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Biomedical subjects

E H Wagner

Publications and source records attributed to E H Wagner.

At least 55 records · Page 3Linked to original sources
PubMed1997

Absence of association between insurance copayments and delays in seeking emergency care among patients with myocardial infarction.

BACKGROUND: The requirement of copayments for emergency care is thought to control costs by reducing "inappropriate" visits to the emergency department. However, requiring copayments may lead to adverse outcomes if patients delay seeking care for emergency conditions. To determine whether such requirements are associated with delays in seeking care, we examined the length of time from the onset of symptoms to arrival at the hospital among patients with myocardial infarction who did or did not have required insurance copayments. METHODS: All patients were enrolled in a single health maintenance organization (HMO) and presented with myocardial infarction at 1 of 19 hospitals in King County, Washington, from 1989 through 1994. There were 602 patients whose health insurance required a copayment for emergency department care (range, $25 to $100) and 729 patients with no copayment requirement. Data on the time to presentation were obtained from a review of ambulance and hospital records. RESULTS: The median length of time from the onset of symptoms to arrival at the hospital, as adjusted for age, sex, and race, was 135 minutes for the copayment group and 137 minutes for the group with no copayment (95 percent confidence interval for the difference, -19 to +16 minutes). There was no significant association between the presence or absence of a copayment requirement and the time to arrival at the hospital after adjustment for calendar year, income, educational level, cardiac history, or clinical symptoms. Since some patients may be unaware of their copayment requirement, we performed a subgroup analysis of data on patients who had a previous visit to the emergency department with the same copayment status - that is, of patients who were likely to know about their copayment. This analysis also showed no significant association between the requirement for a copayment and delays in seeking treatment. CONCLUSIONS: For privately insured patients in this HMO, the requirement of modest, fixed copayments for emergency services did not lead to delays in seeking treatment for myocardial infarction.

Adult↗
PubMed1997

Health outcomes associated with antihypertensive therapies used as first-line agents. A systematic review and meta-analysis.

OBJECTIVE: To review the scientific evidence concerning the safety and efficacy of various antihypertensive therapies used as first-line agents and evaluated in terms of major disease end points. DATA SOURCES: MEDLINE searches and previous meta-analyses for 1980 to 1995. DATA SELECTION: We selected long-term studies that assessed major disease end points as an outcome. For the meta-analysis, we chose placebo-controlled randomized trials. For randomized trials using surrogate end points such as blood pressure, we selected the largest studies that evaluated multiple drugs. Where clinical trial evidence was lacking, we relied on information from observational studies. DATA SYNTHESIS: Diuretics and beta-blockers have been evaluated in 18 long-term randomized trials. Compared with placebo, beta-blocker therapy was effective in preventing stroke (relative risk [RR], 0.71; 95% confidence interval [CI], 0.59-0.86) and congestive heart failure (RR, 0.58; 95% CI, 0.40-0.84). The findings were similar for high-dose diuretic therapy (for stroke, RR, 0.49; 95% CI, 0.39-0.62; and for congestive heart failure, RR, 0.17; 95% CI, 0.07-0.41). Low-dose diuretic therapy prevented not only stroke (RR, 0.66; 95% CI, 0.55-0.78) and congestive heart failure (RR, 0.58; 95% CI, 0.44-0.76) but also coronary disease (RR, 0.72; 95% CI, 0.61-0.85) and total mortality (RR, 0.90; 95% CI, 0.81-0.99). Although calcium channel blockers and angiotensin-converting enzyme (ACE) inhibitors reduce blood pressure in hypertensive patients, the clinical trial evidence in terms of health outcomes is meager. For several short-acting dihydropyridine calcium channel blockers, the available evidence suggests the possibility of harm. Whether the long-acting formulations and the nondihydropyridine calcium channel blockers are safe and prevent major cardiovascular events in patients with hypertension remains untested and therefore unknown. CONCLUSION: Until the results of large long-term clinical trials evaluating the effects of calcium channel blockers and ACE inhibitors on cardiovascular disease incidence are completed, the available scientific evidence provides strong support for the current national guidelines, which recommend diuretics and beta-blockers as firstline agents and low-dose therapy for all antihypertensive agents.

