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1.
Ann Surg ; 277(4): 637-646, 2023 04 01.
Artigo em Inglês | MEDLINE | ID: mdl-35058404

RESUMO

OBJECTIVE: To examine whether depression status before metabolic and bariatric surgery (MBS) influenced 5-year weight loss, diabetes, and safety/utilization outcomes in the PCORnet Bariatric Study. SUMMARY OF BACKGROUND DATA: Research on the impact of depression on MBS outcomes is inconsistent with few large, long-term studies. METHODS: Data were extracted from 23 health systems on 36,871 patients who underwent sleeve gastrectomy (SG; n=16,158) or gastric bypass (RYGB; n=20,713) from 2005-2015. Patients with and without a depression diagnosis in the year before MBS were evaluated for % total weight loss (%TWL), diabetes outcomes, and postsurgical safety/utilization (reoperations, revisions, endoscopy, hospitalizations, mortality) at 1, 3, and 5 years after MBS. RESULTS: 27.1% of SG and 33.0% of RYGB patients had preoperative depression, and they had more medical and psychiatric comorbidities than those without depression. At 5 years of follow-up, those with depression, versus those without depression, had slightly less %TWL after RYGB, but not after SG (between group difference = 0.42%TWL, P = 0.04). However, patients with depression had slightly larger HbA1c improvements after RYGB but not after SG (between group difference = - 0.19, P = 0.04). Baseline depression did not moderate diabetes remission or relapse, reoperations, revision, or mortality across operations; however, baseline depression did moderate the risk of endoscopy and repeat hospitalization across RYGB versus SG. CONCLUSIONS: Patients with depression undergoing RYGB and SG had similar weight loss, diabetes, and safety/utilization outcomes to those without depression. The effects of depression were clinically small compared to the choice of operation.


Assuntos
Cirurgia Bariátrica , Derivação Gástrica , Obesidade Mórbida , Humanos , Obesidade Mórbida/complicações , Obesidade Mórbida/cirurgia , Depressão/epidemiologia , Gastrectomia , Redução de Peso , Estudos Retrospectivos , Resultado do Tratamento
2.
JAMA Surg ; 157(10): 897-906, 2022 10 01.
Artigo em Inglês | MEDLINE | ID: mdl-36044239

RESUMO

Importance: Bariatric surgery is the most effective treatment for severe obesity; yet it is unclear whether the long-term safety and comparative effectiveness of these operations differ across racial and ethnic groups. Objective: To compare outcomes of Roux-en-Y gastric bypass (RYGB) and sleeve gastrectomy (SG) across racial and ethnic groups in the National Patient-Centered Clinical Research Network (PCORnet) Bariatric Study. Design, Setting, and Participants: This was a retrospective, observational, comparative effectiveness cohort study that comprised 25 health care systems in the PCORnet Bariatric Study. Patients were adults and adolescents aged 12 to 79 years who underwent a primary (first nonrevisional) RYGB or SG operation between January 1, 2005, and September 30, 2015, at participating health systems. Patient race and ethnicity included Black, Hispanic, White, other, and unrecorded. Data were analyzed from July 1, 2021, to January 17, 2022. Exposure: RYGB or SG. Outcomes: Percentage total weight loss (%TWL); type 2 diabetes remission, relapse, and change in hemoglobin A1c (HbA1c) level; and postsurgical safety and utilization outcomes (operations, interventions, revisions/conversions, endoscopy, hospitalizations, mortality, 30-day major adverse events) at 1, 3, and 5 years after surgery. Results: A total of 36 871 patients (mean [SE] age, 45.0 [11.7] years; 29 746 female patients [81%]) were included in the weight analysis. Patients identified with the following race and ethnic categories: 6891 Black (19%), 8756 Hispanic (24%), 19 645 White (53%), 826 other (2%), and 783 unrecorded (2%). Weight loss and mean reductions in HbA1c level were larger for RYGB than SG in all years for Black, Hispanic, and White patients (difference in 5-year weight loss: Black, -7.6%; 95% CI, -8.0 to -7.1; P < .001; Hispanic, -6.2%; 95% CI, -6.6 to -5.9; P < .001; White, -5.9%; 95% CI, -6.3 to -5.7; P < .001; difference in change in year 5 HbA1c level: Black, -0.29; 95% CI, -0.51 to -0.08; P = .009; Hispanic, -0.45; 95% CI, -0.61 to -0.29; P < .001; and White, -0.25; 95% CI, -0.40 to -0.11; P = .001.) The magnitude of these differences was small among racial and ethnic groups (1%-3% of %TWL). Black and Hispanic patients had higher risk of hospitalization when they had RYGB compared with SG (hazard ratio [HR], 1.45; 95% CI, 1.17-1.79; P = .001 and 1.48; 95% CI, 1.22-1.79; P < .001, respectively). Hispanic patients had greater risk of all-cause mortality (HR, 2.41; 95% CI, 1.24-4.70; P = .01) and higher odds of a 30-day major adverse event (odds ratio, 1.92; 95% CI, 1.38-2.68; P < .001) for RYGB compared with SG. There was no interaction between race and ethnicity and operation type for diabetes remission and relapse. Conclusions and Relevance: Variability of the comparative effectiveness of operations for %TWL and HbA1c level across race and ethnicity was clinically small; however, differences in safety and utilization outcomes were clinically and statistically significant for Black and Hispanic patients who had RYGB compared with SG. These findings can inform shared decision-making regarding bariatric operation choice for different racial and ethnic groups of patients.


