Bessie A Young

University of Washington Seattle, Seattle, Washington, United States

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Publications (88)522.18 Total impact

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    ABSTRACT: Chronic kidney disease (CKD) remains a prevalent public health problem that disproportionately affects African Americans, despite intense efforts targeting traditional risk factors. Periodontal disease, a chronic bacterial infection of the oral cavity, is both common and modifiable and has been implicated as a novel potential CKD risk factor. We sought to examine to what extent periodontal disease is associated with kidney function decline. Retrospective cohort study of 699 African American participants with preserved kidney function defined by an estimated glomerular filtration rate (eGFR) >60ml/min/1.73m(2) at baseline who underwent complete dental examinations as part of the Dental-Atherosclerosis Risk in Communities study (1996-1998) and subsequently enrolled in the Jackson Heart Study (2000-2004). Using multivariable Poisson regression we examined the association of periodontal disease (severe vs. non-severe) with incident CKD defined as incident eGFR<60ml/min/1.73m(2) and rapid (5% annualized) eGFR decline at follow-up among those with preserved eGFR at baseline. Mean age at baseline was 65.4 years (SD 5.2) and 16.3% (n=114) had severe periodontal disease. There were 21 cases (3.0%) of incident CKD after a mean follow-up of 4.8 (SD 0.6) years. Compared to participants with non-severe periodontal disease, those with severe periodontal disease had a 4-fold greater rate of incident CKD [adjusted incidence rate ratio 4.18, 95% CI (1.68 - 10.39), p=0.002]. Severe periodontal disease is prevalent among a population at high-risk for CKD and is associated with clinically significant kidney function decline. Further research is needed to determine if periodontal disease treatment alters the trajectory of renal deterioration.
    Journal of Periodontology 06/2015; DOI:10.1902/jop.2015.150195 · 2.57 Impact Factor
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    ABSTRACT: The calibration to isotope dilution mass spectrometry-traceable creatinine is essential for valid use of the new Chronic Kidney Disease Epidemiology Collaboration equation to estimate the glomerular filtration rate. For 5,210 participants in the Jackson Heart Study (JHS), serum creatinine was measured with a multipoint enzymatic spectrophotometric assay at the baseline visit (2000-2004) and remeasured using the Roche enzymatic method, traceable to isotope dilution mass spectrometry in a subset of 206 subjects. The 200 eligible samples (6 were excluded, 1 for failure of the remeasurement and 5 for outliers) were divided into 3 disjoint sets-training, validation and test-to select a calibration model, estimate true errors and assess performance of the final calibration equation. The calibration equation was applied to serum creatinine measurements of 5,210 participants to estimate glomerular filtration rate and the prevalence of chronic kidney disease (CKD). The selected Deming regression model provided a slope of 0.968 (95% confidence interval [CI], 0.904-1.053) and intercept of -0.0248 (95% CI, -0.0862 to 0.0366) with R value of 0.9527. Calibrated serum creatinine showed high agreement with actual measurements when applying to the unused test set (concordance correlation coefficient 0.934, 95% CI, 0.894-0.960). The baseline prevalence of CKD in the JHS (2000-2004) was 6.30% using calibrated values compared with 8.29% using noncalibrated serum creatinine with the Chronic Kidney Disease Epidemiology Collaboration equation (P < 0.001). A Deming regression model was chosen to optimally calibrate baseline serum creatinine measurements in the JHS, and the calibrated values provide a lower CKD prevalence estimate.
    The American Journal of the Medical Sciences 03/2015; DOI:10.1097/MAJ.0000000000000446 · 1.52 Impact Factor
  • Margaret K Yu, Wayne Katon, Bessie A Young
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    ABSTRACT: Women with diabetes have a higher prevalence of chronic kidney disease (CKD) risk factors compared to men, but whether they are at higher risk for incident CKD remains uncertain. This was a prospective, observational cohort study of 1,464 patients with diabetes and normal renal function, recruited from primary care clinics at a vertically integrated healthcare system in Seattle, WA, USA. The primary predictor was sex. Incident CKD as defined by an estimated glomerular filtration rate (eGFR) <60 mL/min/1.73 m(2) by CKD-EPI equations or sex-specific microalbuminuria (urine albumin/creatinine ratio ≥25 mg/g for women or ≥17 mg/g for men). Of the 1,464 patients (52.0% women), CKD incidence rates were 154.0 and 144.3 cases per 1,000 patient-years for women and men, respectively. In the competing risks regression, women had an increased risk of incident CKD (subhazard ratio (SHR) 1.37, 95% CI 1.17, 1.60) compared to men after adjustment for demographics, baseline eGFR, and duration of diabetes, which persisted after additional adjustment for CKD risk factors, depressive symptoms, and diabetes self-care (SHR 1.35, 95% 1.15, 1.59). Sex differences in incident CKD were consistent across age groups and appeared to be driven by differences in the development of low eGFR rather than microalbuminuria. Women with diabetes had a higher risk of incident CKD compared to men, which could not be entirely explained by differences in biologic CKD risk factors, depression, or diabetes self-care. Additional work is needed determine if these sex differences contribute to worse outcomes in women with diabetes. This article is protected by copyright. All rights reserved.
