Cynthia L. Leibson

Cross-sectional studies of hospital-level administrative data have shown an association between lower levels of staffing of registered nurses (RNs) and increased patient mortality. However, such studies have been criticized because they have not shown a direct link between the level of staffing and individual patient experiences and have not included sufficient statistical controls.We used data from a large tertiary academic medical center involving 197,961 admissions and 176,696 nursing shifts of 8 hours each in 43 hospital units to examine the association between mortality and patient exposure to nursing shifts during which staffing by RNs was 8 hours or more below the staffing target. We also examined the association between mortality and high patient turnover owing to admissions, transfers, and discharges. We used Cox proportional-hazards models in the analyses with adjustment for characteristics of patients and hospital units.Staffing by RNs was within 8 hours of the target level for 84% of shifts, and patient turnover was within 1 SD of the day-shift mean for 93% of shifts. Overall mortality was 61% of the expected rate for similar patients on the basis of modified diagnosis-related groups. There was a significant association between increased mortality and increased exposure to unit shifts during which staffing by RNs was 8 hours or more below the target level (hazard ratio per shift 8 hours or more below target, 1.02; 95% confidence interval [CI], 1.01 to 1.03; P<0.001). The association between increased mortality and high patient turnover was also significant (hazard ratio per high-turnover shift, 1.04; 95% CI, 1.02 to 1.06; P<0.001).In this retrospective observational study, staffing of RNs below target levels was associated with increased mortality, which reinforces the need to match staffing with patients' needs for nursing care. (Funded by the Agency for Healthcare Research and Quality.).

To compare persons with and without hip fracture for subsequent mortality and change in disability and nursing home (NH) use.Population-based historical cohort study.Olmsted County, Minnesota.All residents who experienced a first hip fracture between January 1, 1989, and December 31, 1993, and, for each case, a resident of the same sex and similar age who had not experienced a hip fracture and was seen by a local care provider.Data on disability (Rankin score), comorbidity (Charlson Index), and NH residency before baseline (fracture date for cases and registration date for controls) were obtained by review of complete community-based medical records. The records were then reviewed from baseline through December 31, 1994, for Rankin disability at 1 month and 1 year, all NH admissions and discharges, and date of death for those who died.There were 312 cases and 312 controls (81% female, mean age +/- standard deviation = 81 +/- 12 years). Before baseline, cases had higher comorbidity (45% vs 30% had Charlson Index >/= 1, P <.001) and disability (mean Rankin score = 2.5 +/- 1.1 vs 2.2 +/- 1.1, P <.001) and were more likely to be in a NH (28% vs 18%, P <.001) than controls. One year after baseline, estimated mortality was 20% (95% confidence interval (CI) = 16-24) for cases vs 11% (95% CI = 8-15) for controls, 51% of cases versus 16% of controls had a level of disability one or more units worse than before baseline (P <.001), and the cumulative incidence of first NH admission was 64% (95% CI = 58-71) for cases versus 7% (95% CI = 4-11) for controls. The risk of NH admission for cases relative to controls diminished over time, but remained elevated 5 years after the event (risk ratio = 20.0 at 3 months and 2.1 at 5 years), but, in persons admitted to a nursing home, cases were two times more likely than controls to be discharged alive within a year (P <.001).Hip fracture is an important contributor to disability and NH use, but the potential savings from hip fracture prophylaxis may be overestimated by studies that fail to consider differential risk, mortality, and long-term follow-up.

The objective of this study was to determine whether diastolic dysfunction is associated with increased risk of nonvalvular atrial fibrillation (NVAF) in older adults with no history of atrial arrhythmia.Few data exist regarding the relationship between diastolic function and NVAF.The clinical and echocardiographic characteristics of patients age > or =65 years who had an echocardiogram performed between 1990 and 1998 were reviewed. Exclusion criteria were history of atrial arrhythmia, stroke, valvular or congenital heart disease, or pacemaker implantation. Patients were followed up in their medical records to the last clinical visit or death for documentation of first AF.Of 840 patients (39% men; mean [+/- SD] age, 75 +/- 7 years), 80 (9.5%) developed NVAF over a mean (+/- SD) follow-up of 4.1 +/- 2.7 years. Abnormal relaxation, pseudonormal, and restrictive left ventricular diastolic filling were associated with hazard ratios of 3.33 (95% confidence interval [CI], 1.5 to 7.4; p = 0.003), 4.84 (95% CI, 2.05 to 11.4; p < 0.001), and 5.26 (95% CI, 2.3 to 12.03; p < 0.001), respectively, when compared with normal diastolic function. After a number of adjustments, diastolic function profile remained incremental to history of congestive heart failure and previous myocardial infarction for prediction of NVAF. Age-adjusted Kaplan-Meier five-year risks of NVAF were 1%, 12%, 14%, and 21% for normal, abnormal relaxation, pseudonormal, and restrictive diastolic filling, respectively. CONCLUSIONS; The presence and severity of diastolic dysfunction are independently predictive of first documented NVAF in the elderly.

It is unclear whether persons with diabetes are at increased risk for dementia, including Alzheimer's disease. Existing studies are limited by small sample size, selection bias, and case-control designs. This population-based historical cohort study provides estimates of the risk of dementia and Alzheimer's disease associated with adult onset diabetes mellitus (AODM). The sample included all persons with AODM residing in Rochester, Minnesota, on January 1, 1970, plus all persons diagnosed in Rochester or who moved to Rochester with the diagnosis between January 1, 1970, and December 31, 1984. Individuals were followed through review of their complete medical records from AODM diagnosis until dementia onset, emigration, death, or January 1, 1985. Standardized morbidity ratios for dementia and Alzheimer's disease were calculated, using an expected incidence based on age- and sex-specific rates for the Rochester population. Poisson regression was used to estimate risks for persons with AODM relative to those without. Of the 1,455 cases of AODM followed for 9,981 person-years, 101 developed dementia, including 77 who met criteria for Alzheimer's disease. Persons with AODM exhibited significantly increased risk of all dementia (Poisson regression relative risk (RR) = 1.66, 95% confidence interval (CI) 1.34-2.05). Risk of Alzheimer's disease was also elevated (for men, R = 2.27, 95% CI 1.55-3.31; for women, RR = 1.37, 95% CI 0.94-2.01). These findings emphasize the importance of AODM prevention and prompt additional investigation of the relation between AODM and dementia.

To illustrate the problem of generalizability of epidemiological findings derived from a single population using data from the Rochester Epidemiology Project and from the US Census.We compared the characteristics of the Olmsted County, Minnesota, population with the characteristics of populations residing in the state of Minnesota, the Upper Midwest, and the entire United States.Age, sex, and ethnic characteristics of Olmsted County were similar to those of the state of Minnesota and the Upper Midwest from 1970 to 2000. However, Olmsted County was less ethnically diverse than the entire US population (90.3% vs 75.1% white), more highly educated (91.1% vs 80.4% high school graduates), and wealthier ($51,316 vs $41,994 median household income; 2000 US Census data). Age- and sex-specific mortality rates were similar for Olmsted County, the state of Minnesota, and the entire United States.We provide an example of analyses and comparisons that may guide the generalization of epidemiological findings from a single population to other populations or to the entire United States.

To evaluate the contribution of left atrial (LA) volume in predicting atrial fibrillation (AF).In this retrospective cohort study, a random sample of 2200 adults was identified from all Olmsted County, Minnesota, residents who had undergone transthoracic echocardiographic assessment between 1990 and 1998 and were 65 years of age or older at the time of examination, were in sinus rhythm, and had no history of AF or other atrial arrhythmias, stroke, pacemaker, congenital heart disease, or valve surgery. The LA volume was measured off-line by using a biplane area-length method. Clinical characteristics and the outcome event of incident AF were determined by retrospective review of medical records. Echocardiographic data were retrieved from the laboratory database. From this cohort, 1655 patients in whom LA size data were available were followed from baseline echocardiogram until development of AF or death. The clinical and echocardiographic associations of AF, especially with respect to the role of LA volume in predicting AF, were determined.A total of 666 men and 989 women, mean +/- SD age of 75.2 +/- 7.3 years (range, 65-105 years), were followed for a mean +/- SD of 3.97 +/- 2.75 years (range, < 1.00-10.78 years); 189 (11.4%) developed AF. Cox model 5-year cumulative risks of AF by quartiles of LA volume were 3%, 12%, 15%, and 26%, respectively. With Cox proportional hazards multivariate models, logarithmic LA volume was an independent predictor of AF, incremental to clinical risk factors. After adjusting for age, sex, valvular heart disease, and hypertension, a 30% larger LA volume was associated with a 43% greater risk of AF, incremental to history of congestive heart failure (hazard ratio [HR], 1.887; 95% confidence interval [CI], 1.230-2.895; P = .004), myocardial infarction (HR, 1.751; 95% CI, 1.189-2.577; P = .004), and diabetes (HR, 1.734; 95% CI, 1.066-2.819; P = .03). Left atrial volume remained incremental to combined clinical risk factors and M-mode LA dimension for prediction of AF (P < .001).This study showed that a larger LA volume was associated with a higher risk of AF in older patients. The predictive value of LA volume was incremental to that of clinical risk profile and conventional M-mode LA dimension.

Summary: Purpose : To provide 1995 estimates of the lifetime and annual cost of epilepsy in the United States using data from patients with epilepsy, and adjusting for the effects of comorbidities and socioeconomic conditions. Methods : Direct treatment‐related costs of epilepsy from onset through 6 years were derived from billing and medical chart data for 608 population‐based incident cases at two sites in different regions of the country. Indirect productivity‐related costs were derived from a survey of 1,168 adult patients visiting regional treatment centers. Direct costs separate the effects of epilepsy and comorbidity conditions. Indirect costs account for the effects of other disabilities and socioeconomic conditions on foregone earnings and household activity. The estimates were applied to 1995 population figures to derive national projections of the lifetime and annual costs of the disorder. Results : The lifetime cost of epilepsy for an estimated 181,000 people with onset in 1995 is projected at $11.1 billion, and the annual cost for the estimated 2.3 million prevalent cases is estimated at $12.5 billion. Indirect costs account for 85% of the total and, with direct costs, are concentrated in people with intractable epilepsy. Conclusions : Direct costs attributable to epilepsy are below previous estimates. Indirect costs adjusted for the socioeconomic conditions of patients are above previous estimates. Findings indicate that epilepsy is unique in the large proportion of costs that are productivity‐related, justifying further investment in the development of effective interventions.

Purpose: To develop a single TBI severity classification system based on commonly used TBI severity measures and indicators that (1) maximally uses available positive evidence to classify TBI severity in three categories: (a) Moderate-Severe (Definite) TBI, (b) Mild (Probable) TBI, (c) Symptomatic (Possible) TBI; (2) reflects current clinical knowledge and relevance; and (3) classifies a larger number of cases than single indicator systems with reasonable accuracy. Main Findings: The study sample of a defined population consisted of 1501 unique Olmsted County residents with at least one confirmed TBI event from 1985 to 1999. Within the sample, 1678 TBI events were confirmed. Single measures of TBI severity were not available in a large percentage of these events, i.e., Glasgow Coma Scale (GCS) was absent in 1242 (74.0%); loss of consciousness, absent in 178 (70.2%), posttraumatic amnesia (PTA), absent in 974 (58.1%), head CT, not done in 827 (49.3%). The Mayo Classification System for TBI Severity was developed to classify cases based on available indicators that included death due to TBI, trauma-related neuroimaging abnormalities, GCS, PTA, loss of consciousness and specified post-concussive symptoms. Using the Mayo system, all cases were classified. For the Moderate-Severe (Definite) TBI classification, estimated sensitivity was 89% and estimated specificity was 98%. Conclusions: By maximally using relevant available positive evidence, the Mayo system classifies a larger number of cases than single indicator systems with reasonable accuracy. This system may be of use in retrospective research and for determination of TBI severity for planning postacute clinical care.

The temporal association between diabetes mellitus and pancreatic cancer is poorly understood. We compared temporal patterns in diabetes prevalence in pancreatic cancer and controls.We reviewed the medical records of pancreatic cancer cases residing within 120 miles or less of Rochester, Minnesota, seen at the Mayo Clinic between January 15, 1981, and July 9, 2004, and approximately 2 matched controls/case residing locally. We abstracted all outpatient fasting blood glucose (FBG) levels for up to 60 months before index (ie, date of cancer diagnosis for cases) and grouped them into 12-month intervals; 736 cases and 1875 controls had 1 or more outpatient FBG levels in the medical record. Diabetes was defined as any FBG level of 126 mg/dL or greater or treatment for diabetes, and was defined as new onset when criteria for diabetes were first met 24 or fewer months before index, with at least 1 prior FBG level less than 126 mg/dL.A higher proportion of pancreatic cancer cases compared with controls met the criteria for diabetes at any time in the 60 months before index (40.2% vs 19.2%, P < .0001). The proportions were similar in the -60 to -48 (P = .76) and -48 to -36 (P = .06) month time periods; however, a greater proportion of cases than controls met criteria for diabetes in the -36 to -24 (P = .04), -24 to -12 (P < .001), and -12 to 0 (P < .001) month time periods. Diabetes was more often new onset in cases vs controls (52.3% vs 23.6%, P < .0001).Diabetes has a high (40%) prevalence in pancreatic cancer and frequently is new onset. Identification of a specific biomarker for pancreatic cancer-induced diabetes may allow screening for pancreatic cancer in new-onset diabetes.

Although diabetes occurs frequently in pancreatic cancer, the value of new-onset diabetes as a marker of underlying pancreatic cancer is unknown.We assembled a population-based cohort of 2122 Rochester, Minnesota, residents age > or =50 years who first met standardized criteria for diabetes between January 1, 1950, and December 31, 1994, and identified those who developed pancreatic cancer within 3 years of meeting criteria for diabetes. We compared observed rates of pancreatic cancer with expected rates based on the Iowa Surveillance Epidemiology and End Results registry. In a nested case control study, we compared body mass index (BMI) and smoking status in diabetes subjects with and without pancreatic cancer.Of 2122 diabetic subjects, 18 (0.85%) were diagnosed with pancreatic cancer within 3 years of meeting criteria for diabetes; 10 of 18 (56%) were diagnosed <6 months after first meeting criteria for diabetes, and 3 were resected. The observed-to-expected ratio of pancreatic cancer in the cohort was 7.94 (95% CI, 4.70-12.55). Compared with subjects without pancreatic cancer, diabetic subjects with pancreatic cancer were more likely to have met diabetes criteria after age 69 (OR = 4.52, 95% CI, 1.61-12.74) years but did not differ significantly with respect to BMI values (29.2 +/- 6.8 vs 26.5 +/- 5.0, respectively). A larger proportion of those who developed pancreatic cancer were ever smokers (92% vs 69%, respectively), but this did not reach statistical significance.Approximately 1% of diabetes subjects aged > or =50 years will be diagnosed with pancreatic cancer within 3 years of first meeting criteria for diabetes. The usefulness of new-onset diabetes as marker of early pancreatic cancer needs further evaluation.

ContextA shortage of data exists on medical care use by persons with attention-deficit/hyperactivity disorder (ADHD).ObjectiveTo compare medical care use and costs among persons with and without ADHD.Design and SettingPopulation-based cohort study conducted in Rochester, Minn.SubjectsAll children born in 1976-1982 were followed up through 1995, using school and medical records to identify those with ADHD. The 4880 birth cohort members (mean age, 7.3 years) still residing in Rochester in 1987 were followed up in medical facility–linked billing databases until death, emigration, or December 31, 1995.Main Outcome MeasuresClinical diagnoses, likelihood and frequency of inpatient and outpatient hospitalizations, emergency department (ED) visits, and total medical costs (including ambulatory care), compared among individuals with and without ADHD.ResultsAmong the 4119 birth cohort members who remained in the area through 1995 (mean age, 15.3 years), 7.5% (n = 309) had met criteria for ADHD. Compared with persons without ADHD, those with ADHD were more likely to have diagnoses in multiple categories, including major injuries (59% vs 49%; P&lt;.001) and asthma (22% vs 13%; P&lt;.001). The proportion with any hospital inpatient, hospital outpatient, or ED admission was higher for persons with ADHD vs those without ADHD (26% vs 18% [P&lt;.001], 41% vs 33% [P = .006], and 81% vs 74% [P = .005], respectively). The 9-year median costs for persons with ADHD compared with those without ADHD were more than double ($4306 vs $1944; P&lt;.001), even for the subset with no hospital or ED admissions (eg, median 1987 costs, $128 vs $65; P&lt;.001). The differences between individuals with and without ADHD were similar for males and females and across all age groups.ConclusionIn our cohort, compared with persons without ADHD, those with ADHD exhibited substantially greater use of medical care in multiple care delivery settings.

We found no significant excess of fractures among Rochester, MN, residents with diabetes mellitus initially recognized in 1950-1969, but more recent studies elsewhere have documented an apparent increase in hip fracture risk. To explore potential explanations for any increase in fractures, we performed an historical cohort study among 1964 Rochester residents who first met glycemic criteria for diabetes in 1970-1994 (mean age, 61.7 +/-14.0 yr; 51% men). Fracture risk was estimated by standardized incidence ratios (SIRs), and risk factors were evaluated in Andersen-Gill time-to-fracture regression models. In 23,236 person-years of follow-up, 700 diabetic residents experienced 1369 fractures documented by medical record review. Overall fracture risk was elevated (SIR, 1.3; 95% CI, 1.2-1.4), but hip fractures were increased only in follow-up beyond 10 yr (SIR, 1.5; 95% CI, 1.1-1.9). As expected, fracture risk factors included age, prior fracture, secondary osteoporosis, and corticosteroid use, whereas higher physical activity and body mass index were protective. Additionally, fractures were increased among patients with neuropathy (hazard ratio [HR], 1.3; 95% CI, 1.1-1.6) and those on insulin (HR, 1.3; 95% CI, 1.1-1.5); risk was reduced among users of biquanides (HR, 0.7; 95% CI, 0.6-0.96), and no significant influence on fracture risk was seen with sulfonylurea or thiazolidinedione use. Thus, contrary to our earlier study, the risk of fractures overall (and hip fractures specifically) was increased among Rochester residents with diabetes, but there was no evidence that the rise was caused by greater levels of obesity or newer treatments for diabetes.

The study was conducted to test the hypothesis that the prevalence of coronary atherosclerosis is greater among diabetic than among nondiabetic individuals and is similar for diabetic individuals without clinical coronary artery disease (CAD) and nondiabetics with clinical CAD.Persons with diabetes but without clinical CAD encounter cardiovascular mortality similar to nondiabetic individuals with clinical CAD. This excess mortality is not fully explained. We examined the association between diabetes and coronary atherosclerosis in a geographically defined autopsied population, while capitalizing on the autopsy rate and medical record linkage system available via the Rochester Epidemiology Project, which allows rigorous ascertainment of coronary atherosclerosis, clinical CAD, and diabetes.Using two measures, namely a global coronary score and high-grade stenoses, the prevalence of atherosclerosis was analyzed in a cohort of autopsied residents of Rochester, Minnesota, age 30 years or older at death, while stratifying on diabetes, clinical CAD diagnosis, age, and gender.In this cohort, diabetes was associated with a higher prevalence of atherosclerosis. Among diabetic decedents without clinical CAD, almost three-fourths had high-grade coronary atherosclerosis and more than half had multivessel disease. Without diabetes, women had less atherosclerosis than men, but this female advantage was lost with diabetes. Among those without clinical CAD, diabetes was associated with a global coronary disease burden and a prevalence of high-grade atherosclerosis similar to that observed among nondiabetic subjects with clinical CAD.These findings provide mechanistic insights into the excess risk of clinical CAD among diabetic individuals, thereby supporting the need for aggressive prevention of atherosclerosis in all diabetic individuals, irrespective of clinical CAD symptoms.

Objective Genome-wide association studies (GWAS) require high specificity and large numbers of subjects to identify genotypeephenotype correlations accurately.The aim of this study was to identify type 2 diabetes (T2D) cases and controls for a GWAS, using data captured through routine clinical care across five institutions using different electronic medical record (EMR) systems.Materials and Methods An algorithm was developed to identify T2D cases and controls based on a combination of diagnoses, medications, and laboratory results.The performance of the algorithm was validated at three of the five participating institutions compared against clinician review.A GWAS was subsequently performed using cases and controls identified by the algorithm, with samples pooled across all five institutions.Results The algorithm achieved 98% and 100% positive predictive values for the identification of diabetic cases and controls, respectively, as compared against clinician review.By standardizing and applying the algorithm across institutions, 3353 cases and 3352 controls were identified.Subsequent GWAS using data from five institutions replicated the TCF7L2 gene variant (rs7903146) previously associated with T2D. Discussion By applying stringent criteria to EMR data collected through routine clinical care, cases and controls for a GWAS were identified that subsequently replicated a known genetic variant.The use of standard terminologies to define data elements enabled pooling of subjects and data across five different institutions to achieve the robust numbers required for GWAS.Conclusions An algorithm using commonly available data from five different EMR can accurately identify T2D cases and controls for genetic study across multiple institutions.

The reported prevalence of chronic inflammatory demyelinating polyradiculoneuropathy (CIDP) varies greatly, from 1.9 to 7.7 per 100,000. CIDP is reported to occur more commonly in patients with diabetes mellitus (DM) but has not been rigorously tested.To determine the incidence (1982-2001) and prevalence (on January 1, 2000) of CIDP in Olmsted County, Minnesota, and whether DM is more frequent in CIDP.CIDP was diagnosed by clinical criteria followed by review of electrophysiology. Cases were coded as definite, probable, or possible. DM was ascertained by clinical diagnosis or current American Diabetes Association glycemia criteria.One thousand five hundred eighty-one medical records were reviewed, and 23 patients (10 women and 13 men) were identified as having CIDP (19 definite and 4 probable). The median age was 58 years (range 4-83 years), with a median disease duration at diagnosis of 10 months (range 2-64 months). The incidence of CIDP was 1.6/100,000/year. The prevalence was 8.9/100,000 persons on January 1, 2000. Only 1 of the 23 CIDP patients (4%) also had DM, whereas 14 of 115 age- and sex-matched controls (12%) had DM.1) The incidence (1.6/100,000/year) and prevalence (8.9/100,000) of chronic inflammatory demyelinating polyradiculoneuropathy (CIDP) are similar to or higher than previous estimates. 2) The incidence of CIDP is similar to that of acute inflammatory demyelinating polyradiculoneuropathy within the same population. 3) Diabetes mellitus (DM) is unlikely to be a major risk covariate for CIDP, but we cannot exclude a small effect. 4) The perceived association of DM with CIDP may be due to misclassification of other forms of diabetic neuropathies and excessive emphasis on electrophysiologic criteria.