Assuntos
Cirurgia Bariátrica , Diabetes Mellitus Tipo 2 , Derivação Gástrica , Obesidade Mórbida , Adolescente , Adulto , Cirurgia Bariátrica/efeitos adversos , Estudos de Coortes , Diabetes Mellitus Tipo 2/cirurgia , Minorias Étnicas e Raciais , Etnicidade , Feminino , Gastrectomia/efeitos adversos , Derivação Gástrica/efeitos adversos , Hemoglobinas Glicadas , Humanos , Pessoa de Meia-Idade , Obesidade Mórbida/cirurgia , Recidiva , Estudos Retrospectivos , Resultado do Tratamento , Redução de Peso
3.
EGEMS (Wash DC) ; 7(1): 9, 2019 Apr 03.
Artigo em Inglês | MEDLINE | ID: mdl-30972358

RESUMO

INTRODUCTION: Priorities Wizard is an electronic health record-linked, web-based clinical decision support (CDS) system designed and implemented at multiple Health Care Systems Research Network (HCSRN) sites to support high quality outpatient chronic disease and preventive care. The CDS system (a) identifies patients who could substantially benefit from evidence-based actions; (b) presents prioritized evidence-based treatment options to both patient and clinician at the point of care; and (c) facilitates efficient ordering of recommended medications, referrals or procedures. METHODS: The CDS system extracts relevant data from electronic health records (EHRs), processes the data using Web-based clinical decision support algorithms, and displays the CDS output seamlessly on the EHR screen for use by the clinician and patient. Through a series of National Institutes of Health-funded projects led by HealthPartners Institute and the HealthPartners Center for Chronic Care Innovation and HCSRN partners, Priorities Wizard has been evaluated in cluster-randomized trials and expanded to include over 20 clinical domains. RESULTS: Cluster-randomized trials show that this CDS system significantly improved glucose and blood pressure control in diabetes patients, reduced 10-year cardiovascular (CV) risk in high-CV risk adults without diabetes, improved management of smoking in dental patients, and improved high blood pressure identification and management in adolescents. CDS output was used at 71-77 percent of targeted visits, 85-98 percent of clinicians were satisfied with the CDS system, and 94 percent reported they would recommend it to colleagues. CONCLUSIONS: Recently developed EHR-linked, Web-based CDS systems have significantly improved chronic disease care outcomes and have high use rates and primary care clinician satisfaction.

