Evaluation of a nurse practitioner disease management model for chronic heart failure: a multi-site implementation study.

While disease management appears to be effective in selected, small groups of CHF patients from randomized controlled trials, its effectiveness in a broader CHF patient population is not known. This prospective, quasi-experimental study compared patient outcomes under a nurse practitioner-led disease management model (intervention group) with outcomes under usual care (control group) in both primary and tertiary medical centers. The study included 969 veterans (458 intervention, 511 control) treated for CHF at six VA medical centers. Intervention patients had significantly fewer (p<0.05) CHF and all-cause admissions at one-year follow-up, and lower mortality at both one- and two-year follow-up. These data provide support for the potential effectiveness of the intervention, and suggest that the evidence from RCTs of disease management models for CHF can be translated into clinical practice, even without the benefits of a selected patient population and dedicated resources often found in RCTs.

Measuring depressive symptoms in heart failure: validity and reliability of the patient health questionnaire-8.

BACKGROUND: Depressive symptoms are common in patients with heart failure, but few investigators have reported the validity and reliability of measures of depressive symptoms among these patients. OBJECTIVES: To evaluate the validity and reliability of a measure of depressive symptoms, the Patient Health Questionnaire-8 (PHQ-8), among 249 patients with chronic heart failure. METHODS: As part of a larger study, patients completed the PHQ-8 and the Living With Heart Failure Questionnaire. New York Heart Association class was assessed as a measure of the severity of heart failure. Construct validity of the PHQ-8 was evaluated by confirmatory factor analysis, Pearson correlation coefficients, and analysis of variance. Internal consistency reliability was estimated by using the Cronbach α. RESULTS: The sample was 63% men, with a mean age of 63 years, and 67% reported their race as white. Construct validity of the PHQ-8 was supported. The confirmatory factor analysis model reflected the emotional and somatic dimensions of depressive symptoms and displayed a good fit with the data. The χ(2) value of the PHQ-8 was 24.75 with 18 degrees of freedom (P =.13) and the goodness-of-fit index was 0.98. The PHQ-8 was significantly correlated with the total and subscale scores on the Living With Heart Failure Questionnaire (P <.001 for all correlations). Differences in the PHQ-8 scores were found among New York Heart Association classes (F=20.4, P<.001). The PHQ-8 internal consistency reliability (Cronbach α) was 0.82. CONCLUSIONS: The PHQ-8 demonstrated satisfactory validity and reliability; these results support its use to measure depressive symptoms in patients with heart failure.

Correlates of depression among people with diabetes: The Translating Research Into Action for Diabetes (TRIAD) study.

AIM: The broad objective of this study was to examine multiple dimensions of depression in a large, diverse population of adults with diabetes. Specific aims were to measure the association of depression with: (1) patient characteristics; (2) outcomes; and (3) diabetes-related quality of care. METHODS: Cross-sectional analyses were performed using survey and chart data from the Translating Research Into Action for Diabetes (TRIAD) study, including 8790 adults with diabetes, enrolled in 10 managed care health plans in 7 states. Depression was measured using the Patient Health Questionnaire (PHQ-8). Patient characteristics, outcomes and quality of care were measured using validated survey items and chart data. RESULTS: Nearly 18% of patients had major depression, with prevalence 2-3 times higher among patients with low socioeconomic status. Pain and limited mobility were strongly associated with depression, controlling for other patient characteristics. Depression was associated with slightly worse glycemic control, but not other intermediate clinical outcomes. Depressed patients received slightly fewer recommended diabetes-related processes of care. CONCLUSIONS: In a large, diverse cohort of patients with diabetes, depression was most prevalent among patients with low socioeconomic status and those with pain, and was associated with slightly worse glycemic control and quality of care.

Thiazolidinediones and fractures: evidence from translating research into action for diabetes.

