Glen H. Murata

Outcomes of Treatment for Hepatitis C Virus Infection by Primary Care Providers

BACKGROUND The Extension for Community Healthcare Outcomes (ECHO) model was developed to improve access to care for underserved populations with complex health problems such as hepatitis C virus (HCV) infection. With the use of video-conferencing technology, the ECHO program trains primary care providers to treat complex diseases. METHODS We conducted a prospective cohort study comparing treatment for HCV infection at the University of New Mexico (UNM) HCV clinic with treatment by primary care clinicians at 21 ECHO sites in rural areas and prisons in New Mexico. A total of 407 patients with chronic HCV infection who had received no previous treatment for the infection were enrolled. The primary end point was a sustained virologic response. RESULTS A total of 57.5% of the patients treated at the UNM HCV clinic (84 of 146 patients) and 58.2% of those treated at ECHO sites (152 of 261 patients) had a sustained viral response (difference in rates between sites, 0.7 percentage points; 95% confidence interval, -9.2 to 10.7; P=0.89). Among patients with HCV genotype 1 infection, the rate of sustained viral response was 45.8% (38 of 83 patients) at the UNM HCV clinic and 49.7% (73 of 147 patients) at ECHO sites (P=0.57). Serious adverse events occurred in 13.7% of the patients at the UNM HCV clinic and in 6.9% of the patients at ECHO sites. CONCLUSIONS The results of this study show that the ECHO model is an effective way to treat HCV infection in underserved communities. Implementation of this model would allow other states and nations to treat a greater number of patients infected with HCV than they are currently able to treat. (Funded by the Agency for Healthcare Research and Quality and others.).

Expanding access to hepatitis C virus treatment—Extension for Community Healthcare Outcomes (ECHO) project: Disruptive innovation in specialty care†

The Extension for Community Healthcare Outcomes (ECHO) Model was developed by the University of New Mexico Health Sciences Center as a platform to deliver complex specialty medical care to underserved populations through an innovative educational model of team‐based interdisciplinary development. Using state‐of‐the‐art telehealth technology, best practice protocols, and case‐based learning, ECHO trains and supports primary care providers to develop knowledge and self‐efficacy on a variety of diseases. As a result, they can deliver best practice care for complex health conditions in communities where specialty care is unavailable. ECHO was first developed for the management of hepatitis C virus (HCV), optimal management of which requires consultation with multidisciplinary experts in medical specialties, mental health, and substance abuse. Few practitioners, particularly in rural and underserved areas, have the knowledge to manage its emerging treatment options, side effects, drug toxicities, and treatment‐induced depression. In addition, data were obtained from observation of ECHO weekly clinics and database of ECHO clinic participation and patient presentations by clinical provider. Evaluation of the ECHO program incorporates an annual survey integrated into the ECHO annual meeting and routine surveys of community providers about workplace learning, personal and professional experiences, systems and environmental factors associated with professional practice, self‐efficacy, facilitators, and barriers to ECHO. The initial survey data show a significant improvement in provider knowledge, self‐efficacy, and professional satisfaction through participation in ECHO HCV clinics. Clinicians reported a moderate to major benefit from participation. We conclude that ECHO expands access to best practice care for underserved populations, builds communities of practice to enhance professional development and satisfaction of primary care clinicians, and expands sustainable capacity for care by building local centers of excellence. (HEPATOLOGY 2010)

Partnering Urban Academic Medical Centers And Rural Primary Care Clinicians To Provide Complex Chronic Disease Care

Many of the estimated thirty-two million Americans expected to gain coverage under the Affordable Care Act are likely to have high levels of unmet need because of various chronic illnesses and to live in areas that are already underserved. In New Mexico an innovative new model of health care education and delivery known as Project ECHO (Extension for Community Healthcare Outcomes) provides high-quality primary and specialty care to a comparable population. Using state-of-the-art telehealth technology and case-based learning, Project ECHO enables specialists at the University of New Mexico Health Sciences Center to partner with primary care clinicians in underserved areas to deliver complex specialty care to patients with hepatitis C, asthma, diabetes, HIV/AIDS, pediatric obesity, chronic pain, substance use disorders, rheumatoid arthritis, cardiovascular conditions, and mental illness. As of March 2011, 298 Project ECHO teams across New Mexico have collaborated on more than 10,000 specialty care consultations for hepatitis C and other chronic diseases.

