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Biomedical subjects

E H Wagner

Publications and source records attributed to E H Wagner.

At least 37 records · Page 2Linked to original sources
PubMed1999

Prostate-specific antigen for prostate cancer screening. Do physician characteristics affect its use?

PURPOSE: Screening for prostate cancer with the prostate-specific antigen (PSA) test remains controversial. This controversy is reflected in a lack of consensus in the medical literature and among professional and policy organizations regarding routine screening by PSA. It is not known how physicians respond when recommendations from experts are inconsistent. METHODS: A questionnaire was mailed to 1369 primary care physicians in active practice in Washington State in 1994. Response rate to the survey was 63%. Chi-square tests and multivariate logistic regression analysis were used to examine the effects of physician characteristics on physicians' self report of use of the PSA test for screening asymptomatic male patients, aged 50 to 80, for prostate cancer. RESULTS: Of the 714 physicians included in the analysis, 68% reported routine use of PSA. Use of PSA varied among physicians on the basis of practice setting, years since medical school graduation, and whether compensation was fee-for-service or salaried. Male physicians trained before 1974 and physicians receiving fee-for-service were significantly more likely than other physicians to recommend screening by PSA. CONCLUSIONS: Results suggest that physicians' personal characteristics such as year of medical school graduation, gender, and mode of reimbursement are related to self-reported PSA use.

Chi-Square Distribution↗
PubMed1999

The use of automated data to identify complications and comorbidities of diabetes: a validation study.

We evaluated the accuracy of administrative data for identifying complications and comorbidities of diabetes using International Classification of Diseases, 9th edition, Clinical Modification and Current Procedural Terminology codes. The records of 471 randomly selected diabetic patients were reviewed for complications from January 1, 1993 to December 31, 1995; chart data served to validate automated data. The complications with the highest sensitivity determined by a diagnosis in the medical records identified within +/-60 days of the database date were myocardial infarction (95.2%); amputation (94.4%); ischemic heart disease (90.3%); stroke (91.2%); osteomyelitis (79.2%); and retinal detachment, vitreous hemorrhage, and vitrectomy (73.5%). With the exception of amputation (82.9%), positive predictive value was low when based on a diagnosis identified within +/-60 days of the database date but increased with relaxation of the time constraints to include confirmation of the condition at any time during 1993-1995: ulcers (88.5%); amputation (85.4%); and retinal detachment, vitreous hemorrhage and vitrectomy (79.8%). Automated data are useful for ascertaining potential cases of some diabetic complications but require confirmatory evidence when they are to be used for research purposes.

Adolescent↗
PubMed1999

Lipid-lowering medication and risk of injury.

Meta-analyses of early primary prevention trials of lipid-lowering therapies suggested increased risk of injury deaths among treated persons. Our population-based case-control study examined the association of lipid-lowering medication use with fatal and nonfatal injuries in 298 cases and 332 controls. No increased injury risk was observed among current (OR = 0.46, 95% CI 0.18-1.21) or past users (OR = .92, 95% CI 0.44-1.95), after adjustment for behavioral disorders, medical conditions, and health status. Stratified analyses did not reveal sub-groups at significantly increased risk. These results, consistent with recent clinical trials and meta-analyses, suggest no increased injury risk associated with lipid-lowering medications.

Accidents, Home↗
PubMed1999

Chronic care clinics: a randomized controlled trial of a new model of primary care for frail older adults.