BACKGROUND: Thiazolidinedione (TZD) treatment has been associated with fractures. The purpose of this study was to examine the association between TZD treatment and fractures in type 2 diabetic patients. METHODS: Using data from Translating Research into Action for Diabetes, a multicenter prospective observational study of diabetes care in managed care, we conducted a matched case-control study to assess the odds of TZD exposure in patients with type 2 diabetes with and without fractures. We identified 786 cases based on fractures detected in health plan administrative data. Up to four controls without any fracture diagnoses were matched to each case. Controls were matched on health plan, date of birth within 5 yr, sex, race/ethnicity, and body mass index within 5 kg/m(2). We performed conditional logistic regression for premenopausal and postmenopausal women and men to assess the odds of exposure to potential risk factors for fracture, including medications, self-reported limited mobility, and lower-extremity amputations. RESULTS: We found statistically significant increased odds of exposure to TZDs, glucocorticoids, loop diuretics, and self-reported limited mobility for women 50 yr of age and older with fractures. Exposure to both loop diuretics and TZDs, glucocorticoids, and insulin and limited mobility and lower-extremity amputation were associated with fractures in men. CONCLUSION: Postmenopausal women taking TZDs and the subset of men taking both loop diuretics and TZDs were at increased risk for fractures. In postmenopausal women, risk was associated with higher TZD dose. No difference between rosiglitazone and pioglitazone was apparent.

Adherence to cardiovascular disease medications: does patient-provider race/ethnicity and language concordance matter?

BACKGROUND: Patient-physician race/ethnicity and language concordance may improve medication adherence and reduce disparities in cardiovascular disease (CVD) by fostering trust and improved patient-physician communication. OBJECTIVE: To examine the association of patient race/ethnicity and language and patient-physician race/ethnicity and language concordance on medication adherence rates for a large cohort of diabetes patients in an integrated delivery system. DESIGN: We studied 131,277 adult diabetes patients in Kaiser Permanente Northern California in 2005. Probit models assessed the effect of patient and physician race/ethnicity and language on adherence to CVD medications, after controlling for patient and physician characteristics. RESULTS: Ten percent of African American, 11 % of Hispanic, 63% of Asian, and 47% of white patients had same race/ethnicity physicians. 24% of Spanish-speaking patients were linguistically concordant with their physicians. African American (46%), Hispanic (49%) and Asian (52%) patients were significantly less likely than white patients (58%) to be in good adherence to all of their CVD medications (p<0.001). Spanish-speaking patients were less likely than English speaking patients to be in good adherence (51% versus 57%, p<0.001). Race concordance for African American patients was associated with adherence to all their CVD medications (53% vs. 50%, p<0.05). Language concordance was associated with medication adherence for Spanish-speaking patients (51% vs. 45%, p<0.05). CONCLUSION: Increasing opportunities for patient-physician race/ethnicity and language concordance may improve medication adherence for African American and Spanish-speaking patients, though a similar effect was not observed for Asian patients or English-proficient Hispanic patients.

Cognitive deficits and health-related quality of life in chronic heart failure.

BACKGROUND: Patients with chronic heart failure (HF) have cognitive deficits in memory, psychomotor speed, and executive function and poor health-related quality of life (HRQL), but the association between cognitive deficits and HRQL is unknown. OBJECTIVES: The objectives of this study were to (1) evaluate the relationship between HF severity, age, comorbidities, and cognitive deficits and HRQL among patients with chronic HF and (2) examine whether cognitive deficits mediated the relationship between HF severity and HRQL. DESIGN AND SAMPLE: This study was part of a larger explanatory study; 249 patients with HF completed face-to-face interviews. METHODS: Measures of HF severity, comorbidity (multiple comorbid conditions, hypertension, and depressive symptoms), cognitive function (domains of language, working memory, memory, psychomotor speed, and executive function), and HRQL were obtained. Clinical variables were abstracted from patients' records. Statistical analyses were conducted using descriptive statistics, Pearson correlation coefficients, and multiple linear regression analyses. RESULTS: Overall, the HRQL of patients was moderately poor. Heart failure severity, age, depressive symptoms, and total recall memory explained 55% of the variance in HRQL, but the contribution of memory was minimal (1%). Patients with more severe HF, younger age, and more depressive symptoms had poorer HRQL. Other cognitive function variables, multiple comorbidity, and hypertension were not significant explanatory variables for HRQL. Cognitive deficits did not mediate the relationship between HF severity and HRQL. CONCLUSIONS: Novel interventions targeted at improving HRQL continue to be urgently needed, particularly among younger patients and patients with depressive symptoms. Measures of HRQL are not sufficient as outcomes when investigating cognitive deficits in HF. Investigators need to include outcome measures of patients' actual abilities to perform daily activities and HF self-care.

