Karin M. Nelson

Prediction of Diabetic Foot Ulcer Occurrence Using Commonly Available Clinical Information: The Seattle Diabetic Foot Study

OBJECTIVE—The ability of readily available clinical information to predict the occurrence of diabetic foot ulcer has not been extensively studied. We conducted a prospective study of the individual and combined effects of commonly available clinical information in the prediction of diabetic foot ulcer occurrence. RESEARCH DESIGN AND METHODS—We followed 1,285 diabetic veterans without foot ulcer for this outcome with annual clinical evaluations and quarterly mailed questionnaires to identify foot problems. At baseline we assessed age; race; weight; current smoking; diabetes duration and treatment; HbA1c (A1C); visual acuity; history of laser photocoagulation treatment, foot ulcer, and amputation; foot shape; claudication; foot insensitivity to the 10-g monofilament; foot callus; pedal edema; hallux limitus; tinea pedis; and onychomycosis. Cox proportional hazards modeling was used with backwards stepwise elimination to develop a prediction model for the first foot ulcer occurrence after the baseline examination. RESULTS—At baseline, subjects were 62.4 years of age on average and 98% male. Mean follow-up duration was 3.38 years, during which time 216 foot ulcers occurred, for an incidence of 5.0/100 person-years. Significant predictors (P ≤ 0.05) of foot ulcer in the final model (hazard ratio, 95% CI) included A1C (1.10, 1.06–1.15), impaired vision (1.48, 1.00–2.18), prior foot ulcer (2.18, 1.61–2.95), prior amputation (2.57, 1.60–4.12), monofilament insensitivity (2.03, 1.50–2.76), tinea pedis (0.73, 0.54–0.98), and onychomycosis (1.58, 1.16–2.16). Area under the receiver operating characteristic curve was 0.81 at 1 year and 0.76 at 5 years. CONCLUSIONS—Readily available clinical information has substantial predictive power for the development of diabetic foot ulcer and may help in accurately targeting persons at high risk of this outcome for preventive interventions.

Health and Health Behavior Differences

BACKGROUND Little is known about health and health behavior differences among military service veterans, active duty service members, National Guard/Reserve members, and civilians. Several important differences were identified among U.S. women from these subpopulations; to identify areas for targeted intervention, studies comparing men from these subpopulations are needed. PURPOSE To compare veteran, military, and civilian men on leading U.S. health indicators. METHODS Data were from the 2010 Behavioral Risk Factor Surveillance Survey, a U.S. population-based study. In 2011, self-reported health outcomes were compared using multivariable logistic regression across male veterans (n=53,406); active duty service members (n=2144); National Guard/Reserve service members (n=3724); and civilians (n=110,116). RESULTS Multivariate logistic regression results are presented. Despite better healthcare access, veterans had poorer health and functioning than civilians and National Guard/Reserve members on several indicators. Veterans also were more likely than those on active duty to report diabetes. Veterans were more likely to report current smoking and heavy alcohol consumption than National Guard/Reserve members and civilian men, and lack of exercise compared to active duty men and National Guard/Reserve members. National Guard/Reserve men had higher levels of obesity, diabetes, and cardiovascular disease (versus active duty and veterans, active duty, and civilians, respectively). Active duty men were more likely to report current smoking and heavy alcohol consumption than civilians and National Guard/Reserve members, and reported more smokeless tobacco use than civilians. CONCLUSIONS Veterans have poorer health and health behaviors; increased prevention efforts are needed from veteran-serving organizations. Despite good health, active duty men reported unhealthy lifestyles, indicating an important area for prevention efforts.