OBJECTIVE: To determine whether a new model of primary care, Chronic Care Clinics, can improve outcomes of common geriatric syndromes (urinary incontinence, falls, depressive symptoms, high risk medications, functional impairment) in frail older adults. DESIGN: Randomized controlled trial with 24 months of follow-up. Physician practices were randomized either to the Chronic Care Clinics intervention or to usual care. SETTING: Nine primary care physician practices that comprise an ambulatory clinic in a large staff-model HMO in western Washington State. PARTICIPANTS: Those patients aged 65 and older in each practice with the highest risk for being hospitalized or experiencing functional decline. INTERVENTION: Intervention practices (5 physicians, 96 patients) held half-day Chronic Care Clinics every 3 to 4 months. These clinics included an extended visit with the physician and nurse dedicated to planning chronic disease management; a pharmacist visit that emphasized reduction of polypharmacy and high-risk medications; and a patient self-management/support group. Control practices (4 physicians, 73 patients) received usual care. MEASUREMENTS: Changes in self-reported urinary incontinence, frequency of falls, depressive symptoms, physical function, and satisfaction were analyzed using an intention-to-treat analysis adjusted for baseline differences, covariates, and practice-level variation. Prescriptions for high-risk medications and cost/utilization data obtained from administrative data were similarly analyzed. RESULTS: After 24 months, no significant improvements in frequency of incontinence, proportion with falls, depression scores, physical function scores, or prescriptions for high risk medications were demonstrated. Costs of medical care including frequency of hospitalization, hospital days, emergency and ambulatory visits, and total costs of care were not significantly different between intervention and control groups. A higher proportion of intervention patients rated the overall quality of their medical care as excellent compared with control patients (40.0% vs 25.3%, P = .10). CONCLUSIONS: Although intervention patients expressed high levels of satisfaction with Chronic Care Clinics, improved outcomes for selected geriatric syndromes were not demonstrated. These findings suggest the need for developing greater system-wide support for managing geriatric syndromes in primary care and illustrate the challenges of conducting practice improvement research in a rapidly changing delivery system.

Aged↗
PubMed1999

Patient-level estimates of the cost of complications in diabetes in a managed-care population.

OBJECTIVE: To develop incidence-based estimates of the cost of several diabetes-related complications. DESIGN AND SETTING: This was a retrospective cohort study in a large health maintenance organisation. A total of 8905 patients with type 1 (insulin-dependent) and type 2 (non-insulin-dependent) diabetes mellitus and 36,520 age- and gender-matched controls without diabetes were observed from 1992 to 1995. Incidence rates of 6 major diabetes-related complications were computed for both populations. Annual health expenditures in the first and second year following diagnosis were computed for each complication. For comparison, annual costs were derived for individuals without diabetes or the complication of interest. MAIN OUTCOME MEASURES AND RESULTS: Over 3 years of observation, incidence rates for the groups with and without diabetes were as follows: myocardial infarction 9.0 versus 3.2%; stroke 8.7 versus 3.8%; hypertension 26.2 versus 16.9%; end-stage renal disease 5.9 versus 1.4%; foot ulcer 7.9 versus 1.1%; and eye disease 44.3 versus 2.8%. Expressed as a multiple of the average annual cost of care for those without diabetes [$US3400/year (1995 dollars) for those over 65 years of age] and the related complication of interest, excess expenditures for those with diabetes were as follows for the first year following diagnosis: no complications 1.59; myocardial infarction 4.1; stroke 3.5; hypertension 2.56; end-stage renal disease 4.32; foot ulcer 4.0; and eye disease 2.46. For younger cohorts (less prevalent in the sample), incremental costs for each complication were generally greater than in the older group. CONCLUSIONS: The high incidences and costs may support the value of aggressive early intervention for patients with diabetes. These data will be useful for pharmacoeconomic modelling of the cost effectiveness of new and existing therapies for this condition.

Adolescent↗
PubMed1999

Incidence, outcomes, and cost of foot ulcers in patients with diabetes.

OBJECTIVE: To determine the incidence of foot ulcers in a large cohort of patients with diabetes, the risk of developing serious complications after diagnosis, and the attributable cost of care compared with that in patients without foot ulcers. RESEARCH DESIGN AND METHODS: Retrospective cohort study of patients with diabetes in a large staff-model health maintenance organization from 1993 to 1995. Patients with diabetes were identified by algorithm using administrative, laboratory, and pharmacy records. The data were used to calculate incidence of foot ulcers, risk of osteomyelitis, amputation, and death after diagnosis of foot ulcer, and attributable costs in foot ulcer patients compared with patients without foot ulcers. RESULTS: Among 8,905 patients identified with type 1 or type 2 diabetes, 514 developed a foot ulcer over 3 years of observation (cumulative incidence 5.8%). On or after the time of diagnosis, 77 (15%) patients developed osteomyelitis and 80 (15.6%) required amputation. Survival at 3 years was 72% for the foot ulcer patients versus 87% for a group of age- and sex-matched diabetic patients without foot ulcers (P < 0.001). The attributable cost for a 40- to 65-year-old male with a new foot ulcer was $27,987 for the 2 years after diagnosis. CONCLUSIONS: The incidence of foot ulcers in this cohort of patients with diabetes was nearly 2.0% per year. For those who developed ulcers, morbidity, mortality, and excess care costs were substantial compared with those for patients without foot ulcers. The results appear to support the value of foot-ulcer prevention programs for patients with diabetes.

