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ObjectiveTo estimate ovarian and peritoneal cancer rates after hysterectomy with and without salpingo-oophorectomy for benign conditions.MethodsAll patients after hysterectomy for benign disease from 1988 to 2006 in Kaiser Permanente Northern California, an integrated health organization. Incidence rates per 100,000 person-years were calculated.ResultsOf 56,692 patients, the majority (54%) underwent hysterectomy with bilateral salpingo-oophorectomy; 7% had hysterectomy with unilateral salpingo-oophorectomy, and 39% had hysterectomy alone. There were 40 ovarian and eight peritoneal cancers diagnosed during follow-up. Median age at ovarian and peritoneal cancer diagnosis was 50 and 64 years, respectively. Age-standardized rates (per 100,000 person-years) of ovarian or peritoneal cancer were 26.7 (95% confidence interval [CI] 16-37.5) for those with hysterectomy alone, 22.8 (95% CI 0.0-46.8) for hysterectomy and unilateral salpingo-oophorectomy, and 3.9 (95% CI 1.5-6.4) for hysterectomy and bilateral salpingo-oophorectomy. Rates of ovarian cancer were 26.2 (95% CI 15.5-37) for those with hysterectomy alone, 17.5 (95% CI 0.0-39.1) for hysterectomy and unilateral salpingo-oophorectomy, and 1.7 (95% CI 0.4-3) for those with hysterectomy and bilateral salpingo-oophorectomy. Compared with women undergoing hysterectomy alone, those receiving an unilateral salpingo-oophorectomy had a hazard ratio (HR) for ovarian cancer of 0.58 (95% CI 0.18-1.9) and those undergoing bilateral salpingo-oophorectomy had an HR of 0.12 (95% CI 0.05-0.28).ConclusionsThe removal of both ovaries decreases the incidence of ovarian and peritoneal cancers. Removal of one ovary might also decrease the incidence of ovarian cancer but warrants further investigation.Level of evidenceII.

The anticoagulant drug warfarin is effective in reducing the risk of stroke in people who have atrial fibrillation, according to a study of 11,526 members of Kaiser Permanente of Northern California. This study shows that warfarin can be used in primary care situations, although 80% of the people involved in this study went to an anticoagulant clinic to receive warfarin. Atrial fibrillation occurs when the upper part of the heart begins beating too fast.

Objective. Breastfeeding rates fall short of goals set in Healthy People 2010 and other national recommendations. The current, national breastfeeding continuation rate of 29% at 6 months lags behind the Healthy People 2010 goal of 50%. The objective of this study was to evaluate associations between breastfeeding discontinuation at 2 and 12 weeks postpartum and clinician support, maternal physical and mental health status, workplace issues, and other factors amenable to intervention. Methods. A prospective cohort study was conducted of low-risk mothers and infants who were in a health maintenance organization and enrolled in a randomized, controlled trial of home visits. Mothers were interviewed in person at 1 to 2 days postpartum and by telephone at 2 and 12 weeks. Logistic regression modeling was performed to assess the independent effects of the predictors of interest, adjusting for sociodemographic and other confounding variables. Results. Of the 1163 mother-newborn pairs in the cohort, 1007 (87%) initiated breastfeeding, 872 (75%) were breastfeeding at the 2-week interview, and 646 (55%) were breastfeeding at the 12-week interview. In the final multivariate models, breastfeeding discontinuation at 2 weeks was associated with lack of confidence in ability to breastfeed at the 1- to 2-day interview (odds ratio [OR]: 2.8; 95% confidence interval [CI]: 1.02-7.6), early breastfeeding problems (OR: 1.5; 95% CI: 1.1-1.97), Asian race/ ethnicity (OR: 2.6; 95% CI: 1.1-5.7), and lower maternal education (OR: 1.5; 95% CI: 1.2-1.9). Mothers were much less likely to discontinue breastfeeding at 12 weeks postpartum if they reported (during the 12-week interview) having received encouragement from their clinician to breastfeed (OR: 0.6; 95% CI: 0.4-0.8). Breastfeeding discontinuation at 12 weeks was also associated with demographic factors and maternal depressive symptoms (OR: 1.18; 95% CI: 1.01-1.37) and returning to work or school by 12 weeks postpartum (OR: 2.4; 95% CI: 1.8-3.3). Conclusions. Our results indicate that support from clinicians and maternal depressive symptoms are associated with breastfeeding duration. Attention to these issues may help to promote breastfeeding continuation among mothers who initiate. Policies to enhance scheduling flexibility and privacy for breastfeeding mothers at work or school may also be important, given the elevated risk of discontinuation associated with return to work or school., ABBREVIATIONS. KPMCP, Kaiser Permanente Medical Care Program; CES-D, Center for Epidemiologic Studies Depression Scale; OR, odds ratio; CI, confidence interval; HMO, health maintenance organization. The promotion and support of breastfeeding [...]

