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Biomedical subjects

E H Wagner

Publications and source records attributed to E H Wagner.

At least 73 records · Page 4Linked to original sources
PubMed1996

Factors associated with changes in gait speed in older adults.

BACKGROUND: The study addressed whether changes in gait speed in community-dwelling older adults were associated with changes in fitness (strength and aerobic capacity), physical health status, and/or depressive symptoms. METHODS: The study sample comprised 152 community-dwelling adults aged 68-85 who had participated in an exercise study. Study measures at baseline and 6-month follow-up included gait speed, a leg strength score, maximal aerobic capacity (VO2max), CES-Depression scale, and physical health status (SIP Physical Dimension). RESULTS: In cross-sectional regression analyses, leg strength, VO2max, weight, and the strength by VO2max interaction term were significant independent predictors of gait speed (R2 = 26%). Based upon the observed 7% increase in VO2max and 8% increase in strength in the exercise groups, the regression model predicted only a 2% (1.5 m/min) increase in gait speed, which did not differ significantly from the observed increase of 0% (.32 m/min). The strongest correlate of change in gait speed was change in CES-D scores (partial R = -.37). Change in physical health status also correlated with change in gait speed (partial R = -.28), while change in fitness did not. CONCLUSIONS: The results suggest, in the range of fitness of the study sample, that changes in gait speed are related to changes in depressive symptoms and physical health status, but not to modest changes in fitness. A model assuming nonlinear relationships may be appropriate for understanding how strength and aerobic capacity affect gait speed.

Aged↗
PubMed1996

The promise and performance of HMOs in improving outcomes in older adults.

In summary, the promise of HMOs in caring for older adults far exceeds their performance to date. Until recently they had neither the motivation nor the knowledge to revamp their delivery systems to better needs of older, chronically ill patients. Market pressures and skyrocketing costs have provided the motivation. Physicians and researchers trained in epidemiology and health services research from programs such as that at UCLA are providing the knowledge. Based on the literature and experience described above, HMOs with the characteristics supportive of population-based care can put into place an approach to geriatric care likely to improve outcomes if they heed their patients and professionals rather than their accountants. These organizations will give highest priority to preserving function and will be guided by explicit clinical guidelines. Care will be rendered by organized primary care teams supported by systematic self-management approaches, standardized interventions for key risk factors, clinically useful computer systems, and available geriatric expertise. It will require a small revolution as old approaches, roles, and relationships will not go quietly. We are in the early phases of this revolution, and it's not too late to join us on the barricades.

Guidelines as Topic↗
PubMed1996

Does walking decrease the risk of cardiovascular disease hospitalizations and death in older adults?

OBJECTIVES: The purpose of this study was to determine whether walking is associated with a reduced risk of cardiovascular disease hospitalization and death in community-dwelling older men and women. DESIGN: A prospective study, with follow-up time of 4 to 5 years (average 4.2 years). SETTING: A western Washington health maintenance organization. PARTICIPANTS: Men and women aged 65 years and older from a random sample of HMO enrollees invited by mail to participate in a health promotion intervention trial (36% accepted the invitation and completed questionnaires). This report is based on 1645 older adults without severe disability and without history of heart disease. Vital status ascertainment was complete (100%), and only 2.6% did not complete the follow-up. MEASUREMENTS: Reported frequency and duration of walking for exercise, work, errands, pleasure, and hiking in the 2 weeks before baseline were used to classify hours of walking per week. The two main outcomes were: (1) cardiovascular disease hospitalizations with a discharge diagnosis of coronary (ICD-9-CM 410-414) or other cardiovascular diseases (ICD-9-CM 390-409, 415-448) documented by computerized hospitalization records and (2) death. Numerous potential confounding factors were considered, including age, sex, treated high blood pressure, current estrogen use and chronic disease score (ascertained by computerized medical and pharmacy records), and ethnicity, education, income, physical function, self-rated health status, smoking, alcohol intake, and body mass index (ascertained by self-report on the mailed questionnaire). RESULTS: Walking more than 4 hours/week was associated significantly with a reduced risk of cardiovascular disease hospitalization in both sexes combined compared with walking less than 1 hour/week (age and sex-adjusted relative risk = 0.69; 95% confidence interval, 0.52-0.90). This association was not altered by adjustment for baseline cardiovascular risk factors and indicators of general health status. The association was present in all age groups, among those with and without physical limitations, and also among those who did and did not also participate in more vigorous physical activities. Walking more than 4 hours/week was also associated with a reduced risk of death (age and sex-adjusted relative risk = 0.73; 95% confidence interval, 0.48-1.10), however, this association was substantially diminished by adjustment for cardiovascular risk factors and measures of general health status. CONCLUSIONS: Walking more than 4 hours/week may reduce the risk of hospitalization for cardiovascular disease events. The association of walking more than 4 hours/week with reduced risk of death may be mediated by effects of walking on other risk factors. These findings provide much stronger evidence than previously available for advising older men and women to embark on or maintain a sustained program of walking to prevent cardiovascular disease events.