Aged↗
PubMed1999

A survey of leading chronic disease management programs: are they consistent with the literature?

Caring for patients with chronic illness in an era of cost constraints and performance monitoring has led to a sharp growth in "disease management" efforts by health systems utilizing internal innovators or outside firms. This paper describes surveys and site visits of the chronic disease management activities of 72 programs nominated by experts in the field of chronic illness care as being particularly innovative and effective. The survey and analysis were guided by a Model for Effective Chronic Illness Care derived from a process of literature synthesis and expert review. The model proved to be useful in describing the characteristics consistently shared by successful programs, and the surveys indicated common barriers to further expansion of innovative pilot programs. The survey indicated that most of the nominated programs were limited in their effectiveness and reach by their reliance on traditional patient education, rather than modern self-management support, poor linkages to primary care, and reliance on referrals rather than population-based approaches.

Case Management↗
PubMed1999

Innovative healthcare for chronically ill older persons: results of a national survey.

OBJECTIVE: To describe the origin, scope, operations, funding, and outcomes of innovative healthcare programs for chronically ill older persons. STUDY DESIGN: Cross-sectional survey. METHODS: A national expert panel nominated chronic illness programs they believed to be innovative and field tested. The directors of the 31 eligible programs provided descriptive information in 60-minute semistructured telephone interviews. RESULTS: The innovative programs we surveyed tended to target their services to high-risk patients, use teams of providers to deliver care, designate providers to coordinate multiple components of complex care plans, and shift care from higher- to lower-cost environments and/or redesign the delivery of primary care. CONCLUSIONS: Recent innovations in healthcare programs hold considerable promise for improving the outcomes of chronic care, but most have yet to be rigorously evaluated.

Aged↗
PubMed1998

A randomized controlled trial of CQI teams and academic detailing: can they alter compliance with guidelines?

BACKGROUND: The availability of clinical guidelines in isolation has generally failed to promote voluntary change in practice patterns. Accordingly, a randomized controlled trial was conducted to determine the effectiveness of academic detailing (AD) techniques and continuous quality improvement (CQI) teams in increasing compliance with national guidelines for the primary care of hypertension and depression. METHODS: Fifteen small group practices at four Seattle primary care clinics were assigned to one of three study arms--AD alone, AD plus CQI teams, or usual care. The activity of 95 providers and 4,995 patients was monitored from August 1, 1993, through January 31, 1996. Twelve-month baseline and study periods were separated by a six-month "wash-in" period during which training sessions were held. Changes in hypertension prescribing, blood pressure control, depression recognition, use of older tricyclics, and scores on the Hopkins Symptom Checklist depression scale were examined. RESULTS: Clinics varied considerably in their implementation of both the AD and the CQI team interventions. Across all sites, AD was associated with change in a single process measure, a decline in the percentage of depressives prescribed first-generation tricyclics (-4.7 percentage points versus control, p = 0.04). No intervention effects were demonstrated for CQI teams across all sites for either disease condition. Within the clinic independently judged most successful at implementing both change strategies, the use of CQI teams and AD in combination did increase the percentage of hypertensives adequately controlled (17.3 percentage points versus control, p = 0.03). SUMMARY AND CONCLUSIONS: The AD techniques and the CQI teams evaluated were generally ineffective in improving guideline compliance and clinical outcomes regarding the primary care of hypertension and depression.

Adult↗
PubMed1998

Organizing health care for people with seizures and epilepsy.

The day-to-day responsibilities of managing seizures and epilepsy fall most heavily on patients and their families. Unfortunately, health care services in the United States are not organized to identify, diagnose, and treat people with seizures effectively nor are they delivered in such a way that patients and their families can engage in a positive, collaborative relationship with health care providers. This article describes a model of chronic illness care as applied to seizures and epilepsy, that is, how care should be structured to help people with seizures live as well as possible.

Chronic Disease↗
PubMed1998

Predicting hospitalization and functional decline in older health plan enrollees: are administrative data as accurate as self-report?

