Perioperative visual loss (POVL) accompanying nonocular surgery is a rare and potentially devastating complication but its frequency in commonly performed inpatient surgery is not well defined. We ...used the Nationwide Inpatient Sample to estimate the rate of POVL in the United States among the eight most common nonocular surgeries.
More than 5.6 million patients in the Nationwide Inpatient Sample who underwent principal procedures of knee arthroplasty, cholecystectomy, hip/femur surgical treatment, spinal fusion, appendectomy, colorectal resection, laminectomy without fusion, coronary artery bypass grafting, and cardiac valve procedures from 1996 to 2005 were included. Rates of POVL, defined as any discharge with an International Classification of Diseases, Ninth Revision, Clinical Modification code of ischemic optic neuropathy (ION), cortical blindness (CB), or retinal vascular occlusion (RVO), were estimated. Potential risk factors were assessed by univariate and multivariable analyses.
Cardiac and spinal fusion surgery had the highest rates of POVL. The national estimate in cardiac surgery was 8.64/10,000 and 3.09/10,000 in spinal fusion. By contrast, POVL after appendectomy was 0.12/10,000. Those undergoing cardiac surgery, spinal fusion, and orthopedic surgery had a significantly increased risk of developing ION, RVO, or CB. Patients younger than 18 yr had the highest risk for POVL, because of higher risk for CB, whereas those older than 50 yr were at greater risk of developing ION and RVO. Other significant positive predictors for some diagnoses of POVL were male gender, Charlson comorbidity index, anemia, and blood transfusion. There was no increased risk associated with hospital surgical volume. During the 10 yr from 1996 to 2005, there was an overall decrease in POVL in the procedures we studied.
The results confirm the clinical suspicion that the risk of POVL is higher in cardiac and spine fusion surgery and show for the first time a higher risk of this complication in patients undergoing lower extremity joint replacement surgery. The prevalence of POVL in the eight most commonly performed surgical operations in the United States has decreased between 1996 and 2005. Increased odds of POVL with male gender and comorbidity index indicate that some risk factors for POVL may not presently be modifiable. The conclusions of this study are limited by factors affecting data accuracy, such as lack of data on the intraoperative course and inability to confirm the diagnostic coding of any of the discharges in the database.
The early onset of puberty may be related to obesity, so there is a need to know the prevalence of early pubertal milestones in nonoverweight children. OBJECTIVE. We compared attainment of stage 2 ...breasts, stage 3 (sexual) pubic hair, and menarche in the Third National Health and Nutrition Examination Survey sample of children with normal BMI with those with excessive BMI (> or =85th percentile).
The ages at which 5%, 50%, and 95% of youth had attained key pubertal stages were estimated by probit models. Logit models were then fit to compare attainment of these milestones in children of excessive and normal BMI.
Pubertal signs occurred before 8.0 years of age in <5% of the normal-BMI general and non-Hispanic white female population. However, pubertal milestones generally appeared earlier in normal-BMI non-Hispanic black and Mexican American girls; thelarche occurred before age 8.0 in 12% to 19% of these groups, and the 5th percentile for menarche was 0.8 years earlier for non-Hispanic black than non-Hispanic white subjects. Pubarche was found in < or =3% of 8.0-year-old girls with normal BMI of all of these ethnic groups but was significantly earlier in minority groups. Pubarche appeared before 10.0 years in <2% of normal-BMI boys. Girls with excessive BMI had a significantly higher prevalence of breast appearance from ages 8.0 through 9.6 years and pubarche from ages 8.0 through 10.2 years than those with normal BMI. Menarche was also significantly more likely to occur in preteen girls with an elevated BMI.
Prevalence estimates are given for the key pubertal milestones in children with normal BMI. Breast and sexual pubic hair development are premature before 8 years of age in girls with normal BMI in the general population. Adiposity and non-Hispanic black and Mexican American ethnicity are independently associated with earlier pubertal development in girls.
The patient-centered medical home has become a prominent model for reforming the way health care is delivered to patients. The model offers a robust system of primary care combined with practice ...innovations and new payment methods. But scant information exists about the extent to which typical US physician practices have implemented this model and its processes of care, or about the factors associated with implementation. In this article we provide the first national data on the use of medical home processes such as chronic disease registries, nurse care managers, and systems to incorporate patient feedback, among 1,344 small and medium-size physician practices. We found that on average, practices used just one-fifth of the patient-centered medical home processes measured as part of this study. We also identify internal capabilities and external incentives associated with the greater use of medical home processes.
