Automated symptom and treatment side effect monitoring for improved quality of life among adults with diabetic peripheral neuropathy in primary care: a pragmatic, cluster, randomized, controlled trial.

AIMS: To evaluate the effectiveness of automated symptom and side effect monitoring on quality of life among individuals with symptomatic diabetic peripheral neuropathy. METHODS: We conducted a pragmatic, cluster randomized controlled trial (July 2014 to July 2016) within a large healthcare system. We randomized 1834 primary care physicians and prospectively recruited from their lists 1270 individuals with neuropathy who were newly prescribed medications for their symptoms. Intervention participants received automated telephone-based symptom and side effect monitoring with physician feedback over 6 months. The control group received usual care plus three non-interactive diabetes educational calls. Our primary outcomes were quality of life (EQ-5D) and select symptoms (e.g. pain) measured 4-8 weeks after starting medication and again 8 months after baseline. Process outcomes included receiving a clinically effective dose and communication between individuals with neuropathy and their primary care provider over 12 months. Interviewers collecting outcome data were blinded to intervention assignment. RESULTS: Some 1252 participants completed the baseline measures [mean age (sd): 67 (11.7), 53% female, 57% white, 8% Asian, 13% black, 20% Hispanic]. In total, 1179 participants (93%) completed follow-up (619 control, 560 intervention). Quality of life scores (intervention: 0.658 ± 0.094; control: 0.653 ± 0.092) and symptom severity were similar at baseline. The intervention had no effect on primary [EQ-5D: -0.002 (95% CI -0.01, 0.01), P = 0.623; pain: 0.295 (-0.75, 1.34), P = 0.579; sleep disruption: 0.342 (-0.18, 0.86), P = 0.196; lower extremity functioning: -0.079 (-1.27, 1.11), P = 0.896; depression: -0.462 (-1.24, 0.32); P = 0.247] or process outcomes. CONCLUSIONS: Automated telephone monitoring and feedback alone were not effective at improving quality of life or symptoms for people with symptomatic diabetic peripheral neuropathy. TRIAL REGISTRATION: ClinicalTrials.gov (NCT02056431).

Changes in physical activity among adults with diabetes: a longitudinal cohort study of inactive patients with Type 2 diabetes who become physically active.

AIMS: To identify the predictors and clinical effects among inactive patients with diabetes who become physically active, in the setting of a large integrated health system. METHODS: We studied adults with Type 2 diabetes with at least two clinic visits between December 2011 and November 2012 who reported being inactive at their first visit. The mean (±sd) interval between their first and last visit was 6.2 (±2.3) months. We analysed self-reported moderate-to-vigorous physical activity data collected using a structured intake form during routine clinical care. RESULTS: The study cohort (N = 6853) had a mean age of 60.2 years; 51.4% were women and 53.6% were non-white. Nearly two-thirds (62.5%, n = 4280) reported remaining physically inactive, while 16.0% reported achieving the recommended moderate-to-vigorous physical activity levels (≥ 150 min/week) by the last visit of the study period. Female gender (odds ratio 0.77, 95% CI 0.67, 0.88), obesity (BMI 30-34.9 kg/m(2) : odds ratio 0.76, 95% CI 0.60, 0.97; BMI ≥ 35 kg/m(2) : odds ratio 0.55, 95% CI 0.42, 0.70), chronic kidney disease (odds ratio 0.78, 95% CI 0.65, 0.94) and depression (odds ratio 0.77, 95% CI 0.62, 0.96) were each independently associated with not achieving the recommended moderate-to-vigorous physical activity level, while physician referral to lifestyle education was a positive predictor (odds ratio 1.40, 95% CI 1.09, 1.85). Controlling for baseline differences, patients achieving the recommended moderate-to-vigorous physical activity target lost 1.0 kg more weight compared with patients remaining inactive (P < 0.001). CONCLUSIONS: Patients with diabetes in a real-world clinical setting lost weight after becoming physically active; however, nearly two-thirds of patients remained inactive. Novel interventions to address physical inactivity in primary care should address barriers faced by older patients with medically complex disease.

Quality of primary care practice in a large HMO according to physician specialty.

