Cardiovascular disease risk stratification and comparison in a California population.

This study was designed to identify the need for primary prevention of cardiovascular disease in an HMO population and to develop appropriate interventions for individuals in different risk groups, based on risk stratification and comparison. The analysis is based on a cross-sectional survey of the HMO members of a large employer group. Respondents (n=17,878) were stratified based on the Framingham model; 34% of respondents without cardiovascular disease were classified as moderate to high attributable risk for the disease, and 66% were classified as low attributable risk. Results of logistic regression analyses suggest that, compared with respondents with pre-existing cardiovascular disease, moderate- to high-risk respondents are more likely to smoke, have unhealthy diets, and be overweight, hypertensive, and hypercholesterolemic. More low-risk respondents had unhealthy diets than did those with pre-existing cardiovascular disease. There were no differences between these groups for physical activity and stress. Respondents had fewer modifiable risk factors and healthier lifestyles than did those who were at risk. These findings suggest that primary prevention should be enhanced, especially among those with significantly increased risk for the disease. Moreover, the approaches of this project-population-based risk assessment, stratification, and comparison-were instrumental in identifying the target population and designing appropriate interventions. (c) 2001 by CHF, Inc.

Variation in managing asthma: experience at the medical group level in California.

OBJECTIVE: To explore the degree of variation in the quality of asthma management among physician groups participating in a managed care network. STUDY DESIGN: Cross-sectional observation. PATIENTS AND METHODS: The study population consisted of patients with moderate or severe asthma identified through a pharmacy database from a managed care plan in 1996. The patients were surveyed to obtain their assessments of asthma care, including components on quality of care, quality of service, and outcomes of care. We selected 47 physician groups that provided services for at least 35 asthma patients who responded to the survey. Variations in the outcome variables across physician groups were described by quartile, range, and histogram. RESULTS: Compliance with national guidelines varied among physician groups but was generally low. Physician group rates for patient use of steroid inhalers ranged from 10.7% to 45.5% and daily peak flow meter use ranged from 0% to 13.1%. Satisfaction ratings were higher, with overall satisfaction with the quality of asthma care ranging from 74.6% to 94.3%. Outcomes also showed considerable variation among groups. One-month absenteeism rates ranged from 32% to 61%, and 65.7% to 94.3% of respondents did not have an emergency room visit in the past year. CONCLUSION: The quality of asthma care and service varied significantly across physician groups. Such reports for different physician groups make evidence-based outcomes information directly available to patients and physician groups, help patients make informed healthcare decisions, and stimulate quality improvement efforts by physician groups.

Preventive pharmacologic therapy among asthmatics: five years after publication of guidelines.

BACKGROUND: Guidelines from the National Heart, Lung, and Blood Institute first published in 1991 have recommended anti-inflammatory (AI) agents as a first-line therapy and the bronchodilator as an acute reliever of symptoms. OBJECTIVE: To examine the current usage of anti-inflammatory steroids (inhaled corticosteroids, Cromolyn, systemic steroids) and bronchodilators and compare them with the national guidelines. The relationship between preventive AI usage and the characteristics of the asthma patients and their providers was also examined. METHODS: Cross-sectional survey data linked with 6-month pharmacy claims of asthmatic members at an HMO in California. RESULTS: AI usage increased with current severity (mild, 36.9%; moderate, 47.3%; and severe, 56.8%), though a large percentage are not receiving this emphasized treatment. Bronchodilators were used at a higher rate and 24% of asthmatics relied solely on bronchodilators. Use of bronchodilators without AI (BWAI) was present at all severity levels (mild, 19.5%; moderate, 24.6%; and severe, 24.7%). Advancing age, increasing severity, care by an asthma specialist, and not smoking increased the likelihood of using AIs. Increasing severity, longer duration of asthma, smoking, younger age group, care by a generalist, and no chronic bronchitis increased the likelihood of BWAI. CONCLUSIONS: These results suggest that there is a low level of AI usage despite emphasis in guidelines. Current asthma management in a community-based setting depicts a significant underutilization of long-term control agents and, conversely, an overutilization of symptom relief agents compared with guidelines published 5 years ago. Actively involving patients in the guideline dissemination process, rather than just the medical community, may increase preventive medication usage.

Validity of clinical information from a maternity survey.

This research was designed to validate data collected through a survey--an inexpensive way to provide information for quality measurement. The survey was sent to health maintenance organization (HMO) enrollees who had given birth(s) between October 1, 1994, and May 31, 1995. The responses were compared with the medical records. A sample of 407 women was randomly selected from the completed surveys. Medical records were reviewed for 89.9% (362/407) of the sample based on medical record availability. Over 98% of responses agreed with the medical record information regarding whether there were cesarean sections for previous deliveries (kappa = 1.0), cesarean section for recent delivery (kappa = 0.95), and vaginal birth after cesarean section (kappa = 0.96). Over 99% of the mothers agreed with the information regarding whether the newborn birth weight was under 2500 g (kappa = 0.91). The findings strongly support the validation of this instrument. Using this validated instrument enables health plans to cost-effectively obtain crucial information.

