Health Maintenance Organization Population Research Articles

Systolic BP and Mortality in Older Adults with CKD.

Optimal BP targets for older adults with CKD are unclear. This study sought to determine whether a nonlinear relationship between BP and mortality-as described for the broader CKD population and for older adults in the general population-is present for older adults with CKD. A cohort of 21,015 adults age 65-105 years with a moderate or severe reduction in eGFR (<60 ml/min per 1.73 m(2)) were identified within the Kaiser Permanente Northwest Health Maintenance Organization population. The relationship between baseline systolic BP (SBP; ≤120, 121-130, 131-140, 141-150, >150 mmHg; referent, 131-140 mmHg) and all-cause mortality across age groups (65-70, 71-80, and >80 years) was examined; patients were followed for up to 11 years after cohort entry. The median times at risk were 3.15 years, 3.53 years, and 2.76 years for adults age 65-70, 71-80, and >80 years, respectively. Mortality during follow-up was 19.6% for those age 65-70 years, 33.4% for those age 71-80 years, and 55.7% for those age >80 years. The relationship between SBP and mortality varied as a function of age. The risk of death was highest for patients with the lowest SBP in all age groups. Only among adults age 65-70 years was an SBP>140 mmHg associated with a higher risk of death compared with the referent category. Patterns of age modification of the relationship between SBP and mortality were consistent in all sensitivity analyses. In a cohort of older adults, the relationship between SBP and mortality varied systematically with age. A relationship between higher SBP and mortality was present only for younger members of this cohort and not for those older than 70. These results raise the question of whether the relative benefits and harms of lowering BP to recommended targets for older adults with CKD may vary as a function of age.

Suicide in a health maintenance organization population.

Suicide in a health maintenance organization population.

An Update on Perfect Depression Care

An Update on Perfect Depression Care

Best practices in specialty pharmacy management.

Specialty pharmacy is a growing area of research, utilization, and cost. Because of the unique nature of the diseases treated by specialty pharmaceuticals, such as cancer and rheumatoid arthritis, novel management approaches are needed. Advocate Physician Partners (APP) is an entity within the Advocate Health Care Health System in the Chicago and the central Illinois area. It coordinates the care management and managed care contracting between the Advocate Health Care System and more than 4,000 physicians on the medical staffs of Advocate hospitals. APP has experienced a per-member-per-month (PMPM) increase of less than 3% in oncology intravenous medications spend in 2012. This spend refers to the intravenous medications covered under the medical benefits for APP's health maintenance organization (HMO) population. The spend has consistently been less than national projections, and we believe this is tied to the adoption of several key best practices. Prior to instituting the best practices, the yearly percentage increases for oncology spending were 5.52% (2007 to 2008), 9.39% (2008 to 2009), and 5.29% (2009 to 2010). After instituting best practices during the first quarter of 2011, the increases in PMPM were 3.11% (2010 to 2011) and 2.11% (2011 to 2012), which were below previous years. To describe the best practices of specialty pharmacy management adopted by APP, specifically (a) establishing a content expert and governing bodies, (b) ensuring compliance with policies, and (c) providing educational resources. APP has several key result areas (KRAs). One KRA was compliance with appropriate utilization of intravenous oncology protocols for its HMO population. The protocols for each medication outline the appropriate indication and patient population. These protocols were developed and reviewed by the APP Pharmacy and Technology (PT) committee. The PT-approved indications reflect FDA indications and indications found in national guidelines. The APP KRA target for the utilization of protocols was 80%. The compliance for completing the protocols that correspond to these medications was calculated by tabulating the number of paid claims over the number of completed protocols, resulting in a compliance percentage. APP defined noncompliance as any utilization not outlined in the protocol. Another KRA was physician feedback. APP requires that physicians complete a certain number of continuing medical education (CME) programs provided by APP each year. Feedback from physicians, provided at the end of the CME, were tabulated and utilized for further programs. Additionally, APP strived to increase physician engagement by placing them in key roles that oversaw clinical and business aspects of the organization. In order to meet the KRAs, investigate inappropriate utilization, and become better involved in engaging oncology specialists, APP invested in an oncology clinical pharmacist position. The primary responsibility of the oncology clinical pharmacist was to be a specialty drug resource for the organization with a focus on provider education. The oncology clinical pharmacist was deemed the content expert who developed clinical protocols, educated providers, and encouraged compliance with organizational policies and procedures as it pertained to the KRAs. Since establishing the oncology clinical pharmacist position, APP has seen an increase in protocol compliance. Prior to the institution of this position, the protocol compliance was 62%. In less than 1 year after hiring the oncology clinical pharmacist, the compliance percentage spiked to over 80%. APP has several committees and boards that oversee the clinical and business aspects of the organization. By placing physicians in chairmanship positions of the committees, APP has seen the benefit of handling difficult patient decisions and increased compliance with policies. Lastly, extensive provider education has led to an improved physician satisfaction in the educational initiatives of APP. Greater than 80% of the physicians felt the CME content was relevant to their practices; the content would likely have a positive impact on their practices; and the clinical content was evidence based and accepted by the medical community. By hiring an oncology clinical pharmacist, engaging physicians by placing them in key roles, and providing more specialist-specific education, APP has improved its KRAs and compliance percentages. APP achieved success in containing expenditures for oncology intravenous medications by implementing key best practices combined with traditional management strategies.