Adrenergic beta-Antagonists↗
PubMed1997

Metabolic control and prevalent cardiovascular disease in non-insulin-dependent diabetes mellitus (NIDDM): The NIDDM Patient Outcome Research Team.

PURPOSE: Cardiovascular disease is a major cause of morbidity and death in non-insulin-dependent diabetes mellitus (NIDDM). While hyperglycemia is clearly related to diabetic microvascular complications, it contribution to large-vessel atherosclerosis is controversial. PATIENTS AND METHODS: We performed an analysis of the association between glycemic control and prevalent cardiovascular disease in 1,539 participants in the NIDDM Patient Outcomes Research Team study who were under usual care in a health maintenance organization. Prevalent cardiovascular disease and its risk factors were identified by self-administered questionnaire. Cardiovascular disease was defined by the presence of coronary heart disease, peripheral vascular disease, and/or cerebrovascular disease. Glycohemoglobin and lipid levels were obtained from a computerized laboratory database. RESULTS: The mean age of participants was 63 years (range 31 to 91); 51% were women. The mean duration of NIDDM was 9 years (range < 1 to 50), 35% took insulin, and 48% took sulfonylureas. Mean glycohemoglobin was 10.6%. Sixty percent had hypertension, 16% currently smoked cigarettes, and the mean total high-density lipoprotein (HDL) cholesterol ratio was 5.7. Fifty-one percent had cardiovascular disease. Cardiovascular disease prevalence remained constant across increasing quartiles of glycohemoglobin for both men and women. In contrast, prevalent cardiovascular disease was associated with established cardiovascular disease risk factors including age (67 versus 59 years, P < 0.0001), hypertension (66% versus 54%, P < 0.0001), current cigarette smoking (17% versus 13%, P < 0.005), and total/HDL cholesterol ratio (5.9 versus 5.6, P < 0.005). Cardiovascular disease was also associated with duration of NIDDM (11 versus 8 years, P < 0.0001). In multiple logistic regression analysis controlling for established cardiovascular disease risk factors and diabetes duration and therapy, glycohemoglobin remained unassociated with cardiovascular disease. CONCLUSIONS: Glycemic control is not associated with prevalent cardiovascular disease in this large population of individuals with NIDDM. Conventional cardiovascular disease risk factors are independently associated with cardiovascular disease and be a more promising focus for clinical intervention to reduce atherosclerotic complications in NIDDM.

Adult↗
PubMed1997

The effect of strength and endurance training on gait, balance, fall risk, and health services use in community-living older adults.

BACKGROUND: The study tested the effect of strength and endurance training on gait, balance, physical health status, fall risk, and health services use in older adults. METHODS: The study was a single-blinded, randomized controlled trial with intention-to-treat analysis. Adults (n = 105) age 68-85 with at least mild deficits in strength and balance were selected from a random sample of enrollees in a health maintenance organization. The intervention was supervised exercise (1-h sessions, three per week, for 24-26 weeks), followed by self-supervised exercise. Exercise groups included strength training using weight machines (n = 25), endurance training using bicycles (n = 25), and strength and endurance training (n = 25). Study outcomes included gait tests, balance tests, physical health status measures, self-reported falls (up to 25 months of follow-up), and inpatient and outpatient use and costs. RESULTS: There were no effects of exercise on gait, balance, or physical health status. Exercise had a protective effect on risk of falling (relative hazard = .53, 95% CI = .30-.91). Between 7 and 18 months after randomization, control subjects had more outpatient clinic visits (p < .06) and were more likely to sustain hospital costs over $5000 (p < .05). CONCLUSIONS: Exercise may have beneficial effects on fall rates and health care use in some subgroups of older adults. In community-living adults with mainly mild impairments in gait, balance, and physical health status, short-term exercise may not have a restorative effect on these impairments.

