Center for Management of Complex Chronic Care

Hines, IL, United States

Center for Management of Complex Chronic Care

Hines, IL, United States
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Al-Aly Z.,Saint Louis Veterans Affairs Medical Center | Al-Aly Z.,Saint Louis Veterans Affairs Clinical Research and Epidemiology Center | Zeringue A.,Saint Louis Veterans Affairs Clinical Research and Epidemiology Center | Fu J.,Saint Louis Veterans Affairs Clinical Research and Epidemiology Center | And 10 more authors.
Journal of the American Society of Nephrology | Year: 2010

The effect of rate of decline of kidney function on risk for death is not well understood. Using the Department of Veterans Affairs national databases, we retrospectively studied a cohort of 4171 patients who had rheumatoid arthritis and early stage 3 chronic kidney disease (CKD; estimated GFR 45 to 60 ml/min) and followed them longitudinally to characterize predictors of disease progression and the effect of rate of kidney function decline on mortality. After a median of 2.6 years, 1604 (38%) maintained stable kidney function; 426 (10%), 1147 (28%), and 994 (24%) experienced mild, moderate, and severe progression of CKD, respectively (defined as estimated GFR decline of 0 to 1, 1 to 4, and >4 ml/min per yr). Peripheral artery disease predicted moderate progression of CKD progression. Black race, hypertension, diabetes, cardiovascular disease, and peripheral artery disease predicted severe progression of CKD. After a median of 5.7 years, patients with severe progression had a significantly increased risk for mortality (hazard ratio 1.54; 95% confidence interval 1.30 to 1.82) compared with those with mild progression; patients with moderate progression exhibited a similar trend (hazard ratio 1.10; 95% confidence interval 0.98 to 1.30). Our results demonstrate an independent and graded association between the rate of kidney function decline and mortality. Incorporating the rate of decline into the definition of CKD may transform a static definition into a dynamic one that more accurately describes the potential consequences of the disease for an individual. Copyright © 2010 by the American Society of Nephrology.

Follett K.A.,Iowa City Veterans Affairs Medical Center | Follett K.A.,University of Nebraska Medical Center | Weaver F.M.,Center for Management of Complex Chronic Care | Weaver F.M.,Loyola University | And 22 more authors.
New England Journal of Medicine | Year: 2010

Background: Deep-brain stimulation is the surgical procedure of choice for patients with advanced Parkinson's disease. The globus pallidus interna and the subthalamic nucleus are accepted targets for this procedure. We compared 24-month outcomes for patients who had undergone bilateral stimulation of the globus pallidus interna (pallidal stimulation) or subthalamic nucleus (subthalamic stimulation). Methods: At seven Veterans Affairs and six university hospitals, we randomly assigned 299 patients with idiopathic Parkinson's disease to undergo either pallidal stimulation (152 patients) or subthalamic stimulation (147 patients). The primary outcome was the change in motor function, as blindly assessed on the Unified Parkinson's Disease Rating Scale, part III (UPDRS-III), while patients were receiving stimulation but not receiving antiparkinsonian medication. Secondary outcomes included selfreported function, quality of life, neurocognitive function, and adverse events. Results: Mean changes in the primary outcome did not differ significantly between the two study groups (P = 0.50). There was also no significant difference in self-reported function. Patients undergoing subthalamic stimulation required a lower dose of dopaminergic agents than did those undergoing pallidal stimulation (P = 0.02). One component of processing speed (visuomotor) declined more after subthalamic stimulation than after pallidal stimulation (P = 0.03). The level of depression worsened after subthalamic stimulation and improved after pallidal stimulation (P = 0.02). Serious adverse events occurred in 51% of patients undergoing pallidal stimulation and in 56% of those undergoing subthalamic stimulation, with no significant between-group differences at 24 months. Conclusions: Patients with Parkinson's disease had similar improvement in motor function after either pallidal or subthalamic stimulation. Nonmotor factors may reasonably be included in the selection of surgical target for deep-brain stimulation. Copyright © 2010 Massachusetts Medical Society.

Ricardo A.C.,University of Illinois at Chicago | Madero M.,Instituto Nacional Of Cardiologia Ignacio Chavez | Yang W.,University of Pennsylvania | Anderson C.,Johns Hopkins Medical Institution | And 6 more authors.
Clinical Journal of the American Society of Nephrology | Year: 2013

