Women's Hospital; Steven E. Gay of the University of Michigan; Richard E. Kanner of the University of Utah Health Sciences Center; Neil MacIntyre of the Duke University Medical Center; Fernando J. Martinez of the Weill Cornell Medical Center; Ralph J. Panos of Cincinnati Veterans Administration Medical Center; Steven Piantadosi of the Cedars-Sinai Medical Center; Frank Sciurba of the University of Pittsburgh; Thomas Stibolt of the Kaiser Permanente Center for Health Research; Roger D. Yusen of the Washington University School of Medicine; and William Bailey of the University of Alabama. This study was funded by the National Heart, Lung, and Blood Institute of the National Institutes of Health (HHSN268200736183C, HHSN268200736184C, HHSN268200736185C, HHSN268200736186C, HHSN268200736187C, HHSN268200736188C, HHSN268200736189C, HHSN268200736190C, HHSN268200736191C, HHSN268200736192C, HHSN268200736193C, HHSN268200736194C, HHSN268200736195C, HHSN268200736196C, HHSN268200736197C, Y1-HR-7019-01, Y1-HR-8076-01) in cooperation with the Centers for Medicare and Medicaid Services.
Elder C.,Center for Health Research
The Permanente journal | Year: 2012
Participants in a randomized trial of traditional Chinese medicine (TCM) for temporomandibular joint dysfunction (TMD) had a linear decline in pain over 16 TCM visits. To investigate whether reductions in pain among participants receiving TCM can be explained by increased use of pain medications, or whether use of pain medications also declined in this group. One hundred sixty-eight participants with TMD were treated with TCM or enhanced self-care according to a stepped-care design. Those for whom self-care failed were sequentially randomized to further self-care or TCM. This report includes 111 participants during their first 16 TCM visits. The initial 8 visits occurred more than once a week; participants and practitioners determined the frequency of subsequent visits.Outcome measures: Average pain (visual analog scale, range 0-10) and morphine and aspirin dose equivalents. The sample was 87% women and the average age was 44 ± 13 years. Average pain of narcotics users (n = 21) improved by 2.73 units over 16 visits (p < 0.001). Overall narcotics use trended downward until visit 11 (-3.27 doses/week, p = 0.156), and then trended upward until week 16 (+4.29 doses/week, p = 0.264). Among those using narcotics, use of nonsteroidal anti-inflammatory drugs (NSAIDs) declined linearly over visits 1-16 (-1.94 doses/week, p = 0.002).Among the top quartile of NSAID-only users (n = 22), average pain decreased linearly over 16 visits (-1.52 units, p = 0.036). Overall NSAID doses/week declined between visits 1 and 7 (-9.95 doses/week, p < 0.001) and then remained stable through 16 visits. NSAID use also declined among the third quartile (n = 23) and remained low and stable among the lower half (sorted by total intake) of NSAID users. Among the heaviest NSAID users, we observed a short-term reduction in NSAID use that was sustained as TCM visits became less frequent. There was no indication that pain reduction during TCM treatment was influenced by drug use.
Bucaloiu I.D.,Geisinger Medical Center |
Kirchner H.L.,Biostatistics and Research Data Core |
Norfolk E.R.,Geisinger Medical Center |
Hartle J.E.,Geisinger Medical Center |
And 2 more authors.
Kidney International | Year: 2012
Acute kidney injury increases mortality risk among those with established chronic kidney disease. In this study we used a propensity score-matched cohort method to retrospectively evaluate the risks of death and de novo chronic kidney disease after reversible, hospital-associated acute kidney injury among patients with normal pre-hospitalization kidney function. Of 30,207 discharged patients alive at 90 days, 1610 with reversible acute kidney injury that resolved within the 90 days were successfully matched across multiple parameters with 3652 control patients who had not experienced acute kidney injury. Median follow-up was 3.3 and 3.4 years (injured and control groups, respectively). In Cox proportional hazard models, the risk of death associated with reversible acute kidney injury was significant (hazard ratio 1.50); however, adjustment for the development of chronic kidney injury during follow-up attenuated this risk (hazard ratio 1.18). Reversible acute kidney injury was associated with a significant risk of de novo chronic kidney disease (hazard ratio 1.91). Thus, a resolved episode of hospital-associated acute kidney injury has important implications for the longitudinal surveillance of patients without preexisting, clinically evident kidney disease. © 2012 International Society of Nephrology.
