Schoenthaler A.M.,New York University |
Schwartz B.S.,Johns Hopkins University |
Wood C.,Geisinger Center for Health Research |
Stewart W.F.,Geisinger Center for Health Research
Diabetes Educator | Year: 2012
Purpose: The purpose of this study was to examine the influence of patient and physician psychosocial, sociodemographic, and disease-related factors on diabetes medication adherence. These factors were also examined as effect modifiers of the association between quality of the patient-physician relationship and medication adherence. Methods: Data were collected from 41 Geisinger Clinic primary care physicians and 608 of their patients with type 2 diabetes. Adherence to oral hypoglycemic medications was calculated using a medication possession ratio based on physician orders in electronic health records (MPR EHR). MPR EHR was defined as the proportion of total time in the 2 years prior to study enrollment that the patient was in possession of oral hypoglycemic medications. Linear regression was used to examine the influence of patient- and physician-level factors on adherence. Effect modification of the patient-physician relationship-adherence association was evaluated by adding the main effects of the individual-level factors and their cross-products to the models. Results: In adjusted analyses, satisfaction with the physician's patient education skills, patient beliefs about the need for their medications, and lower diabetes-related knowledge were associated with better adherence to oral hypoglycemic medications. Shorter duration of time with diabetes and taking only oral hypoglycemic medications were also associated with better adherence. Finally, the association between shared decision making and medication adherence was significantly modified by patients' level of social support. Conclusions: This study identified several patient-, physician-, and disease-related factors that should be targeted to maximize the potential for developing tailored adherence-enhancing interventions within the context of a collaborative patient-physician relationship. © 2012 The Author(s).
Prevots D.R.,National Institute of Allergy and Infectious Diseases |
Shaw P.A.,National Institute of Allergy and Infectious Diseases |
Strickland D.,Kaiser Permanente |
Jackson L.A.,Group Health Research Institute |
And 7 more authors.
American Journal of Respiratory and Critical Care Medicine | Year: 2010
Rationale: Single-site clinic-based studies suggest an increasing prevalence of pulmonary nontuberculous mycobacteria (NTM) disease, but systematic data are lacking. Objectives: To describe prevalence and trends for NTM lung disease at four geographically diverse integrated heath care delivery systems in the United States. Methods: We abstracted mycobacterial culture results from electronic laboratory databases and linked to other datasets containing clinical and demographic information. Possible cases were defined as a single positive NTM pulmonary isolate, and definite cases were defined as two positive sputum cultures, or one positive culture from a bronchoalveolar lavage or lung biopsy. Annual prevalence was calculated using United States census data; average annual prevalence is presented for 2004-2006. Poisson regression models were used to estimate the annual percent change in prevalence. Measurements and Main Results: A total of 28,697 samples from 7,940 patients were included in the analysis. Of these, 3,988 (50%) were defined as possible cases, and 1,865 (47%) of these were defined as definite cases. Average annual (2004-2006) site-specific prevalence ranged from 1.4 to 6.6 per 100,000. Prevalence was 1.l- to 1.6-fold higher among women relative to men across sites. The prevalence of NTM lung disease was increasing significantly at the two sites where trends were studied, by 2.6% per year among women and 2.9% per year among men. Among persons aged greater than or equal to 60 years, annual prevalence increased from 19.6 per 100,000 during 1994-1996 to 26.7 per 100,000 during 2004-2006. Conclusions: The epidemiology of nontuberculous mycobacterial lung disease is changing, with a predominance of women and increasing prevalence at the sites studied.