Factors affecting diabetes knowledge in Type 2 diabetic veterans

Aims/hypothesisTo describe the clinical, psychological and social factors affecting diabetes knowledge of veterans with established Type 2 diabetes.MethodsWe conducted an observational study of 284 insulin-treated veterans with stable Type 2 diabetes. All subjects completed the University of Michigan Diabetes Research and Training Centre Knowledge Test, the Diabetes Care Profile, the Mini-Mental State Examination, the Geriatric Depression Scale, and the Diabetes Family Behaviour Checklist. Stepwise multiple linear regression was used to develop a model for the diabetes knowledge score based upon clinical and psychosocial variables.ResultsOne hundred eighty subjects were evaluated in a derivation set. The mean age ± SD was 65.4±9.6 years, 94% were men, and 36% were members of a minority group. Performance on the diabetes knowledge test was poor (64.9±15.3% correct). Self-perceived understanding of all management objectives explained only 6% of the variance in the knowledge scores. Multivariate analysis showed that age, years of schooling, duration of treatment, cognitive function, sex, and level of depression were independent determinants of the knowledge score. When the model was applied to 104 subjects in a validation set, there was a strong correlation between observed and predicted scores (r=0.537; p<0.001).Conclusions/interpretationStable, insulin-treated veterans have major deficiencies in diabetes knowledge that could impair their ability to provide self-care. A multivariate model comprised of demographic variables and psychosocial profiling can identify patients who have limited diabetes knowledge and be used to assess individual barriers to ongoing diabetes education.

The Cardiovascular Research Network: A New Paradigm for Cardiovascular Quality and Outcomes Research

Background—A clear need exists for a more systematic understanding of the epidemiology, diagnosis, and management of cardiovascular diseases. More robust data are also needed on how well clinical trials are translated into contemporary community practice and the associated resource use, costs, and outcomes. Methods and Results—The National Heart, Lung, and Blood Institute recently established the Cardiovascular Research Network, which represents a new paradigm to evaluate the epidemiology, quality of care, and outcomes of cardiovascular disease and to conduct future clinical trials using a community-based model. The network includes 15 geographically distributed health plans with dedicated research centers, National Heart, Lung, and Blood Institute representatives, and an external collaboration and advisory committee. Cardiovascular research network sites bring complementary content and methodological expertise and a diverse population of ≈11 million individuals treated through various health care delivery models. Each site’s rich electronic databases (eg, sociodemographic characteristics, inpatient and outpatient diagnoses and procedures, pharmacy, laboratory, and cost data) are being mapped to create a standardized virtual data warehouse to facilitate rapid and efficient large-scale research studies. Initial projects focus on (1) hypertension recognition and management, (2) quality and outcomes of warfarin therapy, and (3) use, outcomes, and costs of implantable cardioverter defibrillators. Conclusions—The Cardiovascular Research Network represents a new paradigm in the approach to cardiovascular quality of care and outcomes research among community-based populations. Its unique ability to characterize longitudinally large, diverse populations will yield novel insights into contemporary disease and risk factor surveillance, management, outcomes, and costs. The Cardiovascular Research Network aims to become the national research partner of choice for efforts to improve the prevention, diagnosis, treatment, and outcomes of cardiovascular diseases.

Colorectal cancer screening adherence is higher with fecal immunochemical tests than guaiac-based fecal occult blood tests: a randomized, controlled trial.

