Center for Health Studies

Seattle, WA, United States

Center for Health Studies

Seattle, WA, United States
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Patel V.,London School of Hygiene and Tropical Medicine | Patel V.,Sangath Center | Weiss H.A.,Medical Research Council Tropical Epidemiology Group | Chowdhary N.,Sangath Center | And 10 more authors.
The Lancet | Year: 2010

Background Depression and anxiety disorders are common mental disorders worldwide. The MANAS trial aimed to test the eff ectiveness of an intervention led by lay health counsellors in primary care settings to improve outcomes of people with these disorders. Methods In this cluster randomised trial, primary care facilities in Goa, India, were assigned (1:1) by computergenerated randomised sequence to intervention or control (enhanced usual care) groups. All adults who screened positive for common mental disorders were eligible. The collaborative stepped-care intervention off ered case management and psychosocial interventions, provided by a trained lay health counsellor, supplemented by antidepressant drugs by the primary care physician and supervision by a mental health specialist. The research assessor was masked. The primary outcome was recovery from common mental disorders as defi ned by the International Statistical Classifi cation of Diseases and Related Health Problems-10th revision (ICD-10) at 6 months. This study is registered with ClinicalTrials.gov, number NCT00446407. Findings 24 study clusters, with an equal proportion of public and private facilities, were randomised equally between groups. 1160 of 1360 (85%) patients in the intervention group and 1269 of 1436 (88%) in the control group completed the outcome assessment. Patients with ICD-10-confi rmed common mental disorders in the intervention group were more likely to have recovered at 6 months than were those in the control group (n=620 [65•0%] vs 553 [52•9%]; risk ratio 1•22, 95% CI 1•00-1•47; risk diff erence=12•1%, 95% CI 1•6%-22•5%). The intervention had strong evidence of an eff ect in public facility attenders (369 [65•9%] vs 267 [42•5%], risk ratio 1•55, 95% CI 1•02-2•35) but no evidence for an eff ect in private facility attenders (251 [64•1%] vs 286 [65•9%], risk ratio 0•95, 0•74-1•22). There were three deaths and four suicide attempts in the collaborative stepped-care group and six deaths and six suicide attempts in the enhanced usual care group. None of the deaths were from suicide. Interpretation A trained lay counsellor-led collaborative care intervention can lead to an improvement in recovery from CMD among patients attending public primary care facilities. Funding The Wellcome Trust. © 2010 Elsevier Ltd.


Ogale S.S.,University of Washington | Ogale S.S.,Genentech | Lee T.A.,Hines Veterans Administration Hospital | Lee T.A.,University of Illinois at Chicago | And 3 more authors.
Chest | Year: 2010

Background: Studies have suggested an increased risk of cardiovascular morbidity and mortality associated with the use of ipratropium bromide. We sought to examine the association between ipratropium bromide use and the risk of cardiovascular events (CVEs). Methods: We performed a cohort study of 82,717 US veterans with a new diagnosis of COPD between 1999 and 2002. Subjects were followed until they had their first hospitalization for a CVE (acute coronary syndrome, heart failure, or cardiac dysrhythmia), they died, or the end of the study period (September 30, 2004). Cumulative anticholinergic exposure was calculated as the number of 30-day equivalents (ipratropium bromide) within the past year. We used Cox regression models with time-dependent covariates to estimate the risk of CVE associated with anticholinergic exposure and to adjust for potential confounders, including markers of COPD severity and cardiovascular risk. Results: We identified 6,234 CVEs (44% heart failure, 28% acute coronary syndrome, 28% dysrhythmia). Compared with subjects not exposed to anticholinergics within the past year, any exposure to anticholinergics within the past 6 months was associated with an increased risk of CVE (hazard ratio [95% CI] for ≤ four and > four 30-day equivalents: 1.40 [1.30-1.51] and 1.23 [1.13-1.36], respectively). Among subjects who received anticholinergics more than 6 months prior, there did not appear to be elevated risk of a CVE. Conclusions: We found an increased risk of CVEs associated with the use of ipratropium bromide within the past 6 months. These findings are consistent with previous concerns raised about the cardiovascular safety of ipratropium bromide. © 2010 American College of Chest Physicians.