Objective. Racial/ethnic disparities in hospitalization rates among children with asthma have been documented but are not well-understood. Medicaid programs, which serve many minority children, have markedly increased their use of managed care in recent years. It is unknown whether racial/ethnic disparities in health care use or other processes of care exist in managed Medicaid populations. This study of Medicaid-insured children with asthma in 5 managed care organizations aimed to 1) compare parent-reported health status and asthma care processes among black, Latino, and white children and 2) test the hypothesis that racial/ ethnic variations in processes of asthma care exist after adjusting for socioeconomic status and asthma status. Methods. This cross-sectional study collected data via telephone interviews with parents and computerized records for Medicaid-insured children with asthma in 5 managed care organizations in California, Washington, and Massachusetts. The American Academy of Pediatrics (AAP) Children's Health Survey for Asthma was used to measure parent-reported asthma status. We used multivariate models to evaluate associations between race/ ethnicity and asthma status while controlling for other sociodemographic variables. We evaluated racial/ethnic variations in selected processes of asthma care while controlling for other demographic variables and asthma status. Results. The response rate was 63%. Of the 1658 children in the respondent group, 38% were black, 19% were Latino, and 31% were white. Black children had worse asthma status than white children on the basis of the AAP asthma physical and emotional health scores, symptom-days, and school days missed in the past 2 weeks. Latino children had equivalent AAP scores but missed more school days than white children. On the basis of the AAP asthma physical health score, the black-white disparity persisted after adjusting for other sociodemographic variables. After adjusting for sociodemographic variables and asthma status, black and Latino children were less likely to be using inhaled antiinflammatory medication than white children (relative risk for blacks: 0.69; relative risk for Latinos: 0.58). They were more likely to have home nebulizers. Other processes of asthma care, including ratings of providers and asthma care, use of written management plans, use of preventive visits and specialists, and having no pets or smokers at home, were equal or better for minority children compared with white children. Conclusions. Black and Latino children had worse asthma status and less use of preventive asthma medications than white children within the same managed Medicaid populations. Most other processes of asthma care seemed to be equal or better for minorities in the populations that we studied. Increasing the use of preventive medications is a natural focus for reducing racial disparities in asthma. Pediatrics 2002;109:857-865; asthma, race, race/ethnicity, health status, quality of care, processes of care, managed care., The burden of asthma falls disproportionately and increasingly on racial/ethnic minority and poor children in the United States. (1-3) Black children have higher asthma hospitalization rates and emergency department (ED) [...]

Objective. In January 1997, one of the most significant changes to United States vaccine policy occurred when polio immunization guidelines changed to recommend a schedule containing inactivated polio vaccine (IPV). There were concerns that parent or physician reluctance to accept IPV into the routine childhood immunization schedule would lead to lowered coverage. We determined whether adoption of an IPV schedule had a negative impact on immunization coverage. Design. A cohort study of 2 large health maintenance organizations (HMOs), Group Health Cooperative and Kaiser Permanente Northern California, was conducted. For analysis at 12 months of age, children who were born between October 1, 1996, and December 31, 1997, and were commercially insured and covered by Medicaid were continuously enrolled; for analysis at 24 months of age, children who were born between October 1, 1996, and June 30, 1997, and were commercially insured and covered by Medicaid were continuously enrolled. The 3 measures of immunization status at 12 and 24 months of age were up-to-date status, cumulative time spent up-to-date, and the number of missed opportunity visits. Results. At both HMOs, children who received IPV were as likely to be up to date at 12 months as were children who received oral poliovirus vaccine (OPV), whereas at Group Health, children who received IPV were slightly more likely to be up to date at 24 months (relative risk: 1.12; 95% confidence interval [CI]: 1.05, 1.19). These findings were consistent for children who were covered by Medicaid. At Kaiser Permanente, children who received IPV spent ~3 fewer days up to date in the first year of life, but this difference did not persist at 2 years of age. At Group Health, children who received IPV were no different from those who received OPV in terms of days spent up to date by 1 or 2 years of age. At Group Health, children who received IPV were less likely to have a missed opportunity by 12 months old (odds ratio [OR] 0.46; 95% CI: 0.31, 0.70), but this finding did not persist at 24 months of age. At Kaiser Permanente, children who received IPV were more likely to have a missed opportunity by 12 months (OR 2.06; 95% CI: 1.84, 2.30), and 24 months of age (OR 1.50; 95% CI: 1.36, 1.67). Conclusions. The changeover from an all-OPV schedule to one containing IPV had little if any negative impact on vaccine coverage. Use of IPV was associated with a small increase in the likelihood of being up to date at 2 years of age at one of the HMOs and conversely was associated with a small increase in the likelihood of having a missed-opportunity visit in the other HMO. Pediatrics 2001;107:671-676; polio, poliomyelitis, vaccination, immunization coverage., ABBREVIATIONS. ACIP, Advisory Committee on Immunization Practices; IPV, inactivated polio vaccine; OPV, oral poliovirus vaccine; HMO, health maintenance organization; GHC, Group Health Cooperative of Puget Sound; KPNC, Kaiser Permanente of [...]