Hypertension often persists after adrenalectomy for primary aldosteronism.To determine factors associated with resolution of hypertension after adrenalectomy for primary aldosteronism.Retrospective cohort study.Tertiary care referral center in Rochester, Minnesota.All patients who underwent adrenalectomy for primary aldosteronism between 1 January 1993 and 31 December 1999.Preoperative plasma renin activity, plasma and urinary aldosterone concentrations, and adrenal imaging. Follow-up blood pressure, measured at a clinic visit or at home, was reviewed.97 adrenalectomies were performed, and follow-up was available in 93 patients. Hypertension was resolved at follow-up (blood pressure < 140/90 mm Hg) without use of antihypertensive agents in 31 of 93 patients (33%). According to a stepwise multivariable logistic regression analysis adjusted for duration of follow-up, resolution of hypertension was independently associated with family history of hypertension in no more than 1 first-degree relative (odds ratio [OR], 10.9; P < 0.001) and preoperative use of two or fewer antihypertensive agents (OR, 4.7; P = 0.005). Additional factors associated with resolution of hypertension based on univariate analysis included younger age, shorter duration of hypertension, higher preoperative ratio of plasma aldosterone concentration to plasma renin activity, and higher urine aldosterone level (P < 0.05).Resolution of hypertension after adrenalectomy for primary aldosteronism is independently associated with a lack of family history of hypertension and preoperative use of two or fewer antihypertensive agents.

Little is known on the prevalence and prognostic importance of diabetes mellitus (DM) among individuals with heart failure (HF) in community-based cohorts.Within Olmsted County, Minnesota, a random sample of all subjects with a first diagnosis of HF between 1979 and 1999 was validated using Framingham criteria. DM was validated using glycemic criteria.Among 665 subjects with HF (mean age 77+/-12 years, 46% male), 20% had prior DM. Subjects with DM were younger, had greater body mass index (BMI), and lower left ventricular ejection fraction than subjects without diabetes. The prevalence of DM increased markedly over time (3.8% per year; 95% confidence interval [CI], 0.8 to 6.9; P=.024), independently of BMI, particularly in older subjects (odds ratio of having DM in 1999 compared with 1979 was 3.93 [95% CI, 1.57 to 9.83] in subjects > or = 75 years vs. 1.11 [95% CI, .40 to 3.05] in subjects <75 years). Five-year survival was 37% among subjects with DM versus 46% among subjects without (P=.017). The risk of death associated with DM differed markedly according to clinical coronary artery disease (CAD) (P=.025). Subjects with DM and no CAD had a higher risk of death (relative risk [RR]=1.79 [95% CI, 1.33 to 2.41]) than those with CAD (RR=1.11 [95% CI, .81 to 1.51]), independently of age, sex, BMI, renal function, calendar year of HF, comorbidity and EF.Among community-dwelling patients with HF, the prevalence of DM increased markedly over time. DM is associated with a large increase in mortality, particularly among subjects without clinical CAD, underscoring the importance of aggressive management of DM in HF.

Controversy continues as to whether traumatic brain injury is a risk factor for Alzheimer's disease. The authors examined a related hypothesis that among persons with traumatic brain injury who develop Alzheimer's disease, time to onset of the disease is reduced. They used data on all documented episodes of traumatic brain injury that occurred from 1935 to 1984 among Olmsted County, Minnesota, residents. Community-based medical records were used to follow traumatic brain injury cases who were aged 40 years or older at last contact prior to June 1, 1988, for Alzheimer's disease until last contact, death, or June 1, 1988. The test of the hypothesis was restricted to those cases who developed Alzheimer's disease. The expected time to onset of Alzheimer's disease was derived from a life table constructed by using age-of-onset distributions within sex groups for a previously identified cohort of Rochester, Minnesota, Alzheimer's disease incidence cases without a history of head trauma. The authors found that of the 1,283 traumatic brain injury cases followed, 31 developed Alzheimer's disease, a number similar to that expected (standardized incidence ratio = 1.2, 95% confidence interval 0.8-1.7). However, the observed time from traumatic brain injury to Alzheimer's disease was less than the expected time to onset of Alzheimer's disease (median = 10 vs. 18 years, p = 0.015). The results suggest that traumatic brain injury reduces the time to onset of Alzheimer's disease among persons at risk of developing the disease.

Gastrointestinal (GI) tract symptoms are common among patients with diabetes mellitus (DM) seen in tertiary care centers. The degree to which this reflects referral bias is unclear.To determine whether GI tract symptoms are more prevalent in unselected patients with DM from the general community compared with their age- and sex-matched counterparts without DM and to assess the association of GI tract symptoms in persons with DM with psychosomatic symptoms, medication use, and symptoms of autonomic neuropathy.In this population-based, cross-sectional study, Olmsted County, Minnesota, residents with type 1 DM, a random sample of residents with type 2 DM, and 2 age- and sex-stratified random samples of nondiabetic residents (total of 1262 person for the 4 groups) were mailed a previously validated symptom questionnaire.Heartburn was less common in residents with type 1 DM vs controls (12% vs 23%; P<.05). No significant difference in prevalence was detected (residents with type 1 DM vs controls; residents with type 2 DM vs controls) for nausea or vomiting (12% vs 11%; 6% vs 6%), dyspepsia (19% vs 21%; 13% vs 17%), or constipation (17% vs 14%; 10% vs 12%). However, constipation and/or laxative use was slightly more common in residents with type 1 DM (27% vs 19%; P<.15), particularly in men, and was associated with the intake of calcium channel blockers.In the community, the prevalence of most GI tract symptoms is similar in persons with or without DM, except for a lower prevalence of heartburn and an increased prevalence of constipation or laxative use in residents with type 1 DM, especially in men. This difference is associated with calcium channel blocker use rather than symptoms of autonomic neuropathy. In community-based practices, physicians should not immediately assume that GI tract symptoms in patients with DM represent a complication of DM.

Background & Aims: Although diabetes occurs frequently in pancreatic cancer, the value of new-onset diabetes as a marker of underlying pancreatic cancer is unknown. Methods: We assembled a population-based cohort of 2122 Rochester, Minnesota, residents age ≥50 years who first met standardized criteria for diabetes between January 1, 1950, and December 31, 1994, and identified those who developed pancreatic cancer within 3 years of meeting criteria for diabetes. We compared observed rates of pancreatic cancer with expected rates based on the Iowa Surveillance Epidemiology and End Results registry. In a nested case control study, we compared body mass index (BMI) and smoking status in diabetes subjects with and without pancreatic cancer. Results: Of 2122 diabetic subjects, 18 (0.85%) were diagnosed with pancreatic cancer within 3 years of meeting criteria for diabetes; 10 of 18 (56%) were diagnosed <6 months after first meeting criteria for diabetes, and 3 were resected. The observed-to-expected ratio of pancreatic cancer in the cohort was 7.94 (95% CI, 4.70–12.55). Compared with subjects without pancreatic cancer, diabetic subjects with pancreatic cancer were more likely to have met diabetes criteria after age 69 (OR = 4.52, 95% CI, 1.61–12.74) years but did not differ significantly with respect to BMI values (29.2 ± 6.8 vs 26.5 ± 5.0, respectively). A larger proportion of those who developed pancreatic cancer were ever smokers (92% vs 69%, respectively), but this did not reach statistical significance. Conclusions: Approximately 1% of diabetes subjects aged ≥50 years will be diagnosed with pancreatic cancer within 3 years of first meeting criteria for diabetes. The usefulness of new-onset diabetes as marker of early pancreatic cancer needs further evaluation. Background & Aims: Although diabetes occurs frequently in pancreatic cancer, the value of new-onset diabetes as a marker of underlying pancreatic cancer is unknown. Methods: We assembled a population-based cohort of 2122 Rochester, Minnesota, residents age ≥50 years who first met standardized criteria for diabetes between January 1, 1950, and December 31, 1994, and identified those who developed pancreatic cancer within 3 years of meeting criteria for diabetes. We compared observed rates of pancreatic cancer with expected rates based on the Iowa Surveillance Epidemiology and End Results registry. In a nested case control study, we compared body mass index (BMI) and smoking status in diabetes subjects with and without pancreatic cancer. Results: Of 2122 diabetic subjects, 18 (0.85%) were diagnosed with pancreatic cancer within 3 years of meeting criteria for diabetes; 10 of 18 (56%) were diagnosed <6 months after first meeting criteria for diabetes, and 3 were resected. The observed-to-expected ratio of pancreatic cancer in the cohort was 7.94 (95% CI, 4.70–12.55). Compared with subjects without pancreatic cancer, diabetic subjects with pancreatic cancer were more likely to have met diabetes criteria after age 69 (OR = 4.52, 95% CI, 1.61–12.74) years but did not differ significantly with respect to BMI values (29.2 ± 6.8 vs 26.5 ± 5.0, respectively). A larger proportion of those who developed pancreatic cancer were ever smokers (92% vs 69%, respectively), but this did not reach statistical significance. Conclusions: Approximately 1% of diabetes subjects aged ≥50 years will be diagnosed with pancreatic cancer within 3 years of first meeting criteria for diabetes. The usefulness of new-onset diabetes as marker of early pancreatic cancer needs further evaluation. Pancreatic cancer patients seldom exhibit disease-specific symptoms until the cancer is at an advanced stage. If the tumor is to be discovered early, it will have to be done in asymptomatic individuals. A number of formidable obstacles limit the ability of health care providers to screen for pancreatic cancer. One of them is lack of a high-risk population for sporadic pancreatic cancer. Currently, rare genetic syndromes with a high incidence of pancreatic cancer are being targeted for screening using endoscopic ultrasonography and endoscopic retrograde cholangiopancreatography.1Brentnall T.A. Bronner M.P. Byrd D.R. Haggitt R.C. Kimmey M.B. Early diagnosis and treatment of pancreatic dysplasia in patients with a family history of pancreatic cancer.Ann Intern Med. 1999; 131: 247-255Crossref PubMed Scopus (320) Google Scholar, 2Canto M. Wroblewski L. Goggins M. Petersen G. Brune K. Yea C. Giardello F. Hruban R. Screening for pancreatic neoplasia in high-risk individuals The Johns Hopkins Experience.Gastroenterology. 2002; 122: A-17Google Scholar, 3Goggins M. Canto M. Hruban R. Can we screen high-risk individuals to detect early pancreatic carcinoma?.J Surg Oncol. 2000; 74: 243-248Crossref PubMed Scopus (58) Google ScholarTo make headway in screening for sporadic pancreatic cancer, efforts to define populations at high risk for having or developing sporadic pancreatic cancer will have to develop pari passu with advances in imaging studies and identification of novel biomarkers. In this study, we highlight the potential for utilizing hyperglycemia and diabetes to define a population at high risk for having pancreatic cancer. We also discuss the limitations of this and other studies and provide insights into why we believe hyperglycemia and diabetes may be markers of “early” pancreatic cancer and what studies need to be done to prove this hypothesis.The association between diabetes and pancreatic cancer has long been recognized. However, the assessment of diabetes as a clinically relevant screening target for pancreatic cancer is complicated by the fact that, although long-standing diabetes is an etiologic factor for pancreatic cancer, new-onset diabetes is a manifestation of the cancer. Although most studies show an elevated risk of pancreatic cancer among persons with long-standing diabetes, the strength of this association is modest at best.4Everhart J. Wright D. Diabetes mellitus as a risk factor for pancreatic cancer a meta-analysis.JAMA. 1995; 273: 1605-1609Crossref PubMed Scopus (608) Google Scholar In a meta-analysis of 20 epidemiologic studies, the pooled relative risk of pancreatic cancer for those whose diabetes was diagnosed at least 1 year prior to either diagnosis of pancreatic cancer or to pancreatic cancer death was 2.1 (95% CI: 1.6–2.8).4Everhart J. Wright D. Diabetes mellitus as a risk factor for pancreatic cancer a meta-analysis.JAMA. 1995; 273: 1605-1609Crossref PubMed Scopus (608) Google Scholar Many, but not all, cohort studies reveal that the risk of pancreatic cancer associated with diabetes decreases with increasing duration of follow-up.5Ragozzino M. Melton L.J.D. Chu C.P. Palumbo P.J. Subsequent cancer risk in the incidence cohort of Rochester, Minnesota, residents with diabetes mellitus.J Chronic Dis. 1982; 35: 13-19Abstract Full Text PDF PubMed Scopus (216) Google Scholar, 6Wideroff L. Gridley G. Mellemkjaer L. Chow W.H. Linet M. Keehn S. Borch-Johnsen K. Olsen J.H. Cancer incidence in a population-based cohort of patients hospitalized with diabetes mellitus in Denmark.J Natl Cancer Inst. 1997; 89: 1360-1365Crossref PubMed Scopus (565) Google Scholar, 7Calle E.E. Murphy T.K. Rodriguez C. Thun M.J. Heath Jr, C.W. Diabetes mellitus and pancreatic cancer mortality in a prospective cohort of United States adults.Cancer Causes Control. 1998; 9: 403-410Crossref PubMed Scopus (127) Google Scholar, 8Adami H.O. McLaughlin J. Ekbom A. Berne C. Silverman D. Hacker D. Persson I. Cancer risk in patients with diabetes mellitus.Cancer Causes Control. 1991; 2: 307-314Crossref PubMed Scopus (299) Google Scholar, 9Chow W.H. Gridley G. Nyren O. Linet M.S. Ekbom A. Fraumeni Jr, J.F. Adami H.O. Risk of pancreatic cancer following diabetes mellitus a nationwide cohort study in Sweden.J Natl Cancer Inst. 1995; 87: 930-931Crossref PubMed Scopus (116) Google Scholar Additionally, although the number of persons with pancreatic cancer in the population is small, the number of older persons with long-standing diabetes is large. Thus long-standing diabetes as a marker for pancreatic cancer is likely to have limited clinical utility.There is increasing evidence to support the notion that diabetes may be a consequence of pancreatic cancer. Diabetes and hyperglycemia are present in up to 80% of pancreatic cancer,10Cersosimo E. Pisters P.W. Pesola G. McDermott K. Bajorunas D. et al.Insulin secretion and action in patients with pancreatic cancer.Cancer. 1991; 67: 486-493Crossref PubMed Scopus (104) Google Scholar, 11Permert J. Ihse I. Jorfeldt L. von Schenck H. Arnqvist H.J. Larsson J. Pancreatic cancer is associated with impaired glucose metabolism.Eur J Surg. 1993; 159: 101-107PubMed Google Scholar, 12Permert J. Larsson J. Ihse I. Pour P.M. Diagnosis of pancreatic cancer. Alteration of glucose metabolism.Int J Pancreatol. 1991; 9: 113-117PubMed Google Scholar, 13Chari S.T. Klee G.G. Miller L.J. Raimondo M. DiMagno E.P. Islet amyloid polypeptide is not a satisfactory marker for detecting pancreatic cancer.Gastroenterology. 2001; 121: 640-645Abstract Full Text Full Text PDF PubMed Scopus (70) Google Scholar are usually of recent onset,13Chari S.T. Klee G.G. Miller L.J. Raimondo M. DiMagno E.P. Islet amyloid polypeptide is not a satisfactory marker for detecting pancreatic cancer.Gastroenterology. 2001; 121: 640-645Abstract Full Text Full Text PDF PubMed Scopus (70) Google Scholar, 14Silverman D.T. Swanson C.A. Gridley G. Wacholder S. Greenberg R.S. Brown L.M. Hayes R.B. Swanson G.M. Schoenberg J.B. Pottern L.M. Schwartz A.G. Fraumeni Jr, J.F. Hoover R.N. Dietary and nutritional factors and pancreatic cancer a case control study based on direct interviews.J Natl Cancer Inst. 1998; 90: 1710-1719Crossref PubMed Scopus (233) Google Scholar, 15Jain M. Howe G.R. St Louis P. Miller A.B. Coffee and alcohol as determinants of risk of pancreas cancer a case control study from Toronto.Int J Cancer. 1991; 47: 384-389Crossref PubMed Scopus (105) Google Scholar, 16Gullo L. Pezzilli R. Morselli-Labate A.M. Italian Pancreatic Cancer Study GroupDiabetes and the risk of pancreatic cancer.N Engl J Med. 1994; 331: 81-84Crossref PubMed Scopus (298) Google Scholar, 17Moossa A.R. Levin B. Collaborative studies in the diagnosis of pancreatic cancer.Semin Oncol. 1979; 6: 298-308PubMed Google Scholar, 18Moossa A.R. Levin B. The diagnosis of “early” pancreatic cancer the University of Chicago experience.Cancer. 1968; 47: 1688-1697Crossref Scopus (111) Google Scholar, 19Bonelli L. Aste H. Bovo P. Cavallini G. Felder M. Gusmaroli R. Morandini E. Ravelli P. Briglia R. Lombardo L. De Micheli A. Pugliese V. Exocrine pancreatic cancer, cigarette smoking, and diabetes mellitus a case-control study in northern Italy.Pancreas. 2003; 27: 143-149Crossref PubMed Scopus (101) Google Scholar, 20Cuzick J. Babiker A.G. Pancreatic cancer, alcohol, diabetes mellitus and gall-bladder disease.Int J Cancer. 1989; 43: 415-421Crossref PubMed Scopus (190) Google Scholar, 21Permert J. Ihse I. Jorfeldt L. von Schenck H. Arnquist H.J. Larsson J. Improved glucose metabolism after subtotal pancreatectomy for pancreatic cancer.Br J Surg. 1993; 80: 1047-1050Crossref PubMed Scopus (205) Google Scholar and improve or remit after resection of cancer.21Permert J. Ihse I. Jorfeldt L. von Schenck H. Arnquist H.J. Larsson J. Improved glucose metabolism after subtotal pancreatectomy for pancreatic cancer.Br J Surg. 1993; 80: 1047-1050Crossref PubMed Scopus (205) Google Scholar Based on such observations, new-onset diabetes has been suggested as a possible target for screening for pancreatic cancer.11Permert J. Ihse I. Jorfeldt L. von Schenck H. Arnqvist H.J. Larsson J. Pancreatic cancer is associated with impaired glucose metabolism.Eur J Surg. 1993; 159: 101-107PubMed Google Scholar, 15Jain M. Howe G.R. St Louis P. Miller A.B. Coffee and alcohol as determinants of risk of pancreas cancer a case control study from Toronto.Int J Cancer. 1991; 47: 384-389Crossref PubMed Scopus (105) Google Scholar, 16Gullo L. Pezzilli R. Morselli-Labate A.M. Italian Pancreatic Cancer Study GroupDiabetes and the risk of pancreatic cancer.N Engl J Med. 1994; 331: 81-84Crossref PubMed Scopus (298) Google Scholar, 17Moossa A.R. Levin B. Collaborative studies in the diagnosis of pancreatic cancer.Semin Oncol. 1979; 6: 298-308PubMed Google Scholar, 22Noy A. Bilezikian J.P. Clinical review 63: diabetes and pancreatic cancer: clues to the early diagnosis of pancreatic malignancy.J Clin Endocrinol Metab. 1994; 79: 1223-1231Crossref PubMed Scopus (53) Google Scholar However, it is important to recognize that previous epidemiologic studies of the association between diabetes and pancreatic cancer are generally uninformative about the clinical utility of newly identified diabetes as a marker for pancreatic cancer. In almost all case control studies, duration of diabetes is unclear because it was assessed by self- or proxy report. Three studies have used postload glucose levels at baseline, and persons with and without prevalent diabetes have been followed forward for pancreatic cancer.23Levine W. Dyer A.R. Shekelle R.B. Schoenberger J.A. Stamler J. Post-load plasma glucose and cancer mortality in middle-aged men and women. 12-year follow-up findings of the Chicago Heart Association Detection Project in Industry.Am J Epidemiol. 1990; 131: 254-262Crossref PubMed Scopus (93) Google Scholar, 24Gapstur S.M. Gann P.H. Lowe W. Liu K. Colangelo L. Dyer A. Abnormal glucose metabolism and pancreatic cancer mortality.JAMA. 2000; 283: 2552-2558Crossref PubMed Scopus (343) Google Scholar, 25Smith G.D. Egger M. Shipley M.J. Marmot M.G. Post-challenge glucose concentration, impaired glucose tolerance, diabetes, and cancer mortality in men.Am J Epidemiol. 1992; 136: 1110-1114PubMed Google Scholar However, these studies are relatively uninformative regarding the short-term risk of pancreatic cancer associated with diabetes because the mean age was relatively young,23Levine W. Dyer A.R. Shekelle R.B. Schoenberger J.A. Stamler J. Post-load plasma glucose and cancer mortality in middle-aged men and women. 12-year follow-up findings of the Chicago Heart Association Detection Project in Industry.Am J Epidemiol. 1990; 131: 254-262Crossref PubMed Scopus (93) Google Scholar, 24Gapstur S.M. Gann P.H. Lowe W. Liu K. Colangelo L. Dyer A. Abnormal glucose metabolism and pancreatic cancer mortality.JAMA. 2000; 283: 2552-2558Crossref PubMed Scopus (343) Google Scholar and there were very few pancreatic cancer deaths within the first 5 years among persons with diabetes at baseline.23Levine W. Dyer A.R. Shekelle R.B. Schoenberger J.A. Stamler J. Post-load plasma glucose and cancer mortality in middle-aged men and women. 12-year follow-up findings of the Chicago Heart Association Detection Project in Industry.Am J Epidemiol. 1990; 131: 254-262Crossref PubMed Scopus (93) Google Scholar, 24Gapstur S.M. Gann P.H. Lowe W. Liu K. Colangelo L. Dyer A. Abnormal glucose metabolism and pancreatic cancer mortality.JAMA. 2000; 283: 2552-2558Crossref PubMed Scopus (343) Google ScholarTo assess the potential benefit of screening for pancreatic cancer among subjects with newly identified diabetes, population-based cohort studies are needed. In previous studies, estimates of the prevalence of newly diagnosed diabetes among controls do not afford estimates of the prevalence of newly diagnosed diabetes in the population. This limitation also applies to cohort studies in which the study population is limited to persons with prevalent diabetes who are not necessarily representative of persons with diabetes in the population generally (ie, hospitalized diabetes cases or patients of a diabetes clinic). Thus, there is a need for studies that afford estimates of both the number of newly diagnosed cases of diabetes that exist within the population and of the excess risk of pancreatic cancer associated specifically with newly identified diabetes.Our study used the longitudinal, population-based resources of the Rochester Epidemiology Project (REP)26Melton III, L.J. History of the Rochester Epidemiology Project.Mayo Clin Proc. 1996; 71: 266-274Abstract Full Text Full Text PDF PubMed Scopus (1338) Google Scholar to identify all Rochester, Minnesota, residents who first met standardized research criteria for diabetes on or after age 50 years between January 1, 1950, and December 31, 1994. In this cohort, we determined the likelihood of pancreatic cancer diagnosis within 3 years of meeting criteria for diabetes and compared observed rates with those expected for persons of similar age and sex distribution. Among persons with diabetes, we compared those with and without pancreatic cancer for other known or potential risk factors, ie, age, sex, smoking, and body mass index (BMI).Patients and MethodsThe study was approved by the Mayo Foundation Institutional Review Board (IRB). Population-based studies are possible in Rochester, Minnesota, because essentially all medical care received by local residents is delivered by the Mayo Clinic and the Olmsted Medical Center. Since 1907, every Mayo Clinic patient has been assigned a unique identifier. All information from every contact (including hospital inpatient or outpatient care, office visits, emergency room, and nursing home care, as well as death certificate and autopsy information) is contained within a single dossier for each patient, and diagnoses assigned at each visit are entered into computer files. Under the auspices of the Rochester Epidemiology Project (REP), this diagnostic index and medical records linkage were expanded to include the other providers of care to local residents,26Melton III, L.J. History of the Rochester Epidemiology Project.Mayo Clin Proc. 1996; 71: 266-274Abstract Full Text Full Text PDF PubMed Scopus (1338) Google Scholar thus providing a comprehensive medical database of the Rochester population.Rochester Diabetes Incidence CohortREP resources were used to construct the Rochester diabetes incidence cohort.27Burke J.P. O’Brien P. Ransom J. Palumbo P.J. Lydick E. Yawn B.P. Joseph Melton III, L. Leibson C.L. Impact of case ascertainment on recent trends in diabetes incidence in Rochester, Minnesota.Am J Epidemiol. 2002; 155: 859-865Crossref PubMed Scopus (24) Google Scholar, 28Leibson C.L. Williamson D.F. Melton III, L.J. Palumbo P.J. Smith S.A. Ransom J.E. Schilling P.L. Narayan K.M. Temporal trends in BMI among adults with diabetes.Diabetes Care. 2001; 24: 1584-1589Crossref PubMed Scopus (102) Google Scholar, 29Thomas R.J. Palumbo P.J. Melton III, L.J. Roger V.L. Ransom J. O’Brien P.C. Leibson C.L. Trends in the mortality burden associated with diabetes mellitus a population-based study in Rochester, Minn, 1970–1994.Arch Intern Med. 2003; 163: 445-451Crossref PubMed Scopus (85) Google Scholar The full cohort includes all 2151 individuals who first met research criteria for diabetes as a Rochester resident between 1950 and 1995. In constructing this cohort, confirmation of diabetes status was based on review of provider-linked medical records by trained nurse abstractors, under the direction of an endocrinologist. Records were reviewed from date of first contact with each REP provider until date of last contact, death, or end of the study period for all laboratory glucose values and evidence of any antidiabetic medication. Laboratory glucose values are available within REP medical records for 1930 through the present. Glycemic criteria approximated National Diabetes Data Group (NDDG) recommendations,30National Diabetes Data GroupClassification and diagnosis of diabetes mellitus and other categories of glucose intolerance.Diabetes Care. 1979; 28: 1039-1057Crossref Scopus (5477) Google Scholar ie, 2 consecutive fasting glucose levels ≥140 mg/dL (7.8 mmol/L) or both 1- and 2-hour levels ≥200 mg/dL (11.1 mmol/L) obtained during a standard oral glucose tolerance test. Adjustments were made for changes in laboratory methods over time.31West K. Standardization of definition, classification, and reporting in diabetes-related epidemiologic studies.Diabetes Care. 1979; 2: 65-76Crossref PubMed Scopus (24) Google Scholar Individuals who failed to meet glycemic criteria but who used oral agents or insulin for at least 2 weeks or until death also qualified as cases.Because it was not feasible to review manually all medical records for every Rochester resident over this 45-year period, the review was limited to candidate cases, ie, all residents with any diagnosis suggestive of diabetes (eg, elevated blood glucose, impaired glucose tolerance, diabetes mellitus, rule-out diabetes, diabetic nephropathy) in the REP diagnostic index. In a previous study of all Rochester residents who died on or after age 45 years in 1970–1995, the median number of years of medical records available for review (ie, time from first contact with a REP provider until death) was 43 years (interquartile range, 24–58 years), and over 25% of all decedents had a diagnosis in the REP diagnostic index that qualified them as a candidate case for the diabetes incidence cohort.29Thomas R.J. Palumbo P.J. Melton III, L.J. Roger V.L. Ransom J. O’Brien P.C. Leibson C.L. Trends in the mortality burden associated with diabetes mellitus a population-based study in Rochester, Minn, 1970–1994.Arch Intern Med. 2003; 163: 445-451Crossref PubMed Scopus (85) Google Scholar It has also been demonstrated that essentially all Rochester residents have contact with at least 1 REP provider in any 5-year period.26Melton III, L.J. History of the Rochester Epidemiology Project.Mayo Clin Proc. 1996; 71: 266-274Abstract Full Text Full Text PDF PubMed Scopus (1338) Google Scholar In each year, the proportion of local residents age ≥30 years who have at least 1 blood glucose measurement averages approximately 37% for males and 44% for females.27Burke J.P. O’Brien P. Ransom J. Palumbo P.J. Lydick E. Yawn B.P. Joseph Melton III, L. Leibson C.L. Impact of case ascertainment on recent trends in diabetes incidence in Rochester, Minnesota.Am J Epidemiol. 2002; 155: 859-865Crossref PubMed Scopus (24) Google ScholarThe present study was limited to individuals who first met criteria for diabetes between January 1, 1950, and December 31, 1994, on or after age 50 years and who were residing in Rochester for at least 1 year as of the date they first met criteria (ie, incident cases) (Figure 1). In accordance with a Minnesota statute,32Melton III, L.J. The threat to medical-records research.N Engl J Med. 1997; 337: 1466-1470Crossref PubMed Scopus (198) Google Scholar 24 individuals who declined to authorize the use of their medical records in the research were excluded from the study. Thus, there were 2127 authorized and eligible incident diabetes cases (Figure 1).Ascertainment of Incident Pancreatic CancersThe list of 2127 incident diabetes cases was cross matched with the diagnostic index maintained by the REP to identify those with any diagnosis of pancreatic adenocarcinoma within 3 years of meeting criteria for diabetes (n = 27). After review of the medical records of these 27 subjects, 9 were excluded (5 who were found to have developed diabetes after pancreatectomy or cancer and 4 who were found to not have pancreatic ductal adenocarcinoma) (Figure 1).Selection of Controls for Nested Case Control StudyFor each of the 18 remaining diabetes cases who met criteria for pancreatic ductal adenocarcinoma, 4 members of the diabetes cohort were identified who were of same sex, similar year of birth, and similar year in which criteria for diabetes were met, but for whom there was no diagnosis of pancreatic cancer.Statistical AnalysesIncidence and risk of pancreatic cancer in the diabetes cohortThe incidence of pancreatic cancer among members of the cohort was calculated as the ratio of observed cases to the number of diabetes person-years of follow-up. Diabetes person-years were calculated from the date that all 2122 members of the diabetes cohort first met criteria for diabetes, until the earliest of pancreatic cancer diagnosis, death, or 3 years.The excess risk of pancreatic cancer within 3 years of first meeting criteria for diabetes mellitus was estimated by comparing the observed number of cases among members of the diabetes incidence cohort to the expected number of cases in the general population. The expected number was estimated by multiplying the number of diabetes person-years for each 5-year age group and sex by the corresponding age- and sex-specific incidence rates from data from the Surveillance, Epidemiology, and End Results (SEER) program.33National Cancer Institute. Surveillance and End Results (SEER) Program (www.seer.cancer.gov) SEER*Stat Database: Incidence-SEER 9 Regs Public-Use, Nov 2002 Sub (1973–2000) <18 Age Groups>, National Cancer Institute, DCCPS, Surveillance Research Program, Cancer Statistics Branch, released April 2003, based on the November 2002 submission.Google Scholar The incidence of pancreatic cancer in Olmsted county has been reported.34Riela A. Zinsmeister A.R. Melton III, L.J. Weiland L.H. DiMagno E.P. Increasing incidence of pancreatic cancer among women in Olmsted County, Minnesota, 1940 through 1988.Mayo Clin Proc. 1992; 67: 839-845Abstract Full Text Full Text PDF PubMed Scopus (35) Google Scholar The study by Riela et al34Riela A. Zinsmeister A.R. Melton III, L.J. Weiland L.H. DiMagno E.P. Increasing incidence of pancreatic cancer among women in Olmsted County, Minnesota, 1940 through 1988.Mayo Clin Proc. 1992; 67: 839-845Abstract Full Text Full Text PDF PubMed Scopus (35) Google Scholar showed that the incidence of pancreatic cancer in Olmsted county is very similar to the incidence of pancreatic cancer in the Iowa SEER population. However, the study by Riela et al34Riela A. Zinsmeister A.R. Melton III, L.J. Weiland L.H. DiMagno E.P. Increasing incidence of pancreatic cancer among women in Olmsted County, Minnesota, 1940 through 1988.Mayo Clin Proc. 1992; 67: 839-845Abstract Full Text Full Text PDF PubMed Scopus (35) Google Scholar did not cover the entire period of our study, and the number of patients diagnosed with pancreatic cancer each year is small. We therefore chose to use the Iowa SEER data because Iowa is the nearest state with SEER data available in the United States, and the demographics of Iowa are very similar to those of Rochester, Minnesota.Risk ratios (defined as the ratio of observed to expected number of cases of pancreatic cancer) and 95% confidence intervals (based on the Poisson distribution of the observed number of pancreatic cancer cases) were estimated, both overall and for subgroups (ie, ages <70 vs ≥70 years; male vs female).35Bergstalh EJ, Offord KP, Kosanke JL, Augustine GA. PERSONYEARS: a SAS procedure for person year analyses: Rochester, MN: Section of Medical Research Statistics, Mayo Clinic; April 1986. Technical Report Series, No.31.Google ScholarNested case control studyTo evaluate whether there was an association between smoking or BMI and pancreatic cancer among persons with diabetes, the analysis included the 4 diabetes controls for each case, for a total of 72 controls and 18 cases.36Breslow N.E. Day N.E. Statistical methods in cancer research. IARC Workshop. IARC Scientific Publications. Volume No. 82. IARC, Lyon, France1987Google Scholar The medical records of these 90 individuals were reviewed for smoking history, classified as ever, never, or unknown. BMI (weight in kilograms/height in meters2) as of the date criteria for diabetes were met (±2 years) was noted. To obtain risk ratios and 95% confidence intervals, we employed conditional logistic regression, matching on age and sex. Statistical analyses were conducted using Statistical Analysis Software (SAS) version 8 (SAS Institute, Cary, NC).ResultsBetween January 1, 1950, and December 31, 1994, there were 2122 Rochester residents ≥50 years of age who first met National Diabetes Data Group (NDDG) criteria for diabetes (male, 50%; mean age, 66.2 ± 10.1 years). Persons were followed to the earliest of pancreatic cancer diagnosis, death, or 3 years, for a total of 5799 person-years of follow-up in the diabetes cohort; during which time, 18 subjects (0.85%) met criteria for pancreatic cancer.Characteristics of Diabetes Associated With Pancreatic CancerThere was no family history of diabetes in 11 of 18 (61%) subjects; 3 had siblings with diabetes and 1 each had a parent and uncle with diabetes. Data on family history were not available in 2 patients. Seven (39%) subjects were treated with insulin and 3 with oral hypoglycemics; the remaining subjects were not on hypoglycemic medications. At the time patients met criteria for diabetes, 9 of 18 had cancer-related symptoms, 2 had diabetes-related symptoms (polydipsia and polyphagia), and the remaining had no symptoms or were being investigated for an unrelated problem (eg, atrial fibrillation).Characteristics of Pancreatic Cancer Associated With DiabetesTwelve of 18 (67%) subjects were males (Table 1). Their mean age at cancer diagnosis was 72.3 ± 8.1 years. On average, pancreatic cancer was identified 6.6 ± 7.7 months after the date diabetes criteria were met. In 10 of 18 (56%), the cancer was diagnosed <6 months after first meeting criteria for diabetes. The cancer was resected in 3 and was unresectable in the remaining patients.Table 1Characteristics of the 18 Subjects With Pancreatic Cancer in the Rochester Diabetes Incidence CohortPatient No.Age (y)aAge at diagnosis of pancreatic cancer.SexInterval (mo)bInterval between date criteria for diabetes met and date of diagnosis of pancreas cancer.Procedure to diagnose pancreatic cancerBMI as of date diabetes criteria metSmoking166M<1Laparotomy with biopsy26.8Ever262F<1Distal pancreatectomy27.5Ever374M<1Autopsy24.1Unknown480F<1Laparotomy, biliary bypass35.6Ever589M<1Laparotomy with biopsy21.2Unknown670F<1Pancreatico-duodenect

