Chawla, Neetu
Research interests include cancer care delivery, management, and communications.
ASGE guideline on the management of cholangitis
Cholangitis is a GI emergency requiring prompt recognition and treatment. The purpose of this document from the American Society for Gastrointestinal Endoscopy's (ASGE) Standards of Practice Committee is to provide an evidence-based approach for management of cholangitis. This document addresses…
ASGE guideline on the role of endoscopy in the management of malignant hilar obstruction
This clinical guideline from the American Society for Gastrointestinal Endoscopy (ASGE) provides an evidence-based approach for the management of patients with malignant hilar obstruction (MHO). This document was developed using the Grading of Recommendations Assessment, Development and Evaluation framework and…
Disclosure of New Type 2 Diabetes Diagnoses to Younger Adults: a Qualitative Study
Adults diagnosed with type 2 diabetes at a younger age are at increased risk for poor outcomes. Yet, little is known about the early experiences of these individuals, starting with communication of the diagnosis. Addressing this knowledge gap is important…
Effectiveness and safety of treatments for hospitalized patients with COVID-19
Examine the safety and effectiveness of current treatments for hospitalized patients with COVID-19 and identify patient characteristics and time periods during the disease course that are associated with more favorable treatment response.
Determinants and Cardiovascular Consequences of Disparities in Sleep and Circadian Rhythms between Black and White Adults
Determine the independent and joint contributions of behavioral, psychosocial and clinical characteristics over 35 years of CARDIA participation on sleep and circadian characteristics in middle-aged adults. Identify the relationship of sleep and circadian characteristics to the pathophysiologic stress response. Determine…
Closing the gap: Identification and management of familial hypercholesterolemia in an integrated healthcare delivery system
Familial hypercholesterolemia (FH) is an autosomal dominant genetic disorder that causes markedly elevated risk for early onset coronary artery disease. Despite availability of effective therapy, only 5-10% of affected individuals worldwide are diagnosed. To develop and evaluate a novel approach…
Health Risks and Chronic Health Conditions among Arab American and White Adults in Northern California
To characterize the prevalence of chronic cardiovascular conditions and risk factors among Arab American adults stratified by sex and compare these with non-Hispanic Whites. Cross-sectional study using electronic health record data from visits between January 2015 and December 2016. Age-adjusted…
Understanding Non-Adherence with Hydroxychloroquine Therapy in Systemic Lupus Erythematosus
Hydroxychloroquine (HCQ) is a cornerstone to managing systemic lupus erythematosus (SLE), yet adherence to medication is poor. We sought to measure the association of adherence with 5 "dimensions of adherence" as articulated by the World Health Organization for chronic conditions:…
Prompting Patients with Poorly Controlled Diabetes to Identify Visit Priorities Before Primary Care Visits: a Pragmatic Cluster Randomized Trial
Most patients with diabetes do not meet all evidence-based goals of care, and many patients report poor communication and lack of involvement in decision-making during primary care visits. To test the hypothesis that a "Pre-Visit Prioritization" secure email message could…
Health care improvement and survivorship priorities of colorectal cancer survivors: findings from the PORTAL colorectal cancer cohort survey
Few population-level surveys have explored patient-centered priorities for improving colorectal cancer survivors' care. Working with patients, we designed a survey to identify care improvement and survivorship priorities. We surveyed a random sample of 4000 patients from a retrospective, population-based cohort…
Exploring how patients understand and assess their diabetes control
Poor understanding of diabetes management targets is associated with worse disease outcomes. Patients may use different information than providers to assess their diabetes control. In this study, we identify the information patients use to gauge their current level of diabetes…
Mobile-accessible personal health records increase the frequency and timeliness of PHR use for patients with diabetes
Personal health records (PHRs) offer patients a portal to view lab results, communicate with their doctors, and refill medications. Expanding PHR access to mobile devices could increase patients' engagement with their PHRs. We examined whether access to a mobile-optimized PHR…
Cognitive Impairment in Non-Dialysis-Dependent CKD and the Transition to Dialysis: Findings From the Chronic Renal Insufficiency Cohort (CRIC) Study
Advanced chronic kidney disease is associated with elevated risk for cognitive impairment. However, it is not known whether and how cognitive impairment is associated with planning and preparation for end-stage renal disease. Retrospective observational study. 630 adults participating in the…
Long-Term Outcomes of Adults With Heart Failure by Left Ventricular Systolic Function Status
Patients with heart failure (HF) and preserved (HFpEF) or borderline preserved ejection fraction (HFbEF) outnumber patients with HF and reduced ejection fraction (HFrEF), but limited data exist on outcomes in community-based populations of these patients. We examined clinical outcomes in…
A conceptual model of social networks and mechanisms of cancer mortality, and potential strategies to improve survival
Women with larger personal social networks have better breast cancer survival and a lower risk of mortality. However, little work has examined the mechanisms through which social networks influence breast cancer outcomes and cancer outcomes more generally, potentially limiting the…
Influence of a New Diabetes Diagnosis on the Health Behaviors of the Patient’s Partner
When a person is given a diagnosis of diabetes, the changes in his or her health behaviors may influence the behaviors of his or her partner. The diabetes diagnosis may affect household members' perceptions of their own health risks, which…
Non-recovery from dialysis-requiring acute kidney injury and short-term mortality and cardiovascular risk: a cohort study
The high mortality and cardiovascular disease (CVD) burden in patients with end-stage renal disease (ESRD) is well-documented. Recent literature suggests that acute kidney injury is also associated with CVD. It is unknown whether patients with incident ESRD due to dialysis-requiring…
Adherence to Cardio-protective Medications Prescribed for Secondary Prevention after an Acute Coronary Syndrome Hospitalization Compared to Usual Care
Secondary prevention after an acute coronary syndrome (ACS) hospitalization is critical to prevent additional morbidity and mortality. While poor adherence to prescribed cardio-protective medications is a known problem;1;2 it is unknown whether an ACS event might motivate patients to achieve…
Being Present: A single-arm feasibility study of audio-based mindfulness meditation for colorectal cancer patients and caregivers
A metastatic cancer diagnosis is associated with high levels of distress in patients and caregivers. Mindfulness interventions can reduce distress and improve quality of life in cancer patients. However, standard mindfulness training relies on in-person instruction, which is often not…
Lessons learned in acute heart failure.
