Treatment of Chemical Dependency May Reduce Medical Utilization and Costs

Summarizes a study of the impact of chemical dependency treatment on the costs and utilization of medical services -- hospital days, emergency department visits, and outpatient visits. Points to lack of insurance as a barrier to treatment

Quality of life measurement clarifies the cost-effectiveness of Helicobacter pylori eradication in peptic ulcer disease and uninvestigated dyspepsia 1

Previous economic studies of Helicobacter pylori eradication in dyspepsia and peptic ulcer disease have not measured quality of life using utilities (preference probabilities), which are needed to compare the cost-effectiveness of such treatment to other health care interventions. The goals of this study were to measure quality of life in patients with dyspepsia or peptic ulcer and apply these measurements to published models of disease management to determine cost-effectiveness in dollars per quality-adjusted life year (QALY) gained. Methods : Utilities for dyspepsia and peptic ulcer disease were measured in adult patients (n = 73) on chronic acid suppression for peptic ulcer or ulcer-like dyspepsia. Median utility values were applied to the results of published cost-effectiveness analyses and a previously validated dyspepsia model. Cost-utility ratios for early H. pylori eradication in uninvestigated dyspepsia and peptic ulcer disease were then computed. Results : The total disutility, or lost quality of life, for an ulcer was 0.11 QALY, of which 0.09 QALY was attributed to dyspeptic symptoms. After these results were incorporated into published studies, cost-utility ratios for ulcer treatment varied from $3,100 to$12,500 per QALY gained, whereas estimates for uninvestigated dyspepsia management ranged from $26,800 to$59,400 per QALY. Sensitivity analyses indicated a range of $1,300 to$27,300 per QALY for management of duodenal ulcer and $15,000 to$129,700 per QALY for dyspepsia. Conclusions: Strategies that emphasize early H. pylori eradication were cost-effective for patients with peptic ulcer and possibly cost-effective for patients with uninvestigated dyspepsia, relative to other medical interventions. Dyspeptic symptoms cause significant disutility that should be incorporated in future cost-effectiveness analyses of treatment strategies.Peer Reviewedhttp://deepblue.lib.umich.edu/bitstream/2027.42/73031/1/j.1572-0241.2001.03516.x.pd

Hormone replacement therapy is associated with better glycemic control in women with type 2 diabetes