Physicians' perceptions of barriers to cardiovascular disease risk factor control among patients with diabetes: results from the translating research into action for diabetes (TRIAD) study.

INTRODUCTION: Many patients with diabetes have poorly controlled blood glucose, lipid, or blood pressure levels, increasing their risk for cardiovascular disease (CVD) and other complications. Relatively little is known about what physicians perceive to be barriers to good CVD risk factor control or their own role in helping patients achieve good control. METHODS: We interviewed 34 primary care physicians in 4 states to assess their perceptions of patients' barriers to CVD risk factor control. Interviews were coded and analyzed for emergent themes. RESULTS: Physicians attributed barriers primarily to patients (socioeconomic issues, competing medical conditions, and lack of motivation) or to health system barriers (cost of care or lack of a multidisciplinary team). Physicians also expressed high levels of frustration with their efforts to address barriers. CONCLUSIONS: Physicians felt that barriers to CVD risk factor control often were beyond their abilities to address. Training physicians or other members of the primary health care team to address patients' personal barriers and health system barriers to good control could help alleviate high frustration levels, improve relationships with patients, and improve the treatment of diabetes. Supporting such efforts with adequate reimbursement should be a focus of health care reform.

The predictors of patient-physician race and ethnic concordance: a medical facility fixed-effects approach.

OBJECTIVE: To examine the predictors of patient-physician race/ethnicity concordance among diabetes patients in an integrated delivery system. DATA SOURCE: Kaiser Permanente's Northern California Diabetes Registry of 2005. STUDY DESIGN: Logistic regression predicted concordance for each racial/ethnic group. Availability of a concordant physician, whether a patient chose their physician, and patient language were main explanatory variables. DATA COLLECTION/EXTRACTION METHODS: The study population consisted of 109,745 patients and 1,750 physicians. PRINCIPAL FINDINGS: Patients who chose their physicians were more likely to have a same race/ethnicity physician with OR of 2.2 (95 percent CI 1.74-2.82) for African American patients, 1.71 (95 percent CI 1.44-2.04) for Hispanic patients, 1.11 (95 percent CI 1.04-1.18) for white patients, and 1.38 (95 percent CI 1.23, 1.55) for Asian patients. Availability of a same race/ethnicity physician was also a predictor of concordance for African American patients (OR 2.7; 95 percent CI 2.45-2.98) and marginally significant for Hispanic patients (OR 1.02; 95 percent CI 1.01-1.02), white patients (OR 1.02; 95 percent CI 1.00-1.04), and Asian patients (OR 1.05; 95 percent CI 1.03, 1.07). Limited English language was a strong predictor of concordance for Hispanic patients (OR 4.81; 95 percent CI 4.2-5.51) and Asian patients (OR 9.8; 95 percent CI 7.7, 12.6). CONCLUSION: Patient language, preferences, and the racial composition of the physician workforce predict race/ethnicity concordance.

Cognitive deficits in chronic heart failure.