Acute heart failure (HF) is a global pandemic with more than one million admissions to hospital annually in the US and millions more worldwide. Post-discharge mortality and readmission rates remain unchanged and unacceptably high. Although recent drug development programmes have…
Multiple Chronic Conditions and Adverse Outcomes in Older Adults with Heart Failure
This ancillary pilot study to the Cardiovascular Research Network Heart Failure Consortium will evaluate the frequency and association of multiple chronic condition burden with clinical outcomes in adults who have diagnosed heart failure.
Adherence to Newly Prescribed Diabetes Medications Among Insured Latino and White Patients With Diabetes
Medication adherence is essential to diabetes care. Patient-physician language barriers may affect medication adherence among Latino individuals. To determine the association of patient race/ethnicity, preferred language, and physician language concordance with patient adherence to newly prescribed diabetes medications. This observational…
Preferences, Management and Outcomes in the Oldest Patients with Diabetes
The aim of this study is to develop, pilot and conduct a survey among older diabetes patients (75 years of age or older) or their caregiver surrogates to collect data on: 1) self-management barriers (e.g., poor functional status, financial barriers,…
Mentored Research to Improve Care for Complex Patients With Diabetes
K24 Midcareer Investigator Awards in Patient-Oriented Research are designed to support established scientists with a track record of mentoring to devote time to research mentorship for junior investigators. The overarching goal of this K24 award is to develop innovative approaches…
Multi-Component Behavioral Intervention for Complex Patients with CVD Risk
Disease management programs have had success in CVD risk factor control among uncomplicated patients but often fall short in more complex patients. New approaches are needed to address the multiple barriers faced by CVD patients with complex medical and behavioral…
Pre-Visit Prioritization for Complex Primary Care Patients with Diabetes – DUPLICATED DO NOT ACTIVATE
Patients with type 2 diabetes are increasingly living with multiple concurrent conditions and complicated medical regimens. For these patients, diabetes management decisions and treatment goals must be addressed within the larger context of other competing health concerns. In parallel, clinical…
Aligning the Visit Priorities of Complex Patients and their Primary Care Providers
The primary care visit is a key opportunity for catalyzing changes in care for complex patients with multiple heath issues. With too many items to address in the time allotted, however, the decision of which items to focus on requires…
Advancing Geriatrics Infrastructure and Network Growth
This pilot development grant proposes to: 1) evaluate the available information in existing data resources related to multiple morbidity and aging-related variables through collaborations among HCSRN network collaboratives (e.g., CVRN, CRN, SUPREME-DM); 2) pursue up to 3 pilot analyses using…
Impact of Integrated Patient-Facing Health IT Tools on Quality and Resource Use for Patients with Diabetes
This is a quasi-experimental study of the effect of Health IT use on the quality and efficiency of outpatient care for patients with multiple chronic diseases.
Trends in cancer survivors’ experience of patient-centered communication: results from the Health Information National Trends Survey (HINTS)
Two Institute of Medicine reports almost a decade apart suggest that cancer survivors often feel "lost in transition" and experience suboptimal quality of care. The six core functions of patient-centered communication: managing uncertainty, responding to emotions, making decisions, fostering healing…
Changes in Dyspnea Status During Hospitalization and Postdischarge Health-Related Quality of Life in Patients Hospitalized for Heart Failure: Findings From the EVEREST Trial.