    Nephrology 03/2015; 20(7). DOI:10.1111/nep.12468 · 1.86 Impact Factor
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    ABSTRACT: The association between sickle cell trait (SCT) and chronic kidney disease (CKD) is uncertain.
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    Deborah L Huang, Itamar B Abrass, Bessie A Young
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    ABSTRACT: Medication safety in patients with chronic kidney disease (CKD) is a growing concern. This is particularly relevant in older adults due to underlying CKD. Metformin use is contraindicated in patients with abnormal kidney function; however, many patients are potentially prescribed metformin inappropriately. We evaluated the prevalence of CKD among older adults prescribed metformin for type 2 diabetes mellitus using available equations to estimate kidney function and examined demographic characteristics of patients who were potentially inappropriately prescribed metformin.
    BMC Nephrology 06/2014; 15(1):86. DOI:10.1186/1471-2369-15-86 · 1.52 Impact Factor
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    ABSTRACT: Comorbid major depression is associated with adverse health outcomes in patients with diabetes, but little is known regarding its associations with long-term renal outcomes in this population. Furthermore, the impact of minor depression on renal outcomes is not known. This study evaluated associations between depressive symptoms and risk of incident ESRD in a diabetic cohort. In this prospective, observational cohort study, 3886 ambulatory adults with diabetes were recruited from primary care clinics of a large health maintenance organization in the state of Washington. Demographics, laboratory data, depressive symptoms (based on the Patient Health Questionnaire-9), and patterns of diabetes self-care were collected. Participants were considered depressed if they had the required number of depressive symptoms (≥5 for major or 2-4 for minor depressive symptoms), including depressed mood or anhedonia, >50% of the time for ≥2 weeks and a Patient Health Questionnaire-9 score≥10 for major and ≥5 for minor depressive symptoms. Risk of incident ESRD was estimated using Cox proportional hazards regression, with predialysis death as a competing risk. During a median follow-up of 8.8 years, 87 patients (2.2%) developed ESRD. Major depressive symptoms were associated with a higher risk of incident ESRD (hazard ratio, 1.85; 95% confidence interval, 1.02 to 3.33) after adjusting for age, sex, race/ethnicity, marital status, education, smoking, body mass index, diabetes duration, hemoglobin A1c, baseline kidney function, microalbuminuria, hypertension, renin-angiotensin system blockers, and adherence to diabetes self-care. Minor depressive symptoms were not significantly associated with incident ESRD (hazard ratio, 1.08; 95% confidence interval, 0.52 to 2.25). Major depressive symptoms, but not minor depressive symptoms, were associated with a higher risk of incident ESRD over 10 years. Additional studies are needed to determine whether treatment for depression can improve renal outcomes in patients with diabetes.
    Clinical Journal of the American Society of Nephrology 03/2014; 9(5). DOI:10.2215/CJN.08670813 · 5.25 Impact Factor
  • Margaret K Yu, Wayne Katon, Bessie A Young
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    ABSTRACT: Background/Aims: The associations between major depression and chronic kidney disease (CKD) in patients with diabetes are incompletely characterized. Depressed patients with diabetes are known to have worse diabetes self-care, but it is not known whether this mediates the association between depression and CKD in this population. Methods: We conducted a cross-sectional study of the associations between major depressive symptoms and CKD in the Pathways Study (n = 4,082), an observational cohort of ambulatory diabetic patients from a managed care setting. Depression status was ascertained using the Patient Health Questionnaire-9 (PHQ-9). Stepwise logistic regression models examined the associations between depression and impaired estimated glomerular filtration rate (<60 ml/min/1.73 m(2)) or microalbuminuria, after adjustment for demographics, CKD risk factors, and diabetes self-care variables. Results: Clinically significant depression symptoms (PHQ-9 ≥10) were associated with a greater risk of microalbuminuria after adjustment for demographic variables (OR 1.54, 95% CI 1.21-1.95) and traditional CKD risk factors (OR 1.36, 95% CI 1.04-1.77); this association persisted after additional adjustment for diabetes self-care (OR 1.34, 95% CI 1.02-1.75). Depression was not associated with impaired estimated glomerular filtration rate in any of the models. Conclusion: In this cohort of diabetic subjects, clinically significant depression symptoms were associated with microalbuminuria, which could not be entirely explained by differences in diabetes self-care. © 2013 S. Karger AG, Basel.
