Menopause Is a Key Factor Influencing Postprandial Metabolism, Metabolic Health and Lifestyle: The ZOE PREDICT Study

Objectives

The menopause transition is associated with unfavourable alterations in metabolic and cardiovascular health. However, as an age-related biological event, it is difficult to untangle effects of age from menopause. Here, we investigate the impact of menopause on cardiometabolic health, lifestyle and diet in pre- and post-menopausal females and age-matched subgroups (including males) in the densely phenotyped ZOE PREDICT 1 cohort (NCT03479866).

Methods

Demographic information, diet, cardiometabolic blood biomarkers and postprandial responses (lipid and glucose) to standardized test meals in clinic and free-living settings were assessed (n = 1002). Self-reported pre- (n = 366), peri- (n = 55) and post-menopausal (n = 207) females (aged 18–65 y) and an age-matched subgroup (aged 47–56 y) of males (n = 76), pre- (n = 83) and post-menopausal females (n = 64) were identified. Linear regression analysis assessed differences in cardiometabolic health, anthropometry, lifestyle and diet (adjusted for sex, age, BMI, menopausal hormonal treatment and smoking status).

Results

Post-menopausal females had poorer fasting and postprandial blood measures (glucose, HbA1c, inflammation (GlycA), glucose_2hiauc and insulin_2hiauc; by 6, 5, 4, 42 and 4% respectively) and sleep quality (12%) and higher sugar intakes (12%) compared with pre-menopausal females (p < 0·05 for all). In age-matched females, postprandial glycemia was significantly higher in post- versus pre-menopausal females (p < 0·05), including clinic postprandial glucose peak0-2h (7·6 ± 1·2 vs 7·2 ± 1·0), glycemic variability (using a continuous glucose monitor (CGM)) (18 ± 4% vs 16 ± 4%) and glucose_2hiauc (CGM) following a standardized (typical UK/US nutrient composition) meal (13440 ± 5804 vs 12547 ± 5488). Compared to age-matched males, females (pre- and post-menopausal) had lower systolic blood pressure and ASCVD 10y risk (p < 0.05) and post-menopausal females only had worse glycemic variability (p < 0·001).

Conclusions

In the largest, in-depth nutrition metabolic study of menopause to date, we demonstrate unfavourable links between menopause transition and postprandial glycemic responses, sleep and diet. This emphasises the value of incorporating menopause as a factor in the delivery of nutrition advice.

Funding Sources

ZOE Ltd

Optimised Glucose “Time in Range” Using Continuous Glucose Monitors in 4,805 Non-Diabetic Individuals Is Associated With Favourable Diet and Health: The ZOE PREDICT Studies

Objectives

Continuous glucose monitoring (CGM) enables the dynamic measurement of glycemic control. In diabetic cohorts, time in range (TIR), measured by CGM, is discriminatory of future disease development. However, the value of CGM metrics in non-diabetic populations and their relationship with health outcomes is unclear. This research developed ‘optimised’ TIR targets specific to healthy populations and explored their relationship with diet and health.

Methods

The ZOE PREDICT studies, one (n = 1002, UK), two (n = 987, US) and three (n = 4,500, US) collected demographic information, habitual and free-living diet data, cardiometabolic blood biomarkers and postprandial responses to standardized meals in clinic and free-living settings. TIR was calculated from CGMs (2–4 days free-living) using 1) the American Diabetes Association (ADA); 70–140 mg/dL (TIR_ADA) and 2) a novel optimised; 70–100 mg/dL (TIR_optimised) target. Habitual diet quality (plant-based diet indices; PDI, healthy-PDI and unhealthy-PDI), and free-living nutrient intakes (% energy) were calculated. Associations (spearman's, adjusted for age, sex and BMI) between TIR and diet were examined, and differences in diet and health outcomes between quintile 1 (Q1) and 5 (Q5) of TIR targets were assessed.

Results

Mean fasting glucose was 91 ± 10 mg/dL, HbA1c 5.3 ± 0.4%, TIR_optimised 70 ± 17% and TIR_ADA 91 ± 13% (n = 4805 after exclusions, 78% females, mean age 46 ± 12y). Individuals with better glycemic control (TIR_optimised Q5 vs Q1) were younger (mean ± SD) (45 ± 11 vs 49 ± 12y), had lower HbA1c (5.2 ± 0.4 vs 5.5 ± 0.5) and fasting glucose (91 ± 14 vs 97 ± 23 mg/dL) and higher HDL-cholesterol (1.7 ± 0.4 vs 1.6 ± 0.5mmol/L) (P< 0.001 for all). TIR_optimised (PREDICT 1 n = 868) was associated with a favourable diet (lower unhealthy-PDI and carbohydrate intakes and higher protein intakes) and cardiometabolic risk profile (lower HbA1c and ASCVD) (P < 0.05 for all). However, TIR_ADA was not associated with diet or health outcomes.

Conclusions

We demonstrate that an optimised TIR target (70–100 mg/dL) is discriminatory of ASCVD risk despite normal fasting HbA1c. These findings demonstrate the utility of CGM's in non-diabetic populations and highlight the potential application of dietary strategies to improve TIR and subsequent metabolic complications.

Funding Sources

ZOE Ltd.

Social Jetlag Is Associated With Poor Diet and Increased Inflammation in the ZOE PREDICT 1 Cohort

Objectives

Social jetlag is a habitual pattern of short sleep on work days relative to longer, often later, ‘catch-up sleep’, on work-free days. This chronic pattern of inconsistent sleep times has been associated with poor dietary choices and unfavourable body weight and cardiometabolic health outcomes. We explored associations between social jetlag with dietary intake, body composition, and cardio-metabolic health in the densely phenotyped PREDICT 1 cohort.

Methods

Participants (n = 931) who self-reported habitual sleep on week-days and weekend days, (males, n = 258 and females, n = 673, aged 18–65 years) were identified from the ZOE PREDICT 1 study, a multi-centre dietary intervention study of 1002 healthy UK individuals (NCT03479866). Demographic information (age, gender, education level, ethnicity, menopausal status), habitual diet (FFQ), cardiometabolic blood biomarkers and postprandial responses to standardized test meals in clinic and free-living settings were collected. Social jetlag was calculated as a difference of ≥ 1.5 h in sleep midpoint on week versus weekend days. Differences in diet and cardiometabolic risk factors were tested (analysis of covariance) adjusting for sex, age, BMI, ethnicity and socio-economic status.

Results

Only 3% (n = 26) of participants were short sleepers (< 7 h), 25% (n = 237) were long sleepers (> 9 h) and 16% (n = 145) had social jetlag. The social jetlag group had a higher proportion of males (39% vs 25%) and were younger (mean ± SD) (38.4 ± 11.3 y vs 46.8 ± 11.7 y). Social jetlag was associated with less healthy diets (healthy plant based dietary index) and lower intakes of fruits, nuts and number of plants consumed, as well as higher intakes of sugar-sweetened beverages (p < 0.05 for all). Fasting concentrations of glycoprotein acetylation (GlycA), a composite marker of systemic inflammation, was slightly higher (1.35 ± 0.19 mmol/L vs 1.32 ± 0.18 mmol/L, p = 0.034) in participants with social jetlag.

Conclusions

Our findings support the complex relationship between sleep patterns, diet quality and markers of cardiometabolic health. Multi-factorial diet and lifestyle approaches are needed to improve health, now underpinned by emerging knowledge about the potential long-term impacts of modest circadian misalignments and low grade inflammation.

Funding Sources

ZOE Ltd.

