A. Lauren Crain

Impact of an Electronic Medical Record on Diabetes Quality of Care

PURPOSE This study was designed to evaluate the impact of electronic medical record (EMR) implementation on quality of diabetes care. METHODS We conducted a 5-year longitudinal study of 122 adults with diabetes mellitus at an intervention (EMR) clinic and a comparison (non-EMR) clinic. Clinics had similarly trained primary care physicians, similar patient populations, and used a common diabetes care guideline that emphasized the importance of glucose control. The EMR provided basic decision support, including prompts and reminders for diabetes care. Preintervention and postintervention frequency of testing for glycated hemoglobin (HbA1c) and low-density lipoprotein (LDL) levels were compared with and without adjustment for patient age, sex, comorbidity, and baseline HbA1c level. RESULTS Frequency of HbA1c tests increased at the EMR clinic compared with the frequency at the non-EMR clinic (P <.001). HbA1c levels improved in both clinics (P <.05) with no significant differences between clinics 2 years (P = .10) or 4 years (P = .27) after EMR implementation. Similar results were observed for LDL levels. CONCLUSIONS In this controlled study, EMR use led to an increased number of HbA1c and LDL tests but not to better metabolic control. If EMRs are to fulfill their promise as care improvement tools, improved implementation strategies and more sophisticated clinical decision support may be needed.

Scientists’ Perceptions of Organizational Justice and Self-Reported Misbehaviors

Policymakers concerned about maintaining the integrity of science have recently expanded their attention from a focus on misbehaving individuals to characteristics of the environments in which scientists work. Little empirical evidence exists about the role of organizational justice in promoting or hindering scientific integrity. Our findings indicate that when scientists believe they are being treated unfairly they are more likely to behave in ways that compromise the integrity of science. Perceived violations of distributive and procedural justice were positively associated with self-reports of misbehavior among scientists.

Changes in physical activity and short-term changes in health care charges: a prospective cohort study of older adults

BACKGROUND Better understanding the impact of changes in physical activity behavior on short-term health care charges may inform resource allocation decisions to increase population levels of physical activity. This study examines the prospective relationship of changes in physical activity status on short-term changes in health care charges for older adults. METHODS A prospective cohort study was done on a stratified random sample of 2,393 adults aged 50 and older enrolled in a Minnesota health plan, predicting changes in resource use between two periods (September 1994 to August 1995 and September 1996 to August 1997) based on billed health care charges. RESULTS After adjustment for age, gender, comorbidity, smoking status, and body mass index, all physical activity states had declining health care charges, relative to those who were consistently inactive. Subjects who increased their physical activity from 0-1 to 3+ days/week had significant declines in their mean annualized total charges (-2,202 dollars, P < 0.01) relative to those who remained inactive. CONCLUSIONS Increased physical activity among older adults is associated with lower health care charges within 2 years, relative to charges for those who were persistently inactive. These cost savings may justify investments in effective interventions to increase physical activity in older adults.

Mindfulness-Based Stress Reduction for Family Caregivers: A Randomized Controlled Trial

PURPOSE Caring for a family member with dementia is associated with chronic stress, which can have significant deleterious effects on caregivers. The purpose of the Balance Study was to compare a mindfulness-based stress reduction (MBSR) intervention to a community caregiver education and support (CCES) intervention for family caregivers of people with dementia. DESIGN AND METHODS We randomly assigned 78 family caregivers to an MBSR or a CCES intervention, matched for time and attention. Study participants attended 8 weekly intervention sessions and participated in home-based practice. Surveys were completed at baseline, postintervention, and at 6 months. Participants were 32- to 82-year-old predominately non-Hispanic White women caring for a parent with dementia. RESULTS MBSR was more effective at improving overall mental health, reducing stress, and decreasing depression than CCES. Both interventions improved caregiver mental health and were similarly effective at improving anxiety, social support, and burden. IMPLICATIONS MBSR could reduce stress and improve mental health in caregivers of family members with dementia residing in the community.