Epidemiology and comorbidity of severe mental illnesses in the community: findings from a computerized mental health registry in a large Israeli health organization

Maccabi Healthcare Services, a large health maintenance organization (HMO) operating in Israel, has recently constructed a computerized registry of patients with severe mental illnesses (SMI). In the present study, we aimed to use this registry to investigate the epidemiology of schizophrenia and bipolar affective disorder among adults, and to assess their comorbidity and mortality compared to the general population. In this historical cohort study, we investigated the age- and sex-specific prevalence and incidence rates of HMO members diagnosed with schizophrenia or bipolar affective disorder between 2003 and 2009. We compared their medical comorbidity and mortality to the general HMO population. A total of 8,848 and 5,732 patients were diagnosed with bipolar (crude prevalence rate of 5 per 1,000) and schizophrenia (3 per 1,000), respectively. The annual incidence rates were 4.2 and 2.4 per 1,000 for schizophrenia and bipolar disorder, respectively. On average, schizophrenic men were diagnosed 4-5 years earlier than schizophrenic women. Compared to the general population, schizophrenia and bipolar disorder patients had a 12- and 9-year shorter life expectancy, respectively. They were also more likely to be diagnosed with diabetes mellitus (odds ratio of 1.9 and 1.6, respectively). The current study demonstrates the potential use of automated medical databases to characterize the epidemiology of SMI in the community. The increased comorbidity and mortality among these patients has important implication for health authorities for prevention and delivery of health-care services.

Association of Tea Consumption and Cutaneous Squamous Cell Carcinoma

Laboratory and epidemiologic studies suggest a protective effect of tea consumption on risk of cutaneous squamous cell carcinoma (SCC). We designed a case-control study to examine the association between putative protective exposures, including tea consumption, and SCC risk using a large health maintenance organization population. Cases (n = 415) were defined as Kaiser Permanente Northern California (KPNC) members with a pathology-verified SCC in 2004 and controls (n = 415) were age-, gender-, and race-matched members with no previous history of skin cancer. Tea consumption and SCC risk factors were ascertained by questionnaire. Odds ratios (OR) and 95% confidence intervals (CI) were calculated using conditional logistic regression to estimate the association of SCC with regular use, as well as dose and duration of tea consumption. Risk factor adjusted models included education, smoking, hair and eye color, skin type, family history of skin cancer, and history of freckling, sunburns, sun exposure, and tanning bed use. Adjusted analyses showed no reduction in SCC risk with regular consumption of tea (OR = 1.11, 95% CI: 0.81–1.54). Examining duration, dose, and combined duration and dose exposure variables did not alter findings. We found no evidence that tea consumption was associated with cutaneous SCC risk.