WSTĘP. U kobiet chorych na cukrzycę zmiany towarzyszące menopauzie mogą prowadzić do dalszego pogorszenia kontroli glikemii. Mało jest danych dotyczących wpływu hormonalnej terapii zastępczej (HTZ) na metabolizm glukozy w cukrzycy. Celem badania była ocena zmian stężenia HbA1c u kobiet chorych na cukrzycę typu 2, stosujących HTZ. MATERIAŁ I METODY. W grupie 15 435 kobiet chorych na cukrzycę typu 2, należących do organizacji chorych na cukrzycę, oceniano HTZ i HbA1c na podstawie zapisów komputerowych w laboratorium oraz w rejestrach farmaceutycznych funkcjonujących w ramach jednego programu zdrowotnego. Zestawiono również dane socjodemograficzne oraz kliniczne. WYNIKI. Średni wiek badanych wynosił 64,7 roku (SD ± 8,7). Grupa badana obejmowała 55% kobiet rasy białej i 14% kobiet rasy czarnej pochodzenia innego niż hiszpańskie, 12% kobiet pochodzenia hiszpańskiego, 11% Azjatek, 4% z innych grup etnicznych i 4% z brakiem danych o pochodzeniu etnicznym. Stosowanie HTZ wykazano u 25% kobiet. Stężenie HbA1c było istotnie niższe u kobiet aktualnie stosujących HTZ niż u kobiet niestosujących HTZ (średnia skorygowana względem wieku ± SE: 7,9 ± 0,03 vs. 8,5 ± 0,02, p = 0,0001). Nie stwierdzono różnic pomiędzy kobietami stosującymi estrogeny w monoterapii i w połączeniu z progestagenami. W modelu równania szacunku uogólnionego (Generalized Estimating Equation model), uwzględniającego przypisanie pacjenta do lekarza i zależność względem wieku, pochodzenia etnicznego, wykształcenia, nadwagi, leczenia hipoglikemizującego, czasu trwania cukrzycy, samodzielnego monitorowania glikemii oraz aktywności fizycznej, HTZ pozostawała znamiennym i niezależnym elementem związanym z niższą wartością HbA1c (p = 0,0001). WNIOSKI. Hormonalna terapia zastępcza jest w niezależny sposób powiązana z obniżonym stężeniem HbA1c. Konieczne jest przeprowadzenie badania klinicznego określającego możliwości poprawy kontroli glikemii poprzez stosowanie HTZ u kobiet chorych na cukrzycę.OBJECTIVE. In women with diabetes, the changes that accompany menopause may further diminish glycemic control. Little is known about how hormone replacement therapy (HRT) affects glucose metabolism in diabetes. The aim of this study was to examine whether HbA1c levels varied by current HRT among women with type 2 diabetes. MATERIAL AND METHODS. In a cohort of 15,435 women with type 2 diabetes who were members of a health maintenance organization, HbA1c and HRT were assessed by reviewing records in the health plan’s computerized laboratory and pharmacy systems. Sociodemographic and clinical information were collected by survey. RESULTS. The mean age was 64.7 years (SD ± 8.7). The study cohort comprised 55% non-Hispanic whites, 14% non-Hispanic blacks, 12% Hispanics, 11% Asians, 4% ”other” ethnic groups, and 4% with missing ethnicity data. Current HRT was observed in 25% of women. HbA1c levels were significantly lower in women currently using HRT than in women not using HRT (age-adjusted mean ± SE: 7.9 ± 0.03 vs. 8.5 ± ± 0.02, respectively, P = 0.0001). No differences in HbA1c level were observed between women using unopposed estrogens and women using opposed estrogens. In a Generalized Estimating Equation model, which took into account patient clustering within physician and adjusted for age, ethnicity, education, obesity, hypoglycemic therapy, diabetes duration, self-monitoring of blood glucose, and exercise, HRT remained significantly and independently associated with decreased HbA1c levels (P = 0.0001). CONCLUSIONS. HRT was independently associated with decreased HbA1c level. Clinical trials will be necessary to understand whether HRT may improve glycemic control in women with diabetes

Chronic Kidney Disease and Cognitive Function in Older Adults: Findings from the Chronic Renal Insufficiency Cohort Cognitive Study

To investigate cognitive impairment in older, ethnically diverse individuals with a broad range of kidney function, to evaluate a spectrum of cognitive domains, and to determine whether the relationship between chronic kidney disease (CKD) and cognitive function is independent of demographic and clinical factors.Cross-sectional.Chronic Renal Insufficiency Cohort Study.Eight hundred twenty-five adults aged 55 and older with CKD.Estimated glomerular filtration rate (eGFR, mL/min per 1.73 m 2 ) was estimated using the four-variable Modification of Diet in Renal Disease equation. Cognitive scores on six cognitive tests were compared across eGFR strata using linear regression; multivariable logistic regression was used to examine level of CKD and clinically significant cognitive impairment (score ≤1 standard deviations from the mean).Mean age of the participants was 64.9, 50.4% were male, and 44.5% were black. After multivariable adjustment, participants with lower eGFR had lower cognitive scores on most cognitive domains ( P <.05). In addition, participants with advanced CKD (eGFR<30) were more likely to have clinically significant cognitive impairment on global cognition (adjusted odds ratio (AOR) 2.0, 95% CI=1.1–3.9), naming (AOR=1.9, 95% CI=1.0–3.3), attention (AOR=2.4, 95% CI=1.3–4.5), executive function (AOR=2.5, 95% CI=1.9–4.4), and delayed memory (AOR=1.5, 95% CI=0.9–2.6) but not on category fluency (AOR=1.1, 95% CI=0.6–2.0) than those with mild to moderate CKD (eGFR 45–59).In older adults with CKD, lower level of kidney function was associated with lower cognitive function on most domains. These results suggest that older patients with advanced CKD should be screened for cognitive impairment.Peer Reviewedhttp://deepblue.lib.umich.edu/bitstream/2027.42/78647/1/j.1532-5415.2009.02670.x.pd

Placebo Adherence and Its Association with Morbidity and Mortality in the Studies of Left Ventricular Dysfunction