Postprandial and Fasting Metabolic Signatures: Insights From the ZOE PREDICT 1 Study

Objectives

Postprandial metabolomic signatures, although not well characterized, may provide greater insight into individuals’ responses to food and subsequent cardiometabolic disease risk compared to fasting and routine clinical measures. Using the PREDICT 1 cohort, we assessed postprandial changes and inter-individual variability in metabolites sequenced by NMR.

Methods

The ZOE PREDICT 1 study (n = 1,002 healthy UK adults; NCT03479866) measured 250 metabolite parameters (Nightingale Health NMR panel, related to lipids, amino acids, glycolysis, ketones, and glycoprotein acetyls (GlycA)) by venous cannulation at fasting and postprandially after a mixed nutrient sequential test meal (4 and 6 h after meal 1, 3.7 MJ; meal 2 given at 4 h, 2.2 MJ). Postprandial changes in metabolites and their inter-individual variability (median absolute difference from the median (MADM)/median (%)) were evaluated. Associations (Spearman's correlations) and differences in variances (Fligner-Killeen test) were assessed between fasting and postprandial (6 h) measures.

Results

A significant 6 h postprandial change from fasting was seen in 85% of metabolites; of which, 47% increased, and 53% decreased (Kruskal-Wallis p &lt; 0.05 for all). Ketone bodies and very-large lipoprotein particles showed the greatest changes. Fasting and postprandial measures had large, yet similar, inter-individual variability (MADM/median; 15% at 0, 4 and 6 h (mean for all)) and were strongly correlated (r &gt; 0.8; 71% of measures), although ketone bodies, glucose, branched chain amino acids and LDL diameter were only weakly correlated (r &lt; 0.5). Inter-individual patterns of response differed postprandially compared to fasting (Fligner-Killeen test of variance, p &lt; 0.05).

Conclusions

In this large and generally healthy cohort, we demonstrate significant changes in circulating metabolites between the fasting and postprandial phase, as expected, within lipoprotein size and composition remodelling, glycolysis, essential amino acid and ketone body pathways. The large inter-individual variability in postprandial metabolite levels, suggests dietary challenges offer an opportunity for stratifying metabolic responses.

Funding Sources

ZOE Ltd.

Precision Nutrition and Reliability of Continuous Glucose Monitors: Insights From the PREDICT Study

Objectives

The use of continuous glucose monitors (CGM) provides a more in-depth characterization of glycemic variation in response to environmental stimuli, but concerns about CGM reliability for categorizing glycemic responses to foods and meals exist. We sought to evaluate the concordance and reliability of two simultaneously worn CGM devices on postprandial glycemic responses.

Methods

We examined the correlation and coefficient of variation of the 2h glucose incremental area under the curve (iAUC) for 21,527 standardized and ad libitum meals consumed by 368 healthy participants from the PREDICT-1 Study. Included participants were simultaneously monitored with either two Abbott Freestyle Libre Pro devices (n = 339, same device group) or the combination of Abbott Freestyle Libre Pro and Dexcom G6 devices (n = 29, inter device group).

Within-subject 2 h iAUC glucose meal rankings for paired CGM devices were assessed using the Kendal-tau measure for ranking concordance.

Results

The correlation coefficient of the 2 h glucose iAUC for paired CGM devices was 0.97 (95% CI, 0.96 to 0.97) for same device comparisons and 0.78 (0.76 to 0.80) for inter device comparisons. The coefficient of variation of the 2 h glucose iAUC for standardized meals was 5.1% (interquartile range, 2.2 to 10.1) for same device comparisons and 15.1% (5.9 to 31.2) for inter device comparisons. Similar results were observed for ad libitum meals with same and inter device coefficients of variation of 8.9% (3.3 to 21.3) and 24.2% (10.2 to 53.1%), respectively. Meal rankings for the 2 h glucose iAUC were concordant between paired CGM devices, with a mean Kendall rank correlation coefficient of 0.86 (sd = 0.07) for same device comparisons and 0.63 (sd = 0.011) for inter device comparisons.

Conclusions

These data provide evidence for repeatability and concordance for ranking of glycemic responses, and suggest that factors other than CGM sensors mostly drive within-subject meal categorization. Our findings are critical for identifying sources of variability in glycemic responses for the eventual implementation of precision nutrition.

Funding Sources

Zoe Global, UK Government Department of Health and Social Care, Wellcome Trust. National Institutes of Health.

Microbiome Signatures of Nutrients, Foods and Dietary Patterns: Potential for Personalized Nutrition from The PREDICT 1 Study

Objectives

The human gut microbiome has been linked to risk and severity of a multitude of chronic diseases, but large-scale, high-resolution studies linking it to host diet are lacking. The PREDICT 1 study (NCT03479866) enrolled 1,102 healthy US and UK adults to examine the genetic, metabolic, microbial, and meal composition/context contributions to metabolic responses to food. Here, we identify microbial features (species, genes, pathways) linked with diet and assess their potential to predict personalized food responses.

Methods

Dietary intake was assessed using validated EPIC (UK) and Harvard (US) semi-quantitative food frequency questionnaires (FFQs) to capture habitual intake (1 yr). Nutrient and food consumption (adjusted for energy intake) were calculated, and dietary patterns and diversity of intake were estimated. Shotgun metagenomic profiling was performed on fecal samples collected at baseline from 1,001 UK and 97 US individuals.

Results

We observed strong associations between overall microbial structure, as well as feature-level associations with nutrients, foods, food groups, and established dietary indices. Strongest associations were with daily intake of coffee, meat, and dairy foods, and saturated fatty acids; Spearman's r = 0.45, 0.29, 0.27 and 0.46, respectively. The Healthy Food Diversity Index and the Plant Dietary Index (PDI; comprised of healthy vs. unhealthy PDI, h-PDI, u-PDI) were strongly associated with community structure (r = 0.36, 0.34, and 0.34), highlighting the synergistic impact of dietary diversity, food quality, and microbial outcomes. We identified two clusters of microbial species with consistent, opposed correlations with ‘healthy’ and ‘unhealthy’ nutrients, food groups, and dietary indices with clear segregation between the h-PDI vs. u-PDI. These clusters were also coupled to cardiometabolic biomarkers. The associations observed in the UK cohort were reproducible in the independent US cohort.

Conclusions

The relationship between a healthy diet, resultant microbial signatures, and cardiometabolic outcomes strongly support the interactions between the foods we eat, the bacteria they enrich, and chronic disease outcomes, highlighting the importance of diet quality and diversity in personalized precision nutrition.

Funding Sources

NIHR, Wellcome Trust, Zoe Global Ltd.

Influence of Gut Microbial Communities on Fasting and Postprandial Lipids and Circulating Metabolites: The PREDICT 1 Study

Objectives

The human gut microbiome plays a critical role in host glucose metabolism, but its connections to other key markers of cardiometabolic health in fasting and postprandial conditions is largely unknown. The PREDICT 1 study enrolled n = 1,102 twins and unrelated healthy US/UK adults to explore the genetic, metabolic, microbial, and meal determinants of fasting metabolites and postprandial responses to foods.

Methods

This multi-centre dietary study assessed fasting and postprandial (0-6h) circulating metabolites over a 13d study period incorporating standardized test meals of varying nutrient composition. Shotgun metagenomics was performed from samples collected at baseline (n = 1,001 UK and 97 US). Metabolomics (NMR) was performed on clinic fasting and postprandial samples, blood glucose was continuously assessed, and blood triglycerides and C-peptide were serially measured.