BACKGROUND: Dyspnea is the most common symptom among hospitalized patients with heart failure and represents a therapeutic target. However, the association between short-term dyspnea relief and postdischarge clinical outcomes and health-related quality of life (HRQOL) remains uncertain.METHODS AND RESULTS: A…
Risk of Serious Infection for Patients with Systemic Lupus Erythematosus Starting Glucocorticoids with or without Antimalarials
To compare serious infection risk for systemic lupus erythematosus (SLE) patients starting glucocorticoids (GC), antimalarials (AM), or their combination. We conducted a new-user, historical cohort study, Kaiser Permanente Northern California, 1997-2013. Cox proportional hazards analysis was used to calculate adjusted…
Cancer-Related Information Seeking Among Cancer Survivors: Trends Over a Decade (2003-2013)
The demonstrated benefits of information seeking for cancer patients, coupled with increases in information availability, underscore the importance of monitoring patient information seeking experiences over time. We compared information seeking among cancer survivors to those with a family history of…
Pre-visit prioritization for complex patients with Diabetes: Randomized Trial Design and Implementation within an Integrated Health Care system
Despite robust evidence to guide clinical care, most patients with diabetes do not meet all goals of risk factor control. Improved patient-provider communication during time-limited primary care visits may represent one strategy for improving diabetes care. We designed a controlled,…
Financial Hardship Associated With Cancer in the United States: Findings From a Population-Based Sample of Adult Cancer Survivors
To estimate the prevalence of financial hardship associated with cancer in the United States and identify characteristics of cancer survivors associated with financial hardship. We identified 1,202 adult cancer survivors diagnosed or treated at ? 18 years of age from…
Population Variations in Rheumatoid Arthritis Treatment and Outcomes, Northern California, 1998-2009
To assess variations in rheumatoid arthritis treatment and outcomes at the community level from 1998 through 2009. The study used computerized data from 16 Kaiser Permanente Northern California Medical Centers. Mixed modeling was used to assess patterns across time and…
Adherence to Metformin, Statins, and ACE/ARBs Within the Diabetes Health Plan (DHP)
Reducing patient cost-sharing and engaging patients in disease management activities have been shown to increase uptake of evidence-based care. To evaluate the effect of employer purchase of a disease-specific plan with reduced cost-sharing and disease management (the Diabetes Health Plan/DHP)…
Cancer survivors’ receipt of treatment summaries and implications for patient-centered communication and quality of care
The Institute of Medicine recommends cancer survivors completing treatment be provided with a treatment summary to facilitate delivery of patient-centered survivorship care. However, the relationship between treatment summary receipt and patient-centered communication (PCC) and overall quality of care (QOC) are…
Cost-effectiveness analysis of neurocognitive-sparing treatments for brain metastases.
BACKGROUND: Decisions regarding how to treat patients who have 1 to 3 brain metastases require important tradeoffs between controlling recurrences, side effects, and costs. In this analysis, the authors compared novel treatments versus usual care to determine the incremental cost-effectiveness…
Reach and Validity of an Objective Medication Adherence Measure Among Safety Net Health Plan Members with Diabetes: A Cross-Sectional Study
With the expansion of Medicaid and low-cost health insurance plans among diverse patient populations, objective measures of medication adherence using pharmacy claims could advance clinical care and translational research for safety net care. However, safety net patients may experience fluctuating…
Pulmonary Oedema-Therapeutic Targets.
Pulmonary oedema (PO) is a common manifestation of acute heart failure (AHF) and is associated with a high-acuity presentation and with poor in-hospital outcomes. The clinical picture of PO is dominated by signs of pulmonary congestion, and its pathogenesis has…
Primary Adherence to Controller Medications for Asthma is Poor
Few previous studies have evaluated primary adherence (whether a new prescription is filled within 30 d) to controller medications in individuals with persistent asthma. To compare adherence to the major controller medication regimens for asthma. This was a retrospective cohort…
Wellness Coaching for People With Prediabetes: A Randomized Encouragement Trial to Evaluate Outreach Methods at Kaiser Permanente, Northern California, 2013
Health coaching can improve lifestyle behaviors known to prevent or manage chronic conditions. Little is known about effective ways to encourage health and wellness coaching among people who might benefit. The purpose of this randomized encouragement trial was to assess…
Randomized Trial of Telephone Outreach to Improve Medication Adherence and Metabolic Control in Adults With Diabetes
Medication nonadherence is a major obstacle to better control of glucose, blood pressure (BP), and LDL cholesterol in adults with diabetes. Inexpensive effective strategies to increase medication adherence are needed. In a pragmatic randomized trial, we randomly assigned 2,378 adults…
Social Support and Lifestyle vs. Medical Diabetes Self-Management in the Diabetes Study of Northern California (DISTANCE)
In chronic illness self-care, social support may influence some health behaviors more than others. Examine social support's association with seven individual chronic illness self-management behaviors: two healthy "lifestyle" behaviors (physical activity, diet) and five more highly skilled and diabetes-specific (medical)…
Initiation of TNF inhibitor therapy and change in physiologic measures in psoriasis
Psoriasis may predispose to cardiovascular disease and diabetes. However, the role of tumor necrosis factor (TNF) inhibitor in mediating this risk is controversial. To assess this relationship, we estimated change in metabolic physiologic measures before and after initiation of TNF…
Epidemiology, pathophysiology, and in-hospital management of pulmonary edema: data from the Romanian Acute Heart Failure Syndromes registry.