OBJECTIVE: To compare the predictive accuracy of two validated indices, one that uses self-reported variables and a second that uses variables derived from administrative data sources, to predict future hospitalization. To compare the predictive accuracy of these same two indices for predicting future functional decline. DESIGN: A longitudinal cohort study with 4 years of follow-up. SETTING: A large staff model HMO in western Washington State. PARTICIPANTS: HMO Enrollees 65 years and older (n = 2174) selected at random to participate in a health promotion trial and who completed a baseline questionnaire. MEASUREMENT: Predicted probabilities from the two indices were determined for study participants for each of two outcomes: hospitalization two or more times in 4 years and functional decline in 4 years, measured by Restricted Activity Days. The two indices included similar demographic characteristics, diagnoses, and utilization predictors. The probabilities from each index were entered into a Receiver Operating Characteristic (ROC) curve program to obtain the Area Under the Curve (AUC) for comparison of predictive accuracy. RESULTS: For hospitalization, the AUC of the self-report and administrative indices were .696 and .694, respectively (difference between curves, P = .828). For functional decline, the AUC of the two indices were .714 and .691, respectively (difference between curves, P = .144). CONCLUSIONS: Compared with a self-report index, the administrative index affords wider population coverage, freedom from nonresponse bias, lower cost, and similar predictive accuracy. A screening strategy utilizing administrative data sources may thus prove more valuable for identifying high risk older health plan enrollees for population-based interventions designed to improve their health status.

Activities of Daily Living↗
PubMed1998

Preventing disability and managing chronic illness in frail older adults: a randomized trial of a community-based partnership with primary care.

BACKGROUND: Effective new strategies that complement primary care are needed to reduce disability risks and improve self-management of chronic illness in frail older people living in the community. OBJECTIVE: To evaluate the impact of a 1-year, senior center-based chronic illness self-management and disability prevention program on health, functioning, and healthcare utilization in frail older adults. DESIGN: A randomized controlled trial. SETTING: A large senior center located in a northeast Seattle suburb. The trial was conducted in collaboration with primary care providers of two large managed care organizations. PARTICIPANTS: A total of 201 chronically ill older adults seniors aged 70 and older recruited through medical practices. INTERVENTION: A targeted, multi-component disability prevention and disease self-management program led by a geriatric nurse practitioner (GNP). MEASUREMENTS: Self-reported Physical function, physical performance tests, health care utilization, and health behaviors. RESULTS: Each of 101 intervention participants met with the GNP from 1 to 8 times (median = 3) during the study year. The intervention group showed less decline in function, as measured by disability days and lower scores on the Health Assessment Questionnaire. Other measures of function, including the SF-36 and a battery of physical performance tests, did not change with the intervention. The number of hospitalized participants increased by 69% among the controls and decreased by 38% in the intervention group (P = .083). The total number of inpatient hospital days during the study year was significantly less in the intervention group compared with controls (total days = 33 vs 116, P = .049). The intervention led to significantly higher levels of physical activity and senior center participation and significant reductions in the use of psychoactive medications. CONCLUSIONS: This project provides evidence that a community-based collaboration with primary care providers can improve function and reduce inpatient utilization in chronically ill older adults. Linking organized medical care with complementary community-based interventions may be a promising direction for research and practice.

Activities of Daily Living↗
PubMed1998

Managed care data and public health: the experience of Group Health Cooperative of Puget Sound.

Traditional group and staff model HMOs have contributed to public health investigations for decades. HMOs offer several advantages for this type of research because of their defined population and provider groups and the integrated nature of care delivery in these organizations. Traditional HMOs have also made investments in sophisticated data systems to support evidence-based care that is supported by high-quality clinical data available in automated information systems. This paper reviews why traditional HMOs are ideal places to conduct public health research and analyzes how recent market trends may threaten this role for managed care.

Cooperative Behavior↗
PubMed1998

Use of services by diabetes patients in managed care organizations. Development of a diabetes surveillance system. CDC Diabetes in Managed Care Work Group.

OBJECTIVE: To develop a diabetes surveillance system that estimates the prevalence of diabetes and characterizes service use in diverse managed care organizations (MCOs). RESEARCH DESIGN AND METHODS: Computerized inpatient, pharmacy, outpatient, and laboratory records were used to develop an algorithm to identify diabetes patients and to develop surveillance indicators common to the three participating MCOs. Using 1993 data, the availability, specifications, and limitations of various surveillance indicators were determined. RESULTS: An extensive set of diabetes surveillance indicators was identified from the four sources of data. Consistent data specifications across MCOs needed to consider variation in the type of data collected, a lack of documentation on level of coverage, differences in coding data, and different models of health care delivery. A total of 16,363 diabetes patients were identified. The age-adjusted prevalence of diabetes ranged from 24 to 29 per 1,000 enrollees. Approximately one-third of patients with diabetes (32-34%) were taking insulin. The majority had one or more visits to a primary care physician during the year (72-94%). Visits to specialists were less frequent. Ophthalmologists and optometrists were the most commonly used specialists: 29-60% of the patients with diabetes at the three MCOs had visited an ophthalmologist or optometrist. About one-fifth had an overnight hospital stay during the year. CONCLUSIONS: This diabetes surveillance system is a useful tool for MCOs to track trends in prevalence of diabetes, use of health services, and delivery of preventive care to individuals with diabetes. This system may also be useful for health care planning and for assessing use changes after new developments in diabetes care or new quality management initiatives.

