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Publication Record


Visit-to-visit variability in blood pressure and kidney and cardiovascular outcomes in patients with type 2 diabetes and nephropathy: a post hoc analysis from the RENAAL study and the Irbesartan Diabetic Nephropathy Trial.
McMullan CJ, Lambers Heerspink HJ, Parving HH, Dwyer JP, Forman JP, de Zeeuw D
(2014) Am J Kidney Dis 64: 714-22
MeSH Terms: Aged, Angiotensin II Type 1 Receptor Blockers, Biphenyl Compounds, Blood Pressure, Cardiovascular Diseases, Cohort Studies, Diabetes Mellitus, Type 2, Diabetic Nephropathies, Double-Blind Method, Female, Follow-Up Studies, Humans, Irbesartan, Kidney, Male, Middle Aged, Office Visits, Prospective Studies, Tetrazoles, Treatment Outcome
Show Abstract · Added October 28, 2014
BACKGROUND - Increased systolic blood pressure variability between outpatient visits is associated with increased incidence of cardiovascular end points. However, few studies have examined the association of visit-to-visit variability in systolic blood pressure with clinically relevant kidney disease outcomes. We analyzed the association of systolic blood pressure visit-to-visit variability with renal and cardiovascular morbidity and mortality among individuals with diabetes and nephropathy.
STUDY DESIGN - Observational analysis of IDNT (Irbesartan Diabetic Nephropathy Trial) and the RENAAL (Reduction of End Points in Non-Insulin-Dependent Diabetes With the Angiotensin II Antagonist Losartan) Study.
SETTING & PARTICIPANTS - 2,739 participants with type 2 diabetes and nephropathy with at least 1 year of blood pressure measurements available.
PREDICTORS - Systolic blood pressure visit-to-visit variability was calculated from the SD of the systolic blood pressure from 4 visits occurring 3-12 months postrandomization.
OUTCOMES - The kidney disease outcome was defined as time to confirmed doubling of serum creatinine level, end-stage renal disease, or death; the cardiovascular outcome was defined as time to cardiovascular death, myocardial infarction, stroke, hospitalization for heart failure, or revascularization.
RESULTS - Mean visit-to-visit variability in systolic blood pressure from 3 to 12 months postrandomization was 12.0±6.8(SD)mmHg. Following this ascertainment period, there were 954 kidney disease and 542 cardiovascular events. Greater systolic blood pressure visit-to-visit variability was associated independently with increased risk of the composite kidney disease end point (HR per 1-SD increment, 1.08 [95%CI, 1.01-1.16]; P=0.02) and end-stage renal disease, but not with the cardiovascular outcome.
LIMITATIONS - Observational study with the potential for confounding.
CONCLUSIONS - In diabetic individuals with nephropathy, systolic blood pressure visit-to-visit variability is associated independently with hard kidney disease outcomes.
Copyright © 2014 National Kidney Foundation, Inc. Published by Elsevier Inc. All rights reserved.
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20 MeSH Terms
Increasing burden and risk factors for bronchiolitis-related medical visits in infants enrolled in a state health care insurance plan.
Carroll KN, Gebretsadik T, Griffin MR, Wu P, Dupont WD, Mitchel EF, Enriquez R, Hartert TV
(2008) Pediatrics 122: 58-64
MeSH Terms: Birth Rate, Bronchiolitis, Cost of Illness, Emergency Service, Hospital, Hospitalization, Humans, Infant, Maternal Age, Medicaid, Office Visits, Retrospective Studies, Risk Factors, Seasons, Tennessee, United States
Show Abstract · Added March 21, 2014
OBJECTIVES - The goals were to estimate the year-round burden of health care visits attributable to bronchiolitis and to identify risk factors for bronchiolitis in term healthy infants.
METHODS - We conducted a population-based, retrospective cohort study of 103 670 term, non-low birth weight infants enrolled in Tennessee Medicaid in 1995-2003. We monitored infants through the first year of life. Risk factors for bronchiolitis during infancy and rates of inpatient, emergency department, and outpatient visits during the study period were calculated by using claims data.
RESULTS - Over the 9 study years, rates of bronchiolitis visits were 238 outpatient visits per 1000 infant-years, 77 emergency department visits per 1000 infant-years, and 71 hospitalizations per 1000 infant-years. Average annual rates of bronchiolitis visits increased 41%, from 188 visits per 1000 infant-years to 265 visits per 1000 infant-years, from 1996-1997 to 2002-2003. Analysis of the linear trend in 500-g increments demonstrated a negative association between increasing birth weight and bronchiolitis diagnosis. There was a significant negative trend between maternal age and infant bronchiolitis diagnosis. Compared with infants of mothers 20 to 29 years of age, infants of mothers 15 to 19 years of age had a small increase in risk of having a bronchiolitis visit, whereas infants of older mothers (30-39 or 40-44 years of age) were less likely to have a visit.
