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Objective: To assess whether providing customized clinical information to patients and physicians improves safety or quality of diabetes care.Research Design and Methods: Study subjects included 123 primary care physicians and 3,703 eligible adult diabetic patients with elevated A1C or LDL cholesterol, who were randomly assigned to receive customized feedback of clinical information as follows: 1) patient only, 2) physician only, 3) both the patient and physician, or 4) neither patient nor physician. In the intervention groups, patients received customized mailed information or physicians received printed, prioritized lists of patients with recommended clinical actions and performance feedback. Hierarchical models were used to accommodate group random assignment.Results: Study interventions did not improve A1C test ordering (P = 0.35) and negatively affected LDL cholesterol test ordering (P < 0.001) in the 12 months postintervention. Interventions had no effect on LDL cholesterol values (P = 0.64), which improved in all groups over time. Interventions had a borderline unfavorable effect on A1C values among those with baseline A1C >or=7% (P = 0.10) and an unfavorable effect on A1C values among those with baseline A1C >or=8% (P < 0.01). Interventions did not reduce risky prescribing events or increase treatment intensification. Time to next visit was longer in all intervention groups compared with that for the control group (P < 0.05).Conclusions: Providing customized decision support to physicians and/or patients did not improve quality or safety of diabetes care and worsened A1C control in patients with baseline A1C >or=8%. Future researchers should consider providing point-of-care decision support with redesign of office systems and/or incentives to increase appropriate actions in response to decision-support information. [ABSTRACT FROM AUTHOR]

Purpose: Case-based simulations are powerful training tools that can enhance learning and drive behavior change. This is an overview of the design/development of Dental Decision Simulation (DDSim), a web-based simulation of an electronic dental record (EDR). The purpose was to use DDSim to train dentists to make evidence-based treatment planning decisions consistent with current evidence. This simulated EDR provides case-based information in support of a set of defined evidence-based learning objectives., Methods: The development of this complex simulation model required coordinated efforts to create several components: identify behavior changes, case authoring mechanism, create virtual patient visits, require users to make treatment plan decisions related to learning objectives, and a feedback mechanism to help users recognize departures from those learning objectives. This simulation was evaluated in a 2-arm, clinic-randomized, controlled pilot study examining the extent to which DDSim changed dentists' planned treatment to conform to evidence-based treatment guidelines relative to change in dentists not exposed to DDSim. Outcomes were measured by comparing preintervention and postintervention patient EDR treatment data., Results: Changes in behavior over time did not favor intervention or control clinics., Conclusion: DDSim provides a standardized learning platform that cannot be achieved through the use of live patients. Both live patients and case-based simulations can be used to transfer knowledge and skill development. DDSim offers the advantage of providing a platform for developing treatment planning skills in a low-risk environment. However, further research examining behavior change is needed., (© 2020 American Dental Education Association.)

Purpose: To develop a Spanish version of the Orofacial Esthetic Scale (OES-Sp) and to determine its psychometric properties in dental patients., Methods: We performed a validation study for OES development and validation into Spanish. In the development phase, eight individuals participated in the translation process (cross-cultural adaptation) following the PROMIS methodology. In the validation phase, 331 dental patients (age mean±sd: 42.9±12.3years, 59 % female) from the HealthPartners dental clinics in Minnesota, USA responded to a survey of Spanish speaking patients (n=540, response rate: 61 %). We first explored dimensionality by means of exploratory factor analysis and scree plot, and then we computed reliability measures with the Cronbach's alpha statistic. Finally, we assessed convergent validity by computing Pearson/Spearman rank correlations between OES-Sp and Oral Health Impact Profile (OHIP)-based orofacial appearance measures. All statistical procedures were performed using Stata v.13 for Windows (StataCorp)., Results: Exploratory factor analysis provided evidence that a single factor represents the Spanish OES version. Score reliability was high with Cronbach's alpha statistic of 0.95 (lower limit of the 95 % CI: 0.94). Score validity was sufficient indicated by Pearson and Spearman rank correlations between -0.53 and -0.69 (all 95 % confidence intervals: less than ± 0.10)., Conclusions: OES is a valuable instrument to measure the orofacial appearance construct for Spanish-speaking populations. OES was concluded to be unidimensional with excellent score reliability and sufficient convergent score validity when compared with other Orofacial Appearance measures. Our results suggest that OES could be used in Spanish-speaking patients, an important and growing population around the globe., (Copyright © 2018 Japan Prosthodontic Society. Published by Elsevier Ltd. All rights reserved.)

Introduction: A computer-assisted tobacco decision support tool increased dental practitioners' (dentists and dental hygienists) advice to quit smoking and referral to a quitline during a group randomized trial. The purpose of this study is to document the extent to which use persisted after the trial., Methods: Electronic dental record (EDR) data from 2010 to 2013 were analyzed in 2014 for use of computer-assisted tobacco intervention tool advice scripts and referral to a quitline during four periods: during the trial and post-trial when only intervention clinic dental practitioners had access to the tool, and during full deployment, both before and after an EDR modification., Results: Intervention clinic dental practitioners (18.5 dentist full-time equivalents [FTEs] and 27.8 dental hygienist FTEs practicing in seven clinics) referred 19.0% of 1,368 smokers to a quitline during the trial and referred 15.4% of 4,011 smokers post-trial. After full tool deployment but pre-EDR change, these dental practitioners referred 15.6% of 2,214 intervention clinic smokers, whereas 18.3 dentist FTEs and 29.7 dental hygienist FTEs practicing in eight clinics referred 8.5% of 2,113 smokers. Post-EDR change, dental practitioners referred 12.2% of 2,214 intervention clinic smokers and 8.1% of 2,399 control clinic smokers to a quitline. In the last three quarters of observation, clinic script use ranged from 15.4% to 65.8% and referral to a quitline ranged from 2.0% to 18.7% of visits., Conclusions: Although EDR design affected rates of referral, dental practitioners persisted in using a computer-assisted tobacco intervention tool to refer smokers to a quitline., (Copyright © 2015 American Journal of Preventive Medicine. Published by Elsevier Inc. All rights reserved.)

Purpose: To test a virtual case-based Simulated Diabetes Education intervention (SimDE) developed to teach primary care residents how to manage diabetes., Method: Nineteen primary care residency programs, with 341 volunteer residents in all postgraduate years (PGY), were randomly assigned to a SimDE intervention group or control group (CG). The Web-based interactive educational intervention used computerized virtual patients who responded to provider actions through programmed simulation models. Eighteen distinct learning cases (L-cases) were assigned to SimDE residents over six months from 2010 to 2011. Impact was assessed using performance on four virtual assessment cases (A-cases), an objective knowledge test, and pre-post changes in self-assessed diabetes knowledge and confidence. Group comparisons were analyzed using generalized linear mixed models, controlling for clustering of residents within residency programs and differences in baseline knowledge., Results: The percentages of residents appropriately achieving A-case composite clinical goals for glucose, blood pressure, and lipids were as follows: A-case 1: SimDE = 21.2%, CG = 1.8%, P = .002; A-case 2: SimDE = 15.7%, CG = 4.7%, P = .02; A-case 3: SimDE = 48.0%, CG = 10.4%, P < .001; and A-case 4: SimDE = 42.1%, CG = 18.7%, P = .004. The mean knowledge score and pre-post changes in self-assessed knowledge and confidence were significantly better for SimDE group than CG participants., Conclusions: A virtual case-based simulated diabetes education intervention improved diabetes management skills, knowledge, and confidence for primary care residents.