The decline in hip fracture incidence is now accompanied by a further reduction in the likelihood of a recurrent hip fracture among survivors of the first fracture. Hip fracture incidence is declining in North America, but trends in hip fracture recurrence have not been described. All hip fracture events among Olmsted County, Minnesota residents in 1980–2006 were identified. Secular trends were assessed using Poisson regression, and predictors of recurrence were evaluated with Andersen–Gill time-to-fracture regression models. Altogether, 2,752 hip fractures (median age, 83 years; 76% female) were observed, including 311 recurrences. Between 1980 and 2006, the incidence of a first-ever hip fracture declined by 1.37%/year for women (p < 0.001) and 0.06%/year for men (p = 0.917). Among 2,434 residents with a first-ever hip fracture, the cumulative incidence of a second hip fracture after 10 years was 11% in women and 6% in men with death treated as a competing risk. Age and calendar year of fracture were independently associated with hip fracture recurrence. Accounting for the reduction in first-ever hip fracture rates over time, hip fracture recurrence appeared to decline after 1997. A recent reduction in hip fracture recurrence is somewhat greater than expected from the declining incidence of hip fractures generally. Additional research is needed to determine the extent to which this can be attributed to improved patient management.

Objective: The aim of this study was to evaluate the association between stimulant treatment and the risk for substance abuse among young adults with a childhood diagnosis of attention- deficit/hyperactivity disorder (ADHD). Methods: Subjects included 295 research-identified ADHD incidence cases treated with psychostimulant medication and 84 ADHD cases not treated with psychostimulants. These subjects are from a 1976–1982 population-based birth cohort, retrospectively, followed from birth until emigration, death, or last follow-up (mean = 17.2 years of follow-up). Medical and school records were reviewed for documented substance abuse and psychostimulant treatment. The association was evaluated using logistic regression models. Results: Socioeconomic characteristics at birth, and comorbidities, were similar between treated and untreated ADHD cases. Sixty (20.3%) of treated ADHD cases had documented substance abuse compared to 23 (27.4%) of cases not treated (OR = 0.7; 95% CI = 0.4–1.2). Among treated ADHD boys, 21.8% had substance abuse compared to 36.4% not-treated ADHD boys (OR = 0.5; 95% CI = 0.3–0.9). Among treated ADHD girls, 15.2% had substance abuse compared to 10.3% not-treated ADHD girls (OR = 1.5; 95% CI = 0.4–6.1). Conclusion: While these results cannot demonstrate cause and effect, our findings indicate that psychostimulant treatment of childhood ADHD is associated with reduced risk for later substance abuse among boys with ADHD.

Much of the available data on stroke occurrence, service use, and cost of care originated with hospital discharge abstracts. This article uses the unique resources of the Rochester Epidemiology Project to estimate the sensitivity and positive predictive value of hospital discharge abstracts for incident stroke.The Rochester Stroke Registry was used to identify all confirmed first strokes (hospitalized and nonhospitalized) among Rochester residents for 1970, 1980, 1984, and 1989 (n = 364). The sensitivity of discharge abstracts was estimated by following these individuals for 12 months after stroke to determine the proportion assigned a discharge diagnosis of cerebrovascular disease (International Classification of Diseases [ICD] codes 430 through 438.9). The positive predictive value of discharge abstracts was assessed by identifying all hospitalizations of Rochester residents with an ICD code of 430-438.9 in 1970, 1980, and 1989 (n = 377). Events were categorized as incident stroke, recurrent stroke, stroke sequelae, or nonstroke after review of the complete community-based medical record by a neurologist.Only 86% (n = 313) of all first-stroke patients in 1970, 1980, 1984, and 1989 were hospitalized. Of hospitalized patients, only 76% were assigned a principal discharge diagnosis code of 430-438.9. Fatal strokes and those occurring during a hospitalization were less likely to be identified. Among all hospitalizations of Rochester residents in 1970, 1980, and 1989, there were 377 with a principal diagnosis code of 430-438.9. Less than half (n = 177) were determined by the neurologist to be incident stroke; only 60% (n = 225) were either incident or recurrent stroke. Comparison of alternative approaches showed the validity of discharge abstracts was enhanced by increasing the number of diagnoses and excluding codes with poor positive predictive value.This study provides previously unavailable estimates of the sensitivity of stroke-coded hospitalizations for a US community. A model for improving the sensitivity and positive predictive value of discharge abstracts is presented.

Almost all previous studies of familial risk of epilepsy have had potentially serious methodological limitations. Our goal was to address these limitations and provide more rigorous estimates of familial risk in a population-based study. We used the unique resources of the Rochester Epidemiology Project to identify all 660 Rochester, Minnesota residents born in 1920 or later with incidence of epilepsy from 1935–94 (probands) and their 2439 first-degree relatives who resided in Olmsted County. We assessed incidence of epilepsy in relatives by comprehensive review of the relatives’ medical records, and estimated age-specific cumulative incidence and standardized incidence ratios for epilepsy in relatives compared with the general population, according to proband and relative characteristics. Among relatives of all probands, cumulative incidence of epilepsy to age 40 was 4.7%, and risk was increased 3.3-fold (95% confidence interval 2.75–5.99) compared with population incidence. Risk was increased to the greatest extent in relatives of probands with idiopathic generalized epilepsies (standardized incidence ratio 6.0) and epilepsies associated with intellectual or motor disability presumed present from birth, which we denoted ‘prenatal/developmental cause’ (standardized incidence ratio 4.3). Among relatives of probands with epilepsy without identified cause (including epilepsies classified as ‘idiopathic’ or ‘unknown cause’), risk was significantly increased for epilepsy of prenatal/developmental cause (standardized incidence ratio 4.1). Similarly, among relatives of probands with prenatal/developmental cause, risk was significantly increased for epilepsies without identified cause (standardized incidence ratio 3.8). In relatives of probands with generalized epilepsy, standardized incidence ratios were 8.3 (95% confidence interval 2.93–15.31) for generalized epilepsy and 2.5 (95% confidence interval 0.92–4.00) for focal epilepsy. In relatives of probands with focal epilepsy, standardized incidence ratios were 1.0 (95% confidence interval 0.00–2.19) for generalized epilepsy and 2.6 (95% confidence interval 1.19–4.26) for focal epilepsy. Epilepsy incidence was greater in offspring of female probands than in offspring of male probands, and this maternal effect was restricted to offspring of probands with focal epilepsy. The results suggest that risks for epilepsies of unknown and prenatal/developmental cause may be influenced by shared genetic mechanisms. They also suggest that some of the genetic influences on generalized and focal epilepsies are distinct. However, the similar increase in risk for focal epilepsy among relatives of probands with either generalized (2.5-fold) or focal epilepsy (2.6-fold) may reflect some coexisting shared genetic influences.

Elevated areal bone mineral density (aBMD) in type 2 diabetes mellitus is inconsistent with increased fracture risk at some skeletal sites.Because aBMD is an imperfect surrogate for bone strength, we assessed bone structure and strength more directly using quantitative computed tomography.Diabetic and nondiabetic subjects were evaluated in a cross-sectional study.Subjects were recruited from a random sample of the Rochester, MN, population.Forty-nine subjects (28 women and 21 men) with type 2 diabetes were compared with age- and sex-matched nondiabetic controls.We measured bone geometry, strength, and volumetric BMD (vBMD) at the hip, spine, and wrist, along with hip aBMD, using central and peripheral quantitative computed tomography and estimated bone load to bone strength ratios at each site.Adjusted for differences in body mass index between cases and controls (29.8 vs. 27.6), hip aBMD was greater in diabetic subjects, but this was accounted for by greater trabecular vBMD. Cortical vBMD was similar in the two groups, as was bone cross-sectional area and cortical thickness. Bone strength measures were generally better in diabetic subjects, but bone loads were higher from their greater weight. Consequently, load to strength ratios (i.e. factor-of-risk) were similar.Patients with type 2 diabetes enjoy little benefit from elevated aBMD in terms of improved bone load to strength ratios. With no deficit in bone density, the rationale for antiresorptive therapy in diabetic patients is uncertain, but potential adverse effects of diabetes on bone quality need more study.

Background: Extremely few objective estimates of traumatic brain injury incidence include all ages, both sexes, all injury mechanisms, and the full spectrum from very mild to fatal events. Methods: We used unique Rochester Epidemiology Project medical records-linkage resources, including highly sensitive and specific diagnostic coding, to identify all Olmsted County, MN, residents with diagnoses suggestive of traumatic brain injury regardless of age, setting, insurance, or injury mechanism. Provider-linked medical records for a 16% random sample were reviewed for confirmation as definite, probable, possible (symptomatic), or no traumatic brain injury. We estimated incidence per 100,000 person-years for 1987–2000 and compared these record-review rates with rates obtained using Centers for Disease Control and Prevention (CDC) data-systems approach. For the latter, we identified all Olmsted County residents with any CDC-specified diagnosis codes recorded on hospital/emergency department administrative claims or death certificates during 1987–2000. Results: Of sampled individuals, 1257 met record-review criteria for incident traumatic brain injury; 56% were ages 16–64 years, 56% were male, and 53% were symptomatic. Mechanism, sex, and diagnostic certainty differed by age. The incidence rate per 100,000 person-years was 558 (95% confidence interval = 528–590) versus 341 (331–350) using the CDC data-system approach. The CDC approach captured only 40% of record-review cases. Seventy-four percent of missing cases presented to the hospital/emergency department; none had CDC-specified codes assigned on hospital/emergency department administrative claims or death certificates; and 66% were symptomatic. Conclusions: Capture of symptomatic traumatic brain injuries requires a wider range of diagnosis codes, plus sampling strategies to avoid high rates of false-positive events.