Background and objective Among general populations, a healthy lifestyle has been associated with lower risk of death. This study evaluated this association in individuals with CKD. Design, setting, participants,&measurementsAtotal of 2288 participantswithCKD(estimatedGFR<60 ml/min per 1.73m2 ormicroalbuminuria) in the ThirdNationalHealth andNutrition Examination Surveywere included. A weighted healthy lifestyle score was calculated (range, 24 to 15, with 15 indicating healthiest lifestyle) on the basis of the multivariable Cox proportional hazards model regression coefficients of the following lifestyle factors: smoking habit, bodymass index (BMI), physical activity, and diet.Main outcomewas all-causemortality, ascertained through December 31, 2006. Results Aftermedian follow-up of 13 years, 1319 participants had died. Compared with individuals in the lowest quartile of weighted healthy lifestyle score, adjusted hazard ratios (95% confidence intervals) of all-cause mortality were 0.53 (0.41-0.68), 0.52 (0.42-0.63), and 0.47 (0.38-0.60) for individuals in the second, third, and fourth quartiles, respectively. Mortality increased 30% among individuals with a BMI of 18.5 to <22 kg/m2 versus 22 to <25 kg/m2 (P<0.05); decreased mortality was associated with never-smoking versus current smoking (0.54 [0.41-0.70]) and regular versus no physical activity (0.80 [0.65-0.99]). Diet was not significantly associated with mortality. Conclusions Compared with nonadherence, adherence to a healthy lifestyle was associated with lower all-cause mortality risk in CKD. Examination of individual components of the healthy lifestyle score, with adjustment for other components, suggested that the greatest reduction in all-cause mortality was related to nonsmoking. © 2013 by the American Society of Nephrology.

Amy Janke E.,University of the Sciences in Philadelphia | Amy Janke E.,Center for Management of Complex Chronic Care | Kozak A.T.,Oakland University
Obesity | Year: 2012

Providers frequently report pain as a barrier to weight loss, and initial evidence suggests individuals with chronic pain and obesity experience reduced treatment success. However, scant evidence informs our understanding of how this comorbidity negatively influences treatment outcome. More effective programs might be designed with (i) insight into the patient's experience of comorbid chronic pain and obesity and (ii) improved understanding of the behavioral linkages between the experience of pain, engagement in health behaviors, and obesity treatment outcomes. Thirty adult primary care patients with mean BMI = 36.8 (SD 8.9) and average 0-10 pain intensity = 5.6 (SD 1.9) participated in semistructured, in-depth interviews. Transcriptions were analyzed using the constant comparative method. Five themes emerged indicating that patients with comorbid chronic pain and obesity experience: depression as magnifying the comorbid physical symptoms and complicating treatment; hedonic hunger triggered by physical pain and associated with depression and shame; emotional or binge eating in response to pain; altered dietary choices in response to pain; and low self-efficacy for physical activity due to pain. Individuals with chronic pain and obesity may be less responsive to traditional interventions that fail to address the symbiotic relationship between the two conditions. These individuals are at-risk for depressive symptoms and eating and activity patterns that sustain the comorbidity and make treatment problematic, and they may respond to pain with behaviors that promote weight gain, poor health and low mood. Further research is needed to examine behavioral mechanisms that promote comorbid pain and obesity, and to develop targeted treatment modules.

Rimmer J.H.,University of Alabama at Birmingham | Wang E.,University of Illinois at Chicago | Pellegrini C.A.,Northwestern University | Lullo C.,University of Illinois at Chicago | Gerber B.S.,Center for Management of Complex Chronic Care
American Journal of Physical Medicine and Rehabilitation | Year: 2013

Objective: Weight reduction programs are not generally designed or adapted for people with physical disabilities. This study examined the effect of a 9-months remote, telephone-based weight management program for people with physical disabilities using a Web-based system (Personalized Online Weight and Exercise Response System [POWERS]). Design: A total of 102 participants (mean ± SD age, 46.5 ± 12.7 yrs; body mass index, 32.0 ± 5.8 kg/m) with a physical disability (spinal cord injury, multiple sclerosis, spina bifida, cerebral palsy, stroke, or lupus) were randomized to one of three conditions: physical activity only (POWERS), physical activity plus nutrition (POWERSplus), and control. The POWERS group received a physical activity tool kit and regular coaching telephone calls. The POWERS plus group received an intervention identical to that of the POWERS group plus nutritional information. The control group received the physical activity tool kit and self-guided health promotion resources at the completion of the trial but no coaching. Results: Postintervention differences in body weight were found between the groups. There was a significant group × time interaction (P < 0.01) in postintervention body weight, with both the POWERS and POWERSplus groups demonstrating greater reduction in body weight compared with the control group (POWERS: -2.1 ± 5.5 kg, -2.4 ± -5.9%; POWERSplus: -0.5 ± 5.0 kg, -0.6 ± 4.3%; control: +2.6 ± 5.3 kg, 3.1 ± 7.4%). Conclusions: A low-cost telephone intervention supported with a Web-based remote coaching tool (POWERS) can be an effective strategy for assisting overweight adults with physical disabilities in maintaining or reducing their body weight. Copyright © 2013 Lippincott Williams & Wilkins.