Activities of Daily Living↗
PubMed1996

Improving outcomes in chronic illness.

Usual medical care often fails to meet the needs of chronically ill patients, even in managed, integrated delivery systems. The medical literature suggests strategies to improve outcomes in these patients. Effective interventions tend to fall into one of five areas: the use of a protocol, reorganization of practice systems and provider roles, improved patient education, increased access to expertise, and greater availability of clinical information. The challenge is to organize these components into an integrated system of chronic illness care.

Chronic Disease↗
PubMed1996

Organizing care for patients with chronic illness.

Usual medical care often fails to meet the needs of chronically ill patients, even in managed, integrated delivery systems. The medical literature suggests strategies to improve outcomes in these patients. Effective interventions tend to fall into one of five areas: the use of evidence-based, planned care; reorganization of practice systems and provider roles; improved patient self-management support; increased access to expertise; and greater availability of clinical information. The challenge is to organize these components into an integrated system of chronic illness care. Whether this can be done most efficiently and effectively in primary care practice rather than requiring specialized systems of care remains unanswered.

Chronic Disease↗
PubMed1995

The impact of smoking and quitting on health care use.

BACKGROUND: The magnitude and timing of the impact of effects of smoking cessation on inpatient and outpatient health care use are uncertain. METHODS: Comparison of the use of outpatient and hospital services over time of 2440 persistent smokers and 244 biochemically verified quitters, all of whom were participants in two independent randomized trials of smoking cessation interventions. RESULTS: Continued smokers in both trials experienced a 7% to 15% increase in outpatient visits and a 30% to 45% increase in hospital admissions over 5 to 6 years of follow-up. The positive slopes approached or reached statistical significance for all use variables in both trial populations. Among quitters, all health care use rates significantly increased during the year in which they quit; after that, the rates declined progressively. By the fourth year after quitting, all use rates among quitters were lower than those for smokers. The increase in hospitalizations during the year of quitting was more often a cause rather than a consequence of successful smoking cessation. CONCLUSION: Successful smoking cessation appears to halt the progressive increase in the use of health services associated with continued smoking within a 4-year period.

Health Services↗
PubMed1995

Population-based management of diabetes care.

Meeting the needs of patients with chronic illness in usual primary care practice is difficult. Group Health Cooperative of Puget Sound (GHC), an HMO serving about 400,000 people in western Washington state, is using the strategy of population-based management of care to improve care and outcomes for its 13,000 diabetic patients. Population-based care uses guidelines, and epidemiologic data and techniques to plan, organize, deliver and monitor care to specific clinical sub-populations such as diabetics. Under this approach, guidelines for care and the outcomes effected by those guidelines are defined. Current practice is reviewed, problems are identified, and a new intervention plan devised and put into place. Performance and outcomes are monitored and the plan revised accordingly. Population-based care must occur both centrally to provide guidelines, data, new interventions and other system support, but more importantly at the level of the individual medical practice if it is to reach all patients in the population. In this paper, we describe both central and practice-based efforts at GHC to apply population-based care to improving outcomes for diabetic patients.