Accidental Falls↗
PubMed1997

A dietary intervention in primary care practice: the Eating Patterns Study.

OBJECTIVES: This study evaluated the effectiveness of a low-intensity dietary intervention in primary care practice in lowering dietary fat intake and raising dietary fiber intake. METHODS: A randomized controlled trial of 28 physician practices in six primary care clinics enrolled, by telephone, adult patients who had appointments for nonurgent nonacute visits. Of 3490 eligible patients contacted, 2111 completed baseline interview; 86.1% also completed a 12-month follow-up. Physicians gave intervention participants a self-help booklet and a brief motivational message. Changes in fat and fiber from baseline to 12-month follow-up were evaluated. RESULTS: Intervention and control groups both reported a decrease in fat intake and an increase in fiber intake. The differential change and 95% confidence interval (CI) for the percentage of energy obtained from fat was -1.2 (CI = -0.71, -1.7) (P = .0015), for grams fiber/1000 kcal 0.32 (CI = -0.066, 0.71) (P = .086), for fat score -0.044 (CI = -0.016, -0.072) (P = .010), and for fiber score 0.036 (CI = 0.011, 0.061) (P = .014), with greater reductions in fat and greater increase in fiber in the intervention group. CONCLUSIONS: This low-intensity intervention was effective in dietary behavior change.

Adult↗
PubMed1997

Mammography diffusion and trends in late-stage breast cancer: evaluating outcomes in a population.

The purpose of this study was to assess mammography diffusion in a population offered an organized breast cancer screening program, using intervals of 1-3 years, and to evaluate its effect on the late-stage cancer (tumors > or = 3 cm2) rates compared to rates in the surrounding community. We measured "ever-use" of mammography (1986-1992) among women enrollees of a consumer-controlled health care organization (n > or = 60,000/year; ages > or = 40), Group Health Cooperative of Puget Sound (GHC). Among these same women and the surrounding community (n = > or = 745,000/year), we measured late-stage cancer rates. Using unconditional logistic regression, we compared annual rates of ever-use among GHC women ages 40-49 and > or = 50 (1986-1992) and late-stage breast cancer (1983/84-1991/92) among all women. Among all GHC women ages 40 to 49, and 50 years of age and older, 67.4 and 82.8%, respectively, ever-used mammography by 1992. By 1992, approximately one-third of the mammograms among GHC women occurred in each of the three previous years. The rate of late-stage tumors declined significantly in the GHC and non-GHC populations among women 50 years of age and older (P < 0.001) but not among women ages 40 to 49. In conclusion, implementing a system of automated reminders was not sufficient to maximize mammography use in a population. Reductions in late-stage disease occurred among women ages > or = 50, even when regular" was not synonymous with "annual."

Adult↗
PubMed1997

Preventing decline in function. Evidence from randomized trials around the world.

Over the past decade, increasing epidemiologic evidence points to a few important risk factors for loss of mobility and functional decline, such as inactivity, cigarette smoking, obesity, depression, and alcohol and drug misuse. Global interventions addressing these risk factors along with other medical problems have been evaluated in randomized controlled clinical trials. With few exceptions, these trials have shown that intervention has a positive effect on health and functional status, as well as reducing length of stay in a hospital or nursing home. The extent to which the success of these programs is attributable to risk-factor reduction or to geriatric assessment and management is uncertain.

Aged↗
PubMed1996

Clinically silent electrocardiographic abnormalities and risk of primary cardiac arrest among hypertensive patients.