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., Trial Registration Number: NCT00903071., (Published by the BMJ Publishing Group Limited. For permission to use (where not already granted under a licence) please go to http://group.bmj.com/group/rights-licensing/permissions.)

Dentistry has historically seen tobacco dependence as a medical problem. As a consequence, dentistry has not adopted or developed effective interventions to deal with tobacco dependence. With the expanded use of electronic dental records, the authors identified an opportunity to incorporate standardized expert support for tobacco dependence counseling during the dental visit. Using qualitative results from observations and focus groups, a decision support system was designed that suggested discussion topics based on the patient's desire to quit and his or her level of nicotine addiction. Because dental providers are always pressed for time, the goal was a three-minute average intervention interval. To fulfill the provider's need for an easy way to track ongoing interventions, script usage was recorded. This process helped the provider track what he or she had said to the patient about tobacco dependence during previous encounters and to vary the messages. While the individual elements of the design process were not new, the combination of them proved to be very effective in designing a usable and accepted intervention. The heavy involvement of stakeholders in all components of the design gave providers and administrators ownership of the final product, which was ultimately adopted for use in all the clinics of a large dental group practice in Minnesota.

Background: Decreases in smoking prevalence from recent decades have slowed, and national goals to reduce tobacco use remain unmet. Healthcare providers, including those in physician and dental teams, have access to evidence-based guidelines to help patients quit smoking. Translation of those guidelines into practice, however, remains low. Approaches that involve screening for drug use, brief intervention, and referral to treatment (SBIRT) are a promising, practical solution., Purpose: This study examined whether dentists and dental hygienists would assess interest in quitting, deliver a brief tobacco intervention, and refer to a tobacco quitline more frequently as reported by patients if given computer-assisted guidance in an electronic patient record versus a control group providing usual care., Design: A blocked, group-randomized trial was conducted from November 2010 to April 2011. Randomization was conducted at the clinic level. Patients nested within clinics represented the lowest-level unit of observation., Setting/participants: Participants were patients in HealthPartners dental clinics., Intervention: Intervention clinics were given a computer-assisted tool that suggested scripts for patient discussions. Usual care clinics provided care without the tool., Main Outcome Measures: Primary outcomes were post-appointment patient reports of the provider assessing interest in quitting, delivering a brief intervention, and referring them to a quitline., Results: Patient telephone surveys (72% response rate) indicated that providers assessed interest in quitting (control 70% vs intervention 87%, p=0.0006); discussed specific strategies for quitting (control 26% vs intervention 47%, p=0.003); and referred the patient to a tobacco quitline (control 17% vs intervention 37%, p=0.007) more frequently with the support of a computer-assisted tool integrated into the electronic health record., Conclusions: Clinical decision support embedded in electronic health records can effectively help providers deliver tobacco interventions. These results build on evidence in medical settings supporting this approach to improve provider-delivered tobacco cessation., Trial Registration: This study is registered at ClinicalTrials.govNCT01584882., (Copyright © 2013 American Journal of Preventive Medicine. All rights reserved.)

Background and Objective: Medical groups have invested billions of dollars in electronic medical records (EMRs), but few studies have examined the cost-effectiveness of EMR-based clinical decision support (CDS). This study examined the cost-effectiveness of EMR-based CDS for adults with diabetes from the perspective of the health care system., Data Sources/setting: Clinical outcome and cost data from a randomized clinical trial of EMR-based CDS were used as inputs into a diabetes simulation model. The simulation cohort included 1,092 patients with diabetes with A1c above goal at baseline., Study Design: The United Kingdom Prospective Diabetes Study Outcomes Model, a validated simulation model of diabetes, was used to evaluate remaining life years, quality-adjusted life years (QALYs), and health care costs over patient lifetimes (40-year time horizon) from the health system perspective., Principal Findings: Patients in the intervention group had significantly lowered A1c (0.26 percent, p = .014) relative to patients in the control arm. Intervention costs were $120 (SE = 45) per patient in the first year and $76 (SE = 45) per patient in the following years. In the base case analysis, EMR-based CDS increased lifetime QALYs by 0.04 (SE = 0.01) and increased lifetime costs by $112 (SE = 660), resulting in an incremental cost-effectiveness ratio of $3,017 per QALY. The cost-effectiveness of EMR-based CDS persisted in one-way, two-way, and probabilistic sensitivity analyses., Conclusions: Widespread adoption of sophisticated EMR-based CDS has the potential to modestly improve the quality of care for patients with chronic conditions without substantially increasing costs to the health care system., (© Health Research and Educational Trust.)

Objectives: To compare the outcomes of restorations placed by restorative function auxiliaries (RFAs) with those placed by dentists., Methods: Between July 1, 2007, and June 30, 2008, we matched 455 restorations placed by RFAs working at HealthPartners Dental Group with the same number placed by dentists. Restorations were matched by tooth number, American Dental Association procedure code, and patient age-group., Results: Of 910 restorations, 17 (1.9 percent) had problems potentially related to the filling or crown placement during the first year. Problem rates were not significantly different (p = 0.33) for restorations placed by RFAs (1.3 percent, 6 of 455) and those placed by dentists (2.4 percent, 11 of 455)., Conclusions: There was no significant difference in problem rates for restorations placed by RFAs versus those placed by dentists. This finding may free dentists to handle more difficult cases, alleviating some of the pressures of daily practice and meeting the need for improved access., (© 2012 American Association of Public Health Dentistry.)

Purpose: We wanted to assess the impact of an electronic health record-based diabetes clinical decision support system on control of hemoglobin A(1c) (glycated hemoglobin), blood pressure, and low-density lipoprotein (LDL) cholesterol levels in adults with diabetes., Methods: We conducted a clinic-randomized trial conducted from October 2006 to May 2007 in Minnesota. Included were 11 clinics with 41 consenting primary care physicians and the physicians' 2,556 patients with diabetes. Patients were randomized either to receive or not to receive an electronic health record (EHR)-based clinical decision support system designed to improve care for those patients whose hemoglobin A(1c), blood pressure, or LDL cholesterol levels were higher than goal at any office visit. Analysis used general and generalized linear mixed models with repeated time measurements to accommodate the nested data structure., Results: The intervention group physicians used the EHR-based decision support system at 62.6% of all office visits made by adults with diabetes. The intervention group diabetes patients had significantly better hemoglobin A(1c) (intervention effect -0.26%; 95% confidence interval, -0.06% to -0.47%; P=.01), and better maintenance of systolic blood pressure control (80.2% vs 75.1%, P=.03) and borderline better maintenance of diastolic blood pressure control (85.6% vs 81.7%, P =.07), but not improved low-density lipoprotein cholesterol levels (P = .62) than patients of physicians randomized to the control arm of the study. Among intervention group physicians, 94% were satisfied or very satisfied with the intervention, and moderate use of the support system persisted for more than 1 year after feedback and incentives to encourage its use were discontinued., Conclusions: EHR-based diabetes clinical decision support significantly improved glucose control and some aspects of blood pressure control in adults with type 2 diabetes.

