Search

Blood pressure (BP) is measured in percentiles that are adjusted for sex, age, and height percentile in children and adolescents. Standard tables for the conversion of BP percentiles do not present exact BP percentile cutoffs for extremes in stature, either short (<5th percentile) or tall (>95th percentile). An algorithm can be used to calculate exact BP percentiles across a range of height z scores. We compared values from standard BP tables with exact calculations of BP percentiles to see which were better at identifying hypertension in more than 5,000 children with either short or tall stature. Study subjects were 3-17-year-old patients within HealthPartners Medical Group, an integrated health care delivery system in Minnesota, at any time between 2007 and 2012. Approximately half of the subjects who met the criteria for hypertension using exact calculation would be misclassified as normal using available thresholds in the published BP tables instead of the recommended algorithm, which was not included in the tables. [ABSTRACT FROM AUTHOR]

Purpose To assess the impact of personalised physician learning (PPL) interventions using simulated learning cases on control of hypertension and dyslipidaemia in primary care settings. Methods A total of 132 primary care physicians, 4568 eligible patients with uncontrolled hypertension, and 15 392 eligible patients with uncontrolled dyslipidaemia were cluster-randomised to one of three conditions: (a) no intervention, (b) PPL-electronic medical record (EMR) intervention in which 12 PPL cases were assigned to each physician based on observed patterns of care in the EMR in the previous year, or (c) PPL-ASSESS intervention in which 12 PPL cases were assigned to each physician based on their performance on four standardised assessment cases. General and generalised linear mixed models were used to account for clustering and to model differences in patient outcomes in the study arms. Results Among patients with uncontrolled hypertension at baseline, 49.1%, 46.6% and 47.3% (p=0.43) achieved blood pressure (BP) targets at follow-up. Among patients with uncontrolled dyslipidaemia at baseline, 37.5%, 37.3% and 38.1% (p=0.72) achieved low density lipoprotein cholesterol targets at follow-up in PPL-EMR, PPL-ASSESS and the control group, respectively. Although systolic (BP) (p<0.001) and lipid (p<0.001) values significantly improved during the study, the group-by-time interaction term showed no differential change in systolic BP values (p=0.51) or lipid values (p=0.61) among the three study arms. No difference in intervention effect was noted when comparing the PPL-EMR with the PPL-ASSESS intervention (p=0.47). Conclusions The two PPL interventions tested in this study did not lead to improved control of hypertension or dyslipidaemia in primary care clinics during a mean 14-month follow-up period. This null result may have been due in part to substantial overall improvement in BP and lipid control at the study sites during the study. [ABSTRACT FROM AUTHOR]

The article presents a randomized trial on the impact of electronic health record-based (EHR) clinical decision support system on adults with diabetes in the U.S. It mentions that the trial was conducted from October 2006 to May 2007 in Minnesota. It also concluded that the HER-based diabetes clinical decision support improved glucose and blood pressure control in adults with type 2 diabetes.

Objectives: To build upon state-of- the-art theory and empirical data to estimate the strength of multiple mediators of the efficacious Keep Active Minnesota (KAM) physical activity (PA) maintenance intervention. Methods: The total, direct, and indirect effects through which KAM helped randomized participants (KAM n=523; UC n=526) maintain moderate or vigorous PA (MVPA) for up to 2 years were estimated using structural equation modeling. Results: Multiple mediators explained half (β=.052, P=.13) of the effect of KAM on MVPA (β=.105, P=.004). Self-efficacy was the upstream variable in 2 endogenously mediated effects, and the self-concept mediator emerged as the strongest predictor of MVPA. Conclusions: KAM positively impacted self-efficacy, which was associated with PA enjoyment, integration into the self-concept, and PA maintenance. Successful long-term PA maintenance appears to be influenced by multiple small interrelated mediational pathways. Future research evaluating maintenance models should specify recursive relationships among mediators and outcomes. [ABSTRACT FROM AUTHOR]