Objective: To evaluate data fragmentation across healthcare centers with regard to the accuracy of a high-throughput clinical phenotyping (HTCP) algorithm developed to differentiate (1) patients with type 2 diabetes mellitus (T2DM) and (2) patients with no diabetes. Materials and methods: This population-based study identified all Olmsted County, Minnesota residents in 2007. We used provider-linked electronic medical record data from the two healthcare centers that provide >95% of all care to County residents (ie, Olmsted Medical Center and Mayo Clinic in Rochester, Minnesota, USA). Subjects were limited to residents with one or more encounter January 1, 2006 through December 31, 2007 at both healthcare centers. DM-relevant data on diagnoses, laboratory results, and medication from both centers were obtained during this period. The algorithm was first executed using data from both centers (ie, the gold standard) and then from Mayo Clinic alone. Positive predictive values and false-negative rates were calculated, and the McNemar test was used to compare categorization when data from the Mayo Clinic alone were used with the gold standard. Age and sex were compared between true-positive and false-negative subjects with T2DM. Statistical significance was accepted as p<0.05. Results: With data from both medical centers, 765 subjects with T2DM (4256 non-DM subjects) were identified. When single-center data were used, 252 T2DM subjects (1573 non-DM subjects) were missed; an additional false-positive 27 T2DM subjects (215 non-DM subjects) were identified. The positive predictive values and false-negative rates were 95.0% (513/540) and 32.9% (252/765), respectively, for T2DM subjects and 92.6% (2683/2898) and 37.0% (1573/4256), respectively, for non-DM subjects. Age and sex distribution differed between true-positive (mean age 62.1; 45% female) and false-negative (mean age 65.0; 56.0% female) T2DM subjects. Conclusion: The findings show that application of an HTCP algorithm using data from a single medical center contributes to misclassification. These findings should be considered carefully by researchers when developing and executing HTCP algorithms.

To construct and validate billing code algorithms for identifying patients with peripheral arterial disease (PAD).We extracted all encounters and line item details including PAD-related billing codes at Mayo Clinic Rochester, Minnesota, between July 1, 1997 and June 30, 2008; 22 712 patients evaluated in the vascular laboratory were divided into training and validation sets. Multiple logistic regression analysis was used to create an integer code score from the training dataset, and this was tested in the validation set. We applied a model-based code algorithm to patients evaluated in the vascular laboratory and compared this with a simpler algorithm (presence of at least one of the ICD-9 PAD codes 440.20-440.29). We also applied both algorithms to a community-based sample (n=4420), followed by a manual review.The logistic regression model performed well in both training and validation datasets (c statistic=0.91). In patients evaluated in the vascular laboratory, the model-based code algorithm provided better negative predictive value. The simpler algorithm was reasonably accurate for identification of PAD status, with lesser sensitivity and greater specificity. In the community-based sample, the sensitivity (38.7% vs 68.0%) of the simpler algorithm was much lower, whereas the specificity (92.0% vs 87.6%) was higher than the model-based algorithm.A model-based billing code algorithm had reasonable accuracy in identifying PAD cases from the community, and in patients referred to the non-invasive vascular laboratory. The simpler algorithm had reasonable accuracy for identification of PAD in patients referred to the vascular laboratory but was significantly less sensitive in a community-based sample.

Annals of the New York Academy of SciencesVolume 826, Issue 1 p. 422-427 The Risk of Dementia among Persons with Diabetes Mellitus: A Population-Based Cohort Studya C. L. LEIBSON, Corresponding Author C. L. LEIBSON Health Sciences Division, Mayo Clinic, 200 1st Street, SW, Rochester, Minnesota, 55905, USAc Address for correspondence: C. L. Leibson, Mayo Clinic, Health Sciences Research, 200 1st Street, SW, Rochester, Minnesota 55905. Phone and fax, 507/284-4279; e-mail, leibson@mayo.eduSearch for more papers by this authorW. A. ROCCA, W. A. ROCCA Health Sciences Division, Mayo Clinic, 200 1st Street, SW, Rochester, Minnesota, 55905, USASearch for more papers by this authorV. A. HANSON, V. A. HANSON Health Sciences Division, Mayo Clinic, 200 1st Street, SW, Rochester, Minnesota, 55905, USASearch for more papers by this authorR. CHA, R. CHA Health Sciences Division, Mayo Clinic, 200 1st Street, SW, Rochester, Minnesota, 55905, USASearch for more papers by this authorE. KOKMEN, E. KOKMEN Department of Neurology, Mayo Clinic, 200 1st Street, SW, Rochester, Minnesota, 55905, USASearch for more papers by this authorP. C. O'BRIEN, P. C. O'BRIEN Health Sciences Division, Mayo Clinic, 200 1st Street, SW, Rochester, Minnesota, 55905, USASearch for more papers by this authorP. J. PALUMBO, P. J. PALUMBO Division of Endocrinology, Mayo Clinic, 13400 East Shea Boulevard, Scottsdale, Arizona 85259, USASearch for more papers by this author C. L. LEIBSON, Corresponding Author C. L. LEIBSON Health Sciences Division, Mayo Clinic, 200 1st Street, SW, Rochester, Minnesota, 55905, USAc Address for correspondence: C. L. Leibson, Mayo Clinic, Health Sciences Research, 200 1st Street, SW, Rochester, Minnesota 55905. Phone and fax, 507/284-4279; e-mail, leibson@mayo.eduSearch for more papers by this authorW. A. ROCCA, W. A. ROCCA Health Sciences Division, Mayo Clinic, 200 1st Street, SW, Rochester, Minnesota, 55905, USASearch for more papers by this authorV. A. HANSON, V. A. HANSON Health Sciences Division, Mayo Clinic, 200 1st Street, SW, Rochester, Minnesota, 55905, USASearch for more papers by this authorR. CHA, R. CHA Health Sciences Division, Mayo Clinic, 200 1st Street, SW, Rochester, Minnesota, 55905, USASearch for more papers by this authorE. KOKMEN, E. KOKMEN Department of Neurology, Mayo Clinic, 200 1st Street, SW, Rochester, Minnesota, 55905, USASearch for more papers by this authorP. C. O'BRIEN, P. C. O'BRIEN Health Sciences Division, Mayo Clinic, 200 1st Street, SW, Rochester, Minnesota, 55905, USASearch for more papers by this authorP. J. PALUMBO, P. J. PALUMBO Division of Endocrinology, Mayo Clinic, 13400 East Shea Boulevard, Scottsdale, Arizona 85259, USASearch for more papers by this author First published: 17 December 2006 https://doi.org/10.1111/j.1749-6632.1997.tb48496.xCitations: 106 a This work was supported by Grants AG08729 and AG08031 from the National Institute on Aging. Read the full textAboutPDF ToolsRequest permissionExport citationAdd to favoritesTrack citation ShareShare Give accessShare full text accessShare full-text accessPlease review our Terms and Conditions of Use and check box below to share full-text version of article.I have read and accept the Wiley Online Library Terms and Conditions of UseShareable LinkUse the link below to share a full-text version of this article with your friends and colleagues. Learn more.Copy URL Share a linkShare onFacebookTwitterLinkedInRedditWechat Citing Literature Volume826, Issue1Cerebrovascular Pathology in Alzheimer's DiseaseSeptember 1997Pages 422-427 RelatedInformation

Abstract In an inception cohort of 196 Olmsted County, Minnesota, residents with Parkinson's disease (PD) first recognized in 1976 to 1995, we tested whether the increased risk of bone fractures is associated with concomitant dementia. Using the data resources of the Rochester Epidemiology Project, information about PD, dementia, other clinical risk factors for fracture and fracture events was obtained from review of complete inpatient and outpatient medical records spanning each subject's residence in the community. Compared to an equal number of age‐ and sex‐matched non‐PD referent subjects from the community, PD patients were at a 2.2‐fold increased risk of fractures generally and a 3.2‐fold greater risk of hip fractures specifically. Adjusting for age, the independent predictors of overall fracture risk in the PD subjects included female sex (hazard ratio [HR] 1.6; 95% confidence interval [CI], 1.1–2.3), dementia (HR, 1.6; 95% CI, 1.1–2.4) and chronic depression, which was associated with a reduced risk (HR, 0.4; 95% CI, 0.2–0.8). Hip fractures were predicted by dementia (HR, 2.2; 95% CI, 1.2–4.1). The increased fracture risk in patients with PD is not entirely explained by concomitant dementia, and additional study is needed to determine the relative contributions to fracture risk of falls versus bone loss in these patients. © 2006 Movement Disorder Society

Because nephrolithiasis has been associated with obesity, an important risk factor for type 2 diabetes mellitus (DM), we tested the hypothesis that DM prevalence is increased in individuals who develop renal stones.In an initial electronic analysis, prior diagnoses of DM, hypertension, and obesity were compared between all Olmsted County, MN, residents with a diagnosis code for nephrolithiasis between 1980 and 1999 and matched residents of similar age and sex (N = 3,561 case-control pairs). A random sample of 260 cases and corresponding controls was selected for detailed medical record review to confirm and characterize the stone event and obtain heights, weights, blood pressures, and glucose and cholesterol values.In the electronic analysis, unadjusted odds ratios (ORs) for DM (OR, 1.29; 95% confidence interval [CI], 1.09 to 1.53), obesity (OR, 1.15; 95% CI, 1.02 to 1.31), and hypertension (OR, 1.19; 95% CI, 1.04 to 1.35) were increased significantly for nephrolithiasis cases versus controls; DM remained significant after adjustment for age, sex, calendar year, hypertension, and obesity (OR, 1.22; 95% CI, 1.03 to 1.46). Detailed record review of a subset showed significant increases for cases versus controls for body mass index (OR, 1.05; 95% CI, 1.01 to -1.09) and hypertension (OR, 1.71; 95% CI, 1.17 to 2.59). Odds for DM were increased, but not significantly, in the subsample (OR, 1.44; 95% CI, 0.76 to 2.72). Among cases with stone analyses, those with uric acid stones (n = 10) had a greater percentage of DM compared with those with all other stone types (n = 112; 40% versus 9%; P = 0.02).Findings from this population-based study suggest that DM, obesity, and hypertension are associated with nephrolithiasis, and DM may be a factor in the development of uric acid stones.

To test if observed vs. expected mortality differs by age among traumatic brain injury (TBI) cases, a population-based, historical cohort study was conducted in Olmsted County, Minnesota. From all residents with any diagnosis suggestive of TBI 1985-1999, we randomly sampled 7,800 and reviewed their medical records to confirm the event. Confirmed incident cases were categorized by age in years (<16 = pediatric, 16-65 = adult, > 65 elderly) and severity (moderate/severe vs. mild) and followed for vital status through 6/30/2004. We compared observed 6-month and 10-year mortality with expected and tested if the differences varied by age. Of 1,433 confirmed incident cases, 35% were pediatric; 55% were adult; only 9% were elderly; 11.2% of all cases were moderate/severe; the proportions by increasing age group were 11.4%, 8.5%, 26.7%. The proportions who died within 6 months increased with increasing age group, both for moderate/severe (10.3%, 40.3%, 50.0%) and mild cases (0%, 0%, 9.1%); mortality for moderate/severe cases was nearly 40 times that for mild cases, independent of age. Among 6-month survivors, 10-year mortality differed from expected only for adult cases. For all cases, after adjusting for sex, year of TBI, and severity, the difference between observed and expected 10-year mortality was greater for adult cases than for pediatric cases and similar for adult and elderly cases. Elderly individuals account for <10% of TBI cases and >50% of 10-year mortality, yet much of this discrepancy reflects age-associated mortality in general. Findings have implications for (1) reducing the number of excess deaths following TBI and (2) caring for survivors.

This population-based retrospective study investigates temporal trends in adult-onset diabetes mellitus prevalence, incidence, and survival. The complete community-based medical records, including laboratory results, of all Rochester, Minnesota, residents with a clinical diagnosis of diabetes or diabetes-like condition were reviewed to identify incidence cases aged 30 years or more from 1945 to 1989 (n = 1,847) and prevalence cases aged 45 years or more on January 1, 1970 (n = 465), January 1, 1980 (n = 689), or January 1, 1990 (n = 973). Glucose values and case definitions were standardized throughout. Observed 10-year survival for 1970 and 1980 prevalence cases was compared with that expected for Minnesota white populations in 1970 and 1980, respectively. Age-adjusted prevalence rose 65% for men and 37% for women between 1970 and 1990. There were marked differences among prevalence groups in treatment type, the proportion diagnosed using glucose tolerance tests, and the proportion categorized as obese. Relative survival for 1980 prevalence cases was not greater than that for 1970 prevalence cases. Age-adjusted incidence rates rose 47% for men and 26% for women between 1960 and 1965 and 1985 and 1989. These findings emphasize the need for heightened surveillance and intervention to reduce the burden of illness from adult-onset diabetes mellitus in the population.

The purpose of this study was to offer detailed information about stimulant medication treatment provided throughout childhood to 379 children with research-identified attention-deficit hyperactivity disorder (ADHD) in the 1976-1982 Rochester, MN, birth cohort. Subjects were retrospectively followed from birth until a mean of 17.2 years of age. The complete medical record of each subject was reviewed. The history and results of each episode of stimulant treatment were compared by gender, DSM-IV subtype of ADHD, and type of stimulant medication. Overall, 77.8% of subjects were treated with stimulants. Boys were 1.8 times more likely than girls to be treated. The median age at initiation (9.8 years), median duration of treatment (33.8 months), and likelihood of developing at least one side effect (22.3%) were not significantly different by gender. Overall, 73.1% of episodes of stimulant treatment were associated with a favorable response. The likelihood of a favorable response was comparable for boys and girls. Treatment was initiated earlier for children with either ADHD combined type or ADHD hyperactive-impulsive type than for children with ADHD predominantly inattentive type and duration of treatment was longer for ADHD combined type. There was no association between DSM-IV subtype and likelihood of a favorable response or of side effects. Dextroamphetamine and methylphenidate were equally likely to be associated with a favorable response, but dextroamphetamine was more likely to be associated with side effects. These results demonstrate that the effectiveness of stimulant medication treatment of ADHD provided throughout childhood is comparable to the efficacy of stimulant treatment demonstrated in clinical trials.

OBJECTIVE—The aims of this study were to provide estimates of 1) the risk of mortality for individuals with both diabetes and peripheral arterial disease (PAD) relative to that for individuals with either condition alone and 2) the association between PAD progression and mortality for individuals with diabetes, PAD, and both conditions. RESEARCH DESIGN AND METHODS—This longitudinal cohort study was conducted in Rochester, Minnesota. Local residents age 50–70 years with a prior diagnosis of PAD and/or diabetes were identified from the Mayo Clinic diagnostic registry and invited to a baseline examination (1977–1978). Those who met inclusion criteria were assessed for PAD progression at 2 and 4 years and followed for vital status through 31 December 1999. RESULTS—The numbers who met criteria for PAD, diabetes, and both conditions at baseline were 149, 238, and 186, respectively. Within each group, observed survival was less than expected (P &amp;lt; 0.001). The adjusted risk of death for both conditions was 2.2 times that for PAD alone. Among the 449 who returned at 4 years, the risk of subsequent death was greater for those whose PAD had progressed; among individuals with diabetes alone at baseline, 100% (17 of 17) who met criteria for PAD progression were dead by 31 December 1999 compared with 62% (111 of 178) of those who had not met criteria (adjusted relative hazard 2.29 [95% CI 1.30–4.02], P = 0.004). The increased mortality associated with PAD progression was significant only for individuals with diabetes (alone or with PAD). CONCLUSIONS—Diabetes is a risk factor for both PAD and PAD-associated mortality, emphasizing the critical need to detect and monitor PAD in diabetic patients.

This population-based retrospective cohort study identified all Olmsted County, MN residents with any diagnosis indicative of potential traumatic brain injury (TBI) during the years 1985 to 2000. The complete community-based medical records of a random sample (n = 7,175) were reviewed to confirm and characterize the event, and to determine vital status through 2002. The review identified 1,448 confirmed incident cases; 164 (11%) were moderate to severe; 1,284 were mild. The estimated 30-day case fatality rate was 29% for moderate to severe cases and 0.2% for mild cases. Comparison of observed mortality over the full period of follow-up with that expected revealed a risk ratio (95% CI) of 5.29 (4.11-6.71) for moderate to severe cases and 1.33 (1.05-1.65) for mild cases. Proportional hazards modeling showed the adjusted hazard of all-cause mortality for moderate to severe cases relative to mild cases was 5.18 (3.65-7.3) within six months of the event and 1.04 (0.57-1.88) for the remaining follow-up period. This analysis indicates that persons who experience mild TBI exhibit a small but statistically significant reduction in long-term survival compared to the general population. The case fatality rate for persons with moderate to severe TBI is very high, but among six-month survivors, long-term survival is similar to that for persons with mild TBI.

The burden of comorbidity in Parkinson's disease (PD) remains unclear. All Olmsted County, Minnesota, residents with incident PD in 1976-1995 (n = 197) plus one age- and sex-matched non-PD referent subject per case were followed for all clinical diagnoses from 5 years before through 15 years after index (i.e., year of PD onset for each case and same year for the referent subject). Both members of a case-referent pair were censored at death or emigration of either member to ensure equivalent follow-up. Cases and referent subjects were compared for summary comorbidity (Charlson index) and for the likelihood of having one or more diagnoses within each International Classification of Diseases chapter/subchapter. Before index, the groups were similar for all comparisons. After index, cases had a higher likelihood of diagnoses within the chapters "Mental Disorders" and "Diseases of the Genitourinary System," and within the subchapters "Organic Psychotic Conditions," "Other Psychoses," "Neurotic/Personality/Other Nonpsychotic Disorders," "Hereditary/Degenerative Diseases of Central Nervous System," "Symptoms," "Other Diseases of Digestive System," "Other Diseases of Urinary System," "Diseases of Veins/Lymphatics/Other Circulatory System Diseases," "Fractures of Lower Limb," "Other Diseases of Skin/Subcutaneous Tissue," "Osteopathies/Chrondropathies/Acquired Musculoskeletal Deformities," and "Pneumonia and Influenza." The excess morbidity and mortality observed for persons with PD are consistent with recognized PD sequelae.

Patients with type 2 diabetes mellitus (DM) may be at increased colorectal cancer (CRC) risk. However, existing data are inconsistent. We investigated CRC risks, overall and by anatomic subsite, within a population-based inception cohort of clinically confirmed type 2 DM subjects.All residents of Rochester, Minnesota who first met standardized criteria for type 2 DM from 1970 to 1994 (997 men and 978 women) were identified and followed forward in time until emigration, death, or December 31, 1999. Incident CRC cases were identified by review of inpatient and outpatient medical records. Standardized incidence ratios (SIRs) and 95% confidence intervals (CIs) were estimated to compare CRC incidence within the type 2 DM inception cohort with previously published rates for the Rochester general population.Over 19,158 person-years of follow-up, 51 incident CRC cases were identified within the type 2 DM cohort, while only 36.8 cases were expected (SIR = 1.39, 95% CI 1.03-1.82). Among men, type 2 DM was associated with increased overall (SIR = 1.67, 95% CI 1.16-2.33) and proximal (SIR = 1.96, 95% CI 1.16-3.10) CRC risks; distal CRC risk was also increased, but the point estimate was not statistically significant (SIR = 1.43, 95% CI 0.82-2.32). Among women, type 2 DM was not a risk factor for overall, proximal, or distal CRC (SIR = 1.03, 95% CI 0.60-1.66; SIR = 1.17, 95% CI 0.58-2.09; and SIR = 0.74, 95% CI 0.24-1.72, respectively). Within the type 2 DM cohort, current and former cigarette smokers were at higher CRC risk (SIR = 1.77, 95% CI 1.24-2.47) than never smokers (SIR = 0.99, 95% CI 0.57-1.61) and the interaction between type 2 DM and cigarette smoking status was statistically significant (p= 0.05).In this population-based, retrospective cohort study, clinically confirmed type 2 DM was associated with increased CRC risk, predominantly among men. Cigarette smoking appeared to positively modify DM-associated CRC risk, which to our knowledge has not been previously reported. These data suggest that further investigation of potential interactions between endogenous and exogenous factors involved in colorectal carcinogenesis may help to clarify the magnitude and extent of CRC risk experienced by persons with type 2 DM.

Although the association between diabetes mellitus (DM) and pancreatic cancer is well described, temporal patterns of changes in fasting blood glucose (FBG) and body mass index (BMI) before pancreatic cancer diagnosis are not known.We reviewed the medical records of pancreatic cancer cases seen at the Mayo Clinic from 15 January 1981 through to 9 July 2004 and selected those residing within 120 miles of Rochester, MN and who were seen at the Mayo Clinic within 30 days of the date of cancer diagnosis (index date). We identified approximately two matched controls per case residing locally and seen at Mayo in the year of their case index date. For the 736 cases and 1,875 controls with at least one outpatient FBG measurement, we abstracted all FBG values, and corresponding heights and weights up to 60 months before the index date and grouped them into 12-month intervals preceding the index. We compared FBG and BMI in each interval between cases and controls.Mean FBG values were similar between cases, compared with controls, in the intervals from months -60 to -48 (102 mg per 100 ml vs. 100 mg per 100 ml, P=0.34) and from months -48 to -36 (106 mg per 100 ml vs. 102 mg per 100 ml, P=0.09), but progressively increased in the intervals from months -36 to -24 (105 mg per 100 ml vs. 100 mg per 100 ml, P=0.01), from months -24 to -12 (114 mg per 100 ml vs. 102 mg per 100 ml, P=0.001), and from months -12 to +1 (123 mg per 100 ml vs. 102 mg per 100 ml, P<0.0001). Though mean BMI values were generally similar in cases and controls up to 12 months before index, they were significantly lower in cases vs. controls in the interval from months -12 to +1 (P<0.001).Pancreatic cancer is characterized by progressive hyperglycemia beginning up to 24 months before cancer diagnosis in the setting of decreasing BMI. Pancreatic cancer can potentially be diagnosed early if biomarkers are identified that can distinguish pancreatic cancer-induced DM from type II DM.

Although diabetes mellitus is reported as a risk factor for venous thromboembolism (VTE), persons with diabetes are frequently hospitalized for medical illness or surgery, or confined to a nursing home, all major VTE risk factors. Consequently, we tested diabetes for an independent association with incident VTE.Using Rochester Epidemiology Project resources, we identified all Olmsted County, Minn residents who met objective criteria for incident VTE over the 25-year period, 1976 to 2000 (n=1922), and 1 to 2 resident controls per case, matched on age, gender, and length of medical history (n=2115). Complete medical histories in the community were reviewed for previously identified independent VTE risk factors and diabetes-related variables. We tested diabetes and diabetes complications (retinopathy, nephropathy or neuropathy, and ketoacidosis) as potential VTE risk factors, both alone and after adjusting for VTE risk factors. Univariately, diabetes by clinical diagnosis or by stricter criteria (fasting ambulatory blood glucose >/=140 mg/dL or antidiabetic drug therapy), and diabetes complications, were associated with overall incident VTE. However, after controlling for hospitalization for major surgery or medical illness and nursing home confinement, diabetes was no longer associated with VTE.Diabetes mellitus and diabetes complications are not independent risk factors for incident VTE.