Case Management↗
PubMed1995

Optimal survey design for community intervention evaluations: cohort or cross-sectional?

Community intervention evaluations that measure changes over time may conduct repeated cross-sectional surveys, follow a cohort of residents over time, or (often) use both designs. Each survey design has implications for precision and cost. To explore these issues, we assume that two waves of surveys are conducted, and that the goal is to estimate change in behavior for people who reside in the community at both times. Cohort designs are shown to provide more accurate estimates (in the sense of lower mean squared error) than cross-sectional estimates if (1) there is strong correlation over time in an individual's behavior at time 0 and time 1, (2) relatively few subjects are lost to followup, (3) the bias is relatively small, and (4) the available sample size is not too large. Otherwise, a repeated cross-sectional design is more efficient. We developed methods for choosing between the two designs, and applied them to actual survey data. Owing to drop-outs and losses to followup, the cohort estimates were usually more biased than the cross-sectional estimates. The correlations over time for most of the variables studied were also high. In many instances the cohort estimate, although biased, is preferred to the relatively unbiased cross-sectional estimate because the mean squared error was smaller for the cohort than for the cross-sectional estimate. If these results are replicated in other data, they may result in guidelines for choosing a more efficient study design.

Cohort Studies↗
PubMed1995

A randomized trial of self-help materials, personalized feedback, and telephone counseling with nonvolunteer smokers.

The incremental effects of (a) a self-help booklet alone, (b) self-help booklet with computer-generated personalized feedback, and (c) self-help booklet, personalized feedback, and outreach telephone counseling were evaluated in a population-based, nonvolunteer sample of smokers. Smokers (N = 1,137) were identified through a telephone survey of a random sample of 5,903 enrollees in a health maintenance organization and randomized to a no-treatment control group or 1 of the 3 intervention conditions. Smoking status was ascertained 3, 12, and 21 months postrandomization. Cotinine validation of self-reported cessation was obtained at the 12-month follow-up. Overall, the telephone counseling significantly increased smoking cessation at the 3-month follow-up, but not at 12 or 21 months. Among smokers who were precontemplative at baseline, telephone counseling significantly increased prevalent abstinence at 3 and 12 months and continuous abstinence at 21 months (defined as self-reported abstinence at 3, 12, and 21 months).

Adult↗
PubMed1995

Do surgical brain lesions present as isolated dementia? A population-based study.

OBJECTIVE: To determine the incidence of clinically important subdural hematoma (SDH), hydrocephalus not associated with a recent intracranial bleed, and intracranial tumor that is not obviously metastatic, and to test the sensitivity of a promising decision rule for computerized tomography (CT) in dementia. DESIGN: Population-based, retrospective, sequential case series. SETTING: Staff model health maintenance organization (HMO). PATIENTS: Patients aged 65 years and older with one of the three lesions, diagnosed over a 4.5-year period, identified mainly through computerized databases of hospital discharge diagnoses and a registry of malignant tumors. MEASUREMENTS: Clinical data were based on chart review. The decision rule, based on one that had been previously proposed and tested, stated that CT would be required if any one of 11 clinical criteria were met by a patient with cognitive impairment. Rule sensitivity was evaluated using clinical information recorded before CT. MAIN RESULTS: One hundred forty-five clinically important lesions were identified among 137,100 person-years at risk. Average annual incidence per 100,000 was 46.7 (95% CI 36.0, 59.6) for SDH, 5.8 (95% CI 2.5, 11.5) for hydrocephalus not associated with a recent intracranial bleed, and 53.2 (95% CI 41.7, 66.9) for intracranial tumors that were not obviously metastatic. Using the 65 to 74- year age strata as a reference, the relative risk for SDH was 4.8 (95% CI 2.7, 8.5) in 75 to 84-year-olds and 13.1 (95% CI 7.7, 22.5) in the 85 and older strata. Among 59 patients who presented with cognitive impairment, without altered sensorium or physical evidence of trauma, decision rule sensitivity was 93.2% (95% CI 83.5%, 98.1%). Sensitivity was 90.7% (95% CI 77.9%, 97.4%) in the subgroup that presented to an ambulatory care clinic rather than to an emergency department. CONCLUSIONS: These three lesions, which are the most common surgical lesions that may present as dementia, are rare. Most cases have presentations that easily distinguish them from typical Alzheimer's disease. This case series indicates that it may be feasible to develop a decision rule for the selective use of CT in dementia. Disease spectrum will influence measures of decision rule performance such as sensitivity and specificity.

