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BackgroundAlthough disease management programs are widely implemented, little is known about their effectiveness.ObjectiveTo determine whether disease management by physician groups is associated with diabetes care processes, control of intermediate outcomes, or the amount of medication used when intermediate outcomes are above target levels.DesignCross-sectional study.SettingPatients were randomly sampled from 63 physician groups nested in 7 health plans sponsored by Translating Research into Action for Diabetes (87%) and from 4 health plans with individual physician contracts (13%).Patients8661 adults with diabetes who completed a survey (2000-2001) and had medical record data.MeasurementsPhysician group and health plan directors described their organizations' use of physician reminders, performance feedback, and structured care management on a survey; their responses were used to determine measures of intensity of disease management. The current study measured 8 processes of care, including most recent hemoglobin A1c level, systolic blood pressure, serum low-density lipoprotein cholesterol level, and several measures of medication use.ResultsIncreased use of any of 3 disease management strategies was significantly associated with higher adjusted rates of retinal screening, nephropathy screening, foot examinations, and measurement of hemoglobin A1c levels. Serum lipid level testing and influenza vaccine administration were associated with greater use of structured care management and performance feedback. Greater use of performance feedback correlated with an increased rate of foot examinations (difference, 5 percentage points [95% CI, 1 to 8 percentage points]), and greater use of physician reminders was associated with an increased rate of nephropathy screening (difference, 15 percentage points [CI, 6 to 23 percentage points]). No strategies were associated with intermediate outcome levels or level of medication management.LimitationsPhysician groups were not randomly sampled from population-based listings, and disease management strategies were not randomly allocated across groups.ConclusionsDisease management strategies were associated with better processes of diabetes care but not with improved intermediate outcomes or level of medication management. A greater focus on direct measurement, feedback, and reporting of intermediate outcome levels or of level of medication management may enhance the effectiveness of these programs.

ObjectiveTo examine the association between the organizational model and diabetes processes of care.Research design and methodsWe used data from the Translating Research into Action for Diabetes (TRIAD), a multicenter study of diabetes care in managed care, including 8354 patients with diabetes. We identified five model types: for-profit group/network, for-profit independent practice association (IPA), nonprofit group/network, nonprofit IPA, and nonprofit group/staff. Process measures included retinal, renal, foot, lipid, and HbA(1c) testing; aspirin recommendations; influenza vaccination; and a sum of these seven processes of care over 1 year. Hierarchical regression models were constructed for each process measure and accounted for clustering at the health plan and provider group levels and adjusted for participant age, sex, race, ethnicity, diabetes treatment and duration, education, income, health status, and survey language.ResultsParticipant membership in the model types ranged from 9% in nonprofit IPA models to 38% in nonprofit group/staff models. Over 75% of participants received most of the processes of care, regardless of model type. However, among for-profit plans, group/network models provided on average more processes of care than IPA models (5.5 vs. 4.7, P < 0.0001), and group/network models generally increased the probability of receiving a process by >or=10 percentage points. Among nonprofit plans, no effect of model type was found.ConclusionsAmong for-profit plans, group/network models provided better diabetes processes of care than IPA models. Although reasons are speculative, this may be due to the clinical infrastructure available in group models that is not available in IPA models.

ObjectiveTo examine the effect of referral management on diabetes care.Study designCross-sectional analysis.Patients and methodsTranslating Research Into Action for Diabetes (TRIAD) is a multicenter study of managed care enrollees with diabetes. Prospective referral management was defined as "gatekeeping" and mandatory preauthorization from a utilization management office, and retrospective referral management as referral profiling and appropriateness reviews. Outcomes included dilated eye exam; self-reported visit to specialists; and perception of difficulty in getting referrals. Hierarchical models adjusted for clustering and patient age, gender, race, ethnicity, type and duration of diabetes treatment, education, income, health status, and comorbidity.ResultsReferral management was commonly used by health plans (55%) and provider groups (52%). In adjusted analyses, we found no association between any referral management strategies and any of the outcome measures.ConclusionsReferral management does not appear to have an impact on referrals or perception of referrals related to diabetes care.

