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Wong N.D.,University of California at Irvine | Nelson J.C.,Group Health Center for Health Studies | Nelson J.C.,University of Washington | Granston T.,University of Washington | And 12 more authors.
JACC: Cardiovascular Imaging | Year: 2012

Objectives: This study sought to examine and compare the incidence and progression of coronary artery calcium (CAC) among persons with metabolic syndrome (MetS) and diabetes mellitus (DM) versus those with neither condition. Background: MetS and DM are associated with subclinical atherosclerosis as evidenced by CAC. Methods: The MESA (Multiethnic Study of Atherosclerosis) included 6,814 African American, Asian, Caucasian, and Hispanic adults 45 to 84 years of age, who were free of cardiovascular disease at baseline. Of these, 5,662 subjects (51% women, mean age 61.0 ± 10.3 years) received baseline and follow-up (mean 2.4 years) cardiac computed tomography scans. We compared the incidence of CAC in 2,927 subjects without CAC at baseline and progression of CAC in 2,735 subjects with CAC at baseline in those with MetS without DM (25.2%), DM without MetS (3.5%), or both DM and MetS (9.0%) to incidence and progression in subjects with neither MetS nor DM (58%). Progression of CAC was also examined in relation to coronary heart disease events over an additional 4.9 years. Results: Relative to those with neither MetS nor DM, adjusted relative risks (95% confidence intervals [CI]) for incident CAC were 1.7 (95% CI: 1.4 to 2.0), 1.9 (95% CI: 1.4 to 2.4), and 1.8 (95% CI: 1.4 to 2.2) (all p < 0.01), and absolute differences in mean progression (volume score) were 7.8 (95% CI: 4.0 to 11.6; p < 0.01), 11.6 (95% CI: 2.7 to 20.5; p < 0.05), and 22.6 (95% CI: 17.2 to 27.9; p < 0.01) for those with MetS without DM, DM without MetS, and both DM and MetS, respectively. Similar findings were seen in analysis using Agatston calcium score. In addition, progression predicted coronary heart disease events in those with MetS without DM (adjusted hazard ratio: 4.1, 95% CI: 2.0 to 8.5, p < 0.01) and DM (adjusted hazard ratio: 4.9 [95% CI: 1.3 to 18.4], p < 0.05) among those in the highest tertile of CAC increase versus no increase. Conclusions: Individuals with MetS and DM have a greater incidence and absolute progression of CAC compared with individuals without these conditions, with progression also predicting coronary heart disease events in those with MetS and DM. © 2012 American College of Cardiology Foundation.


McCusrry S.M.,University of Washington | Larson E.B.,Group Health Center for Health Studies
Cognitive and Behavioral Neurology | Year: 2010

Objective: To determine the relation of age-related auditory processing dysfunction and executive functioning. Background: Central auditory dysfunction is common in Alzheimer dementia, but the mechanism is not established. METHOD: A total of 313 volunteers from the Adult Changes in Thought surveillance cohort with adequate peripheral hearing were included in the study. Outcome measures such as (1) peripheral audition; (2) auditory-evoked potentials; (3) central auditory tests (Synthetic Sentence Identification with Ipsilateral Competing Message, Dichotic Sentence Identification, Dichotic Digits); (4) Executive Functioning: Trail Making; Clock Drawing, Stroop Color and Word, and subtests from the Cognitive Abilities Screening Instrument were used to measuring the mental concentration. A composite executive functioning score was created using item response theory. Results: The composite executive functioning score was significantly associated with each central auditory measure, explaining 8% to 21% of the variance. Trails B test was most strongly associated with the auditory outcomes, explaining 8% to 14% of the variance. The relation between executive functioning and central auditory function was still significant when participants diagnosed with memory impairment or dementia were excluded. Conclusions: In elderly persons, reduced executive functioning is associated with central auditory processing, but not with primary auditory function. This suggests that central presbycusis and executive dysfunction may result from similar neurodegenerative processes. Copyright © 2010 by Lippincott Williams & Wilkins.