OBJECTIVES Determine whether colorectal cancer screening adherence is greater with fecal immunochemical tests (FIT) or guaiac-based fecal occult blood tests (gFOBT). METHODS We used electronic health records to identify 3869 New Mexico Veterans Affairs Health Care System primary care patients due for screening in 2008 for whom fecal blood testing was appropriate. We invited randomly selected patients by mail to participate in a study comparing FIT and gFOBT. We randomly allocated 404 subjects to receive FIT (n=202) or gFOBT (n=202) by mail. We determined the proportion of subjects completing testing within 90days of agreeing to participate in the study. We also used multivariate logistic regression to evaluate screening completion, adjusting for age, gender, race/ethnicity, clinic site, previous gFOBT testing, and co-morbidity. RESULTS Screening adherence was higher with FIT than gFOBT (61.4% vs. 50.5%, P=0.03). The adjusted odds ratio for completing FIT vs. gFOBT was 1.56, 95% CI 1.04, 2.32. CONCLUSION In a clinic setting of patients who were due for colorectal cancer screening, adherence was significantly higher with FIT than gFOBT.

Estimates of interdialytic sodium and water intake based on the balance principle : Differences between nondiabetic and diabetic subjects on hemodialysis

Whether salt or water intake is the primary cause of interdialytic weight gain (ΔW) has important implication for the design of measures to prevent large ΔW. In 17 hemodialysis patients dialyzed against a bath containing 140 mmol/L of sodium, monthly predialysis serum sodium was compared with post dialysis serum sodium. A decrease in serum sodium in the interdialytic period would indicate that primary water consumption accounts for at least part of the ΔW. Interdialytic sodium intake, isotonic fluid gain (ΔWisotonic) and net pure water gain (ΔWH2O) were calculated by balance formulae. Serum sodium concentration was corrected in diabetic subjects to the value corresponding to euglycemia (100 mg/dl). Estimated interdialytic sodium intake was compared with the prescribed sodium intake and, in seven subjects, to sodium intake estimated from dietary records. Results for nondiabetic subjects (N = 9): [Na]post 139.3 ± 1.9 mmol/L, [Na]pre 140.1 ± 2.1 mmol/L (NS), ΔW 1.15 ± 0.55 L/24 hr, Δ Wisotonic 1.33 ± 0.57 L/24 hr, ΔWH2O −0.20 ± 0.58 L/24 hr, estimated sodium intake 206 ± 75 mmol/24 hr, prescribed sodium intake 121 ± 29 mmol/24 hr (p = 0.028). Results for diabetic subjects (N = 7): [Na]post140.1 ± 2.5 mmol/L, [Na]pre 137.7 ± 3.1 mmol/L (p < 0.01), ΔW 1.26 ± 0.38 L/24 hr, ΔWisotonic 0.59 ± 0.63 L/24 hr, ΔWH2O 0.66 ± 0.39 L/24 hr, estimated sodium intake 160 ± 81 mmol/24 hr, prescribed sodium intake 124 ± 30 mmol/24 hr (NS), glycosylated hemoglobin 9.7 ± 2.8% (normal, 4.1–5.7%). In seven subjects, estimates of sodium intake from balance formulae (233 ± 113 mmol/24 hr) were not different from estimates from dietary records (212 ± 87 mmol/24 hr). Sodium intake accounted for all the interdialytic weight gain in nondiabetic subjects. In diabetic patients, only approximately half of the interdialytic weight gain was accounted for by sodium intake. The other half was due to pure water gain, probably caused by hyperglycemia.

Use of emergency medical services by patients with decompensated obstructive lung disease

Little information is available about the risk of relapse when patients with decompensated obstructive lung disease are treated in an emergency department for dyspnea. The purpose of our study was to determine if the risk of relapse was related to the severity and type of airway obstruction or to the time and duration of treatment. Over a period of 29 months, 496 patients with decompensated chronic obstructive pulmonary disease (COPD), asthma, or both were seen in the ED of the Albuquerque Veterans Administration Medical Center. Of 868 visits in which patients were treated and released, 244 (28.1%) were followed by a relapse within 14 days. Those who relapsed had a slightly higher one-second forced expiratory volume at baseline than those who did not (50.1 +/- 22.2% versus 45.5 +/- 20.6% predicted, P = .054). For 94 patients (group 1), asthma was the exclusive clinical diagnosis, and all available pulmonary function tests showed a bronchodilator response. For 268 patients (group 2), COPD was the exclusive diagnosis, and all tests showed no bronchodilator response. One hundred thirty-four patients (group 3) were either diagnosed as having both disorders or had varying bronchodilator response on sequential testing. The risk of relapse for group 3 patients (35.6%) was higher than for those in groups 2 (23.1%, P less than .001) or 1 (19.7%, P = .001). The frequency of relapse was higher for nighttime than daytime visits (36.1% versus 24.5%, P = .006) and for weekend than weekday visits (33.6% versus 26.6%, P = .049). Prognosis did not vary with the season or duration of treatment.(ABSTRACT TRUNCATED AT 250 WORDS)