Background: Since many individuals who initiate physical activity programs are highly likely to return to a sedentary lifestyle, innovative strategies to efforts to increase the number of physically active older adults who successfully maintain beneficial levels of PA for a substantial length of time are needed. Methods/Design: The Keep Active Minnesota Trial is a randomized controlled trial of an interactive phone- and mail-based intervention to help 50-70 year old adults who have recently increased their physical activity level, maintain that activity level over a 24-month period in comparison to usual care. Baseline, 6, 12, and 24 month measurement occurred via phone surveys with kilocalories expended per week in total and moderate-to-vigorous physical activity (CHAMPS Questionnaire) as the primary outcome measures. Secondary outcomes include hypothesized mediators of physical activity change (e.g., physical activity enjoyment, self-efficacy, physical activity self-concept), body mass index, and depression. Seven day accelerometry data were collected on a sub-sample of participants at baseline and 24-month follow-up. Discussion: The Keep Active Minnesota study offers an innovative approach to the perennial problem of physical activity relapse; by focusing explicitly on physical activity maintenance, the intervention holds considerable promise for modifying the typical relapse curve. Moreover, if shown to be efficacious, the use of phone- and mail-based intervention delivery offers potential for widespread dissemination. Trial registration: ClinicalTrials.gov Identifier: NCT00283452. [ABSTRACT FROM AUTHOR]

The article examines how diabetes is diagnosed and initially managed in primary care. The authors conducted a historical study of patients in a large multispecialty medical group in Minnesota. The main outcome measures were the type of symptoms at diagnosis, changes in glycemic control, low-density lipoprotein cholesterol level, blood pressure, aspirin use and body weight in the first year after diagnosis. The results show that being vigilant for symptoms of diabetes, by examining those at high risk for the disease and by instituting appropriate treatments at the time of diagnosis, primary care practices may improve detection of undiagnosed diabetes and improve one-year outcomes.

We propose an explanation for variation in disease outcomes based on patient adaptation to the conditions of chronic disease. We develop a model of patient adaptation using the example of Type 2 diabetes mellitus and assumptions about the process entailed in transforming self-care behaviors of compliance with treatment, compliance with glucose monitoring, and patient's knowledge seeking behavior into health outcomes of glycemic control and patient satisfaction. Using data from 609 adults with diagnosed Type 2 diabetes we develop an efficiency (fitness) frontier in order to identify best practice (maximally adapted) patients and forms (archetypes) of patient inefficiency. Outcomes of frontier patients are partitioned by categories of returns to scale. Outcomes for off-frontier patients are associated with disease severity and patient archetype. The model implicates strategies for improved health outcomes based on fitness and self-care behaviors. [ABSTRACT FROM AUTHOR]

Aims: To develop and externally validate a prediction model for the 6-month risk of a severe hypoglycemic event among individuals with pharmacologically treated diabetes.Methods: The development cohort consisted of 31,674 Kaiser Permanente Colorado members with pharmacologically treated diabetes (2007-2015). The validation cohorts consisted of 38,764 Kaiser Permanente Northwest members and 12,035 HealthPartners members. Variables were chosen that would be available in electronic health records. We developed 16-variable and 6-variable models, using a Cox counting model process that allows for the inclusion of multiple 6-month observation periods per person.Results: Across the three cohorts, there were 850,992 6-month observation periods, and 10,448 periods with at least one severe hypoglycemic event. The six-variable model contained age, diabetes type, HgbA1c, eGFR, history of a hypoglycemic event in the prior year, and insulin use. Both prediction models performed well, with good calibration and c-statistics of 0.84 and 0.81 for the 16-variable and 6-variable models, respectively. In the external validation cohorts, the c-statistics were 0.80-0.84.Conclusions: We developed and validated two prediction models for predicting the 6-month risk of hypoglycemia. The 16-variable model had slightly better performance than the 6-variable model, but in some practice settings, use of the simpler model may be preferred. [ABSTRACT FROM AUTHOR]

Purpose: Here we describe our experience using a comprehensive diabetes quality of care measure, and report trends in diabetes quality of care since the measure was adopted community-wide 4 years ago. Methods: Seven Minnesota health plans initiated Minnesota Community Measurement in 2002. The program measures and publicly reports care across multiple clinical domains in fifty plus primary care and multi-specialty group practices. To assess quality of diabetes care, the project sampled 60 diabetes patients per medical group and classified each as meeting or not meeting all the following measures: glycated hemoglobin (A1c) ≤8%, LDL-cholesterol (LDL) ≤130 mg/dl, documented non-smoking status (NSMK), and regular aspirin (ASA) use. Statistical comparisons across time and across groups were done using the Chi-square statistic and nested multivariate logistic regression models. Results: The proportion of diabetes patients who met all 5 quality components was 7.6% in 2001, 11.7% in 2002, 12.0% in 2003, 15.5% in 2004, and 19.9% in 2005. In 2001 the range across provider groups was 0% to 20%, and in 2004 the range across provider groups was 1% to 40%. In 2001 6% of provider groups had over 15% of patient meeting this measure, and in 2004, 46% of provider groups had over 15% of patients at this goal (χ²=20.8, p<.0001). In 2005, among the 5 measures, the one with the lowest proportion of patients at goal was BP (47.7%), followed by A1c (65.7%), ASA (66.6%), LDL (66.8%), and NSMK (70.1%). Discussion: These data show substantial improvement in diabetes care in a short period of time, motivated in part by a commonly agreed upon publicly reported comprehensive diabetes control measure. Further substantial improvement in community levels of diabetes care are possible, and special attention to BP control may be indicated. [ABSTRACT FROM AUTHOR]