Leveille S.G.,Beth Israel Deaconess Medical Center | Leveille S.G.,University of Massachusetts Boston | Walker J.,Beth Israel Deaconess Medical Center | Ralston J.D.,Center for Health Studies | And 3 more authors.
BMC Medical Informatics and Decision Making | Year: 2012

Background: Providers and policymakers are pursuing strategies to increase patient engagement in health care. Increasingly, online sections of medical records are viewable by patients though seldom are clinicians' visit notes included. We designed a one-year multi-site trial of online patient accessible office visit notes, OpenNotes. We hypothesized that patients and primary care physicians (PCPs) would want it to continue and that OpenNotes would not lead to significant disruptions to doctors' practices. Methods/Design. Using a mixed methods approach, we designed a quasi-experimental study in 3 diverse healthcare systems in Boston, Pennsylvania, and Seattle. Two sites had existing patient internet portals; the third used an experimental portal. We targeted 3 key areas where we hypothesized the greatest impacts: beliefs and attitudes about OpenNotes, use of the patient internet portals, and patient-doctor communication. PCPs in the 3 sites were invited to participate in the intervention. Patients who were registered portal users of participating PCPs were given access to their PCPs' visit notes for one year. PCPs who declined participation in the intervention and their patients served as the comparison groups for the study. We applied the RE-AIM framework to our design in order to capture as comprehensive a picture as possible of the impact of OpenNotes. We developed pre- and post-intervention surveys for online administration addressing attitudes and experiences based on interviews and focus groups with patients and doctors. In addition, we tracked use of the internet portals before and during the intervention. Results: PCP participation varied from 19% to 87% across the 3 sites; a total of 114 PCPs enrolled in the intervention with their 22,000 patients who were registered portal users. Approximately 40% of intervention and non-intervention patients at the 3 sites responded to the online survey, yielding a total of approximately 38,000 patient surveys. Discussion. Many primary care physicians were willing to participate in this "real world" experiment testing the impact of OpenNotes on their patients and their practices. Results from this trial will inform providers, policy makers, and patients who contemplate such changes at a time of exploding interest in transparency, patient safety, and improving the quality of care. © 2012 Leveille et al; licensee BioMed Central Ltd.


Simon G.E.,Center for Health Studies | Imel Z.E.,University of Utah | Ludman E.J.,Group Health Research Institute | Steinfeld B.J.,Behavioral Health Services
Psychiatric Services | Year: 2012

Objective: The authors compared outcomes reported by patients who did or did not return for treatment after an initial psychotherapy visit. Methods: Members of a group health plan were surveyed about initial psychotherapy visits occurring between March and September 2010. The survey assessed satisfaction with care and therapeutic alliance during the visit and later clinical improvement. Results: Of the 2,666 members who returned surveys, 906 (34%) did not return for a second visit within 45 days. The distribution of satisfaction, therapeutic alliance, and self-rated improvement scores between patients who did and did not return differed significantly (p<.001). Patients who did not return were more likely to report the most favorable and the least favorable outcomes. Conclusions: Failure to return after an initial psychotherapy visit can represent successful and satisfying treatment. Systematic outreach and outcome assessment are necessary to identify the patients who drop out of therapy after unsuccessful and unsatisfying treatment.


Garrison M.M.,Seattle Childrens Research Institute | Lozano P.,Seattle Childrens Research Institute | Lozano P.,University of Washington | Lozano P.,Center for Health Studies | And 2 more authors.
Archives of Pediatrics and Adolescent Medicine | Year: 2011

Objective: To determine the effect of asthma controller medication use, choice, and adherence on sleep in children with asthma. Design: A case-crossover analysis examining withinsubject differences in controller use between time points with and without sleep problems, based on survey data from 3 time points (baseline, 6 months, and 1 year) of a randomized trial. Setting: Families were recruited from 2 area practice networks; all assessments were completed by parents online. Participants: Children with asthma, aged 2 to 10 years, as identified by asthma-related medical encounters and prescription fills. Main Exposures: Parent report of asthma controller medication use (yes/no), type (inhaled corticosteroid or leukotriene inhibitor), and adherence (daily use, nonadherent use, or nonuse). Main Outcome Measures: Children's sleep problems, as defined by parent report regarding how often the child had difficulty falling asleep or experienced daytime sleepiness. Results: The analysis included 482 children; 82.6% and 75.9% completed the 6-month and 1-year follow-up visits, respectively. Sleep problems were common, with 19.4% of parents at baseline reporting frequent problems with the child falling asleep and 12.1% reporting frequent daytime sleepiness. Compared with children who did not use a controller medication, children had a decreased risk of problems falling asleep during periods with daily controller use (odds ratio [OR],0.34; 95% confidence interval [CI], 0.13-0.92), with a trend toward an effect in those with nonadherent use (0.47; 0.20-1.12). Any controller use, regardless of adherence, was also associated with decreased odds of daytime sleepiness (OR,0.69; 95% CI, 0.51-0.94). When controller class was examined, leukotriene inhibitors were associated with significantly decreased odds of problems falling asleep (OR,0.18; 95% CI, 0.04-0.78), with or without concomitant use of inhaled corticosteroids, but the results for use of inhaled corticosteroids alone were not statistically significant (0.69; 0.32-1.53). Conclusions: Controller medications appear to be effective in reducing sleep problems in children with asthma, and leukotriene inhibitor medications may be especially effective in this population. ©2011 American Medical Association. All rights reserved.