Because the risk of venous thromboembolism (VTE) associated with progestin is uncertain, we tested oral contraceptives, estrogen and progestin as independent VTE risk factors.Using longitudinal, population-based Rochester Epidemiology Project resources, we identified all Olmsted County, MN women with objectively-diagnosed incident VTE over the 13-year period, 1988-2000 (n=726) and one to two Olmsted County women per case matched on age, event year and duration of prior medical history (n=830), and reviewed their complete medical history in the community for previously-identified VTE risk factors (i.e., hospitalization with or without surgery, nursing home confinement, trauma/fracture, leg paresis, active cancer, varicose veins and pregnancy/postpartum), and oral contraceptive, oral estrogen, and oral or injectable progestin exposure. Using conditional logistic regression we tested these hormone exposures as VTE risk factors, both unadjusted and after adjusting for previously-identified VTE risk factors.In unadjusted models, oral contraceptives, progestin alone, and estrogen plus progestin were significantly associated with VTE. Individually adjusting for body mass index (BMI) and previously-identified VTE risk factors, these effects remained essentially unchanged except that progestin alone was not associated with VTE after adjusting for active cancer. Considering only case-control pairs without active cancer, progestin alone was positively but non-significantly associated with VTE (OR=2.49; p=0.16). Adjusting for BMI and previously-identified VTE risk factors including active cancer, oral contraceptives, estrogen alone, and progestin with or without estrogen were significantly associated with VTE.Oral contraceptives, estrogen alone, estrogen plus progestin, and progestin with or without estrogen are independent VTE risk factors.

To determine the association between asthma and proinflammatory conditions.This population-based retrospective matched cohort study enrolled all asthmatic patients among Rochester, Minnesota, residents between January 1, 1964, and December 31, 1983. For each asthmatic patient, 2 age-and sex-matched nonasthmatic individuals were drawn from the same population. The asthmatic and nonasthmatic cohorts were followed forward in the Rochester Epidemiology Project diagnostic index for inflammatory bowel disease (IBD), rheumatoid arthritis (RA), diabetes mellitus (DM), and coronary heart disease (CHD) as outcome events. Data were fitted to Cox proportional hazards models.We identified 2392 asthmatic patients and 4784 nonasthmatic controls. Of the asthmatic patients, 1356 (57%) were male, and mean age at asthma onset was 15.1 years. Incidence rates of IBD, RA, DM, and CHD in nonasthmatic controls were 32.8, 175.9, 132.0, and 389.7 per 100,000 person-years, respectively; those for asthmatic patients were 41.4, 227.9, 282.6, and 563.7 per 100,000 person-years, respectively. Asthma was associated with increased risks of DM (hazard ratio, 2.11; 95% confidence interval, 1.43-3.13; P<.001) and CHD (hazard ratio, 1.47; 95% confidence interval, 1.05-2.06; P=.02) but not with increased risks of IBD or RA.Although asthma is a helper T cell type 2-predominant condition, it may increase the risks of helper T cell type 1-polarized proinflammatory conditions, such as CHD and DM. Physicians who care for asthmatic patients need to address these unrecognized risks in asthmatic patients.

The purpose of this study was to offer detailed information about stimulant medication treatment provided throughout childhood to 379 children with research-identified attention-deficit hyperactivity disorder (ADHD) in the 1976–1982 Rochester, MN, birth cohort. Subjects were retrospectively followed from birth until a mean of 17.2 years of age. The complete medical record of each subject was reviewed. The history and results of each episode of stimulant treatment were compared by gender, DSMIV subtype of ADHD, and type of stimulant medication. Overall, 77.8% of subjects were treated with stimulants. Boys were 1.8 times more likely than girls to be treated. The median age at initiation (9.8 years), median duration of treatment (33.8 months), and likelihood of developing at least one side effect (22.3%) were not significantly different by gender. Overall, 73.1% of episodes of stimulant treatment were associated with a favorable response. The likelihood of a favorable response was comparable for boys and girls. Treatment was initiated earlier for children with either ADHD combined type or ADHD hyperactive-impulsive type than for children with ADHD predominantly inattentive type and duration of treatment was longer for ADHD combined type. There was no association between DSM-IV subtype and likelihood of a favorable response or of side effects. Dextroamphetamine and methylphenidate were equally likely to be associated with a favorable response, but dextroamphetamine was more likely to be associated with side effects. These results demonstrate that the effectiveness of stimulant medication treatment of ADHD provided throughout childhood is comparable to the efficacy of stimulant treatment demonstrated in clinical trials.

Objective cost estimates and source of cost differences are needed across the spectrum of cognition, including cognitively normal (CN), mild cognitive impairment (MCI), newly discovered dementia, and prevalent dementia.Subjects were a subset of the Mayo Clinic Study of Aging stratified-random sampling of Olmsted County, MN, residents aged 70 to 89 years. A neurologist reviewed provider-linked medical records to identify prevalent dementia (review date = index). Remaining subjects were invited to participate in prospective clinical/neuropsychological assessments; participants were categorized as CN, MCI, or newly discovered dementia (assessment date = index). Costs for medical services/procedures 1-year pre-index (excluding indirect and long-term care costs) were estimated using line-item provider-linked administrative data. We estimated contributions of care-delivery site and comorbid conditions (including and excluding neuropsychiatric diagnoses) to between-category cost differences.Annual mean medical costs for CN, MCI, newly discovered dementia, and prevalent dementia were $6042, $6784, $9431, $11,678, respectively. Hospital inpatient costs contributed 70% of total costs for prevalent dementia and accounted for differences between CN and both prevalent and newly discovered dementia. Ambulatory costs accounted for differences between CN and MCI. Age-, sex-, education-adjusted differences reached significance for CN versus newly discovered and prevalent dementia and for MCI versus prevalent dementia. After considering all comorbid diagnoses, between-category differences were reduced (e.g., prevalent dementia minus MCI (from $4842 to $3575); newly discovered dementia minus CN (from $3578 to $711)). Following the exclusion of neuropsychiatric diagnoses from comorbidity adjustment, between-category differences tended to revert to greater differences.Cost estimates did not differ significantly between CN and MCI. Substantial differences between MCI and prevalent dementia reflected high inpatient costs for dementia and appear partly related to co-occurring mental disorders. Such comparisons can help inform models aimed at identifying where, when, and for which individuals proposed interventions might be cost-effective.

To assess quality of life and barriers to participation in vocational and community life for persons with traumatic brain injury (TBI) over the very-long term, a population-based cohort was identified in Olmsted County, Minnesota; 1623 individuals were identified as having experienced a confirmed TBI while a resident of Olmsted County, Minnesota, during the period from 1935-2000. A survey was sent to eligible individuals that included elements of standardized instruments addressing health status and disability, and questions that assessed issues important to successful social reintegration after TBI. Of 1623 eligible participants sent surveys, 605 responded (37% response rate). Thirty-nine percent of respondents were female and 79% had mild injuries. Mean age at injury was 30.8 years, and mean years since injury was 28.8. Overall, respondents reported living in the community; the majority were married and had achieved education beyond high school. Problems with memory, thinking, and physical and emotional health were most often reported. Respondents reported low levels of depression and anxiety, and high levels of satisfaction with life. Seventy-three percent of respondents reported no problems that they attributed to their TBI. Increasing injury severity was associated with a significant risk of reporting injury-related problems at survey completion. Respondents with a longer time since injury were less likely to report any TBI-related problems. These results indicate that self-reported outcomes and adaptation to impairment-related limitations improve as the time since injury increases. These findings highlight the importance of providing coordinated medical rehabilitation and community-based support services to promote positive outcomes over the life span after TBI.

This study sought to compare survival of patients with poorly compressible arteries (PCA) to those with a normal ankle-brachial index (ABI) and those with peripheral arterial disease (PAD). Limited data are available regarding survival in patients with PCA identified in the clinical setting by noninvasive lower extremity arterial evaluation. We conducted a historical cohort study of consecutive patients who underwent outpatient, noninvasive lower extremity arterial evaluation at the Mayo Clinic, Rochester, Minnesota, from January 1998 through December 2007, and who were followed for a mean duration of 5.8 ± 3.1 years. An ABI 1.00 to 1.30 was considered normal, PAD was defined as a resting or post-exercise ABI ≤0.90, and PCA defined as an ABI ≥1.4 and/or an ankle systolic blood pressure >255 mm Hg. Patients were followed for all-cause mortality through September 30, 2009. Of 16,493 individuals (mean age 67.8 ± 13.0 years, 59% male); 29% had normal ABI, 54% had PAD, and 17% had PCA. During follow-up (mean duration 5.8 ± 3.1 years), 4,365 patients (26%) died. The percent alive at the end of the study period was 88%, 70%, and 60% for normal ABI, PAD, and PCA, respectively. After adjustment for age, sex, cardiovascular risk factors, comorbid conditions, and medication use, the hazard ratios (95% confidence intervals) of death associated with PCA were 2.0 (1.8 to 2.2) and 1.3 (1.2 to 1.4) compared with the normal ABI and PAD groups, respectively. Patients identified by noninvasive vascular testing to have poorly compressible leg arteries have poor survival, worse than those with a normal ABI or those with PAD.

Increasing obesity within the general population has been accompanied by rising rates of diabetes. The extent to which obesity has increased among people with diabetes is unknown, as are the potential consequences for diabetes outcomes.Community medical records (hospital and ambulatory) of all Rochester, Minnesota, residents aged > or =30 years who first met standardized research criteria for diabetes from 1970 to 1989 (n = 1,306) were reviewed to obtain data on BMI and related characteristics as of the diabetes identification date (+/-3 months). Vital status as of 31 December 1999 and date of death for those who died were obtained from medical records, State of Minnesota death tapes, and active follow-up.As of the identification date, data on BMI were available for 1,290 cases. Of the 272 who first met diabetes criteria in 1970-1974, 33% were obese (BMI > or =30), including 5% who were extremely obese (BMI > or =40). These proportions increased to 49% (P < 0.001) and 9% (P = 0.012), respectively, for the 426 residents who first met diabetes criteria in 1985-1989. BMI increased significantly with increasing calendar year of diabetes identification in multivariable regression analysis. Analysis of survival revealed an increased hazard of mortality for BMI > or =41, relative to BMI of 23-25 (hazard ratio 1.60, 95% CI 1.09-2.34, P = 0.016).The prevalence of obesity and extreme obesity among individuals at the time they first met criteria for diabetes has increased over time. This is disturbing in light of the finding that diabetic individuals who are extremely obese are at increased risk of mortality compared with their nonobese diabetic counterparts.

The prevalence of diabetes mellitus (DM) has increased markedly in recent decades, but trends in the mortality burden associated with DM are unclear. Therefore, we analyzed population-based longitudinal data to address this issue.The community-based medical records of all Rochester residents 45 years and older who died between January 1, 1970, and December 31, 1994, were reviewed to identify those who met the standardized criteria for DM before death. Trends over successive quinquenniums were assessed for the proportion of all deaths in the community of persons with prevalent DM, for mortality rates for persons with and without DM, and for the distribution of causes of death among decedents with and without DM.Of 10 152 total deaths in 1970-1994, 1384 (13.6%) met the criteria for prevalent DM. Between 1970-1974 and 1990-1994, the proportion of decedents with DM increased by 48.2%. Mortality rates for persons with and without DM declined by 13.8% and 21.4%, respectively. This disparity in mortality trends was most apparent for older women and younger men. There were temporal declines in the proportion of all persons dying of cardiovascular disease, but temporal declines in persons dying of cerebrovascular disease were found only in decedents without DM.The mortality burden associated with DM increased significantly between 1970 and 1994, probably due to increases in DM incidence and smaller declines in mortality for persons with DM relative to those without DM. In the absence of improved DM prevention and treatment, the steady declines in mortality observed for the general population since the 1960s will likely begin to slow or even reverse.

OBJECTIVE The American Diabetes Association (ADA) has recommended that the fasting plasma glucose (FPG) level used to diagnose diabetes be changed from 7.8 mmol/l (the level recommended by the National Diabetes Data Group [NDDG] in 1979) to 7.0 mmol/l. We examined the impact of this change on rates of progression to overt diabetes from different levels of FPG. RESEARCH DESIGN AND METHODS Using the laboratory database of Mayo Clinic, we assembled a cohort of 8,098 nondiabetic Olmsted County residents 40 years of age or older on 1 July 1983. Subjects were followed for a median of 9 years. RESULTS Among 7,567 individuals with follow-up FPG data, 778 (10.3%) progressed to ADA diabetes and 513 (6.8%; P &amp;lt; 0.0001) progressed to NDDG diabetes. The risk of developing ADA diabetes was 7, 19, and 39% for individuals with initial FPG values in the ranges of &amp;lt;5.6, 5.6–6.0, and 6.1–6.9 mmol/l, respectively. For progression to NDDG diabetes, the respective risks were 3, 11, and 25%. A clear gradient of risk was observed within the “normal” range of FPG (&amp;lt;5.6 mmol/l). Among the 793 individuals who developed ADA diabetes, 222 (29%) developed NDDG diabetes simultaneously and 291 (37%) developed NDDG diabetes later. In all FPG subgroups, progression to ADA diabetes occurred ∼7 years sooner than progression to NDDG diabetes. CONCLUSIONS The baseline level of FPG is a major predictor of an individual's risk of developing diabetes. The proposed change in the diagnostic criteria for diabetes will lead to earlier diagnosis among individuals who are destined to develop the disease.

Depression is under-diagnosed and under-treated in the primary care sector. The purpose of this study was to determine the association between self-reported indications of depression by community-dwelling elderly enrollees in a managed care organization and clinical detection of depression by primary care clinicians.This was a 2-year cohort study of elderly people (n = 3410) who responded to the Geriatric Depression Scale (GDS) at the midpoint of the study period. A broad measure of clinical detection was used consisting of one or more of three indicators: diagnosis of depression, visit to a mental health specialist, or antidepressant medication treatment.Approximately half of the community-based elderly people with self-reported indications of depression (GDS > or = 11) did not have documentation of clinical detection of depression by health providers. Physician recognition of depression tended to increase with the severity of enrollees' self-reported feelings of depression. Men 65-74 years old and those > or = 85 years old were at highest risk for under-detection of depression by primary care providers.Clinical detection of depression of elderly people living in the community continues to be a problem. The implications of failure to recognize the possibility of depression among elderly White men suggest a serious public health problem.

To examine the influence of obesity and prevention of weight gain on the incidence of type 2 diabetes.We examined participants in the San Antonio Heart Study, a prospective population-based study of Mexican Americans and non-Hispanic whites residing in San Antonio, Texas. BMI was stratified into four categories: normal (<25 kg/m(2)), overweight (> or =25 kg/m(2) and <30 kg/m(2)), obese (> or =30 kg/m(2) and <35 kg/m(2)), and very obese (> or =35 kg/m(2)). The number and proportion of incident cases prevented by targeting each BMI category were estimated. In addition, we calculated the decrease in risk of developing type 2 diabetes associated with weight gain prevention across both the BMI and age spectra.Preventing normal individuals from becoming overweight would result in the greatest reduction in incidence of type 2 diabetes. This would result in a 62 and 74% reduction in the incidence of type 2 diabetes in Mexican Americans and non-Hispanic whites, respectively. Preventing the entire population from gaining, on average, 1 BMI unit would result in a reduction in incidence of type 2 diabetes of 12.4 and 13.0% in Mexican Americans and non-Hispanic whites, respectively.The majority of cases of type 2 diabetes were in individuals who were overweight or mildly obese with a family history of type 2 diabetes. Public health resources should be directed toward the prevention of weight gain among normal and overweight individuals in order to prevent the maximum number of cases of type 2 diabetes.

ObjectiveWe examined whether widespread use of laparoscopy was accompanied by increased diagnosis of asymptomatic endometriosis, inflated rates of diagnosis, or changes in the clinical spectrum of disease.DesignPopulation-based cohort.SettingOlmsted County, Minnesota.Patient(s)All participants were women residents, aged ≥15 years.Intervention(s)None.Main outcome measure(s)We estimated the likelihood that women with a surgical procedure during which endometriosis could be visualized would receive a surgical diagnosis, as well as the proportions of all diagnoses, regardless of setting, that were [1] assigned without surgery, [2] refuted by surgery, [3] surgically confirmed, and [4] asymptomatic. The incidence of diagnosed endometriosis for 1987 to 1999 was compared with published rates for 1970 to 1979.Result(s)Of 8,229 women aged ≥15 years with ≥1 surgery during which endometriosis could be visualized, 11.5% received a surgical diagnosis of endometriosis. The incidence of diagnosed endometriosis, regardless of setting, was 1.9 per 1,000 person-years (10% were without relevant surgery, 6% had surgery but no surgical evidence, 85% had surgical evidence); 85% of surgically confirmed diagnoses had presenting symptoms. Using definitions comparable with those in the 1970 to 1979 study, the 1987 to 1999 incidence was 2.46 per 1,000 versus 2.49 per 1,000 for 1970 to 1979; 88% of symptomatic incident diagnoses were surgically confirmed versus 65% for 1970 to 1979.Conclusion(s)Widespread use of laparoscopy does not appear to have contributed to dramatically increased rates of endometriosis diagnoses but rather to a smaller proportion of diagnoses being assigned without surgical confirmation.

To validate a brief screening instrument for identifying people with epilepsy in epidemiologic or genetic studies.We designed a nine-question screening instrument for epilepsy and administered it by telephone to individuals with medical record-documented epilepsy (lifetime history of >or=2 unprovoked seizures, n = 168) or isolated unprovoked seizure (n = 54), and individuals who were seizure-free on medical record review (n = 120), from a population-based study using Rochester Epidemiology Project resources. Interviewers were blinded to record-review findings.Sensitivity (the proportion of individuals who screened positive among affected individuals) was 96% for epilepsy and 87% for isolated unprovoked seizure. The false positive rate (FPR, the proportion who screened positive among seizure-free individuals) was 7%. The estimated positive predictive value (PPV) for epilepsy was 23%, assuming a lifetime prevalence of 2% in the population. Use of only a single question asking whether the subject had ever had epilepsy or a seizure disorder resulted in sensitivity 76%, FPR 0.8%, and estimated PPV 66%. Subjects with epilepsy were more likely to screen positive with this question if they were diagnosed after 1964 or continued to have seizures for at least 5 years after diagnosis.Given its high sensitivity, our instrument may be useful for the first stage of screening for epilepsy; however, the PPV of 23% suggests that only about one in four screen-positive individuals will be truly affected. Screening with a single question asking about epilepsy yields a higher PPV but lower sensitivity, and screen-positive subjects may be biased toward more severe epilepsy.

Data on traumatic brain injury (TBI) economic outcomes are limited. We used Rochester Epidemiology Project (REP) resources to estimate long-term medical costs for clinically-confirmed incident TBI across the full range of severity after controlling for pre-existing conditions and co-occurring injuries. All Olmsted County, Minnesota, residents with diagnoses indicative of potential TBI from 1985–2000 (n=46,114) were identified, and a random sample (n=7175) was selected for medical record review to confirm case status, and to characterize as definite (moderate/severe), probable (mild), or possible (symptomatic) TBI. For each case, we identified one age- and sex-matched non-TBI control registered in REP in the same year (±1 year) as case's TBI. Cases with co-occurring non-head injuries were assessed for non-head-injury severity and assigned similar non-head-injury-severity controls. The 1145 case/control pairs for 1988–2000 were followed until earliest death/emigration of either member for medical costs 12 months before and up to 6 years after baseline (i.e., injury date for cases and comparable dates for controls). Differences between case and control costs were stratified by TBI severity, as defined by evidence of brain injury; comparisons used Wilcoxon signed-rank plus multivariate modeling (adjusted for pre-baseline characteristics). From baseline until 6 years, each TBI category exhibited significant incremental costs. For definite and probable TBI, most incremental costs occurred within the first 6 months; significant long-term incremental medical costs were not apparent among 1-year survivors. By contrast, cost differences between possible TBI cases and controls were not as great within the first 6 months, but were substantial among 1-year survivors. Although mean incremental costs were highest for definite cases, probable and possible cases accounted for>90% of all TBI events and 66% of total incremental costs. Preventing probable and possible events might facilitate substantial reductions in TBI-associated medical care costs.

Background Predictors of venous thromboembolism (VTE) after trauma are uncertain. Objective To identify independent predictors of VTE after acute trauma. Methods Using Rochester Epidemiology Project (REP) resources, we identified all Olmsted County, MN residents with objectively-diagnosed incident VTE within 92 days after hospitalization for acute trauma over the 18-year period, 1988–2005. We also identified all Olmsted County residents hospitalized for acute trauma over this time period and chose one to two residents frequency-matched to VTE cases on sex, event year group and ICD-9-CM trauma code predictive of surgery. In a case-cohort study, demographic, baseline and time-dependent characteristics were tested as predictors of VTE after trauma using Cox proportional hazards modeling. Results Among 200 incident VTE cases, the median (interquartile range) time from trauma to VTE was 18 (6, 41) days. Of these, 62% cases developed VTE after hospital discharge. In a multiple variable model including 370 cohort members, patient age at injury, male sex, increasing injury severity as reflected by the Trauma Mortality Prediction Model (TMPM) Mortality Score, immobility prior to trauma, soft tissue leg injury, and prior superficial vein thrombosis were independent predictors of VTE (C-statistic = 0.78). Conclusions We have identified clinical characteristics which can identify patients at increased risk for VTE after acute trauma, independent of surgery. Almost two thirds of all incident VTE events occurred after initial hospital discharge (18 day median time from trauma to VTE) which questions current practice of not extending VTE prophylaxis beyond hospital discharge.

Despite increases in obesity and diabetes mellitus, mortality caused by coronary disease continues to decline. Recent trends in coronary disease prevalence are unknown.There were 3237 deaths among Olmsted County, Minnesota, residents aged 16 through 64 years during the 1981-2004 period. Of the 515 due to accident, suicide, homicide, or a manner that could not be determined, 425 individuals (82%) had coronary anatomy graded. Pathology reports were reviewed for the grade of coronary disease (range, 0-5) assigned each of 4 arteries: left anterior descending (LAD), left circumflex (LCx), right coronary artery (RCA), and left main artery (LMA). High-grade disease was defined as more than a 75% reduction in cross-sectional luminal area (grade >or=4) in any of LAD, LCx, or RCA or more than 50% reduction (grade >or=3) in LMA. Evidence of any disease was defined as a grade higher than 0 in any artery. Calendar-year trends were analyzed as linear and nonlinear functions.Over the full period (1981-2004), 8.2% of the 425 individuals had high-grade disease, and 83% had evidence of any disease. Age- and sex-adjusted regression analyses revealed temporal declines over the full period (1981-2004) for high-grade disease, any disease, and grade of coronary disease. Declines in the grade of coronary disease ended after 1995 (P <or= .01 for every artery) and possibly reversed after 2000 (P = .06 for LCx).Declines in coronary disease prevalence overall (during 1981-2004) reinforce arguments that any increased prevalence resulting from improved survival among persons with disease was offset by reductions in disease incidence. Study findings suggest that declines in coronary disease prevalence have ended. The question of whether recent trends are attributable to increasing obesity and diabetes mellitus awaits further investigation.

