Janelle Lee

Comorbid depression, chronic pain, and disability in primary care.

Objectives: The objectives of this study were to provide estimates of the prevalence and strength of association between major depression and chronic pain in a primary care population and to examine the clinical burden associated with the two conditions, singly and together. Methods: A random sample of Kaiser Permanente patients who visited a primary care clinic was mailed a questionnaire assessing major depressive disorder (MDD), chronic pain, pain-related disability, somatic symptom severity, panic disorder, other anxiety, probable alcohol abuse, and health-related quality of life (HRQL). Instruments included the Patient Health Questionnaire, SF-8, and Graded Chronic Pain Questionnaire. A total of 5808 patients responded (54% of those eligible to participate). Results: Among those with MDD, a significantly higher proportion reported chronic (i.e., nondisabling or disabling) pain than those without MDD (66% versus 43%, respectively). Disabling chronic pain was present in 41% of those with MDD versus 10% of those without MDD. Respondents with comorbid depression and disabling chronic pain had significantly poorer HRQL, greater somatic symptom severity, and higher prevalence of panic disorder than other respondents. The prevalence of probable alcohol abuse/dependence was significantly higher among persons with MDD compared with individuals without MDD regardless of pain or disability level. Compared with participants without MDD, the prevalence of other anxiety among those with MDD was more than sixfold greater regardless of pain or disability level. Conclusions: Chronic pain is common among those with MDD. Comorbid MDD and disabling chronic pain are associated with greater clinical burden than MDD alone. MDD = major depressive disorder; HRQL = health-related quality of life; HMO = health maintenance organization; PHQ = Patient Health Questionnaire; GCPS = Graded Chronic Pain Scale; CP = chronic pain; DCP = disabling chronic pain; GAD = generalized anxiety disorder; SCID = Structured Clinical Interview for DSM-III-R; PRIME-MD = Primary Care Evaluation of Mental Disorders; CI = confidence interval; DSM-IV = Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition; DSM-III-R = Diagnostic and Statistical Manual of Mental Disorders, Third Edition Revised.

Effectiveness of heptavalent pneumococcal conjugate vaccine in children younger than 5 years of age for prevention of pneumonia: Updated analysis using World Health Organization standardized interpretation of chest radiographs

Background: A World Health Organization (WHO) working group in 2001 developed a method for standardizing interpretation of chest radiographs in children for epidemiologic purposes. We reevaluated radiographs from the Kaiser Permanente Pneumococcal Efficacy trial using this method. Methods: Seven-valent pneumococcal conjugate vaccine was evaluated in a randomized, controlled study including 37,868 infants. Effectiveness against pneumonia was previously evaluated using the original treating radiologist reading. There were 2841 sets of radiographs from this trial and all available radiographs were scanned and read blindly by 2 WHO crosstrained readers (A and B); discordance between the 2 primary readers was resolved through a consensus reading by an adjudicating panel of 2 radiologists. Results: Of the 2841 radiographs, 2446 were available for scanning and were reviewed using WHO-defined descriptive categories. Two hundred fifty of the 2446 radiographs were read as positive by both readers. An additional 129 were read as positive by reader A only and 142 by reader B only for a total of 521 radiographs that were read as positive by one or both of the reviewers. The concordance rate between the 2 reviewers was 250 of 521 (48%). Of the 271 discordant radiographs, 45 of 129 (34.9%) of reader A and 66 of 142 (46.5%) for reader B were finalized as positive by the adjudicating panel. Overall, 361 radiographs were finalized as positive (12.7%). With these 361 images as the standard, the sensitivity and specificity of reader A were 82% and 97%, respectively, and for reader B, 88% and 97%, respectively. Kappa between the 2 readers was 0.58. Of 25 control radiographs read as positive by both A and B, 80% were also read as positive by the panel and all 25 control negative radiographs were read as negative by the panel. Using original readings by point-of-care radiologists, efficacy against first episode of radiograph confirmed pneumonia was 17.7% (95% confidence interval [CI] = 4.8–28.9%) in intent-to-treat and 20.5% (95% CI = 4.4–34%) in per protocol. Using the WHO method, the efficacy against first episode of radiograph confirmed pneumonia adjusting for age, gender and year of vaccination of 25.5% (95% CI = 6.5–40.7%, P = 0.011) for intent-to-treat and 30.3% (95% CI = 10.7–45.7%, P = 0.0043) for per protocol. Conclusion: Using WHO criteria for reading of radiographs increased point estimates of vaccine efficacy presumably as a result of improved specificity.