Objectives: The objectives of this secondary analysis of a retrospectively constructed dataset are: 1) to explore methods of measuring the efficiency of diabetes mellitus (DM) care across medical groups(MG)s, 2) to quantitate variation in the provision of diabetes care provided by MGs, and 3) to estimate potential resource savings and quality improvements. Methods: Study subjects were 2,511 adults with DM, insured by a single payer during 2003-2004, and receiving care at one of 33 Minnesota medical groups. Chart abstractions assessed Ale <8%, BP<130/85, and LDL<130 mg/dl. Standard methods were used to calculate resource utilization by converting all billing into RVUs scaled by a single cost factor. Quality of care(QofC) was defined as the proportion of patients achieving two or more clinical goals (A1c < 8%, BP < 130/85, or LDL < 130mg/dl). Nun-parametric Data Envelopment Analysis(DEA) model the relationship between resource utilization and QofC, rank MGs in terms of patient likelihood of achieving two or more clinical goals, and identify performance benchmarks for MGs. Results: MGs with fewer than 30 DM patients (n=5) were excluded. The remaining 28 MGs averaged 109 sampled DM patients (range: 174 to 38). Median per patient costs were $19,045 with MG-specific medians ranging from $8,822 to $38,842. 73% of all patients (n=1,824) achieved two or more goals with MG-specific range from 57% to 82%. After controlling for age and comorbidities, three MGs were identified as relatively efficient "benchmarks", four were classified as outliers, and twenty-one were found inefficient. If inefficient MGs performed at benchmark levels an estimated 35% decrease in resource use OR an 8% increase in patients achieving two or more goals could be realized. Conclusions: There is considerable variation in efficiency of diabetes care across MGs. Health plans can use existing data to assess MG efficiency. Improved diabetes care in terms of both cost reduction and quality improvement is possible and could have substantial benefits for both patients and payers. [ABSTRACT FROM AUTHOR]

: BackgroundBetter understanding the impact of changes in physical activity behavior on short-term health care charges may inform resource allocation decisions to increase population levels of physical activity. This study examines the prospective relationship of changes in physical activity status on short-term changes in health care charges for older adults.: MethodsA prospective cohort study was done on a stratified random sample of 2,393 adults aged 50 and older enrolled in a Minnesota health plan, predicting changes in resource use between two periods (September 1994 to August 1995 and September 1996 to August 1997) based on billed health care charges.: ResultsAfter adjustment for age, gender, comorbidity, smoking status, and body mass index, all physical activity states had declining health care charges, relative to those who were consistently inactive. Subjects who increased their physical activity from 0–1 to 3+ days/week had significant declines in their mean annualized total charges (−$2,202, P < 0.01) relative to those who remained inactive.: ConclusionsIncreased physical activity among older adults is associated with lower health care charges within 2 years, relative to charges for those who were persistently inactive. These cost savings may justify investments in effective interventions to increase physical activity in older adults. [Copyright &y& Elsevier]

Abstract: Objective: To evaluate the efficacy at 6-, 12-, and 24-month follow-up of Keep Active Minnesota (KAM), a telephone and mail-based intervention designed to promote physical activity (PA) maintenance among currently active adults age 50 to 70. Method: Participants who reported having recently increased their MVPA to a minimum of 2d/wk, 30min/bout, (N =1049) were recruited in 2004 and 2005 from one large managed care organization in Minnesota, and randomly assigned to either treatment (KAM; N =523), or Usual Care (UC; N =526) with PA assessed using the CHAMPS questionnaire, and expressed as kcal/wk energy expenditure. Results: We find a sustained, significant benefit of the intervention at 6, 12 and 24months. kcal/wk expenditure in moderate or vigorous activities was higher at 6 (p <.03, Cohen''s d 6m =.16), 12 (p <.04, d 12m =.13) and 24months (p <.01, d 24m =.16) for KAM participants, compared to UC participants. Conclusions: The KAM telephone- and mail-based PA maintenance intervention was effective at maintaining PA in both the short-term (6months) and longer-term (12 and 24months) relative to usual care. [Copyright &y& Elsevier]