    Nephron Clinical Practice 10/2013; 124(1-2):106-112. DOI:10.1159/000355551 · 1.65 Impact Factor
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    ABSTRACT: To determine the association between health-related quality of life (HRQOL) and oral health in older U.S. adults with diabetes mellitus (DM). Cross-sectional. Data from the U.S. Behavioral Risk Factor Surveillance System 2006, 2008, and 2010. Nationally representative sample of 70,363 adults aged 65 and older with DM. Older adults with DM were more likely to report permanent tooth loss due to caries or periodontal disease than those without (82.3% vs 74.3%, P < .001) and less likely to receive dental care in the past year (59.0% vs 70.9%, P < .001). Loss of permanent teeth from caries or periodontal disease was associated with 1.25 times greater odds of worse self-rated general health (95% confidence interval (CI) = 1.13-1.37). Lack of dental care in the preceding 12 months was associated with 1.34 times greater odds of worse self-rated general health (95% CI = 1.25-1.44) than receiving dental care in the preceding 12 months. Poor dentition and longer time since last dental visit were associated with more physically unhealthy days. Poor dentition and lack of dental care were associated with worse HRQOL in older adults with DM. Further research is needed to determine whether better oral health improves HRQOL in this population.
    Journal of the American Geriatrics Society 09/2013; 61(10). DOI:10.1111/jgs.12452 · 4.22 Impact Factor
  • Bessie Ann Young
    American Journal of Kidney Diseases 07/2013; 62(1):3-6. DOI:10.1053/j.ajkd.2013.04.003 · 5.76 Impact Factor
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    ABSTRACT: BACKGROUND: Although chronic kidney disease (CKD) is a highly prevalent condition among older adults with diabetes, the associations between health-related quality of life (HRQoL) and severity of CKD in this population are not well understood. The objective of this study was to assess HRQoL and depressive symptoms across estimated glomerular filtration rate (eGFR) stages. STUDY DESIGN: Cross-sectional. SETTING & PARTICIPANTS: 5,805 members of Kaiser Permanente Northern California, 60 years or older with diabetes, from the 2005-2006 Diabetes Study of Northern California (DISTANCE) survey. PREDICTOR: eGFR categories were defined as ≥90 (referent category), 75-89, 60-74, 45-59, 30-44, or ≤29 mL/min/1.73 m(2). OUTCOMES: HRQoL was measured using the modified Short Form-8 Physical Component Summary (PCS) and Mental Component Summary (MCS) scores. Depressive symptoms were measured using the Patient Health Questionnaire-8. RESULTS: In unadjusted linear regression analyses, physical (PCS) and mental (MCS) HRQoL scores were significantly lower with worsening eGFR level. However, after adjustment for sociodemographics, diabetes duration, obesity, and cardiovascular comorbid conditions and taking into account interactions with proteinuria, none of the eGFR categories was significantly or substantively associated with PCS or MCS score. In both unadjusted and adjusted analyses, higher risk of depressive symptoms was observed in respondents with eGFR ≤29 mL/min/1.73 m(2) (relative risk, 2.02; 95% CI, 1.10-3.71; P < 0.05) compared with the referent group. However, this eGFR-depression relationship was no longer significant after adjusting for hemoglobin level. LIMITATIONS: Participants are part of a single health care delivery system. CONCLUSIONS: Our findings suggest the need for greater attention to and potential interventions for depression in patients with reduced eGFR.