The estimates from cause-specific excess deaths associated with underweight body mass index (BMI) were found to vary considerably by cause of death.

A study is conducted to estimate deaths associated with underweight, overweight, and obesity in the United States in the year 2000. The results suggest that underweight and obesity, particularly higher levels of obesity, were associated with increased mortality relative to the normal weight category.

A study was conducted to examine 40-year trends in cardiovascular disease (CVD) risk factors with body mass index (BMI) groups among US adults aged 20 to 74 years. The results suggested that CVD risk factors except for diabetes have declined considerably since the year 1965 in all BMI groups.

Estimates of deaths attributable to obesity in the United States rely on estimates from epidemiological cohorts of the relative risk of mortality associated with obesity. However, these relative risk estimates are not necessarily appropriate for the total US population, in part because of exclusions to control for baseline health status and exclusion or under-representation of older adults. Most deaths occur among older adults; estimates of deaths attributable to obesity can vary widely depending on the assumptions about the relative risks of mortality associated with obesity among the elderly. Thus, it may be difficult to estimate deaths attributable to obesity with adequate accuracy and precision. We urge efforts to improve the data and methods for estimating this statistic.

Objective: Childhood abuse and other adverse childhood experiences (ACEs) have historically been studied individually, and relatively little is known about the co-occurrence of these events. The purpose of this study is to examine the degree to which ACEs co-occur as well as the nature of their co-occurrence. Method: We used data from 8,629 adult members of a health plan who completed a survey about 10 ACEs which included: childhood abuse (emotional, physical, and sexual), neglect (emotional and physical), witnessing domestic violence, parental marital discord, and living with substance abusing, mentally ill, or criminal household members. The bivariate relationship between each of these 10 ACEs was assessed, and multivariate linear regression models were used to describe the interrelatedness of ACEs after adjusting for demographic factors. Results: Two-thirds of participants reported at least one ACE; 81%--98% of respondents who had experienced one ACE reported at least one additional ACE (median: 87%). The presence of one ACE significantly increased the prevalence of having additional ACEs, elevating the adjusted odds by 2 to 17.7 times (median: 2.8). The observed number of respondents with high ACE scores was notably higher than the expected number under the assumption of independence of ACEs (p < .0001), confirming the statistical interrelatedness of ACEs. Conclusions: The study provides strong evidence that ACEs are interrelated rather than occurring independently. Therefore, collecting information about exposure to other ACEs is advisable for studies that focus on the consequences of a specific ACE. Assessment of multiple ACEs allows for the potential assessment of a graded relationship between these childhood exposures and health and social outcomes. Keywords: Child abuse; Child neglect; Household dysfunction; interrelationship

Boys born in the US in 2000 have a 33% lifetime risk of developing diabetes and girls born in 2000 have a 38% lifetime risk of developing diabetes. Diabetes will shorten the men's lives by about 12 years and the women's lives by about 14 years. It will also increase their risk of disability. Hispanic men and women have the highest lifetime risk of developing diabetes.

The authors examine the psychological impact of witnessing intimate partner violence has on children and how it effects them as adults. Topics include types of violence experienced, growing-up in a dysfunctional household, and relationship of witnessing family violence and long-term mental health care problems.