Objective: Inexpensive and standardized methods to deliver medical education to primary care physicians (PCPs) are desirable. Our objective was to assess the impact of an individualized simulated learning intervention on diabetes care provided by PCPs., Research Design and Methods: Eleven clinics with 41 consenting PCPs in a Minnesota medical group were randomized to receive or not receive the learning intervention. Each intervention PCP was assigned 12 simulated type 2 diabetes cases that took about 15 min each to complete. Cases were designed to remedy specific physician deficits found in their electronic medical record observed practice patterns. General linear mixed models that accommodated the cluster randomized study design were used to assess patient-level change from preintervention to 12-month postintervention of A1C, blood pressure, and LDL cholesterol. The relationship between the study arm and the total of intervention and patient health care costs was also analyzed., Results: Intervention clinic patients with baseline A1C >or=7% significantly improved glycemic control at the last postintervention A1C measurement, intervention effect of -0.19% mean A1C (P = 0.034) and +6.7% in A1C <7% goal achievement (P = 0.0099). Costs trended lower, with the cost per patient -$71 (SE = 142, P = 0.63) relative to nonintervention clinic patients. The intervention did not significantly improve blood pressure or LDL control. Models adjusting for age, sex, and comorbidity showed similar results. PCPs reported high satisfaction., Conclusions: A brief individualized case-based simulated learning intervention for PCPs led to modest but significant glucose control improvement in adults with type 2 diabetes without increasing costs.

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.

Objective: To assess two physician learning interventions designed to improve safety and quality of diabetes care delivered by primary care physicians (PCPs)., Research Design and Methods: This group randomized clinical trial included 57 consenting PCPs and their 2,020 eligible adult patients with diabetes. Physicians were randomized to no intervention (group A), a simulated case-based physician learning intervention (group B), or the same simulated case-based learning intervention with physician opinion leader feedback (group C). Dependent variables included A1C values, LDL cholesterol values, pharmacotherapy intensification rates in patients not at clinical goals, and risky prescribing events., Results: Groups B and C had substantial reductions in risky prescribing of metformin in patients with renal impairment (P = 0.03). Compared with groups A and C, physicians in group B achieved slightly better glycemic control (P = 0.04), but physician intensification of oral glucose-lowering medications was not affected by interventions (P = 0.41). Lipid management improved over time (P < 0.001) but did not differ across study groups (P = 0.67)., Conclusions: A simulated, case-based learning intervention for physicians significantly reduced risky prescribing events and marginally improved glycemic control in actual patients. The addition of opinion leader feedback did not improve the learning intervention. Refinement and further development of this approach is warranted.

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 examine the relative contribution of current caries activity, past caries experience, and dentists' subjective assessment of caries risk classifications., Methods: Administrative data from two dental plans were analyzed to determine dentists' risk classification, as well as current caries activity and previous caries experience at the time of the classification. The performance of these predictors in identifying patients who would experience subsequent caries was then modeled using logistic regression., Results: In both plans, current caries activity alone had relatively low sensitivity and high specificity in identifying patients who would experience subsequent caries. Sensitivity improved, but at the cost of specificity when previous caries experience was included in the models. Further improvement in sensitivity accrued when dentists' subjective assessment was included, but performance was different in the two plans in terms of false-positives., Conclusions: Consideration of previous caries experience tends to strengthen the predictive power of caries risk assessments. Dentists' subjective assessments also tend to improve sensitivity, but overall accuracy may suffer.

Aim: Dentistry has been slow to adopt innovations in dental practice even when they are recommended by national organizations and supported by evidence-based guidelines. The objective of this review is to describe clinical inertia, a concept described frequently in the medical literature, and to use findings from tobacco cessation and dental sealant studies as evidence of its existence., Methods and Materials: A review of the literature published during the past 30 years was conducted to determine the state of affairs of two very different areas of dental practice, tobacco cessation intervention and application of sealants, to demonstrate the concept of clinical inertia in dental practice. Factors such as over estimating services provided, unfounded reasons not to act, lack of adequate training, and competing demands that account for the inertia were examined., Discussion: Clinical inertia is a complex concept that needs more attention in dentistry. A variety of strategies will be required to overcome it in order to provide the best care for the public., Conclusion: Clinical inertia is a useful paradigm for explaining delays in the incorporation of new knowledge into clinical practice. It offers a model against which the broader dental community can develop and test strategies to reduce the delays in translating best practices into daily practices., Clinical Significance: The path to providing state-of-the-art care for the public is to engage in the discovery, dissemination, and acquisition of new knowledge then transform it into evidence-based best practices to be used in daily clinical practice.

Introduction: We studied variance in glycated hemoglobin (HbA1c) values among adults with diabetes to identify variation in quality of diabetes care at the levels of patient, physician, and clinic, and to identify which levels contribute the most to variation and which variables at each level are related to quality of diabetes care., Methods: Study subjects were 120 primary care physicians and their 2589 eligible adult patients with diabetes seen at 18 clinics. The dependent variable was HbA1c values recorded in clinical databases. Multivariate hierarchical models were used to partition variation in HbA1c values across the levels of patient, physician, or clinic and to identify significant predictors of HbA1c at each level., Results: More than 95% of variance in HbA1c values was attributable to the patient level. Much less variance was seen at the physician and clinic level. Inclusion of patient and physician covariates did not substantially change this pattern of results. Intensification of pharmacotherapy (t = -7.40, P < .01) and patient age (t = 2.10, P < .05) were related to favorable change in HbA1c. Physician age, physician specialty, number of diabetes patients per physician, patient comorbidity, and clinic assignment did not predict change in HbA1c value. The overall model with covariates explained 11.8% of change in HbA1c value over time., Conclusion: These data suggest that most variance in HbA1c values is attributable to patient factors, although physicians play a major role in some patient factors (e.g., intensification of medication). These findings may lead to more effective care-improvement strategies and accountability measures.

Objectives: This retrospective, longitudinal cohort study quantified the strength of the association between xerogenic cardiovascular medication use and dental restorations, using the latter as a proxy measure for dental caries experience., Methods: Study data were collected from 11 years of electronic clinical/pharmacy records in two large dental group practices associated with managed care organizations (MCO). Records were extracted for all members who were at least 55 years old at the end of the 11 year window, and had at least 48 months of concurrent dental, medical, and pharmacy coverage. The authors identified 4448 individuals whose only xerogenic medication exposure was to drugs treating a cardiovascular condition. This group was compared to a group not taking any medications (n=1183), and a group taking medications with no known xerostomic side effect (n=5622). Poisson regression compared restoration incidence and mean restoration rates among the three groups., Results: MCO members taking cardiovascular or nonxerogenic medications had higher restoration incidence and mean restoration rates than individuals taking no medications. A small difference in mean restoration rate between the non-xerogenic medication group and the cardiovascular drug group was observed; no significant difference in restoration incidence was seen between these two groups., Conclusions: This study provides objective quantification of cardiovascular medication's long-term effects on increased restorations in older adults. When grouped under a single category labeled "cardiovascular", drugs with effects targeting the cardiovascular system did not appear to unequivocally lead to higher restorative experiences.