Blood Pressure Trajectories and Associations With Treatment Intensification, Medication Adherence, and Outcomes Among Newly Diagnosed Coronary Artery Disease Patients

Blood pressure (BP) control among coronary artery disease patients remains suboptimal in clinical practice, potentially due to gaps in treatment intensification and medication adherence. However, longitudinal studies evaluating these relationships and outcomes are limited. We assessed BP trajectories among health maintenance organization patients with hypertension and incident coronary artery disease. BP trajectories were modeled over the year after coronary artery disease diagnosis, stratified by target BP goal. Treatment intensification (increase in BP therapies in the setting of an elevated BP), medication adherence (percentage of days covered with BP therapies), and outcomes (all-cause mortality, myocardial infarction, and revascularization) were evaluated in multivariable models: 9569 patients had a <140/90 mm Hg BP target and 12,861 had a <130/80 mm Hg BP target. Within each group, 4 trajectories were identified: good, borderline, improved, and poor control. After adjustment, increasing BP treatment intensity was significantly associated with better BP trajectories in both groups. Medication adherence had inconsistent effects. There were no significant differences in combined outcomes by BP trajectory, but among the diabetes and renal disease cohort, borderline control patients were less likely to have myocardial infarction (odds ratio, 0.61; 95% confidence interval, 0.40-0.93), and good control patients were less likely to have myocardial infarction (odds ratio, 0.53; 95% confidence interval, 0.34-0.84) or a revascularization procedure (odds ratio, 0.66; 95% confidence interval, 0.47-0.93) compared with poor control patients. In this health maintenance organization population, treatment intensification but not medication adherence significantly affects BP trajectories in the year after coronary artery disease diagnosis. Better BP trajectories are associated with lower rates of myocardial infarction and revascularization.

Spatial Cluster Detection for Weighted Outcomes Using Cumulative Geographic Residuals

Spatial cluster detection is an important methodology for identifying regions with excessive numbers of adverse health events without making strong model assumptions on the underlying spatial dependence structure. Previous work has focused on point or individual-level outcome data and few advances have been made when the outcome data are reported at an aggregated level, for example, at the county- or census-tract level. This article proposes a new class of spatial cluster detection methods for point or aggregate data, comprising of continuous, binary, and count data. Compared with the existing spatial cluster detection methods it has the following advantages. First, it readily incorporates region-specific weights, for example, based on a region's population or a region's outcome variance, which is the key for aggregate data. Second, the established general framework allows for area-level and individual-level covariate adjustment. A simulation study is conducted to evaluate the performance of the method. The proposed method is then applied to assess spatial clustering of high Body Mass Index in a health maintenance organization population in the Seattle, Washington, USA area.

Epidemiology of Barrett Esophagus in a University Hospital Health Maintenance Organization

Introduction: Barrett esophagus (BE) is a complication of gastro-esophageal reflux disease (GERD) and subtantially increases the risk of esophageal adenocarcinoma. There are no direct data supporting screening among the general population or even in patients with chronic reflux symptoms but surveillance programmes for the detection of dysplasia and neoplasia are accepted. Issues related to clinical manifestations, diagnosis and malignant transformations have not been well stablished in our country. Aims: To assess the prevalence of endoscopic diagnosis, epidemiology and progress of BE in a population belonging to a health maintenance organization (HMO). Methods: Adult patients diagnosed with BE from January 2004 to August 2008 in a HMO were included. Age at onset, sex, symptoms, previous diagnosis of BE, endoscopic findings, histopatological results and surveillance were reviewed from their electronic medical records. Results: Among 147.109 individuals enrolled in the HMO, 110 patients were diagnosed as Barrett (estimated prevalence 74.8/100.000). Mean age at time of diagnosis was 67 years (30-90). The male: female ratio was 1.5: 1. Patients were initially refered because of symptoms associated with GERD (66%), dyspepsia (8%), others (13%) or because of BE control (13%). According to Prague criteria 37 patients had circumferential extent, 19 (51%) of them had long-segment BE (more than 3 cm) and 18 (49%) short-segment BE (less than 3 cm). On the other hand, 67 patients only had tongue like extent, of which 52 (78%) had long-segment BE and 15 (22%) short-segment BE. Four patients had both circumferencial and tongue like extents (1 short-segment BE and 3 long-segment BE) and 2 had esophageal stenosis. Most patients had concomitant endoscopic lessions: hiatus hernia (47%), erosive esophagitis (7%), both of them (24%), others (11%) and only 11% had no other finding but BE. At their first endoscopy 79 patients (72%) did not have dysplasia, 28 (25%) had low grade dysplasia (LGD), 1 (1%) had high grade dysplasia (HGD) and 2 (2%) had adenocarcinoma. Fifty seven patients underwent endoscopic surveillance with a total of 88 endoscopic procedures with biopses: in 65 dysplasia remained stable, in 14 dysplasia presented some kind of regression and in 9 metaplasia progressed (7 to LGD, 1 to HGD and 1 to adenocarcinoma). Conclusions: Prevalence of endoscopic diagnosis of BE in a HMO population from Argentina is lower than previous reports from other countries. The same occurs with male: female ratio although mean age is higher. We found more dysplasia than that reported in other series. However we should initiate a prospective study in order to corroborate these findings.