Adolescent↗
PubMed1997

Collaborative management of chronic illness.

In chronic illness, day-to-day care responsibilities fall most heavily on patients and their families. Effective collaborative relationships with health care providers can help patients and families better handle self-care tasks. Collaborative management is care that strengthens and supports self-care in chronic illness while assuring that effective medical, preventive, and health maintenance interventions take place. In this paper, the following essential elements of collaborative management developed in light of behavioral principles and empirical evidence about effective care in chronic illness are discussed: 1) collaborative definition of problems, in which patient-defined problems are identified along with medical problems diagnosed by physicians; 2) targeting, goal setting, and planning, in which patients and providers focus on a specific problem, set realistic objectives, and develop an action plan for attaining those objectives in the context of patient preferences and readiness; 3) creation of a continuum of self-management training and support services, in which patients have access to services that teach skills needed to carry out medical regimens, guide health behavior changes, and provide emotional support; and 4) active and sustained follow-up, in which patients are contacted at specified intervals to monitor health status, identify potential complications, and check and reinforce progress in implementing the care plan. These elements make up a common core of services for chronic illness care that need not be reinvented for each disease.

Chronic Disease↗
PubMed1997

Starting insulin therapy in patients with type 2 diabetes: effectiveness, complications, and resource utilization.

CONTEXT: Although experimental studies show that insulin therapy can be safe and efficacious in improving glycemic control in type 2 diabetes under optimal conditions (ie, using patient volunteers with close monitoring under strict study protocols), little is known about its effectiveness, complication rates, and associated resource utilization in actual clinical practice. DESIGN: Cohort study. SETTING: Large staff-model health maintenance organization. PARTICIPANTS: A total of 8668 patients with type 2 diabetes cared for by generalist physicians from 1990 through 1993. OUTCOME MEASURES: Resource use (hospitalizations, outpatient visits, laboratory testing, and home glucose monitoring) and glycemic control were evaluated using combined clinical, survey, and administrative information systems data. Detailed clinical case-mix data, including a newly validated case-mix method, the Total Illness Burden Index, were collected on a subsample of 1738 patients. RESULTS: Among patients starting insulin therapy, hemoglobin A1c (HbA1c) decreased by 0.9 percentage point (95% confidence interval, 0.7-1.0) at 1 year compared with those receiving stable medication regimens; however, 2 years after starting insulin therapy, 60% still had HbA1c levels of 8% or greater. There was no evidence that some primary care physicians achieved better results than other primary care physicians when starting insulin therapy in their patients. Patients with the poorest baseline glycemic control achieved substantially greater HbA1c reductions; those with a baseline HbA1c level of 13% had a 3-fold greater decline in HbA1c than those whose baseline HbA1c level was 9%. For a subset of all patients for whom detailed clinical case-mix data were obtained, those taking insulin had higher resource use than those taking sulfonylureas, independent of illness severity. After adjusting for age, sex, race, socioeconomic status, disease duration, and severity of diabetes and comorbidities, insulin users had slightly more laboratory tests performed, 2.4 more outpatient visits per year, and almost 300 more fingersticks for home glucose testing per year compared with sulfonylurea users (all P<.01). Although 15% of patients receiving insulin therapy reported weekly symptoms of hypoglycemia, insulin therapy was not associated with an increase in emergency department visits (after case-mix adjustment) and resulted in only 0.5 hypoglycemia-related hospitalizations per 100 patient-years. CONCLUSIONS: For patients with type 2 diabetes who were cared for by generalist physicians, starting insulin therapy was generally safe and effective in achieving moderate glycemic control in patients who initially had poor glycemic control. However, insulin therapy was associated with increases in resource use and was rarely effective in achieving tight glycemic control, even for those with moderate control.

Adult↗