Adverse childhood experiences may increase the risk of suicidal behavior as an adult, according to a survey of 17,337 people. Adverse childhood experiences include emotional, physical, or sexual child abuse, parental mental illness, incarceration, substance abuse, domestic violence, separation, and divorce., Context: Suicide is a leading cause of death in the United States, but identifying persons at risk is difficult. Thus, the US surgeon general has made suicide prevention a national priority. An expanding body of research suggests that childhood trauma and adverse experiences can lead to a variety of negative health outcomes, including attempted suicide among adolescents and adults. Objective: To examine the relationship between the risk of suicide attempts and adverse childhood experiences and the number of such experiences (adverse childhood experiences [ACE] score). Design, Setting, and Participants: A retrospective cohort study of 17337 adult health maintenance organization members (54% female; mean [SD] age, 57 [15.3] years) who attended a primary care clinic in San Diego, Calif, within a 3-year period (1995-1997) and completed a survey about childhood abuse and household dysfunction, suicide attempts (including age at first attempt), and multiple other health-related issues. Main Outcome Measure: Self-reported suicide attempts, compared by number of adverse childhood experiences, including emotional, physical, and sexual abuse; household substance abuse, mental illness, and incarceration; and parental domestic violence, separation, or divorce. Results: The lifetime prevalence of having at least 1 suicide attempt was 3.8%. Adverse childhood experiences in any category increased the risk of attempted suicide 2-to 5-fold. The ACE score had a strong, graded relationship to attempted suicide during childhood/adolescence and adulthood (P Conclusions: A powerful graded relationship exists between adverse childhood experiences and risk of attempted suicide throughout the life span. Alcoholism, depressed affect, and illicit drug use, which are strongly associated with such experiences, appear to partially mediate this relationship. Because estimates of the attributable risk fraction caused by these experiences were large, prevention of these experiences and the treatment of persons affected by them may lead to progress in suicide prevention.

The risk of mortality may be higher among people who are overweight. Researchers compared mortality rates in a 12-year period among 62,116 men and 262,019 women aged 30 to 74 years. Greater body weight relative to height at the beginning of the study was associated with greater risk of death during the 12 years studied. The risk of death associated with excess body weight appeared to be more significant among younger participants in the study. Overall, the negative effect of excess body weight declined with age.

Rates of obesity appear to be increasing among children and young adults. Body measurements including body fat, height, and weight were performed on 11,564 school children and young adults during seven time points between 1973 and 1994. Accounting for other variables, both weight and body fat for these participants increased significantly during this time period, particularly among young adults. Increases were even higher between 1983 and 1994 compared to between 1973 and 1982. There were twice as many participants defined as being overweight in 1994 as those measured between 1973 and 1974., Objective. To examine trends in relative weight and obesity among 5- to 24-year-olds between 1973 and 1994. Design. A panel design consisting of seven cross-sectional surveys of schoolchildren and three surveys of post-high-school subjects. Anthropometric measurements included height, weight, and subscapular and triceps skinfolds. Study Population. All schoolchildren residing in Ward 4 of Washington Parish, Louisiana, a biracial community, were considered eligible; participation rates were [is greater than] 80%. Young adults were eligible if they had participated previously as schoolchildren. A total of 26 371 examinations were performed on 11564 persons. Results. During the study period, substantial increases in mean levels of weight (0.2 kg/y) and skinfold thickness (0.15 mm/y) were observed; these changes were independent of height, age, and other covariates. The prevalence of overweight, defined by the 85th percentile of weight-for-height in 1973 to 1974, increased approximately twofold by 1994. Although secular increases were seen both among boys and girls and among blacks and whites, the largest increases were seen among 19- to 24-year-olds. Furthermore, the yearly increases in relative weight and obesity during the latter part of the study period (1983 through 1994) were ~50% greater than those between 1973 and 1982. Conclusions. The increasing prevalence of obesity in early life indicates a need for primary prevention. Additional study is needed to determine whether these trends are continuing to accelerate and to examine possible explanations, such as diet and physical activity, for these changes. Pediatrics 1997;99:420-426; child, obesity, body weight, secular trends, blacks, longitudinal studies., ABBREVIATIONS. GEE, generalized estimating equations; NHANES, National Health and Nutrition Examination Survey. The 30 million adults in the United States who are [is greater than or equla to] 20% desirable [...]

Diet changes and increased physical activity may not consistently produce desired weight loss among adults, according to an analysis of several studies. Results varied with respect to total caloric intake, certain foods, fat content, and physical activity. There were also differences in weight changes between men and women. Research efforts should be fine-tuned towards longer observation periods, more accurate reporting of life style habits, and better monitoring of diet and exercise.

A study of the total mortality of 4,614 women and 3,573 men, using the NHANES I Epidemiologic Follow-Up Study data, revealed the role of average alcohol consumption in protecting middle-aged men from ischemic heart disease mortality. However, after eliminating previously diseased people, the protective influence of moderate alcohol consumption on total mortality was negligible.