Nichols G.A.,Kaiser Permanente |
Nichols G.A.,Center for Health Research |
Joshua-Gotlib S.,Astrazeneca |
Journal of General Internal Medicine | Year: 2013
Background: Cardiovascular disease (CVD) prevention in diabetes requires broad-based treatment of dyslipidemia, hypertension, and hyperglycemia. The independent contribution of all combinations of risk factor control to CVD risk has not been evaluated. Objective: To estimate the independent association of control of glycosylated hemoglobin (A1C), systolic blood pressure (SBP), and low-density lipoprotein cholesterol (LDL-C) with risk of cardiovascular disease hospitalization. Design: Non-concurrent longitudinal cohort study. Patients: The study included 26,636 patients with type 2 diabetes who were members of an integrated group model HMO with multiple A1C, SBP, and LDL-C measurements. Main Measures: Patients were followed for a mean (SD) of 5.6 (2.5) years until they died or disenrolled, or until 31 December 2010. The outcome was a firstobserved CVD hospitalization. Using the mean of all A1C, SBP, and LDL-C measures during follow-up, we created dichotomous categories of A1C control (7 %), SBP control (130 mmHg), and LDL-C control (100 mg/dL) to estimate the incidence rate of CVD hospitalization associated with all combinations of risk factor control adjusting for demographic and clinical characteristics. Key Results: Patients with no controlled risk factors (18.2/1,000 person-years, 95 % CI 16.5-20.2) or with only A1C in control (16.9, 15.0-19.0) had the highest rate of CVD hospitalization, whereas those with all three risk factors controlled (7.2, 6.2-8.4) or with SBP and LDL-C in control (6.1, 5.1-7.2) had the lowest rates. Those with only SBP or LDL-C in control, A1C and SBP controlled, or A1C and LDL-C controlled had statistically similar incidence between the highest and lowest rates. Conclusions: Maintaining SBP 130 mmHg or LDLC 100 mg/dL was significantly associated with reduced CVD hospitalization risk, especially when both risk factors were well controlled. Maintaining A1C 7 % was not independently associated with reduced CVD hospitalization risk. © Society of General Internal Medicine 2012.
Lynch F.L.,Center for Health Research
American Journal of Preventive Medicine | Year: 2014
Background: Suicide is a leading cause of death in the U.S. and results in immense suffering and significant cost. Effective suicide prevention interventions could reduce this burden, but policy makers need estimates of health outcomes achieved by alternative interventions to focus implementation efforts. Purpose: To illustrate the utility of health outcome models to help in achieving goals defined by the National Action Alliance for Suicide Prevention's Research Prioritization Task Force. The approach is illustrated specifically with psychotherapeutic interventions to prevent suicide reattempt in emergency department settings. Methods: A health outcome model using decision analysis with secondary data was applied to estimate suicide attempts and deaths averted from evidence-based interventions. Results: Under optimal conditions, the model estimated that over 1 year, implementing evidence-based psychotherapeutic interventions in emergency departments could decrease the number of suicide attempts by 18,737, and if offered over 5 years, it could avert 109,306 attempts. Over 1 year, the model estimated 2,498 fewer deaths from suicide, and over 5 years, about 13,928 fewer suicide deaths. Conclusions: Health outcome models could aid in suicide prevention policy by helping focus implementation efforts. Further research developing more sophisticated models of the impact of suicide prevention interventions that include a more complex understanding of suicidal behavior, longer time frames, and inclusion of additional outcomes that capture the full benefits and costs of interventions would be helpful next steps. © 2014 American Journal of Preventive Medicine.
News Article | November 3, 2016
Radiance Planner, a complete nutrition and health diary and planner, has been released. The dietary journal helps users track all aspects of their daily routine and diet to help them customize their routine to their individual body’s system. More information on Radiance Planner is available at: https://www.amazon.com/dp/product/B01FTGIDHQ Studies show that keeping a food diary can double a person’s weight loss according to Science Daily. The best predictors of weight loss were how frequently food diaries were kept and how many support sessions participants attended the study reports. People who kept daily food records lost twice as much weight as those who kept no records. The simple act of a person writing down what they eat encourages them to consume fewer calories according Jack Hollis Ph.D., a researcher at Kaiser Permanente’s Center for Health Research in Portland, Oregon. The Kaiser Permanente Care Management Institute’s Weight Management Initiative recommends food journaling as a strategy for losing weight. The Initiative unites clinicians, researchers, insurers and policymakers in identifying practical, effective, non-surgical approaches for the prevention and treatment of overweight and obesity. Radiance Planner offers people a new way to track their diet and lifestyle habits. It helps users raise their awareness about food, happiness and success with by offering methods of tracking all aspects of not only their daily diet, but their routines and habits as well. The planner focuses on the number one priority for most people, their health and well being. It does not consist of dieting or strict regimes, but its goal is to generate a general and better understanding of how and why a person feels vibrant one day, full of energy and drive, and wake up the next day feeling drained and listless lacking a spark. Radiance Planner was designed according to the fact that each individual is unique, and each approach to acquiring a firm grip on their well-being must be unique, too. It helps users track and see what they are missing in their daily routines including meals, hours of sleep and energy levels and guides them on how to plan their days ahead. The planner includes charts for visual assistance and tracking for Complete Protein Foods, Good and Bad Fats, Gluten Free Foods, Ketogenic Diet Foods, Acupressure and Reflexology, Aromatherapy, Moon Calendar, Yin-Yang Juicing and Food Combining. More information on the Radiance Planner is available at the website listed above. For more information, please visit http://radianceplanner.com