BACKGROUND: Patients with heart failure (HF) have been found to have cognitive deficits, but it remains unclear whether these deficits are associated with HF or with aging or comorbid conditions common in HF. OBJECTIVES: : The purpose of this study was (a) to determine the types, the frequency, and the severity of cognitive deficits among patients with chronic HF compared with age- and education-matched healthy participants and participants with major medical conditions other than HF, and (b) to evaluate the relationships between HF severity, age, and comorbidities and cognitive deficits. METHODS: A sample of 414 participants completed the study (249 HF patients, 63 healthy and 102 medical participants). The HF patients completed measures of HF severity, comorbidity (multiple comorbidity, depressive symptoms), and neuropsychological functioning. Blood pressure and oxygen saturation were assessed at interview; clinical variables were abstracted from records. Participants in the comparison groups completed the same measures as the HF patients except those specific to HF. RESULTS: Compared with the healthy and medical participants, HF patients had poorer memory, psychomotor speed, and executive function. Significantly more HF patients (24%) had deficits in three or more domains. Higher (worse) HF severity was associated with more cognitive deficits; HF severity interacted with age to explain deficits in executive function. Surprisingly, men with HF had poorer memory, psychomotor speed, and visuospatial recall ability than women. Multiple comorbidity, hypertension, depressive symptoms, and medications were not associated with cognitive deficits in this sample. DISCUSSION: HF results in losses in memory, psychomotor speed, and executive function in almost one fourth of patients. Patients with more severe HF are at risk for cognitive deficits. Older patients with more severe HF may have more problems in executive function, and men with HF may be at increased risk for cognitive deficits. Studies are urgently needed to identify the mechanisms for the cognitive deficits in HF and to test innovative interventions to prevent cognitive loss and decline.

Barriers to insulin initiation: the translating research into action for diabetes insulin starts project.

OBJECTIVE: Reasons for failing to initiate prescribed insulin (primary nonadherence) are poorly understood. We investigated barriers to insulin initiation following a new prescription. RESEARCH DESIGN AND METHODS: We surveyed insulin-naïve patients with poorly controlled type 2 diabetes, already treated with two or more oral agents who were recently prescribed insulin. We compared responses for respondents prescribed, but never initiating, insulin (n = 69) with those dispensed insulin (n = 100). RESULTS: Subjects failing to initiate prescribed insulin commonly reported misconceptions regarding insulin risk (35% believed that insulin causes blindness, renal failure, amputations, heart attacks, strokes, or early death), plans to instead work harder on behavioral goals, sense of personal failure, low self-efficacy, injection phobia, hypoglycemia concerns, negative impact on social life and job, inadequate health literacy, health care provider inadequately explaining risks/benefits, and limited insulin self-management training. CONCLUSIONS: Primary adherence for insulin may be improved through better provider communication regarding risks, shared decision making, and insulin self-management training.

Fidelity of implementation: development and testing of a measure.

BACKGROUND: Along with the increasing prevalence of chronic illness has been an increase in interventions, such as nurse case management programs, to improve outcomes for patients with chronic illness. Evidence supports the effectiveness of such interventions in reducing patient morbidity, mortality, and resource utilization, but other studies have produced equivocal results. Often, little is known about how implementation of an intervention actually occurs in clinical practice. While studies often assume that interventions are used in clinical practice exactly as originally designed, this may not be the case. Thus, fidelity of an intervention's implementation reflects how an intervention is, or is not, used in clinical practice and is an important factor in understanding intervention effectiveness and in replicating the intervention in dissemination efforts. The purpose of this paper is to contribute to the understanding of implementation science by (a) proposing a methodology for measuring fidelity of implementation (FOI) and (b) testing the measure by examining the association between FOI and intervention effectiveness. METHODS: We define and measure FOI based on organizational members' level of commitment to using the distinct components that make up an intervention as they were designed. Semistructured interviews were conducted among 18 organizational members in four medical centers, and the interviews were analyzed qualitatively to assess three dimensions of commitment to use--satisfaction, consistency, and quality--and to develop an overall rating of FOI. Mixed methods were used to explore the association between FOI and intervention effectiveness (inpatient resource utilization and mortality). RESULTS: Predictive validity of the FOI measure was supported based on the statistical significance of FOI as a predictor of intervention effectiveness. The strongest relationship between FOI and intervention effectiveness was found when an alternative measure of FOI was utilized based on individual intervention components that had the greatest variation across medical centers. CONCLUSIONS: In addition to contextual factors, implementation research needs to consider FOI as an important factor in influencing intervention effectiveness. Our proposed methodology offers a systematic means for understanding organizational members' use of distinct intervention components, assessing the reasons for variation in use across components and organizations, and evaluating the impact of FOI on intervention effectiveness.

Patient race/ethnicity and patient-physician race/ethnicity concordance in the management of cardiovascular disease risk factors for patients with diabetes.

