Association between cancer prevalence and use of thiazolidinediones: results from the Vermont Diabetes Information System.
(49/187)
BACKGROUND: Peroxisome proliferator-activated receptors (PPARs) have emerged as important drug targets for diabetes. Drugs that activate PPARgamma, such as the thiazolidinediones (TZDs), are widely used for treatment of Type 2 diabetes mellitus. PPARgamma signaling could also play an anti-neoplastic role in several in vitro models, although conflicting results are reported from in vivo models. The effects of TZDs on cancer risk in humans needs to be resolved as these drugs are prescribed for long periods of time in patients with diabetes. METHODS: A total of 1003 subjects in community practice settings were interviewed at home at the time of enrolment into the Vermont Diabetes Information System, a clinical decision support program. Patients self-reported their personal and clinical characteristics, including any history of malignancy. Laboratory data were obtained directly from the clinical laboratory and current medications were obtained by direct observation of medication containers. We performed a cross-sectional analysis of the interviewed subjects to assess a possible association between cancer diagnosis and the use of TZDs. RESULTS: In a multivariate logistic regression model, a diagnosis of cancer was significantly associated with TZD use, even after correcting for potential confounders including other oral anti-diabetic agents (sulfonylureas and biguanides), age, glycosylated hemoglobin A1C, body mass index, cigarette smoking, high comorbidity, and number of prescription medications (odds ratio = 1.59, P = 0.04). This association was particularly strong among patients using rosiglitazone (OR = 1.89, P = 0.02), and among women (OR = 2.07, P = 0.01). CONCLUSION: These data suggest an association between TZD use and cancer in patients with diabetes. Further studies are required to determine if this association is causal. (+info)
Attitudes toward physician-assisted suicide among physicians in Vermont.
(50/187)
BACKGROUND: Legislation on physician-assisted suicide (PAS) is being considered in a number of states since the passage of the Oregon Death With Dignity Act in 1994. Opinion assessment surveys have historically assessed particular subsets of physicians. OBJECTIVE: To determine variables predictive of physicians' opinions on PAS in a rural state, Vermont, USA. DESIGN: Cross-sectional mailing survey. PARTICIPANTS: 1052 (48% response rate) physicians licensed by the state of Vermont. RESULTS: Of the respondents, 38.2% believed PAS should be legalised, 16.0% believed it should be prohibited and 26.0% believed it should not be legislated. 15.7% were undecided. Males were more likely than females to favour legalisation (42% vs 34%). Physicians who did not care for patients through the end of life were significantly more likely to favour legalisation of PAS than physicians who do care for patients with terminal illness (48% vs 33%). 30% of the respondents had experienced a request for assistance with suicide. CONCLUSIONS: Vermont physicians' opinions on the legalisation of PAS is sharply polarised. Patient autonomy was a factor strongly associated with opinions in favour of legalisation, whereas the sanctity of the doctor-patient relationship was strongly associated with opinions in favour of not legislating PAS. Those in favour of making PAS illegal overwhelmingly cited moral and ethical beliefs as factors in their opinion. Although opinions on legalisation appear to be based on firmly held beliefs, approximately half of Vermont physicians who responded to the survey agree that there is a need for more education in palliative care and pain management. (+info)
Relationship of literacy and heart failure in adults with diabetes.
(51/187)
BACKGROUND: Although reading ability may impact educational strategies and management of heart failure (HF), the prevalence of limited literacy in patients with HF is unknown. METHODS: Subjects were drawn from the Vermont Diabetes Information System Field Survey, a cross-sectional study of adults with diabetes in primary care. Participants' self-reported characteristics were subjected to logistic regression to estimate the association of heart failure and literacy while controlling for social and economic factors. The Short Test of Functional Health Literacy was used to measure literacy. RESULTS: Of 172 subjects with HF and diabetes, 27% had limited literacy compared to 15% of 826 subjects without HF (OR 2.05; 95% CI 1.39, 3.02; P < 0.001). Adjusting for age, sex, race, income, marital status and health insurance, HF continued to be significantly associated with limited literacy (OR 1.55, 95% CI 1.00, 2.41, P = .05).After adjusting for education, however, HF was no longer independently associated with literacy (OR 1.31; 95% CI 0.82 - 2.08; P = 0.26). CONCLUSION: Over one quarter of diabetic adults with HF have limited literacy. Although this association is no longer statistically significant when adjusted for education, clinicians should be aware that many of their patients have important limitations in dealing with written materials. (+info)
Covariations of emotional states and alcohol consumption: evidence from 2 years of daily data collection.