AIM: The objective of this study was to evaluate the clinical presentation, inpatient management, and in-hospital outcome of patients hospitalized for acute heart failure syndromes (AHFS) and classified as pulmonary edema (PE).METHODS: The Romanian Acute Heart Failure Syndromes (RO-AHFS) study…
Prescription medication burden in patients with newly diagnosed diabetes: A SUrveillance, PREvention, and ManagEment of Diabetes Mellitus (SUPREME-DM) study
To understand the burden of medication use for patients with newly diagnosed diabetes both before and after diabetes diagnosis and to identify subpopulations of patients with newly diagnosed diabetes who face a relatively high drug burden. Retrospective cohort study. 11…
National Trends in US Hospital Admissions for Hyperglycemia and Hypoglycemia Among Medicare Beneficiaries, 1999 to 2011
The increasing intensity of diabetes mellitus management over the past decade may have resulted in lower rates of hyperglycemic emergencies but higher rates of hospital admissions for hypoglycemia among older adults. Trends in these hospitalizations and subsequent outcomes are not…
Characteristics of Diabetic Patients associated with Achieving and Maintaining Blood Pressure Targets in the Adherence and Intensification of Medications Program
To determine patient characteristics associated with achieving and sustaining blood pressure (BP) targets in the Adherence and Intensification of Medications program, a program led by pharmacists trained in motivational interviewing and authorized to make BP medication changes. We conducted a…
Rates of Complications and Mortality in Older Patients With Diabetes Mellitus: The Diabetes and Aging Study
In the coming decades, the population of older adults with type 2 diabetes mellitus is expected to grow substantially. Understanding the clinical course of diabetes in this population is critical for establishing evidence-based clinical practice recommendations, identifying research priorities, allocating…
Effectiveness of a pharmacist-based gout care management programme in a large integrated health plan: results from a pilot study
The study objective was to determine the feasibility of using a pharmacist-staffed, protocol-based structured approach to improving the management of chronic, recurrent gout. The study was carried out in the outpatient clinic of a single Kaiser Permanente medical centre. This…
Obesity and Late-Age Survival Without Major Disease or Disability in Older Women
The effect of obesity on late-age survival in women without disease or disability is unknown. To investigate whether higher baseline body mass index and waist circumference affect women's survival to 85 years of age without major chronic disease (coronary disease,…
Glycemic Control and Urinary Incontinence in Women with Diabetes Mellitus
Although many studies have shown that diabetes increases the risk for urinary incontinence, it is unclear whether poor glycemic control in women with diabetes is associated with incontinence. This study aims to determine the relationship between the hemoglobin A1c (HbA1c)…
Establishing visit priorities for complex patients: A summary of the literature and conceptual model to guide innovative interventions
With the aging of the population and continuing advances in health care, patients seen in the primary care setting are increasingly complex. At the same time, the number of screening and chronic condition management tasks primary care providers are expected…
Branched chain and aromatic amino acids change acutely following two medical therapies for type 2 diabetes mellitus
Elevated circulating levels of branched chain and aromatic amino acids (BCAA/AAAs) are associated with insulin resistance and incident type 2 diabetes (T2D). BCAA/AAAs decrease acutely during an oral glucose tolerance test (OGTT), a diagnostic test for T2D. It is unknown…
Risk Adjustment for Health Care Financing in Chronic Disease: What Are We Missing By Failing to Account for Disease Severity?
BACKGROUND: Adjustment for differing risks among patients is usually incorporated into newer payment approaches, and current risk models rely on age, sex, and diagnosis codes. It is unknown the extent to which controlling additionally for disease severity improves cost prediction…
Super learning to hedge against incorrect inference from arbitrary parametric assumptions in marginal structural modeling
OBJECTIVE: Clinical trials are unlikely to ever be launched for many comparative effectiveness research (CER) questions. Inferences from hypothetical randomized trials may however be emulated with marginal structural modeling (MSM) using observational data, but success in adjusting for time-dependent confounding…
Health System Factors and Antihypertensive Adherence in a Racially and Ethnically Diverse Cohort of New Users
BACKGROUND: The purpose of this study was to identify potential health system solutions to suboptimal use of antihypertensive therapy in a diverse cohort of patients initiating treatment. METHODS: Using a hypertension registry at Kaiser Permanente Northern California, we conducted a…
Mycobacterial diseases and antitumour necrosis factor therapy in USA
OBJECTIVE: In North America, tuberculosis and nontuberculous mycobacterial (NTM) disease rates associated with antitumour necrosis factor alpha (anti-TNFalpha) therapy are unknown. METHODS: At Kaiser Permanente Northern California, the authors searched automated pharmacy records to identify inflammatory disease patients who received…
Surviving Colorectal Cancer: Long-term, Persistent Ostomy-Specific Concerns and Adaptations
The purpose of this article was to describe persistent ostomy-specific concerns and adaptations in long-term (>5 years) colorectal cancer survivors with ostomies. Thirty-three colorectal cancer survivors who participated in 8 gender- and health-related quality of life stratified focus groups and…
Tumor necrosis factor alpha inhibitor therapy and cancer risk in chronic immune mediated diseases
OBJECTIVE: To compare the incidence of cancer following tumor necrosis factor alpha (TNFalpha) inhibitor therapy to that with commonly used alternative therapies across multiple immune-mediated diseases. METHODS: The Safety Assessment of Biological Therapeutics study used data from 4 sources: national…
The association of psoriasis with autoimmune diseases
BACKGROUND: Previous studies provide evidence that there is a greater frequency of autoimmune diseases among patients with psoriasis than in the general population. OBJECTIVE: This study examined the association between psoriasis and 21 common autoimmune diseases, specified a priori. METHODS:…
Irrigation practices in long-term survivors of colorectal cancer with colostomies
For some patients diagnosed with rectal cancer, surgery will involve the creation of a temporary or permanent ostomy. When the colostomy is located in the sigmoid or descending colon, regulation of fecal output can occur through irrigation, a procedure that…
Is the physical functioning of older adults with diabetes associated with the processes and outcomes of care? Evidence from Translating Research Into Action for Diabetes (TRIAD)
AIMS: To examine the relationship between physical function limitations and diabetes self-management, processes of care and intermediate outcomes in adults >/= 65 years of age with Type 2 diabetes. METHODS: We studied 1796 participants 65 years of age and older…