Influenza Vaccination and Mortality: Differentiating Vaccine Effects From Bias

It is widely believed that influenza (flu) vaccination of the elderly reduces all-cause mortality, yet randomized trials for assessing vaccine effectiveness are not feasible and the observational research has been controversial. Efforts to differentiate vaccine effectiveness from selection bias have been problematic. The authors examined mortality before, during, and after 9 flu seasons in relation to time-varying vaccination status in an elderly California population in which 115,823 deaths occurred from 1996 to 2005, including 20,484 deaths during laboratory-defined flu seasons. Vaccine coverage averaged 63%; excess mortality when the flu virus was circulating averaged 7.8%. In analyses that omitted weeks when flu circulated, the odds ratio measuring the vaccination-mortality association increased monotonically from 0.34 early in November to 0.56 in January, 0.67 in April, and 0.76 in August. This reflects the trajectory of selection effects in the absence of flu. In analyses that included weeks with flu and adjustment for selection effects, flu season multiplied the odds ratio by 0.954. The corresponding vaccine effectiveness estimate was 4.6% (95% confidence interval: 0.7, 8.3). To differentiate vaccine effects from selection bias, the authors used logistic regression with a novel case-centered specification that may be useful in other population-based studies when the exposure-outcome association varies markedly over time.

The impact of removing financial incentives from clinical quality indicators: Longitudinal analysis of four Kaiser Permanente indicators

Objective To evaluate the effect of financial incentives on four clinical quality indicators common to pay for performance plans in the United Kingdom and at Kaiser Permanente in California. Design Longitudinal analysis. Setting 35 medical facilities of Kaiser Permanente Northern California, 1997-2007. Participants 2 523 659 adult members of Kaiser Permanente Northern California. Main outcomes measures Yearly assessment of patient level glycaemic control (HbA1c <8%), screening for diabetic retinopathy, control of hypertension (systolic blood pressure <140 mm Hg), and screening for cervical cancer. Results Incentives for two indicators—screening for diabetic retinopathy and for cervical cancer—were removed during the study period. During the five consecutive years when financial incentives were attached to screening for diabetic retinopathy (1999-2003), the rate rose from 84.9% to 88.1%. This was followed by four years without incentives when the rate fell year on year to 80.5%. During the two initial years when financial incentives were attached to cervical cancer screening (1999-2000), the screening rate rose slightly, from 77.4% to 78.0%. During the next five years when financial incentives were removed, screening rates fell year on year to 74.3%. Incentives were then reattached for two years (2006-7) and screening rates began to increase. Across the 35 facilities, the removal of incentives was associated with a decrease in performance of about 3% per year on average for screening for diabetic retinopathy and about 1.6% per year for cervical cancer screening. Conclusion Policy makers and clinicians should be aware that removing facility directed financial incentives from clinical indicators may mean that performance levels decline.

Catastrophizing, depression and pain-related disability.

OBJECTIVE The objective of the study was to examine catastrophizing, depression and their interactive effects in predicting disability in patients with chronic pain. METHOD A battery of questionnaires was mailed to primary care patients in a large integrated health care delivery system. The Patient Health Questionnaire was used to assess major depression, the Coping Strategies Questionnaire assessed catastrophizing and the Graded Chronic Pain Scale was used to assess pain intensity and two measures of disability, including self-report of pain interference and days missed from usual activities. Patient medical records were used to assess severe medical illness. Of the 5808 respondents, 2618 met criteria for chronic pain. Multiple regression analyses, covarying for age, gender, severe medical illness and pain intensity, estimated the main and interactive effects of catastrophic thinking and depression on two measures of pain-related disability. RESULTS Both catastrophic thinking and depression were statistically significant predictors of both measures of pain-related disability, with larger effect sizes observed for catastrophic thinking. CONCLUSIONS Routine assessment of both catastrophic thinking and depression is important in the treatment of chronic pain patients, and modification of these factors may reduce disability and increase the ability of chronic pain patients to participate in daily life activity.

Evidence of Bias in Studies of Influenza Vaccine Effectiveness in Elderly Patients

Although studies have shown influenza vaccines to be effective in preventing death in the elderly population, these findings may be the result of selection bias. We examined the relationship between vaccination, age, underlying morbidity, and probability of death in the upcoming year. Vaccination coverage varied in a curvilinear fashion with age, morbidity, and risk of death. Forgoing vaccination predicted death in those who had received vaccinations in the previous 5 years, but it predicted survival in patients who had never before received a vaccination. We conclude that bias is inherent in studies of influenza vaccination and death among elderly patients.

Meaningful variation in performance: what does variation in quality tell us about improving quality?