Dunivan G.C.,University of North Carolina at Chapel Hill | Heymen S.,University of North Carolina at Chapel Hill | Palsson O.S.,University of North Carolina at Chapel Hill | von Korff M.,Center for Health Studies | And 3 more authors.
American Journal of Obstetrics and Gynecology | Year: 2010

Objective: We sought to estimate the frequency of self-reported fecal incontinence (FI), identify what proportion of these patients have a diagnosis of FI in their medical record, and compare health care costs and utilization in patients with different severities of FI to those without FI. Study Design: Patients in a health maintenance organization were eligible and 1707 completed a survey. Patients with self-reported FI were assessed for a diagnosis of FI in their medical record for the last 5 years. Health care costs and utilization were obtained from claims data. Results: FI was reported by 36.2% of primary care patients, but only 2.7% of patients with FI had a medical diagnosis. FI adversely affected quality of life and severe FI was associated with 55% higher health care costs (including 77% higher gastrointestinal-related health care costs) compared to continent patients. Conclusion: Increased screening of FI is needed. © 2010 Mosby, Inc. All rights reserved.


Sinclair K.A.,University of Hawaii at Manoa | Bogart A.,Center for Health Studies | Buchwald D.,University of Washington | Henderson J.A.,Black Hills Center for American Indian Health
Diabetes Care | Year: 2011

OBJECTIVE - To estimate the prevalence of metabolic syndrome by age, sex, and diabetes status in Northern Plains and Southwest American Indians. RESEARCH DESIGN AND METHODS - Data for this analysis came from the Education and Research Toward Health (EARTH) study, a 5-year cross-sectional study of Southwest and Northern Plains American Indian adults. The National Cholesterol Education Program's Adult Treatment Panel III (NCEP/ATP III) guidelines were used to identify adults with metabolic syndrome. RESULTS - The age-adjusted prevalence of the metabolic syndrome was 49.8% among 4,457 participants aged 18-88 years. Age-adjusted prevalence was 42.4% for participants without diabetes and 86.6% for participants with diabetes. In participants aged <40 years, the overall prevalence of metabolic syndrome was 53.1%; 44.9% after excluding individuals with diabetes. CONCLUSIONS - This study confirms a high prevalence of the metabolic syndrome among Northern Plains and Southwest American Indians of all ages. © 2011 by the American Diabetes Association.


Baumann M.,University of Luxembourg | Couffignal S.,Center for Health Studies | Le Bihan E.,University of Luxembourg | Chau N.,University of Paris Descartes
BMC Neurology | Year: 2012