Implementation of the Patient-Centered Medical Home in the Veterans Health Administration: Associations With Patient Satisfaction, Quality of Care, Staff Burnout, and Hospital and Emergency Department Use

IMPORTANCE In 2010, the Veterans Health Administration (VHA) began implementing the patient-centered medical home (PCMH) model. The Patient Aligned Care Team (PACT) initiative aims to improve health outcomes through team-based care, improved access, and care management. To track progress and evaluate outcomes at all VHA primary care clinics, we developed and validated a method to assess PCMH implementation. OBJECTIVES To create an index that measures the extent of PCMH implementation, describe variation in implementation, and examine the association between the implementation index and key outcomes. DESIGN, SETTING, AND PARTICIPANTS We conducted an observational study using data on more than 5.6 million veterans who received care at 913 VHA hospital-based and community-based primary care clinics and 5404 primary care staff from (1) VHA clinical and administrative databases, (2) a national patient survey administered to a weighted random sample of veterans who received outpatient care from June 1 to December 31, 2012, and (3) a survey of all VHA primary care staff in June 2012. Composite scores were constructed for 8 core domains of PACT: access, continuity, care coordination, comprehensiveness, self-management support, patient-centered care and communication, shared decision making, and team-based care. MAIN OUTCOMES AND MEASURES Patient satisfaction, rates of hospitalization and emergency department use, quality of care, and staff burnout. RESULTS Fifty-three items were included in the PACT Implementation Progress Index (Pi2). Compared with the 87 clinics in the lowest decile of the Pi2, the 77 sites in the top decile exhibited significantly higher patient satisfaction (9.33 vs 7.53; P < .001), higher performance on 41 of 48 measures of clinical quality, lower staff burnout (Maslach Burnout Inventory emotional exhaustion subscale, 2.29 vs 2.80; P = .02), lower hospitalization rates for ambulatory care-sensitive conditions (4.42 vs 3.68 quarterly admissions for veterans 65 years or older per 1000 patients; P < .001), and lower emergency department use (188 vs 245 visits per 1000 patients; P < .001). CONCLUSIONS AND RELEVANCE The extent of PCMH implementation, as measured by the Pi2, was highly associated with important outcomes for both patients and providers. This measure will be used to track the effectiveness of implementing PACT over time and to elucidate the correlates of desired health outcomes.

Research articleHealth and Health Behavior Differences: U.S. Military, Veteran, and Civilian Men

BACKGROUND Little is known about health and health behavior differences among military service veterans, active duty service members, National Guard/Reserve members, and civilians. Several important differences were identified among U.S. women from these subpopulations; to identify areas for targeted intervention, studies comparing men from these subpopulations are needed. PURPOSE To compare veteran, military, and civilian men on leading U.S. health indicators. METHODS Data were from the 2010 Behavioral Risk Factor Surveillance Survey, a U.S. population-based study. In 2011, self-reported health outcomes were compared using multivariable logistic regression across male veterans (n=53,406); active duty service members (n=2144); National Guard/Reserve service members (n=3724); and civilians (n=110,116). RESULTS Multivariate logistic regression results are presented. Despite better healthcare access, veterans had poorer health and functioning than civilians and National Guard/Reserve members on several indicators. Veterans also were more likely than those on active duty to report diabetes. Veterans were more likely to report current smoking and heavy alcohol consumption than National Guard/Reserve members and civilian men, and lack of exercise compared to active duty men and National Guard/Reserve members. National Guard/Reserve men had higher levels of obesity, diabetes, and cardiovascular disease (versus active duty and veterans, active duty, and civilians, respectively). Active duty men were more likely to report current smoking and heavy alcohol consumption than civilians and National Guard/Reserve members, and reported more smokeless tobacco use than civilians. CONCLUSIONS Veterans have poorer health and health behaviors; increased prevention efforts are needed from veteran-serving organizations. Despite good health, active duty men reported unhealthy lifestyles, indicating an important area for prevention efforts.