Kan H.,Fudan University |
Wong C.-M.,University of Hong Kong |
Vichit-Vadakan N.,Thammasat University |
Qian Z.,Pennsylvania State University |
Qian Z.,Geisinger Center for Health Research
Environmental Research | Year: 2010
Sulfur dioxide (SO2) has been associated with increased mortality and morbidity, but only few studies were conducted in Asian countries. Previous studies suggest that SO2 may have adverse health effects independent of other pollutants. In the Public Health and Air Pollution in Asia (PAPA) project, the short-term associations between ambient sulfur dioxide (SO2) and daily mortality were examined in Bangkok, Thailand, and three Chinese cities: Hong Kong, Shanghai, and Wuhan. Poisson regression models incorporating natural spline smoothing functions were used to adjust for seasonality and other time-varying covariates. Effect estimates were obtained for each city and then for the cities combined. The impact of alternative model specifications, such as lag structure of pollutants and degree of freedom (df) for time trend, on the estimated effects of SO2 were also examined. In both individual-city and combined analysis, significant effects of SO2 on total non-accidental and cardiopulmonary mortality were observed. An increase of 10 μg/m3 of 2-day moving average concentrations of SO2 corresponded to 1.00% [95% confidence interval (CI), 0.75-1.24], 1.09% (95% CI, 0.71-1.47), and 1.47% (95% CI, 0.85-2.08) increase of total, cardiovascular and respiratory mortality, respectively, in the combined analysis. Sensitivity analyzes suggested that these findings were generally insensitive to alternative model specifications. After adjustment for PM10 or O3, the effect of SO2 remained significant in three Chinese cities. However, adjustment for NO2 diminished the associations and rendered them statistically insignificant in all four cities. In conclusion, ambient SO2 concentration was associated with daily mortality in these four Asian cities. These associations may be attributable to SO2 serving as a surrogate of other substances. Our findings suggest that the role of outdoor exposure to SO2 should be investigated further in this region. © 2010 Elsevier Inc. All rights reserved.
Roy J.,University of Pennsylvania |
Stewart W.F.,Geisinger Center for Health Research
American Journal of Epidemiology | Year: 2011
Knowledge about remission rates can affect treatment decisions and facilitate etiologic discoveries. However, little is known about remission of many chronic episodic disorders, including migraine. This is partly due to the fact that medical records do not fully capture the history of these conditions, since patients might stop seeking care once they no longer have symptoms. For these disorders, remission rates would typically be obtained from prospective observational studies. Prospective studies of remission for chronic episodic conditions are rarely conducted, however, and suffer from many analytical challenges, such as outcome-dependent dropout. Here the authors propose an alternative approach that is appropriate for use with cross-sectional survey data in which reported age of onset was recorded. The authors estimated migraine remission rates using data from a 2004 national survey. They took a Bayesian approach and modeled sex- and age-specific remission rates as a function of incidence and prevalence. The authors found that remission rates were an increasing function of age and were similar for men and women. Follow-up survey data from migraine cases (2005) were used to validate the methods. The remission curves estimated from the validation data were very similar to the ones from the cross-sectional data. © 2011 The Author.
Snyder S.R.,Geisinger Center for Health Research |
Mitropoulou C.,Erasmus Medical Center |
Patrinos G.P.,University of Patras |
Williams M.S.,00 N Academy Avenue
Public Health Genomics | Year: 2014
Evidence of the value of pharmacogenomic testing is needed to inform policymakers and clinicians for decision making related to adoption and coverage, and to facilitate prioritization for research and development. Pharmacogenomics has an important role in creating a more efficient healthcare system, and this article addresses how economic evaluation can strategically target evidence gaps for public health priorities with examples from pharmacogenomic medicine. This article begins with a review of the need for and use of economic evaluations in value-based decision making for pharmacogenomic testing. Three important gaps are described with examples demonstrating how they can be addressed: (1) projected impact of hypothetical new technology, (2) pre-implementation assessment of a specific technology, and (3) post-implementation assessment from relevant analytical stakeholder perspectives. Additional needs, challenges and approaches specific to pharmacogenomic economic evaluation in the developing world are also identified. These pragmatic approaches can provide much needed evidence to support real-world value-based decision making for pharmacogenomic-based screening and treatment strategies. © 2014 S. Karger AG, Basel.
Graham J.,Geisinger Center for Health Research |
Tomcavage J.,Geisinger Center for Health Research |
Salek D.,Geisinger Center for Health Research |
Sciandra J.,Geisinger Center for Health Research |
And 2 more authors.
Medical Care | Year: 2012
Background: Automated home monitoring systems have been used to coordinate care to improve patient outcomes and reduce rehospitalizations, but with little formal study of efficacy. The Geisinger Monitoring Program (GMP) interactive voice response protocol is a post-hospital discharge telemonitoring system used as an adjunct to existing case management in a primary care Medicare population to reduce emergency department visits and hospital readmissions. Objectives: To determine if use of GMP reduced 30-day hospital readmission rates among case-managed patients. Research Design: A pre-post parallel quasi-experimental study. Methods: A total of 875 Medicare patients who were enrolled in the combined case-management and GMP program were compared with 2420 matched control patients who were only case managed. Claims data were used to document an acute care admission followed by a readmission within 30 days in the preintervention and postintervention periods (ie, before and during 2009). Regression modeling was used to estimate the within-patient effect of the intervention on readmission rates. Results: The use of GMP with case management was associated with a 44% reduction in 30-day readmissions in the study cohort (95% confidence interval, 23%-60%, P=0.0004), when using the control group to control for secular trends. Similar estimates were obtained when using different propensity score adjustment methods or different approaches to handling dropout observations. Conclusions: Investing in automated monitoring systems may reduce hospital readmission rates among primary care case-managed patients. Evidence from this quasi-experimental study demonstrates that the combination of telemonitoring and case management, as compared with case management alone, may significantly reduce readmissions in a Medicare Advantage population.