Care Quality and Implementation of the Chronic Care Model: A Quantitative Study

PURPOSE We wanted to test whether improvements in care quality were correlated with changes in the Chronic Care Model (CCM) in a large medical group that attempted to implement the CCM. METHODS The leaders of 17 primary care clinics in this medical group completed the Assessing Chronic Illness Care (ACIC) survey measure of CCM implementation before and after care system changes were made. We used administrative data to measure care quality changes for yearly samples of patients with diabetes, coronary heart disease, or depression. RESULTS The total ACIC score for the CCM increased by an overall average of 1.4 points (from 5.8 to 7.2 on a scale of 1 to 11, P = .02) and significant increases occurred for 3 of the 6 components of the CCM. During this time, patients experienced a significant increase in the proportion meeting a composite outcome measure for low-density lipoprotein (LDL) and glycated hemoglobin levels (from 15.7% to 25.5%, P = .001). Heart disease patients meeting a composite measure for LDL values increased from 46.8% to 57.8%, and the percentage of patients with 1 or more cardiac events dropped from 17.2% to 11.4% (P = .001 for each). Persistent use of new antidepressants did not change, but more of these patients had follow-up visits (P = .02). Only the diabetes measure was significantly correlated with 2 CCM elements—clinical information systems and decision support. CONCLUSION Despite implementation of the CCM and improvements in quality measures for 3 chronic diseases, there were few significant correlations between these changes. Showing such a relationship may require larger changes, a larger number of clinics, changes in other CCM elements, or a more-sensitive measurement tool.

Severity of Depression and Magnitude of Productivity Loss

PURPOSE Depression is associated with lowered work functioning, including absences, impaired productivity, and decreased job retention. Few studies have examined depression symptoms across a continuum of severity in relationship to the magnitude of work impairment in a large and heterogeneous patient population, however. We assessed the relationship between depression symptom severity and productivity loss among patients initiating treatment for depression. METHODS Data were obtained from patients participating in the DIAMOND (Depression Improvement Across Minnesota: Offering a New Direction) initiative, a statewide quality improvement collaborative to provide enhanced depression care. Patients newly started on antidepressants were surveyed with the Patient Health Questionnaire 9-item screen (PHQ-9), a measure of depression symptom severity; the Work Productivity and Activity Impairment (WPAI) questionnaire, a measure of loss in productivity; and items on health status and demographics. RESULTS We analyzed data from the 771 patients who reported being currently employed. General linear models adjusting for demographics and health status showed a significant linear, monotonic relationship between depression symptom severity and productivity loss: with every 1-point increase in PHQ-9 score, patients experienced an additional mean productivity loss of 1.65% (P <.001). Even minor levels of depression symptoms were associated with decrements in work function. Full-time vs part-time employment status and self-reported fair or poor health vs excellent, very good, or good health were also associated with a loss of productivity (P <.001 and P=.045, respectively). CONCLUSIONS This study shows a relationship between the severity of depression symptoms and work function, and suggests that even minor levels of depression are associated with a loss of productivity. Employers may find it beneficial to invest in effective treatments for depressed employees across the continuum of depression severity.

Do All Components of the Chronic Care Model Contribute Equally to Quality Improvement

BACKGROUND The Chronic Care Model (CCM) is a widely used conceptual model for improving chronic illness care, but there is limited evidence to support the validity of this model. Seventeen clinics in a single medical group used the CCM in a diabetes improvement initiative, and the study tested which CCM components at the clinic level were associated with improved glycohemoglobin (A1C) and low-density (LDL) outcomes for patients with diabetes. DESIGN Three leaders from each of 17 clinics completed a survey in 2002 that assessed the presence of CCM components in their clinics. Clinic scores from this survey were correlated with change in clinic-level measures of the quality of care for their diabetes patients (A1C and LDL outcomes) during the preceding year. RESULTS Delivery system design (DSD) scores were positively correlated with improvements in A1C and lipid test rates and levels at these clinics (r = 0.49-0.57, p < .05). Self-management support and clinical information systems demonstrated associations that may have substantive significance but did not reach p < 05. CONCLUSIONS These data suggest that delivery system design is associated with improved A1C and LDL outcomes for people with diabetes. Additional studies are necessary to determine the association of other CCM components with improved outcomes.