The relationship between glycemic control and morbidity and mortality for diabetics on dialysis.

This study was conducted to determine the association between glycemic control and clinical outcomes of diabetic patients maintained on chronic dialysis. The study group consisted of 226 diabetics (60 Type I and 166 Type II) classified as having either good glycemic control (>5 0% of blood glucose determinations within 3.3-11.1 mmol/L) or poor glycemic control (<50% of blood glucose measurements >3.3 and <11.1 mmol/L). The following variables were analyzed in each group: demographics; vascular and diabetic complications; laboratory values; and patient survival. In comparison to diabetics with poor control (Type I, n=44; Type II, n=57), those with good control, either Type I (n=16), or Type II (n=109), were dialyzed for longer periods and had shorter hospitalizations, lower prevalence rates of myocardial infarctions, congestive heart failure, orthostatic hypotension, gastroparesis and enteropathy, and higher mean serum albumin. Mean patient survival by life-table analysis was as follows: Type I diabetics, good control 128.9 + 8.1 months, poor control 29.5 + 5.0 months, p=0.0014. Type II diabetics, good control 56.9 + 6.8 months, poor control 22.8 + 4.6 months, p<0.0001. Good glycemic control during the first 6 months of dialysis predicted long-term survival for Type II but not for Type I diabetics. Poor glycemic control is associated with increased morbidity from vascular and diabetic complications, malnutrition, and shortened survival in diabetics on chronic dialysis. Although further studies are needed to determine whether poor glycemic control causes shortened survival or merely reflects comorbid conditions shortening survival, good glycemic control may constitute a Worthwhile therapeutic goal for diabetics on dialysis.

Osteoporosis Management in Prostate Cancer Patients Treated with Androgen Deprivation Therapy

BackgroundThe use of androgen deprivation therapy (ADT) for prostate cancer has increased substantially in recent years, exposing more men to potential treatment complications, including osteoporosis and fractures.ObjectiveTo determine whether men treated with ADT for prostate cancer received osteoporosis screening, prevention, or treatment.DesignCross-sectional observational study using a retrospective review of electronic medical records.SubjectsOne hundred seventy-four patients with prostate cancer on ADT or status-post orchiectomy enrolled in primary care at the New Mexico Veterans Affairs Health Care System as of July 2005.MeasurementsPatient demographics, tumor characteristics (Gleason score, stage, last PSA value, documented bone metastases), history of hip or vertebral fracture, osteoporosis risk factors (number of ADT shots, diabetes, smoking, heavy alcohol use or prescriptions for corticosteroids, thyroid hormone or dilantin). We defined recommended management as performing DXA scans or prescribing bisphosphonates, calcitonin, calcium or vitamin D.ResultsJust 60 of 174 (34%) patients received recommended osteoporosis management based on DXA scans (13%) or treatment with oral or IV bisphosphonates (21%), calcitonin (1%), calcium (16%) or vitamin D (10%). On multivariate analysis, bone metastases, higher last PSA, and younger age at diagnosis were associated with recommended management, whereas Hispanic race/ethnicity was inversely associated.ConclusionsMost men treated with ADT for prostate cancer did not receive osteoporosis screening, prevention or treatment. Evidence for advanced cancer though not risk factors for osteoporosis or fracture—was associated with receiving osteoporosis management. Further research is needed to identify optimal strategies for screening, prevention, and treatment in this population.