OBJECTIVE Patient-physician race/ethnicity concordance can improve care for minority patients. However, its effect on cardiovascular disease (CVD) care and prevention is unknown. We examined associations of patient race/ethnicity and patient-physician race/ethnicity concordance on CVD risk factor levels and appropriate modification of treatment in response to high risk factor values (treatment intensification) in a large cohort of diabetic patients. RESEARCH DESIGN AND METHODS The study population included 108,555 adult diabetic patients in Kaiser Permanente Northern California in 2005. Probit models assessed the effect of patient race/ethnicity on risk factor control and treatment intensification after adjusting for patient and physician-level characteristics. RESULTS African American patients were less likely than whites to have A1C <8.0% (64 vs. 69%, P < 0.0001), LDL cholesterol <100 mg/dl (40 vs. 47%, P < 0.0001), and systolic blood pressure (SBP) <140 mmHg (70 vs. 78%, P < 0.0001). Hispanic patients were less likely than whites to have A1C <8% (62 vs. 69%, P < 0.0001). African American patients were less likely than whites to have A1C treatment intensification (73 vs. 77%, P < 0.0001; odds ratio [OR] 0.8 [95% CI 0.7-0.9]) but more likely to receive treatment intensification for SBP (78 vs. 71%, P < 0.0001; 1.5 [1.3-1.7]). Hispanic patients were more likely to have LDL cholesterol treatment intensification (47 vs. 45%, P < 0.05; 1.1 [1.0-1.2]). Patient-physician race/ethnicity concordance was not significantly associated with risk factor control or treatment intensification. CONCLUSIONS Patient race/ethnicity is associated with risk factor control and treatment intensification, but patient-physician race/ethnicity concordance was not. Further research should investigate other potential drivers of disparities in CVD care.

Current blood pressure self-management: a qualitative study.

Blood pressure (BP) self-management is advocated to manage hypertension and reduce the risk of a future stroke. The purpose of this study was to identify BP self-management strategies used by individuals who had sustained a stroke or transient ischemic attack (TIA). As part of a mixed-methods study, we conducted six focus groups and achieved saturation with 16 stroke survivors and 12 TIA survivors. Each participant completed a questionnaire regarding current BP management. We analyzed and coded qualitative transcripts from the focus groups and found four emergent themes that were supported by questionnaire results. The four self-management themes include: (1) external support for BP self-management is helpful; (2) BP self-management strategies include medication adherence, routine development, and BP monitoring; (3) BP risk factor management involves diet, exercise, and stress reduction; and (4) taking advantage of the"teachable moment" may be advantageous for behavior change to self-manage BP. This research provides key elements for the development of a successful BP self-management program.

Do cardioselective beta-adrenoceptor antagonists reduce mortality in diabetic patients with congestive heart failure?

BACKGROUND: The relative benefits of cardioselective beta-adrenoceptor antagonists (CSB) among patients with congestive heart failure (CHF) and diabetes mellitus are not firmly established. OBJECTIVE: To determine whether diabetic patients with CHF accrue the same mortality benefit from CSB therapy as non-diabetic patients. METHOD: Between October 1999 and November 2000 consecutive patients with CHF at the Veteran's Affairs Medical Center in Indianapolis, IN, USA, were enrolled in a randomized controlled trial and prospectively followed for 5 years. Disease severity and CHF-specific functional status were obtained from patients at baseline. Medical records were accessed for data regarding co-morbidities, medications, and mortality. Propensity-score analysis was used to balance co-variates because of the observational nature of CSB use, given this was a post hoc analysis. A multivariate Cox proportional hazards model was used to compare survival between diabetic and non-diabetic patients stratified by whether they were or were not receiving CSB therapy. RESULTS: Of the 412 evaluable patients, 222 (54%) had diabetes and 212 (51%) were taking a CSB. At 5-year follow-up, 186 (45%) patients had died. In the multivariate analysis, using propensity scores to balance co-variates, CSB therapy was an independent predictor of survival in patients without diabetes (hazard ratio 0.60; p = 0.054) only. CONCLUSIONS: These results extend prior observations that patients with diabetes and CHF may not accrue the same mortality benefit from CSB therapy as patients without diabetes, and warrant further prospective investigation.