Kositsawat J.,Sonny Montgomery Medical Center | Kositsawat J.,University of Mississippi | Freeman V.L.,University of Illinois at Chicago | Gerber B.S.,University of Illinois at Chicago | And 2 more authors.
Diabetes Care | Year: 2010

OBJECTIVE - Data relating vitamin D status with indices of glucose homeostasis as manifested by A1C in the U.S. adult population are few. RESEARCH DESIGN AND METHODS- We examined the association between serum 25 hydroxyvitamin D [25(OH)D] and A1C levels in 9,773 adults (age ≥18 years old) participating in the 2003-2006 National Health and Nutrition Examination Survey. Multivariate linear regression analyzed the association after accounting for potential confounders. RESULTS- Serum 25(OH)D levels were inversely associated with A1C levels in subjects age 35-74 years (P = 0.0045) and those who did not report a history of diabetes (P = 0.0282). CONCLUSIONS- These findings support a mechanistic link between serum vitamin D concentrations, glucose homeostasis, and the evolution of diabetes in a large segment of the U.S. adult population. Screening people with elevated A1C levels for vitamin D insufficiency should be considered. © 2010 by the American Diabetes Association.

Gerber B.S.,Center for Management of Complex Chronic Care | Gerber B.S.,University of Illinois at Chicago | Cho Y.I.,University of Illinois at Chicago | Arozullah A.M.,University of Illinois at Chicago | Lee S.-Y.D.,University of North Carolina at Chapel Hill
American Journal Geriatric Pharmacotherapy | Year: 2010

Background: Racial differences in adherence to prescribed medication regimens have been reported among the elderly. It remains unclear, however, whether these differences persist after controlling for confounding variables. Objective: The objective of this study was to determine whether racial differences in medication adherence between African American and white seniors persist after adjusting for demographic characteristics, health literacy, depression, and social support. We hypothesized that differences in adherence between the 2 races would be eliminated after adjusting for confounding variables. Methods: A survey on medication adherence was conducted using face-to-face interviews with Medicare recipients ≥65 years of age living in Chicago. Participants had to have good hearing and vision and be able to speak English to enable them to respond to questions in the survey and sign the informed-consent form. Medication adherence measures included questions about: (1) running out of medications before refilling the prescriptions; (2) following physician instructions on how to take medications; and (3) forgetting to take medications. Individual crude odds ratios (CORs) were calculated for the association between race and medication adherence. Adjusted odds ratios (AORs) were calculated using the following covariates in multivariate logistic regression analyses: race; age; sex; living with a spouse, partner, or significant other; income; Medicaid benefits; prescription drug coverage; having a primary care physician; history of hypertension or diabetes; health status; health literacy; depression; and social support. Results: Six hundred thirty-three eligible cases were identified. Of the 489 patients who responded to the survey, 450 (266 African American [59%; mean age, 78.2 years] and 184 white [41%; mean age, 76.8 years]; predominantly women) were included in the sample. The overall response rate for the survey was 77.3%. African Americans were more likely than whites to report running out of medications before refilling them (COR = 3.01; 95% CI, 1.72-5.28) and not always following physician instructions on how to take medications (COR = 2.64; 95% CI, 1.50-4.64). However, no significant difference between the races was observed in forgetting to take medications (COR = 0.90; 95% CI, 0.61-1.31). In adjusted analyses, race was no longer associated with low adherence due to refilling (AOR = 1.60; 95% CI, 0.74-3.42). However, race remained associated with not following physician instructions on how to take medications after adjusting for confounding variables (AOR = 2.49; 95% CI, 1.07-5.80). Conclusion: Elderly African Americans reported that they followed physician instructions on how to take medications less frequently than did elderly whites, even after adjusting for differences in demographic characteristics, health literacy, depression, and social support. © 2010 Excerpta Medica Inc.

Prasad B.,University of Illinois at Chicago | Carley D.W.,University of Illinois at Chicago | Krishnan J.A.,University of Illinois at Chicago | Weaver T.E.,University of Illinois at Chicago | Weaver F.M.,Center for Management of Complex Chronic Care
Journal of Clinical Sleep Medicine | Year: 2012

