Publications (11)82.08 Total impact
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Article: Association of online patient access to clinicians and medical records with use of clinical services.
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ABSTRACT: Prior studies suggest that providing patients with online access to health records and e-mail communication with physicians may substitute for traditional health care services. To assess health care utilization by both users and nonusers of online access to health records before and after initiation of MyHealthManager (MHM), a patient online access system. Retrospective cohort study of the use of health care services by members (≥18 years old) who were continuously enrolled for at least 24 months during the study period March 2005 through June 2010 in Kaiser Permanente Colorado, a group model, integrated health care delivery system. Propensity scores (using age, sex, utilization frequencies, and chronic illnesses) were used for cohort matching. Unadjusted utilization rates were calculated for both MHM users and nonusers and were the basis for difference-of-differences analyses. We also used generalized estimating equations to compare the adjusted rates of utilization of health care services before and after online access. Rates of office visits, telephone encounters, after-hours clinic visits, emergency department encounters, and hospitalizations between members with and without online access. Comparing the unadjusted rates for use of clinical services before and after the index date between the matched cohorts, there was a significant increase in the per-member rates of office visits (0.7 per member per year; 95% CI, 0.6-0.7; P < .001) and telephone encounters (0.3 per member per year; 95% CI, 0.2-0.3; P < .001). There was also a significant increase in per-1000-member rates of after-hours clinic visits (18.7 per 1000 members per year; 95% CI, 12.8-24.3; P < .001), emergency department encounters (11.2 per 1000 members per year; 95% CI, 2.6-19.7; P = .01), and hospitalizations (19.9 per 1000 members per year; 95% CI, 14.6-25.3; P < .001) for MHM users vs nonusers. Having online access to medical records and clinicians was associated with increased use of clinical services compared with group members who did not have online access.JAMA The Journal of the American Medical Association 11/2012; 308(19):2012-9. · 30.03 Impact Factor -
Article: Detection and recognition of hypertension in anxious and depressed patients.
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ABSTRACT: OBJECTIVE:: Hypertension management requires detection (i.e. confirmation of persistently high blood pressure (BP) after an initial elevated measurement) and recognition of the condition (evidenced by a formal diagnosis and/or initiation of treatment). Our objective was to determine whether disparities exist in detection of elevated BP and recognition (i.e. diagnosis or treatment) of hypertension in patients with depression and anxiety. METHODS:: Using data from the Cardiovascular Research Network Hypertension Registry, we assessed time-to-detection of elevated BP and recognition of hypertension in patients with comorbid anxiety and depression compared with patients with neither disorder. We performed multivariable survival analysis of time to detection and recognition in patients who entered the registry in 2002-2006. We adjusted for primary care visit rate and other relevant clinical factors. RESULTS:: In 168 630 incident hypertension patients, detection occurred earlier among patients with anxiety and depression compared with patients without these diagnoses [adjusted hazard ratio for anxiety and depression 1.30, 95% confidence interval (CI) 1.26-1.35]. Recognition of hypertension within 12 months of the second elevated BP was similar (adjusted hazard ratio for anxiety and depression 0.94, 95% CI 0.89-1.00) or delayed (adjusted hazard ratio for anxiety 0.93, 95% CI 0.88-0.99 and for depression 0.93, 95% CI 0.90-0.97). CONCLUSIONS:: Detection of elevated BP occurred earlier in patients with anxiety and depression. Time from detection to diagnosis or treatment was similar or delayed in patients with and without these diagnoses. Our findings suggest that as-yet-unidentified factors contribute to disparities in hypertension detection and recognition.Journal of hypertension 10/2012; · 4.02 Impact Factor -
Article: CC1-04: Online Patient Access to Their Medical Record and Health Providers is Associated With a Greater Use of Clinical Services.