Schauer D.P.,University of Cincinnati | Arterburn D.E.,Group Health Center for Health Studies | Livingston E.H.,University of Texas at Dallas | Fischer D.,University of Cincinnati | Eckman M.H.,University of Cincinnati
Archives of Surgery | Year: 2010

Objective: To create a decision analytic model to estimate the balance between treatment risks and benefits for patients with morbid obesity. Design: Decision analytic Markov state transition model with multiple logistic regression models as inputs. Data from the 2005 National Inpatient Survey were used to calculate in-hospital mortality risk associated with bariatric surgery and then adjusted for 30-day mortality. To calculate excess mortality associated with obesity, we used the 1991-1996 National Health Interview Survey linked to the National Death Index. Bariatric surgery was assumed to influence mortality only through its impact on the excess mortality associated with obesity, and the efficacy of surgery was estimated from a recent large observational trial. Intervention: Gastric bypass surgery. Main Outcome Measure: Life expectancy. Results: Our base case, a 42-year-old woman with a body mass index of 45, gained an additional 2.95 years of life expectancy with bariatric surgery. No surgical treatment was favored in our base case when the 30-day surgical mortality exceeded 9.5% (baseline 30-day mortality, 0.2%) or when the efficacy of bariatric surgery for reducing mortality decreased to 2% or less (baseline efficacy, 53%). Conclusions: The optimal decision for individual patients varies based on the balance of risk between perioperative mortality, excess annual mortality risk associated with increasing body mass index, and the efficacy of surgery; however, for the average morbidly obese patient, gastric bypass improves life expectancy. ©2010 American Medical Association. All rights reserved.


Levine M.D.,Northgate Medical Center | Ross T.R.,Group Health Center for Health Studies | Balderson B.H.K.,Group Health Center for Health Studies | Phelan E.A.,Group Health Center for Health Studies | Phelan E.A.,University of Washington
Journal of the American Geriatrics Society | Year: 2010

In a pair of randomized controlled trials in the Kaiser Permanente delivery system in Colorado in the 1990s, group visits for older adults (monthly non-disease-specific group medical appointments for a cohort of patients led by primary care teams) were proven to reduce costs, decrease hospitalizations, and improve patient and provider satisfaction. As part of a translational effort, this group visit intervention was replicated in a delivery system in Seattle, Washington, and the log of total healthcare costs was measured in the first year of the intervention. Utilization and patient and physician satisfaction were secondary outcomes. For the cost and utilization analysis, a retrospective case-control design compared 221 case patients aged 65 and older with high outpatient usage in the previous 18 months with 1,015 control patients selected randomly from clinics not participating in the intervention. Controls were matched to cases on the number of primary care visits in the prior 18 months. Total costs were not statistically different for intervention patients and controls ($8,845 vs $10,288, P=.11), nor were there statistically significant differences in utilization, including hospital admissions and outpatient visits, but patient and provider satisfaction with the intervention was high. This translational effort did not demonstrate the cost savings of the original efficacy trials. Possible explanations for these divergent results may have to do with differences between those who participated and differences between the two delivery systems. © 2009 The American Geriatrics Society.


Upson K.,University of Washington | Reed S.D.,University of Washington | Reed S.D.,Fred Hutchinson Cancer Research Center | Reed S.D.,Group Health Center for Health Studies | And 3 more authors.
Contraception | Year: 2010

Background: Women ages 35 years and older have the greatest proportion of contraceptive nonuse and unintended pregnancies ending in abortion. Study Design: We conducted a population-based case-control study among women ages 35-44 years at risk of unwanted pregnancy using the National Survey of Family Growth (NSFG) data to investigate risk factors for contraceptive nonuse. Results: At last intercourse, 9.8% of women reported not using any contraceptive method. Contraceptive nonusers, as compared to users, were more likely to be ages 40-44 years (OR=2.0, 95% CI 1.1-3.7), foreign-born (OR=4.3, 95% CI 1.9-9.7), black (OR=2.8, 95% CI 1.1-7.0), with household incomes 100-249% of the federal poverty level (FPL) (OR=2.5, 95% CI 1.1-5.8). Women who received contraceptive counseling in the past year had an 80% decreased risk of nonuse (95% CI 0.1-0.5). Conclusion: Public health strategies to reduce unintended pregnancy, particularly among women ages 35 years and older, should focus on addressing disparities in contraceptive use and promoting contraceptive counseling. © 2010 Elsevier Inc. All rights reserved.