Secular trends in kidney disease: is the decreased incidence of renal replacement therapy due to a decrease in chronic kidney disease incidence?

Little is known about trends in renal replacement therapy among patients with chronic kidney disease (CKD) or about changes in the incidence of CKD. We studied the incidence of renal replacement therapy within the population of a health maintenance organization (HMO) both among the entire HMO population and among those with CKD. We calculated yearly incidence rates of renal replacement therapy for each year from 1998 to 2005. We defined CKD using the National Kidney Foundation definition of 2 estimated glomerular filtration rates below 60 ml/min/1.73 m2 90 or more days apart. Poisson regression assessed year-to-year differences. The number of patients with CKD rose consistently from 3,861 in 1998 to 5,242 in 2005. The proportion of patients who had been diagnosed with hypertension rose from 86.7% (starting renal replacement therapy) or 34.5% (with CKD) to 99.1 and 46.9%. The proportion of patients with diabetes changed little throughout the years studied. The mean estimated glomerular filtration rate among CKD patients rose minimally from 38.4 ml/min/1.73 m2 in 1998 to 39.9 ml/min/1.73 m2 in 2005. Age- and sex-adjusted rates of RRT among patients with CKD varied (p=0.0034), but did not follow a consistent pattern over time. Incidence of renal replacement therapy among patients with CKD changed little between 1998 and 2005, despite an increase in the number of patients diagnosed with CKD. The discrepancy may be due to increased laboratory identification of CKD.

Diabetes as a Risk Factor for Herpes Zoster Infection: Results of a Population-Based Study in Israel

Studies showed that diabetes mellitus (DM) is often accompanied by impaired cell-mediated immunity, which potentially may increase the risk for infectious diseases, including herpes zoster (HZ). However, data on the relation between DM and HZ are scarce. This case-control study explored the association between DM and HZ. This study was nested within a cohort of all members of a large health maintenance organization (HMO) in Israel. Cases totaled 22,294 members who were diagnosed with HZ between 2002 and 2006. Controls (n=88,895) were randomly selected from the remaining HMO population using frequency-matched age, sex, and duration of follow-up. Personal data on history of DM, lymphoma, leukemia, or AIDS, were obtained from computerized medical records. Adjusted analyses showed that the risk of HZ was associated with history of leukemia, lymphoma, use of steroids or antineoplastic medications, and AIDS, particularly among patients below 45 years of age. In a multivariate analysis, DM was associated with an increased risk of HZ (OR=1.53; 95% CI: 1.44-1.62). The data suggest that individuals with DM are at increased risk of HZ. Well-designed cohort studies may help to clarify the nature of this association.

Review of Food Bolus Management

Foreign object ingestion and esophageal food bolus impactions are common problems faced by gastroenterologists. Fortunately, the majority of ingested foreign objects and food boluses will pass spontaneously. However, 10% to 20% may become lodged in the esophagus or other locations in the gastrointestinal tract and may require nonoperative intervention, and 1% or less will require surgery (1–4). A recent study (5) reported an estimated annual incidence rate of food impactions of 13 episodes per 100,000 in a health maintenance organization population. The overall mortality rate is unknown, but deaths have been rarely reported (6,7). The purpose of the present review is to focus on esophageal food bolus impaction – its pathophysiology, clinical presentations, diagnosis and management. Dr Hin Hin Ko

Knee replacement: epidemiology, outcomes, and trends in Southern California 17,080 replacements from 1995 through 2004