Aged↗
PubMed1995

School-level application of a social bonding model to adolescent risk-taking behavior.

Adolescent bonding--attachment to, commitment to, and involvement in conventional social activities-decreases the likelihood of engaging in some risk-taking behaviors. The extent to which bonding opportunities in the school environment affect individual's bonding and risk-taking behaviors is less explored. This study tested a model that includes individual and environmental indicators of bonding to predict cigarette smoking, drinking, drug use, and sexual activity among ninth grade students. Survey data representing students in 20 schools in seven western states are reported. Twelfth grade students' bonding and other demographic variables aggregated by school served as environmental indicators of bonding opportunities to predict ninth grade students' bonding and risk-taking behavior. Path analyses indicate the school environment has a direct influence on ninth grade students' bonding and, in turn, on the likelihood they will engage in risky behavior. Implications of these findings for future research directions and intervention design are discussed.

Adolescent↗
PubMed1995

PSA screening: a public health dilemma.

Screening for prostate cancer with serum prostate specific antigen (PSA) is one of the most controversial practices in health care today and guidelines from professional and policy organizations are contradictory. Prostate cancer is unique because of a wide discrepancy between prevalent asymptomatic cancer and clinical disease and an uncertain natural history. Proponents and critics of mass screening agree that PSA can detect early cancer and that definitive data that PSA reduces prostat cancer mortality are not available. Differences in screening recommendations reflect distinct viewpoints regarding what constitutes screening benefit and what level of evidence is needed to endorse a screening practice. This review describes what is known about the areas most relevant to the conflicting perspectives: the epidemiology and natural history of prostate cancer, the ability of PSA to detect disease and operational characteristics of PSA as a screening test, and the efficacy of treatment of early disease.

Decision Making↗
PubMed1995

A case-control study to evaluate efficacy of screening for faecal occult blood.

OBJECTIVES: Faecal occult blood testing is routinely used for early detection of colorectal cancer, but evidence of its efficacy in preventing death from colorectal cancer is limited. A case-control study was carried out to evaluate whether screening for faecal occult blood is associated with a reduced risk of fatal colorectal cancer. SETTING: A health maintenance organisation in western Washington State, which has offered its members faecal occult blood testing every two years since 1983. METHODS: Cases (n = 248) were members of the health maintenance organisation who died from colorectal cancer between 1986 and 1991. For each case, two control subjects, who did not die from colorectal cancer and who were similar to each case in age, gender, and year of enrollment at the health maintenance organisation, were randomly selected from the membership list of the year in which the case was diagnosed (n = 496). Information about episodes of faecal occult blood testing (including the location and reason for the test, and the evaluation of positive tests) and potential confounders was obtained from medical records. RESULTS: Cases were less likely than controls to have ever been screened (odds ratio (OR) = 0.7, 95% confidence interval (CI) 0.5 to 1.0), consistent with a beneficial impact of screening. There was little difference, however, for screening that had taken place within a three year period before diagnosis (OR = 0.9, 95% CI 0.6 to 1.2), the maximum interval during which most tumours ought to have been detectable by faecal occult blood testing. A reduction in risk was seen for home testing but not for office testing, and in individuals aged less than 75 but not in those aged 75 or older. Although most of the 21 controls with a positive faecal occult blood test underwent some additional testing, only five (24%) were evaluated with colonoscopy or air contrast barium enema. CONCLUSIONS: While there can be uncertainty as to whether specific faecal occult blood tests were performed as screening or diagnostic tests, those performed at home and in younger persons may be relatively less likely to be diagnostic tests that were misclassified as screening. Thus the modest reduced risk associated with faecal occult blood testing in these settings/persons may reflect genuine benefit. However, the presence of a reduced risk associated with a screening faecal occult blood test received in the past, well before a tumour or polyp might bleed enough to allow detection, is compatible with uncontrolled confounding. Interpretation is further complicated by the fact that a number of individuals in the study group who had positive test results underwent limited or no diagnostic testing. Thus our results should be interpreted with considerable caution.