Is Food Insufficiency Associated with Health Status and Health Care Utilization Among Adults with Diabetes

AbstractOBJECTIVES: Preliminary studies have shown that among adults with diabetes, food insufficiency has adverse health consequences, including hypoglycemic episodes and increased need for health care services. The purpose of this study was to determine the prevalence of food insufficiency and to describe the association of food insufficiency with health status and health care utilization in a national sample of adults with diabetes. METHODS: We analyzed data from adults with diabetes (n=1,503) interviewed in the Third National Health and Nutrition Examination Survey. Bivariate and multivariate analyses were used to examine the relationship of food insufficiency to self-reported health status and health care utilization. RESULTS: Six percent of adults with diabetes reported food insufficiency, representing more than 568,600 persons nationally (95% confidence interval, 368,400 to 768,800). Food insufficiency was more common among those with incomes below the federal poverty level (17% vs 4%, P≤.001). Adults with diabetes who were food insufficient were more likely to report fair or poor health status than those who were not (63% vs 43%; odds ratio, 2.2; P=.05). In a multivariate analysis, fair or poor health status was independently associated with poverty, nonwhite race, low educational achievement, and number of chronic diseases, but not with food insufficiency. Diabetic adults who were food insufficient reported more physician encounters, either in clinic or by phone, than those who were food secure (12 vs 7, P<.05). In a multivariate linear regression, food insufficiency remained independently associated with increased physician utilization among adults with diabetes. There was no association between food insufficiency and hospitalization in bivariate analysis. CONCLUSIONS: Food insufficiency is relatively common among low-income adults with diabetes and was associated with higher physician utilization.

Health Indicators for Military, Veteran, and Civilian Women

BACKGROUND Women who have served in the military are a rapidly growing population. No previous studies have compared directly their health status to that of civilians. PURPOSE To provide estimates of several leading U.S. health indicators by military service status among women. METHODS Data were obtained from the 2010 Behavioral Risk Factor Surveillance Survey, a U.S. population-based study. Health outcomes were compared by military status using multivariable logistic regression among the female participants (274,399 civilians, 4221 veterans, 661 active duty, and 995 National Guard or Reserves [NG/R]). Data were analyzed in August 2011. RESULTS Veterans reported poorer general health and greater incidence of health risk behaviors, mental health conditions, and chronic health conditions than civilian women. Active duty women reported better access to health care, better physical health, less engagement in health risk behaviors, and greater likelihood of having had a recent Pap than civilian women. Women from the NG/R were comparable to civilians across most health domains, although they had a greater likelihood of being overweight or obese and reporting a depressive and anxiety disorder. CONCLUSIONS Compared with civilian women, NG/R women rated their health and access to health care similarly and active duty women rated theirs better on several domains, but veterans consistently reported poorer health.

Factors Influencing Disease Self-Management Among Veterans with Diabetes and Poor Glycemic Control

Specific AimAlthough the Department of Veterans Affairs (VA) has made significant organizational changes to improve diabetes care, diabetes self-management has received limited attention. The purpose of this study is to assess factors influencing diabetes self-management among veterans with poorly controlled diabetes.MethodsSurveys were mailed to patients with type 2 diabetes and a HbA1c of 8% or greater who attended 1 of 2 VA Medical Centers in Washington State (n = 1,286). Validated survey instruments assessed readiness to change, self-efficacy, provider advice, and diabetes self-care practices.ResultsOur response rate was 56% (n = 717). Most respondents reported appropriate advice from physicians regarding physical activity, nutrition, and glucose monitoring (73%, 92%, and 98%, respectively), but many were not ready to change self-management behaviors. Forty-five percent reported non-adherence to medications, 42% ate a high-fat diet, and only 28% obtained either moderate or vigorous physical activity. The mean self-efficacy score for diabetes self-care was low and half of the sample reported readiness to change nutrition (52%) or physical activity (51%). Individuals with higher self-efficacy scores were more likely to adhere to medications, follow a diabetic meal plan, eat a lower fat diet, have higher levels of physical activity, and monitor their blood sugars (P < .001 for all).ConclusionsAlthough veterans with poor diabetes control receive appropriate medical advice, many were not sufficiently confident or motivated to make and maintain self-management changes. Targeted patient-centered interventions may need to emphasize increasing self-efficacy and readiness to change to further improve VA diabetes outcomes.