Results

Using machine learning models, we found the fasting metabolites most strongly associated with overall gut community structure were the inflammatory marker GlycA (r = 0.31), and HDL and VLDL particle diameter (HDL-D and VLDL-D; r = 0.3 and 0.28 respectively). Variance explained was slightly greater for postprandial HDL-D and VLDL-D (at 6h; r = 0.32 and 0.31, respectively) than fasting levels, whilst the other metabolites did not differ (e.g., GlycA r = 0.28). Lipid-mediated metabolites were more closely associated with the gut microbiome in both fasting and postprandial states compared with glycemic-mediated measurements. There were distinct microbial clusters that segregated both fasting and postprandial metabolites according to their known association with cardiometabolic disease; ApoA and HDL vs. ApoB, VLDL, IDL LDL, remnant C, GlycA, IL-6, blood pressure, glucose, insulin and HbA1c. We also identified differential abundance among several microbes associated with metabolic health, including Prevotella copri and Faecalibacterium prausnitzii. Results obtained in the UK cohort were validated in the US cohort.

Conclusions

An individual's gut microbial composition is predictive of their cardiometabolic markers and personalized responses to food. Our data highlight the potential of the gut microbiome as a target amenable to modulation in personalized nutrition to ameliorate cardiometabolic risk.

Funding Sources

Zoe Global Ltd., NIHR GSTT BRC, Wellcome Trust.

Impact of Postprandial Lipemia and Glycemia on Inflammatory Factors in over 1000 Individuals in the US and UK: Insights from the PREDICT 1 and InterCardio Studies

Objectives

Postprandial glycemia (PPG) and lipemia (PPL) initiate an acute inflammatory response, which may be relevant to future CVD. We characterised the impact of PPL and PPG on inflammatory responses using traditional (IL-6) and emerging (glycoprotein acetyls; GlycA) biomarkers of inflammation in a large scale, tightly controlled study (PREDICT 1; NCT03479866) and an independent validation study (InterCardio; NCT03438084).

Methods

The PREDICT 1 dietary intervention study of 1102 healthy individuals from the US and UK, assessed the postprandial (0–6 h) metabolic responses to sequential mixed-nutrient meals (50 g fat and 85 g carb at 0 h; 22 g fat and 71 g carb at 4 h). Baseline microbial diversity (16S Shannon diversity) and visceral fat mass (VFM; based on DXA) were also measured. Results were validated in an independent randomised crossover trial (n = 50). For both studies, glucose, triacylglycerol (TG), IL-6 and GlycA were measured at multiple intervals.

Results

In PREDICT 1, GlycA and IL-6 concentrations increased significantly after meals (by 4.5 and 169%; peak 6 h, respectively) but were not correlated. Peak postprandial TG and glucose concentrations were strongly associated with GlycA (r = 0.832 and r = 0.239, respectively) but not IL-6. Machine learning with cross-validation, revealed that PPL was the strongest predictor of postprandial GlycA. There was evidence of an interaction; individuals with higher microbial diversity and lower VFM had an attenuated inflammatory response. Individuals eliciting an enhanced response (30% rise at 6 h) had higher predicted CVD risk compared to the rest of the cohort. In the InterCardio study, the postprandial inflammatory increase in GlycA was also significantly correlated with PPL and varied within the four different types of fat tested.

Conclusions

In the first study to investigate postprandial inflammation at scale, we observed that PPL was a stronger determinant of systemic inflammation compared with PPG. The clinically significant and variable postprandial inflammatory response, and its association with lipemia and glycemia, highlights the potential for personalized dietary strategies to lower postprandial metabolic responses to reduce low grade inflammatory related diseases.

Funding Sources

NIHR, Wellcome Trust, Zoe Global Ltd, BBSRC DRINC.

Genome-wide Association Analysis in Humans Links Nucleotide Metabolism to Leukocyte Telomere Length

Leukocyte telomere length (LTL) is a heritable biomarker of genomic aging. In this study, we perform a genome-wide meta-analysis of LTL by pooling densely genotyped and imputed association results across large-scale European-descent studies including up to 78,592 individuals. We identify 49 genomic regions at a false dicovery rate (FDR) < 0.05 threshold and prioritize genes at 31, with five highlighting nucleotide metabolism as an important regulator of LTL. We report six genome-wide significant loci in or near SENP7, MOB1B, CARMIL1, PRRC2A, TERF2, and RFWD3, and our results support recently identified PARP1, POT1, ATM, and MPHOSPH6 loci. Phenome-wide analyses in >350,000 UK Biobank participants suggest that genetically shorter telomere length increases the risk of hypothyroidism and decreases the risk of thyroid cancer, lymphoma, and a range of proliferative conditions. Our results replicate previously reported associations with increased risk of coronary artery disease and lower risk for multiple cancer types. Our findings substantially expand current knowledge on genes that regulate LTL and their impact on human health and disease.

Integrating Metagenomic Information into Personalized Nutrition Tools: The PREDICT I Study (P20-005-19)

Objectives

The existence of a link between the intestinal microbiome and diet is well established. The demonstration that the microbiome information increases the prediction accuracy of postprandial blood glucose levels (Zeevi et al, 2015) is opening intriguing perspectives for developing personalized nutrition tools. However, reproducibly inferring the diet-induced microbiome changes and stratifying individual responses to dietary interventions based on the microbiome remain open challenges. The PREDICT I study aims to develop: (i) a protocol for gut microbiome sampling and analysis for large-scale nutritional studies and (ii) a microbiome-based machine learning integrative component for predictive personalized nutrition tools.

Methods

We performed three metagenomic investigations to; (i) identify the best combination for stool collection, sample storage, DNA extraction, and sequencing (n = 45); (ii) develop and validate the computational pipeline on an exploratory dietary interventional cohort (n = 1000); (iii) apply the validated pipeline on an independent validation cohort (n = 100). The generated total dataset (>8x10^12 sequenced bases) was analyzed with existing and newly developed computational tools and integrated with the metagenomic profiles of >10,000 samples processed from public repositories.

Results

Our resulting validated protocol involves a minimally time-demanding procedure for at-home sample collection, sample storage in a preservation buffer, and DNA extraction with a recently commercialized kit (Qiagen). Metagenomic sequencing proved substantially more accurate than 16S rRNA sequencing and was able to perfectly capture subject-specific strain-level features with longitudinal sampling. This method was also able to stratify by pre-intervention habitual dietary regimes. Our prediction algorithm showed that embedding the microbiome features in a 50-dimension space was sufficient to improve the prediction performance of postprandial blood glucose levels.

Conclusions

We present the largest investigation to date on the reproducible connections between the gut microbiome and dietary interventions. Further we describe our methods and results in using the microbiome as a component of a precise integrated postprandial blood glucose and blood lipid level predictor.

Funding Sources

Zoe Global Limited, National Institute for Health Research (NIHR), Wellcome Trust.

Genome-Wide and Abdominal MRI Data Provide Evidence That a Genetically Determined Favorable Adiposity Phenotype Is Characterized by Lower Ectopic Liver Fat and Lower Risk of Type 2 Diabetes, Heart Disease, and Hypertension

Recent genetic studies have identified alleles associated with opposite effects on adiposity and risk of type 2 diabetes. We aimed to identify more of these variants and test the hypothesis that such favorable adiposity alleles are associated with higher subcutaneous fat and lower ectopic fat. We combined MRI data with genome-wide association studies of body fat percentage (%) and metabolic traits. We report 14 alleles, including 7 newly characterized alleles, associated with higher adiposity but a favorable metabolic profile. Consistent with previous studies, individuals carrying more favorable adiposity alleles had higher body fat % and higher BMI but lower risk of type 2 diabetes, heart disease, and hypertension. These individuals also had higher subcutaneous fat but lower liver fat and a lower visceral-to-subcutaneous adipose tissue ratio. Individual alleles associated with higher body fat % but lower liver fat and lower risk of type 2 diabetes included those in PPARG, GRB14, and IRS1, whereas the allele in ANKRD55 was paradoxically associated with higher visceral fat but lower risk of type 2 diabetes. Most identified favorable adiposity alleles are associated with higher subcutaneous and lower liver fat, a mechanism consistent with the beneficial effects of storing excess triglycerides in metabolically low-risk depots.

