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Neugebauer R.,Kaiser Permanente | Fireman B.,Kaiser Permanente | Roy J.A.,University of Pennsylvania | O'Connor P.J.,Health Partners Institute for Education and Research
Diabetes Care | Year: 2013

OBJECTIVE-Comparative effectiveness research methods are used to compare the effect of four distinct glucose-control strategies on subsequent myocardial infarction and nephropathy in type 2 diabetes. RESEARCH DESIGN AND METHODSdA total of 58,000 adults with type 2 diabetes and A1C <7% (53 mmol/mol) while taking two or more oral agents or basal insulin had subsequent A1C ≥7% (53 mmol/mol) to 8.5% (69 mmol/mol). Follow-up started on date of first A1C ≥7% and ended on date of a specific clinical event, death, disenrollment, or study end. Glucose-control strategies were defined as first intensification of glucose-lowering therapy at A1C ≥7, ≥7.5, ≥8, or ≥8.5% with subsequent control for treatment adherence. Logistic marginal structural models were fitted to assess the discrete-time hazards for each dynamic glucosecontrol strategy, adjusting for baseline and time-dependent confounding and selection bias through inverse probability weighting. RESULTS-After adjustment for age, sex, race/ethnicity, comorbidities, blood pressure, lipids, BMI, and other covariates, progressively more aggressive glucose-control strategies were associated with reduced onset or progression of albuminuria but not associated with significant reduction in occurrence of myocardial infarction or preserved renal function based on estimated glomerular filtration rate over 4 years of follow-up. CONCLUSIONS-In a large representative cohort of adults with type 2 diabetes, more aggressive glucose-control strategies havemixed short-term effects onmicrovascular complications and do not reduce the myocardial infarction rate over 4 years of follow-up. These findings are consistent with the results of recent clinical trials, but confirmation over longer periods of observation is needed. © 2013 by the American Diabetes Association. Source

Kunin-Batson A.,Health Partners Institute for Education and Research | Kunin-Batson A.,University of Minnesota | Kadan-Lottick N.,Yale University | Neglia J.P.,University of Minnesota
Psycho-Oncology | Year: 2014

Background Neurocognitive late effects after childhood acute lymphoblastic leukemia (ALL) are well-documented, but their impact on quality of life (QOL) is not well understood. In this multi-site study, we examined the relative influence of neurocognitive functioning, steroid randomization (prednisone vs. dexamethasone), and demographic characteristics on QOL in first-remission survivors of childhood ALL. Methods Participants included 263 ALL survivors (ages 7-17 years at the time of evaluation; mean age at diagnosis 3.9 years) who were treated on similar legacy Children's Cancer Group chemotherapy protocols and did not receive cranial radiation. Children completed detailed neuropsychological performance tests. The Pediatric QOL Inventory was completed by children and their parents. Participants were a mean of 9 years from diagnosis at the time of assessment (with a range of 4 to 13 years). Results Children and their parents reported lower mean child psychosocial QOL than healthy population norms (p<0.05), but were not in the impaired range. Physical QOL was similar to population norms. Though neurocognitive difficulties were predominantly mild for the sample as a whole, neurocognitive deficits, specifically problems in verbal cognitive abilities and visual-motor integration skills, were significantly associated with poor physical (p<0.01) and Psychosocial QOL (p<0.01). QOL was not associated with previous steroid randomization. Conclusions ALL survivors with neurocognitive deficits are at risk for poor QOL, with broad implications for their physical, social, and school functioning. Copyright © 2014 John Wiley & Sons, Ltd. Source

Wilson K.S.,Honoring Choices Minnesota | Kottke T.E.,Health Partners Institute for Education and Research | Schettle S.,Twin Cities Medical Society
Journal of the American Geriatrics Society | Year: 2014

Advance care planning (ACP) increases the likelihood that individuals who are dying receive the care that they prefer. It also reduces depression and anxiety in family members and increases family satisfaction with the process of care. Honoring Choices Minnesota is an ACP program based on the Respecting Choices model of La Crosse, Wisconsin. The objective of this report is to describe the process, which began in 2008, of implementing Honoring Choices Minnesota in a large, diverse metropolitan area. All eight large healthcare systems in the metropolitan area agreed to participate in the project, and as of April 30, 2013, the proportion of hospitalized individuals 65 and older with advance care directives in the electronic medical record was 12.1% to 65.6%. The proportion of outpatients aged 65 and older was 11.6% to 31.7%. Organizations that had sponsored recruitment initiatives had the highest proportions of records containing healthcare directives. It was concluded that it is possible to reduce redundancy by recruiting all healthcare systems in a metropolitan area to endorse the same ACP model, although significantly increasing the proportion of individuals with a healthcare directive in their medical record requires a campaign with recruitment of organizations and individuals. © 2014, The American Geriatrics Society. Source

