Publications by authors named "Usha Subramanian"
As the population ages, the prevalence of cognitive impairment due to neurodegenerative diseases such as Alzheimer disease (AD) is expected to double in the United States to nearly 14 million over the next 40 years. AD and related dementias (ADRD) are a leading cause of morbidity and mortality and among the costliest to society. Although emerging biomedical interventions for ADRD focus on early stages and are currently limited to AD, care management can benefit patients with ADRD across the disease course.
View Article and Find Full Text PDFWhile disease management appears to be effective in selected, small groups of CHF patients from randomized controlled trials, its effectiveness in a broader CHF patient population is not known. This prospective, quasi-experimental study compared patient outcomes under a nurse practitioner-led disease management model (intervention group) with outcomes under usual care (control group) in both primary and tertiary medical centers. The study included 969 veterans (458 intervention, 511 control) treated for CHF at six VA medical centers.
View Article and Find Full Text PDFBackground: Along with the increasing prevalence of chronic illness has been an increase in interventions, such as nurse case management programs, to improve outcomes for patients with chronic illness. Evidence supports the effectiveness of such interventions in reducing patient morbidity, mortality, and resource utilization, but other studies have produced equivocal results. Often, little is known about how implementation of an intervention actually occurs in clinical practice.
View Article and Find Full Text PDFAim: The broad objective of this study was to examine multiple dimensions of depression in a large, diverse population of adults with diabetes. Specific aims were to measure the association of depression with: (1) patient characteristics; (2) outcomes; and (3) diabetes-related quality of care.
Methods: Cross-sectional analyses were performed using survey and chart data from the Translating Research Into Action for Diabetes (TRIAD) study, including 8790 adults with diabetes, enrolled in 10 managed care health plans in 7 states.
Background: Thiazolidinedione (TZD) treatment has been associated with fractures. The purpose of this study was to examine the association between TZD treatment and fractures in type 2 diabetic patients.
Methods: Using data from Translating Research into Action for Diabetes, a multicenter prospective observational study of diabetes care in managed care, we conducted a matched case-control study to assess the odds of TZD exposure in patients with type 2 diabetes with and without fractures.
Background: Patient-physician race/ethnicity and language concordance may improve medication adherence and reduce disparities in cardiovascular disease (CVD) by fostering trust and improved patient-physician communication.
Objective: To examine the association of patient race/ethnicity and language and patient-physician race/ethnicity and language concordance on medication adherence rates for a large cohort of diabetes patients in an integrated delivery system.
Design: We studied 131,277 adult diabetes patients in Kaiser Permanente Northern California in 2005.
Background: Depressive symptoms are common in patients with heart failure, but few investigators have reported the validity and reliability of measures of depressive symptoms among these patients.
Objectives: To evaluate the validity and reliability of a measure of depressive symptoms, the Patient Health Questionnaire-8 (PHQ-8), among 249 patients with chronic heart failure.
Methods: As part of a larger study, patients completed the PHQ-8 and the Living With Heart Failure Questionnaire.
Background: Patients with chronic heart failure (HF) have cognitive deficits in memory, psychomotor speed, and executive function and poor health-related quality of life (HRQL), but the association between cognitive deficits and HRQL is unknown.
Objectives: The objectives of this study were to (1) evaluate the relationship between HF severity, age, comorbidities, and cognitive deficits and HRQL among patients with chronic HF and (2) examine whether cognitive deficits mediated the relationship between HF severity and HRQL.
Design And Sample: This study was part of a larger explanatory study; 249 patients with HF completed face-to-face interviews.
Objective: To examine the predictors of patient-physician race/ethnicity concordance among diabetes patients in an integrated delivery system.
Data Source: Kaiser Permanente's Northern California Diabetes Registry of 2005.
Study Design: Logistic regression predicted concordance for each racial/ethnic group.
Background: Patients with heart failure (HF) have been found to have cognitive deficits, but it remains unclear whether these deficits are associated with HF or with aging or comorbid conditions common in HF.
Objectives: : The purpose of this study was (a) to determine the types, the frequency, and the severity of cognitive deficits among patients with chronic HF compared with age- and education-matched healthy participants and participants with major medical conditions other than HF, and (b) to evaluate the relationships between HF severity, age, and comorbidities and cognitive deficits.
Methods: A sample of 414 participants completed the study (249 HF patients, 63 healthy and 102 medical participants).
Introduction: Many patients with diabetes have poorly controlled blood glucose, lipid, or blood pressure levels, increasing their risk for cardiovascular disease (CVD) and other complications. Relatively little is known about what physicians perceive to be barriers to good CVD risk factor control or their own role in helping patients achieve good control.
Methods: We interviewed 34 primary care physicians in 4 states to assess their perceptions of patients' barriers to CVD risk factor control.
Objective: Reasons for failing to initiate prescribed insulin (primary nonadherence) are poorly understood. We investigated barriers to insulin initiation following a new prescription.
Research Design And Methods: We surveyed insulin-naïve patients with poorly controlled type 2 diabetes, already treated with two or more oral agents who were recently prescribed insulin.