4.
J Transcult Nurs ; 30(1): 55-63, 2019 01.
Artigo em Inglês | MEDLINE | ID: mdl-30170512

RESUMO

INTRODUCTION: Eastern Africa has the highest rates of cervical cancer incidence (42.7 per 100,000) and mortality (27.6 per 100,000), substantially higher than worldwide incidence (14.0 per 100,000) and mortality (6.8 per 100,000). The purpose of this study was to explore facilitators and barriers to cervical cancer screening and human papilloma virus (HPV) vaccination among Somali refugee women and their children. METHOD: Focus group discussions were conducted in August of 2016. Investigators performed systematic, comparative, and thematic data analyses. RESULTS: The 31 Somali refugee participants ranged from 23 to 64 years old. Four major themes emerged: (1) knowledge, (2) facilitators, (3) decision making, and (4) views on intervention strategies. Doctor recommendation and family support were important facilitators. Community education was the most popular strategy in promoting screening and vaccine uptake. DISCUSSION: Multilevel targeted interventions should increase knowledge and include family members to increase cervical cancer screening and HPV vaccination uptake in the Somali community.


Assuntos
Emigrantes e Imigrantes/psicologia , Programas de Rastreamento/normas , Neoplasias do Colo do Útero/diagnóstico , Vacinação/psicologia , Adulto , Detecção Precoce de Câncer/métodos , Detecção Precoce de Câncer/normas , Emigrantes e Imigrantes/estatística & dados numéricos , Feminino , Grupos Focais/métodos , Humanos , Programas de Rastreamento/métodos , Pessoa de Meia-Idade , Minnesota , Papillomaviridae/efeitos dos fármacos , Papillomaviridae/patogenicidade , Vacinas contra Papillomavirus/uso terapêutico , Pesquisa Qualitativa , Somália/etnologia , Inquéritos e Questionários , Neoplasias do Colo do Útero/etnologia , Neoplasias do Colo do Útero/psicologia , Vacinação/métodos , Vacinação/normas
5.
J Am Med Inform Assoc ; 25(9): 1137-1146, 2018 09 01.
Artigo em Inglês | MEDLINE | ID: mdl-29982627

RESUMO

Objective: To test the hypothesis that use of a clinical decision support (CDS) system in a primary care setting can reduce cardiovascular (CV) risk in patients. Materials and Methods: Twenty primary care clinics were randomly assigned to usual care (UC) or CDS. For CDS clinic patients identified algorithmically with high CV risk, rooming staff were prompted by the electronic health record (EHR) to print CDS that identified evidence-based treatment options for lipid, blood pressure, weight, tobacco, or aspirin management and prioritized them based on potential benefit to the patient. The intention-to-treat analysis included 7914 adults who met high CV risk criteria at an index clinic visit and had at least one post-index visit, accounted for clustering, and assessed impact on predicted annual rate of change in 10-year CV risk over a 14-month period. Results: The CDS was printed at 75% of targeted visits, and providers reported 85% to 98% satisfaction with various aspects of the intervention. Predicted annual rate of change in absolute 10-year CV risk was significantly better in CDS clinics than in UC clinics (-0.59% vs. +1.66%, -2.24%; P < .001), with difference in 10-year CV risk at 12 months post-index favoring the CDS group (UC 24.4%, CDS 22.5%, P < .03). Discussion: Deploying to both patients and providers within primary care visit workflow and limiting CDS display and print burden to two mouse clicks by rooming staff contributed to high CDS use rates and high provider satisfaction. Conclusion: This EHR-integrated, web-based outpatient CDS system significantly improved 10-year CV risk trajectory in targeted adults.