Purpose: Mechanistic and observational studies support an independent increase in risk of hypertension and abnormal glucose metabolism associated with obstructive sleep apnea (OSA). However, the specifi c populations and outcomes that improve with treatment of OSA in clinical practice are not established. We examined the effectiveness of OSA treatment on clinical blood pressure and diabetes control measures in men with preexisting systemic hypertension or type 2 diabetes. Methods: A retrospective cohort of veterans (n = 221) with a new diagnosis of OSA and initiation of positive airway pressure treatment was identifi ed using administrative databases and clinical records. Measurements and Results: Outcomes were changes in blood pressure (BP; mean of 3 highest recordings; systolic and diastolic) and glycemic control (mean of 3 highest fasting glucose and hemoglobinA1C values) at 3-6 months (T1) and 9-12 months (T2) following treatment compared to pretreatment. A generalized estimating equation model was used with adjustment for potential confounders: demographics, body mass index (BMI), OSA severity, Charlson comorbidity index, and pharmacologic treatment for hypertension and diabetes. Sustained independent effects of OSA treatment (mean change [95% CI]) were noted in both systolic BP (T1; -7.44 [-10.41 to -4.47] and T2; -6.81 [-9.94 to -3.67]) and diastolic BP (T1; -3.14, [-4.99 to -1.29] and T2; -3.69, [-5.53 to -1.85]). Diabetes control measures did not change with OSA treatment. Conclusions: Treatment of OSA improves offi ce blood pressure in hypertensive men. Prospective studies are necessary to better characterize specifi c populations with OSA that benefi t from treatment with respect to progression of hypertension and type 2 diabetes.

Fischer M.J.,Center for Management of Complex Chronic Care | Stroupe K.T.,Center for Management of Complex Chronic Care | Kaufman J.S.,Center for Management of Complex Chronic Care | O'Hare A.M.,Center for Management of Complex Chronic Care | And 3 more authors.
The American journal of managed care | Year: 2010

OBJECTIVE: To examine the effect of exclusive and dual use of Department of Veterans Affairs (VA) and Medicare healthcare systems on outpatient predialysis nephrology care. STUDY DESIGN: Retrospective cohort study. METHODS: Receipt, timeliness, and intensity of predialysis nephrology care were evaluated among 8033 veterans who initiated dialysis in 2000 and 2001 and were eligible for both VA and Medicare coverage in the 12 months preceding dialysis initiation. Propensity scores were incorporated into analyses to minimize potential selection bias from nonrandom veteran allocation to healthcare systems. RESULTS: Among the cohort, 17.4% were users of VA services only (VA-only users), 38.5% were users of Medicare-covered services only (Medicare-only users), and 44.1% were users of both VA and Medicare-covered services (dual users). Sixty-six percent of VA-only and dual users and 58.1% of Medicare-only users received predialysis nephrology care. Compared with Medicare-only users, dual users were more likely (risk ratio [RR], 1.12; 95% confidence interval [CI], 1.07-1.17) and VA-only users were as likely (RR, 0.98; 95% CI, 0.88-1.08) to have received predialysis nephrology care. Compared with Medicare-only use, VA-only use (RR, 0.63; 95% CI, 0.50-0.81) and dual use (RR, 0.78; 95% CI, 0.70-0.88) were associated with a lower likelihood of late nephrology care (<3 months before dialysis initiation). CONCLUSIONS: More than one-third of older veterans initiating dialysis do not receive nephrology care beforehand. Dual use of VA and Medicare-covered services was associated with greater receipt and favorable timeliness of predialysis nephrology care, while use of only Medicare-covered services was associated with late predialysis nephrology care. Further studies to identify reasons for system-level variations in access to predialysis nephrology care may assist in identifying opportunities for improvement.

Fitzgibbon M.L.,University of Illinois at Chicago | Fitzgibbon M.L.,Center for Management of Complex Chronic Care | Stolley M.R.,University of Illinois at Chicago | Stolley M.R.,Center for Management of Complex Chronic Care | And 4 more authors.
Obesity | Year: 2010

Obesity is a chronic condition that is prevalent in black women. The Obesity Reduction Black Intervention Trial (ORBIT) was a randomized controlled weight loss and weight-loss maintenance (WLM) trial. Participants (N = 213) were randomized to the intervention or control groups in August 2005 and September 2006. Follow-up data were collected 6 and 18 months after randomization. The main outcome was change in weight and BMI from baseline to 18 months. The mean weight at baseline was 104.9kg, and the mean weight loss in the intervention group at 6 months was 3.0kg and a gain of 0.2kg in the control group (mean difference between groups in weight change at 6 months, adjusting for baseline weight and cohort, 3.27kg; 95% confidence interval (CI), 4.50 to 2.05kg; P= 0.001). Both groups gained weight between 6 and 18 months (mean 1.0kg in the intervention group and 0.1kg in the control group). However, intervention participants lost significantly more weight than control participants during the 18-month intervention (adjusted mean difference between groups at 18 months, 2.83kg; 95% CI, 4.71 to 0.95; P = 0.003). At 18 months, intervention participants were more likely than control participants to have lost at least 5% of baseline weight (24% vs. 12%, P<0.04). Our results indicate that the ORBIT program did promote weight loss and weight-loss maintenance. However, the results also clearly illustrate there is more to learn about what will contribute to meaningful weight loss and maintenance in this population. © 2010 The Obesity Society.

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