The Association Between Medication Adherence and Treatment Intensification With Blood Pressure Control in Resistant Hypertension
Patients with resistant hypertension are at risk for poor outcomes. Medication adherence and intensification improve blood pressure (BP) control; however, little is known about these processes or their association with outcomes in resistant hypertension. This retrospective study included patients from…
Improving Blood Pressure Control through a Clinical Pharmacist Outreach Program in Diabetes Patients in Two-High Performing Health Systems: The Adherence and Intensification of Medications (AIM) Cluster Randomized Controlled Pragmatic Trial
BACKGROUND: Even in high-performing health systems, some patients with diabetes mellitus have poor blood pressure (BP) control because of poor medication adherence and lack of medication intensification. We examined whether the Adherence and Intensification of Medications intervention, a pharmacist-led intervention…
A comparison between antihypertensive medication adherence and treatment intensification as potential clinical performance measures
BACKGROUND: Medication adherence and treatment intensification have been advocated as performance measures to assess the quality of care provided. Whereas previous studies have shown that adherence and treatment intensification (TI) of antihypertensive medications is associated with blood pressure (BP) control…
Dynamic marginal structural modeling to evaluate the comparative effectiveness of more or less aggressive treatment intensification strategies in adults with type 2 diabetes
PURPOSE: Chronic disease care typically involves treatment decisions that are frequently adjusted to the patient's evolving clinical course (e.g., hemoglobin A1c monitoring and treatment intensification in diabetes patients). Thus, in comparative effectiveness and safety research (CER), it often is less…
Getting Under the Skin of Clinical Inertia in Insulin Initiation: The Translating Research Into Action for Diabetes (TRIAD) Insulin Starts Project
PURPOSE: The purpose of this cross-sectional study is to explore primary care providers' (PCPs) perceptions about barriers to initiating insulin among patients. Studies suggest that many patients with poorly controlled type 2 diabetes do not receive insulin initiation by PCPs.METHODS:…
Implementation of a web-based tool for patient medication self-management: the Medication Self-titration Evaluation Programme (Med-STEP) for blood pressure control
BACKGROUND: Informatics tools may help support hypertension management. OBJECTIVE: To design, implement and evaluate a web-based system for patient anti-hypertensive medication self-titration. METHODS: Study stages included: six focus groups (50 patients) to identify barriers/facilitators to patient medication self-titration, software design…
Defining patient complexity from the primary care physician’s perspective: a cohort study.
BACKGROUND: Patients with complex health needs are increasingly the focus of health system redesign.OBJECTIVE: To characterize complex patients, as defined by their primary care physicians (PCPs), and to compare this definition with other commonly used algorithms.DESIGN: Cohort study.SETTING: 1 hospital-based…
The Comparative Effectiveness of Mail Order Pharmacy Use vs. Local Pharmacy Use on LDL-C Control in New Statin Users
BACKGROUND: Mail order pharmacies are commonly used to deliver CVD risk factor medications. Previous studies have shown that mail order pharmacy use is associated with greater medication adherence; however, no studies have examined whether mail order pharmacy use is related…
Changes in cotherapies after initiation of disease-modifying antirheumatic drug therapy in patients with rheumatoid arthritis
Objective. We hypothesized that initiation of a new disease-modifying antirheumatic drug (DMARD) for treatment of rheumatoid arthritis (RA) would decrease the use of corticosteroids, nonsteroidal antiinflammatory drugs (NSAIDs), and narcotics.Methods. Using administrative databases, we assembled 4 retrospective cohorts of RA…
Glycemic control, complications, and death in older diabetic patients: the diabetes and aging study
OBJECTIVE: To identify the range of glycemic levels associated with the lowest rates of complications and mortality in older diabetic patients. RESEARCH DESIGN AND METHODS: We conducted a retrospective cohort study (2004-2008) of 71,092 patients with type 2 diabetes, aged…
Age-dependent gender differences in hypertension management
OBJECTIVE: Despite gender-neutral guidelines, prior studies suggest that women have lower rates of hypertension control and these differences may vary with age. Accordingly, we compared rates of hypertension control between women and men as a function of age. METHODS: Within…
Competing demands for time and self-care behaviors, processes of care, and intermediate outcomes among people with diabetes: Translating Research Into Action for Diabetes (TRIAD)
OBJECTIVE: To determine whether competing demands for time affect diabetes self-care behaviors, processes of care, and intermediate outcomes. RESEARCH DESIGN AND METHODS: We used survey and medical record data from 5,478 participants in Translating Research Into Action for Diabetes (TRIAD)…
Development of disability in chronic obstructive pulmonary disease: beyond lung function
BACKGROUND: COPD is a major cause of disability, but little is known about how disability develops in this condition. METHODS: The authors analysed data from the Function, Living, Outcomes and Work (FLOW) Study which enrolled 1202 Kaiser Permanente Northern California…
Hypoglycemia is more common among type 2 diabetes patients with limited health literacy: the Diabetes Study of Northern California (DISTANCE)
BACKGROUND: Little is known about the frequency of significant hypoglycemic events in actual practice. Limited health literacy (HL) is common among patients with type 2 diabetes, may impede diabetes self-management, and thus HL could increase the risk of hypoglycemia. OBJECTIVE:…
Race/ethnicity, social support, and associations with diabetes self-care and clinical outcomes in NHANES
PURPOSE: The purpose of this study was to evaluate how social support and race/ethnicity were associated with diabetes self-care behaviors and clinical outcomes. METHODS: Using the cross-sectional 2005-2006 National Health and Nutrition Examination Survey (NHANES), the authors examined white, black,…
The COPD Helplessness Index: a new tool to measure factors affecting patient self-management
BACKGROUND: Psychologic factors affect how patients with COPD respond to attempts to improve their self-management skills. Learned helplessness may be one such factor, but there is no validated measure of helplessness in COPD. METHODS: We administered a new COPD Helplessness…
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…
Early and late complications among long-term colorectal cancer survivors with ostomy or anastomosis
PURPOSE: Among long-term (>or=5 y) colorectal cancer survivors with permanent ostomy or anastomosis, we compared the incidence of medical and surgical complications and examined the relationship of complications with health-related quality of life. BACKGROUND: The incidence and effects of complications…
Parent-assisted or nurse-assisted epidural analgesia: is this feasible in pediatric patients?