Satisfaction with access to and quality of health care among Medicare enrollees in a health maintenance organization.

This study was designed to determine the levels and predictors of Medicare enrollees' satisfaction with access to medical care and quality of health care in a health maintenance organization. Data collected by an instrument adapted from the Group Health Association of America's Consumer Satisfaction Survey were analyzed after being linked with administrative data. In general, Medicare enrollees reported high satisfaction with both access to and quality of health care. Most members (96%) rated skill, experience, and training of physicians and the friendliness and courtesy of the staff favorably. A lower percentage of members (77%) rated favorably the ability to contact a physician after hours. Levels of satisfaction were essentially not explained by patient characteristics such as age, sex, geographic region, medications, or utilization. Stepwise regression identified the ease of arranging appointments as the strongest predictor of satisfaction, with access to care and outcomes of medical care as the strongest predictor of overall satisfaction with quality of health care. These findings indicate that items that members rated least favorably, such as ability to contact a physician after hours, added little to the prediction of satisfaction with access to and quality of health care.

Identifying predictors of satisfaction with access to medical care and quality of care.

Satisfaction with access to medical care and quality of care were compared using a survey instrument adapted from the Group Health Association of America Consumer Satisfaction Survey. Participants were members of a large health maintenance organization employed by an employer group (Company) and other non-company members (Control). Overall, members reported high satisfaction with both access to medical care and quality of care. There were no significant differences in satisfaction between Company and Control respondents. Stepwise regression identified the strongest predictor of satisfaction with access to care as ease of arranging appointments. Satisfaction with quality of care was predicted most strongly by outcomes of medical care. These findings indicate that items with which members are least satisfied (access to doctor after hours, office waiting time, and time for routine appointment) do not predict either satisfaction with access to care or satisfaction with quality of care. Managed care organizations must develop and utilize evidence-based evaluation tools such as this one to assess the quality of care.

Weight variability effects: a prospective analysis from the Stanford Five-City Project.

For determination of the effects of weight variability on cardiovascular risk factors, a random community sample of 269 men and 361 women aged 25-74 years, drawn from the Stanford Five-City Project, was followed for up to 10 years (1979-1989). Systolic and diastolic blood pressure, total and high density lipoprotein cholesterol, and pulse were measured. Body mass index slope (BMI-slope) was determined by regressing five BMI values on time for each individual. BMI variability was defined as the root mean square error (BMI-RMSE) of a regression line fitted to each individual's BMI values over time. The slopes of the five cardiovascular risk factors were most strongly related to the baseline value of each risk factor and BMI-slope in both men and women. Neither BMI-RMSE nor the interaction of BMI-RMSE with BMI-slope was related to risk factor slopes. In this population, BMI variability had little impact on cardiovascular risk factors compared with BMI-slope and baseline BMI.

Effects of life-style on body mass index change.

The objective of this study was to determine the effects of age and life-style factors on body mass index (BMI) in a longitudinal, community-based sample. A total of 568 men and 668 women (20-60 years of age) were randomly chosen from four Northern California communities and followed for up to 7 years. Age, sex, marital status, smoking status, hours of television watched, frequency of consumption of several food items, and physical activity were used to predict rate of change of body mass index (BMI-slope). BMI increased the most for both sexes through at least age 54. The BMI-slope was higher for women compared with men, and for smokers who stopped compared with those who never smoked or continued to smoke during the study. The BMI-slopes were lower for individuals who increased activity. Other life-style variables had weak or inconsistent effects on the BMI-slope. We conclude that the BMI-slope increases over age for both sexes and that increased physical activity may reduce the BMI-slope.

Associations between changes in physical activity and risk factors for coronary heart disease in a community-based sample of men and women: the Stanford Five-City Project.

Aerobic exercise training studies involving volunteers generally result in an improved cardiovascular risk factor profile. Little is known, however, about associations between physical activity change and risk factor change in a more representative sample, such as a community. This investigation evaluated correlations between a composite physical activity change score and change in cardiovascular risk factors from 1979 to 1985 in the cohort sample of the Stanford Five-City Project. Men (n = 380) and women (n = 427) between the ages of 18 and 74 years were evaluated for change in self-reported physical activity and change in total cholesterol, high density lipoprotein cholesterol (HDL cholesterol), systolic blood pressure, resting pulse rate, and body mass index (weight (kg)/height (m)2). For men, improvement in the composite physical activity score significantly correlated with an increase in HDL cholesterol (r = 0.14, p = 0.005) and decreases in body mass index (r = -0.16, p = 0.001) and estimated 10-year coronary heart disease risk score (r = -0.10, p = 0.056). For women, improvement in the physical activity score was associated with changes in HDL cholesterol (r = 0.11, p = 0.028) and resting pulse rate (r = -0.15, p = 0.001). These data demonstrate that an increase in physical activity over 5 years is favorably associated with changes in major cardiovascular disease risk factors in men and women and support the public health efficacy of community-wide promotion of physical activity.