Venous Disease: The New International Challenge

This paper reviews data on the socio-economic aspects of venous disease and venous insufficiency. It will cover data on the burden of disease and the effects of venous insufficiency on quality of life. It will also cover varicose veins, chronic venous insufficiency and venous ulcers of the leg. The use of the WHO International Classification of Diseases allows for comparisons across countries, with costs expressed not only in local currency, but also in terms of ECUs and as a percentage of health care costs.

The paper presents estimates on the costs of venous disease in the UK, France and Germany. Using standard diagnoses, costs are estimated to amount to 1.5–2.0% of total health care expenditure in these three countries. This is divided between inpatient, outpatient and community nursing programmes. Prescribing costs for venous diseases range from 0.26% of the total in the UK to 5.38% in France, with Germany in the middle of the range at 2.87%. The paper also summarizes costs in terms of reduced quality of life and loss of work-time. In Germany venous diseases contributed significantly to total disability, accounting for 1.2% of invalidity days in the late 1980s.

As a result of dissatisfaction with current treatment programmes there have been moves towards new ones. The paper sets out the evidence on innovations in care through investment programmes aimed at reducing costs and improving efficacy. Current developments in Britain, Germany and France are set out, summarizing likely costs and benefits.

Alcohol consumption and risk of type 2 diabetes in European men and women: influence of beverage type and body size The EPIC-InterAct study

OBJECTIVE

To investigate the association between alcohol consumption and type 2 diabetes, and determine whether this is modified by sex, body mass index (BMI) and beverage type.

DESIGN

Multicentre prospective case-cohort study.

SETTING

Eight countries from the European Prospective Investigation into Cancer and Nutrition cohort.

SUBJECTS

A representative baseline sample of 16 154 participants and 12 403 incident cases of type 2 diabetes.

INTERVENTIONS

Alcohol consumption assessed using validated dietary questionnaires.

MAIN OUTCOME MEASURES

Occurrence of type 2 diabetes based on multiple sources (mainly self-reports), verified against medical information.

RESULTS

Amongst men, moderate alcohol consumption was nonsignificantly associated with a lower incidence of diabetes with a hazard ratio (HR) of 0.90 (95% CI: 0.78-1.05) for 6.1-12.0 versus 0.1-6.0 g day(-1) , adjusted for dietary and diabetes risk factors. However, the lowest risk was observed at higher intakes of 24.1-96.0 g day(-1) with an HR of 0.86 (95% CI: 0.75-0.98). Amongst women, moderate alcohol consumption was associated with a lower incidence of diabetes with a hazard ratio of 0.82 (95% CI: 0.72-0.92) for 6.1-12.0 g day(-1) (P interaction gender <0.01). The inverse association between alcohol consumption and diabetes was more pronounced amongst overweight (BMI ≥ 25 kg m(-2) ) than normal-weight men and women (P interaction < 0.05). Adjusting for waist and hip circumference did not alter the results for men, but attenuated the association for women (HR=0.90, 95% CI: 0.79-1.03 for 6.1-12.0 g day(-1) ). Wine consumption for men and fortified wine consumption for women were most strongly associated with a reduced risk of diabetes.

CONCLUSIONS

The results of this study show that moderate alcohol consumption is associated with a lower risk of type 2 diabetes amongst women only. However, this risk reduction is in part explained by fat distribution. The relation between alcohol consumption and type 2 diabetes was stronger for overweight than normal-weight women and men.

Genetic variation in UCP2 (uncoupling protein-2) is associated with energy metabolism in Pima Indians

AIMS/HYPOTHESIS

Uncoupling protein-2 (UCP2) is thought to play a role in insulin secretion and the development of obesity. In this study, we investigated the effects of genetic variation in UCP2 on type 2 diabetes and obesity, as well as on metabolic phenotypes related to these diseases, in Pima Indians.

METHODS

The coding and untranslated regions of UCP2, and approximately 1 kb of the 5' upstream region, were sequenced in DNA samples taken from 83 extremely obese Pima Indians who were not first-degree relatives.

RESULTS

Five variants were identified: (1) a -866G/A in the 5' upstream region; (2) a G/A in exon 2; (3) a C/T resulting in an Ala55Val substitution in exon 4; and (4, 5) two insertion/deletions (ins/del; 45-bp and 3-bp) in the 3' untranslated region. Among the 83 subjects whose DNA was sequenced, the -866G/A was in complete genotypic concordance with the Ala55Val and the 3-bp ins/del polymorphism. The G/A polymorphism in exon 2 was extremely rare. To capture the common variation in this gene for association analyses, the -866G/A variant (as a representative of Ala55Val and the 3-bp ins/del polymorphism) and the 45-bp ins/del were also genotyped for 864 full-blooded Pima Indians. Neither of these variants was associated with type 2 diabetes or body mass index. However, in a subgroup of 185 subjects who had undergone detailed metabolic measurements, these variants were associated with 24-h energy expenditure as measured in a human metabolic chamber (p=0.007 for the 45-bp ins/del and p=0.03 for the -866G/A after adjusting for age, sex, family membership, fat-free mass and fat mass).

CONCLUSIONS/INTERPRETATION

Our data indicate that variation in UCP2 may play a role in energy metabolism, but this gene does not contribute significantly to the aetiology of type 2 diabetes and/or obesity in Pima Indians.

Racial/ethnic inequities in continuity and site of care: location, location, location

OBJECTIVE

To examine how continuity of care with the same provider varies by race/ethnicity and by site of care.

DATA SOURCES/STUDY SETTING

Secondary data analyses of the 1996-97 Community Tracking Study household survey, a representative cross-sectional sample of 34,858 U.S. adults (aged 18 to 64 years), were employed.

STUDY DESIGN

Logistic regression analyses were conducted to explore relationships between respondents' race/ethnicity and having a regular site of care, type of site, and continuity with the same provider at this site.

PRINCIPAL FINDINGS

Racial/ethnic minority group members were less likely than whites to identify a regular site of care. Among respondents who identified a regular site, minorities, particularly Spanish-speaking Hispanics, reported less continuity of care with the same provider. However, these disparities in continuity were largely explained by racial/ethnic differences in the types of places where care was obtained. Compared to those who were seen in physicians' offices, continuity with the same provider was much lower among respondents who were seen in hospital out patient departments or health centers or other clinics.

CONCLUSIONS

Racial and ethnic minority group members receive less continuity of care for reasons including lack of a regular site of care and less continuity with the same provider. Greater use of hospital clinics and community health centers by minorities also contributes to this discontinuity.

Effectiveness of telephone reminders in improving rate of appointments kept at an outpatient clinic: a randomized controlled trial

BACKGROUND

Clinic appointments in which patients do not appear (no-show) result in loss of provider time and revenue. Previous studies have shown variable effectiveness in telephone and mailed reminders to patients.

METHODS

We conducted a randomized controlled trial of telephone reminders 1 day before the scheduled appointments in an urban family practice residency clinic. Patients with appointments were randomized to be telephoned 1 day before the scheduled visit; 479 patients were telephoned and 424 patients were not telephoned.