BACKGROUND: Whether continuous ECG indexes that reflect the severity of left ventricular hypertrophy (LVHI), myocardial injury (CIIS), and QT-interval prolongation (QTI) are associated with the risk of primary cardiac arrest among hypertensive patients, independent of conventional binary ECG criteria, remains unknown. METHODS AND RESULTS: We conducted a population-based case-control study among patients who were free of clinically recognized heart disease and who received care at a health maintenance organization. Cases (n = 131) were treated hypertensive patients who had had a primary cardiac arrest between 1977 and 1990. Controls (n = 562) were a stratified random sample of treated hypertensive patients. Resting ECGs were reviewed to estimate the severity of left ventricular hypertrophy, myocardial injury, and QT-interval prolongation on the basis of the algorithms of the Novacode ECG classification system. After adjustment for other risk factors and binary ECG criteria for the abnormalities, the LVHI, CIIS, and QTI scores were directly related to the risk of primary cardiac arrest. In a comparison of the 80th with the 20th percentile score for the LVHI, the risk was increased 40% (odds ratio, 1.4; 95% CI, 1.0 to 2.0); for the CIIS, the risk was increased 70% (odds ratio, 1.7; 95% CI, 1.2 to 2.5); and for the QTI, the risk was increased 80% (odds ratio, 1.8; 95% CI, 1.3 to 2.7). CONCLUSIONS: Our findings suggest that continuous ECG indexes that reflect left ventricular hypertrophy, myocardial injury, and QT-interval prolongation are directly related to the risk of primary cardiac arrest among hypertensive patients without clinically recognized heart disease. Binary ECG criteria may underestimate the prognostic importance of these pathophysiological abnormalities.

Adult↗
PubMed1996

Initial antidepressant choice in primary care. Effectiveness and cost of fluoxetine vs tricyclic antidepressants.

OBJECTIVE: To compare the clinical, functional, and economic outcomes of initially prescribing fluoxetine with outcomes of initially selecting imipramine or desipramine. DESIGN: Randomized controlled trial. SETTING: Primary care clinics of a Seattle, Wash, area staff-model health maintenance organization from 1992 through 1994. PATIENTS: A total of 536 adults beginning antidepressant treatment for depression. INTERVENTION: Random assignment of initial antidepressant prescription (desipramine, fluoxetine, or imipramine). Subsequent antidepressant treatment (doses, medication changes or discontinuation, specialty referral) was managed by the primary care physician. MAIN OUTCOME MEASURES: Assessments after 1, 3, and 6 months examined clinical outcomes (Hamilton Depression Rating Scale and the depression subscale of the Hopkins Symptom Checklist) and quality-of-life outcomes (Medical Outcomes Study SF-36). Medication use and health care costs were assessed using the health maintenance organization's computerized data. RESULTS: Patients assigned to receive fluoxetine reported fewer adverse effects, were more likely to continue the original medication, and were more likely to reach adequate doses than patients beginning treatment with either tricyclic drug. The fluoxetine group reported marginally better clinical outcomes after 1 month, but these differences were not statistically significant and disappeared by the 3-month assessment. Quality-of-life outcomes in the 3 groups did not differ. Total health care costs over 6 months were approximately equal for the 3 groups, with higher antidepressant costs in the fluoxetine group balanced by lower outpatient visit and inpatient costs. CONCLUSIONS: Clinical outcomes, quality-of-life outcomes, and overall treatment costs provide no clear guidance on initial selection of fluoxetine or tricyclic drugs. Thus, patients' and physicians' preferences are an appropriate basis for treatment selection.

Adult↗
PubMed1996

Physicians' experience with the acquired immunodeficiency syndrome as a factor in patients' survival.