Objective: To assess the impact of organizational features and improvement strategies of primary care clinics on health care costs of adults with diabetes., Research Design and Methods: This study included a prospective cohort study of 1,628 adults with diabetes in a large, health care organization receiving care in 84 clinics within 18 medical groups. Data from surveys of patients, clinic medical directors and managers, and medical record reviews were merged with 3 years of medical claims. Costs were estimated using health plan data on resource use and common Medicare payment methodologies. Generalized linear regression models were used to analyze costs related to clinic characteristics, adjusting for individual patient comorbidity, demographic, and socioeconomic factors., Results: Clinics with regular clinician meetings to discuss patient care problems and clinics that used diabetes registries to prioritize patients based on cardiovascular risk were associated with lower 3-year costs: -$3,962 (P = 0.002) and -$2,916 (P = 0.019), respectively. The use of databases to monitor lab results was associated with higher costs ($2,439, P = 0.038). Quality improvement strategies focused on resource use related to diabetes care (-$2,883, P = 0.017) or heart disease care (-$3,228, P = 0.014) were associated with lowered costs, whereas quality improvement strategies that emphasized pharmacy use for patients with heart disease ($3,059, P = 0.029) or depression ($2,962, P = 0.038) were associated with increased costs., Conclusions: Several organizational features of primary care offices were significant predictors of future health care costs for adults with diabetes. The mechanism by which such factors affect costs of care and the relationship of costs to clinical outcomes merits further evaluation.

Purpose: We undertook this study to examine the symptoms, clinical events, and types of health care encounters that preceded the diagnosis of diabetes mellitus in adults, and to examine changes in glycemic control and cardiovascular risk factors in the first year after a diabetes diagnosis., Methods: We conducted a historical cohort study of patients in a large multispecialty medical group in Minnesota. Among 55,121 adults who were continuously enrolled in the health plan and receiving care at the study medical group from January 1, 1993, to December 31, 1996, we identified 504 who received a new diagnosis of diabetes in 1995 or 1996. Our main outcome measures were the type of symptoms at diagnosis; the clinical circumstances and type of encounter that led to diabetes diagnosis; and changes in glycemic control (assessed by hemoglobin A1c [HbA1c] value), low-density lipoprotein cholesterol level, blood pressure (BP), aspirin use, and body weight in the first year after diagnosis, ascertained from a detailed review of medical records., Results: Almost one third (32.3%) of adults with newly diagnosed diabetes had symptoms of hyperglycemia at initial diagnosis. Compared with patients who did not have hyperglycemia symptoms at diagnosis, those who did were younger and more often male, and had lower comorbidity scores and higher HbA1c values (9.9% vs 8.1%) at diagnosis (P <.01 for each comparison). In the 12 months after diagnosis, the group as a whole had significant improvements (P <.001) in HbA1c values (from 8.8% to 7.1%), systolic blood pressure (137.5 to 133.2 mm Hg), diastolic blood pressure (80.7 to 77.3 mm Hg), weight (207.7 to 201.1 lb), and aspirin use (15.3% to 26.1%). Improvements were seen in all patient subgroups, including those defined by symptoms at diagnosis and by visit type at diagnosis., Conclusions: Primary care practices may improve detection of undiagnosed diabetes in primary care and improve 1-year outcomes by being vigilant for symptoms of diabetes, by evaluating those at high risk for this disorder, and by instituting appropriate treatments at the time of diagnosis.

Objective: To assess the impact of a quality improvement (QI) intervention on the quality of diabetes care at primary care clinics., Research Design and Methods: Twelve primary care medical practices were matched by size and location and randomized to intervention or control conditions. Intervention clinic staff were trained in a seven-step QI change process to improve diabetes care. Surveys and medical record reviews of 754 patients, surveys of 329 clinic staff, interviews with clinic leaders, and analysis of training session videotapes evaluated compliance with and impact of the intervention. Mixed-model nested analyses compared differences in the quality of diabetes care before and after intervention., Results: All intervention clinics completed at least six steps of the seven-step QI change process in an 18-month period and, compared with control clinics, had broader staff participation in QI activities (P = 0.04), used patient registries more often (P = 0.03), and had better test rates for HbA(1c) (A1C), LDL, and blood pressure (P = 0.02). Other processes of diabetes care were unchanged. The intervention did not improve A1C (P = 0.54), LDL (P = 0.46), or blood pressure (P = 0.69) levels or a composite of these outcomes (P = 0.35)., Conclusions: This QI change process was successfully implemented but failed to improve A1C, LDL, or blood pressure levels. Data suggest that to be successful, such a QI change process should direct more attention to specific clinical actions, such as drug intensification and patient activation.

Purpose: This study was designed to evaluate the impact of electronic medical record (EMR) implementation on quality of diabetes care., Methods: We conducted a 5-year longitudinal study of 122 adults with diabetes mellitus at an intervention (EMR) clinic and a comparison (non-EMR) clinic. Clinics had similarly trained primary care physicians, similar patient populations, and used a common diabetes care guideline that emphasized the importance of glucose control. The EMR provided basic decision support, including prompts and reminders for diabetes care. Preintervention and postintervention frequency of testing for glycated hemoglobin (HbA1c) and low-density lipoprotein (LDL) levels were compared with and without adjustment for patient age, sex, comorbidity, and baseline HbA1c level., Results: Frequency of HbA1c tests increased at the EMR clinic compared with the frequency at the non-EMR clinic (P < .001). HbA1c levels improved in both clinics (P < .05) with no significant differences between clinics 2 years (P = .10) or 4 years (P = .27) after EMR implementation. Similar results were observed for LDL levels., Conclusions: In this controlled study, EMR use led to an increased number of HbA1c and LDL tests but not to better metabolic control. If EMRs are to fulfill their promise as care improvement tools, improved implementation strategies and more sophisticated clinical decision support may be needed.

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.

Objective: This study examined the predictive validity of a simple subjective method promoted to dentists for assessing their patients' caries risk., Methods: Data from two large group practices that have used guideline-assisted caries risk assessment (CRA) for several years were analyzed retrospectively to determine the receipt of caries-related treatment following a CRA. Patient age and receipt of caries preventive treatment subsequent to the CRA were control variables in logistic regressions to determine the likelihood of caries-related treatment for low, moderate, and high risk groups., Results: Among 45,693 individuals in the two plans, those categorized as being at high caries risk were approximately four times as likely to receive any caries-related treatment as those categorized as being at low caries risk. Those categorized as at moderate risk were approximately twice as likely to receive any treatment. In addition, for those at elevated risk who required any treatment, the number of teeth requiring treatment was larger., Conclusion: The results of this study provide the first large-scale, generalizable evidence for the validity of dentists' subjective assessment of caries risk.

Objectives: This report examines the association between xerogenic antidepressant medication use and dental restorations (a proxy for dental caries)., Methods: Data for this study was collected from the electronic databases of two large dental group practices associated with two managed care organizations. The population examined was at least 55-year-old on the reference date and had at least 48 months of concurrent dental, medical and pharmacy coverage. We identified 915 individuals whose only exposure to a xerogenic medication was to an antidepressant. This group was compared with a group not on any medications and to a group on medications without any known xerostomic side effect., Results: Poisson regression was used to compare restoration occurrence and restoration rates among the three groups. The antidepressant medication and the no xerogenic medication groups were more likely to have restorations than the no medication group but there was no difference in restoration rates between the two medication groups. The mean restoration rates were significantly different between the three groups with the antidepressant group having the highest restoration rate. The no xerogenic group also had a higher rate than the no medication group but not as high as the antidepressant group rate., Conclusions: This study provides objective quantification of the long-term effects that anti-depressant medications have on restoration use., (Copyright Blackwell Munksgaard, 2005.)