(52/187)
We examined inter- and intra-individual covariations of mood and alcohol consumption in a sample of 171 light, medium, and heavy alcohol consumers aged 21 and over who reported daily about drinking and mood for a period of up to 2 years. The sample was recruited by advertisements in local newspapers and referral from former respondents in Northern Vermont, USA, between July 1997 and September 2000. Participants reported daily alcohol consumption and mood via interactive voice response (IVR) technology. Within-subject correlations were calculated for each individual separately and analyzed via cluster analysis. The cluster solution was subsequently used as a categorical Level-2 predictor in hierarchical linear modeling of daily alcohol consumption. Cluster analyses of the within-subject correlations revealed four clusters: (1) emotion-inhibited drinking (drinking combined with reduced emotional arousal, n=12); (2) "positive emotion drinking" (drinking in combination with positive mood, n=69); (3) "stress drinking" (drinking combined with negative mood, n=12); and (4) "non-emotional drinking" (no relationship between alcohol consumption and mood, n=78). Hierarchical linear modeling (HLM) analyses revealed that a significant amount of random variance of the Level-1 mood slopes (38% and 40%) was accounted for by the clusters, demonstrating the predictive power of cluster membership on individual drinking patterns. Although Cluster 3 members (stress drinking) did not report significantly higher levels of alcohol consumption, they were more likely to report current and lifetime dependence symptoms. The results point to the existence of stable, but diverse drinking patterns among non-clinical alcohol consumers with potentially different implications for development into alcohol abuse and dependence. (+info)
Improving newborn preventive services at the birth hospitalization: a collaborative, hospital-based quality-improvement project.
(53/187)
OBJECTIVE: The goal was to test the effectiveness of a statewide, collaborative, hospital-based quality-improvement project targeting preventive services delivered to healthy newborns during the birth hospitalization. METHODS: All Vermont hospitals with obstetric services participated. The quality-improvement collaborative (intervention) was based on the Breakthrough Series Collaborative model. Targeted preventive services included hepatitis B immunization; assessment of breastfeeding; assessment of risk of hyperbilirubinemia; performance of metabolic and hearing screens; assessment of and counseling on tobacco smoke exposure, infant sleep position, car safety seat fit, and exposure to domestic violence; and planning for outpatient follow-up care. The effect of the intervention was assessed at the end of an 18-month period. Preintervention and postintervention chart audits were conducted by using a random sample of 30 newborn medical charts per audit for each participating hospital. RESULTS: Documented rates of assessment improved for breastfeeding adequacy (49% vs 81%), risk for hyperbilirubinemia (14% vs 23%), infant sleep position (13% vs 56%), and car safety seat fit (42% vs 71%). Documented rates of counseling improved for tobacco smoke exposure (23% vs 53%) and car safety seat fit (38% vs 75%). Performance of hearing screens also improved (74% vs 97%). No significant changes were noted in performance of hepatitis B immunization (45% vs 30%) or metabolic screens (98% vs 98%), assessment of tobacco smoke exposure (53% vs 67%), counseling on sleep position (46% vs 68%), assessment of exposure to domestic violence (27% vs 36%), or planning for outpatient follow-up care (80% vs 71%). All hospitals demonstrated preintervention versus postintervention improvement of > or = 20% in > or = 1 newborn preventive service. CONCLUSIONS: A statewide, hospital-based quality-improvement project targeting hospital staff members and community physicians was effective in improving documented newborn preventive services during the birth hospitalization. (+info)
Outcomes of a quality improvement project integrating mental health into primary care.
(54/187)
OBJECTIVE: Depression is commonly seen, but infrequently adequately treated, in primary care clinics. Improving access to depression care in primary care clinics has improved outcomes in clinical trials; however, these interventions are largely unstudied in clinical settings. This study examined the effectiveness of a quality improvement project improving access to mental healthcare in a large primary care clinic. METHODS: A before-after study evaluating the efficacy of the integration of a primary mental healthcare (PMHC) clinic into a large primary care clinic at the White River Junction, Vermont Veterans Affairs Medical Center (VAMC). In the before period (2003), a traditional referral and schedule model was used to access mental healthcare services. Patients who had screened positive for depression using a depression screen for 6 months after entry into either model were retrospectively followed. VA clinics without a PMHC were used as a control. The proportion of patients who received any depression treatment and guideline-adhering depression treatment in each model was compared, as well as the volume of patients seen in mental health clinics and the wait time to be seen by mental health personnel. RESULTS: 383 and 287 patients screened positive for depression at VAMC and the community-based outreach clinic, respectively. Demographics of the before and after cohorts did not differ. The PMHC model was associated with a greater proportion of patients who had screened positive for depression obtaining some depression treatment (52.3% vs 37.8%; p<0.001), an increase in guideline-adherent depression treatment for depression (11% vs 1%; p<0.001). CONCLUSIONS: Implementation of the PMHC model was associated with more rapid and improved treatment for depression in the population of patients who screened positive for depression. More widespread implementation of this model should be investigated. (+info)
Comprehensive health care reform in Vermont: a conversation with Governor Jim Douglas. Interview by James Maxwell.
(55/187)
In this conversation, Vermont's Republican governor, Jim Douglas, discusses his role in and views on the state's comprehensive health reforms adopted in 2006. The reforms are designed to provide universal access to coverage, improve the quality and performance of the health care system, and promote health and wellness across the lifespan. He describes the specific features of the reforms, the plan for their financing, and the difficult compromises that had to be reached with the Democratically controlled legislature. He talks about his need, as governor, to balance the goals of health reform against other state priorities such as education and economic development. (+info)
Vermont's Catamount Health: a roadmap for health care reform?
(56/187)
Vermont's new health reform program was enacted under a Republican governor in a state with a Democrat-controlled legislature. It thus serves as an intriguing approach to resolving political differences in health care. James Maxwell's interview of Vermont governor Jim Douglas provides background and insight on these reforms. I build on the interview, focusing on what changed between the 2005 reform failure and the passage of the new reforms. Key to the reform's political success was the recognition by both sides that it focused on issues of bipartisan concern: cost control through the effective management and prevention of disease. (+info)