Assuntos
Doenças Cardiovasculares/prevenção & controle , Sistemas de Apoio a Decisões Clínicas , Registros Eletrônicos de Saúde , Atenção Primária à Saúde , Adolescente , Adulto , Idoso , Assistência Ambulatorial , Atitude Frente aos Computadores , Apresentação de Dados , Sistemas de Apoio a Decisões Clínicas/estatística & dados numéricos , Feminino , Humanos , Intervenção Baseada em Internet , Masculino , Pessoa de Meia-Idade , Médicos de Atenção Primária , Fatores de Risco , Adulto Jovem
6.
Diabetes Care ; 38(5): 905-12, 2015 May.
Artigo em Inglês | MEDLINE | ID: mdl-25710922

RESUMO

OBJECTIVE: The objective of this study was to assess the incidence of major cardiovascular (CV) hospitalization events and all-cause deaths among adults with diabetes with or without CV disease (CVD) associated with inadequately controlled glycated hemoglobin (A1C), high LDL cholesterol (LDL-C), high blood pressure (BP), and current smoking. RESEARCH DESIGN AND METHODS: Study subjects included 859,617 adults with diabetes enrolled for more than 6 months during 2005-2011 in a network of 11 U.S. integrated health care organizations. Inadequate risk factor control was classified as LDL-C ≥100 mg/dL, A1C ≥7% (53 mmol/mol), BP ≥140/90 mm Hg, or smoking. Major CV events were based on primary hospital discharge diagnoses for myocardial infarction (MI) and acute coronary syndrome (ACS), stroke, or heart failure (HF). Five-year incidence rates, rate ratios, and average attributable fractions were estimated using multivariable Poisson regression models. RESULTS: Mean (SD) age at baseline was 59 (14) years; 48% of subjects were female, 45% were white, and 31% had CVD. Mean follow-up was 59 months. Event rates per 100 person-years for adults with diabetes and CVD versus those without CVD were 6.0 vs. 1.7 for MI/ACS, 5.3 vs. 1.5 for stroke, 8.4 vs. 1.2 for HF, 18.1 vs. 40 for all CV events, and 23.5 vs. 5.0 for all-cause mortality. The percentages of CV events and deaths associated with inadequate risk factor control were 11% and 3%, respectively, for those with CVD and 34% and 7%, respectively, for those without CVD. CONCLUSIONS: Additional attention to traditional CV risk factors could yield further substantive reductions in CV events and mortality in adults with diabetes.


Assuntos
Diabetes Mellitus Tipo 1/prevenção & controle , Diabetes Mellitus Tipo 2/prevenção & controle , Angiopatias Diabéticas/prevenção & controle , Fumar/efeitos adversos , Adulto , Idoso , Idoso de 80 Anos ou mais , Glicemia/metabolismo , Pressão Sanguínea/fisiologia , Determinação da Pressão Arterial , Causas de Morte , LDL-Colesterol/sangue , Diabetes Mellitus Tipo 1/mortalidade , Diabetes Mellitus Tipo 1/fisiopatologia , Diabetes Mellitus Tipo 2/mortalidade , Diabetes Mellitus Tipo 2/fisiopatologia , Angiopatias Diabéticas/mortalidade , Angiopatias Diabéticas/fisiopatologia , Feminino , Hemoglobinas Glicadas/metabolismo , Insuficiência Cardíaca/mortalidade , Hospitalização/estatística & dados numéricos , Humanos , Hipertensão/complicações , Incidência , Masculino , Pessoa de Meia-Idade , Infarto do Miocárdio/mortalidade , Fatores de Risco , Fumar/mortalidade , Acidente Vascular Cerebral/mortalidade , Estados Unidos , Adulto Jovem
7.
Ann Fam Med ; 2(1): 26-32, 2004.
Artigo em Inglês | MEDLINE | ID: mdl-15053280

RESUMO

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


Assuntos
Diabetes Mellitus/epidemiologia , Conhecimentos, Atitudes e Prática em Saúde , Autocuidado , Fumar/epidemiologia , Comorbidade , Estudos Transversais , Depressão/epidemiologia , Diabetes Mellitus/psicologia , Feminino , Nível de Saúde , Humanos , Masculino , Pessoa de Meia-Idade , Minnesota/epidemiologia , Análise Multivariada , Cooperação do Paciente , Análise de Regressão , Autocuidado/psicologia , Fumar/psicologia , Apoio Social
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