RESULTS

The proportions of patients not showing up for their appointments were 19% in the telephoned and 26% in the not-telephoned groups (P = .0065). Significantly more cancelations were made when telephoning patients before their visit, 17% compared with 9.9%. The opened scheduling slots were used for appointments for other patients. This additional revenue offset the cost of telephone intervention in our cost analysis.

CONCLUSION

Reminding patients by telephone calls 1 day before their appointments yields increased cancelations that can be used to schedule other patients. Telephone reminders provide substantial net revenue, but the results may be population specific.

Improving physicians' HIV risk-assessment skills using announced and unannounced standardized patients

OBJECTIVE

To evaluate feasibility and to validate a rating scale for two educational programs that use standardized patient-instructors (SPIs) in the office setting to improve physicians' HIV risk communication skills.

DESIGN

Pilot randomized trial of announced and unannounced SPIs.

PARTICIPANTS/SETTINGS

Twenty four primary care physicians in the Rochester, NY, area.

MEASUREMENTS

The Rochester HIV Interview Rating Scale (RHIRS), HIV test ordering, physician satisfaction questionnaire.

RESULTS

Physicians found the intervention useful, and predicted a positive effect on their future HIV-related communication. HIV test ordering and RHIRS scores increased similarly in both intervention groups. Announced SPI visits were more convenient and preferred by physicians. Cost for each SPI visit was $75.

CONCLUSIONS

A brief office-based intervention using SPIs was feasible, well-accepted, convenient, and inexpensive. Announced SPIs were preferred to unannounced SPIs. Pilot results suggesting improvement in HIV-related communication should be confirmed in a larger randomized trial.

Impact of patient socioeconomic status on physician profiles: a comparison of census-derived and individual measures

BACKGROUND

Patient education has been shown to affect physician performance profiles. It is not known whether census-derived measures of patient socioeconomic status (SES) show comparable effects.

OBJECTIVE

The objective of this study was to compare the effects on physician profiles for patient satisfaction and physical and mental health of adjustment for patient SES derived from patient addresses geocoded to the census block group level, zip codes, and patient education.

DESIGN

This was a cross-sectional survey of patients in physician practices.

SETTING

Subjects came from adult primary care practices in western New York.

PARTICIPANTS

A random sample of 100 primary care physicians and 50 consecutive patients seen by each physician participated in the study.

MEASUREMENTS

Independent variables were census-derived (block group and zip code) patient SES and patient-reported education. The outcomes were physician ranks for patient satisfaction (Patient Satisfaction Questionnaire) and physical and mental health status (SF-12). RESULTS. In empirical Bayes models that adjusted for patient age, age squared, gender, insurance, and case mix, both the census-derived measures (block group and zip code) of SES and education had similar effects on each of the physician profiles. CONCLUSIONS. The results suggest that SES derived from either patient addresses geocoded to the census block group level or zip codes may offer a convenient alternative to individually collected SES when adjusting physician profiles for the socioeconomic characteristics of physicians' practices. The relative ease of using zip codes compared with geocoded addresses and loss of information associated with incomplete matching during geocoding suggest that zip code-derived SES may be preferable.

Racial and ethnic disparities in perceptions of physician style and trust

CONTEXT

While pervasive racial and ethnic inequalities in access to care and health status have been documented, potential underlying causes, such as patients' perceptions of their physicians, have not been explored as thoroughly.

OBJECTIVE

To assess whether a person's race or ethnicity is associated with low trust in the physician.

DESIGN, SETTING, AND PARTICIPANTS

Data were obtained from the 1996 through 1997 Community Tracking Survey, a nationally representative sample. Adults who identified a physician as their regular provider and had at least 1 physician visit in the preceding 12 months were included (N = 32,929).

MAIN OUTCOME MEASURE

Patients' ratings of their satisfaction with the style of their physician and their trust in physicians. The Satisfaction With Physician Style Scale measured respondents' perceptions of their physicians' listening skills, explanations, and thoroughness. The Trust in Physician Scale measured respondents' perceptions that their physicians placed the patients' needs above other considerations, referred the patient when needed, performed unnecessary tests or procedures, and were influenced by insurance rules.

RESULTS

After adjustment for socioeconomic and other factors, minority group members reported less positive perceptions of physicians than whites on these 2 conceptually distinct scales. Minority group members who lacked physician continuity on repeat clinic visits reported even less positive perceptions of their physicians on these 2 scales than whites.

CONCLUSIONS

Patients from racial and ethnic minority groups have less positive perceptions of their physicians on at least 2 important dimensions. The reasons for these differences should be explored and addressed. Arch Fam Med. 2000;9:1156-1163

Physician referral rates: style without much substance?

BACKGROUND

Primary care physicians (PCPs) exhibit widely varying referral rates, resulting in dramatic differences in the exposure of their patients to specialists. The relationships between this physician behavior and costs and patient outcomes are unknown.

OBJECTIVES

To examine the relationships between PCP referral rates and costs, risk of avoidable hospitalization, health status, and satisfaction.

DESIGN

Cross-sectional analyses of claims and patient survey data.

SETTING AND SUBJECTS

Independent practice association (IPA)-style managed care organization in the Rochester, NY, metropolitan area. The 1995 claims data included 457 PCPs in the IPA and 217,606 adult patients assigned to their panels. Approximately 50 consecutive patients of each of a random sample of 100 PCPs completed a patient survey in 1997-1998.

MEASURES

From the claims data, total expenditures per panel member, the risk of avoidable hospitalization, and physician referral rate were measured. Measures derived from the survey included SF-12 scores, satisfaction, and physician referral rate.

RESULTS

The relationship between physician referral rate and per-panel-member costs was not statistically significant after case-mix adjustment of the referral rate. There was no relationship between the case-mix-adjusted referral rate and risk of avoidable hospitalization. In the survey data, there was no adjusted relationship between the physicians' referral rate and their patients' self-rated physical or mental health. There was a modest direct relationship between patient satisfaction and survey-derived referral rate.

CONCLUSIONS

Despite stable, wide variations in PCP referral rates, there are few discemible relationships between this physician behavior and costs and patient outcomes. Efforts to constrain PCP referrals to specialists may be misguided.

Inequality in quality: addressing socioeconomic, racial, and ethnic disparities in health care

Socioeconomic and racial/ethnic disparities in health care quality have been extensively documented. Recently, the elimination of disparities in health care has become the focus of a national initiative. Yet, there is little effort to monitor and address disparities in health care through organizational quality improvement. After reviewing literature on disparities in health care, we discuss the limitations in existing quality assessment for identifying and addressing these disparities. We propose 5 principles to address these disparities through modifications in quality performance measures: disparities represent a significant quality problem; current data collection efforts are inadequate to identify and address disparities; clinical performance measures should be stratified by race/ethnicity and socioeconomic position for public reporting; population-wide monitoring should incorporate adjustment for race/ethnicity and socioeconomic position; and strategies to adjust payment for race/ethnicity and socioeconomic position should be considered to reflect the known effects of both on morbidity. JAMA. 2000;283:2579-2584

Individual income, income inequality, health, and mortality: what are the relationships?

OBJECTIVE

To examine the pathways between income inequality, self-rated health, and mortality in the United States.

DATA SOURCE

The first National Health and Nutrition Examination Survey and Epidemiologic Follow-up Study.

DESIGN

This was a longitudinal, multilevel study.

DATA COLLECTION

Baseline data were collected on county income inequality, individual income, age, sex, self-rated health, level of depressive symptoms, and severity of biomedical morbidity from physical examination. Follow-up data included self-rated health assessed in 1982 through 1984 and mortality through 1987.