AIM: The aim of this study was to assess the feasibility of parent-assisted or nurse-assisted epidural analgesia (PNEA) for control of postoperative pain in a pediatric surgical population.METHODS: After the institutional review board (IRB) approval was obtained, an analysis of…
COPD and cognitive impairment: the role of hypoxemia and oxygen therapy
BACKGROUND: several studies have shown an association between chronic obstructive pulmonary disease (COPD) and cognitive impairment. These studies have been limited by methodological issues such as diagnostic uncertainty, cross-sectional design, small sample size, or lack of appropriate referent group. This…
Study protocol: the Adherence and Intensification of Medications (AIM) study–a cluster randomized controlled effectiveness study
BACKGROUND: Many patients with diabetes have poor blood pressure (BP) control. Pharmacological therapy is the cornerstone of effective BP treatment, yet there are high rates both of poor medication adherence and failure to intensify medications. Successful medication management requires an…
Timing of myelosuppression during thiopurine therapy for inflammatory bowel disease: implications for monitoring recommendations
BACKGROUND & AIMS: Thiopurines (azathioprine and 6-mercaptopurine) can induce life-threatening myelosuppression. This study determined the frequency, timing, and outcomes of mild and severe myelosuppression after initiation of thiopurine therapy. METHODS: This retrospective cohort study included patients with inflammatory bowel disease…
Validity of computerized diagnoses, procedures, and drugs for inflammatory bowel disease in a northern California managed care organization
PURPOSE: Resources for studying inflammatory bowel disease (IBD) are needed in evaluations of drug safety including traditional drugs and new biologics agents. We developed an IBD registry, with ascertainment from computerized visit information. OBJECTIVE: We sought to characterize the positive…
Health-related quality of life among long-term rectal cancer survivors with an ostomy: manifestations by sex
PURPOSE: Intestinal stomas can pose significant challenges for long-term (> or = 5 years) rectal cancer (RC) survivors. Specifying common challenges and sociodemographic or clinical differences will further the development of tailored interventions to improve health-related quality of life (HRQOL)…
Gender differences in sleep disruption and fatigue on quality of life among persons with ostomies
STUDY OBJECTIVES: The aim of this study is to examine differences in sleep disruption and fatigue of men and women colorectal cancer (CRC) survivors with intestinal ostomies and associated health-related quality of life (HR-QOL). METHODS: Participants in this cross-sectional study…
Time trends in therapies and outcomes for adult inflammatory bowel disease, Northern California, 1998-2005
BACKGROUND & AIMS: The management of inflammatory bowel disease (IBD) has become increasingly complicated, and it is unknown whether poor outcomes (prolonged steroid use, hospitalizations, and surgery) have declined in the general population. METHODS: This multilevel study used computerized clinical…
Generalized megaviscera of lupus: refractory intestinal pseudo-obstruction, ureterohydronephrosis and megacholedochus.