    American Journal of Kidney Diseases 06/2013; 62(3). DOI:10.1053/j.ajkd.2013.03.039 · 5.76 Impact Factor
  • Bessie Young
    Clinical Journal of the American Society of Nephrology 06/2013; 8(6):898-900. DOI:10.2215/CJN.03970413 · 5.25 Impact Factor
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    ABSTRACT: PURPOSE Although psychosocial and clinical factors have been found to be associated with hypoglycemic episodes in patients with diabetes, few studies have examined the association of depression with severe hypoglycemic episodes. This study examined the prospective association of depression with risk of hypoglycemic episodes requiring either an emergency department visit or hospitalization. METHODS In a longitudinal cohort study, a sample of 4,117 patients with diabetes enrolled between 2000 and 2002 were observed from 2005 to 2007. Meeting major depression criteria on the Patient Health Questionnaire-9 was the exposure of interest, and the outcome of interest was an International Classification of Disease, Ninth Revision code for a hypoglycemic episode requiring an emergency department visit or hospitalization. Proportional hazard models were used to analyze the association of baseline depression and risk of one or more severe hypoglycemic episodes. Poisson regression was used to determine whether depression status was associated with the number of hypoglycemic episodes. RESULTS After adjusting for sociodemographic, clinical measures of diabetes severity, non-diabetes-related medical comorbidity, prior hypoglycemic episodes, and health risk behaviors, depressed compared with nondepressed patients who had diabetes had a significantly higher risk of a severe hypoglycemic episode (hazard ratio = 1.42, 95% CI, 1.03-1.96) and a greater number of hypoglycemic episodes (odds ratio = 1.34, 95% CI, 1.03-1.74). CONCLUSION Depression was significantly associated with time to first severe hypoglycemic episode and number of hypoglycemic episodes. Research assessing whether recognition and effective treatment of depression among persons with diabetes prevents severe hypoglycemic episodes is needed.
    The Annals of Family Medicine 05/2013; 11(3):245-250. DOI:10.1370/afm.1501 · 4.57 Impact Factor
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    ABSTRACT: Patients with chronic diabetic complications experience high morbidity and mortality. Sex disparities in modifiable factors such as processes of care or self-care activities have not been explored in detail, particularly in these high-risk patients. Sex differences in processes of care and self-care activities were assessed in a cross-sectional analysis of the Pathways Study, an observational cohort of primary care diabetic patients from a managed care organization (N = 4,839). Compared to men, women had decreased odds of dyslipidemia screening (adjusted odds ratio (AOR) 0.73, 95% CI 0.62-0.85), reaching low-density lipoprotein goal (AOR 0.70, 95% CI 0.58-0.86), and statin use (AOR 0.69, 95% CI 0.58-0.81); women had 19% greater odds of reaching hemoglobin A1c <7% (95% CI 1.02-1.41). There were no sex differences in hemoglobin A1c testing, microalbuminuria screening, or angiotensin-converting enzyme inhibitor use. Women were less likely to report regular exercise but had better adherence to healthy diet, glucose monitoring, and self-foot examination compared to men. Patterns of sex differences were consistent in subjects with diabetic complications. Significant sex disparities exist in diabetes process of care measures and self-care, even amongst patients known to have chronic diabetic complications.
    Journal of Diabetes Research 03/2013; 2013(3):575814. DOI:10.1155/2013/575814 · 3.54 Impact Factor
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    ABSTRACT: Objective: Determine the association between periodontal disease (PD) and dentition with self-reported general health among community-dwelling U.S. older adults (≥65 years). Method: Cross-sectional analysis of National Health and Nutrition Examination Survey (NHANES) 2009-2010 data. Predictors of interest were dentition, self-reported PD and oral health measures. Primary outcome of interest was health-related quality of life (HRQOL-4 CDC Healthy Days Module). Descriptive analyses and multivariable logistic regression analyses were performed. Result: Participants’ (N=1,050) mean age was 73.2±0.2 years, female 55.5%, non-Hispanic white 80.3%. Mean number of teeth was 19.5±0.4; 39.5% had <20 teeth, and 31.2% rated their oral health as excellent/very good. PD was self-reported by 14.8%, 15.1% reported prior non-injury-related tooth mobility, and 19.2% reported any prior PD treatment. More participants with reported PD had <20 teeth (42.9%) compared to those without reported PD (38.3%). Likewise, 46.6% of participants with prior PD treatment had <20 teeth compared to 37.6% without prior treatment. Self-rated general health was fair/poor in more participants with <20 teeth (25.3%) compared to subjects with ≥20 teeth (22.6%), and among those with reported PD (37.4%) compared to no reported PD (21.7%). However, participants with reported PD and/or <20 teeth reported fewer unhealthy days compared to those without reported PD or ≥20 teeth. Self-reported PD was associated with worse self-rated general health (OR=2.14, 95% CI 1.00-4.60, p=0.05) after adjustment for demographics and smoking status. Worse general health was not associated with <20 teeth (OR=1.09, 95% CI 0.65-1.82) or prior PD treatment (OR=0.72, 95% CI 0.35-1.52). Dentition and self-reported PD were not associated with number of unhealthy days. Conclusion: Dentition and self-reported oral health measures appear to reflect self-rated general health in community-dwelling older adults, but not number of unhealthy days. These findings should be confirmed in larger studies.