Abstract: Objective. : We evaluate the 6-month efficacy of Keep Active Minnesota, a phone- and mail-based physical activity maintenance intervention designed for use with adults age 50 to 70 years who have increased their physical activity within the past year. Method. : Participants (N =1049) recruited in 2004 and 2005 from one large managed-care organization in Minnesota were randomly assigned to either treatment (N =523) or usual care (N =526) with physical activity assessed using the Community Healthy Activities Model Program for Seniors questionnaire, and expressed as kcal/week expenditures. Results. : Total physical activity at baseline was similar for treatment and usual care participants (p <0.44) as was moderate/vigorous physical activity (p <0.21). Maintenance of physical activity was higher among treatment participants whose mean 6-month change in total kcal/week energy expenditure was −91, compared to −683 for usual care participants (p <0.002). Mean 6-month change in kcal/week expenditure in moderate or vigorous activities was −49 for treatment participants, compared to −612 for usual care participants (p <0.001). Conclusions. : This phone- and mail-based physical activity maintenance intervention is efficacious at maintaining physical activity at 6 months. [Copyright &y& Elsevier]

Importance: Hypertension is a leading cause of cardiovascular disease. The results were previously reported of a trial of home blood pressure (BP) telemonitoring and pharmacist management intervention in which the interventions stopped after 12 months. There were significantly greater reductions in systolic BP (SBP) in the intervention group than in the usual care group at 6, 12, and 18 months (-10.7, -9.7, and -6.6 mm Hg, respectively)., Objectives: To examine the durability of the intervention effect on BP through 54 months of follow-up and to compare BP measurements performed in the research clinic and in routine clinical care., Design, Setting, and Participants: Follow-up of a cluster randomized clinical trial among 16 primary care clinics and 450 patients with uncontrolled hypertension in a large health system from March 2009 to November 2015., Interventions: A home BP telemonitoring intervention with pharmacist management or usual care., Main Outcomes and Measures: Change from baseline to 54 months in SBP and diastolic BP (DBP) measured as the mean of 3 measurements obtained at each research clinic visit., Results: Among 450 patients, 228 (mean [SD] age, 62.0 [11.7] years; 54.8% male) were randomized to the telemonitoring intervention and 222 (mean [SD] age, 60.2 [12.2] years; 55.9% male) to usual care. Research clinic BP measurements were obtained from 326 of 450 (72.4%) study patients at the 54-month follow-up visit, including 162 (mean [SD] age, 62.0 [11.1] years; 54.9% male) randomized to the telemonitoring intervention and 164 (mean [SD] age, 60.0 [11.2] years; 57.3% male) to usual care. Routine clinical care BP measurements were obtained from 439 of 450 (97.6%) study patients at 6248 visits during the follow-up period. Based on research clinic measurements, baseline mean SBP was 148 mm Hg in both groups. In the intervention group, mean SBP at 6-, 12-, 18-, and 54-month follow-up was 126.7, 125.7, 126.9, and 130.6 mm Hg, respectively. In the usual care group, mean SBP at 6-, 12-, 18-, and 54-month follow-up was 136.9, 134.8, 133.0, and 132.6 mm Hg, respectively. The differential reduction by study group in SBP from baseline to 54 months was -2.5 mm Hg (95% CI, -6.3 to 1.2 mm Hg; P = .18). The DBP followed a similar pattern, with a differential reduction by study group from baseline to 54 months of -1.0 mm Hg (95% CI, -3.2 to 1.2 mm Hg; P = .37). The SBP and DBP results from routine clinical measurements suggested significantly lower BP in the intervention group for up to 24 months., Conclusions and Relevance: This intensive intervention had sustained effects for up to 24 months (12 months after the intervention ended). Long-term maintenance of BP control is likely to require continued monitoring and resumption of the intervention if BP increases., Trial Registration: ClinicalTrials.gov Identifier: NCT00781365.