ABSTRACT. Background. Postpartum hospital stays seem likely to remain limited even under new laws which mandate that insurers cover 48-hour hospitalization after uncomplicated delivery. Clinicians, who are increasingly practicing in [...]

Written asthma management plans that parents can follow at home can significantly reduce hospitalization and emergency department visits for asthmatic children. In a study of 1,498 children with asthma, those whose parents had a plan were half as likely to be hospitalized or visit the emergency department than those whose parents did not. Washing bedsheets frequently, and promptly medicating asthmatic symptoms or illness, also reduced the risk of hospitalization. Physicians must make the effort to provide parents with written management plans and medications to fully realize the potential benefit from this type of initial intervention., Objectives. Effective outpatient care is believed to prevent hospitalization and emergency department (ED) visits resulting from childhood asthma. The aim of this study was to suggest priority areas for intervention by identifying outpatient management practices associated with the risk of these adverse outcomes in a large population. Methods. This case-control study included children aged 0 to 14 years with asthma who were members of a regional health maintenance organization. Cases were children undergoing either a hospitalization or an ED visit for asthma during the study period. Control subjects were children with asthma without a hospitalization or an ED visit during the study period who were matched to patients on age, gender, and number of asthma-related hospitalizations in the past 24 months. Data on provider and parent asthma management practices were collected using chart review, closed-ended telephone interviews with parents, and computerized use databases. Multivariate analyses were conducted using conditional logistic regression models. Results. Data were collected on 508 cases and 990 control subjects. A total of 43% of cases were reported by their parents to have moderately severe or severe asthma, compared with 20% of control subjects. Parents of cases with hospitalization were less likely than control subjects to have a written asthma management plan (44% vs 51%) and to report washing bedsheets in hot water at least twice a month (77% vs 86%). Cases with hospitalization were more likely to have a nebulizer (74% vs 56%). In the final multivariate model, race/ethnicity was not associated with having had either a hospitalization or an ED visit, as was lower socioeconomic status. Having a written asthma management plan [odds ratio (OR): 0.54; 95% confidence interval (CI): 0.30, 0.99] and washing bedsheets in hot water at least twice a month (OR: 0.45; 95% CI: 0.21, 0.94) were associated with reduced odds of hospitalization. Having a written asthma management plan (OR: 0.45; 95% CI: 0.27, 0.76) and starting or increasing medications at the onset of a cold or flu were associated with reduced odds of making an ED visit. Conclusions. Practices that support early intervention for asthma flare-ups by parents at home, particularly written management plans, are strongly associated with reduced risk of adverse outcomes among children with asthma. Pediatrics 1997,100:334-341; asthma, primary care, outpatient care, parents, behaviors, managed care., Hospitalization for childhood asthma has increased in the United States over the past decade.[1,2] Adverse outcomes such as hospitalization and emergency department (ED) visits account for almost three fourths of [...]