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ABSTRACT: Background/Aims To compare utilization of office and telephone encounters by patients with online access to their electronic medical record (EMR) to patients without online access. Methods Administrative data for ambulatory care patients enrolled in a group model HMO from May 2006 through June 2009, using an electronic medical record with an online patient access feature, which includes: appointment requests, results review, medication list, refill request, problem list, care instructions, and email communication with their healthcare providers. We collected administrative data for health plan utilization documented in the EMR for patients 12 months before and after the activation of their online access and for a matched cohort of patients without online access. The analytic data set included those with and without online access matched on propensity scores within a 5% range based on age, gender, and co-morbidity within baseline visit and year strata. Results The propensity matched cohorts (N = 51,535; in each cohort) contained 54.2% females, an average age of 43.7 years, 6.9% were less than age 20, 36.2% ages 20-39, 43.3% ages 40-59, and 13.7% ages 60 and over. Eighty-six percent of the cohort had none of four chronic illnesses, 7.4% with asthma, 5.7% with diabetes, 1.5% with coronary artery disease, and 1% with congestive heart failure. In the year following activation of their on-line access, this cohort had increased rates (per patient per year) of office visits (3.1 vs. 2.2, p<0.001), telephone contacts (3.9 vs. 3.4, p<0.001), after-hour clinic visits (0.1 vs. 0.07, p<0.001), in-patient hospitalizations (0.07 vs. 0.06, p<0.01) compared to a matched cohort of patients without on-line access. However, on-line access patients had a decreased incidence rate of emergency department use (0.15 vs. 0.18, p <0.001) during the year of follow-up compared to the cohort without on-line access. Discussion Patients with online access to their health information and to their healthcare providers also had an increased use of clinical services. Further research is needed to understand this association and to evaluate the effect online access has on patient health outcomes.Clinical Medicine & Research 08/2012; 10(3):167. -
Article: The association between medication adherence and treatment intensification with blood pressure control in resistant hypertension.
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ABSTRACT: 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 2002 to 2006 with incident hypertension from 2 health systems who developed resistant hypertension or uncontrolled BP despite adherence to ≥3 antihypertensive medications. Patterns of hypertension treatment, medication adherence (percentage of days covered), and treatment intensification (increase in medication class or dose) were described in the year after resistant hypertension identification. Then, the association between medication adherence and intensification with 1-year BP control was assessed controlling for patient characteristics. Of the 3550 patients with resistant hypertension, 49% were male, and mean age was 60 years. One year after resistance hypertension determination, fewer patients were taking diuretics (77.7% versus 92.2%; P<0.01), β-blockers (71.2% versus 79.4%; P<0.01), and angiotensinogen-converting enzyme inhibitor/angiotensin receptor blocker (64.8% versus 70.1%; P<0.01) compared with baseline. Rates of BP control improved over 1 year (22% versus 55%; P<0.01). During this year, adherence was not associated with 1-year BP control (adjusted odds ratio, 1.18 [95% CI: 0.94-1.47]). Treatment was intensified in 21.6% of visits with elevated BP. Increasing treatment intensity was associated with 1-year BP control (adjusted odds ratio, 1.64 [95% CI, 1.58-1.71]). In this cohort of patients with resistant hypertension, treatment intensification but not medication adherence was significantly associated with 1-year BP control. These findings highlight the need to investigate why patients with uncontrolled BP do not receive treatment intensification.Hypertension 06/2012; 60(2):303-9. · 6.21 Impact Factor -
Article: Incidence and prognosis of resistant hypertension in hypertensive patients.
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ABSTRACT: Despite a recent American Heart Association (AHA) consensus statement emphasizing the importance of resistant hypertension, the incidence and prognosis of this condition are largely unknown. This retrospective cohort study in 2 integrated health plans included patients with incident hypertension in whom treatment was begun between 2002 and 2006. Patients were followed up for the development of resistant hypertension based on AHA criteria of uncontrolled blood pressure despite use of ≥3 antihypertensive medications, with data collected on prescription filling information and blood pressure measurement. We determined incident cardiovascular events (death or incident myocardial infarction, heart failure, stroke, or chronic kidney disease) in patients with and without resistant hypertension with adjustment for patient and clinical characteristics. Among 205 750 patients with incident hypertension, 1.9% developed resistant hypertension within a median of 1.5 years from initial treatment (0.7 cases per 100 person-years of follow-up). These patients were more often men, were older, and had higher rates of diabetes mellitus than nonresistant patients. Over 3.8 years of median follow-up, cardiovascular event rates were significantly higher in those with resistant hypertension (unadjusted 18.0% versus 13.5%, P<0.001). After adjustment for patient and clinical characteristics, resistant hypertension was associated with a higher risk of cardiovascular events (hazard ratio, 1.47; 95% confidence interval, 1.33-1.62). Among patients with incident hypertension in whom treatment was begun, 1 in 50 patients developed resistant hypertension. Patients with resistant hypertension had an increased risk of cardiovascular events, which supports the need for greater efforts toward improving hypertension outcomes in this population.Circulation 02/2012; 125(13):1635-42. · 14.74 Impact Factor -
Article: Relationship between blood pressure and incident chronic kidney disease in hypertensive patients.