Objective: To develop a model to predict hypertension risk among children with incident elevated blood pressure (BP); to test the external validity of the model., Methods: A retrospective cohort study was conducted in 3 organizations: Kaiser Permanente Colorado was the model derivation site; HealthPartners of Minnesota and Kaiser Permanente Northern California served as external validation sites. During study years 2006 through 2012, all children aged 3 through 17 years with incident elevated BP in an outpatient setting were identified. The predictor variables were demographic and clinical characteristics collected during routine care. Cox proportional hazards regression was used to predict subsequent hypertension, and diagnostic statistics were used to assess model performance., Results: Among 5598 subjects at the derivation site with incident elevated BP, 160 (2.9%) developed hypertension during the study period. Eight characteristics were used to predict hypertension risk: age, sex, race, BP preceding incident elevated BP, body mass index percentile, systolic BP percentile, diastolic BP percentile, and clinical setting of the incident elevated BP. At the derivation site, the model discriminated well between those at higher versus lower risk of hypertension (c-statistic = 0.77). At external validation sites, the observed risk of hypertension was higher than the predicted risk, and the model showed poor discrimination (c-statistic ranged from 0.64 to 0.67)., Conclusions: Among children with incident elevated BP, a risk model demonstrated good internal validity with respect to predicting subsequent hypertension. However, the risk model did not perform well at 2 external validation sites, which might limit transportability to other settings., (Copyright © 2016 Academic Pediatric Association. Published by Elsevier Inc. All rights reserved.)

Introduction: Elevated blood pressure in childhood may predict increased cardiovascular risk in young adulthood. The Task Force on the Diagnosis, Evaluation and Treatment of High Blood pressure in Children and Adolescents recommends that blood pressure be measured in children aged 3 years or older at all health care visits. Guidelines from both Bright Futures and the Expert Panel of Integrated Guidelines for Cardiovascular Health and Risk Reduction in Children and Adolescents recommend annual blood pressure screening. Adherence to these guidelines is unknown., Methods: We conducted a cross-sectional study to assess compliance with blood pressure screening recommendations in 2 integrated health care delivery systems. We analyzed electronic health records of 103,693 subjects aged 3 to 17 years. Probability of blood pressure measurement documented in the electronic health record was modeled as a function of visit type (well-child vs nonwell-child); patient age, sex, race/ethnicity, and body mass index; health care use; insurance type; and type of office practice or clinic department (family practice or pediatrics)., Results: Blood pressure was measured at 95% of well-child visits and 69% of nonwell-child outpatient visits. After adjusting for potential confounders, the percentage of nonwell-child visits with measurements increased linearly with patient age (P < .001). Overall, the proportion of children with annual blood pressure measurements was high and increased with age. Family practice clinics were more likely to adhere to blood pressure measurement guidelines compared with pediatric clinics (P < .001)., Conclusion: These results show good compliance with recommendations for routine blood pressure measurement in children and adolescents. Findings can inform the development of EHR-based clinical decision support tools to augment blood pressure screening and recognition of prehypertension and hypertension in pediatric patients.

Objectives: To describe changes in systolic blood pressure (SBP), diastolic blood pressure (DBP), and body mass index (BMI) associated with initiation and continued use of combined oral contraceptives (COCs) in healthy adolescents., Study Design: This observational, matched cohort study was conducted in 2 large health systems. Utilizing claims and electronic medical records, we identified adolescents 14-17.9 years of age initiating medium-dose COCs (containing 30 or 35 (μg of ethinyl estradiol or equivalent and a progestin) between July 1, 2007 and December 31, 2009 with a baseline and at least 1 follow-up blood pressure (BP) and BMI. COC-users were matched 1:2 by age, race/ethnicity, and site to controls (COC-nonusers). All BPs and BMIs recorded during outpatient visits starting 1 month prior to COC initiation (index date for controls), through December 31, 2010 were collected. Mixed model linear regression with random intercepts and slopes were then used to estimate changes in SBP, DBP, and BMI over time., Results: The 510 adolescent COC-users and 912 controls did not differ significantly by age, race/ethnicity, insurance, and baseline SBP, DBP, or BMI. After adjusting for baseline values, over a median of 18 months follow-up, COC-users had an decrease in SBP of 0.07 mm Hg/mo, and controls had an increase of 0.02 mm Hg/mo (P = .65). Similarly, DBP decreased by 0.007 mm Hg/mo in COC-users vs 0.006 mm Hg/mo in controls (P = .99). BMI increased by 0.04 (kg/m(2))/mo in COC-users vs 0.025 (kg/m(2))/mo in controls (P = .09)., Conclusions: These data should provide reassurance to patients and providers regarding the lack of significant associations between COC-use and BMI or BP changes in adolescents., (Copyright © 2014 Elsevier Inc. All rights reserved.)