To evaluate the impact of insufficient longitudinal data on the accuracy of a high-throughput clinical phenotyping (HTCP) algorithm for identifying (1) patients with type 2 diabetes mellitus (T2DM) and (2) patients with no diabetes.Retrospective study conducted at Mayo Clinic in Rochester, Minnesota. Eligible subjects were Olmsted County residents with ≥1 Mayo Clinic encounter in each of three time periods: (1) 2007, (2) from 1997 through 2006, and (3) before 1997 (N = 54,283). Diabetes relevant electronic medical record (EMR) data about diagnoses, laboratories, and medications were used. We employed the HTCP algorithm to categorize individuals as T2DM cases and non-diabetes controls. Considering the full 11 years (1997-2007) as the gold standard, we compared gold-standard categorizations with those using data for 10 subsequent intervals, ranging from 1998-2007 (10-year data) to 2007 (1-year data). Positive predictive values (PPVs) and false-negative rates (FNRs) were calculated. McNemar tests were used to determine whether categorizations using shorter time periods differed from the gold standard. Statistical significance was defined as P < 0.05.We identified 2770 T2DM cases and 21,005 controls when the algorithm was applied using 11-year data. Using 2007 data alone, PPVs and FNRs, respectively, were 70% and 25% for case identification and 59% and 67% for control identification. All time frames differed significantly from the gold standard, except for the 10-year period.The accuracy of the algorithm reduced remarkably as data were limited to shorter observation periods. This impact should be considered carefully when designing/executing HTCP algorithms.

To assess obesity rates during childhood and young adulthood in patients with attention-deficit/hyperactivity disorder (ADHD) and age- and sex-matched controls derived from a population-based birth cohort because cross-sectional studies suggest an association between ADHD and obesity.Study subjects included patients with childhood ADHD (n=336) and age- and sex-matched non-ADHD controls (n=665) from a 1976 to 1982 birth cohort (N=5718). Height, weight, and stimulant treatment measurements were abstracted retrospectively from medical records documenting care provided from January 1, 1976, through August 31, 2010. The association between ADHD and obesity in patients with ADHD relative to controls was estimated using Cox models.Patients with attention-deficit/hyperactivity disorder were 1.23 (95% CI, 1.00-1.50; P<.05) times more likely to be obese during the follow-up period than were non-ADHD controls. This association was not statistically significant in either sex (female participants: hazard ratio [HR], 1.49; 95% CI, 0.98-2.27; P=.06; male participants HR, 1.17, 95% CI, 0.92-1.48; P=.20). Patients with ADHD who were not obese as of the date ADHD research diagnostic criteria were met were 1.56 (95% CI, 1.14-2.13; P<.01) times more likely to be obese during the subsequent follow-up than were controls. This association was statistically significant in female study subjects (HR, 2.02; 95% CI, 1.13-3.60; P=.02), but not in male participants (HR, 1.41; 95% CI, 0.97-2.05; P=.07). A higher proportion of patients with ADHD were obese after the age of 20 years compared with non-ADHD controls (34.4% vs 25.1%; P=.01); this difference was observed only in female patients (41.6% vs 19.2%). There were no differences in obesity rates between stimulant-treated and nontreated patients with ADHD.Childhood ADHD is associated with obesity during childhood and young adulthood in females. Treatment with stimulant medications is not associated with the development of obesity up to young adulthood.

To assess the hazard of death in persons with and without amnestic mild cognitive impairment (aMCI).From 1987 through 2003, persons with aMCI (n = 243) and an age- and gender-matched reference group of cognitively normal persons in Olmsted County, MN, were recruited through the Mayo Clinic Alzheimer's Disease Patient Registry and followed prospectively through 2004. Survival was estimated using Kaplan-Meier survival curves, and the hazard of death for the aMCI cohort vs the reference cohort was estimated using Cox proportional hazards models.Over a median follow-up of 5.7 years, persons with aMCI had increased mortality (hazard ratio [HR] = 1.7; 95% CI: 1.3 to 2.3) vs reference subjects. The hazard of death by aMCI subtype was 1.5 in persons with single-domain aMCI (95% CI: 1.1 to 2.1) and 2.9 in persons with multiple-domain aMCI (95% CI: 1.9 to 4.6) vs reference subjects. Analyses restricted to aMCI cases showed an interaction between aMCI subtype and APOE-epsilon4 allele status (p = 0.003). Among aMCI cases with an APOE-epsilon4 allele, there was no difference in mortality between single- and multiple-domain aMCI (HR = 1.2; 95% CI: 0.6 to 2.3). However, among aMCI cases with no APOE-epsilon4 allele, the hazard of death in multiple-domain aMCI was 4.6 (95% CI: 2.3 to 9.1) vs single-domain aMCI.Amnestic mild cognitive impairment is associated with increased mortality, which is greater in multiple-domain aMCI than in single-domain aMCI. Mortality in aMCI subtypes may vary by APOE-epsilon4 allele status.

Propose a five-step multigating, multimodal procedure for research case definition and identification of attention-deficit/hyperactivity disorder (AD/HD) in population-based epidemiologic studies. Subjects included a birth cohort of all children born between 1976 and 1982 who remained in Rochester after age 5. Screening for AD/HD required 4 steps, using these sources: school/medical records, computerized diagnostic index, and private psychiatry records. In step 5, research criteria were applied to potential cases. The model for defining cases used combinations of three categories of information (DSM-IV, questionnaire, clinical diagnosis). Validity was tested by comparing medication treatment, substance abuse, school outcomes, and comorbidities between cases who did or did not meet DSM-IV criteria. Among 5718 subjects, 1344 potential cases were identified; 379 met research criteria. No difference in gender, treatment, school outcome, or professional making clinical diagnoses was found between cases who did (N = 228) and did not (N = 151) meet DSM-IV criteria. However, cases not meeting DSM-IV criteria were more inattentive (33.8% vs. 17.1%; p < 0.001), older (age 12.8 vs. 10.5 years; p = 0.01), with less substance abuse (15.2% vs. 26.3%; p < 0.001) and psychiatric comorbidities (43.1% vs. 54.4%; p = 0.031). If only DSM-IV criteria were applied, 151 cases would not have been identified. This study underscores the importance of using multiple sources and combinations of documented information for case definition and identification.

PurposeThe purpose of this study is to estimate medical costs attributable to venous thromboembolism among patients with active cancer.MethodsIn a population-based cohort study, we used Rochester Epidemiology Project (REP) resources to identify all Olmsted County, Minn. residents with incident venous thromboembolism and active cancer over the 18-year period, 1988-2005 (n = 374). One Olmsted County resident with active cancer without venous thromboembolism was matched to each case on age, sex, cancer diagnosis date, and duration of prior medical history. Subjects were followed forward in REP provider-linked billing data for standardized, inflation-adjusted direct medical costs from 1 year prior to index (venous thromboembolism event date or control-matched date) to the earliest of death, emigration from Olmsted County, or December 31, 2011, with censoring on the shortest follow-up to ensure a similar follow-up duration for each case-control pair. We used generalized linear modeling to predict costs for cases and controls and bootstrapping methods to assess uncertainty and significance of mean adjusted cost differences. Outpatient drug costs were not included in our estimates.ResultsAdjusted mean predicted costs were 1.9-fold higher for cases ($49,351) than for controls ($26,529) (P < .001) from index to up to 5 years post index. Cost differences between cases and controls were greatest within the first 3 months (mean difference = $13,504) and remained significantly higher from 3 months to 5 years post index (mean difference = $12,939).ConclusionsVenous thromboembolism-attributable costs among patients with active cancer contribute a substantial economic burden and are highest from index to 3 months, but may persist for up to 5 years.

There are few population-based data available regarding nursing home use after stroke. This study clarifies the use of a nursing home after stroke, as well as its dependence on stroke severity, in a defined population.All first stroke events among residents of Rochester, Minn, during 1987-1989 were ascertained, subtyped, and assigned Rankin disability scores (RS) before the event, at maximal deficit, and at specified intervals after stroke. Persons were followed from the date of stroke event to death, emigration from Rochester, or December 31, 1994, in complete community-based medical records and Minnesota Case Mix Review Program data tapes to determine nursing home residency before stroke and at 90 days and 1 year after stroke, proportion of survival days in a nursing home, and cumulative risk of admission to a nursing home.There were 251 cases of first cerebral infarction, 24 intracerebral hemorrhages, and 15 subarachnoid hemorrhages among residents of Rochester during 1987-1989. The maximal deficit RS was 1 or 2 for 62 (25%), RS 3 for 72 (29%), and RS 4 or 5 for 117 (47%) of the cerebral infarct patients. Among patients surviving to 90 days or 1 year after cerebral infarction, 25% were in nursing home at 90 days and 22% at 1 year, respectively. Within these maximal deficit RS categories, the percentages of follow-up time spent in a nursing home during the first post-cerebral infarction year are as follows: RS 1 to 2, 4%; RS 3, 10%; and RS 4 to 5, 54%. Multivariate logistic regression revealed that increasing age and RS 4 to 5 at maximal deficit were independent predictors (P<0.0001) of nursing home residency at 90 days and 1 year after stroke, whereas stroke type was not an independent predictor. At 1 year after cerebral infarction, the Kaplan-Meier estimates of proportion of people with at least 1 nursing home admission were 11% for RS 1 to 2, 22% for RS 3, and 68% for RS 4 to 5.This study provides unique population-based data regarding the short- and long-term use of a nursing home after stroke and its dependence on stroke severity. More than 50% of people with a severe cerebral infarction are in a nursing home 90 days and 1 year after the stroke, and by 1 year, nearly 70% will have required some nursing home stay. Age and stroke severity are independent predictors of nursing home residency after stroke.

There is a need for accurate population-based data on the utilization of medical resources after stroke. The present study used the Rochester Stroke Registry to identify all Rochester, Minnesota residents with confirmed first stroke (hospitalized and nonhospitalized) during the period of 1987 to 1989 (n=292). Events were categorized by type of stroke and assigned Rankin severity. Inpatient and outpatient acute care activity for the 12 months before and after stroke for each individual were obtained from billing tapes provided by Mayo Clinic, Olmstead Medical Group, and affiliated hospitals. These providers account for >95% of acute care received by Rochester residents. The results showed that despite high poststroke mortality, total charges in the year after stroke were 3.4 times those for the previous year. Although greater than 50% of utilization in the year poststroke occurred within the first 30 days, mean monthly charges for acute care remained significantly above prestroke levels for up to 5 months after the event. Poststroke charges per person-day of follow-up were significantly higher for individuals who were hospitalized for the event, who had subarachnoid hemorrhage, whose stroke occurred after admission to the hospital for another reason, and who died within 7 days. Significantly lower poststroke charges were evident for persons with mild cerebral infarctions and persons whose stroke occurred in a nursing home. Neither prestroke utilization, age category, nor sex were predictive of poststroke charges. The unique population-based data presented here have important implications for efforts toward stroke prevention, intervention, and cost containment.

Background: There is no rigorously developed and empirically validated screening tool to identify, early in the hospital stay, those adults who will use specialized hospital discharge planning services. Objectives: To develop and validate a screen using hospital admission clinical data that discriminates between adults who use and do not use specialized discharge planning services. Methods: Subjects consisted of prospectively sampled adult patients admitted to two hospitals located in a Midwestern United States city in 1998 (tool development sample, n = 991) and 2002 (validation sample, n = 303). Variables suggestive of being predictive of use of specialized hospital discharge planning services were identified from the literature and were obtained from direct participant interviews, record review, and administrative databases. The outcome was a documented referral for involvement of specialized discharge planning personnel with the patient's plan of care and was identified from review of hospital records. Results: Of 24 variables examined, only age, disability, living alone, and self-rated walking limitation were jointly predictive of use of specialized discharge planning services in the development sample. Standardized coefficients from the joint model were used to estimate a screening score. A cut-point was derived and had a sensitivity of 75% and specificity of 78% in the development sample. The screen performed equally well in the validation sample and the development sample. Conclusion: A screening tool consisting of a limited number of characteristics readily available early in the hospital stay that were shown to be highly predictive of the use of specialized discharge planning services was developed. The application of such a tool will hopefully assist providers to deploy services appropriately and in a timely fashion.

Background: Efforts to identify hospital-acquired complications from claims data by applying exclusion rules to discharge diagnosis codes exhibit low positive predictive value (PPV). The PPV improves when a variable is added to each secondary diagnosis to indicate whether the condition was “present-on-admission” (POA) or “hospital-acquired”. Such indicator variables will soon be required for Medicare reimbursement. No estimates are available, however, of the proportion of hospital-acquired complications that are missed (sensitivity) using either exclusion rules or indicator variables. We estimated sensitivity, specificity, PPV, and negative predictive value (NPV) of claims-based approaches using the Rochester Epidemiology Project (REP) venous thromboembolism (VTE) cohort as a “gold standard.” Methods: All inpatient encounters by Olmsted County, Minnesota, residents at Mayo Clinic-affiliated hospitals 1995–1998 constituted the at-risk-population. REP-identified hospital-acquired VTE consisted of all objectively-diagnosed VTE among County residents 1995–1998, whose onset of symptoms occurred during inpatient stays at these hospitals, as confirmed by detailed review of County residents' provider-linked medical records. Claims-based approaches used billing data from these hospitals. Results: Of 37,845 inpatient encounters, 98 had REP-identified hospital-acquired VTE; 47 (48%) were medical encounters. NPV and specificity were >99% for both claims-based approaches. Although indicator variables provided higher PPV (74%) compared with exclusion rules (35%), the sensitivity for exclusion rules was 74% compared with only 38% for indicator variables. Misclassification was greater for medical than surgical encounters. Conclusions: Utility and accuracy of claims data for identifying hospital-acquired conditions, including POA indicator variables, requires close attention be paid by clinicians and coders to what is being recorded.

Objective: To examine the contribution of cooccurring nonhead injuries to hazard of death after traumatic brain injury (TBI). Participants: A random sample of Olmsted County, Minnesota, residents with confirmed TBI from 1987 through 1999 was identified. Design: Each case was assigned an age- and sex-matched, non-TBI “regular control” from the population. For “special cases” with accompanying nonhead injuries, 2 matched “special controls” with nonhead injuries of similar severity were assigned. Measures: Vital status was followed from baseline (ie, injury date for cases, comparable dates for controls) through 2008. Cases were compared first with regular controls and second with regular or special controls, depending on case type. Results: In total, 1257 cases were identified (including 221 special cases). For both cases versus regular controls and cases versus regular or special controls, the hazard ratio was increased from baseline to 6 months (10.82 [2.86–40.89] and 7.13 [3.10–16.39], respectively) and from baseline through study end (2.92 [1.74–4.91] and 1.48 [1.09–2.02], respectively). Among 6-month survivors, the hazard ratio was increased for cases versus regular controls (1.43 [1.06–2.15]) but not for cases versus regular or special controls (1.05 [0.80–1.38]). Conclusions: Among 6-month survivors, accounting for nonhead injuries resulted in a nonsignificant effect of TBI on long-term mortality.

We estimated medical costs attributable to venous thromboembolism (VTE) among patients currently or recently hospitalized for major operation.Using Rochester Epidemiology Project resources, we identified all Olmsted County, MN, residents with objectively diagnosed incident VTE within 92 days of hospitalization for major operation during an 18-year period, 1988-2005 (n = 355). One Olmsted County resident hospitalized for major operation without VTE was matched to each case on event date (±1 year), type of operation, duration of previous medical history, and active cancer status. Subjects were followed in Rochester Epidemiology Project provider-linked billing data for standardized, inflation-adjusted direct medical costs from 1 year before index (case's VTE event date and control's matched date) to earliest of death, emigration, or December 31, 2011. We used generalized linear modeling to predict costs for cases and controls and used bootstrapping methods to assess uncertainty and significance of mean adjusted cost differences.Adjusted mean predicted costs were more than 1.5-fold greater for cases ($55,956) than for controls ($32,718) (P ≤ .001) from index to up to 5 years postindex. Cost differences between cases and controls were greatest within the first 3 months after index (mean difference = $12,381). Costs were greater for cases than controls (mean difference = $10,797) from 3 months to up to 5 years postindex and together accounted for about half of the overall cost difference.VTE during or after recent hospitalization for major operation contributes a substantial economic burden; VTE-attributable costs are greatest in the initial 3 months but persist for up to 5 years.

Blood pressure (BP) is not well controlled in the majority of patients with both diabetes and hypertension. This study was designed to identify predictors of BP control in patients with both diabetes and hypertension who are seen in primary care clinics.This retrospective study was conducted by identifying a cohort of patients diagnosed with diabetes before January 1, 2000 (inception) who met predefined criteria for hypertension at inception and who received primary care in the ensuing 3-year study period (January 1, 2000, to February 31, 2002). Using the mean of all BP values between January 1, 2002, and December 31, 2002, subjects were divided into two groups: those with controlled BP and those with uncontrolled BP. The distribution of clinical predictors was compared between the two groups. Independent predictors were identified using multivariate logistic regression.Predictors of poor BP control were as follows: 1) isolated systolic hypertension at inception (OR= 0.62, CI = 0.47 to 0.82); 2) uncontrolled BP at inception (OR = 0.71, CI = 0.55 to 0.93); 3) use of oral hypoglycemic drugs versus diet and exercise alone or insulin use (OR = 0.73, CI = 0.56 to 0.95); 4) use of three or more antihypertensive drugs (OR = 0.74, CI = 0.56 to 0.97); and 5) older age (OR = 0.98, CI = 0.97 to 0.99). Predictors of better control were 1) use of nitrates (OR = 1.82, CI = 1.26 to 2.64); 2) history of coronary heart disease (OR = 1.47, CI = 1.08 to 2.00); and 3) at least one annual visit to subspecialist physician (OR = 1.43, CI = 1.09 to 1.88).Patients with both diabetes and hypertension who are older, have isolated systolic hypertension, use oral hypoglycemic drugs, or use three or more antihypertensive drugs should be targeted for better BP control. The roles of nitrate medication and subspecialist physicians in achieving better BP control needs further study.

Abstract The objective was to provide population‐based estimates of incremental medical costs associated with Parkinson's disease (PD) from onset forward. All Olmsted County, Minnesota, residents with confirmed PD onset from 1987 through 1995 (n = 92) and one age‐ and sex‐matched non‐PD referent subject per case were identified with retrospective record review and followed in provider‐linked billing data for direct medical costs (excluding outpatient pharmaceutical costs) from 1 year before index (i.e., year of symptom onset) through 10 years after index. Costs for each referent subject were subtracted from those for his/her matched case. Tests for statistical significance used Wilcoxon signed ranks. Preindex costs were similar [median difference in annual costs (MD) = −$3; P = 0.59]. One year post index, PD subjects exhibited borderline significantly higher costs compared to referent subjects (MD = $581; P = 0.052); the difference diminished over 5 years (MD = $118; P = 0.82). By 5 to 10 years, however, PD subjects exhibited significantly higher costs (MD = $1,146; P = 0.01). Over the full 10 years, excess costs were concentrated among PD subjects without rest tremor (MD = $2,261, P &lt; 0.01, for those without tremor and −$229, P = 0.99, for those with tremor). These population‐based estimates of PD‐associated direct medical costs from onset forward can uniquely inform policy decisions and cost–effectiveness research. © 2006 Movement Disorder Society

We enrolled 543 elderly participants of a managed care organization in a cross-sectional study to test whether the association between self-rated physical health and clinically defined illness differs for persons who are not depressed compared with persons with minor or serious depression. Depression was measured with the Diagnostic Interview Schedule (DIS). Clinically defined illness was measured with the Chronic Disease Score (CDS), a pharmacy-based measure. Additional variables included age, sex, and selfreported pain and physical function. Self-rated physical health was associated with both minor and serious depression, independent of clinically defined illness; minor depression was no longer significant when self-reported pain and physical function were added to the model. A significant negative correlation between self-rated physical health and clinically defined illness was observed for minor and no depression, but no correlation was seen for serious depression. These results confirm the association between depression and selfrated physical health and emphasize that, for persons with serious depression, self-rated health provides a less accurate picture of clinically defined illness at both ends of the spectrum. Also, a diagnosis of minor depression should not forestall investigation of inconsistencies between patient report and clinical evidence.

Attention has been focused on the need to adjust hospital reimbursement and outcomes of hospital care for level of illness. Extant measures of disease severity, however, fail to consider the contribution of disease complexity. We developed an easily retrievable measure of disease complexity (COMPLEX) by modifying an existing severity system, computerized Disease Staging. The contribution of COMPLEX (the number of body systems affected with a Disease Staging score of 2 or more) to the prediction of outcome was assessed in two studies: (1) a population-based analysis of readmission and mortality after hospitalization and (2) an analysis of hospital charges among patients who were in an intensive-care unit. The amount of variation in mortality explained by factors included in the Health Care Financing Administration model was significantly improved when COMPLEX was added to the model (adjusted odds ratio per body system, 1.83; 95% confidence interval, 1.61 to 2.08). A significant association was also observed between COMPLEX score and hospital readmission after adjustment for age, sex, case-mix, and disease severity (adjusted odds ratio, 1.31; 95% confidence interval, 1.20 to 1.44). When COMPLEX was added to case-mix and disease severity in a model for predicting hospital charges, the percentage of variation in hospital charges explained by the model increased from 25% to 38%. These findings demonstrate the important contribution of disease complexity to the analysis of outcome of medical care and utilization of resources. Outcome or reimbursement models that do not incorporate disease complexity may negatively affect institutions with a high proportion of patients who have complex conditions. Attention has been focused on the need to adjust hospital reimbursement and outcomes of hospital care for level of illness. Extant measures of disease severity, however, fail to consider the contribution of disease complexity. We developed an easily retrievable measure of disease complexity (COMPLEX) by modifying an existing severity system, computerized Disease Staging. The contribution of COMPLEX (the number of body systems affected with a Disease Staging score of 2 or more) to the prediction of outcome was assessed in two studies: (1) a population-based analysis of readmission and mortality after hospitalization and (2) an analysis of hospital charges among patients who were in an intensive-care unit. The amount of variation in mortality explained by factors included in the Health Care Financing Administration model was significantly improved when COMPLEX was added to the model (adjusted odds ratio per body system, 1.83; 95% confidence interval, 1.61 to 2.08). A significant association was also observed between COMPLEX score and hospital readmission after adjustment for age, sex, case-mix, and disease severity (adjusted odds ratio, 1.31; 95% confidence interval, 1.20 to 1.44). When COMPLEX was added to case-mix and disease severity in a model for predicting hospital charges, the percentage of variation in hospital charges explained by the model increased from 25% to 38%. These findings demonstrate the important contribution of disease complexity to the analysis of outcome of medical care and utilization of resources. Outcome or reimbursement models that do not incorporate disease complexity may negatively affect institutions with a high proportion of patients who have complex conditions.