Glucose level varies over time due to a number of complex physiologic processes. Evidence suggests variation in glucose level contributes to risk of complications. The timescale associated with variation in glucose level is on the order of seconds to minutes, yet diabetes complications stem from years of cumulative effects. This difference between timescale suggests a slower timescale may better represent the influential component of variation. We hypothesize variation in glycated hemoglobin captures the component of variation associated with future complications. Moreover, we hypothesize that patient-management strategies influence variation in glycated hemoglobin level. From a systems control perspective, increasing variation may well reflect a policy of closed loop feedback control where changes in patient glycated hemoglobin are addressed after the fact. Such a strategy attends to problems as they arise. In contrast, decreasing variation may result from a clinical strategy that is anticipatory and proactive. A physician using a proactive strategy will base current moves on anticipation of future states, controlling variation in patient outcomes such as glycated hemoglobin. We motivate our discussion using observational data from a large multispecialty medical group in Minnesota: we characterize the within-patient trend and variation of glycated hemoglobin in adults with type 2 diabetes, describe patterns of variation, and identify factors associated with variation. Our hypotheses imply: (1) patterns of variation in glycated hemoglobin reflect physician treatment strategy; (2) variation provides an independent contribution to risk of diabetes complications; (3) the development of treatment strategies that control variation may be a beneficial goal in the management of type 2 diabetes.

Objective: The purpose of this study was to assess the impact of baseline A1c, cardiovascular disease, and depression on subsequent health care costs among adults with diabetes., Research Design and Methods: A prospective analysis was performed of data from a patient survey and medical record review merged with 3 years of medical claims. Costs were estimated using detailed data on resource use and Medicare payment methodologies. Generalized linear models were used to analyze costs related to clinical predictors after adjusting for demographic and socioeconomic factors., Results: In multivariate analysis of 1,694 adults with diabetes, 3-year costs in those with coronary heart disease (CHD) and hypertension were over 300% of those with diabetes only (46,879 dollars vs. 14,233 dollars; P < 0.05). Depression was associated with a 50% increase in costs (31,967 dollars vs. 21,609 dollars; P < 0.05). Relative to those with a baseline A1c of 6%, those with an A1c of 10% had 3-year costs that were 11% higher (26,408 dollars vs. 23,873 dollars; P < 0.05). Higher A1c predicted higher costs only for those with baseline A1c >7.5% (P = 0.015)., Conclusions: In adults with diabetes, CHD, hypertension, and depression spectrum disorders more strongly predicted future costs than the A1c level. Concurrent with aggressive efforts to control glucose, greater efforts to prevent or control CHD, hypertension, and depression are necessary to control health care costs in adults with diabetes.

Objective: To test the hypothesis that patient readiness to change (RTC) predicts future changes in glycemic control in adults with diabetes., Research Design and Methods: We linked survey data with HbA1c data for a stratified random sample of consenting adults with diabetes. Change in HbA1c from baseline to the 1-year follow-up was computed and used as a dependent variable. Linear regression models assessed RTC and other patient variables as predictors of HbA1c change., Results: Among 617 patients with baseline HbA1c > or = 7% and complete data for analysis, RTC predicted subsequent improvement in HbA1c for those with higher physical functioning (interaction t = -2.45, P < 0.05). Other factors that predicted HbA1c improvement in multivariate linear regression models included higher self-reported medication adherence (t = -4.41, P < 0.01), higher baseline HbA1c (t = -15.08, P < 0.01), and older age (t = -2.61, P < 0.01)., Conclusions: Diabetes RTC independently predicts change in HbA1c for patients with high but not for patients with low functional health status. Customized use of RTC assessment may have potential to improve care., (Copyright 2004 American Diabetes Association)

Objectives: To determine whether depression is treated differently in older and younger patients in primary care clinics., Design: Administrative data were used to identify patients with a depression diagnosis code. The sources of data were baseline and 3-month follow-up surveys, the health plan electronic database, and chart audits., Setting: Nine primary care clinics owned by a health maintenance organization in the Midwest., Participants: The study sample (N=1023) consisted of adult patients, aged 19 to 93, and was divided into six age groups, from young adult, under age 35, to old old, 75 or older., Measurements: Independent variables were a series of dummy variables: age groups, baseline depression severity, sex, and incident depression. Outcomes were defined as care processes (assessment, resources) and improvement in depression symptoms (Center for Epidemiologic Studies-Depression scale short form). Univariate and multivariate logistic regression analyses were used to analyze patient characteristics, depression symptoms, and care process variables. Significance level was reported based on the chi-square test of probability, P

Background: The quality of diabetes care provided to older adults has usually been judged to be poor, but few data provide direct comparison to other age groups. In this study, we hypothesized that adults age 65 and over receive lower quality diabetes care than adults age 45-64 years old., Methods: We conducted a cohort study of members of a health plan cared for by multiple medical groups in Minnesota. Study subjects were a random sample of 1109 adults age 45 and over with an established diagnosis of diabetes using a diabetes identification method with estimated sensitivity 0.91 and positive predictive value 0.94. Survey data (response rate 86.2%) and administrative databases were used to assess diabetes severity, glycemic control, quality of life, microvascular and macrovascular risks and complications, preventive care, utilization, and perceptions of diabetes., Results: Compared to those aged 45-64 years (N = 627), those 65 and older (N = 482) had better glycemic control, better health-related behaviors, and perceived less adverse impacts of diabetes on their quality of life despite longer duration of diabetes and a prevalence of cardiovascular disease twice that of younger patients. Older patients did not ascribe heart disease to their diabetes. Younger adults often had explanatory models of diabetes that interfere with effective and aggressive care, and accessed care less frequently. Overall, only 37% of patients were simultaneously up-to-date on eye exams, foot exams, and glycated hemoglobin (A1c) tests within one year., Conclusion: These data demonstrate the need for further improvement in diabetes care for all patients, and suggest that customisation of care based on age and explanatory models of diabetes may be an improvement strategy that merits further evaluation.

Objectives: To understand the process, outcomes, and patient satisfaction of usual primary care for patients given a diagnostic code for depression., Study Design: Health plan data were used to identify patients with a diagnostic code for depression (and no such diagnosis in the preceding 6 months). Patients were surveyed by mail soon after the coded visit and again 3 months later about the care they had received; their charts were also audited., Methods: The 274 patients in 9 primary care clinics who responded to both surveys reported on their personal characteristics, depression symptoms and history, the care received in that initial visit, and the follow-up care during the next 3 months. They also reported on their satisfaction with various aspects of that care., Results: These patients were likely to be given antidepressant medications as their main or only treatment. Referral for mental health therapies was not used often, even though referral is readily available in this setting; other types of self-management recommendations and support were even less frequent. Patient outcomes and levels of satisfaction during a 3-month follow-up period were unimpressive., Conclusions: To successfully maintain a key role in the care of this important problem for their patients, primary care physicians may need to incorporate a more comprehensive and systematic approach to management that involves other team members and is more satisfying to patients.