Background: Gender concordance between patients and their physicians is related to prevention screening and other quality indicators. Research suggests female physicians may place greater emphasis on preventive care than male physicians; however, little is known about whether physician gender and patient-physician gender concordance are associated with cardiovascular disease (CVD) risk factor levels and treatment. Our objective was to examine associations between patient gender, physician gender, and their interaction with CVD risk factor control, medication adherence, and treatment intensification in diabetes.
View Article and Find Full Text PDFOBJECTIVE Patient-physician race/ethnicity concordance can improve care for minority patients. However, its effect on cardiovascular disease (CVD) care and prevention is unknown. We examined associations of patient race/ethnicity and patient-physician race/ethnicity concordance on CVD risk factor levels and appropriate modification of treatment in response to high risk factor values (treatment intensification) in a large cohort of diabetic patients.
View Article and Find Full Text PDFBlood pressure (BP) self-management is advocated to manage hypertension and reduce the risk of a future stroke. The purpose of this study was to identify BP self-management strategies used by individuals who had sustained a stroke or transient ischemic attack (TIA). As part of a mixed-methods study, we conducted six focus groups and achieved saturation with 16 stroke survivors and 12 TIA survivors.
View Article and Find Full Text PDFBackground: The relative benefits of cardioselective beta-adrenoceptor antagonists (CSB) among patients with congestive heart failure (CHF) and diabetes mellitus are not firmly established.
Objective: To determine whether diabetic patients with CHF accrue the same mortality benefit from CSB therapy as non-diabetic patients.
Method: Between October 1999 and November 2000 consecutive patients with CHF at the Veteran's Affairs Medical Center in Indianapolis, IN, USA, were enrolled in a randomized controlled trial and prospectively followed for 5 years.
Background: While inadequate treatment intensification may contribute to sub-optimal CVD risk factor control in older patients with diabetes, the relationship between patient age and treatment intensification is largely unexplored.
Objective: To examine differences in treatment intensification and control for blood pressure (BP), lipids and A1c in older vs. younger adults with diabetes.
Objectives: To examine whether treatment change for diabetic patients presenting with elevated blood pressure (BP) differed between physicians and midlevel providers (nurse practitioners [NPs] and physician assistants [PAs]) and to determine reasons for any observed differences.
Methods: Analyses were part of a prospective cohort study of 1169 diabetic patients with scheduled visits to 92 primary care providers (PCPs) in 9 Midwest Veterans Health Administration facilities presenting with a triage BP of > or =140/90 mm Hg. We analyzed predicted probabilities of treatment change by provider type.
Objective: The purpose of this study was to examine the predictors of intensification of antihyperglycemic therapy in patients with type 2 diabetes; its impact on A1C, body weight, symptoms of anxiety/depression, and health status; and patient characteristics associated with improvement in A1C.
Research Design And Methods: We analyzed survey, medical record, and health plan administrative data collected in Translating Research into Action for Diabetes (TRIAD). We examined patients who were using diet/exercise or oral antihyperglycemic medications at baseline, had A1C >7.
Background: The impact of open access (OA) scheduling on chronic disease care and outcomes has not been studied.
Objective: To assess the effect of OA implementation at 1 year on: (1) diabetes care processes (testing for A1c, LDL, and urine microalbumin), (2) intermediate outcomes of diabetes care (SBP, A1c, and LDL level), and (3) health-care utilization (ED visits, hospitalization, and outpatient visits).
Methods: We used a retrospective cohort study design to compare process and outcomes for 4,060 continuously enrolled adult patients with diabetes from six OA clinics and six control clinics.
Background: Outcomes after acute coronary disease are reportedly worse among women in general and more so among women with diabetes compared with men. Sex differences were evaluated in postmyocardial infarction (MI) mortality among veterans (who are predominantly male) to determine whether evaluation and treatment in Veterans Affairs hospitals amplifies sex differences in outcome.
Methods: All patients discharged with the primary diagnosis of acute MI from any Veterans hospitals in the United States between October 1990 and September 1997 were identified.
Introduction: Tight blood pressure (BP) control is the single most important intervention to prevent cardiovascular mortality among patients with diabetes mellitus (DM). However, little is known about how many patients have specific target BP levels or the factors associated with patients' knowledge of these targets.
Objectives: (1) To determine what proportion of patients with diabetes have BP targets; (2) To determine patient characteristics associated with having a BP target.
Background: Factors underlying failure to intensify therapy in response to elevated blood pressure have not been systematically studied.
Objective: To examine the process of care for diabetic patients with elevated triage blood pressure (> or =140/90 mm Hg) during routine primary care visits to assess whether a treatment change occurred and to what degree specific patient and provider factors correlated with the likelihood of treatment change.
Design: Prospective cohort study.
Background: Published studies of patients with heart failure may not include details about the challenges in the recruitment process.
Objectives: To describe the recruitment process during the first 18 months of a study being conducted to evaluate cognitive deficits in patients with chronic heart failure.
Methods: Details of the recruitment process are described for 2 clinic sites.