Age Factors↗
PubMed1995

Practicing population-based care in an HMO: evaluation after 18 months.

OBJECTIVE: To determine whether population-based care in a primary care practice results in improvement in compliance with patient care guidelines. DESIGN: Time series analysis. SETTING: One primary care practice in Group Health Cooperative of Puget Sound (GHC). PARTICIPANTS: Approximately 1500 enrollees cared for by the practice. INTERVENTIONS: An ongoing approach to aid clinical planning at the level of the primary care team--population-based care--that depends on clinical guidelines, a computing system to provide epidemiologic data on guideline performance in the practice and reminders, and a process whereby the practice team analyzed and designs interventions for specific clinical problems. MAIN OUTCOME MEASURES: We compared compliance with practice guidelines for preventive care and chronic illness management at baseline and after 18 months in the intervention population with other patients in the same clinic and with patients in GHC as a whole. RESULTS: Compliance with breast cancer screening and colorectal cancer screening guidelines in the intervention population increased from baseline 32% and 18% respectively. These increases were significantly greater than in the remainder of the clinic or in GHC as a whole. CONCLUSIONS: The availability of practice-based data, clinical guidelines and a local intervention design process resulted in significant improvements in compliance with patient care guidelines.

Algorithms↗
PubMed1995

Estimating annual charges for ambulatory care from limited utilization data.

OBJECTIVE: This study explores the types of utilization information needed to produce a reasonable estimate of annual charges for ambulatory care that could be used in the absence of charge or cost data as an aggregate utilization measure. DATA SOURCE: Charge and utilization data from the RAND Health Insurance Experiment were used. STUDY DESIGN: Services provided to enrollees in the Health Insurance Experiment at each of the six sites for a one-year period were grouped into categories according to California Relative Value Studies (CRVS) codes. Using annual charges as the dependent variable, we evaluated linear regression models for their predictive accuracy, as indicated by adjusted R2-values. Categories of services were combined on the basis of clinical meaningfulness (e.g., all provider visits into one group), and predictive accuracy of models with these groupings of services examined. We examined model validity by applying the derived models to each of the 30 remaining site-years of data from the Health Insurance Experiment. PRINCIPAL FINDINGS: We were able to explain 84 percent of the variance in charges with a model containing counts of provider visits exclusive of mental health visits, mental health provider visits, days drugs were prescribed, days radiologic procedures were performed, procedural visits subdivided according to whether they were performed by a surgical or medical provider, days laboratory and/or pathology tests were performed, days a grouping of miscellaneous tests were performed, and days supplies were purchased. When applied to the validation data, this model predicted a mean of 77 percent of the variance and mean charges 102 +/- 9 percent of actual mean charges. A model with only the first four of the listed categories explained 77 percent of the variance in charges. CONCLUSIONS: Models using only counts of several broad categories of services perform rather well in predicting annual charges for ambulatory care.

Ambulatory Care↗