Beebe T.J.,Survey Research Center | Ziegenfuss J.Y.,Health Partners Institute for Education and Research | Jenkins S.M.,Mayo Medical School | Lackore K.A.,Mayo Medical School | Johnson T.P.,University of Illinois at Chicago
BMC Medical Research Methodology | Year: 2014

Background: Self-reported colorectal cancer (CRC) screening behavior is often subject to over-reporting bias. We examined how the inclusion of a future intention to screen item (viz. asking about future intentions to get screened before asking about past screening) and mode of survey administration impacted the accuracy of self-reported CRC screening. Methods. The target population was men and women between 49 and 85 years of age who lived in Olmsted County, MN, for at least 10 years at the time of the study. Eligible residents were randomized into four groups representing the presence or absence the future intention to screen item in the questionnaire and administration mode (mail vs. telephone). A total of 3,638 cases were available for analysis with 914, 838, 956, and 930 in the mail/future intention, mail/no future intention, telephone/future intention, and telephone/no future intention conditions, respectively. False positives were defined as self-reporting being screened among those with no documented history of screening in medical records and false negatives as not self-reporting screening among those with history of screening. Results: Comparing false positive and false negative reporting rates for each specific screening test among the responders at the bivariate level, regardless of mode, there were no statistically significant differences by the presence or absence of a preceding future intention question. When considering all tests combined, the percentage of false negatives within the telephone mode was slightly higher for those with the future intention question (6.7% vs 4.2%, p = 0.04). Multivariate models that considered the independent impact of the future intention question and mode, affirmed the results observed at the bivariate level. However, individuals in the telephone arm (compared to mail) were slightly (though not significantly) more likely to report a false positive (36.4% vs 31.8%, OR = 1.11, p = 0.55). Conclusion: It may be that in the context of a questionnaire that is clearly focused on CRC and with specific descriptions of the various CRC screening tests, certain design features such as including intention to screen items or mode of administration will have very little impact on the accuracy of self-reported CRC screening. © 2014Beebe et al.; licensee BioMed Central Ltd. Source

Cortes-Puentes G.A.,University of Minnesota | Gard K.E.,Regions Hospital | Adams A.B.,Regions Hospital | Faltesek K.A.,Health Partners Research Foundation | And 3 more authors.
Critical Care Medicine | Year: 2013

Objective: To clarify the effect of progressively increasing intra-abdominal pressure on esophageal pressure, transpulmonary pressure, and functional residual capacity. Design: Controlled application of increased intra-abdominal pressure at two positive end-expiratory pressure levels (1 and 10 cm H2O) in an anesthetized porcine model of controlled ventilation. Setting: Large animal laboratory of a university-affiliated hospital. Subjects: Eleven deeply anesthetized swine (weight 46.2 ± 6.2 kg). Interventions: Air-regulated intra-abdominal hypertension (0-25 mm Hg). Measurements: Esophageal pressure, tidal compliance, bladder pressure, and end-expiratory lung aeration by gas dilution. MAIN Results: Functional residual capacity was significantly reduced by increasing intra-abdominal pressure at both positive end-expiratory pressure levels (p ≤ 0.0001) without corresponding changes of end-expiratory esophageal pressure. Above intra-abdominal pressure 5 mm Hg, plateau airway pressure increased linearly by ~ 50% of the applied intra-abdominal pressure value, associated with commensurate changes of esophageal pressure. With tidal volume held constant, negligible changes occurred in transpulmonary pressure due to intra-abdominal pressure. Driving pressures calculated from airway pressures alone (plateau airway pressure - positive end-expiratory pressure) did not equate to those computed from transpulmonary pressure (tidal changes in transpulmonary pressure). Increasing positive end-expiratory pressure shifted the predominantly negative end-expiratory transpulmonary pressure at positive end-expiratory pressure 1 cm H2O (mean -3.5 ± 0.4 cm H2O) into the positive range at positive end-expiratory pressure 10 cm H2O (mean 0.58 ± 1.2 cm H2O). Conclusions: Despite its insensitivity to changes in functional residual capacity, measuring transpulmonary pressure may be helpful in explaining how different levels of positive end-expiratory pressure influence recruitment and collapse during tidal ventilation in the presence of increased intra-abdominal pressure and in calculating true transpulmonary driving pressure (tidal changes of transpulmonary pressure). Traditional interpretations of respiratory mechanics based on unmodified airway pressure were misleading regarding lung behavior in this setting. Copyright © 2013 by the Society of Critical Care Medicine and Lippincott Williams & Wilkins. Source

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