Veterans Using and Uninsured Veterans Not Using Veterans Affairs (VA) Health Care

Objectives. The objectives of this study were to: (1) examine veteran reliance on health services provided by the Veterans Health Administration (VA), (2) describe the characteristics of veterans who receive VA care, and (3) report rates of uninsurance among veterans and characteristics of uninsured veterans. Methods. The authors analyzed data from the 2000 Behavioral Risk Factor Surveillance System. Using bivariate and multivariate analyses, the association of veterans demographic characteristics, health insurance coverage, and use of VA services were examined. Veterans not reporting VA coverage and having no other source of health insurance were considered uninsured. Results. Among veteran respondents, 6.2% reported receiving all of their health care at the VA, 6.9% reported receiving some of their health care at the VA, and 86.9% did not use VA health care. Poor, less-educated, and minority veterans were more likely to receive all of their health care at the VA. Veterans younger than age 65 who utilized the VA for all of their health care also reported coverage with either private insurance (42.6%) or Medicare (36.3%). Of the veterans younger than age 65, 8.6% (population estimate: 1.3 million individuals) were uninsured. Uninsured veterans were less likely to be able to afford a doctor or see a doctor within the last year. Conclusions. Veterans who utilized the VA for all of their health care were more likely to be from disadvantaged groups. A large number of veterans who could use VA services were uninsured. They should be targeted for VA enrollment given the detrimental clinical effects of being uninsured.

Effect of health beliefs on delays in care for abnormal cervical cytology in a multiethnic population

AbstractCONTEXT: Women from racial and ethnic minorities in the United States have higher rates of cervical cancer and present with later stage disease compared to whites. Delays in care for abnormal Papanicolaou (Pap) smears can lead to missed cases of cervical cancer or late-stage presentation and may be one explanation for these differences. OBJECTIVE: To determine if race and ethnicity, health beliefs, and cancer knowledge are associated with delays in care for abnormal Pap smears. DESIGN, PARTICIPANTS, AND SETTING: We conducted a mailed survey with telephone follow-up of all women with an abnormal Pap smear who received care at Kaiser Permanente Los Angeles Medical Center between October 1998 and October 1999 (n=1,049). MEASUREMENTS AND MAIN RESULTS: A delay in care was defined as not attending the first scheduled clinic visit to follow up on an abnormal Pap smear, or requiring multiple contact attempts, including a certified letter, to schedule a follow-up visit. Our response rate was 70% (n=733) and the sample was 51% Latina. Spanish-speaking Latinas and women of Asian descent were more likely to endorse fatalistic beliefs and misconceptions about cancer. Thirteen percent of the sample delayed follow-up on their abnormal Pap smear. Women who delayed care were more fatalistic and endorsed more misconceptions about cervical cancer. Delays in care were not independently associated with race and ethnicity. CONCLUSIONS: Health beliefs and cancer knowledge differed by race and ethnicity among women in a large managed care organization. Fatalistic health beliefs and misconceptions about cancer, but not race and ethnicity, were independently associated with delays in care.

Do patient consent procedures affect participation rates in health services research

Background. Few studies have examined the effects of Institutional Review Board (IRB) requirements to contact potential research participants. Objective. To examine the association between requirements to contact potential research subjects and participation rates in a multisite health services research study. Research Design, Subjects. Prospective observational study of survey participation by 2673 individuals with diabetes and 1974 individuals with congestive heart failure treated at 15 clinical sites in the United States that had implemented a quality improvement intervention. Main Outcome Measures. Telephone survey response rates. Results. Of 15 IRBs, seven required sites to obtain authorization from participants to release contact information to the study team. Five required oral and two required written advance permission. The response rate was 58% (913/1571) at sites where no advance permission was required, 39% (989/2530) from sites that required oral advance permission and 27% (145/546, P <0.001) at sites requiring written advance permission. Although 85% of eligible participants contacted directly by the study team consented to complete the survey, only 43% of individuals at sites requiring written advance permission allowed the release of contact information to the study team. Conclusions. Many potential participants did not grant advance permission to be contacted by the study team. Requiring advance permission reduced participation rates, especially at sites requiring written authorization.