    IADR/AADR/CADR General Session and Exhibition 2013; 03/2013
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    ABSTRACT: The aim of this study was to examine whether patients who received a multicondition collaborative care intervention for chronic illnesses and depression had greater improvement in self-care knowledge and efficacy, and whether greater knowledge and self-efficacy was positively associated with improved target outcomes. A randomized controlled trial with 214 patients with comorbid depression and poorly controlled diabetes and/or coronary heart disease tested a 12-month team-based intervention that combined self-management support and collaborative care management. At 6 and 12 month outcomes the intervention group showed significant improvements over the usual care group in confidence in ability to follow through with medical regimens important to managing their conditions and to maintain lifestyle changes even during times of stress. Improvements in self care-efficacy were significantly related to improvements in depression, and early improvements in confidence to maintain lifestyle changes even during times of stress explained part of the observed subsequent improvements in depression.
    Behavioral Medicine 01/2013; 39(1):1-6. DOI:10.1080/08964289.2012.708682 · 1.14 Impact Factor
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    ABSTRACT: Home hemodialysis (HD) is an underused dialysis modality in the United States, even though it provides an efficient and probably cost-effective way to provide more frequent or longer dialysis. With the advent of newer home HD systems that are easier for patients to learn, use, and maintain, patient and provider interest in home HD is increasing. Although barriers for providers are similar to those for peritoneal dialysis, home HD requires more extensive patient training, nursing education, and infrastructure support in order to maintain a successful program. In addition, because many physicians and patients do not have experience with home HD, reluctance to start home HD programs is widespread. This in-depth review describes barriers to home HD, focusing on patients, individual physicians and practices, and dialysis facilities, and offers suggestions for how to overcome these barriers and establish a successful home HD program.
    Clinical Journal of the American Society of Nephrology 10/2012; 7(12). DOI:10.2215/CJN.07080712 · 5.25 Impact Factor
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    ABSTRACT: Background/Aims: Women with diabetes experience a disproportionately greater burden of diabetic kidney disease (DKD) risk factors compared to men; however, sex-specific differences in DKD are not well defined. The effect of age on sex differences in DKD is unknown. Methods: We performed a cross-sectional analysis of the prevalence of DKD (eGFR <60 ml/min/1.73 m(2) or microalbuminuria), advanced DKD (eGFR <30 ml/min/1.73 m(2)), and common DKD risk factors in the Pathways Study (n = 4,839), a prospective cohort study of diabetic patients from a managed care setting. Subjects were stratified by age <60 and ≥60 years to examine for differences by age. Logistic regression models examined the association between sex and prevalence of DKD and risk factors. Results: Women of all ages had 28% decreased odds of DKD (OR 0.72, 95% CI 0.62-0.83); however, they had a greater prevalence of advanced DKD (OR 1.67, 95% CI 1.05-2.64), dyslipidemia (OR 1.42, 95% CI 1.16-1.74), and obesity (OR 1.87, 95% CI 1.60-2.20) compared to men. Women had similar odds of hypertension and poor glycemic control as men. Women ≥60 years had increased odds of advanced DKD, hypertension, dyslipidemia, and obesity compared to similarly aged men. Women <60 years had increased odds of obesity compared to their male counterparts. Conclusion: Women with diabetes had an increased prevalence of advanced DKD and common DKD risk factors compared to men and these disparities were most prominent amongst the elderly.