Dilated dysfunction involving multiple visceral organs has been reported in patients with systemic lupus erythematosus (SLE). Chronic intestinal pseudo-obstruction (CIPO) resulting from intestinal smooth muscle damage has presented in conjunction with ureterohydronephrosis and, more rarely, biliary dilatation (megacholedochus). While the…
Cluster randomized trials to study the comparative effectiveness of therapeutics: stakeholders’ concerns and recommendations
PURPOSE: To describe the concerns raised by health plan members, providers and purchasers related to studying the comparative effectiveness of therapeutics using cluster randomized trials (CRTs) within health plans. An additional goal was to develop recommendations for increasing acceptability. METHODS:…
Treatment intensification and risk factor control: toward more clinically relevant quality measures
BACKGROUND: Intensification of pharmacotherapy in persons with poorly controlled chronic conditions has been proposed as a clinically meaningful process measure of quality. OBJECTIVE: To validate measures of treatment intensification by evaluating their associations with subsequent control in hypertension, hyperlipidemia, and…
Early adverse drug event signal detection within population-based health networks using sequential methods: key methodologic considerations
PURPOSE: Active surveillance of population-based health networks may improve the timeliness of detection of adverse events (AEs). Our objective was to expand our previous signal detection work by investigating the effect on signal detection of alternative study specifications. METHODS: We…
Medication errors among adults and children with cancer in the outpatient setting
PURPOSE: Outpatients with cancer receive complicated medication regimens in the clinic and home. Medication errors in this setting are not well described. We aimed to determine rates and types of medication errors and systems factors associated with error in outpatients…
Epidemiology of acute infections among patients with chronic kidney disease
The objectives of this review were (1) to review recent literature on the rates, risk factors, and outcomes of infections in patients who had chronic kidney disease (CKD) and did or did not require renal replacement therapy; (2) to review…
Screening differences and risk of cervical cancer in inflammatory bowel disease
BACKGROUND: Cervical cancer risk is high among immune suppressed women. AIM: To evaluate inflammatory bowel disease (IBD) with medications and risk of cervical cancer. METHODS: Members of Kaiser Permanente Northern California (KPNC), 15-68 years from 1996 to 2006 with IBD…
Patterns of infliximab use among Crohn’s disease patients in a community setting
BACKGROUND: Information on infliximab use in a community setting is important to understand patterns of medication use and to anticipate and plan for costs associated with the drug. We sought to understand predictors of initiation and discontinuation of infliximab in…
Chronic conditions and mortality among the oldest old
OBJECTIVES: We sought to determine whether chronic conditions and functional limitations are equally predictive of mortality among older adults. METHODS: Participants in the 1998 wave of the Health and Retirement Study (N=19430) were divided into groups by decades of age,…
When more is not better: treatment intensification among hypertensive patients with poor medication adherence
BACKGROUND: Hypertension may be poorly controlled because patients do not take their medications (poor adherence) or because providers do not increase medication when appropriate (lack of medication intensification, or 'clinical inertia'). We examined the prevalence of and relationship between patient…
Why don’t diabetes patients achieve recommended risk factor targets? Poor adherence versus lack of treatment intensification
BACKGROUND: Despite the availability of effective hypertension, hyperlipidemia, and hyperglycemia therapies, target levels of systolic blood pressure (SBP), LDL-cholesterol (LDL-c), and hemoglobin A1c control are often not achieved. OBJECTIVE: To examine the relative importance of patient medication nonadherence versus clinician…
Diffusion of aromatase inhibitors for breast cancer therapy between 1996 and 2003 in the Cancer Research Network
PURPOSE: Clinical trials demonstrated adjuvant aromatase inhibitor treatment is superior for decreasing breast cancer recurrence risk over adjuvant tamoxifen treatment as early as 2001. Yet clinical use for adjuvant treatment was not recommended by the American Society of Clinical Oncology…
Patient Assessment of Chronic Illness Care (PACIC) and improved patient-centered outcomes for chronic conditions
BACKGROUND: The Patient Assessment of Chronic Illness Care (PACIC) has potential for use as a patient-centered measure of the implementation of the Chronic Care Model (CCM), but there is little research on the relationship between the PACIC and important behavioral…
Mortality by medication use among patients with inflammatory bowel disease, 1996-2003
BACKGROUND & AIMS: Most previous population-based studies of mortality in inflammatory bowel disease (IBD) did not account for medication use. We evaluated mortality by IBD medication use among members of the Kaiser Permanente Northern California IBD Registry. METHODS: The retrospective,…
Creating a culture of research
There is widespread concern about the ability of the current model of clinical research to keep pace with the growing need for testing new approaches to disease management and prevention. In response, important innovations are emerging in critical areas of…
Estimation of the period prevalence of inflammatory bowel disease among nine health plans using computerized diagnoses and outpatient pharmacy dispensings
BACKGROUND: There are few contemporary estimates of prevalence rates for inflammatory bowel disease (IBD) in diverse North American communities. METHODS: We estimated the period prevalence of IBD for January 1, 1999, through June 30, 2001, among 1.8 million randomly sampled…
Predicted quality-adjusted life years as a composite measure of the clinical value of diabetes risk factor control
BACKGROUND: Control of blood pressure, low-density lipoprotein cholesterol (LDL-c), and A1c can lower the risk for diabetes complications. These quality indicators often are examined separately and weighted equally in performance measurement, potentially discarding important information. OBJECTIVES: We sought to create…
Racial differences in tumor stage and survival for colorectal cancer in an insured population
BACKGROUND: Despite declining death rates from colorectal cancer (CRC), racial disparities have continued to increase. In this study, the authors examined disparities in a racially diverse group of insured patients. METHODS: This study was conducted among patients who were diagnosed…