Background: Patients with high blood pressure (BP) visit a physician an average of 4 times or more per year in the U.S., yet BP is controlled in fewer than half. Practical, robust and sustainable models are needed to improve BP in patients with uncontrolled hypertension., Objectives: The Home Blood Pressure Telemonitoring and Case Management to Control Hypertension study (HyperLink) is a cluster-randomized trial designed to determine whether an intervention that combines home BP telemonitoring with pharmacist case management improves BP control compared to usual care at 6 and 12 months in patients with uncontrolled hypertension. Secondary outcomes are maintenance of BP control at 18 months, patient satisfaction with their health care, and costs of care., Methods: HyperLink enrolled 450 hypertensive patients with uncontrolled BP from 16 primary care clinics. Eight clinics were randomized to provide usual care (UC) to their patients (n=222) and 8 were randomized to provide the telemonitoring intervention (TI) (n=228). TI patients received home BP telemonitors that internally store and electronically transmit BP data to a secure database. Pharmacist case managers adjust antihypertensive therapy based on the home BP data under a collaborative practice agreement with the clinics' primary care teams. The length of the intervention is 12 months, with follow-up to 18 months to determine the durability of the intervention., Conclusions: We will test in a real primary care setting whether combining BP telemonitoring and pharmacist case management can achieve and maintain high rates of BP control compared to usual care., (Copyright © 2012 Elsevier Inc. All rights reserved.)

Purpose: In this study, we compared the rate of depression diagnoses in adults with and without diabetes mellitus, while carefully controlling for number of primary care visits., Methods: We matched adults with incident diabetes (n = 2,932) or prevalent diabetes (n = 14,144) to nondiabetic control patients based on (1) age and sex, or (2) age, sex, and number of outpatient primary care visits. Logistic regression analysis was used to assess the association between various predictors and a diagnosis of depression in each diabetes cohort relative to matched nondiabetic control patients., Results: With matching for age and sex alone, patients with prevalent diabetes having few primary care visits were significantly more likely to have a new depression diagnosis than matched control patients (odds ratio [OR] = 1.46, 95% confidence interval [CI], 1.19-1.80), but this relationship diminished when patients made more than 10 primary care visits (OR = 0.95, 95% CI, 0.77-1.17). With additional matching for number of primary care visits, patients with prevalent diabetes mellitus with few primary care visits were more likely to have a new diagnosis of depression than those in control group (OR = 1.32, 95% CI, 1.07-1.63), but this relationship diminished and reversed when patients made more than 4 primary care visits (OR = 0.99, 95% CI, 0.80-1.23). Similar results were observed in the subset of patients with incident diabetes and their matched control patients., Conclusions: Patients with diabetes have little or no increase in the risk of a new diagnosis of depression relative to nondiabetic patients when analyses carefully control for the number of outpatient visits. Studies showing such an association may have inadequately adjusted for comorbidity or for exposure to the medical care system.

Introduction: To examine whether depressive symptoms are associated with achievement of recommended goals for control of glucose, lipids, and blood pressure among patients with diabetes., Methods: We used a prospective cohort study of 1223 adults with diabetes that obtained self-reported depression symptoms from a survey. Medication use was obtained from claims data, and pharmacy and clinical data were obtained by manual review of paper medical records., Results: Diabetes patients with depression symptoms were less likely to be at their glucose goal (43% vs 50%; P = .0176) but more likely to be at their blood pressure goal (57% vs 51%; P = .0435). The association between lipids and depression symptoms was related to a lower rate for low-density lipoprotein testing (56% vs 68%; P < .0001). Treatment with antidepressants resulted in a greater percentage achieving glucose and blood pressure goals but not lipid goals., Conclusions: Depression seems to have a variable impact on achieving these clinical goals, perhaps because the goals have differing measurement logistics and biological profiles. Further research is needed to learn whether better treatment of depressive symptoms leads to improvements in meeting diabetes clinical goals.