OBJECTIVE: To describe sexual activity, behavior, and problems among middle-age and older adults by diabetes status. RESEARCH DESIGN AND METHODS: This was a substudy of 1,993 community-residing ...adults, aged 57-85 years, from a cross-sectional, nationally representative sample (N = 3,005). In-home interviews, observed medications, and A1C were used to stratify by diagnosed diabetes, undiagnosed diabetes, or no diabetes. Logistic regression was used to model associations between diabetes conditions and sexual characteristics, separately by gender. RESULTS: The survey response rate was 75.5%. More than 60% of partnered individuals with diagnosed diabetes were sexually active. Women with diagnosed diabetes were less likely than men with diagnosed diabetes (adjusted odds ratio 0.28 95% CI 0.16-0.49) and other women (0.63 0.45-0.87) to be sexually active. Partnered sexual behaviors did not differ by gender or diabetes status. The prevalence of orgasm problems was similarly elevated among men with diagnosed and undiagnosed diabetes compared with that for other men, but erectile difficulties were elevated only among men with diagnosed diabetes (2.51 1.53 to 4.14). Women with undiagnosed diabetes were less likely to have discussed sex with a physician (11%) than women with diagnosed diabetes (19%) and men with undiagnosed (28%) or diagnosed (47%) diabetes. CONCLUSIONS: Many middle-age and older adults with diabetes are sexually active and engage in sexual behaviors similarly to individuals without diabetes. Women with diabetes were more likely than men to cease all sexual activity. Older women with diabetes are as likely to have sexual problems but are significantly less likely than men to discuss them.
Background: In 1998, the Health Resources and Services Administration's Bureau of Primary Health Care began the Health Disparities Collaboratives (HDC) to improve chronic disease management in ...community health centers (HCs) nationwide. The HDC incorporates rapid quality improvement, a chronic care model, and best practice learning sessions. Objectives: To determine whether the HDC improves diabetes care in HCs over 4 years and whether more intensive interventions enhance care further. Subjects: Chart review of 2364, 2417, and 2212 randomly selected patients with diabetes from 34 HCs in 17 states in 1998, 2000, and 2002, respectively. Measures: American Diabetes Association standards. Research Design: We performed a randomized controlled trial with an embedded prospective longitudinal study. We randomized 34 HCs that had undergone 1-2 years of the HDC. The standard-intensity arm continued the baseline HDC intervention. High-intensity arm centers received 4 additional learning sessions, provider training in behavioral change, and patient empowerment materials. To assess the impact of the HDC, we analyzed changes in clinical processes and outcomes in the standard- intensity centers. To determine the effect of more intensive interventions, we compared the standard- and high-intensity centers. Results: Between 1998 and 2002, HCs undertaking the standard HDC improved 11 diabetes processes and lowered hemoglobin Alc -0.45%; 95% confidence interval (CI), -0.72 to -0.17 and low-density lipoprotein cholesterol (-19.7 mg/dL; 95% CI, -25.8 to -13.6). High-intensity intervention centers had greater use of angiotensin converting enzyme inhibitors adjusted odds ratio (OR), 1.47; 95% CI, 1.07-2.01 and aspirin (OR, 2.20; 95% CI, 1.28-3.76), but lower use of dietary (OR, 0.24; 95% CI, 0.08-0.68) and exercise counseling (OR, 0.34; 95% CI, 0.15-0.75). Conclusions: Diabetes care and outcomes improved in HCs during the first 4 years of the HDC quality improvement collaborative. More intensive interventions helped marginally.