Background and purpose There are limited popula-tion-based data on utilization, outcomes, and trends in total knee arthroplasty (TKA). The purpose of this study was to examine TKA utilization and short-term outcomes in a pre-paid health maintenance organization (HMO), and to determine whether rates and revision burden changed over time. We also studied whether this population is representative of the general population in California and in the United States.Methods Using hospital utilization and membership databases from 1995 through 2004, we calculated incidence rates (IRs) of primary and revision TKA for every 10,000 health plan members. The demographics of the HMO population were compared to published census data from California and the United States.Results The age and sex distributions of the study population were similar to those of the general population in California and the United States. 15,943 primary TKAs and 1,137 revision TKAs were performed during the 10-year period. Patients below the age of 65 accounted for one-third of all primary replacements and one-third of all revision replacements. IRs of primary TKAs increased from 6.3 per 10,000 in 1995 to 11.0 per 10,000 in 2004, at a rate of 5% per year (p<0.001). IRs of revision TKAs increased from 0.41 per 10,000 in 1995 to 0.74 per 10,000 in 2004 (p=0.4). Revision burden remained stable over the 10-year observation period. Surgical complications were higher in revision TKA than in primary TKA (10% vs. 7.7%; p=0.007). 90day complication rates for primary and revision TKA including death were 0.3% and 0.6% (p=0.1) and for pulmonary embolism 0.5% and 0.4% (p=0.6). 90day re-admission rates for primary and revision TKA including infection were 0.5% and 4.2% (p<0.001), for myocardial infarction 0.1% each, and for pneumonia 0.2% and 0.4% (p=0.08).Interpretation The incidence of primary and revision TKA increased between 1995 and 2005. The rates of postoperative complications were low. Comparisons of the study population and the underlying general populations of interest indicate that this population can be used to predict the incidences and outcomes of TKA in the general population of California and of the United States as a whole.

Medication adherence and associated outcomes in medicare health maintenance organization‐enrolled older adults with Parkinson's disease

Maintenance of symptom control in Parkinson's disease (PD) requires continuous titration of medication and addition of multiple therapies over the course of the disease. Adherence to medication is vital to symptom control and key to maximizing the efficacy of existing therapies. However, adherence is compromised by a variety of factors, including motor symptoms, complex dosing regimens, multiple medications, and lack of patient/physician awareness of the impact and prevalence of suboptimal adherence. This retrospective, longitudinal cohort study assessed the prevalence of suboptimal adherence [measured as the medication possession ratio (MPR)] to PD medications, and its impact on the worsening of PD symptoms (measured as increase in monotherapy dose, augmentation of therapy, PD-related emergency department visit, or hospitalization), in a Medicare Health Maintenance Organization population in the United States. Irrespective of the MPR threshold chosen, a high percentage of patients were categorized as suboptimally adherent to their PD medications, and patients with suboptimal adherence to their PD medications had higher risks of worsening of PD symptoms, compared with those who were adherent. Increased awareness of both the magnitude and impact of suboptimal adherence to PD medications, coupled with dosage simplification and a unified effort by healthcare professionals and patients, may improve adherence to PD medications and ultimately improve symptom control.

HSV-2 Serologic Testing in an HMO Population: Uptake and Psychosocial Sequelae

To prospectively measure the uptake of Herpes simplex virus Type 2 (HSV-2) testing and psychosocial response to a new serologic diagnosis of HSV-2 in a health maintenance organization (HMO) population. Randomly selected urban HMO enrollees were invited to be tested for HSV-2 antibody at a research clinic. Participants had blood drawn and completed demographic and psychosocial questionnaires. Of 3111 eligible enrollees contacted, 344 (11%) were tested. Eighty-seven (26%) tested HSV-2 seropositive, and 44 (51%) of these did not report a prior genital herpes diagnosis. Distress, measured by the total mood disturbance, was 6.5 points higher on average following a new genital herpes diagnosis relative to baseline (actual range = 109 points, P = 0.003) but not statistically different from HSV-2 negative or previously diagnosed participants. HMO enrollees unexpectedly testing HSV-2 positive showed short-term psychosocial distress that resolved during 6-month follow-up. Findings suggest that concerns about psychosocial burden should not deter voluntary serologic HSV-2 testing in primary care settings.