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ABSTRACT: Hypertension is an important cause of chronic kidney disease (CKD). Identifying risk factors for progression to CKD in patients with normal kidney function and hypertension may help target therapies to slow or prevent decline of kidney function. Our objective was to identify risk factors for development of incident CKD and decline in estimated GFR (eGFR) in hypertensive patients. Cox proportional hazards models were used to assess the relationship between incident CKD (defined as eGFR <60 ml/min per 1.73 m(2)) and potential risk factors for CKD from a registry of hypertensive patients. Of 43,305 patients meeting the inclusion criteria, 12.1% (5236 patients) developed incident CKD. Diabetes was the strongest predictor of incident CKD (hazard ratio, 1.96; 95% confidence interval, 1.84 to 2.09) and was associated with the greatest rate of decline in eGFR (-2.2 ml/min per 1.73 m(2) per year). Time-varying systolic BP was associated with incident CKD with risk increasing above 120 mmHg; each 10-mmHg increase in baseline and time-varying systolic BP was associated with a 6% increase in the risk of developing CKD (hazard ratio, 1.06; 95% confidence interval, 1.04 to 1.08 for both). Time-weighted systolic BP was associated with a more rapid decline in eGFR of an additional 0.2 ml/min per 1.73 m(2) per year decline for every 10-mmHg increase in systolic BP. We found that time-varying systolic BP was associated with incident CKD, with an increase in risk above a systolic BP of 120 mmHg among individuals with hypertension.Clinical Journal of the American Society of Nephrology 09/2011; 6(11):2605-11. · 5.23 Impact Factor -
Article: Impact of medication nonadherence on hospitalizations and mortality in heart failure.
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ABSTRACT: Limited literature exists on the association between medication adherence and outcomes among patients with heart failure. We conducted a retrospective longitudinal cohort study of 557 patients with heart failure with reduced ejection fraction (HFrEF) (defined by EF <50%) in a large health maintenance organization. We used multivariable Cox proportional hazards models to assess the relationship between adherence (with angiotensin-converting enzyme inhibitors or angiotensin receptor blockers, β-blockers, and aldosterone antagonists) and the primary outcome of all-cause mortality plus cardiovascular hospitalizations. Mean follow-up time was 1.1 years. Nonadherence (defined as <80% adherence) was associated with a statistically significant increase in the primary outcome in the cohort overall (hazard ratio 2.07, 95% confidence interval 1.62-2.64; P < .0001). This association remained significant when all 3 classes of heart failure medications and the components of the composite end point were considered separately and when the adherence threshold was varied to 70% or 90%. Medication nonadherence was associated with an increased risk of all-cause mortality and cardiovascular hospitalizations in a community heart failure population. Further research is needed to define systems of care that optimize adherence among patients with heart failure.Journal of cardiac failure 08/2011; 17(8):664-9. · 3.25 Impact Factor -
Article: Response to Letter Regarding Article, "Increased Risk of Bleeding in Patients on Clopidogrel Therapy After Drug-Eluting Stents Implantation: Insights From the HMO Research Network-Stent Registry (HMORN-Stent)".
Circulation Cardiovascular Interventions 10/2010; 3(5):e25. · 6.06 Impact Factor -
Article: Increased risk of bleeding in patients on clopidogrel therapy after drug-eluting stents implantation: insights from the HMO Research Network-Stent Registry (HMORN-stent).