PRINCIPAL FINDINGS

After adjustment for age and sex, income inequality had a modest independent effect on the level of depressive symptoms, and on baseline and follow-up self-rated health, but no independent effect on biomedical morbidity or subsequent mortality. Individual income had a larger effect on severity of biomedical morbidity, level of depressive symptoms, baseline and follow-up self-rated health, and mortality.

CONCLUSION

Income inequality appears to have a small effect on self-rated health but not mortality; the effect is mediated in part by psychological, but not biomedical pathways. Individual income has a much larger effect on all of the health pathways.

Do physicians who diagnose more mental health disorders generate lower health care costs?

BACKGROUND

Underrecognition and undertreatment of mental health disorders in primary care have been associated with poor health outcomes and increased health care costs, but little is known about the impact of the diagnoses of mental health disorders on health care expenditures or outcomes. Our goal was to examine the relationships between the proportion of mental health diagnoses by primary care physicians and both health care expenditures and the risk of avoidable hospitalizations.

METHODS

We used cross-sectional analyses of claims data from an independent practice association-style (IPA) managed care organization in Rochester, New York, in 1995. The sample was made up of the 457 primary care physicians in the IPA and the 243,000 adult patients assigned to their panels. We looked at total expenditures per panel member per year generated by each primary care physician and avoidable hospitalizations among their patients.

RESULTS

After adjustment for case mix, physicians who recorded a greater proportion of mental health diagnoses generated significantly lower per panel member expenditures. For physicians in the highest quartile of recording mental health diagnoses, expenditures were 9% lower than those of physicians in the lowest quartile (95% confidence interval, 5% - 13%). There was a trend (P = .051) for patients of physicians in the highest quartile of recording mental health diagnoses to be at lower risk for an avoidable hospitalization than those of physicians in the lowest quartile.

CONCLUSIONS

Primary care physicians with higher proportions of recorded mental health diagnoses generate significantly lower panel member costs, and their patients may be less likely to be admitted for avoidable hospitalization conditions.

Why do physicians vary so widely in their referral rates?

OBJECTIVE

To determine which physician practice and psychological factors contribute to observed variation in primary care physicians' referral rates.

DESIGN

Cross-sectional questionnaire-based survey and analysis of claims database.

SETTING

A large managed care organization in the Rochester, NY, metropolitan area.

PARTICIPANTS

Internists and family physicians.

MEASUREMENTS AND MAIN RESULTS

Patient referral status (referred or not) was derived from the 1995 claims database of the managed care organization. The claims data were also used to generate a predicted risk of referral based on patient age, gender, and case mix. A physician survey completed by a sample of 182 of the physicians (66% of those eligible) included items on their practice and validated psychological scales on anxiety from uncertainty, risk aversiveness, fear of malpractice, satisfaction with practice, autonomous and controlled motivation for referrals and test ordering, and psycho-social beliefs. The relation between the risk of referral and the physician practice and psychological factors was examined using logistic regression. After adjustment for predicted risk of referral (case mix), patients were more likely to be referred if their physician was female, had more years in practice, was an internist, and used a narrower range of diagnoses (a higher Herfindahl index, also derived from the claims data). Of the psychological factors, only greater psychosocial orientation and malpractice fear was associated with greater likelihood of referral. When the physician practice factors were excluded from the analysis, risk aversion was positively associated with referral likelihood.

CONCLUSIONS

Most of the explainable variation in referral likelihood was accounted for by patient and physician practice factors like case mix, physician gender, years in practice, specialty, and the Herfindahl index. Relatively little variation was explained by any of the examined physician psychological factors.

Supplemental insurance and mortality in elderly Americans. Findings from a national cohort

CONTEXT

As the burden of out-of-pocket health care expenditures for Medicare beneficiaries has grown, the need to assess the relationship between uncovered costs and health outcomes has become more pressing.

OBJECTIVE

To assess the relationship between risk for out-of-pocket expenditures and mortality in elderly persons with private supplemental insurance.

DESIGN

Retrospective cohort study using proportional hazards survival analyses to assess mortality as a function of health insurance, adjusting for sociodemographic, access, and case mix-health status measures.

SETTING

The 1987 National Medical Expenditure Survey, a representative cohort of the US civilian population, linked to the National Death Index.

PARTICIPANTS

A total of 3751 persons aged 65 years and older.

MAIN OUTCOMES MEASURES

Five-year mortality rate.

RESULTS

After 5 years, 18.5% of persons at low risk for out-of-pocket expenditures, 22.5% of those at intermediate risk, and 22.6% of those at high risk had died. After multivariate adjustment, a significant linear trend (P = .02) toward increasing mortality with increasing risk category was observed. Compared with the low-risk group, persons in the intermediate-risk group had an adjusted hazard ratio of 1.2 (95% confidence interval, 0.9-1.6), whereas those in the high-risk group had an adjusted hazard ratio of 1.4 (95% confidence interval, 1.0-1.9).

CONCLUSIONS

Increasing risk for out-of-pocket costs is associated with higher subsequent mortality among elderly Americans with supplemental private coverage. Although research is needed to identify which specific components of out-of-pocket expenditures are adversely associated with health outcomes, findings support policies to decrease out-of-pocket health care expenditures to reduce the risk for premature mortality in elderly Americans.

Influence of patient education on profiles of physician practices

BACKGROUND

Few data are available about the effect of patient socioeconomic status on profiles of physician practices.

OBJECTIVE

To determine the ways in which adjustment for patients' level of education (as a measure of socioeconomic status) changes profiles of physician practices.

DESIGN

Cross-sectional survey of patients in physician practices.

SETTING

Managed care organization in western New York State.

PARTICIPANTS

A random sample of 100 primary care physicians and 50 consecutive patients seen by each physician.

MEASUREMENTS

Ranks of physicians for patient physical and mental health (Short Form 12-Item Health Survey) and satisfaction (Patient Satisfaction Questionnaire), adjusted for patient age, sex, morbidity, and education.

RESULTS

Physicians whose patients had a lower mean level of education had significantly better ranks for patient physical and mental health status after adjustment for patients' level of education level than they did before adjustment (P < 0.001); this result was not seen for patient satisfaction. After adjustment for patients' level of education, each 1-year decrease in mean educational level was associated with a rank that improved by 8.1 (95% CI, 6.6 to 9.6) for patient physical health status and by 4.9 (CI, 3.9 to 5.9) for patient mental health status. Adjustment for education had similar effects for practices with more educated patients and those with less educated patients.

CONCLUSIONS

Profiles of physician practices that base ratings of physician performance on patients' physical and mental health status are substantially affected by patients' level of education. However, these results do not suggest that physicians who care for less educated patients provide worse care. Physician profiling should account for differences in patients' level of education.

Telephone ownership and deaf people: implications for telephone surveys

OBJECTIVES

This study was done to determine the prevalence of telephone ownership in different deaf populations and to explore its implications for telephone-based surveys.

METHODS

Multivariate analyses, with adjustments for sociodemographics and health status, were done of National Health Interview Survey (NHIS) data from 1990 and 1991, the years in which the NHIS Hearing Supplement was administered.

RESULTS

Prelingually deafened adults were less likely than members of the general population to own a telephone (adjusted odds ratio [AOR] = 0.35; 95% confidence interval [CI] = 0.15, 0.82), whereas postlingually deafened adults were as likely as members of the general population to own one (AOR = 1.00; 95% CI = 0.78, 1.28).