Objective: To ascertain the impact of advanced access and productivity-based pay on physician productivity and compensation, patient satisfaction, and medical group cost of delivering care., Study Design: Longitudinal case study., Methods: Study subjects were 105 primary care physicians (PCPs) continuously employed at a Minnesota medical group that implemented major changes in access to primary care appointments and to PCP compensation arrangements in 2000. We tracked physician productivity, physician compensation, patient satisfaction, and cost to the medical group per relative value unit (RVU) of patient care from 1998 through 2002., Results: In 1998, 105 PCPs (99.6 full-time equivalents [FTEs]) generated 275,000 work RVUs (WRVUs), and PCP pay averaged 123,500 dollars per FTE. In 2002, the same 105 PCPs (now 98.1 FTEs) generated 374,000 WRVUs and 148,000 dollars pay per FTE. From 1998 through 2002, WRVUs per FTE rose 38%, PCP compensation increased 20%, cost of PCP compensation per WRVU produced fell by 13%, overall direct cost of running the clinics per total RVU fell by 20%, and patient satisfaction remained constant. Improvement in operating costs was due to increased physician productivity, lower physician compensation per RVU, and a decline in support staff per 10,000 RVUs from 6.80 to 4.50., Conclusions: It is possible to substantially and simultaneously improve costs of care, physician compensation, and patient access without harming patient satisfaction. Advanced access and productivity-based pay may be effective ways to address the challenges of timeliness, efficiency, and patient centeredness identified by the Institute of Medicine.

Pressure is building for performance measures that can be collected inexpensively and repeatedly for internal and external accountability and quality improvement. The objective of this study was to develop and test measures obtainable from administrative data covering each of the Institute of Medicine's (IOM) 6 aims. Measure definitions were developed for 3 common chronic conditions and were revised after testing the feasibility of collecting them from claims data. The setting was a large, multispecialty medical group in the Midwest and included all adult patients with diabetes, coronary heart disease, or depression. Problems identified in the original 99 measures led to refinements or elimination. The resulting 46 measures ready for use include 11 measures for 5 aims applicable to most common chronic conditions, plus 10 to 14 effectiveness measures for each condition. They have been successfully used to describe care quality changes for these patients over time. This starter set for the 6 IOM aims should be tested and expanded by others.

Introduction: Therapy with 3-hydroxy-3-methylglutaryl coenzyme A (HMG-CoA) reductase inhibitors, or statins, has proven to be effective in the treatment of lipid disorders. However, statin therapy continues to be underused, even though statins are a relatively safe and well-tolerated class of agents. In this study, we assessed trends in lipid control in patients with heart disease who receive most of their health care in primary care clinics. The objective was to determine whether systems of care implemented within a large medical group are associated with improved treatment and control of dyslipidemia in a high-risk group of coronary heart disease patients., Methods: All adults with heart disease in a Minnesota medical group (N = 2947) were identified using diagnosis and procedure codes related to coronary heart disease (sensitivity = 0.85; positive predictive value = 0.89) in 1996. Study subjects were observed from 1995 to 1998. Subjects had a baseline and follow-up test for low-density lipoprotein cholesterol and high-density lipoprotein cholesterol. Changes between baseline and follow-up measurements and trends in the use of statins and other lipid-active agents among the study subjects were analyzed., Results: Among 1388 subjects with two or more eligible lipid measurements, mean low-density lipoprotein cholesterol improved from 137.6 mg/dL to 111.0 mg/dL (P < .001), and mean high-density lipoprotein cholesterol improved from 42.3 mg/dL to 46.3 mg/dL (P < .001). The percentage of patients with low-density lipoprotein cholesterol < or = 100 mg/dL rose from 12.5% to 39.8% (P < .001), and the percentage with high-density lipoprotein cholesterol > or = 40 mg/dL rose from 52.5% to 67.6% (P < .001). In multivariate models, statin use was identified as the main factor that contributed to the improvement in low-density lipoprotein cholesterol (P < .001). Men had greater decreases in low-density lipoprotein cholesterol than women after adjusting for other variables (P < .001). Statin use rose from 24.3% at baseline to 69.6% at follow-up. The statin discontinuation rate was 8.3% for baseline statin users and 12.2% for subjects who used statins at any time during the study period., Conclusion: Investment in better heart disease care for patients in primary care clinics led to major improvement in lipid control over 30 months, primarily due to increased statin use. Improvements in low-density lipoprotein cholesterol and high-density lipoprotein cholesterol were sufficient to substantially reduce risk of subsequent major cardiovascular events.