Background:Variance reduction is sometimes considered as a goal of clinical quality improvement. Variance among physicians, hospitals, or health plans has been evaluated as the proportion of total variance (or intraclass correlation, ICC) in a quality measure; low ICCs have been interpreted to indicate low potential for quality improvement at that level. However, the absolute amount of variation, expressed in clinically meaningful units, is less frequently reported. Moreover, changes in variance components have not been studied as quality improves. Objectives:To examine changes in variance components at primary care physician and medical facility levels as performance improved for 4 quality indicators: systolic blood pressure levels in hypertension; low-density lipoprotein-cholesterol levels in hyperlipidemia; patient-reported care experience scores after primary care visits; and mammography screening rates. Population:Adult members (n = 62,596–410,976) of Kaiser Permanente in Northern California, served by more than 1000 primary care physicians in 35 facilities, from 2001 to 2006. Methods:Multilevel linear and logistic regression to examine the interphysician and interfacility variances in 4 quality indicators over 6 years, after case-mix adjustment. Results:ICCs were low for all 4 indicators at both levels (0.0021–0.086). Nevertheless, variances at both levels were statistically and clinically significant. For systolic blood pressure and the care experience score, interfacility and interphysician variance as well as ICCs decreased further as quality improved; declines were greater at the facility level. For low-density lipoprotein-cholesterol, variability at both levels increased with quality improvement; and for screening mammography, small declines were not statistically significant for either physicians or facilities. Conclusions:Low proportions of variance do not predict low potential for quality improvement. Despite low ICCs for facilities, quality improvement efforts directed primarily at facilities improved quality for all 4 indicators.

Does Gender Moderate the Relationship Between Childhood Maltreatment and Adult Depression

Although considerable evidence demonstrates that adults who report childhood maltreatment are at increased risk of depression in adulthood, little is known about whether gender moderates risk. In a sample of 5,673 adult Health Maintenance Organization (HMO) patients, the authors employed the Patient Health Questionnaire-8 (PHQ-8) to assess major depressive disorder (MDD) and the Childhood Trauma Questionnaire (CTQ) to assess five different types of childhood maltreatment: emotional, physical, and sexual abuse, as well as emotional and physical neglect. Logistic regression models tested the main and interactive effects of gender and childhood maltreatment. Consistent with previous studies, men and women with histories of each type of childhood adversity were significantly more likely to meet criteria for MDD. However, the authors found no evidence that gender moderates the risk of depression. These findings suggest that men and women reporting history of childhood maltreatment are equally likely to suffer major depression in adulthood.

Trends in Time to Confirmation and Recognition of New-Onset Hypertension, 2002–2006

Achieving full benefits of blood pressure control in populations requires prompt recognition of previously undetected hypertension. In 2003, the Seventh Report of the Joint National Committee on Prevention, Detection, Evaluation, and Treatment of High Blood Pressure provided definitions of hypertension and recommended that single elevated readings be confirmed within 1 to 2 months. We sought to determine whether the time required to confirm and recognize (ie, diagnose and/or treat) new-onset hypertension decreased from 2002 to 2006 for adult members of 2 large integrated healthcare delivery systems, Kaiser Permanente Northern California and Colorado. Using electronically stored office blood pressure readings, physician diagnoses, and pharmacy prescriptions, we identified 200 587 patients with new-onset hypertension (2002-2006) marked by 2 consecutive elevated blood pressure readings in previously undiagnosed, untreated members. Mean confirmation intervals (time from the first to second consecutive elevated reading) declined steadily from 103 to 89 days during this period. For persons recognized within 12 months after confirmation, the mean interval to recognition declined from 78 to 61 days. However, only 33% of individuals were recognized within 12 months. One third were never recognized during observed follow-up. For these patients, most subsequent blood pressure recordings were not elevated. Higher initial blood pressure levels, history of previous cardiovascular disease, and older age were associated with shorter times to recognition. Times to confirmation and recognition of new-onset hypertension have become shorter in recent years, especially for patients with higher cardiovascular disease risk. Variability in office-based blood pressure readings suggests that further improvements in recognition and treatment may be achieved with more specific automated approaches to identifying hypertension.

Evaluation of Immunization Rates and Safety Among Children With Inborn Errors of Metabolism

BACKGROUND: Children with inherited metabolic disorders are a potential high-risk group for vaccine-preventable diseases, yet information regarding immunization rates and vaccine safety within this population is limited. METHODS: Using Northern California Kaiser Permanentes electronic medical record, we identified children with inborn errors of metabolism from 1990 to 2007. We assessed immunization rates among infants with inborn errors of metabolism born at Northern California Kaiser Permanente matched to healthy infants (1 to 20), comparing both vaccines received by 2 years of age and age at vaccination. We assessed postvaccination adverse events among children up to 18 years old with inborn errors of metabolism, separately comparing emergency-department visits and hospitalizations during postvaccine days 0 to 30 (primary) and days 0 to 14 (secondary). RESULTS: Comparing infants with inborn errors of metabolism (n = 77) versus matched control subjects (n = 1540), similar proportions were up to date for vaccines at 2 years of age, and there was no evidence of delay in receipt of recommended vaccines during the first year. Vaccination of children with inborn errors of metabolism (n = 271) was not associated with any significant increase in emergency-department visits or hospitalizations during the 30 days after vaccination. Secondary analyses suggested that there may be increased rates of hospitalizations 2 weeks after vaccination for the sickest 1- to 4-year-old children. CONCLUSIONS: Children with inborn errors of metabolism at Northern California Kaiser Permanente received vaccines on the same immunization schedule as healthy infants. Immunization was not associated with increased risk for serious adverse events during the month after vaccination, providing overall reassurance that routine vaccination of children with inborn errors of metabolism does not result in adverse effects.