A provocative finding from several double-blind clinical trials has been the association between greater adherence to placebo study medication and better health outcomes. We used data from the Studies of Left Ventricular Dysfunction (SOLVD) Treatment Trial (SOLVD-TT) and the SOLVD Prevention Trial (SOLVD-PT) to examine whether such associations could be validated and to examine several sources of bias and potential confounding. Survival analytic methods were used to estimate the association between placebo adherence and several health outcomes, employing a number of modeling techniques to test for the existence of alternative explanations for the association. Higher adherence was defined as having taken ≥75% of prescribed study medication. Higher placebo adherence was associated with improved overall survival in both SOLVD-TT and SOLVD-PT [hazard ratio (HR) = 0.52, 95% confidence interval (CI): 0.35 to 0.79 and HR = 0.52, 95%CI: 0.38 to 0.71, respectively]. Associations were similar for fatal or non-fatal cardiovascular or coronary heart disease events. Adjustment for both modifiable and non-modifiable cardiac risk factors (including age, gender, diabetes, blood pressure, smoking, weight, alcohol use, and levels of education) had minimal effect on the strength of the association. Little evidence of bias was found as an explanation for this relationship. In these two trials, better adherence to placebo was associated with markedly superior health outcomes, including total in-study mortality and incident cardiovascular events. No important confounders were identified. These data suggest there may exist strong but unrecognized determinants of health outcomes for which placebo adherence is a marker

Prevalence of Childhood and Adolescent Overweight and Obesity from 2003 to 2010 in an Integrated Health Care Delivery System

An observational study of the Kaiser Permanente Northern California (KPNC) BMI coding distributions was conducted to ascertain the trends in overweight and obesity prevalence among KPNC members aged 2–19 between the periods of 2003–2005 and 2009-2010. A decrease in the prevalence of overweight (−11.1% change) and obesity (−3.6% change) and an increase in the prevalence of healthy weight (+2.7% change) were demonstrated. Children aged 2–5 had the greatest improvement in obesity prevalence (−11.5% change). Adolescents aged 12–19 were the only age group to not show a decrease in obesity prevalence. Of the racial and ethnic groups, Hispanics/Latinos had the highest prevalence of obesity across all age groups. The KPNC prevalence of overweight and obesity compares favorably to external benchmarks, although differences in methodologies limit our ability to draw conclusions. Physician counseling as well as weight management programs and sociodemographic factors may have contributed to the overall improvements in BMI in the KPNC population. Physician training, practice tools, automated BMI reminders and performance feedback improved the frequency and quality of physician counseling. BMI screening and counseling at urgent visits, in addition to well-child care visits, increased the reach and dose of physician counseling

Sex and Racial/Ethnic Disparities in Outcomes After Acute Myocardial Infarction

Background Previous studies have documented sex and racial/ethnic disparities in outcomes after acute myocardial infarction (AMI), but the explanation of these disparities remains limited. In a setting that controls for access to medical care, we evaluated whether sex and racial/ethnic disparities in prognosis after AMI persist after consideration of socioeconomic background, personal medical history, and medical management. Methods We conducted a prospective cohort study of the members (20 263 men and 10 061 women) of an integrated health care delivery system in northern California who had experienced an AMI between January 1, 1995, and December 31, 2002, and were followed up for a median of 3.5 years (maximum, 8 years). Main outcome measures included AMI recurrence and all-cause mortality. Results In age-adjusted analyses relative to white men, black men (hazard ratio [HR], 1.44; 95% confidence interval [CI], 1.26-1.65), black women (HR, 1.47; 95% CI, 1.26-1.72), and Asian women (HR, 1.37; 95% CI, 1.13-1.65) were at increased risk of AMI recurrence. However, multivariate adjustment for sociodemographic background, comorbidities, medication use, angiography, and revascularization procedures effectively removed the excess risk of AMI recurrence in these 3 groups. Similarly, the increased age-adjusted risk of all-cause mortality seen in black men (HR, 1.55; 95% CI, 1.37-1.75) and black women (HR, 1.45; 95% CI, 1.27-1.66) was greatly attenuated in black men and reversed in black women after full multivariate adjustment. Conclusion In a population with equal access to medical care, comprehensive consideration of social, personal, and medical factors could explain sex and racial/ethnic disparities in prognosis after AMI