Background: It is important to know whether medical groups have quality improvement (QI) priorities, approaches, activities, and congruence that will allow them to achieve major improvements in quality of care., Methods: Simultaneous surveys were sent to medical and administrative leaders of 18 medical groups, 84 of their constituent clinics, and their primary care physicians providing the majority of the primary care in the Minneapolis/St. Paul metropolitan area., Results: Of the 18 medical groups, 17 have an overall physician leader for QI and 11 have the same at each of their constituent clinics. Nearly 100% of clinic leaders report their group leaders see QI as important and expect clinics to improve care, while 69%-84% of their physicians report the clinic leaders are committed to QI for diabetes and heart disease. Diabetes and coronary heart disease are the priorities for improvement by 14 and 12 medical groups respectively. Only seven groups report adequate QI resources and only three report that incentives are aligned with quality. Intermediate groups generally appear to be just as active and supportive of QI as large ones., Discussion: These medical groups and their constituent clinics and physicians appear ready to work on the issues raised by the Institute of Medicine (IOM). However, they believe that limited resources and financial incentives that are not aligned with quality constrain their ability to help America cross the quality chasm.

Background: We wanted to identify differences between diabetic patients who smoke and those who do not smoke to design more effective strategies to improve their diabetes care and encourage smoking cessation., Methods: A random sample of adult health plan members with diabetes were mailed a survey questionnaire, with telephone follow-up, asking about their attitudes and behaviors regarding diabetes care and smoking. Among the 1,352 respondents (response rate 82.4%), we found 188 current smokers whose answers we compared with those of 1,264 nonsmokers, with statistical adjustment for demographic characteristics and duration of diabetes., Results: Smokers with diabetes were more likely to report fair or poor health (odds ratio [OR] = 1.5, P = .03) and often feeling depressed (OR = 1.7, P = .004). Relative to nonsmokers, smokers had lower rates of checking blood glucose levels, were less physically active, and had fewer diabetes care visits, glycated hemoglobin (A1c) tests, foot examinations, eye examinations, and dental checkups (P < or = .01). Smokers also reported receiving and desiring less support from family and friends for specific diabetic self-management activities and had lower readiness to quit smoking than has been observed in other population groups., Conclusions: Clinicians should be aware that diabetic patients who smoke are more likely to report often feeling depressed and, even after adjusting for depression, are less likely to be active in self-care or to comply with diabetes care recommendations. Diabetic patients who smoke are special clinical challenges and are likely to require more creative and consistent clinical interventions and support.

Background: The 2001 Institute of Medicine (IOM) report highlighted the need for transformation of the U.S. health care system. This rigorous qualitative evaluation of transformational change for patient access in one large multispecialty group practice identifies the major issues facing organizations addressing the IOM challenge., Methods: Semistructured depth interviews were conducted with the medical and administrative leaders at all levels, physicians, and nurses from 17 primary care clinics in one integrated medical group two years after they began to transform their approach to primary care patient appointment access., Results: The mean time to third-next-available appointment was reduced by 76% during one year, from 17.8 days to 4.2 days. Nine important issues related to the change process were identified from clinic interviews. When combined with issues identified by central leaders, 13 themes stood out as lessons in transformational change. A major issue is the tension between physician autonomy and both effective organizational function and putting patients first. Physician autonomy is also diminished by the need to standardize and systematize care., Conclusions: Transformational change in care delivery is possible in large and complex group practices. Changes that directly affect care delivery and physician autonomy present particular challenges to physicians that need to be attended to if the changes are to be successful.

Purpose: We hypothesize that elevated charges among former smokers reflect differential cessation of sicker individuals. We ascertained the relationship between prior health care charges and time to smoking cessation., Design: Prospective, observational study using panel survey data and administrative health plan records., Setting: A large managed care organization in Minnesota., Subjects: A stratified random sample of 8000 health plan members 40 years and older, yielding 611 current smokers at baseline., Measures: Smoking cessation measured via self-report survey. Health care charges, mortality, and disenrollment data derived from automated health plan databases., Results: Among smoking adults without chronic disease diagnoses at baseline, a first attempt at quitting smoking was positively associated with the presence of any inpatient charges (relative risk [RR], 1.9; p < .05) or any emergency department or urgent care charges (RR, 1.4; p < .10). We also observed positive associations between total charges and ambulatory charges in the top textile (RR, 1.5 and 1.6, respectively; p < .05) with a first attempt at quitting smoking, further suggesting graded relationships. Among smoking adults with one or more of four chronic disease diagnoses at baseline, being in the top two tertiles of total charges or ambulatory care charges was predictive of a subsequent attempt at quitting smoking., Conclusions: Higher health care charges, particularly from ambulatory (primary care clinic) settings, predicted smoking cessation among both individuals with and without chronic diseases. These charges may be proxies for other factors, such as smoking-related symptoms or physician advice or messaging regarding smoking cessation.