BACKGROUND: Previous studies have found that patients with the acquired immunodeficiency syndrome (AIDS) who are admitted to hospitals that admit many such patients have lower mortality rates than patients in hospitals with less experience with AIDS. We examined the relation between physicians' experience with AIDS and the survival of their patients with AIDS. METHODS: We studied 403 adult male patients enrolled in a staff-model health maintenance organization in whom first AIDS-defining illnesses were diagnosed from 1984 through mid-1994; we determined that these illnesses met the 1987 case definition of the Centers for Disease Control. We defined three levels of experience for the patients' 125 primary care physicians according to their experience with AIDS during residency training and the cumulative number of patients with AIDS they had cared for in their practices. RESULTS: The median survival of the patients of physicians with the least experience in the management of AIDS was 14 months, as compared with 26 months for the patients of physicians with the most experience (P<0.001). Controlling for the severity of illness and the year of diagnosis, we found that the patients cared for by physicians with the most experience had a 31 percent lower risk of death than the patients cared for by physicians with the least experience (P<0.02). Among 244 patients with an AIDS-defining illness diagnosed from 1989 through 1994, after adjustment for the CD4+ cell count and the severity of illness, the risk of death was 44 percent lower for patients of the most experienced physicians than for patients of the least experienced (P<0.02). CONCLUSIONS: The experience of primary care physicians in the management of AIDS is significantly associated with survival among their patients.

Acquired Immunodeficiency Syndrome↗
PubMed1996

Diastolic blood pressure and the risk of primary cardiac arrest among pharmacologically treated hypertensive patients.

BACKGROUND: Previous studies have raised the concern that the reduction of diastolic blood pressure below 85 mm Hg among treated hypertensive patients may have cardiac hazards. However, these reports have not fully assessed potential confounding from coexisting cardiovascular disease. METHODS: We conducted a population-based case-control study to examine the relation between treated diastolic blood pressure and the risk of primary cardiac arrest among hypertensive patients free of clinically diagnosed cardiovascular disease. Cases were hypertensive enrollees of the Group Health Cooperative of Puget Sound, an HMO, who had primary cardiac arrest between 1977 and 1990 (n = 80). Control patients were a stratified random sample of hypertensive enrollees (n = 426). Ambulatory-care records were reviewed to assess blood pressures and other clinical characteristics. Medication use was assessed through the HMO computerised pharmacy database. RESULTS: Logistic regression models suggested a curvilinear relation between the level of treated diastolic blood pressure and the risk of primary cardiac arrest, after adjustment for pretreatment diastolic blood pressure, antihypertensive therapy, and other potential confounders. Compared with a treated diastolic blood pressure of 85 mm Hg, a treated diastolic blood pressure of 80 mm Hg was associated with a small increase in risk (relative risk [RR] 1.2; 95% confidence interval [CI] 1.0, 1.6), 75 mm Hg was associated with a modest increase in risk [RR 1.6; 95% CI 1.2, 2.1], and 70 mm Hg was associated with more than a twofold increase in the risk of primary cardiac arrest [RR 2.3; 95% CI 1.4; 3.8). There was little evidence of effect modification by pretreatment diastolic blood pressure. CONCLUSIONS: Our findings support available evidence that among hypertensive patients a treated diastolic blood pressure level below 85 mm Hg is associated with cardiac hazards.

Antihypertensive Agents↗
PubMed1996

Hypertension and outcomes research. From clinical trials to clinical epidemiology.

Outcomes research seeks to identify effective evidence-based methods of providing the best medical care. While randomized clinical trials (RCT) usually provide the clearest answers, they are often not done or not practicable. More than a decade after the introduction of calcium channel blockers and angiotensin converting enzyme (ACE) inhibitors, clinical trial data about their effect on major disease endpoints in patients with hypertension are still not available. The primary alternatives are the use of randomized trials that include surrogate endpoints, such as level of blood pressure or extent of carotid atherosclerosis, and the use of observational studies that include major disease endpoints. Both approaches, their strengths and limitations, are discussed in detail. The possibility of residual confounding limits the strength of inferences that can be drawn from observational studies. Similarly, the possibility of important drug effects, other than those involving the surrogate endpoint, limits the inferences that can be drawn from randomized trials that rely solely on surrogate outcomes as guides to therapy. In the absence of evidence from large clinical trials that include major disease endpoints, treatment decisions and guidelines need to synthesize the best available information from a variety of sources. Consistency of findings across various study designs, outcomes, and populations is critical to the practice of evidence-based medicine and the effort to maximize the health benefits of antihypertensive therapies.