Robins L.S.,University of Washington | Jackson J.E.,Battelle | Green B.B.,Group Health Center for Health Studies | Korngiebel D.,University of Washington | And 2 more authors.
Journal of the American Board of Family Medicine | Year: 2013

Introduction: The Electronic Communications and Home Blood Pressure Monitoring trial (e-BP) demonstrated that team care incorporating a pharmacist to manage hypertension using secure E-mail with patients resulted in almost twice the rate of blood pressure (BP) control compared with usual care. To translate e-BP into community practices, we sought to identify contextual barriers and facilitators to implementation. Methods: Interviews were conducted with medical providers, staff, pharmacists, and patients associated with community-based primary care clinics whose physician leaders had expressed interest in implementing e-BP. Transcripts were analyzed using qualitative template analysis, incorporating codes derived from the Consolidated Framework for Implementation Research (CFIR). Results: Barriers included incorporating an unfamiliar pharmacist into the health care team, lack of information technology resources, and provider resistance to using a single BP management protocol. Facilitators included the intervention's perceived potential to improve quality of care, empower patients, and save staff time. Sustainability of the intervention emerged as an overarching theme. Conclusion: A qualitative approach to planning for translation is recommended to gain an understanding of contexts and to collaborate to adapt interventions through iterative, bidirectional information gathering. Interviewees affirmed that web pharmacist care offers small primary care practices a means to expand their workforce and provide patient-centered care. Reproducing e-BP in these practices will be challenging, but our interviewees expressed eagerness to try and were optimistic that a tailored intervention could succeed.


Morris D.E.,Fred Hutchinson Cancer Research Center | Pepe M.S.,Fred Hutchinson Cancer Research Center | Barlow W.E.,Group Health Center for Health Studies
Medical Decision Making | Year: 2010

Background. Statistical evaluation of medical imaging tests used for diagnostic and prognostic purposes often employs receiver operating characteristic (ROC) curves. Two methods for ROC analysis are popular. The ordinal regression method is the standard approach used when evaluating tests with ordinal values. The direct ROC modeling method is a more recently developed approach, motivated by applications to tests with continuous values. Objective. The authors compare the methods in terms of model formulations, interpretations of estimated parameters, the ranges of scientific questions that can be addressed with them, their computational algorithms, and the efficiencies with which they use data. Results. The authors show that a strong relationship exists between the methods by demonstrating that they fit the same models when only a single test is evaluated. The ordinal regression models are typically alternative parameterizations of the direct ROC models and vice versa. The direct method has two major advantages over the ordinal regression method: 1) estimated parameters relate directly to ROC curves, facilitating interpretations of covariate effects on ROC performance, and 2) comparisons between tests can be done directly in this framework. Comparisons can be made while accommodating covariate effects and even between tests that have values on different scales, such as between a continuous biomarker test and an ordinal valued imaging test. The ordinal regression method provides slightly more precise parameter estimates from data in our simulated data models. Conclusion. Although the ordinal regression method is slightly more efficient, the direct ROC modeling method has important advantages in regard to interpretation, and it offers a framework to address a broader range of scientific questions, including the facility to compare tests.


Schauer D.P.,University of Cincinnati | Arterburn D.E.,Group Health Center for Health Studies | Livingston E.H.,Southwestern University | Coleman K.J.,Kaiser Permanente | And 5 more authors.
Annals of Surgery | Year: 2015