Objectives: To assess the separate effects of depressive symptoms and antidepressant treatment on healthcare utilization and cost., Setting: Social Health Maintenance Organization (HMO) at HealthPartners in Minnesota., Participants: Geriatric Social HMO enrollees were screened for depressive symptoms using the 30-item Geriatric Depression Scale. A stratified sample was created, composed of geriatric enrollees with depressive symptoms, with antidepressant prescriptions, or with neither (n = 516)., Design: Regression analyses were conducted with separate equations for utilization and charge outcome variables, both outpatient and inpatient (log-transformed). The Charlson Comorbidity Index, age, and gender served as covariates., Measurement: Depressive symptoms were identified through the Diagnostic Interview Schedule. Antidepressant treatment was determined from the HMO pharmacy database., Results: Having depressive symptoms was associated with a 19 increase in the number of outpatient encounters and a 30 increase in total outpatient charges. Antidepressant treatment was associated with a 32 increase in total outpatient charges but was not significantly associated with number of outpatient encounters. Depressive symptoms and antidepressant therapy were not significantly associated with inpatient utilization or charges., Conclusion: This study found that patients with depressive symptoms generated more outpatient health care and higher charges but not necessarily more inpatient care. Our findings suggest that programs targeted to geriatric patients whose depression is comorbid with other chronic medical conditions might be cost-effective and particularly appropriate for geriatric care.

Context: Although new strategies for managing depression in primary care (e.g., nurse telephone calls, collaborative care) have been shown to be effective, no models are available for their systematic implementation in the "real world.", Objective: To test whether a continuous quality improvement (CQI) intervention could be used to implement systems in primary care clinics to improve the care and outcomes for patients diagnosed with depression., Design: Before-after study with concurrent controls., Intervention: A multidisciplinary team from the three intervention clinics developed and implemented a graded set of five care management options, ranging from watchful waiting (nurse telephone call in 4 to 6 weeks) to mental health management, which clinicians could order for their patients with depression., Setting: 9 primary care clinics in greater Minneapolis-St. Paul, Minnesota., Patients: Outpatients 18 years of age and older whose primary care clinic visit included an International Classification of Diseases, 9th revision, code for depression and who completed baseline and 3-month follow-up surveys before and after the intervention., Main Outcome Measures: Measures of process of care (follow-up depression visits to physician, mental health visits, follow-up telephone calls) and outcomes of care (improved depression symptoms over 3 months, satisfaction with care)., Results: Although the CQI team appeared to function well, only 30 of the 257 patients identified from depression-coded visits for this study were referred to the new system during the 3-month evaluation period. In both the intervention and control clinics, follow-up visits, mental health referrals, and follow-up telephone calls did not improve significantly from the preintervention levels of about 0.5 for a primary care visit, 0.4 for a mental health visit, or 0.1 for a follow-up phone call per person. The same was true of patient outcomes: The proportion of patients in the intervention and control clinics who had improved depression symptoms and those who were very satisfied with their depression care did not change significantly from the preintervention levels of 43% and 26%, respectively., Conclusions: Our attempt to improve the primary care management of depression failed because physicians used the new order system so infrequently. Whether a greater leadership commitment to change or a different improvement process would alter our findings is an open question.

Context: Although universal screening for diabetes mellitus is generally not recommended, recent reports suggest that screening individuals with multiple diabetes risk factors may be worthwhile. Little is known about the cost, yield, or acceptability of this kind of screening., Practice Pattern Examined: Screening of high-risk patients for diabetes mellitus using a two-step, glucose-based screening protocol: Patients were initially screened with a random glucose test; those with abnormal results received a follow-up fasting, 2-hour, 75-gram oral glucose tolerance test. CLINIC SELECTION: Three volunteer clinics from a large medical group in Minnesota., Patient Selection: Of 38,989 adults receiving care at the three clinics, we identified 1548 high-risk patients with evidence of both dyslipidemia and hypertension in laboratory and administrative databases. Many of these 1548 patients were not eligible for screening: Twenty-five percent already had diagnosed diabetes; 41% had been screened for diabetes in the past year; and 3% had died, disenrolled, or changed clinics before screening commenced. The remaining 30% (n = 469) were invited for diabetes screening., Results: Of the 469 high-risk patients invited, 206 (44%) initiated screening; 176 (38%) completed diabetes screening. Five new patients with diabetes were identified in this high-risk group (one from the random glucose test and four from the glucose tolerance test). One new patient with diabetes was identified for every 40 high-risk patients screened. The program cost $4064 per new case of diabetes identified (screening costs alone)., Conclusion: In this high-risk managed care population, the yield and acceptability of systematic diabetes screening were low, and the costs were relatively high. The acceptability of office-based diabetes screening may be improved by using a one-step screening test, such as glycosylated hemoglobin, during routine visits.

Objective: To ascertain factors related to readiness to change behavioral risk factors in members of a managed care organization (MCO)., Study Design: Cross-sectional study., Patients and Methods: A telephone survey reached 4667 (73%) of 6409 adult members of a Minnesota MCO attending 2 primary care clinics. Of these, 3826 members (82%) completed an interview designed to identify behavioral risk factors (smoking, consuming a high-fat diet, and physical inactivity) and readiness to change these behaviors., Results: Among MCO members consuming a high-fat diet, those most ready to change were older, were women, used more preventive services, and reported receiving professional advice about diet. For physical inactivity, those most ready to change were younger, women, and more educated; used more preventive services; and reported receiving professional advice about physical activity. Among smokers, those with higher readiness to change smoked fewer than 15 cigarettes a day, had higher self-efficacy, had no other smokers in the household, and reported receiving professional advice about smoking. After controlling for demographic variables and for use of preventive services, greater readiness to change for smoking (beta = 0.336, odds ratio [OR] = 1.40, P = .056), physical activity (beta = 0.651, OR = 1.92, P < .001), and diet (beta = 0.532, OR = 1.70, P < .001) was associated with having received professional advice to change these behaviors., Conclusions: Levels of readiness to change behaviors in MCO members who smoke, are inactive, or consume high-fat diets are similar to those reported in other populations. The association of professional advice to change behaviors with increased readiness to change for smoking, physical activity, and diet suggests that receiving professional advice on these topics might assist patients in changing adverse health-related behaviors.

Background: A worsening of blood pressure control has occurred in the 1990s despite the availability of sophisticated technologic, pharmacologic, and educational advances applicable to hypertension care. Clinical guidelines that are intended to improve hypertension care by making specific recommendations on drug use, frequency of follow-up care, and target levels of blood pressure have been developed., Methods: The Institute for Clinical Systems Integration's (ICSI's; Minneapolis) Hypertension Treatment Guideline was developed in 1994 and is updated annually. This study employed a quasi-experimental, before-and-after design at two medical groups to assess changes in the care provided to patients 18 years of age and older with identified hypertension (International Classification of Diseases-9 codes 401.0, 401.1, or 401.9)., Results: Among adults with hypertension, the proportion meeting the blood pressure goal of < 140/90 mm Hg increased from 36.8% (of 685 patients) preguideline to 50.3% (of 928 patients) postguideline (chi-square = 29.4, p < 0.001); the mean arterial pressure decreased from 102.7 mm Hg to 99.4 mm Hg (t = 5.45, p < 0.001). Cohort analysis of patients enrolled at both points in time confirmed these findings and showed an increase in the number of office visits from 5.4 to 6.7 visits per patient per year after guideline implementation (F = 10.9, p = 0.001). The use of a guideline-recommended medication for treatment of blood pressure was 35.9% preguideline and 36.2% postguideline., Conclusions: Implementation of a hypertension treatment guideline in primary care clinics was related to significantly improved hypertension control. Identification, tracking, and active outreach to patients with hypertension were used by all clinics.