Background: Life satisfaction (LS) of cerebrovascular disease survivors and their family caregivers may relate to socioeconomic factors, impaired functions, health-related quality of life (QoL), but their respective influences remain unclear. This study assessed, two years post-stroke onset, the effects of these factors on patients' LS and family caregivers' LS in Luxembourg.Methods: All stroke patients admitted to all hospitals in Luxembourg were identified by the 'Inspection Général de la Sécurité Sociale' using the only national system database for care expenditure reimbursement. Their diagnosis was confirmed by medical investigator. The sample included ninety four patients living at home having given consent (mean age 65.5 years) and sixty two main caregivers (mean age 59.3 years). Questionnaires were completed during face-to-face interviews. LS was assessed via European single question (range 1-10), survivors' QoL via Newsqol (11 dimensions), and caregivers' QoL via Whoqol-bref (4 domains) (range 0-100). Data were analysed using multiple regression models.Results: Two years after stroke onset, 44.7% of patients suffered from impaired sensory function, 35.1% from impaired motor function, and 31.9% from impaired memory function. Mean patient' LS was 7.1/10 (SD 1.9). It was higher in women (+12.4) and lower among unemployed socioeconomically active patients (-13.1, vs. retired people). Adjusted for sex, occupation, impaired motor and memory functions, LS positively correlated with scores of Newsqol feelings, sleep, emotion, cognition and pain dimensions (slopes 0.20 to 0.31), but did not correlate with those of caregivers' Whoqol-bref domains. Family caregiver' LS was 7.2 (SD 1.7). It was lower in those with patients suffering from impaired memory function (-12.8) as well as from feelings and emotion issues (slopes 0.22). It was associated with all caregivers' Whoqol-bref domains (physical health, psychological health, environment, and social relationships) (slopes 0.53 to 0.68).Conclusions: Two-year post-cerebrovascular disease patient' LS was associated with gender, occupation, and impaired memory function. It correlated with feelings, sleep, emotion, cognition, and pain issues. Family caregivers of patients with impaired memory function had lower LS. Family caregiver' LS correlated with dimensions of patients' feelings (less independent, yourself, life changed, depressed, useless, less control because of stroke) and emotion (get more emotional, fear of another stroke or to become dependent on others), and with their own QoL. LS, Newsqol, and Whoqol appeared to be appropriate tools. Our findings may be useful for policy makers in relation to family and medical-social issues of stroke home-based rehabilitation. © 2012 Baumann et al.; licensee BioMed Central Ltd.


O'Beirne M.,University of Calgary | Sterling P.,University of Calgary | Reid R.,Center for Health Studies | Tink W.,University of Calgary | And 2 more authors.
Quality and Safety in Health Care | Year: 2010

Objective To determine the required components for developing the reporting components of a safety learning system (SLS) for community-based family practice. Methods Multiple databases were searched for all languages for all types of papers related to medical safety in community practice: Books@Ovid, BIOSIS Previews, CDSR, ACP Journal Club, DARE, CCTR, Ageline, AMED, CINAHL, EMBASE, HealthSTAR, Ovid MEDLINE In-Process, Other Non-Indexed Citations, Ovid MEDLINE, PsycINFO, HAPI and PsycBOOKS. A grey literature search was done in Google. Results The online search identified 190 papers. English abstracts were read and the full papers (or chapters) were retrieved for 90, of which 18 were deemed appropriate. The grey literature search revealed 18 additional papers, and an additional 12 papers were identified from bibliographies of included papers. The common themes identified from the articles became the main consideration for developing an SLS for family practice and include current and past initiatives, system design, incident reporting form and classification system. Conclusion There is a small but growing body of literature concerning the requirements for developing the reporting component of an SLS for family practice. For the reporting component of an SLS to be successful, there needs to be strong leadership, voluntary reporting, legal protection and feedback to reporters.


Pransky G.,Liberty Mutual Research Institute for Safety | Young A.E.,Liberty Mutual Research Institute for Safety | Cherkin D.C.,Center for Health Studies
Spine | Year: 2011

Study Design. Synthesis and analysis of presentation and discussion highlights, with a focus on emerging trends and promising new directions in primary care research on low back pain (LBP). Objective. To present a summary of findings, themes, and insights from the Tenth International Forum on Primary Care Research on Low Back Pain, a meeting of researchers designed to share the latest concepts, methods, and results of research on LBP diagnosis, treatment, and disability prevention. Summary of Background Data. Earlier Forum meetings have developed several common themes and general conclusions. These are contrasted with the presentations and discussions at the 10th International Forum. Results. Major themes included concerns about the epidemic of chronic, disabling LBP, associated treatments, iatrogenesis, and the "LBP medical industrial complex"; the variability and complexity of outcomes and how their importance differed across patients in defining recovery and recurrence; the power of nonspecific effects, expectations, and therapeutic alliance; and the challenges of identifying important therapeutic subgroups. New research addressed early risk factor screening and linked intervention, nonmedical approaches to reframe the LBP problem and avoid unnecessary care, cognitive and behavioral aspects of LBP, and ways to train clinicians to implement these innovations. More appropriate use of longitudinal designs and a greater focus on implementation research was called for. Conclusion. Although the field of primary care LBP research often seems to progress slowly, the Forum highlighted several important, promising developments that could substantially improve LBP research and primary care practice. © 2011, Lippincott Williams & Wilkins.

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