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ABSTRACT: Studies suggest that extended clopidogrel use after drug-eluting stent (DES) implantation may decrease the risk of myocardial infarction (MI) and death. Little is known about the competing risk of bleeding from clopidogrel in "real world" clinical practice. We studied 7689 patients undergoing drug-eluting stent implantation enrolled in the HMO Research Network-Stent Registry between 2004 and 2007. Patients were analyzed in 6-month intervals for the occurrence of major bleeding, MI, and death. Clopidogrel use was determined by pharmacy dispensing data. Regression models assessed the association between clopidogrel use and outcomes. Overall, 3603 patients (49.1%) received clopidogrel for >6 months. During a mean follow-up of 418 days (SD, +/-168 days), 217 (2.9%) patients died, 279 (3.7%) had a MI, and 271 (3.6%) had major bleeding. After adjustment, patients on clopidogrel therapy were associated with increased major bleeding in all time intervals (0 to 6 months: relative risk (RR)=2.70, 95% CI=1.41 to 5.19; 7 to 12 months: RR=1.71, 95% CI=1.05 to 2.79; 13 to 18 months: RR=2.34, 95% CI=1.26 to 4.34), compared with patients off clopidogrel. Clopidogrel use was also associated with decreased risk of MI for all time intervals (0 to 6 months: RR=0.52, 95% CI=0.36 to 0.77; 7 to 12 months: RR=0.46, 95% CI=0.30 to 0.70; 13 to 18 months: RR=0.53, 95% CI=0.29 to 0.99) and decreased death in the 7 to 12 month interval (RR=0.50, 95% CI=0.30 to 0.83). Clopidogrel use was associated with increased major bleeding and decreased MI persisting to 18 months. Bleeding risks on clopidogrel therapy deserve consideration in the ongoing debate regarding optimal clopidogrel duration after PCI.Circulation Cardiovascular Interventions 06/2010; 3(3):230-5. · 6.06 Impact Factor -
Article: Delays in filling clopidogrel prescription after hospital discharge and adverse outcomes after drug-eluting stent implantation: implications for transitions of care.
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ABSTRACT: Adjuvant clopidogrel therapy is essential after drug-eluting stent (DES) implantation. The frequency with which patients delay filling a clopidogrel prescription after DES implantation and the association of this delay with adverse outcomes is unknown. This was a retrospective cohort study of patients discharged after DES implantation from 3 large integrated health care systems. Filling a clopidogrel prescription was based on pharmacy dispensing data. The primary end point was all-cause mortality or myocardial infarction (MI). Of 7402 patients discharged after DES implantation, 16% (n=1210) did not fill a clopidogrel prescription on day of discharge and the median time delay was 3 days (interquartile range, 1 to 23 days). Compared with patients filling clopidogrel on day of discharge, patients with any delay in filling clopidogrel had higher death/MI rates during follow-up (14.2% versus 7.9%; P<0.001). In multivariable analysis, patients with any delay had increased risk of death/MI (hazard ratio, 1.53; 95% confidence interval, 1.25 to 1.87). Patients with any delay remained at increased risk of adverse outcomes when the delay cutoff was changed to >1, >3, or >5 days after discharge. Factors associated with delay included older age, prior MI, diabetes, renal failure, prior revascularization, cardiogenic shock, in-hospital bleeding, and clopidogrel use within 24 hours of admission. One in 6 patients delay filling their index clopidogrel prescription after hospital discharge after DES implantation. This delay was associated with increased risk of adverse outcomes and highlights the importance of the transition period from hospital discharge to outpatient setting as a potential opportunity to improve care delivery and patient outcomes.Circulation Cardiovascular Quality and Outcomes 05/2010; 3(3):261-6. · 4.91 Impact Factor -
Article: An assessment of cholesterol goal attainment in patients with chronic kidney disease.
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ABSTRACT: Patients with chronic kidney disease (CKD) are at significant risk for cardiovascular disease (CVD). The National Kidney Foundation developed clinical practice guidelines (Kidney Disease Outcomes Quality Initiative) for targeting low-density lipoprotein cholesterol (LDL-C) goals. This study evaluated the extent to which these guidelines were adhered to among patients with CKD and to examine factors associated with the attainment of LDL-C goals. In this cross-sectional study we evaluated patients with a glomerular filtration rate of 15 to 59 mL/min per 1.73 m². Patients with previous CVD, who were receiving dialysis, or were post kidney transplant were excluded. Administrative databases were used to determine the percentage of patients with a fasting lipid profile performed within the previous year, the percentage who attained a LDL-C goal less than 100 mg/dL, and to determine lipid-lowering medications prescribed. Logistic regression analysis was used to identify factors associated with LDL-C goal attainment. Of the 4541 patients evaluated, 3157 (69.5%) had a fasting lipid profile performed within the previous year. Overall, 60.8% attained a LDL-C less than 100 mg/dL. Among patients at goal, 72.2% were taking lipid-lowering therapy compared with 37.9% of those not at goal (P < .01). Characteristics independently associated with LDL-C goal attainment were increasing age, male gender, increasing chronic disease score, history of diabetes, and statin use. Although most patients were screened and attained LDL-C goal, there was room for improvement. Statin use was independently associated with LDL-C goal attainment. Future prospective studies should focus on evaluating clinical outcomes of lipid-lowering interventions within the CKD population.Journal of Clinical Lipidology 4(4):298-304. · 1.58 Impact Factor