To determine population-based estimates of medical costs attributable to venous thromboembolism (VTE) among patients currently or recently hospitalized for acute medical illness.Population-based cohort study conducted in Olmsted County, Minnesota.Using Rochester Epidemiology Project (REP) resources, we identified all Olmsted County residents with objectively diagnosed incident VTE during or within 92 days of hospitalization for acute medical illness over the 18-year period of 1988 to 2005 (n=286). One Olmsted County resident hospitalized for medical illness without VTE was matched to each case for event date (±1 year), duration of prior medical history, and active cancer status. Subjects were followed forward in REP provider-linked billing data for standardized, inflation-adjusted direct medical costs (excluding outpatient pharmaceutical costs) from 1 year before their respective event or index date to the earliest of death, emigration from Olmsted County, or December 31, 2011 (study end date). We censored follow-up such that each case and matched control had similar periods of observation. We used generalized linear modeling (controlling for age, sex, preexisting conditions, and costs 1 year before index) to predict costs for cases and controls.Adjusted mean predicted costs were 2.5-fold higher for cases ($62,838) than for controls ($24,464) (P<.001) from index to up to 5 years post index. Cost differences between cases and controls were greatest within the first 3 months after the event date (mean difference=$16,897) but costs remained significantly higher for cases compared with controls for up to 3 years.VTE during or after recent hospitalization for medical illness contributes a substantial economic burden.

Background and ObjectivesAmong health care providers (HCPs), neurologists have one of the highest rates of burnout in the United States, compromising the quality and accessibility of patient care. Patients with refractory epilepsy are especially challenging to treat. This study aims to understand the burnout level in neurologists treating patients with refractory epilepsy and identify key contributing factors.MethodsUS board-certified pediatric/adult neurologists who devote ≥50% of their time to clinical practice and treat ≥10 unique patients with refractory epilepsy annually were invited to take a noninterventional quantitative survey, designed to capture key elements of the HCP's background, burnout level, current practice, burden domains, and satisfaction with current antiseizure medications (ASMs). Burnout in 3 domains (emotional exhaustion, depersonalization, and personal accomplishment) was assessed by the validated Maslach Burnout Inventory–Human Services Survey.ResultsFrom March 11, 2022, to April 10, 2022, a total of 138 neurology-specialist HCPs participated in the survey, divided between adult epileptologists (n = 44), adult neurologists (n = 41), pediatric epileptologists (n = 36), and pediatric neurologists (n = 17). Of participating HCPs, 61% experienced at least some burnout (≥1 of 3 burnout domains categorized as high), and 4% experienced high burnout (3 of 3 burnout domains categorized as high). High burnout levels were driven by high pediatric and inpatient caseloads and unexpected pediatric patient reluctance to transition to adult care. HCPs with high burnout had a higher yearly caseload of patients with refractory epilepsy. Most HCPs (approximately 90%) indicated that patients with refractory epilepsy were more difficult to manage than those with nonrefractory epilepsy. The proportion of HCPs satisfied or extremely satisfied with ASMs was lower for patients with refractory epilepsy (20%) than that for patients with nonrefractory epilepsy (73%). Dissatisfaction was mostly due to workload and latency of the insurance approval process, out-of-pocket costs, and poor efficacy, safety, and tolerability. For 32% of HCPs, stopping practicing or moving to another practice within 5 years was probable or very probable.DiscussionSome burnout is common among HCPs who treat patients with refractory epilepsy. However, management of refractory epilepsy is challenging, and satisfaction with available ASMs is low. Thus, addressing these contributing factors may help to alleviate HCP burnout.

OBJECTIVE Despite widespread acceptance of continuous insulin infusion (CII) over bolus insulin injection (BII) for treatment of diabetic ketoacidosis (DKA), there are no population-based studies demonstrating whether CII has resulted in lower morbidity and mortality. RESEARCH DESIGN AND METHODS We addressed this issue using a provider-linked database and retrospectively reviewing the complete medical records of all incidence cases of diabetes among Rochester, Minnesota, residents from 1950 to 1989 with a discharge diagnosis of DKA. This population-based study describes the consequences of the widespread change in treatment modality outside the confines of a controlled clinical trial. RESULTS Among the diabetes incident cohort, there were 59 subjects with confirmed first episodes of DKA during 1950-1992; 29 of 30 subjects treated with BII occurred before 1970. All 29 CII cases occurred between 1976 and 1992. Sex, etiology, diabetes duration, and age at DKA were similar for the two groups. The proportion of obese individuals (BII = 2/28, CII = 8/21; P = 0.01) differed between groups. The CII group exhibited higher glucose values (BII = 24.9 ± 8.5 mmol/l, CII = 37.1 ± 15.1 mmol/l; P = 0.002) and lower bicarbonate values (BII = 7.7 ± 3.0 nmol/l, CII = 6.2 ± 2.9 nmol/l; P = 0.04) upon admission. The mean quantity of insulin administered was higher in the BII group than in the CII group (179 ± 140 and 99 ± 70 U, P &amp;lt; 0.006). The outcome of hypoglycemia occurred more frequently in the BII group than in the CII group (BII = 8/30, CII = 1/29; P = 0.03). The proportion with hypokalemia, neurological deficit, myocardial arrhythmia, or mortality did not differ significantly between groups. CONCLUSIONS Our findings suggest the introduction of CII was accompanied by a decreased incidence of hypoglycemia.

To address the paucity of patient-level data regarding the effectiveness of Medicare's prospective payment system (PPS), we conducted a population-based study of inpatient hospitalizations among individually identified elderly residents of Olmsted County, Minnesota, 1970-1987. A 4.3% increase in total days of care/1000 population from 2,652/1,000 in 1970 to 2,766/1,000 in 1980 was followed by a 9.8% decline from 1980 to 1987 (2,495/1,000). The decline was due primarily to a 13.4% decrease in mean length stay (9.7 days in 1980 to 8.4 days in 1987). The number of hospitalizations/1,000 Olmsted County elderly in 1980 was already below 1987 U.S. figures and did not exhibit the decline evidenced nationally between 1980 and 1987. A 4.6% decline in the proportion of county residents age 65-74 years who were hospitalized (174/1,000 in 1980 to 166/1,000 in 1987) was offset by an 8.3% increase for persons age greater than or equal to 75 (252/1,000 to 273/1,000) and by a 5.7% increase in the number of hospitalizations per individual hospitalized for persons age 65-74 years (1.34 to 1.42). Using a time-dependent Cox model, which adjusted for differences in patients characteristics between years, there was a significantly higher risk of readmission within 14 days in 1987 vs 1980 (hazard ratio (HR) = 1.33, 95% confidence interval (CI) = 1.05-1.70). The difference between years was no longer evident at 30 or 60 days (HR = 0.84, 95% CI = 0.63-1.11 between 15 and 30 days; HR = 1.12, 95% CI = 0.84-1.49 between 31 and 60 days). This study suggests that initial effects of PPS on utilization may be temporary and that more research is needed to appreciate the impact of cost-containment on patient outcome.

To investigate whether, among youth with attention-deficit/hyperactivity disorder (ADHD), stimulant treatment is associated with reduced emergency department (ED) use and medical costs. We previously reviewed the complete and detailed school and medical records of all individuals born 1976–1982 in Rochester, Minn, to identify those who met criteria for ADHD between age 5 years and emigration from the area. Stimulant treatment (all start/stop dates, dosages) was also abstracted. This study followed birth cohort members with ADHD in provider-linked billing data from January 1, 1987 (billing data first available), to age 18 for outcomes: ED visits, ED costs, and medical costs. For each outcome, we analyzed associations with 1) any stimulants (yes/no), 2) proportion of follow-up time on stimulants, and 3) among those treated with stimulants, periods on versus off stimulants. Of 313 youth with ADHD, 231 (74%) received any stimulants; treatment duration ranged from 14 days to 11.8 years. Treated and untreated youth were similar with respect to median annual ED visits (0.5 vs 0.5) and medical costs ($661 vs $741) (P > .05); however, increasing proportion of follow-up on stimulants was associated with fewer ED visits (P= .02) and higher medical costs (P< .001). The 231 treated youth experienced an average of 3.7 periods on and off stimulants; while receiving stimulants, they exhibited fewer ED visits (P= .02), lower ED costs (P = .03), and higher medical costs (P< .001) compared with periods off stimulants. Among youth with ADHD, extended stimulant treatment is associated with decreased ED visits and ED costs, but higher total medical costs.

OBJECTIVE To determine the temporal trends in prevalence of confirmed diabetes mellitus (DM), time from the date DM criteria were met to myocardial infarction (MI), and impact of DM on survival. SUBJECTS AND METHODS A retrospective cohort design was used to identify residents of Olmsted County, Minnesota, with incident MI from 1979 to 1998. The MI cases were characterized according to prevalent DM. Cases with and without DM were followed up for vital status until January 1, 2003. RESULTS Of 2171 MI cases, 364 (17%) met criteria for prevalent DM. In the age- and sex-adjusted logistic regression models, the odds of prevalent DM increased 3% with each increasing year between 1979 and 1998 (95% confidence interval [CI], 1%-5%; P=.007). Survival for MI cases with DM was unchanged between 1979-1983 and 1994-1998 (P=.74). For all MI cases, age-, sex-, and DM-adjusted risk of death decreased 3% from 1979 to 1998 (95% CI, 1%-5%) per year for 28-day survival (P=.02) and 2% (95% CI, 1%-3%) per year for 5-year survival (P=.02). There was a significant adverse effect of DM on 5-year survival after MI (age-, sex-, and calendar year-adjusted hazard ratio, 1.70; 95% CI, 1.38-2.09; P<.001). The adverse effect of DM persisted after adjusting for other cardiovascular disease risk factors, MI severity, and reperfusion therapy (hazard ratio, 1.66; 95% CI, 1.34-2.05; P<.001) and was unchanged over time (interaction between DM and calendar year, P=.63). CONCLUSION These data indicate that the prevalence of DM among patients with MI is increasing and that its adverse impact on survival after MI remains unchanged. To determine the temporal trends in prevalence of confirmed diabetes mellitus (DM), time from the date DM criteria were met to myocardial infarction (MI), and impact of DM on survival. A retrospective cohort design was used to identify residents of Olmsted County, Minnesota, with incident MI from 1979 to 1998. The MI cases were characterized according to prevalent DM. Cases with and without DM were followed up for vital status until January 1, 2003. Of 2171 MI cases, 364 (17%) met criteria for prevalent DM. In the age- and sex-adjusted logistic regression models, the odds of prevalent DM increased 3% with each increasing year between 1979 and 1998 (95% confidence interval [CI], 1%-5%; P=.007). Survival for MI cases with DM was unchanged between 1979-1983 and 1994-1998 (P=.74). For all MI cases, age-, sex-, and DM-adjusted risk of death decreased 3% from 1979 to 1998 (95% CI, 1%-5%) per year for 28-day survival (P=.02) and 2% (95% CI, 1%-3%) per year for 5-year survival (P=.02). There was a significant adverse effect of DM on 5-year survival after MI (age-, sex-, and calendar year-adjusted hazard ratio, 1.70; 95% CI, 1.38-2.09; P<.001). The adverse effect of DM persisted after adjusting for other cardiovascular disease risk factors, MI severity, and reperfusion therapy (hazard ratio, 1.66; 95% CI, 1.34-2.05; P<.001) and was unchanged over time (interaction between DM and calendar year, P=.63). These data indicate that the prevalence of DM among patients with MI is increasing and that its adverse impact on survival after MI remains unchanged.

To examine possible adverse effects of sulfonylureas on survival among patients with diabetes mellitus (DM) who experience a myocardial infarction (MI).Residents of Olmsted County, Minnesota, with an MI that met standardized criteria from January 1, 1985, through December 31, 2002, were followed up for mortality.Among 2189 patients with MI (mean+/-SD age, 68+/-14 years; 1237 men [57%]), 409 (19%) had DM. The 23 patients treated with first-generation sulfonylureas, biguanides, or thiazolidinediones were excluded from analyses. Among the remaining 386 patients with DM, 120 (31%) were taking second-generation sulfonylureas, 180 (47%) were taking insulin, and 86 (22%) were receiving nonpharmacological treatment. Patients with DM treated with second-generation sulfonylureas were more likely to be men and have higher creatinine clearance than those treated with insulin. After adjusting for age, sex, Killip class, duration of DM, creatinine clearance, and reperfusion therapy or revascularization, patients treated with second-generation sulfonylureas had a lower risk of death than did diabetic patients receiving insulin (hazard ratio, 0.41; 95% confidence interval, 0.21-0.80; P=.009).These population-based data do not support the concern about an adverse effect of second-generation sulfonylureas on survival after MI and underscore the importance of population-based studies of surveillance of drug safety.

To estimate differences in use of acute care services between persons with and without Alzheimer's disease (AD).Population-based historical cohort study.All Rochester, Minnesota, residents with AD onset between January 1, 1980, and December 31, 1984 (n = 301), plus one age- and sex-matched nondemented control per case, were identified with a retrospective review of community-based medical records.Cases and controls were followed in their medical records for number of acute care encounters in the year before January 1 of the index year (year of onset for AD case and their matched control) and in the 4 years following December 31 of the index year. Encounters included clinician visits (office or nursing home), emergency room (ER) visits, hospitalizations (inpatient and outpatient), and inpatient days. Multivariate regression analyses were adjusted for age, sex, pre-index level of illness, and follow-up time.In the pre-index period, cases and controls were similar with respect to level of illness, number of office visits, ER visits, and hospitalizations. In the year before AD onset, 17 cases (7%) had a clinician visit in the nursing home compared with no controls. In the 4 years after the index year, mean length of follow-up was 3.4 years for both cases and controls. The numbers of ER visits, hospitalizations, and inpatient days were similar for cases and controls. Sixty-four percent of AD cases had a clinician visit in a nursing home versus 1% of controls. Controls experienced more office visits than cases (median = 16 vs 10, P < .001).The onset of AD is not associated with greater use of acute care services. However, neither is the high use of nursing home care offset by fewer ER or hospital encounters.

Our goal was to use cross-sectional national mortality data to provide a multivariable statistical analysis of the factors that contribute to the decision of whether an autopsy will be performed. The identification of determinants of the autopsy is an important prerequisite for finding cost-effective alternatives for arresting or reversing the decline of autopsy rates in the circumstances in which the autopsy can continue to make a crucial contribution to clinical medicine and public health. The source of the data was 1986 National Center for Health Statistics (Washington, DC) mortality data tapes for Kentucky, Maryland, Minnesota, and Washington for the 1986 calendar year. Separate multiple logistic regressions were conducted on these data on a state-by-state basis, with a total of 139,063 individual mortality records as the unit of analysis. The dependent variable in all models was autopsy (yes/no). Odds ratios for selected explanatory variables were estimated for all four states, and the relative contribution of each explanatory variable was studied in a detailed analysis of one state. In general, the following independent variables had a statistically significant positive relationship with whether an autopsy will be performed: male sex; nonwhite ethnicity; death due to ill-defined or unknown cause; death due to accident, suicide, or homicide; presence of a nationally recognized medical center in the county of death; and death occurring in a standard metropolitan statistical area. In general, the following independent variables had a statistically significant negative relationship with whether an autopsy will be performed: older age at death; higher income level of the decedent; death in a nursing home; death at home; and residency in the county of death. The two most important variables influencing the autopsy decision were age at death (especially old age) and death due to accident, homicide, or suicide.

Since 1965, expenditures for medical care in the United States have increased 10-fold. As a result, corporate outlays for health benefits have skyrocketed. Employers have instituted various cost-containment measures based in part on reports of wide variations in rates of utilization and the assumption that unnecessary or inappropriate utilization of medical care contributes to increasing costs. Frequently, however, employers lack adequate means for identifying sources of variation or for evaluating its appropriateness. In this article, we report on a project in which hospital utilization among several US corporate populations was compared with that for a geographically defined benchmark population to assist employers in the assessment of their rates of utilization and expenditures and to identify specific areas that merit further investigation. Our findings illuminate the difficulties in constructing valid rates from medical-care claims data and emphasize potential biases due to problems of comparability between populations. We also address the potential value of such comparison for helping corporations identify areas in which cost-containment efforts may be most effective and yet not jeopardize the quality of medical care.

OBJECTIVE—Birth weight is a risk factor for both diabetes and mortality. Diabetes is a risk factor for mortality. Whether the excess mortality observed for diabetes varies with birth weight is unclear. RESEARCH DESIGN AND METHODS—Among all 2,508 Rochester, Minnesota, residents who first met research criteria for adult-onset diabetes in 1960–1995, 171 were born locally in-hospital after 1922 (i.e., birth weights available) as singleton, term infants. Each case subject and two age- and sex-matched nondiabetic control subjects (born locally, residing locally when the case subject met the criteria for diabetes) were followed through 31 December 2000 for vital status. RESULTS—Of the diabetic case subjects, 16% (27 of 171) died vs. 7% (25 of 342) of control subjects (P = 0.004). The difference was less for normal-birth-weight (NBW) (2,948–&amp;lt;3,856 g) individuals (12% [12 of 102] vs. 8% [20 of 246], P = 0.31) than for abnormal-birth-weight individuals (low birth weight [LBW] 20% [8 of 39] vs. 2% [1 of 46], P = 0.01; high birth weight [HBW] 23% [7 of 30] vs. 8% [4 of 50], P = 0.16), as confirmed with age- and sex-adjusted Cox proportional hazards (diabetes-associated hazard ratio 1.4 [95% CI 0.69–2.90] for NBW vs. 4.8 [1.7–13.3] for abnormal birth weight, test for interaction P = 0.056). The observed diabetes deaths were greater than expected, based on mortality for the general population (27 vs. 13.3, P &amp;lt; 0.001), with 70% of excess deaths occurring among LBW (8 vs. 2.2, P &amp;lt; 0.001) and HBW (7 vs. 3.1, P = 0.03) individuals. CONCLUSIONS—The excess mortality observed for diabetes appears disproportionately concentrated among abnormal-birth-weight individuals, thus identifying a subset of at-risk diabetic individuals and reinforcing the importance of NBW deliveries.

OBJECTIVE To determine risk factors for venous thromboembolism (VTE) among nursing home (NH) residents. PARTICIPANTS AND METHODS This population-based historical cohort study used Minnesota Case Mix Review Program (MCMRP) Public Research Files to identify all unique Olmsted County, Minnesota, residents in any local NH from January 1, 1988, through December 31, 1994. Cases were defined as residents with a VTE diagnosis at any NH assessment. For each case, we identified 2 age- and sex-matched controls, defined as NH residents who did not have VTE but were assessed in the year of the case's earliest VTE diagnosis (ie, index assessment). Cases and controls were compared for preindex assessment characteristics. Accuracy of MCMRP VTE ascertainment was explored by comparing MCMRP cases with members of the Rochester Epidemiology Project incident cohort who were objectively diagnosed with VTE from January 1, 1988, through December 31, 1994, while residing in an Olmsted County NH. RESULTS At the preindex assessment, cases were more likely than controls to have returned from hospital; to require assistance with grooming, toileting, transferring, bed positioning, or wheelchair use; or to need physical therapy, rehabilitation, clinical monitoring, or wound care and were less likely to have neurologic disease. There were 53 MCMRP VTE cases vs 161 Rochester Epidemiology Project NH VTE cases; the proportion with pulmonary embolism was 21% vs 62%; 1-year mortality was 24% vs 55%. CONCLUSION Administrative data from NHs reveal important VTE risk factors not routinely documented in hospital or ambulatory records. However, ascertainment of VTE from NH administrative data appears biased toward surviving cases, highlighting concerns about using such data to assess provider quality and pointing to the need for studies that track individuals through multiple data sources across institutional settings. To determine risk factors for venous thromboembolism (VTE) among nursing home (NH) residents. This population-based historical cohort study used Minnesota Case Mix Review Program (MCMRP) Public Research Files to identify all unique Olmsted County, Minnesota, residents in any local NH from January 1, 1988, through December 31, 1994. Cases were defined as residents with a VTE diagnosis at any NH assessment. For each case, we identified 2 age- and sex-matched controls, defined as NH residents who did not have VTE but were assessed in the year of the case's earliest VTE diagnosis (ie, index assessment). Cases and controls were compared for preindex assessment characteristics. Accuracy of MCMRP VTE ascertainment was explored by comparing MCMRP cases with members of the Rochester Epidemiology Project incident cohort who were objectively diagnosed with VTE from January 1, 1988, through December 31, 1994, while residing in an Olmsted County NH. At the preindex assessment, cases were more likely than controls to have returned from hospital; to require assistance with grooming, toileting, transferring, bed positioning, or wheelchair use; or to need physical therapy, rehabilitation, clinical monitoring, or wound care and were less likely to have neurologic disease. There were 53 MCMRP VTE cases vs 161 Rochester Epidemiology Project NH VTE cases; the proportion with pulmonary embolism was 21% vs 62%; 1-year mortality was 24% vs 55%. Administrative data from NHs reveal important VTE risk factors not routinely documented in hospital or ambulatory records. However, ascertainment of VTE from NH administrative data appears biased toward surviving cases, highlighting concerns about using such data to assess provider quality and pointing to the need for studies that track individuals through multiple data sources across institutional settings.

BackgroundWe previously investigated trends in subclinical coronary artery disease and associated risk factors among autopsied non-elderly adults who died from nonnatural causes. Although grade of atherosclerosis declined from 1981 through 2009, the trend was nonlinear, ending in 1995, concurrent with increasing obesity/diabetes in this population. The previous study used linear regression and examined trends for all 4 major epicardial coronary arteries combined. The present investigation of coronary artery disease trends for the period 1995 through 2012 was prompted by a desire for more detailed examination of more recent coronary artery disease trends in light of reports that the epidemics of obesity and diabetes have slowed and are perhaps ending.MethodsThis population-based series of cross-sectional investigations identified all Olmsted County, Minnesota residents aged 16-64 years who died 1995 through 2012 (N = 2931). For decedents with nonnatural manner of death, pathology reports were reviewed for grade of atherosclerosis assigned each major epicardial coronary artery. Using logistic regression, we estimated calendar-year trends in grade (unadjusted and age- and sex-adjusted) for each artery, initially as an ordinal measure (range, 0-4); then, based on evidence of nonproportional odds, as a dichotomous variable (any atherosclerosis, yes/no) and as an ordinal measure for persons with atherosclerosis (range, 1-4).ResultsOf 474 nonnatural deaths, 453 (96%) were autopsied; 426 (90%) had coronary stenosis graded. In the ordinal-logistic model for trends in coronary artery disease grade (range, 0-4), the proportional odds assumption did not hold. In subsequent analysis as a dichotomous outcome (grades 0 vs 1-4), each artery exhibited a significant temporal decline in the proportion with any atherosclerosis. Conversely, for subjects with coronary artery disease grade 1-4, age- and sex-adjusted ordinal regression revealed no change over time in 2 arteries and statistically significant temporal increases in severity in 2 arteries.ConclusionsFindings suggest that efforts to prevent coronary artery disease onset have been relatively successful. However, statistically significant increases in the grade of atherosclerosis in 2 arteries among persons with coronary artery disease may be indicative of a major public health challenge.