The association of patient age with cardiovascular disease risk factor treatment and control in diabetes.

BACKGROUND: While inadequate treatment intensification may contribute to sub-optimal CVD risk factor control in older patients with diabetes, the relationship between patient age and treatment intensification is largely unexplored. OBJECTIVE: To examine differences in treatment intensification and control for blood pressure (BP), lipids and A1c in older vs. younger adults with diabetes. METHODS: A total of 161,697 Kaiser Permanente Northern California adult diabetes patients were stratified by age (<50, 50-64, 65-74 and 75-85) and assessed for control of A1c (<8%), LDL-c (<100 mg/dl) and SBP (<140 mmHg). Probit models assessed the marginal effects of patient age on treatment intensification and control for all three CVD risk factors. RESULTS: Patients aged 50-64 and 65-74 were significantly more likely to receive treatment intensification for elevated SBP than patients under 50 (74% and 76% vs. 71%) and significantly less likely to receive treatment intensification for elevated A1c (73% and 72% vs. 76%), with no differences noted for LDL-c treatment. Older patients had significantly worse SBP control, but better control of A1c and LDL-c. CONCLUSIONS: Both treatment intensification rates and control of BP, A1c and LDL cholesterol control varied somewhat by age, suggesting room for further improvement in treatment intensification and control.

Treatment decisions for complex patients: differences between primary care physicians and midlevel providers.

OBJECTIVES: To examine whether treatment change for diabetic patients presenting with elevated blood pressure (BP) differed between physicians and midlevel providers (nurse practitioners [NPs] and physician assistants [PAs]) and to determine reasons for any observed differences. METHODS: Analyses were part of a prospective cohort study of 1169 diabetic patients with scheduled visits to 92 primary care providers (PCPs) in 9 Midwest Veterans Health Administration facilities presenting with a triage BP of > or =140/90 mm Hg. We analyzed predicted probabilities of treatment change by provider type. RESULTS: The PCPs included 64 physicians, 21 NPs, and 7 PAs. Patients treated by physicians and midlevel providers did not differ in their mean visit BP, number of chronic conditions, age, or number of BP medications. Controlling for current and past BP readings and patient characteristics, physicians were significantly more likely than midlevel providers to initiate a treatment change for elevated BP at a visit (53.8% vs 36.4%; P = .001). After controlling for additional visit-specific factors, practice style, measurement, and organizational factors, physicians were still more likely to initiate a treatment change (52.5% vs 37.5%; P = .02). CONCLUSIONS: Midlevel providers were significantly less likely than physicians to change BP treatment for diabetic patients with multiple chronic conditions presenting with elevated BP at a single visit. We could not find good explanations for this difference. Given the expanding role of midlevel providers in delivering primary care to complex patients, we need to understand whether these treatment change differences lead to long-term differences in BP control.

Predictors and impact of intensification of antihyperglycemic therapy in type 2 diabetes: translating research into action for diabetes (TRIAD).

OBJECTIVE: The purpose of this study was to examine the predictors of intensification of antihyperglycemic therapy in patients with type 2 diabetes; its impact on A1C, body weight, symptoms of anxiety/depression, and health status; and patient characteristics associated with improvement in A1C. RESEARCH DESIGN AND METHODS: We analyzed survey, medical record, and health plan administrative data collected in Translating Research into Action for Diabetes (TRIAD). We examined patients who were using diet/exercise or oral antihyperglycemic medications at baseline, had A1C >7.2%, and stayed with the same therapy or intensified therapy (initiated or increased the number of classes of oral antihyperglycemic medications or began insulin) over 18 months. RESULTS: Of 1,093 patients, 520 intensified therapy with oral medications or insulin. Patients intensifying therapy were aged 58 +/- 12 years, had diabetes duration of 11 +/- 9 years, and had A1C of 9.1 +/- 1.5%. Younger age and higher A1C were associated with therapy intensification. Compared with patients who did not intensify therapy, those who intensified therapy experienced a 0.49% reduction in A1C (P < 0.0001), a 3-pound increase in weight (P = 0.003), and no change in anxiety/depression (P = 0.5) or health status (P = 0.2). Among those who intensified therapy, improvement in A1C was associated with higher baseline A1C, older age, black race/ethnicity, lower income, and more physician visits. CONCLUSIONS: Treatment intensification improved glycemic control with no worsening of anxiety/depression or health status, especially in elderly, lower-income, and minority patients with type 2 diabetes. Interventions are needed to overcome clinical inertia when patients might benefit from treatment intensification and improved glycemic control.