Understanding panel management: a comparative study of an emerging approach to population care
Context: Panel management is an innovative approach for population care that is tightly linked with primary care. This approach, which is spreading rapidly across Kaiser Permanente, represents an important shift in population-care structure and emphasis, but its potential and implications…
The influence of perceived control of asthma on health outcomes
BACKGROUND: Psychosocial factors play an important role in outcomes of asthma. Perceived control, a measure of patients' beliefs about their ability to control their disease, has not been studied in association with asthma health outcomes METHODS: We used data from…
Risk factors for work disability in severe adult asthma
PURPOSE: We aimed to elucidate the prevalence of and risk factors for work disability in severe adult asthma and to evaluate the impact of work disability on downstream health outcomes. METHODS: We used data from a prospective cohort study of…
Variations in hospice use among cancer patients
BACKGROUND: Previous studies have documented that hospice enrollment by terminally ill cancer patients varies substantially by patient characteristics and across broad geographic regions, but little is known about how local practice patterns and individual physicians contribute to these variations. We…
Longitudinal study of new and prevalent use of self-monitoring of blood glucose
OBJECTIVE: We sought to assess longitudinal association between self-monitoring of blood glucose (SMBG) and glycemic control in diabetic patients from an integrated health plan (Kaiser Permanente Northern California). RESEARCH DESIGN AND METHODS: Longitudinal analyses of glycemic control among 1) 16,091…
The association between quality of care and the intensity of diabetes disease management programs
BACKGROUND: Although disease management programs are widely implemented, little is known about their effectiveness. OBJECTIVE: To determine whether disease management by physician groups is associated with diabetes care processes, control of intermediate outcomes, or the amount of medication used when…
Alcohol consumption is inversely associated with adherence to diabetes self-care behaviours
AIMS: Our aim was to examine the associations of alcohol consumption with six diabetes self-care behaviours. METHODS: We determined levels of alcohol consumption and examined associations between alcohol consumption and six self-care behaviours in 65 996 adults with diabetes who…
Cost-utility analysis in a UK setting of self-monitoring of blood glucose in patients with type 2 diabetes
BACKGROUND: Self-monitoring of blood glucose (SMBG) in type 2 diabetes patients has been shown in meta-analyses of randomized trials to improve HbA(1c) by approximately 0.4% when compared to no SMBG. However, the cost of testing supplies is high, improvements in…
Effect of primary health care orientation on chronic care management
PURPOSE: It has been suggested that the best way to improve chronic illness care is through a redesign of primary care emphasizing comprehensive, coordinated care as espoused by the Chronic Care Model (CCM). This study examined the relationship between primary…
Role of self-monitoring of blood glucose in glycemic control
OBJECTIVE: To examine the role of self-monitoring of blood glucose (SMBG) in the management of diabetes mellitus. METHODS: Current trends and published evidence are reviewed. RESULTS: Despite the widespread evidence that lowering glycemic levels reduces the risks of complications in…
Current evidence regarding the value of self-monitored blood glucose testing
Many people with diabetes are falling short of attaining or maintaining glycemic goals. Self-monitoring of blood glucose (SMBG) is among the many strategies proposed to address the problem. SMBG complements hemoglobin A1c (HbA1c) testing by providing specific information regarding the…
Brief report: The prevalence and use of chronic disease registries in physician organizations. A national survey
OBJECTIVE: Disease registries are lists of patients with a particular chronic illness, including clinical information, to improve the care of individuals and populations. The objective of this study was to determine the prevalence of disease registries in physician organizations and…
Achieving good glycemic control: initiation of new antihyperglycemic therapies in patients with type 2 diabetes from the Kaiser Permanente Northern California Diabetes Registry
OBJECTIVE: To compare the effectiveness of antihyperglycemic therapies in type 2 diabetic patients with poor glycemic control (baseline glycosylated hemoglobin [HbA1C] > 8%). STUDY DESIGN: Longitudinal (cohort) study. METHODS: Study patients were 4775 type 2 diabetic patients who initiated new…
High rates of co-occurrence of hypertension, elevated low-density lipoprotein cholesterol, and diabetes mellitus in a large managed care population
OBJECTIVE: To examine prevalence and co-occurrence of diabetes mellitus (DM), hypertension (HT), and elevated low-density lipoprotein cholesterol (dyslipidemia, or DL) in a managed care population. STUDY DESIGN: Period prevalence study. PATIENTS AND METHODS: The study population included all adults (age…
Missed appointments and poor glycemic control: an opportunity to identify high-risk diabetic patients
OBJECTIVE: When patients miss scheduled medical appointments, continuity and effectiveness of healthcare delivery is reduced, appropriate monitoring of health status lapses, and the cost of health services increases. We evaluated the relationship between missed appointments and glycemic control (glycosylated hemoglobin…
A cohort study of systemic and local complications of toe prostheses
We investigated the role of toe implants in systemic disease and evaluated local complications after foot surgery. Information was obtained from the medical records of Kaiser Permanente (northern California) patients who had undergone toe surgery between 1979 and 1988. Computerized…
Self-monitoring of blood glucose levels and glycemic control: the Northern California Kaiser Permanente Diabetes registry
PURPOSE: We sought to evaluate the effectiveness of self-monitoring blood glucose levels to improve glycemic control. SUBJECTS AND METHODS: A cohort design was used to assess the relation between self-monitoring frequency (1996 average daily glucometer strip utilization) and the first…
Self-monitoring of blood glucose: language and financial barriers in a managed care population with diabetes
OBJECTIVE: Self-monitoring of blood glucose (SMBG) is a cornerstone of diabetes care, but little is known about barriers to this self-care practice. RESEARCH DESIGN AND METHODS: This cross-sectional study examines SMBG practice patterns and barriers in 44,181 adults with pharmacologically…