CONCLUSIONS - The disease burden of bronchiolitis is substantial, with increasing rates of all types of visits among term, otherwise-healthy infants enrolled in Tennessee Medicaid between 1995 and 2003. Protective factors in this cohort of term infants included higher birth weight and older maternal age.
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15 MeSH Terms
EPSDT preventive services in a low-income pediatric population: impact of a nursing protocol.
Hull PC, Husaini BA, Tropez-Sims S, Reece M, Emerson J, Levine R
(2008) Clin Pediatr (Phila) 47: 137-42
MeSH Terms: Adolescent, Child, Child, Preschool, Feasibility Studies, Female, Humans, Infant, Mass Screening, Medicaid, Nursing Assessment, Office Visits, Pediatrics, Poverty, Preventive Health Services, Primary Health Care, United States
Show Abstract · Added March 5, 2014
Medicaid mandates coverage of clinical preventive services for children under the Early and Periodic Screening, Diagnosis, and Treatment program (EPSDT). This article assesses the usefulness of a nursing protocol for delivering comprehensive EPSDT services to pediatric patients during any primary care visit. Secondary data from a recent controlled trial were analyzed. An intervention group received the clinical protocol (n = 514 children in a low-income pediatric clinic), whereas data from a "usual care" comparison group were obtained from medical records (n = 115 children). The nursing protocol included 52 items corresponding to EPSDT services and was administered by a prevention nurse. In the intervention group, 11 605 out of 11 607 (approximately 100.0%) EPSDT service needs were initiated, as compared to 21.2% (572 out of 2695) in the comparison group (P < .001). The study demonstrates the feasibility of using a nursing protocol to integrate EPSDT clinical preventive services into pediatric visits.
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16 MeSH Terms
Health care utilization after medical and surgical therapy for gastroesophageal reflux disease: a population-based study, 1996 to 2000.
Khaitan L, Ray WA, Holzman MD, Smalley WE
(2003) Arch Surg 138: 1356-61
MeSH Terms: Adult, Chi-Square Distribution, Cohort Studies, Drug Utilization, Female, Gastroesophageal Reflux, Hospitalization, Humans, Male, Middle Aged, Office Visits, Statistics, Nonparametric, Tennessee
Show Abstract · Added March 5, 2014
HYPOTHESIS - Patients who undergo surgical treatment for gastroesophageal reflux disease (GERD) will use fewer health care resources than those who continue to be treated medically during the same follow-up period.
DESIGN - Matched cohort study of patients with a diagnosis of GERD receiving surgical therapy or medical therapy.
SETTING - Tennessee Medicaid (TennCare) program from 1996 through 2000.
PATIENTS - Population-based sample of 7635 TennCare enrollees with a diagnosis of GERD served as the underlying population. Of these, 111 surgical patients who underwent fundoplication in 1996 met inclusion criteria. The 200 patients in the medically treated cohort were randomly matched to patients in the surgical cohort by demographic characteristics and previous use of acid-suppressing drugs.
INTERVENTIONS - The surgical group all underwent fundoplication in 1996. The medical group was treated without fundoplication.
MAIN OUTCOME MEASURES - Health care utilization (medication use, outpatient visits, hospitalizations, and diagnostic studies) for each cohort through December 2000.
RESULTS - In the 4-year follow-up period, the surgical group had fewer GERD-related outpatient physician visits (5.5 +/- 6.9 visits vs 6.7 +/- 6.1 visits; P =.10). Utilization of other types of outpatient and inpatient care was similar. During each year of follow-up, the proportion of persons using GERD medication was lower in the surgical group. (0.67 vs 0.93 in year 1, 0.67 vs 0.91 in year 2, 0.72 vs 0.85 in year 3, and 0.74 vs 0.90 in year 4).
CONCLUSION - The utilization of health care resources in patients treated surgically for GERD is associated with a modest decrease in the use of GERD-related medications and GERD-related visits.
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13 MeSH Terms
Use of healthcare resources among medically and surgically treated patients with gastroesophageal reflux disease: a population-based study.
Holzman MD, Mitchel EF, Ray WA, Smalley WE
(2001) J Am Coll Surg 192: 17-24
MeSH Terms: Adolescent, Adult, Aged, Aged, 80 and over, Cohort Studies, Diagnostic Techniques, Digestive System, Drug Utilization, Female, Gastroesophageal Reflux, Hospitalization, Humans, Male, Middle Aged, Office Visits, Retrospective Studies
Show Abstract · Added March 5, 2014
BACKGROUND - Gastroesophageal reflux disease (GERD) is a common disorder that may be effectively managed medically or surgically. Direct evaluations of medical resource use are needed to better understand the relative costs of these alternatives. This study compared medical care use for a group of patients receiving surgical treatment for GERD with that for a comparable group of patients receiving medical management.