Effect of advanced access scheduling on processes and intermediate outcomes of diabetes care and utilization.

BACKGROUND: The impact of open access (OA) scheduling on chronic disease care and outcomes has not been studied. OBJECTIVE: To assess the effect of OA implementation at 1 year on: (1) diabetes care processes (testing for A1c, LDL, and urine microalbumin), (2) intermediate outcomes of diabetes care (SBP, A1c, and LDL level), and (3) health-care utilization (ED visits, hospitalization, and outpatient visits). METHODS: We used a retrospective cohort study design to compare process and outcomes for 4,060 continuously enrolled adult patients with diabetes from six OA clinics and six control clinics. Using a generalized linear model framework, data were modeled with linear regression for continuous, logistic regression for dichotomous, and Poisson regression for utilization outcomes. RESULTS: Patients in the OA clinics were older, with a higher percentage being African American (51% vs 34%) and on insulin. In multivariate analyses, for A1c testing, the odds ratio for African-American patients in OA clinics was 0.47 (CI: 0.29-0.77), compared to non-African Americans [OR 0.27 (CI: 0.21-0.36)]. For urine microablumin, the odds ratio for non-African Americans in OA clinics was 0.37 (CI: 0.17-0.81). At 1 year, in adjusted analyses, patients in OA clinics had significantly higher SBP (mean 6.4 mmHg, 95% CI 5.4 - 7.5). There were no differences by clinic type in any of the three health-care utilization outcomes. CONCLUSION: OA scheduling was associated with worse processes of care and SBP at 1 year. OA clinic scheduling should be examined more critically in larger systems of care, multiple health-care settings, and/or in a randomized controlled trial.

The association of patient-physician gender concordance with cardiovascular disease risk factor control and treatment in diabetes.

BACKGROUND: Gender concordance between patients and their physicians is related to prevention screening and other quality indicators. Research suggests female physicians may place greater emphasis on preventive care than male physicians; however, little is known about whether physician gender and patient-physician gender concordance are associated with cardiovascular disease (CVD) risk factor levels and treatment. Our objective was to examine associations between patient gender, physician gender, and their interaction with CVD risk factor control, medication adherence, and treatment intensification in diabetes. METHODS: In this study, 157,458 Kaiser Permanente Northern California adult diabetes patients with a primary care physician (PCP) were assessed for above target levels of hemoglobin A1c (HbA1c) (>or=8%), low-density lipoprotein cholesterol (LDL-C) (>or=100 mg/dL), and systolic blood pressure (SBP>or=130 mm Hg) in 2005. Medication adherence and appropriate CVD treatment intensification were assessed using pharmacy data. Probit models assessed the adjusted marginal effects of patient gender, PCP gender, and their interaction on control, adherence, and intensification. RESULTS: Female patients had lower adjusted rates of LDL-C (46% vs. 55%, p<0.001) and SBP control (52% vs. 60%, p<0.001) than males. Female patients of female PCPs had the highest adjusted rates of HbA1c control of the four patient-physician gender dyads (70% vs. 66%-68%, p<0.05). Male patients were more likely than female patients to receive treatment intensification for high SBP (60% vs. 57%, p<0.001). Female PCPs were more likely than their male counterparts to intensify therapy for hyperlipidemia and hypertension. CONCLUSIONS: Patient and physician gender and gender concordance are modestly associated with CVD risk factor control and treatment in diabetes. Further understanding of these differences could lead to improved CVD outcomes for women.