OBJECTIVE: To determine whether physician specialty was associated with differences in the quality of primary care practice and patient satisfaction in a large, group model HMO. DATA SOURCES/STUDY SETTING: 10,608 patients ages 35-85 years, selected using stratified probability sampling from the primary care panels of 60 family physicians (FPs), 245 general internists (GIMs), and 55 subspecialty internists (SIMs) at 13 facilities in the Kaiser Permanente Medical Care Program of Northern California. Patients were surveyed in 1995. STUDY DESIGN: A cross-sectional patient survey measured patient reports of physician performance on primary care measures of coordination, comprehensiveness, and accessibility of care, preventive care procedures, and health promotion. Additional items measured patient satisfaction and health values and beliefs. PRINCIPAL FINDINGS: Patients were remarkably similar across physician specialty groups in their health values and beliefs, ratings of the quality of primary care, and satisfaction. Patients rated GIMs higher than FPs on coordination (adjusted mean scores 68.0 and 58.4 respectively, p<.001) and slightly higher on accessibility and prevention; GIMs were rated more highly than SIMs on comprehensiveness (adjusted mean scores 76.4 and 73.8, p<.01). There were no significant differences between specialty groups on a variety of measures of patient satisfaction. CONCLUSIONS: Few differences in the quality of primary care were observed by physician specialty in the setting of a large, well-established group model HMO. These similarities may result from the direct influence of practice setting on physician behavior and organization of care or, indirectly, through the types of physicians attracted to a well-established group model HMO. In some settings, practice organization may have more influence than physician specialty on the delivery of primary care.

Differences in resource use and costs of primary care in a large HMO according to physician specialty.

OBJECTIVE: To determine if primary care physician specialty is associated with differences in use of health services. DATA SOURCES: Automated outpatient diagnostic, utilization, and cost data on 15,223 members (35-85 years of age) of a large group model HMO. STUDY DESIGN: One-year prospective comparison of primary care provided by 245 general internists (GIMs), 60 family physicians (FPs), and 55 subspecialty internists (SIMs) with case-mix assessed during a nine-month baseline period using Ambulatory Diagnostic Groups. PRINCIPAL FINDINGS: Adjusting for demographics and case mix, patients of GIMs and FPs had similar hospitalization and ambulatory visit rates, and similar laboratory and radiology costs. Patients of FPs made fewer visits to dermatology, psychiatry, and gynecology (combined visit rate ratio: 0.86, 95% CI: 0.74-0.96). However, they made more urgent care visits (rate ratio 1.19, 95% CI: 1.07-1.23). Patients of SIMs had higher hospitalization rates than those of GIMs (rate ratio 1.33, 95% CI: 1.06-1.68), greater use of urgent care (rate ratio: 1.14, 95% CI: 1.04-1.25), and higher costs for pharmacy (cost ratio: 1.17, 95% CI: 0.93-1.18) and radiologic services (cost ratio: 1.14, 95% CI: 1.01-1.30). The hospitalization difference was due partly to the inclusion of patients with specialty-related diagnoses in panels of SIMs. Radiology and pharmacy differences persisted after excluding these patients. CONCLUSIONS: In this uniform practice environment, specialty differences in primary care practice were small. Subspecialists used slightly more resources than generalists. The broader practice style of FPs may have created access problems for their patients.

A cost analysis of a Helicobacter pylori eradication strategy in a large health maintenance organization.

OBJECTIVES: We sought to describe the effect of a Helicobacter pylori eradication strategy on health care costs among a cohort of health maintenance organization (HMO) members with peptic ulcer disease (PUD). METHODS: Patients were identified from an outpatient diagnosis database and verified at chart review to have new-onset PUD by upper endoscopy or upper gastrointestinal radiographic series. Health plan registration and accounting databases were used to track costs over 12 months after initial diagnosis. Costs were analyzed separately for an initial 2-month interval and a 10-month follow-up period. Inpatient and pharmacy costs are those directly attributable to PUD (either a PUD-related discharge diagnosis or an antiulcer medication prescription). Outpatient costs are total costs. All cost differences were adjusted for age and gender. RESULTS: Twenty-seven of 93 patients meeting selection criteria received H. pylori treatment. During the 2-month treatment window, adjusted PUD-related inpatient costs were higher for the H. pylori treated group (difference, $234.00/person), whereas total outpatient costs and PUD-related pharmacy costs were similar. During the 10-month follow-up period, PUD-related inpatient and pharmacy adjusted costs were similar, but adjusted outpatient costs in the H. pylori treated group were lower than in the untreated group (difference, $508.00/person). Total adjusted follow-up period costs were $555.00/person less in the H. pylori treated group (p = 0.05). Total 12-month costs in the H. pylori treated group were $285.00/per person less than in untreated patients, (p > 0.2); 30% of H. pylori treated patients were still receiving antisecretory therapy 1 yr after diagnosis, compared to 41.9% of untreated patients. CONCLUSIONS: H. pylori treatment is associated with a decreased cost of follow-up care for patients with PUD, primarily due to decreased outpatient utilization.