Clinical Trials as Topic↗
PubMed1996

Skin cancer diagnosis in a primary care setting.

BACKGROUND: Primary care providers are in a good position to detect sk in cancers early, but their current involvement in diagnosis and referral of patients with skin cancer is unknown. Some managed care settings utilize a primary care case manager approach to health care. OBJECTIVE: The purpose of this study was to assess the incidence and demographic associations of skin cancer in a managed care population served by primary care providers. METHODS: this study analyzed 1215 skin biopsy specimens obtained by family physicians, internists, and supervised certified physician assistants within an eastern Washington health maintenance organization and the 69 biopsy specimens obtained by referral specialists and confirmed by pathologic consultation. RESULTS: Internists, family physicians, and their physician assistants performed 94.7% of the biopsies on 87% of all malignancies. Dermatologists and surgeons performed the rest. Primary care providers and dermatologists detected malignant melanomas at a rate comparable to a similar study from British Columbia but lower than other previous investigations. CONCLUSION: Melanomas were diagnosed in this managed care system at a rate comparable to a similar system in Canada. Lower rates for other skin cancers are probably because of methodologic differences from other studies, but variation in histologic diagnoses between pathologists and differences in skin cancer detection cannot be excluded.

Adult↗
PubMed1996

Conducting a randomized controlled trial of CQI and academic detailing to implement clinical guidelines.

BACKGROUND: A multisite, randomized controlled trial was conducted from August 1994 through January 1996 to compare the impact of two strategies-academic detailing (AD) and continuous quality improvement (CQI) teams-on the implementation of national guidelines for the primary care of hypertension and depression. STUDY: Twelve small groups of providers at four clinics-two at Group Health Cooperative of Puget Sound (Seattle) and two at academic medical centers-were randomized in blocks along with their primary care patients to receive AD alone, AD plus CQI, or usual care. A detailing session conducted by a physician and two follow-up sessions conducted by a pharmacist lasted an average of 8-9 minutes. Each CQI team, which met, on average, 14 times in nine months, devised at least one intervention (for example, weight loss counseling for hypertensives by nurse practitioners). RESULTS: The detailing endeavors differed greatly across organizations. Although all teams generally worked well together, organizational factors such as staff layoffs and reorganizations competed for the teams' attention. Team leaders differed in their ability to inspire members to "run with" ideas and to motivate personnel outside the team to implement interventions. SUMMARY AND CONCLUSIONS: Surveys and semi-structured interviews suggest that both the AD and CQI interventions involved complex social interactions that resulted in varied implementation across the different organizations. Final analyses will need to focus on identifying factors associated with the relative success or failure of both clinical change techniques.

Academic Medical Centers↗
PubMed1996

Evidence for a non-linear relationship between leg strength and gait speed.

Although the relationship between strength and physical performance in older adults is probably non-linear, few empirical studies have demonstrated that this is so. In a population-based sample of adults aged 60-96 years (n = 409), leg strength was measured in four muscle groups (knee extensor, knee flexor, ankle plantar flexor, ankle dorsiflexor) of both legs using an isokinetic dynamometer. A leg strength score was calculated as the sum of the four strength measurements in the right leg. Usual gait speed was measured over a 15.2 metre course. With a linear model, leg strength explained 17% of the variance in gait speed. Non-linear models (quadratic and inverse) explained significantly more variance (22%). The nature of the non-linear relationship was that, in stronger subjects, there was no association between strength and gait speed, while in weaker subjects, there was an association. Body weight and age also explained significant amounts of variance in gait speed, while sex and height did not. The results supported the hypothesis of a non-linear relationship between leg strength and gait speed that is similar for older men and women. This finding represents a mechanism for how small changes in physiological capacity may have substantial effects on performance in frail adults, while large changes in capacity have little or no effect in healthy adults.

Adult↗