Pemphigus Variant Associated With Penicillin Use

To determine whether medication use is associated with the development of a pemphigus variant. Population-based case-cohort study. Health maintenance organization in Israel. All incident pemphigus variant cases diagnosed from January 1, 1997, through December 31, 2001, among 1.5 million members were identified. A cohort of 150,000 was randomly selected from the health maintenance organization population as the control group. Data on case patients and control subjects, including all medication purchased during the 6 months before the diagnosis, were obtained using the health maintenance organization's central database. We identified a total of 363 case patients diagnosed as having pemphigus during the 5-year study (6,961,853 person-years of follow-up). The mean age at diagnosis was 49.8 (SD, 22.7) years, and 53% of the cases were women. Results of a multivariate analysis showed that increased risk for pemphigus was associated with purchasing penicillin during the 6 months before the diagnosis (odds ratio, 2.03; 95% confidence interval, 1.56-2.64). Compared with individuals with no penicillin purchases, we calculated increased risks of 1.84 (95% CI, 1.36-2.49) and 3.02 (95% CI, 1.41-6.49) in those with 1 and 3 or more purchases, respectively. None of the other examined medications, including cephalosporins, angiotensin-converting enzyme inhibitors, dipyrone, anticonvulsants, and nonsteroidal anti-inflammatory drugs, showed similar risks. To our knowledge, the present research is one of the largest published epidemiological studies on pemphigus variant. The use of computerized medical and administrative databases allowed the detection of case patients in the community, resulting in a higher calculated incidence rate than previously reported. The findings suggest a relationship between the use of penicillin and pemphigus variant. Further studies to assess the nature of this statistical association are warranted.

Total and component health care costs in a non-Medicare HMO population of patients with and without type 2 diabetes and with and without macrovascular disease.

Type 2 diabetes (T2DM) is one of the most prevalent and costly chronic conditions in the United States. Macrovascular disease (MVD) remains a common and costly comorbidity in T2DM. Understanding the impact of MVD on total health care costs in patients with T2DM is of great importance to managed care organizations (MCOs). To examine from the perspective of an MCO the impact of MVD on health care costs in patients with T2DM and in a matched comparison group of patients without diabetes. This study involved retrospective analysis of administrative claims (eligibility, pharmacy, and medical) using data from a commercial health maintenance organization population of approximately 700,000 members in an East Coast health plan. Patients were included in this study if they (a) had 2 or more claims for T2DM ( International Classification of Diseases, Ninth Revision, Clinical Modification[ICD-9-CM] codes 250.X0 or 250.X2), or (b) had a prescription drug claim for insulin and a diagnosis of T2DM, or (c) had at least 1 pharmacy claim for an oral glycemic-modifying agent during the 12-month period from January 1, 2003, through December 31, 2003. Patients with 2 or more medical claims for type 1 diabetes (ICD-9-CM codes 250.X1 or 250.X3) were excluded from the study. A random group of comparison patients without diabetes (ICD-9 code 250.xx) were matched on age group and sex. Study patients in these 2 groups were subdivided into 4 groups based on the presence of medical claims with diagnosis codes for MVD (acute myocardial infarction, other ischemic heart disease, coronary artery bypass surgery, percutaneous transluminal angioplasty, congestive heart failure, cerebrovascular accident, peripheral vascular disease, cerebrovascular disease, and peripheral vascular disease). Direct medical costs were aggregated for 12 months after the index date for patients in all 4 groups. Bootstrapping technique was used to compare the health care costs between patients with T2DM and those without diabetes, stratified by MVD status. A total of 9,059 patients with T2DM were identified and were matched by age group and sex to a random group of patients without diabetes. MVD was present in 26.9% (n=2,441) of patients with T2DM versus 11.3% (n=1,027) of patients without diabetes. Patients with MVD and T2DM were, on average, a year younger than patients with MVD but without diabetes (54.55 vs. 55.55 years, P <0.001). Patients with T2DM but without MVD were nearly the same age as patients with neither diabetes nor MVD (50.44 vs. 50.59 years, P=0.092). The T2DM patients with MVD had average 12-month costs more than 3 times the costs for patients with T2DM but without medical claims with diagnosis codes for MVD--10,450 dollars versus 3,385 dollars, respectively. Pharmacy costs accounted for 29.0% and inpatient hospital costs accounted for 43.9% of total medical costs in T2DM patients with MVD versus 55.0% and 17.3%, respectively, in T2DM patients without MVD. Patients with MVD diagnoses and T2DM had total average medical costs that were 1.7 times the total medical costs for MVD patients without T2DM--10,450 dollars versus 6,090 dollars, respectively. The results of this analysis suggest that MVD may triple the total medical care costs in patients with T2DM. These economic consequences would appear to support the importance of interventions intended to prevent macrovascular events in patients with T2DM.