Changes in adult cigarette smoking prevalence after 5 years of community health education: the Stanford Five-City Project.

To determine the effects of 5 years of community-wide cardiovascular health education on smoking prevalence and cessation, the authors analyzed data from the Stanford Five-City Project, an experimental field study with two treatment cities and two control cities. Representative samples of the population aged 12-74 years were drawn at baseline and every 2 years thereafter to obtain four independent cross-sectional surveys; participants aged 25-74 years are included in this paper (n approximately 440 per city per survey; total n = 6,981). The baseline sample was asked to return to three follow-up surveys, also 2 years apart, and those that did (n = 805) constitute the cohort survey sample. Self-reported cigarette smoking was confirmed by plasma thiocyanate and expired-air carbon monoxide levels. Smoking prevalence decreased over time in all cities, but in the cohort the decrease tended to be greater in treatment than in control cities (p = 0.10, two-tailed); the treatment-control difference was consistent over time (-1.51 percentage points/year in treatment vs. -0.78 percentage points/year in control, p = 0.007, two-tailed). In contrast, smoking prevalence in the independent samples declined similarly in treatment and control cities, changes were not linear, and rates varied within cities between times. Baseline smokers in both the cohort and the follow-up independent surveys were significantly more likely to quit in the treatment cities than in the control cities.

Socioeconomic status and health: how education, income, and occupation contribute to risk factors for cardiovascular disease.

BACKGROUND: Socioeconomic status (SES) is usually measured by determining education, income, occupation, or a composite of these dimensions. Although education is the most commonly used measure of SES in epidemiological studies, no investigators in the United States have conducted an empirical analysis quantifying the relative impact of each separate dimension of SES on risk factors for disease. METHODS: Using data on 2380 participants from the Stanford Five-City Project (85% White, non-Hispanic), we examined the independent contribution of education, income, and occupation to a set of cardiovascular disease risk factors (cigarette smoking, systolic and diastolic blood pressure, and total and high-density lipoprotein cholesterol). RESULTS: The relationship between these SES measures and risk factors was strongest and most consistent for education, showing higher risk associated with lower levels of education. Using a forward selection model that allowed for inclusion of all three SES measures after adjustment for age and time of survey, education was the only measure that was significantly associated with the risk factors (P less than .05). CONCLUSION: If economics or time dictate that a single parameter of SES be chosen and if the research hypothesis does not dictate otherwise, higher education may be the best SES predictor of good health.

The Behavioral Risk Factor Survey and the Stanford Five-City Project Survey: a comparison of cardiovascular risk behavior estimates.

BACKGROUND: Nearly all state health departments collect Behavioral Risk Factor Survey (BRFS) data, and many report using these data in public health planning. Although the BRFS is widely used, little is known about its measurement properties. This study compares the cardiovascular risk behavior estimates of the BRFS with estimates derived from the physiological and interview data of the Stanford Five-City Project Survey (FCPS). METHOD: The BRFS is a random telephone sample of 1588 adults aged 25 to 64; the FCPS is a random household sample of 1512 adults aged 25 to 64. Both samples were drawn from the same four California communities. RESULTS: The surveys produced comparable estimates for measures of current smoking, number of cigarettes smoked per day, rate of ever being told one has high blood pressure, rate of prescription of blood pressure medications, compliance in taking medications, and mean total cholesterol. Significant differences were found for mean body mass index, rates of obesity, and, in particular, rate of controlled hypertension. CONCLUSIONS: These differences indicate that, for some risk variables, the BRFS has limited utility in assessing public health needs and setting public health objectives. A formal validation study is needed to test all the risk behavior estimates measured by this widely used instrument.

Survival of patients with the acquired immune deficiency syndrome after development of cytomegalovirus retinopathy. UCLA CMV Retinopathy Study Group.

To study the survival of patients with acquired immune deficiency syndrome (AIDS) who develop cytomegalovirus (CMV) retinopathy, the medical records of 100 consecutive patients with AIDS and CMV retinopathy were reviewed Data of AIDS diagnosis, CMV retinopathy diagnosis, and death were determined for each patient. The median interval from CMV retinopathy diagnosis to death for patients whose infection was diagnosed between May 1984 and September 1987 was 5 months. The interval had increased significantly since 1981. The interval from AIDS diagnosis to CMV retinopathy diagnosis (median, 9 months) did not increase. Based on extent and location of retinal lesions at the time patients were first examined, increased survival could not be attributed to earlier diagnosis of CMV retinopathy. Patients treated with ganciclovir lived longer after diagnosis of CMV retinopathy (median, 7 months) than untreated patients (median, 2 months; P less than 0.001). Although this finding suggests that ganciclovir may prolong survival, the effect of treatment cannot be established conclusively because patients were not randomly assigned to treatment or no treatment groups. The location of retinal lesions had no apparent prognostic significance for survival. Survival after diagnosis of AIDS was significantly shorter if CMV retinopathy was the initial manifestation of the syndrome.