Moore M.,Children's Hospital of Philadelphia |
Kirchner H.L.,Geisinger Center for Health Research |
Drotar D.,Cincinnati Childrens Hospital Medical Center |
Johnson N.,Case Western Reserve University |
And 2 more authors.
Sleep Medicine | Year: 2011
Objectives: Adolescents are predisposed to short sleep duration and irregular sleep patterns due to certain host characteristics (e.g., age, pubertal status, gender, ethnicity, socioeconomic class, and neighborhood distress) and health-related variables (e.g., ADHD, asthma, birth weight, and BMI). The aim of the current study was to investigate the relationship between such variables and actigraphic measures of sleep duration and variability. Method: Cross-sectional study of 247 adolescents (48.5% female, 54.3% ethnic minority, mean age of 13.7. years) involved in a larger community-based cohort study. Results: Significant univariate predictors of sleep duration included gender, minority ethnicity, neighborhood distress, parent income, and BMI. In multivariate models, gender, minority status, and BMI were significantly associated with sleep duration (all p<05), with girls, non-minority adolescents, and those of a lower BMI obtaining more sleep.Univariate models demonstrated that age, minority ethnicity, neighborhood distress, parent education, parent income, pubertal status, and BMI were significantly related to variability in total sleep time. In the multivariate model, age, minority status, and BMI were significantly related to variability in total sleep time (all p<05), with younger adolescents, non-minority adolescents, and those of a lower BMI obtaining more regular sleep. Conclusions: These data show differences in sleep patterns in population sub-groups of adolescents which may be important in understanding pediatric health risk profiles. Sub-groups that may particularly benefit from interventions aimed at improving sleep patterns include boys, overweight, and minority adolescents. © 2011 Elsevier B.V.
Jones J.B.,Geisinger Center for Health Research |
Stewart W.F.,Geisinger Center for Health Research |
Darer J.D.,Geisinger Clinic |
Sittig D.F.,University of Texas Health Science Center at Houston
BMC Medical Informatics and Decision Making | Year: 2013
In two landmark reports on Quality and Information Technology, the Institute of Medicine described a 21st century healthcare delivery system that would improve the quality of care while reducing its costs. To achieve the improvements envisioned in these reports, it is necessary to increase the efficiency and effectiveness of the clinical decision support that is delivered to clinicians through electronic health records at the point of care. To make these dramatic improvements will require significant changes to the way in which clinical practice guidelines are developed, incorporated into existing electronic health records (EHR), and integrated into clinicians' workflow at the point of care. In this paper, we: 1) discuss the challenges associated with translating evidence to practice; 2) consider what it will take to bridge the gap between the current limits to use of CPGs and expectations for their meaningful use at the point of care in practices with EHRs; 3) describe a framework that underlies CDS systems which, if incorporated in the development of CPGs, can be a means to bridge this gap, 4) review the general types and adoption of current CDS systems, and 5) describe how the adoption of EHRs and related technologies will directly influence the content and form of CPGs. Achieving these objectives should result in improvements in the quality and reductions in the cost of healthcare, both of which are necessary to ensure a 21st century delivery system that consistently provides safe and effective care to all patients. © 2013 Jones et al.; licensee BioMed Central Ltd.
Hematomas of at least 5 cm and outcomes in patients undergoing elective percutaneous coronary intervention: Insights from the SafeTy and Efficacy of Enoxaparin in PCI patients, an internationaL randomized Evaluation (STEEPLE) trial
White H.D.,Green City |
Aylward P.E.,Flinders Medical Center |
Gallo R.,Montreal Heart Institute |
Bode C.,University Hospital Freiburg |
And 3 more authors.