Background: We investigated whether having a regular health care provider for diabetes was related to the intensity of care, use of preventive services, or glycemic control in a well-defined population of adults with diabetes., Methods: Adults with diabetes who were continuously enrolled in a health maintenance organization (HMO) for 1 year were identified by diagnostic and pharmacy databases (estimated sensitivity = 0.91, positive predictive value = 0.94). In a stratified random sample, 1828 patients were sent a survey by mail that had a corrected response rate of 85.6%. Further data on utilization of services and glycosylated hemoglobin values were obtained from administrative databases and linked to survey responses., Results: HMO members who reported having a regular health care provider (RP) for their diabetes (N = 1243) were comparable with those (N = 144) who denied having such a provider (NRP) in age, race, sex, comorbidity, and years of education, but had longer-duration diabetes (10.9 years vs 8.3 years; P = .002). After adjusting for age, sex, education level, duration of diabetes, and type of HMO clinic (owned vs contracted), RP subjects were more likely than NRPs (all P < .001) to follow a special diet for patients with diabetes (55% vs 33%), regularly monitor glucose levels at home (68% vs 47%), have greater frequency of glycosylated hemoglobin (Hb A1c) testing (65% vs 38%), have more foot examinations (42% vs 17%), have recommended cholesterol checks (77% vs 63%), and have had a recent preventive examination (86% vs 68%). Smaller differences favoring having a regular provider were noted for insulin use (48% vs 33%, odds ratio [OR] = 1.71, P = .013), for an influenza immunization within 1 year (65% vs 51%, P = .029), and for dilated retinal examinations (64% vs 51%, P < .027). No differences between groups were noted for dental checkups (69% vs 67%, P = .724) or likelihood of endocrinology referral (17% vs 10%, P = .104). Mean Hb A1c level was 8.2% (normal is < 6.1%) in the RP group and 8.6% in the NRP group (P = .182). Twelve percent of RPs and 24% of NRPs had an Hb A1c level of greater than 10% (chi 2 = 3.7, OR = 0.48, P = .05) after adjusting for age, sex, duration of diabetes, and education level., Conclusions: After adjustment for case mix, patients with diabetes who identified a regular primary health care provider for their diabetes were more likely to receive most recommended elements of diabetes care and to have better glycemic control than patients without such a provider. This effect was partially, but not completely, mediated by a higher number of clinic visits for those with a regular health care provider. Innovators seeking to improve diabetes care should be mindful of the relationship between having a regular primary health care provider and the quality of diabetes care.

Objective: Aspirin use seems to reduce coronary artery disease events in some groups of patients. Factors associated with use of aspirin to prevent heart disease in an HMO population were examined., Design: A population-based survey., Setting: A large HMO in the midwestern United States., Participants: 8000 health plan members 40 years of age and older., Main Outcome Measures: The survey assessed use of aspirin, professional advice to use aspirin, and coronary heart disease risk factors and status. The sample was stratified by whether members had none, one, or more than one of the following chronic conditions: diabetes, hypertension, lipid disorder, or heart disease. The mailed survey had a corrected response rate of 82.4%., Results: Overall, 38% of respondents reported using aspirin at least three times a week to prevent heart disease. Aspirin use did not vary in owned versus contracted clinics. Aspirin use was 71.3% in patients with and 27.7% in patients without diagnosed coronary heart disease (P < 0.001). In logistic regression models, professional advice to take aspirin was strongly associated with self-reported use of aspirin (odds ratio, 13.86) (P < 0.001) after adjustment for age, sex, level of education, and chronic disease status., Conclusions: Aspirin is widely used by HMO members with coronary artery disease to prevent subsequent coronary artery disease events. Professional advice to use aspirin seems to be strongly related to aspirin use.

We conducted a study of the sensitivity, specificity, positive predictive value, and cost of two methods of identifying diagnosed diabetes mellitus or heart disease among members of a health maintenance organization (HMO). Among 3186 adult HMO members who were attending one primary care clinic, 2326 were reached for a telephone survey (efficiency = 0.73). Among these members, 1991 answered standardized questions to ascertain whether they had diabetes or heart disease (corrected response rate = 0.85). Linkage was then made to computerized diagnostic databases. By means of both a database method and a survey method, the 1976 members with complete data for analysis were classified as having or not having diabetes or heart disease. When results with the two methods disagreed, charts were reviewed to confirm the presence or absence of diabetes or heart disease. Diabetes was identified among 4.7% of adult members, and heart disease was identified among 3.7%. Identification of diabetes differed between the database method and the survey method (sensitivity 0.91 vs 0.98, specificity 0.99 vs 0.99, positive predictive value 0.94 vs 0.83). Identification of heart attach history was similar for the database method and the survey method (sensitivity 0.89 vs 0.95, specificity 0.99 vs 0.99, positive predictive value 0.79 vs 0.81). The cost of obtaining data was $13.50 per member for the survey method and $0.30 per member for the database method. Database methods or survey methods of identifying selected chronic diseases among HMO members may be acceptable for various purposes, but database identification methods appear to be less expensive and provide information on a higher proportion of HMO members than do survey methods. Accurate identification of chronic diseases among patients supports clinic-level measures for clinical improvement, research, and accountability.

Objective: We tested the hypothesis that level of glycemic control is related to medical care costs in adults with diabetes., Research Design and Methods: Regression analysis was used to estimate the relationship between glycemic control and medical care charges for 3,017 adults with diabetes who were continuously enrolled in a large health maintenance organization (HMO) over a 4-year period. Diagnosis of diabetes was ascertained from diagnostic and pharmaceutical databases using a method with an estimated sensitivity of 0.91 and an estimated specificity of 0.99. Charges for care included defined outpatient and inpatient services. Patients who disenrolled or who died during the 4-year period were excluded from the main analysis., Results: Charges for medical care for patients with diabetes from 1993 to 1995 were closely related to HbA1c level in 1992 before and after adjustment for age, sex, coronary heart disease, and hypertension. Standardized 3-year estimates of charges ranged from $10,439 for patients without comorbid conditions to $44,417 for those with heart disease and hypertension. Medical care charges increased significantly for every 1% increase above HbA1c of 7%. For a person with an HbA1c value of 6%, successive 1% increases in HbA1c resulted in cumulative increases in charges of approximately 4, 10, 20, and 30%. The increase in charges accelerated as the HbA1c value increased. For patients with diabetes only, or with diabetes plus other chronic conditions, the rate of increase in charges with HbA1c was consistent., Conclusions: HbA1c provides useful information to providers and patients regarding both health status and future medical care charges. Economic data suggest that clinicians should assign high importance to low HbA1c results and aggressively maintain the HbA1c status of patients who have low HbA1c values. For economic as well as clinical reasons, it may be beneficial to lower HbA1c when it is > 8% and to reduce cardiovascular risk factors. The medical charge data suggest that investment in clinical systems to improve diabetes care may benefit both payers and patients.