    American Journal of Nephrology 09/2012; 36(3):245-251. DOI:10.1159/000342210 · 2.65 Impact Factor
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    ABSTRACT: Chronic kidney disease is characterized, in part, as a state of decreased production of 1,25-dihydroxyvitamin D (1,25(OH)(2)D); however, this paradigm overlooks the role of vitamin D catabolism. We developed a mass spectrometric assay to quantify serum concentration of 24,25-dihydroxyvitamin D (24,25(OH)(2)D), the first metabolic product of 25-hydroxyvitamin D (25(OH)D) by CYP24A1, and determined its clinical correlates and associated outcomes among 278 participants with chronic kidney disease in the Seattle Kidney Study. For eGFRs of 60 or more, 45-59, 30-44, 15-29, and under 15 ml/min per 1.73 m(2), the mean serum 24,25(OH)(2)D concentrations significantly trended lower from 3.6, 3.2, 2.6, 2.6, to 1.7 ng/ml, respectively. Non-Hispanic black race, diabetes, albuminuria, and lower serum bicarbonate were also independently and significantly associated with lower 24,25(OH)(2)D concentrations. The 24,25(OH)(2)D concentration was more strongly correlated with that of parathyroid hormone than was 25(OH)D or 1,25(OH)(2)D. A 24,25(OH)(2)D concentration below the median was associated with increased risk of mortality in unadjusted analysis, but this was attenuated with adjustment for potential confounding variables. Thus, chronic kidney disease is a state of stagnant vitamin D metabolism characterized by decreases in both 1,25(OH)(2)D production and vitamin D catabolism.Kidney International advance online publication, 30 May 2012; doi:10.1038/ki.2012.193.
    Kidney International 05/2012; 82(6). DOI:10.1038/ki.2012.193 · 8.52 Impact Factor
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    ABSTRACT: Patients with depression and poorly controlled diabetes mellitus, coronary heart disease (CHD), or both have higher medical complication rates and higher health care costs, suggesting that more effective care management of psychiatric and medical disease control might also reduce medical service use and enhance quality of life. To evaluate the cost-effectiveness of a multicondition collaborative treatment program (TEAMcare) compared with usual primary care (UC) in outpatients with depression and poorly controlled diabetes or CHD. Randomized controlled trial of a systematic care management program aimed at improving depression scores and hemoglobin A(1c) (HbA(1c)), systolic blood pressure (SBP), and low-density lipoprotein cholesterol (LDL-C) levels. Fourteen primary care clinics of an integrated health care system. Population-based screening identified 214 adults with depressive disorder and poorly controlled diabetes or CHD. Physician-supervised nurses collaborated with primary care physicians to provide treatment of multiple disease risk factors. Blinded assessments evaluated depressive symptoms, SBP, and HbA(1c) at baseline and at 6, 12, 18, and 24 months. Fasting LDL-C concentration was assessed at baseline and at 12 and 24 months. Health plan accounting records were used to assess medical service costs. Quality-adjusted life-years (QALYs) were assessed using a previously developed regression model based on intervention vs UC differences in HbA(1c), LDL-C, and SBP levels over 24 months. Over 24 months, compared with UC controls, intervention patients had a mean of 114 (95% CI, 79 to 149) additional depression-free days and an estimated 0.335 (95% CI, -0.18 to 0.85) additional QALYs. Intervention patients also had lower mean outpatient health costs of $594 per patient (95% CI, -$3241 to $2053) relative to UC patients. For adults with depression and poorly controlled diabetes, CHD, or both, a systematic intervention program aimed at improving depression scores and HbA(1c), SBP, and LDL-C levels seemed to be a high-value program that for no or modest additional cost markedly improved QALYs. Identifier: NCT00468676
    Archives of general psychiatry 05/2012; 69(5):506-14. DOI:10.1001/archgenpsychiatry.2011.1548 · 13.75 Impact Factor
  • Spring Clinical Meeting of the National-Kidney-Foundation; 04/2012

Publication Stats

4k Citations
522.18 Total Impact Points


  • 2003–2014
    • University of Washington Seattle
      • • Department of Health Services
      • • Department of Medicine
      • • Department of Psychiatry and Behavioral Sciences
      Seattle, Washington, United States
  • 2009–2012
    • Group Health Cooperative
      • Group Health Research Institute
      Seattle, WA, United States
  • 2004–2011
    • VA Puget Sound Health Care System
      Washington, Washington, D.C., United States
    • University of Alabama at Birmingham
      • Division of Preventive Medicine
      Birmingham, AL, United States
  • 2006
    • University of California, Davis
      • Department of Family and Community Medicine
      Davis, CA, United States
  • 2001–2005
    • Northwest Kidney Centers
      Seattle, Washington, United States