MOVING BEYOND THE TRANSTHEORETICAL MODEL

MOVING BEYOND THE TRANSTHEORETICAL MODEL

Seasonal variation in food intake, physical activity, and body weight in a predominantly overweight population

To describe seasonal variation in food intake, physical activity, and body weight in a predominantly overweight population. A longitudinal observational study. Most of the study participants were recruited from a health maintenance organization (HMO) in central Massachusetts, USA. Additional individuals of Hispanic descent were recruited from outside of the HMO population to increase the ethnic diversity of this sample. Data from 593 participants, aged 20-70, were used for this investigation. Each participant was followed quarterly (five sampling points: baseline and four consecutive quarters) for 1-year period. Body weight measurements and three 24-h dietary and physical activity recalls were obtained on randomly selected days (including 2 weekdays and 1 weekend day) per quarter. Sinusoidal regression models were used to estimate peak-to-trough amplitude and phase of the peaks. Daily caloric intake was higher by 86 kcal/day during the fall compared to the spring. Percentage of calories from carbohydrate, fat and saturated fat showed slight seasonal variation, with a peak in the spring for carbohydrate and in the fall for total fat and saturated fat intake. The lowest physical activity level was observed in the winter and the highest in the spring. Body weight varied by about 1/2 kg throughout the year, with a peak in the winter (P<0.001 winter versus summer). Greater seasonal variation was observed in subjects who were male, middle aged, nonwhite, and less educated. Although there is seasonal variation in diet, physical activity and body weight, the magnitude of the change is generally small in this population. US National Heart, Lung and Blood Institute.

STRESS, TRAUMA, AND CORONARY HEART DISEASE AMONG NATIVE AMERICANS

In the May 2005 issue, which focused on Native Americans/Alaska Natives, we were especially interested in the article by the American Indian Service Utilization, Psychiatric Epidemiology, Risk and Protective Factors Project (AI-SUPERPFP) Team, “Social Epidemiology of Trauma Among 2 American Indian Reservation Populations.”1 This study quantified exposure to trauma among American Indians, adding to the existing evidence2,3 that this population experiences a disproportional amount of trauma. We were intrigued by the statement “It may be that high rates of trauma exposure contribute to the increasing prevalence of cardiovascular disease among American Indian men and women, the leading cause of death among this population”1(p858) and wanted to lend support to this assertion. Indeed, American Indians now have the highest rates of cardiovascular disease in the United States.4 In a study similar to the AI-SUPERPFP study, Koss et al.5 documented adverse childhood exposures among 7 Native American tribes and compared these exposures to levels observed in the Adverse Childhood Experiences (ACE) Study conducted by Kaiser Permanente and the Centers for Disease Control and Prevention in a health maintenance organization population. Compared with participants in the ACE study, not only did the American Indians have a significantly higher rate of exposure to any trauma (86% vs 52%), but they also had a more than 5-fold risk of having been exposed to 4 or more categories of adverse childhood experiences (33% vs 6.2%). We know from the ACE study that there is a linear, dose–response relationship between the number of adverse childhood experiences and not only coronary heart disease (CHD) risk factors such as cigarette smoking6 but also the occurrence of ischemic heart disease.7 The INTERHEART study8 found that large traumatic exposures were associated with increased risk of myocardial infarction and, further, that current or recent psychosocial stress alone resulted in a population attributable risk of 33% for myocardial infarction. Because 1 of the 2 most important risk factors in the INTERHEART study was smoking, and because there is a strong association between cigarette smoking and psychosocial stress, psychosocial stress may contribute even more strongly to CHD risk than even this high population-attributable risk would indicate. We are indebted to studies such as these for helping to answer the myriad questions associated with the relationship between stress and trauma and CHD risk. Such research allows those of us in clinical and academic medicine to turn our attention to the challenge of developing interventions to mitigate the health effects associated with traumatic life experiences.