The investigators constructed an index measure of cardiovascular risk and scored 1.991 adults as having high, average, or low cardiovascular risk. High cardiovascular risk was positively associated with hospital admissions (odds ratio [OR] = 3.9, p < 0.0001), total hospital days (OR = 4.0, p < 0.001), primary care clinic visits (OR = 7.3, p < 0.0001), and subspecialty clinic visits (OR = 2.3, p = 0.0003), compared to low cardiovascular risk, after controlling in multivariate analyses for gender and age. The index can provide estimates of utilization, costs, and potential preventability of adverse cardiovascular events, can be used to identify groups of patients in need of various systematic interventions, and can provide population-based ways to evaluate the results of interventions.

Background: We conducted an historical cohort study to evaluate the relative effectiveness of niacin and lovastatin in the treatment of dyslipidemias in patients enrolled in a health maintenance organization (HMO)., Methods: To be eligible for this study, adults aged 18 years and older who were initially treated with either niacin or lovastatin between January 1, 1992, and December 31, 1993, were identified from pharmacy databases. Each potentially eligible member with a fasting lipid panel prior to initiation of drug therapy and with a second fasting lipid panel between 9 and 15 months after initiation of drug therapy was included in the study. A total of 244 patients treated with niacin and 160 patients treated with lovastatin had complete data and are subjects of this report., Results: Patients initially treated with lovastatin had higher baseline mean cholesterol and low-density lipoprotein (LDL) levels as well as higher rates of diabetes mellitus and heart disease than did patients initially treated with niacin. Lovastatin use was associated with a mean 25.8% decrease in LDL cholesterol, while niacin use was associated with a mean 17.5% drop in LDL cholesterol (t = 3.19, P < .002). Niacin use was associated with a 16.3% improvement in high-density lipoprotein (HDL) cholesterol, while HDL-cholesterol levels in the lovastatin group improved 1.5% (t = 4.74, P < .001). Niacin use was associated with an 18.4% improvement in triglycerides, while lovastatin use was associated with an 8% improvement in triglyceride levels (t = 2.81, P = .005). Differences in LDL/HDL ratio from before treatment to follow-up were no different in the two groups of patients (t = -1.21, P = .22). A total of 46% of patients initially treated with either drug reached their treatment goals in accordance with those set by the National Cholesterol Education Program. Drug discontinuation rates were 73% for niacin and 52% for lovastatin at follow-up, which averaged 10.7 months in each group., Conclusions: These results suggest that both niacin and lovastatin are effective in treating dyslipidemic patients in this care system, and that physicians appropriately use lovastatin more often for patients with higher baseline LDL levels and more comorbidity. The data also strongly suggest that establishing an organized, population-based approach to systematically identify, treat, and monitor patients with dyslipidemias may be the single most important intervention HMOs should consider for improving control of dyslipidemias on a population basis.

Objective: To evaluate the impact of a continuous quality improvement (CQI) intervention on glycemic control of patients with diabetes mellitus attending a primary care clinic., Methods: A CQI process designed by the Minnesota Department of Health to improve diabetes care was implemented at a volunteer clinic, with another similar clinic not using the CQI process assessed for comparison. Adults with diabetes were identified at both clinics using diagnostic and pharmacy databases. Glycosylated hemoglobin (HbA1c) values (reference range, 4.3%-6.1%) and out-patient utilization and charges were compared for all patients with diabetes at each clinic for the 12 months before and 18 months after initiation of the CQI intervention., Results: The mean HbA1c value at the intervention clinic fell from 8.9% at baseline to 8.4% at 12 months and to 7.9% at 18 months. The mean HbA1c value at the comparison clinic was 8.9% at baseline, 8.9% at 12 months, and 8.8% at 18 months (difference between clinics, t = 4.13, P < .001). Differences after the intervention in the proportion of patients at the comparison clinic (n = 121) vs the intervention clinic (n = 122) with HbA1c values of 8% or less (40% vs 51%), between 8% and 10% (33% vs 37%), and 10% or greater (27% vs 12%) were unlikely due to chance (chi 2 = 9.7, 2 df, P = .008). The intervention was not associated with increased utilization of outpatient visits or outpatient charges., Conclusions: Involvement of nurses, physicians, and managers in a CQI process can improve patients' glycemic control in some health maintenance organization primary care settings, without increasing utilization or charges. Health maintenance organizations should consider CQI as one possible method to improve diabetes outcomes.

Experiments were conducted to determine whether transovarial transmission (TOT) of St. Louis encephalitis (SLE) virus occurs in Culex pipiens complex mosquitoes, the principal vectors of SLE virus in the central-eastern United States. In 1978, field-collected mosquitoes from Memphis, Tennessee, and McLeansboro, Illinois, were used; during 1979, colonized mosquitoes from Chicago, Illinois, and Memphis, Tennessee, were used. Mosquitoes were infected by feeding on viremic chicks inoculated with an SLE virus strain isolated from Cx. pipiens complex mosquitoes collected from Memphis, Tennessee, in 1976. During the 1979 experiments, progeny larval and adult mosquitoes were held at two temperatures, 18 and 25 degrees C. Progeny were tested for virus by plaque assay in duck embryo cell cultures and by inoculation of Aedes albopictus C6/36 cells and examination by immunofluorescence. In 1978, most of the progeny tested were from the first ovarian cycle, and a single occurrence of TOT was documented. In 1979, a single TOT occurred from 46,856 first ovarian cycle progeny, whereas 7 of 9,234 progeny of the second ovarian cycle were infected. The rate of TOT was higher for progeny of Memphis than Chicago mosquitoes, and for mosquitoes held at 18 degrees C than at 25 degrees C; however, these differences were not statistically significant. Four positive pools were females, and three were fed on chicks for transmission attempts. The positive Chicago mosquito pool failed to transmit, but both Memphis pools successfully transmitted virus. The overall rates of TOT of SLE virus in progeny of the first and second ovarian cycle were, respectively, 1/45, 151 and 1/1,460. The significance of these results as they relate to the natural history of SLE virus is discussed.

Six species of rodents from Kern County, California, were inoculated subcutaneously with western equine encephalomyelitis (WEE) virus to determine their susceptibility to infection and their potential as natural hosts. Ammospermophilus nelsoni, Citellus beecheyi, Dipodomys heermanni, Dipodomys nitratoides, Peromyscus maniculatus, and Sciurus griseus were readily infected. Infection was usually fatal in Dipodomys species, C. beecheyi, and S. griseus, but was clinically inapparent in other species. Viremic responses varied greatly in magnitude and duration in different species and with different viral strains. Viremic animals that survived developed high titers of hemagglutination-inhibiting antibody. Hemagglutination-inhibiting and neutralizing antibodies persisted at high titers for at least 8 to 58 weeks after infection, except in P. maniculatus. If animals died during or shortly after the viremic phase of infection, the virus usually was recoverable from numerous organs. Long-term survival of virus could not be demonstrated in A. nelsoni and Dipodomys species. It is concluded that A. nelsoni and P. maniculatus are not important natural hosts of WEE virus; they are susceptible to infection and develop antibodies, but serological surveys of the same species rarely reveal evidence of infection. S. griseus, D. heermanni, D. nitratoides, and possibly C. beecheyi are aberrant hosts of WEE virus since most of them died when infected. Two species of ticks that are ectoparasitic on rodents in Kern County were evaluated as vectors of WEE virus. Dermacentor parumapertus failed to become infected after feeding on viremic hosts, and Ornithodorus parkeri became infected but failed to transmit virus.