Objective. More than half of Medicaid enrollees are now in managed care. Scant information exists about which policies of practice sites improve quality of care in managed Medicaid. Children with asthma are a sentinel group for Medicaid quality monitoring because they are at elevated risk for adverse outcomes. The objective of this study was to identify practice-site policies and features associated with quality of care for Medicaid-insured children with asthma. Methods. A prospective cohort study with 1-year follow-up was conducted in 5 health plans in California, Washington, and Massachusetts. Data were collected via telephone interviews with parents at baseline and I year, surveys of practice sites and clinicians, and computerized databases. The practice site survey asked about policies to promote cultural competence, the use of several types of reports to clinicians, support for self-management of asthma, case management and care coordination, and access to and continuity of care. Quality of care was evaluated on the basis of 5 measures: 1) preventive medication underuse based on parent report; 2) the parent's rating of asthma care; 3) the 1-year change in the child's asthma physical status based on a standardized measure; 4) preventive medication underprescribing based on computerized data; and 5) the occurrence of a hospital-based episode. Results. Of the 1663 children in the study population, 67% had persistent asthma at baseline based on parent report of symptoms and medications. At 1-year follow-up, 65% of the children with persistent asthma were underusing preventive medication based on parent report. In multivariate analyses, patients of practice sites with the highest cultural competence scores were less likely to be underusing preventive asthma medications based on parent report at follow-up (odds ratio [OR]: 0.15; 95% confidence interval [CI]: 0.06-0.41 for the highest vs lowest categories) and had better parent ratings of care. The use of asthma reports to clinicians was predictive of less preventive medication underprescribing based on computerized data (OR: 0.33; 95% CI: 0.16-0.69), better parent ratings of care, and better asthma physical status at follow-up. Patients of practice sites with policies to promote access and continuity had less underuse of preventive medications (OR: 0.56; 95% CI: 0.34-0.93). Among the 83 practice sites, the practice site's size, organizational type, percentage of patients insured by Medicaid, mechanism of payment for specialty care, and other primary care features were not consistently associated with quality measures. Conclusions. Practice-site policies to promote cultural competence, the use of reports to clinicians, and access and continuity predicted higher quality of care for children with asthma in managed Medicaid. Pediatrics 2004;114:e102-e110. URL: http://www.pediatrics.org/cgi/ content/full/114/1/e102; asthma, Medicaid, cultural competence, quality of care.

The article discusses a study which examined whether glycemic control measured by serial homoglobin A1c was linked with colorectal adenoma risk. Patients with type 2 diabetes mellitus who were included in the study had at least one colorectal adenoma identified at either colonoscopy or sigmoidoscopy. Results showed that the adjusted mean HbA1c levels among those without adenomas was 8.20% versus 8.26% among those with at least one adenoma. It was concluded that glycemic control was not linked with the risk of colorectal adenoma.

Low circulating levels of sex hormone-binding globulin (SHBG), a putative marker of androgenicity, have been associated with poor glucose control in studies conducted primarily among post-menopausal women. However, the relation of long-term changes in endogenous SHBG to risk of type 2 diabetes (T2DM) in women during and after the menopause transition is unclear. We aimed to assess the longitudinal associations between SHBG levels and risk of developing T2DM among such women. We included 3,060 participants in the Study of Women's Health Across the Nation (SWAN) who were free of diabetes at baseline. SWAN is a longitudinal cohort study with up to 17 years of follow-up. SHBG levels were measured at 13 visits. Participants reported diagnosed diabetes status at all visits, and fasting glucose was measured at 8 follow-up visits. T2DM was defined based on self-report or fasting glucose levels. Women averaged 46 (SD=3) years of age at baseline. 311 women developed T2DM during follow-up. We used complementary log-log-based discrete time survival models anchored at baseline to estimate associations of longitudinal SHBG with incident T2DM. A 5-unit (nM) increase in time-varying SHBG was associated with a hazard ratio (HR) of 0.86 (95% CI 0.82, 0.90), for T2DM, after controlling for race-ethnicity, age, cycle day of blood draw, site, time-varying body mass index (BMI), testosterone, and baseline SHBG level. After adjusting for covariates, women in the lowest ((-92.0 - -1.1 nM/year) vs. highest quartile (0.7 - 42.1 nM/year) for time-invariant average rate of change per year in SHBG levels) had a HR of 5.18 (95% CI: 3.55,7.56). No association was observed for other quartiles in rate of change of SHBG with developing T2DM. Women with low levels of SHBG and/or decreases in SHBG levels were at increased risk to develop T2DM. Clinicians should be aware that declining levels of SHBG in mid-life women is strongly associated with developing T2DM, independent known T2DM risk factors. Disclosure: M.M. Hedderson: None. C. Lee: None. A. Capra: None. J. Lee: None. P. Chang: None. E. Gold: None. E. Waetjen: None. L.A. Habel: None. S.R. El Khoudary: None. Funding: National Institutes of Health [ABSTRACT FROM AUTHOR]