Improving Diabetes Care in Midwest Community Health Centers With the Health Disparities Collaborative
Marshall H. Chin , MD, MPH 1 ,
Sandy Cook , PHD 1 ,
Melinda L. Drum , PHD 1 ,
Lei Jin , MA, MS 1 ...,
Myriam Guillen , BA 1 ,
Catherine A. Humikowski , BA 1 ,
Julie Koppert , RNC, BSN, CDE 2 ,
James F. Harrison , MD 3 ,
Susan Lippold , MD, MPH 4 and
Cynthia T. Schaefer , RN, CS 5
1 Departments of Medicine and Health Studies, Diabetes Research and Training Center, The University of Chicago, Chicago, Illinois
2 Midwest Cluster Health Disparities Collaborative, Kenton, Ohio
3 North Woods Community Health Center, Minong, Wisconsin
4 Health Resources and Services Administration, Chicago, Illinois
5 Department of Nursing and Health Sciences, University of Evansville, Evansville, Indiana
Address correspondence and reprint requests to Marshall H. Chin, MD, MPH, University of Chicago, Section of General Internal
Medicine, 5841 South Maryland Ave., MC 2007, Chicago, Illinois 60637. E-mail: mchin{at}medicine.bsd.uchicago.edu
Abstract
OBJECTIVE —To evaluate the Diabetes Health Disparities Collaborative, an initiative by the Bureau of Primary Health Care to reduce health
disparities and improve the quality of diabetes care in community health centers.
RESEARCH DESIGN AND METHODS —One year before- after trial. Beginning in 1998, 19 Midwestern health centers undertook a diabetes quality improvement initiative
based on a model including rapid Plan-Do-Study-Act cycles from the continuous quality improvement field; a Chronic Care Model
emphasizing patient self-management, delivery system redesign, decision support, clinical information systems, leadership,
health system organization, and community outreach; and collaborative learning sessions. We reviewed charts of 969 random
adults for American Diabetes Association standards, surveyed 79 diabetes quality improvement team members, and performed qualitative
interviews.
RESULTS —The performance of several key processes of care assessed by chart review increased, including rates of HbA 1c measurement (80–90%; adjusted odds ratio 2.1, 95% CI 1.6–2.8), eye examination referral (36–47%; 1.6, 1.1–2.3), foot examination
(40–64%; 2.7, 1.8–4.1), and lipid assessment (55–66%; 1.6, 1.1–2.3). Mean value of HbA 1c tended to improve (8.5–8.3%; difference −0.2, 95% CI −0.4 to 0.03). Over 90% of survey respondents stated that the Diabetes
Collaborative was worth the effort and was successful. Major challenges included needing more time and resources, initial
difficulty developing computerized patient registries, team and staff turnover, and occasional need for more support by senior
management.
CONCLUSIONS —The Health Disparities Collaborative improved diabetes care in health centers in 1 year.
BPHC, Bureau of Primary Health Care
HLM, hierarchical linear model
PDSA, Plan, Do, Study, Act
Footnotes
J.F.H. is currently affiliated with South Lane Medical Group, Cottage Grove, Oregon, and S.L. is currently affiliated with
the Centers for Disease Control City of Chicago Tuberculosis Program, Chicago, Illinois.
A table elsewhere in this issue shows conventional and Système International (SI) units and conversion factors for many substances.
Accepted September 15, 2003.
Received May 15, 2003.
DIABETES CARE
OBJECTIVE: Insulin resistance is greater in racial/ethnic minorities than in non-Hispanic whites (NHWs) for those with and without type 2 diabetes. Because previous research on insulin resistance in ...type 1 diabetes was limited to NHWs, racial/ethnic variation in an estimated measure of insulin resistance in type 1 diabetes was determined. RESEARCH DESIGN AND METHODS: The sample included 79 individuals with type 1 diabetes diagnosed at age <18 years (32.9% NHWs, 46.8% non-Hispanic black NHB, 7.6% other/mixed, and 12.7% Hispanic) and their families. Estimated glucose disposal rate (eGDR) (milligrams per kilogram per minute; a lower eGDR indicates greater insulin resistance) was calculated using A1C, waist circumference, and hypertension status. RESULTS: Mean current age was 13.5 years (range 3.2-32.5) and diabetes duration was 5.7 years (0.1-19.9). eGDR was inversely associated with age. Compared with that in NHWs, age-adjusted eGDR was significantly lower among nonwhites (NHB, other/mixed, and Hispanic: Δ = -1.83, P = 0.0006). Age-adjusted eGDR was negatively associated with body fat, triglycerides, urinary albumin/creatinine, acanthosis nigricans, parental obesity, and parental insulin resistance and positively related to HDL and sex hormone-binding globulin. In multivariable analysis, lower eGDR was significantly associated with older age, nonwhite race/ethnicity, acanthosis, and lower HDL. CONCLUSIONS: Minorities with type 1 diabetes are significantly more insulin resistant, as measured by eGDR, than NHWs. Exploring potential mechanisms, including disparities in care and/or physiological variation, may contribute to preventing racial/ethnic differences in insulin resistance-associated outcomes.