American Heart Journal | Year: 2010
Background: Major bleeding significantly impacts outcomes in patients undergoing percutaneous coronary intervention (PCI). No uniform definitions exist for major and minor bleeding. Hematomas ≥5 cm at the femoral puncture site are considered major bleeding events in some trials and minor in others. Limited information is available on the incidence and clinical relevance of hematomas ≥5 cm in PCI patients. Methods: Data from the STEEPLE trial in patients undergoing elective PCI were used to assess the impact of hematomas ≥5 cm on ischemic outcomes (mortality, nonfatal myocardial infarction, or urgent target vessel revascularization) up to day 30 and all-cause 1-year mortality. Hematoma data were available for 3,342 of 3,528 patients in STEEPLE. Patients with (n = 103) and without (n = 3,239) hematomas ≥5 cm were evenly distributed across treatment groups. Results: No differences were observed in 30-day ischemic outcomes between patients with and without hematomas (5.8% vs 5.9%, respectively; P = .96). No transfusions were observed in patients with hematomas as compared with patients without hematomas (0% and 0.4%, respectively; P = .52). A greater reduction in hemoglobin was observed (pre- vs post-PCI) in patients with hematomas as compared with patients without hematomas (-0.84 vs -0.35 g/L, P ≤ .001). No significant difference in all-cause 1-year mortality was observed between patients with and without hematomas (0.0% vs 1.7%, P = .98). Conclusions: After PCI, hematomas ≥5 cm had no effect on 30-day ischemic events or 1-year mortality. Although there is no agreed classification for large hematomas, the lack of a relationship between hematomas ≥5 cm and clinical outcome after PCI justifies the classification of these hematomas as minor bleeds in STEEPLE. © 2010 Mosby, Inc.
News Article | September 20, 2016
When it comes to childhood obesity, we tend to focus a lot on processed food and lack of physical activity. But those aren't the only factors contributing to the epidemic, which affects close to 1 in 5 American kids. A study published Tuesday shows how the trillions of bacteria that already live in children's guts also impact their risk of obesity. And this understanding may pave the way to new, and better, treatments for obesity. By studying the gut flora of 84 children and teens—from normal weight to severely obese—researchers were able to determine that the composition of microbes in the gut flora of obese children and adolescents share a lot of similarities. Eight distinct group of microbes were associated with higher body weight, and these groups were less often found in the gut flora of leaner kids, according to the study published in the Journal of Clinical Endocrinology & Metabolism. These differences in microbiome populations—the term for the unique blend of bacteria that live in and on every human body—mean that obese kids and teens more often have bacteria that are better at fermenting carbohydrates in the stomach, which produces higher levels of short-chain fatty acids (the term for a number of acids produced in the colon when food breaks down). "Once short-chain fatty acids are produced, either they get expelled through feces, or most of them get absorbed," said Dr. Nicola Santoro, a Yale endocrinology research scientist and co-author of the paper. Santoro said the researchers believe the short chain fatty acids are being absorbed in the liver and converted to fat, which would explain part of the reason why obese kids might be predisposed to put on weight. Read More: Scientists Are Now Trying Fecal Transplants on Kids These findings are similar to those of studies looking at the gut flora of obese adults. It's part of a slow piecing together of a puzzle that explains what role the microbiome plays in our body fat composition, and how we might be able to influence changes. "Studies have consistently reported an association between antibiotics and gut flora and we know the microbiome plays a role in the development of metabolism and immunity," Annemarie Hirsch, a researcher at the Geisinger Center for Health Research who has authored studies on the impact of antibiotics on the development of the microbiome. "It's the connection between antibiotics to microbiome to obesity that's somewhat still a black box." Though the microbiome in adults is more or less static—antibiotics can knock out a lot of the microbes, they will repopulate—Hirsch's research has shown that the gut flora of babies is still developing, and the overuse of antibiotics at an early age can change the composition. That overuse is also associated with a higher risk of obesity and food allergies. Both Hirsch and Santoro said there's still a lot of work to be done and there are a lot of factors that impact risk of obesity: most obviously, diet and amount of physical exercise. But as we learn more about the role the gut flora plays, we might be able to design more strategic treatments for kids and adults who are already obese—or prevent it for those who aren't. These could include things like probiotics, or even fecal transplants, where the fecal matter of a healthy person is introduced into the bowel of another person to repopulate the gut flora with different microbes. "That's the million dollar question," Santoro said. "If you look at animal studies, fecal transplants work perfectly in mice [for treating obesity.] The issue is: can we do this in humans? Does it work? For obesity, we don't know yet." Get six of our favorite Motherboard stories every day by signing up for our newsletter.