Placebo Adherence and Mortality in the Heart and Estrogen/Progestin Replacement Study

BackgroundAnalyses from double-blind randomized trials have reported lower mortality among participants who were more adherent to placebo compared with those who were less adherent. We explored this phenomenon by analyzing data from the placebo arm of the Heart and Estrogen/Progestin Replacement Study (HERS), a randomized, double-blind, placebo-controlled trial of estrogen plus progestin for secondary prevention of coronary heart disease in postmenopausal women. Our primary aim was to measure and explain the association between adherence to placebo and total mortality among the placebo-allocated participants in the HERS. Secondary aims included assessment of the association between placebo adherence and cause-specific morbidity and mortality.MethodsParticipants with "higher placebo adherence" were defined as having taken at least 75% of their placebo study medication during each individual's participation in the study, whereas those with "lower placebo adherence" took less than 75%. The primary outcome was in-study all-cause mortality.ResultsMore adherent participants had significantly lower total mortality compared with less adherent participants (hazard ratio, 0.52; 95% confidence interval, 0.29-0.93). Adjusting for available confounders did not change the magnitude or significance of the estimates. Analyses revealed that the association of higher adherence and mortality might be explained, in part, by time-dependent confounding.ConclusionsAnalyses of the HERS data support a strong association between adherence to placebo study medication and mortality. Although probably not due to simple confounding by healthy lifestyle factors, the underlying mechanism for the association remains unclear. Further analyses of this association are necessary to explain this observation

Effectiveness and reach of the FLU-FIT program in an integrated health care system: a multisite randomized trial.

ObjectivesWe tested the effectiveness of offering home fecal immunochemical tests (FITs) during influenza vaccination clinics to increase colorectal cancer screening (CRCS).MethodsIn a clinical trial at Kaiser Permanente Northern California influenza clinics in Redwood City, Richmond, South San Francisco, Union City, and Fresno, we randomly assigned influenza clinic dates to intervention (FIT offered) or control (FIT not offered) and compared subsequent CRCS activity.ResultsClinic staff provided FITs to 53.9% (1805/3351) of intervention patients aged 50 to 75 years. In the intent-to-treat analysis, 26.9% (900/3351) and 11.7% (336/2884) of intervention and control patients completed an FIT, respectively, within 90 days of vaccination (P ≤ .001). The adjusted odds ratio for completing FIT in the intervention versus the control arm was 2.75 (95% confidence interval = 2.40, 3.16). In the per protocol analysis, 35.4% (648/1830) of patients given FIT and 13.3% (588/4405) of patients not given FIT completed FIT within 90 days of vaccination (P ≤ .001).ConclusionsThis intervention may increase CRCS among those not reached by other forms of CRCS outreach. Future research should include the extent to which these programs can be disseminated and implemented nationally

Effectiveness and reach of the FLU-FIT program in an integrated health care system: a multisite randomized trial.

ObjectivesWe tested the effectiveness of offering home fecal immunochemical tests (FITs) during influenza vaccination clinics to increase colorectal cancer screening (CRCS).MethodsIn a clinical trial at Kaiser Permanente Northern California influenza clinics in Redwood City, Richmond, South San Francisco, Union City, and Fresno, we randomly assigned influenza clinic dates to intervention (FIT offered) or control (FIT not offered) and compared subsequent CRCS activity.ResultsClinic staff provided FITs to 53.9% (1805/3351) of intervention patients aged 50 to 75 years. In the intent-to-treat analysis, 26.9% (900/3351) and 11.7% (336/2884) of intervention and control patients completed an FIT, respectively, within 90 days of vaccination (P ≤ .001). The adjusted odds ratio for completing FIT in the intervention versus the control arm was 2.75 (95% confidence interval = 2.40, 3.16). In the per protocol analysis, 35.4% (648/1830) of patients given FIT and 13.3% (588/4405) of patients not given FIT completed FIT within 90 days of vaccination (P ≤ .001).ConclusionsThis intervention may increase CRCS among those not reached by other forms of CRCS outreach. Future research should include the extent to which these programs can be disseminated and implemented nationally