Objective: To create a decision analytic model to estimate the balance between treatment risks and benefits for severely obese patients with diabetes. Background: Bariatric surgery leads to many desirable metabolic changes, but long-term impact of bariatric surgery on life expectancy in patients with diabetes has not yet been quantified. Methods: We developed a Markov state transition model with multiple Cox proportional hazards models and logistic regression models as inputs to compare bariatric surgery versus no surgical treatment for severely obese diabetic patients. The model is informed by data from 3 large cohorts: (1) 159,000 severely obese diabetic patients (4185 had bariatric surgery) from 3 HMO Research Network sites; (2) 23,000 infjects from the Nationwide Inpatient Sample; and (3) 18,000 infjects from the National Health Interview Survey linked to the National Death Index. Results: In our main analyses, we found that a 45-year-old woman with diabetes and a body mass index (BMI) of 45 kg/m2 gained an additional 6.7 years of life expectancy with bariatric surgery (38.4 years with surgery vs 31.7 years without surgery). Sensitivity analyses revealed that the gain in life expectancy decreased with increasing BMI, until a BMI of 62 kg/m2 is reached, at which point nonsurgical treatment was associated with greater life expectancy. Similar results were seen for both men and women in all age groups. Conclusions: For most severely obese patients with diabetes, bariatric surgery seems to improve life expectancy; however, surgery may reduce life expectancy for the super obese with BMIs over 62 kg/m2. © 2014 Wolters Kluwer Health, Inc. All rights reserved.


Viola-Saltzman M.,Loyola University | Watson N.F.,University of Washington | Bogart A.,Group Health Center for Health Studies | Goldberg J.,University of Washington | Buchwald D.,University of Washington
Journal of Clinical Sleep Medicine | Year: 2010

Study Objectives: To investigate the prevalence of restless legs syndrome (RLS) in fibromyalgia (FM) and determine the presence and amount of sleep disruption in FM patients with RLS. RLS and FM have been associated in uncontrolled studies using a variety of RLS definitions. We explored this relationship using a cross-sectional study design. Methods: FM cases that met the American College of Rheumatology diagnostic criteria were recruited through an academic referral clinic and advertising. Pain- and fatigue-free controls were recruited from the Seattle metropolitan area. We enrolled 172 FM patients (mean age 50 years, 93% female) and 63 pain- and fatigue-free controls (mean age 41 years, 56% female). RLS was ascertained by a self-administered validated diagnostic interview. Results: The age- and gender-adjusted prevalence of RLS was higher in the FM group than the control group (33.0%; 95% Cl: 25.9, 40.1 vs. 3.1%; 95% Cl: 0.0, 7.4; p = 0.001). Likewise, the FM group was more likely to report RLS (OR = 11.7; 95% Cl: 2.6, 53.0), even after adjusting for age and gender. The mean Pittsburgh Sleep Quality Index score was higher among FM patients with RLS than those without (11.8 vs. 9.9; p = 0.01) but subjective limb pain measures did not differ between these 2 groups. Conclusions: There is a higher prevalence and odds of RLS in those with FM compared to controls. Clinicians should routinely query FM patients regarding RLS symptoms because treatment of RLS can potentially improve sleep and quality of life in these patients.


Hanley G.E.,University of British Columbia | Morgan S.,University of British Columbia | Reid R.J.,Group Health Center for Health Studies
Medical Care | Year: 2010

BACKGROUND: Given that prescription drugs have become a major financial component of health care, there is an increased need to explain variations in the use of and expenditure on medicines. Case-mix systems built from existing administrative datasets may prove very useful for such prediction. OBJECTIVE: We estimated the concurrent and prospective predictive validity of the adjusted clinical groups (ACG) system in pharmaceutical research and compared the ACG system with the Charlson index of comorbidity. RESEARCH DESIGN: We ran a generalized linear models to examine the predictive validity of the ACG system and the Charlson index and report the correlation between the predicted and observed expenditures. We reported mean predictive ratios across medical condition and cost-defined groups. When predicting use of medicines, we used C-statistics to summarize the area under the receiver operating characteristic curve. SUBJECTS: The 3,908,533 British Columbia residents who were registered for the universal health care plan for 275+ days in the calendar years 2004 and 2005. MEASURES: Outcomes were total pharmaceutical expenditures, use of any medicines, and use of medicines from 4+ different therapeutic categories. RESULTS: The ACG case mix system predicted drug expenditures better than the Charlson index. The mean predictive ratios for the ACG system models were all within 4% of the actual costs when examining medical condition group and the C-stats for the 2 dichotomous outcomes were between 0.82 and 0.89. CONCLUSION: ACG case-mix adjusters are a valuable predictor of pharmaceutical use and expenditures with much higher predictive power than age, sex, and the Charlson index of comorbidity. © 2010 by Lippincott Williams & Wilkins.

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