CONCLUSIONS

Telephone surveys risk marginalizing prelingually deafened adults because of low telephone ownership and language barriers between the deaf and hearing communities.

Is family care associated with reduced health care expenditures?

BACKGROUND

Specific components of family medicine associated with reduced health care costs are not well understood. We examined whether people who received "family care," the sharing of a personal physician across familial generations, had lower health care expenditures than those who received "individual care" that lacked generational continuity.

METHODS

We studied 1728 children and 2543 adults using a data subset of the 1987 National Medical Expenditure Survey, a representative sample of the civilian noninstitutionalized US population, to examine the relationship between care category and total health care expenditures, adjusting for potential confounders and effect modifiers. Survey respondents from households with either a married or a single woman aged 18 to 55 years as head of household and at least 1 child younger than 18 years were included. Only individuals reporting a family physician (FP) or general practitioner (GP) as their personal doctor were examined, since intergenerational family care is provided almost exclusively by FPs and GPs.

RESULTS

Family care provided by an FP or GP was associated with 14% lower expenditures for adults ($51), after adjustment for covariates (P = .04), compared with individual care provided by a family or general practitioner. Although not statistically significant, for children family care was associated with 9% lower expenditures ($19).

CONCLUSIONS

These findings suggest that family care provided by FPs or GPs is associated with lower health care costs. Policies promoting family care may reduce health care costs.

Does skepticism towards medical care predict mortality?

OBJECTIVES

Attitudes towards medical care have a strong effect on utilization and outcomes. However, there has been little attention to the impact on outcomes of doubts about the value of medical care. This study examines the impact of skepticism toward medical care on mortality using data from the 1987 National Medical Expenditure Survey (NMES).

METHODS

A nationally representative sample from the United States comprising 18,240 persons (> or = 25 years) were surveyed. Skepticism was measured through an 8-item scale. Mortality at 5-year follow-up was ascertained through the National Death Index.

RESULTS

In a proportional hazards survival analysis of 5-year mortality that controlled for age, sex, race, education, income, marital status, morbidity, and health status, skepticism toward medical care independently predicted subsequent mortality. That risk was attenuated after adjustment for health behaviors but not after adjustment for health insurance status.

CONCLUSION

Medical skepticism may be a risk factor for early death. That effect may be mediated through higher rates of unhealthy behavior among the medically skeptical. Further studies using more reliable measures are needed.

The adequacy of Papanicolaou smears as performed by family physicians and obstetrician-gynecologists

BACKGROUND

Little is known about the quality of Papanicolaou (Pap) smears performed by family physicians and obstetrician-gynecologists.

METHODS

Using hospital archival records of Pap smears performed from 1995 to 1997, we compared the quality of Pap smear sampling and the rate of detection of significant cytologic abnormalities by family physicians and obstetrician-gynecologists. Using hierarchic logistic regression, we examined the relationship between physician specialty and Pap smear reports, controlling for patient age and socioeconomic position, multiple Pap smears performed by the same clinician, and physician attending status.

RESULTS

A total of 34,916 Pap smears performed by 130 family physicians and 88 obstetrician-gynecologist residents and attending physicians were included in the analysis. There were no statistically significant differences by specialty in the rates of unsatisfactory reports (adjusted odds ratio [AOR] = 0.82; 95% confidence interval [CI], 0.48 - 1.38), satisfactory but limited reports (AOR = 1.16; 95% CI, 0.93 - 1.48), or detection rates of significant cytologic abnormalities (AOR = 0.83; 95% CI, 0.66 - 1.04). However, family physicians submitted more Pap smears with an absent endocervical component (AOR = 1.50; 95% CI, 1.07 - 2.11).

CONCLUSIONS

These findings show no significant differences by specialty in Pap smear quality as measured by rates of unsatisfactory and satisfactory but limited reports, or detection of cytologic abnormalities. The finding of higher rates of absent endocervical cells, if replicated by further study, may suggest the need for improved training of family physicians in sampling the endocervix.

Variations in primary care physician referral rates

OBJECTIVE

To examine primary care physician referral rate variations, including their extent and their stability over time and across diagnostic categories.

DATA SOURCES

1995/1996 claims data for adult patients from a large Independent Practitioner Association (IPA) model managed care organization (MCO) in the Rochester, NY metropolitan area. The IPA includes over 95 percent of area primary care physicians (PCPs), and the MCO includes over 50 percent area residents.

STUDY DESIGN

Referral rates (patients referred to and seen by specialists one or more times/patients seen by PCP/year) were developed for the PCPs (457 general practitioners, family physicians, and internists) in the MCO, including observed referral rates, expected referral rates based on case-mix adjustment across the whole sample, physician-specific case mix-adjusted referral rates (empirical Bayes estimates), and diagnostic category-specific case mix-adjusted referral rates.

PRINCIPAL FINDINGS

Wide variations in observed referral rates (0.01-0.69 patients referred/patients seen/year) were attenuated relatively little by case-mix adjustment and persisted in case mix-adjusted empirical Bayes estimates (0.02-0.65). The year-to-year case mix-adjusted referral rate correlation was .90. Correlations of case mix adjusted-referral rates across diagnostic categories were moderate (r=.46-.67).

CONCLUSIONS

PCP referral rates exhibit wide variations that are independent of case mix, remain stable over time, and are generalizable across diagnostic categories. Understanding this physician practice variation and its relationship to costs and outcomes is critical to evaluating the effect of current efforts to reduce PCP referral rates.

Smoking and deaf adults: associations with age at onset of deafness

Smoking is a major health problem whose prevalence in different populations is thought to be influenced by sociocultural and linguistic factors. Although smoking and hearing loss are positively correlated, little is known about the smoking habits of deaf populations. Using national survey data, this study determined the smoking prevalence in two socioculturally distinct deaf populations, based on age at onset of deafness. The smoking prevalence in each deaf population was compared to the smoking prevalence in the hearing population in multivariate analyses that adjusted for sociodemographics and health status. The smoking prevalence among postlingually deafened adults was not significantly different from that among hearing adults. Prelingually deafened adults were found to be less likely to smoke than hearing adults, even though they have less education and lower income, factors both associated with higher smoking prevalence in other populations. The lower smoking prevalence among prelingually deafened adults may be due to cultural differences or to limited access to English-language tobacco advertising.

Low-dose mifepristone 200 mg and vaginal misoprostol for abortion

The objectives of this study were to determine the effectiveness, side effects, and acceptability of one-third the standard 600 mg dose of mifepristone (200 mg) to induce abortion. A prospective trial at seven sites enrolled women > or = 18 years, up to 8 weeks pregnant, and wanting an abortion. The women received 200 mg mifepristone orally, self-administered 800 micrograms misoprostol vaginally at home 48 h later, and returned 1-4 days later for ultrasound evaluation. Surgical intervention was indicated for continuing pregnancy, excessive bleeding, persistent products of conception 5 weeks later, or other serious medical conditions. Of the 933 subjects, 906 (97%) had complete medical abortions, 22 had surgical intervention, two were protocol failures, and three were lost to follow up. Of the 746 subjects who had no or minimal bleeding before misoprostol, 80% bled within 4 h and 98% within 24 h of using misoprostol. By day 7, 95% of women had a complete abortion. Side effects were aceptable in 85% of subjects, and 94% found the procedure acceptable. Low-dose mifepristone followed by vaginal misoprostol was highly effective as an abortifacient.

Deafness and mortality: analyses of linked data from the National Health Interview Survey and National Death Index

OBJECTIVE

To examine the association between age at onset of deafness and mortality.