Does Diabetes Double the Risk of Depression

PURPOSE In this study, we compared the rate of depression diagnoses in adults with and without diabetes mellitus, while carefully controlling for number of primary care visits. METHODS We matched adults with incident diabetes (n = 2,932) or prevalent diabetes (n = 14,144) to nondiabetic control patients based on (1) age and sex, or (2) age, sex, and number of outpatient primary care visits. Logistic regression analysis was used to assess the association between various predictors and a diagnosis of depression in each diabetes cohort relative to matched nondiabetic control patients. RESULTS With matching for age and sex alone, patients with prevalent diabetes having few primary care visits were significantly more likely to have a new depression diagnosis than matched control patients (odds ratio [OR] = 1.46, 95% confidence interval [CI], 1.19–1.80), but this relationship diminished when patients made more than 10 primary care visits (OR = 0.95, 95% CI, 0.77–1.17). With additional matching for number of primary care visits, patients with prevalent diabetes mellitus with few primary care visits were more likely to have a new diagnosis of depression than those in control group (OR = 1.32, 95% CI, 1.07–1.63), but this relationship diminished and reversed when patients made more than 4 primary care visits (OR = 0.99, 95% CI, 0.80–1.23). Similar results were observed in the subset of patients with incident diabetes and their matched control patients. CONCLUSIONS Patients with diabetes have little or no increase in the risk of a new diagnosis of depression relative to nondiabetic patients when analyses carefully control for the number of outpatient visits. Studies showing such an association may have inadequately adjusted for comorbidity or for exposure to the medical care system.

Partnership research: a practical trial design for evaluation of a natural experiment to improve depression care.

Background:Translational research is increasingly important as academic health centers transform themselves to meet new requirements of National Institutes of Health funding. Most attention has focused on T1 translation studies (bench to bedside) with considerable uncertainty about how to enhance T2 (effectiveness trials) and especially T3 (implementation studies). Objective:To describe an innovative example of a T3 study, conducted as partnership research with the leaders of a major natural experiment in Minnesota to improve the primary care of depression. Methods:All health plans in the state have agreed on a new payment model to support clinics that implement the well-evidenced collaborative care model for depression in the Depression Improvement Across Minnesota: Offering a New Direction initiative. The Depression Improvement Across Minnesota: Offering a New Direction study was developed in an ongoing partnership with the Initiative leaders from 7 health plans, 85 clinics, and a regional quality improvement collaborative to evaluate the implementation and its impacts on patients and other stakeholders. We agreed on a staggered implementation, multiple baseline research design, using the concepts of practical clinical trials and engaged scholarship and have collaborated on all aspects of conducting the study, including joint identification of patient and clinic survey recipients. Results:Complex study methods have worked well through 20 months because of the commitment of all stakeholders to both the Initiative and the Study. Over 1500 subjects have been recruited from health plan information delivered weekly, and 99.7% of 316 physicians and administrators from all participating clinical organizations have completed the Study surveys. Conclusions:Partnership research can greatly facilitate translational research studies.

The Effect of Exercise During Pregnancy on Maternal Outcomes: Practical Implications for Practice

The American College of Obstetricians and Gynecologists recommends that women with low-risk pregnancies participate in moderate-intensity exercise during their pregnancy. Currently, only 15.1% of pregnant women exercise at the recommended levels, which is significantly lower than the general populations 45%. One potential reason is that exercise during pregnancy is perceived as risky. In this article, the authors provide a critical review of the literature examining the effect of exercise on preeclampsia, gestational diabetes, weight gain, labor and birth, and other issues associated with pregnancy. Overall, the evidence indicates that exercise during pregnancy is safe and perhaps even reduces the risk of preeclampsia and gestational diabetes. The evidence for weight gain and labor and birth (rates of cesarean sections, duration of labor) is mixed. Unfortunately, much of the research examining exercise during pregnancy is observational, and the few randomized controlled trials that do exist are small and inadequately powered. Taken together, given the potential benefits of exercise during pregnancy and the lack of evidence for harmful effects on the mother and newborn, practitioners should encourage their healthy pregnant patients to exercise. Practical guidelines for recommending exercise to pregnant women are presented.