The impact of aging and chronic disease on use of hospital and outpatient services in a large HMO: 1971-1991.

OBJECTIVES: To examine overall and diagnosis-specific trends in the use of inpatient and outpatient medical services (1970-1988) among older members of a large HMO. DESIGN: Two cohorts of approximately 3000 persons aged 65 or older in 1971 and 1980 were compared for hospital and outpatient utilization during 9-year follow-up periods (1971-79 and 1980-88). All subjects were evaluated for vital status throughout the follow-up period as well. PARTICIPANTS: All 6057 subjects were members of the Northern California Kaiser Permanente Medical Care Program in 1971 or 1980. The study sample was sex-age stratified (65-69,70-79,80+) at baseline. MEASUREMENTS: Data on demographics, outpatient health services utilization, categories of outpatient utilization and disease diagnoses were obtained from membership lists or medical chart review; inpatient utilization, including admitting and discharge diagnosis, length of stay, and number of hospital days was assessed from computerized hospitalization records. RESULTS: Hospital discharge rates (sex-age adjusted) increased by 12% between cohorts, with the largest increases at the oldest ages. There was a 25% increase among women and a 9% increase among men. Length of stay decreased by 20%. Hospitalization for ischemic heart disease decreased by 17%. Congestive heart failure (CHF) discharge rates (sex-age adjusted) were 92% higher in the 1980-88 cohort. For diagnoses related to nursing home institutionalization and frailty, discharge rates were significantly higher in the 1980-88 cohort: pneumonia (+34%), urinary tract infections (+104%), dehydration (+110%), osteoarthritis (+64%), syncope (+246%), leg cellulitis (+70%). In-hospital survival improved, but overall percent of readmissions also increased by 4%; readmissions for CHF increased by 13% and those for conditions of frailty by 120%. Overall outpatient visits increased by 17%. Use of laboratory tests (+57%) and outpatient surgeries (+99%) increased for all age strata in 1980-88 compared with 1971-79. CONCLUSIONS: While overall outpatient and inpatient utilization has largely decreased over the past 30 years, as a result of economic factors and improved treatments for some major diseases, there has been an increase in utilization among older people. Hospitalization for diagnoses associated with end-stage cardiovascular disease (CHF), musculoskeletal disease, frailty and iatrogenic aspects of institutionalization are clearly increasing substantially. The largest impact of aging on health care may be the result of institutionalization and its sequelae. Improved treatment for cardiovascular disease may also be leading to increased utilization at later stages in the disease process.

Costs of acid-related disorders to a health maintenance organization.

BACKGROUND: Little is known about the economic impact of the acid-related disorders (ARDs), which include dyspepsia, gastritis, gastroesophageal reflux disease (GERD), and peptic ulcer disease (PUD), in managed care patient populations. OBJECTIVES: To describe the prevalence of medically attended ARDs, and their direct medical costs from the perspective of a large health maintenance organization (HMO). METHODS: A total of 1,550 ARDs subjects (age > or = 18 years), were randomly sampled from outpatient diagnosis and pharmacy databases of the Kaiser Permanente Medical Care Program of Northern California and verified by chart review. Five age- and gender-matched controls were identified per subject. One-year prevalence, excess annual costs, and initial 6-month costs for incident cases were estimated using the HMO cost accounting system. RESULTS: Total ARDs prevalence (5.8%) increases with advancing age. GERD is the most common ARD (2.9% overall prevalence). Annual per person attributable costs were $1,183, $471, and $431 respectively for PUD, GERD, and gastritis/dyspepsia. Excess inpatient costs for PUD explain its higher costs. Outpatient costs were somewhat higher for GERD ($279) than for PUD or gastritis/dyspepsia. Pharmacy costs were relatively low for each condition, in part because many patients were treated with generic cimetidine. Total annual HMO expenditures for ARDs were $59.4 million, with 40.6%, 36.8%, and 22.6% respectively for GERD, PUD, and gastritis/dyspepsia. CONCLUSIONS: Acid-related disorders, particularly GERD and PUD, contribute substantially to the direct costs of medical care in this managed care population.