STUDY DESIGN - We conducted a retrospective matched cohort study of Tennessee Medicaid (TennCare) patients with GERD undergoing surgical treatment in 1996 and a group of patients who received medical therapy during the same period. Administrative TennCare data provided computerized records that could be used to identify patients and measure healthcare use. There were 7,502 people who met all of the conditions for inclusion in the study, including at least two encounters with a diagnosis of GERD. One hundred thirty-five of these who underwent fundoplication constituted the surgically treated cohort. The 250 persons in the medically treated cohort were selected randomly from the remaining nonsurgical patients and matched to the surgical cohort by age, gender, race, managed care organization, and acid suppression drug use in the baseline year. The principal outcome of interest was total use of medical resources, including prescription medication.
RESULTS - The surgical and medical cohorts did not differ significantly by demographic characteristics or by baseline use of pharmaceuticals. During the baseline year the surgically treated patients were prescribed 302 (95% CI: 270-334) days ofGERD treatment and the matched medical patients were prescribed 292 (95% CI: 267-317) days of GERD treatment. Surgically treated patients used more GERD-related outpatient resources (physician visits and diagnostic testing) in the baseline year, particularly in the 3 months before operation, when they had a mean of more than four outpatient encounter-days. In the followup year, use of GERD-related pharmaceuticals decreased markedly in the surgical cohort. These patients were prescribed an average of 123 days (95% CI: 94-153) of therapy, which was only 36% of that for medical patients (339 days [95% CI: 308-370]). More than 29% of surgical patients were prescribed no GERD-related drugs in the followup year compared with 6% of the medically treated group. The mean number of inpatient days for the fundoplication procedure was 3.2 (95% CI: 2.7-3.6), with a range of 0 to 13 days. There were no differences between the two groups in other healthcare use.
CONCLUSIONS - Our results show that in a 1-year period of followup, surgical treatment of severe gastroesophageal reflux disease led to a 64% postsurgical reduction in GERD medication use, with no increase in use of other medical services.
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15 MeSH Terms
National patterns and predictors of beta-blocker use in patients with coronary artery disease.
Wang TJ, Stafford RS
(1998) Arch Intern Med 158: 1901-6
MeSH Terms: Adrenergic beta-Antagonists, Adult, Aged, Ambulatory Care, Analysis of Variance, Coronary Disease, Female, Humans, Logistic Models, Male, Middle Aged, Office Visits, Social Class, United States
Show Abstract · Added April 15, 2014
BACKGROUND - Prior studies suggest underuse of beta-blockers in patients with coronary artery disease, but these studies have been based on selected populations of recently hospitalized patients.
OBJECTIVE - To describe national patterns and determinants of beta-blocker use in the ambulatory setting.
METHODS - We analyzed 11745 visits by patients with coronary artery disease to randomly selected, office-based physicians in the National Ambulatory Medical Care Surveys for 1980, 1981, 1985, and 1989 through 1996. We used multiple logistic regression to determine the independent effect of sociodemographic and clinical factors on beta-blocker use.
OUTCOME MEASURE - Beta-blocker use at patient visits.
RESULTS - Beta-blocker use was reported in only 20.9% of office visits by patients with coronary artery disease and no strong contraindications between 1993 and 1996. In multivariate analyses, age younger than 75 years, residence in the Northeast, and visits to cardiologists and internists compared with family and general practitioners predicted greater use of beta-blocker therapy. White race and private insurance also were significant predictors of beta-blocker use between 1980 and 1996. Longitudinal analyses revealed a significant decline in beta-blocker use from 1980 to 1990, followed by a gradual increase in recent years.
CONCLUSIONS - Beta-blockers appear to be underused in ambulatory patients with coronary artery disease. Our data suggest that nonclinical factors may influence rates of use, indicating the need for closer scrutiny of variations in physician prescribing practices.
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14 MeSH Terms
Variation in cuff blood pressure in untreated urban outpatients with mild hypertension in Harare, Zimbabwe--implications for the diagnosis of hypertension.
Stein M, Neill P, Arrow J
(1991) J Hum Hypertens 5: 11-3
MeSH Terms: Adult, Analysis of Variance, Blood Pressure, Diastole, Humans, Hypertension, Male, Middle Aged, Office Visits, Outpatients, Systole, Urban Health, Zimbabwe
Show Abstract · Added December 10, 2013
Duplicate measurements of BP were recorded at six visits in 32 male urban factory workers found to have raised BP (systolic blood pressure (SBP) greater than or equal to 160 mmHg or diastolic blood pressure (DBP) greater than or equal to 90 mmHg) at the initial visit). A systematic decrease in both SBP and DBP occurred over the first three visits. The BP at visits 4-6 was not significantly different. Most of the decrease in BP occurred between the first and second visit (mean SBP decreased 8.5 mmHg and mean DBP decreased 11.1 mmHg). After 6 visits 66% of subjects could be classified into clear clinical groups (normotensive 53.5%, hypertensive 12.5%) but in 34% the variation in cuff BP precluded classification. In these subjects prolonged observation or home BP monitoring may be required before initiating lifelong treatment.
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13 MeSH Terms