We sought to compare quality of diabetes care by insurance type in federally funded community health centers. Method. We categorized 2018 diabetes patients, randomly selected from 27 community health ...centers in 17 states in 2002, into 6 mutually exclusive insurance groups. We used multivariate logistic regression analyses to compare quality of diabetes care according to 6 National Committee for Quality Assurance Health Plan Employer Data and Information Set diabetes processes of care and outcome measures.
Thirty-three percent of patients had no health insurance, 24% had Medicare only, 15% had Medicaid only, 7% had both Medicare and Medicaid, 14% had private insurance, and 7% had another insurance type. Those without insurance were the least likely to meet the quality-of-care measures; those with Medicaid had a quality of care similar to those with no insurance.
Research is needed to identify the major mediators of differences in quality of care by insurance status among safety-net providers such as community health centers. Such research is needed for policy interventions at Medicaid benefit design and as an incentive to improve quality of care.
OBJECTIVE:--Insulin downregulates hepatic production of sex hormone-binding globulin (SHBG), which in turn influences sex hormone bioavailability. The effects of childhood-onset diabetes and insulin ...resistance in nondiabetic individuals on SHBG and testosterone in children and young adults are poorly understood. RESEARCH DESIGN AND METHODS--Individuals with diabetes diagnosed at <18 years of age (n = 48) and their siblings without diabetes (n = 47) were recruited for the Chicago Childhood Diabetes Registry Family Study. SHBG and total and free testosterone were measured. Participants ranged in age from 10 to 32 years; 39% were non-Hispanic white. The majority of individuals with diabetes had the classic type 1 phenotype (75%), while the remainder exhibited features of type 2 or mixed diabetes; 96% were treated with insulin. RESULTS:--SHBG and total testosterone were higher in male subjects with diabetes compared with those in male siblings. Elevated SHBG was associated with the absence of endogenous insulin independent of sex; elevated total testosterone was similarly associated with the absence of C-peptide for male subjects only. Diabetes type and treatment were unrelated. In those without diabetes, greater insulin resistance had a small, nonsignificant association with lower SHBG and higher free testosterone. CONCLUSIONS:--SHBG and total testosterone appear to be higher in male children and young adults with diabetes compared with nondiabetic male siblings, which is apparently related to the absence of endogenous insulin. This may have implications for sex hormone-dependent processes across the lifespan in male individuals diagnosed with diabetes as children.
Background
Existing tools to measure patient-centered medical home (PCMH) adoption are not designed for research evaluation in safety-net clinics.
Objective
Develop a scale to measure PCMH adoption ...in safety-net clinics.
Research Design
Cross-sectional survey.
Subjects
Sixty-five clinics in five states.
Main Measures
Fifty-two-item Safety Net Medical Home Scale (SNMHS). The total score ranges from 0 (worst) to 100 (best) and is an average of multiple subscales (0–100): Access and Communication, Patient Tracking and Registry, Care Management, Test and Referral Tracking, Quality Improvement, and External Coordination. The scale was tested for internal consistency reliability and tested for convergent validity using The Assessment of Chronic Illness Care (ACIC) and the Patient-Centered Medical Home Assessment (PCMH-A). The scale was applied to centers in the sample. In addition, linear regression models were used to measure the association between clinic characteristics and medical home adoption.
Results
The SNMHS had high internal consistency reliability (Cronbach’s alpha = 0.84). The SNMHS score correlated moderately with the ACIC score (r = 0.64, p < 0.0001) and the PCMH-A (r = 0.56, p < 0.001). The mean SNMHS score was 61 ± SD 13. Among the subscales, External Coordination (66 ± 16) and Access and Communication (65 ± 14) had the highest mean scores, while Quality Improvement (55 ± 17) and Care Management (55 ± 16) had lower mean scores. Clinic characteristics positively associated with total SNMHS score were having more providers (β 15.8 95% CI 8.1–23.4 >8 provider FTEs compared to <4 FTEs) and participation in financial incentive programs (β 8.4 95% 1.6–15.3).
Conclusion
The SNMHS demonstrated reliability and convergent validity for measuring PCMH adoption in safety-net clinics. Some clinics have significant PCMH adoption. However, room for improvement exists in most domains, especially for clinics with fewer providers.
PDF