METHODS

The authors analyzed National Health Interview Survey data from 1990 and 1991--the years the Hearing Supplement was administered--linked with National Death Index data for 1990-1995. Adjusting for sociodemographic variables and health status, the authors compared the mortality of three groups of adults ages > or = 19 years: those with prelingual onset of deafness (< or = age 3 years), those with postlingual onset of deafness (> age 3 years), and a representative sample of the general population.

RESULTS

Multivariate analyses adjusted for sociodemographics and stratified by age found that adults with postlingual onset of deafness were more likely to die in the given time frames than non-deaf adults. However, when analyses were also adjusted for health status, there was no difference between adults with postlingual onset of deafness and a control group of non-deaf adults. No differences in mortality were found between adults with prelingual onset of deafness and non-deaf adults.

CONCLUSIONS

Adults with postlingual onset of deafness appear to have higher mortality than non-deaf adults, which may be attributable to their lower self-reported health status.

The risk of low birth weight associated with vaginal douching

OBJECTIVE

To examine the association between vaginal douching and low birth weight (LBW) after accounting for known risk factors.

METHODS

We used cross-sectional interview data from the 1988 National Survey of Family Growth, a nationally representative sample of 4665 women of child-bearing age and 11,553 singleton live births. We compared the risk of LBW among women who reported they douched regularly with the risk among women who did not douche, after controlling for potential confounders including maternal age, race, household income, marital status, total number of pregnancies, smoking, alcohol use, drug use during the pregnancy, year of birth of each infant, geographic region, and self-reported history of pelvic inflammatory disease.

RESULTS

In multivariate analysis, regular douching was associated with an increased risk of LBW (adjusted odds ratio [OR], 1.29; 95% confidence interval [CI] 1.06, 1.57). Frequency of douching and LBW exhibited a dose-response. The adjusted OR for the association between daily douching and LBW was 2.49 (95% CI 1.23, 5.01) compared with an adjusted OR of 1.13 (95% CI 0.83, 1.55) for the association between monthly douching and LBW. There was no racial difference in the risk of LBW associated with douching.

CONCLUSION

These preliminary data suggest an association between douching and LBW risk. If these findings are replicated in future studies, douching may represent a major preventable risk factor for LBW.

Primary care physicians and specialists as personal physicians. Health care expenditures and mortality experience

BACKGROUND

The advent of managed care has resulted in considerable debate regarding the relative effects of specialist and primary care on patient outcomes and costs. Studies on these subjects have been limited to a disease-focused orientation rather than a patient-focused orientation inherent in primary care management. We examined whether persons using a primary care physician have lower expenditures and mortality than those using a specialist as their personal physician.

METHODS

Using data on a nationally representative sample of 13,270 adult respondents tot he 1987 National Medical Expenditure Survey reporting as their personal physician either a primary care physician (general practitioner, family physician, internist, or obstetrician-gynecologist) or a specialist, we examined total annual health care expenditures and 5-year mortality experience.

RESULTS

Respondents with a primary care physician, rather than a specialist, as a personal physician were more likely to be women, white, live in rural areas, report fewer medical diagnoses and higher health perceptions and have lower annual healthcare expenditures (mean: $2029 vs $3100) and lower mortality (hazard ratio = 0.76, 95% confidence interval [CI], 0.64-0.90). After adjustment for demographics, health insurance status, reported diagnoses, health perceptions, and smoking status, respondents reporting using a primary care physician compared with those using a specialist had 33% lower annual adjusted health care expenditures and lower adjusted mortality (hazard ratio = 0.81; 95% CI, 0.66-0.98).

CONCLUSIONS

These findings provide evidence for the cost-effective role of primary care physicians in the health care system. More research is needed on how to optimally integrate primary and specialty care.

Toward consistency in cost-utility analyses: using national measures to create condition-specific values

OBJECTIVES

The authors developed an "off-the-shelf" source of health-related quality of life (HRQL) scores for cost-effectiveness analysts unable to collect primary data.

METHODS

The authors derived and conducted preliminary validation on a set of health-related quality of life scores for chronic conditions using nationally representative data from the National Health Interview Survey (NHIS) and the Healthy People 2000 Years of Healthy Life measure developed to monitor the health (longevity and health-related quality of life) of Americans during this decade. The measure comprises two domains, role function and self-rated health, and is scaled from 0 (death) to 1 (best health state). Health-related quality of life scores for chronic conditions were calculated using the Years of Healthy Life scores associated with chronic conditions reported in the 1987-1992 National Health Interview Survey. Preliminary validation was examined by comparing the health-related quality of life scores with those obtained in two other studies.

RESULTS

Tables provide health-related quality of life scores for persons with and without conditions. The scores had reasonable face validity, ranging from 0.87 for allergic rhinitis to 0.27 for hemiplegia. Correlations of the health-related quality of life condition weight scores with those from two other studies were 0.78 and 0.86.

CONCLUSIONS

These condition weights may prove useful to investigators conducting cost-effectiveness analyses using secondary data, where community ratings of health-related quality of life for chronic conditions are required. Use of a standard set of health-related quality of life weights gathered from a national sample can enhance the comparability of cost-effectiveness analyses. Improvements in national data collection techniques, with empirical gathering of preferences, will further strengthen this measure.

Skepticism toward medical care and health care utilization

OBJECTIVES

As health care moves toward systems that assume accountability for defined populations, there has been increasing emphasis on developing performance measures for those systems and their providers, with little attention given to patient demand or attitudinal factors. The impact of skepticism toward health care providers on health behavior and health care utilization was assessed using a cross-sectional analysis of data from the 1987 National Medical Expenditure Survey (NMES).

METHODS

A nationally representative sample from the United States comprising 18,240 persons 25 years and older was surveyed. Skepticism, defined as doubts about the ability of conventional medical care to appreciably alter one's health status, was assessed through a 4-item scale. Outcome measures included health behavior, access (health care insurance, having a regular source of care, and physician type), utilization (annual number of physician or emergency department visits and hospitalizations), total annual health care expenditures, and preventive health care behavior (having had a Pap smear within 3 years or ever having had a mammogram).

RESULTS

In multivariate analyses, skepticism was associated with younger age, white race, lower income, less education, and higher health perceptions. After adjusting for these variables, skepticism was associated with less healthy behavior, with not having health insurance, not having one's own physician, choice of a physician, fewer physician and emergency department visits, less frequent hospitalizations, lower annual health care expenditures, and less prevention compliance.

CONCLUSIONS

Medical skepticism represents a relevant patient demand factor that demonstrates significant associations with a variety of health care access and utilization measures with important policy implications.

Does psychological distress contribute to racial and socioeconomic disparities in mortality?

Being black or poor are powerful predictors of mortality. Although psychological distress has been proposed as mediating the effects of race and socioeconomic status on mortality, this hypothesis has not been previously directly tested. We used data from the National Health and Nutrition Examination I (NHANES I), a nationally representative sample from the U.S, and the NHANES I Epidemiological Follow-up Survey (NHEFS) of subsequent mortality to test this hypothesis. Both black race and lower family income were associated with significantly higher psychological distress as measured at the time of the initial survey by reports of hopelessness, depression, and life dissatisfaction. Black race and low income in addition to each of the measures of psychological distress were associated with higher mortality at follow-up. In a series of Cox proportional hazards models that controlled for the effects of age and gender, additional adjustment for hopelessness, depression, or life dissatisfaction had little effect on the relationship between either African American race or family income and subsequent all-cause mortality. We conclude that the effects of both race and income on mortality are largely independent of psychological distress. These findings do not support the hypothesis that psychological distress is a significant mediator of the effects of race or class on health.