OBJECTIVE To examine possible adverse effects of sulfonylureas on survival among patients with diabetes mellitus (DM) who experience a myocardial infarction (MI). PATIENTS AND METHODS Residents of Olmsted County, Minnesota, with an MI that met standardized criteria from January 1, 1985, through December 31, 2002, were followed up for mortality. RESULTS Among 2189 patients with MI (mean ± SD age, 68±14 years; 1237 men [57%]), 409 (19%) had DM. The 23 patients treated with first-generation sulfonylureas, biguanides, or thiazolidinediones were excluded from analyses. Among the remaining 386 patients with DM, 120 (31%) were taking second-generation sulfonylureas, 180 (47%) were taking insulin, and 86 (22%) were receiving nonpharmacological treatment. Patients with DM treated with second-generation sulfonylureas were more likely to be men and have higher creatinine clearance than those treated with insulin. After adjusting for age, sex, Killip class, duration of DM, creatinine clearance, and reperfusion therapy or revascularization, patients treated with second-generation sulfonylureas had a lower risk of death than did diabetic patients receiving insulin (hazard ratio, 0.41; 95% confidence interval, 0.21-0.80; P=.009). CONCLUSION These population-based data do not support the concern about an adverse effect of second-generation sulfonylureas on survival after MI and underscore the importance of population-based studies of surveillance of drug safety. To examine possible adverse effects of sulfonylureas on survival among patients with diabetes mellitus (DM) who experience a myocardial infarction (MI). Residents of Olmsted County, Minnesota, with an MI that met standardized criteria from January 1, 1985, through December 31, 2002, were followed up for mortality. Among 2189 patients with MI (mean ± SD age, 68±14 years; 1237 men [57%]), 409 (19%) had DM. The 23 patients treated with first-generation sulfonylureas, biguanides, or thiazolidinediones were excluded from analyses. Among the remaining 386 patients with DM, 120 (31%) were taking second-generation sulfonylureas, 180 (47%) were taking insulin, and 86 (22%) were receiving nonpharmacological treatment. Patients with DM treated with second-generation sulfonylureas were more likely to be men and have higher creatinine clearance than those treated with insulin. After adjusting for age, sex, Killip class, duration of DM, creatinine clearance, and reperfusion therapy or revascularization, patients treated with second-generation sulfonylureas had a lower risk of death than did diabetic patients receiving insulin (hazard ratio, 0.41; 95% confidence interval, 0.21-0.80; P=.009). These population-based data do not support the concern about an adverse effect of second-generation sulfonylureas on survival after MI and underscore the importance of population-based studies of surveillance of drug safety.

Nursing home (NH) residents are at increased risk for both VTE and bleeding from pharmacologic prophylaxis. Construction of prophylaxis guidelines is hampered by NH-specific limitations with VTE case identification and characterization of risk. We addressed these limitations by merging detailed provider-linked Rochester Epidemiology Project (REP) medical records with Centers for Medicare and Medicaid Services Minimum Data Set (MDS) NH assessments.This population-based nested case-control study identified all Olmsted County, Minnesota, residents with first-lifetime VTE October 1, 1998, through December 31, 2005, while a resident of an NH (N = 91) and one to two age-, sex-, and calendar year-matched NH non-VTE control subjects. For each NH case without hospitalization 3 months before VTE (n = 23), we additionally identified three to four nonhospitalized NH control subjects. REP and MDS records were reviewed before index date (VTE date for cases; respective REP encounter date for control subjects) for numerous characteristics previously associated with VTE in non-NH populations. Data were modeled using conditional logistic regression.The multivariate model consisting of all cases and control subjects identified only three characteristics independently associated with VTE: respiratory infection vs no infection (OR, 5.9; 95% CI, 2.6-13.1), extensive or total assistance with walking in room (5.6, 2.5-12.6), and general surgery (3.3, 1.0-10.8). In analyses limited to nonhospitalized cases and control subjects, only nonrespiratory infection vs no infection was independently associated with VTE (8.8, 2.7-29.2).Contrary to previous assumptions, most VTE risk factors identified in non-NH populations do not apply to the NH population. NH residents with infection, substantial mobility limitations, or recent general surgery should be considered potential candidates for VTE prophylaxis.

Our previous study of nonelderly adult decedents with nonnatural (accident, suicide, or homicide) cause of death (96% autopsy rate) between 1981 and 2004 revealed that the decline in subclinical coronary artery disease (CAD) ended in the mid-1990s. The present study investigated the contributions of trends in obesity and diabetes mellitus to patterns of subclinical CAD and explored whether the end of the decline in CAD persisted.We reviewed provider-linked medical records for all residents of Olmsted County, Minnesota, who died from nonnatural causes within the age range of 16 to 64 years between 1981 and 2009 and who had CAD graded at autopsy. We estimated trends in CAD risk factors including age, sex, systolic blood pressure, diabetes (qualifying fasting glucose or medication), body mass index, smoking, and diagnosed hyperlipidemia. Using multiple regression, we tested for significant associations between trends in CAD risk factors and CAD grade and assessed the contribution of trends in diabetes and obesity to CAD trends. The 545 autopsied decedents with recorded CAD grade exhibited significant declines between 1981 and 2009 in systolic blood pressure and smoking and significant increases in blood pressure medication, diabetes, and body mass index ≥30 kg/m(2). An overall decline in CAD grade between 1981 and 2009 was nonlinear and ended in 1994. Trends in obesity and diabetes contributed to the end of CAD decline.Despite continued reductions in smoking and blood pressure values, the previously observed end to the decline in subclinical CAD among nonelderly adult decedents was apparent through 2009, corresponding with increasing obesity and diabetes in that population.

To estimate 1) among patients with stroke, nursing home use attributable to stroke, and 2) the savings in nursing home use, assuming strokes were prevented.All confirmed cases of first stroke among Rochester, Minnesota, residents from 1987 through 1989 (n = 290) and one nonstroke control of same gender and similar age for each patient were followed up in provider-linked medical records and State of Minnesota nursing home files until emigration, death, or December 31, 1994. Data included disability and place of residence at baseline (i.e., date of stroke for each patient and their corresponding control), length of follow-up, cumulative incidence of nursing home admission, proportion of follow-up spent in a nursing home, and number of nursing home days.Before baseline, patients and controls were similar in the level of disability (mean Rankin = 1.7 for patients and 1.6 for controls) and the proportion in a nursing home (11% for both groups). Among those not in the nursing home at baseline, 5-year cumulative incidence of first admission was 48% for cases versus 20% for controls. Survival was significantly shorter for cases than for controls; the proportion of follow-up spent in the nursing home was 20% for cases versus 11% for controls. When controlling for survival, cases experienced an average of 110 (95% CI, 63 to 156) more nursing home days per person than controls in the first five years. When nursing home use during differential survival was included, the difference in nursing home days between cases and controls was no longer significant (p = 0.16).Stroke prevention would result in fewer cases admitted to the nursing home, older age at first admission, and a smaller proportion of remaining life spent in the nursing home, but stroke prevention would not result in fewer nursing home days.

PURPOSE: Autopsy studies can provide insight into disease trends and their determinants, including data on the prevalence of atherosclerosis. However, such studies are subject to autopsy bias, which limits their generalizability to the source population. The impact of this bias on autopsy based estimates of time trends in heart disease prevalence is unknown. To report on the trends over time in autopsy rates in Olmsted County, MN, to examine the association between clinical diagnoses of cardiovascular diseases (CVDs) and referral to autopsy and how this association may have changed over time. METHODS: We examined the trends in autopsy rates between 1979 and 1994 in Olmsted County, and the association between antemortem characteristics including cardiovascular diagnoses and autopsy referral. RESULTS: From 1979 to1994, a total of 9110 residents died in Olmsted County. The average annual autopsy rate was 30%. Autopsy rates declined from 36% in 1979 to 23% in 1994, corresponding to an average decline of 0.6%/year (p < 0.01). Referral to autopsy was positively associated with younger age, male sex, in-hospital place of death, antemortem diagnoses of myocardial infarction (MI) or peripheral vascular disease (PVD), and earlier calendar period. There was no evidence of an interaction between calendar period and any of these predictor variables. Antemortem diagnosis of heart failure was associated with a decrease in the odds of referral to autopsy over time as compared to persons without such diagnosis. CONCLUSIONS: In Olmsted County, autopsy rates, although declining over time, have remained on average approximately 30%. Antemortem diagnoses of MI or PVD are associated with autopsy referral but this association did not change over time. While the greater decline overtime in the use of autopsy observed among decedents with an antemortem diagnosis of congestive heart failure (CHF) deserves further studies, the present findings reduce the concern for bias of time trends in the prevalence of atherosclerosis by changes in the clinical characteristics of decedents referred to autopsy.

There is renewed interest in the relationship between birth weight and type 2 diabetes. Previous case-control studies (1) of elderly European residents showed a linear association between low birth weight and type 2 diabetes. More recent cohort studies (2) in Pima Indians have shown a U-shaped curve between birth weight and diabetes, where both low and high birth weight were shown to increase the risk for developing type 2 diabetes. In addition, a few studies (3,4) found an association between high birth weight and type 2 diabetes in Caucasian populations. Using the resources of the Rochester Epidemiology Project (REP), we examined the association of birth weight and type 2 diabetes in individuals who were born and developed type 2 diabetes while residing in Rochester, Minnesota. The unique resources of the REP were used to construct the Rochester Diabetes Incident cohort. As described elsewhere (5,6), case assignment was determined by retrospective review of each patient’s complete (hospital and ambulatory) medical records by trained nurse abstractors under the direction of an endocrinologist (P.J.P.). The records were reviewed for all laboratory glucose values and for evidence of any antidiabetic medication over the entire duration of residence in the community. Standardized case criteria were applied that approximated the National Diabetes Data Group recommendations, and adjustments were made for temporal changes in laboratory methods (7 …

ObjectivesAccurate estimates of autism spectrum disorder (ASD)–associated medical costs are essential for predicting future care needs, allocating resources, identifying best practices, and modeling cost-effectiveness. Most existing studies have either employed subjective cost data or ascertained ASD using self-reported or International Classification of Diseases–coded diagnoses. Such ascertainment is especially problematic for identifying milder ASD among older individuals never diagnosed with ASD.MethodsThis 1976 through 2000 population-based birth-cohort study was set in Olmsted County, Minnesota. ASD cases and age- and sex-matched unaffected controls were identified by applying uniform operational research criteria for ASD (using the guidelines of the Diagnostic and Statistical Manual of Mental Disorders, fourth edition, text revision) after rigorous review of provider-linked medical and public, private, or home school records available for all members from birth to a maximum age of 21 years. Medical cost estimates for the 901 case-control pairs used line-item provider-linked billing data (including all payers) from 2003 through 2014 (ages 3-38 years). Outpatient pharmaceutical costs were unavailable. Temporal changes in diagnostic criteria, clinical practice, public awareness, and access were addressed by separating analyses into 5-year age group and 4-year calendar period cells. Unadjusted and adjusted (age and age plus co-occurring conditions) cost estimates were provided for cases, controls, and case-control differences. Additional factors (co-occurring conditions, percentage hospitalized, intellectual disability) were investigated using unadjusted descriptive analyses.ResultsCell sample sizes ranged from 93 to 402 for age groups 3 through 19 years and from 45 to 395 for age groups 20 through 38 years. Unadjusted, age-adjusted, and fully adjusted medical costs were significantly higher for cases versus controls in 100% of cells for age groups 3 through 19 years and in 50% (unadjusted), 38% (age adjusted), and 12% (fully adjusted) of cells for age groups 20 through 38 years.ConclusionsThese unique estimates can help inform the construction of cost-effectiveness models; decisions by payers, providers, and policy makers; and predictions of lifetime costs.

OBJECTIVE To determine risk factors for venous thromboembolism (VTE) among nursing home (NH) residents. PARTICIPANTS AND METHODS This population-based historical cohort study used Minnesota Case Mix Review Program (MCMRP) Public Research Files to identify all unique Olmsted County, Minnesota, residents in any local NH from January 1, 1988, through December 31, 1994. Cases were defined as residents with a VTE diagnosis at any NH assessment. For each case, we identified 2 age- and sex-matched controls, defined as NH residents who did not have VTE but were assessed in the year of the case's earliest VTE diagnosis (ie, index assessment). Cases and controls were compared for preindex assessment characteristics. Accuracy of MCMRP VTE ascertainment was explored by comparing MCMRP cases with members of the Rochester Epidemiology Project incident cohort who were objectively diagnosed with VTE from January 1, 1988, through December 31, 1994, while residing in an Olmsted County NH. RESULTS At the preindex assessment, cases were more likely than controls to have returned from hospital; to require assistance with grooming, toileting, transferring, bed positioning, or wheelchair use; or to need physical therapy, rehabilitation, clinical monitoring, or wound care and were less likely to have neurologic disease. There were 53 MCMRP VTE cases vs 161 Rochester Epidemiology Project NH VTE cases; the proportion with pulmonary embolism was 21% vs 62%; 1-year mortality was 24% vs 55%. CONCLUSION Administrative data from NHs reveal important VTE risk factors not routinely documented in hospital or ambulatory records. However, ascertainment of VTE from NH administrative data appears biased toward surviving cases, highlighting concerns about using such data to assess provider quality and pointing to the need for studies that track individuals through multiple data sources across institutional settings. To determine risk factors for venous thromboembolism (VTE) among nursing home (NH) residents. This population-based historical cohort study used Minnesota Case Mix Review Program (MCMRP) Public Research Files to identify all unique Olmsted County, Minnesota, residents in any local NH from January 1, 1988, through December 31, 1994. Cases were defined as residents with a VTE diagnosis at any NH assessment. For each case, we identified 2 age- and sex-matched controls, defined as NH residents who did not have VTE but were assessed in the year of the case's earliest VTE diagnosis (ie, index assessment). Cases and controls were compared for preindex assessment characteristics. Accuracy of MCMRP VTE ascertainment was explored by comparing MCMRP cases with members of the Rochester Epidemiology Project incident cohort who were objectively diagnosed with VTE from January 1, 1988, through December 31, 1994, while residing in an Olmsted County NH. At the preindex assessment, cases were more likely than controls to have returned from hospital; to require assistance with grooming, toileting, transferring, bed positioning, or wheelchair use; or to need physical therapy, rehabilitation, clinical monitoring, or wound care and were less likely to have neurologic disease. There were 53 MCMRP VTE cases vs 161 Rochester Epidemiology Project NH VTE cases; the proportion with pulmonary embolism was 21% vs 62%; 1-year mortality was 24% vs 55%. Administrative data from NHs reveal important VTE risk factors not routinely documented in hospital or ambulatory records. However, ascertainment of VTE from NH administrative data appears biased toward surviving cases, highlighting concerns about using such data to assess provider quality and pointing to the need for studies that track individuals through multiple data sources across institutional settings.

To examine the effect of skilled nursing facility (SNF) use on hospitalizations in patients with heart failure (HF) and to examine predictors of hospitalization in patients with HF admitted to a SNF.Olmsted County, Minnesota, residents with first-ever HF from January 1, 2000, through December 31, 2010, were identified, and clinical data were linked to SNF utilization data from the Centers for Medicare and Medicaid Services. Andersen-Gill models were used to determine the association between SNF use and hospitalizations and to determine predictors of hospitalization.Of 1498 patients with incident HF (mean ± SD age, 75±14 years; 45% male), 605 (40.4%) were admitted to a SNF after HF diagnosis (median follow-up, 3.6 years; range, 0-13.0 years). Of those with a SNF admission, 225 (37%) had 2 or more admissions. After adjustment for age, sex, ejection fraction, and comorbidities, SNF use was associated with a 50% increased risk of hospitalization compared with no SNF use (adjusted hazard ratio, 1.52; 95% CI, 1.31-1.76). In SNF users, arrhythmia, asthma, chronic kidney disease, and the number of activities of daily living requiring assistance were independently associated with an increased risk of hospitalization.Approximately 40% of patients with HF were admitted to a SNF at some point after diagnosis. Compared with SNF nonusers, SNF users were more likely to be hospitalized. Characteristics associated with hospitalization in SNF users were mostly noncardiovascular, including reduced ability to perform activities of daily living. These findings underscore the effect of physical functioning on hospitalizations in patients with HF in SNFs and the importance of strategies to improve physical functioning.

To provide nursing home (NH)-specific estimates to assess whether venous thromboembolism (VTE) risk factors identified for the general population apply to NH residents.Population-based case-control study.Olmsted County, Minnesota.All county residents with symptomatic objectively diagnosed incident VTE while resident in a NH from 1988 through 2000 (N = 182) and two age-, sex-, calendar-year-matched non-VTE Olmsted County NH residents per case (N = 364).Provider-linked medical records were reviewed to obtain information on active malignancy and recent hospitalization, surgery, trauma, or fracture as of index date (case's VTE date; respective provider registration date for controls). Risk factor prevalence and VTE-associated odds ratios (OR) were estimated and compared with previously obtained data for all Olmsted County residents from 1988 through 2000. For analyses, both groups were limited to individuals aged 65 and older.In NH residents, active malignancy, recent hospitalization, and recent surgery significantly increased VTE risk, but the magnitude of risk appeared much lower than general population estimates (e.g., for major surgery, OR = 2.5, 95% confidence interval (CI) = 1.4-4.3 for NH residents vs OR = 11, 95% CI = 7.0-17 for general population). In general, the prevalence of all evaluated VTE risk factors appeared much higher in NH controls than in general population controls. Thromboprophylaxis rates appeared higher for NH cases and controls than in the general population; disconcertingly, 47% of NH cases received prophylaxis.Although general population VTE risk factors (active cancer and recent hospitalization or surgery) can identify NH residents at higher risk for VTE, these exposures do not adequately stratify VTE risk for thromboprophylaxis recommendations. Further research into NH-specific risk factors and prophylaxis effectiveness is required.

This study investigates temporal trends in the prevalence and incidence of persistent proteinuria among people with adult-onset diabetes (age > or =40 years).The complete community-based medical records of all Rochester, Minnesota, residents with a diagnosis of diabetes or diabetes-like condition from 1945 through 1989 were reviewed to determine whether they met National Diabetes Data Group (NDDG) criteria. All confirmed diabetes cases residing in Rochester on 1 January 1970 (n = 446), 1980 (n = 647), and/or 1990 (n = 940) were identified. The medical records of these prevalence cases were reviewed from the time of the first laboratory urinalysis value to the last visit, death, or 1 April 1992 (whichever came first) for evidence of persistent proteinuria (two consecutive urinalyses positive for protein, with no subsequent negative values). Similarly, the medical records of all 1970-1989 diabetes incidence cases (n = 1,252) were reviewed to investigate temporal changes in 1) the likelihood of having persistent proteinuria before the date NDDG criteria was met, i.e., baseline; 2) the risk of persistent proteinuria after baseline; and 3) the relative risk of mortality associated with persistent proteinuria.The proportion of diabetes prevalence cases with persistent proteinuria on or before the prevalence date declined from 20% in 1970 to 11% in 1980 and 8% in 1990. Among the 1970-1989 diabetes incidence cases, 77 (6%) had persistent proteinuria on or before baseline; the adjusted odds declined by 50% with each 10-year increase in baseline calendar year (P<0.001). Among individuals free of persistent proteinuria at baseline, 136 subsequently developed persistent proteinuria; the estimated 20-year cumulative incidence was 41% (95% CI 31-59); the adjusted risk did not differ as a function of baseline calendar year. Survival of individuals with persistent proteinuria relative to those without was reduced but did not differ by baseline calendar year.The prevalence of persistent proteinuria among people with adult-onset diabetes in Rochester, Minnesota, declined 60% between 1970 and 1990. The decline appears because of a decrease in the proportion of diabetes incidence cases with persistent proteinuria before baseline rather than secular declines in the risk of persistent proteinuria after baseline or secular increases in the risk of mortality associated with persistent proteinuria. Similarity over time in age and fasting glucose at baseline, and at prevalence dates, is evidence that earlier detection of diabetes is not the sole explanation for the decline.

Nursing home (NH) residency is an independent risk factor for venous thromboembolism (VTE), but the VTE burden within the NH population is uncertain. This study estimates VTE incidence and VTE-associated mortality among NH residents. We identified all NH residents in any NH in Olmsted County, Minnesota, United States, 1 October 1998 to 31 December 2005 and all first lifetime VTE among county residents to estimate VTE incidence while resident of local NHs (NHVTE), using Centers for Medicare and Medicaid Services Minimum Data Set and Rochester Epidemiology Project resources. We tested associations between NHVTE and age, sex and time since each NH admission using Poisson modelling. Additionally, we tested incident NHVTE as a potential predictor of survival using Cox proportional hazards, adjusting for age, sex and NH residency. Between 1 October 1998 and 31 December 2005, 3,465 Olmsted County residents with ≥1 admission to a local NH, contributed 4,762 NH stays. Of the 3,465 NH residents, 111 experienced incident NHVTE (2.3% of all eligible stays), for an overall rate of 3,653/100,000 NH person-years (NH-PY). VTE incidence was inversely associated with time since each NH admission, and was highest in the first 7 days after each NH admission (18,764/100,000 NH-PY). The adjusted hazard of death for incident NHVTE was 1.90 (95% confidence interval [CI]: 1.38-2.62). In conclusion, VTE incidence among NH residents was nearly 30-fold higher than published incidence rates for the general Olmsted County population. VTE incidence was highest within 7 days after NH admission, and NHVTE was associated with significantly reduced survival. These data can inform future research and construction of clinical trials regarding short-term prophylaxis.

Objective To estimate the impact of incident stroke on nursing home (NH) costs and level of care. Subjects and Methods This retrospective population-based cohort study is part of a larger study that identified all Rochester, Minn, residents with a confirmed first stroke occurring between January 1, 1988, and December 31, 1989. One Rochester resident who had not had a stroke was matched to each person with stroke. Persons with and without stroke were followed up in provider-linked medical records and NH files from baseline (ie, date of stroke) through December 31, 1994, for evidence of NH use. This study characterized the NH activity of those individuals with any NH activity after baseline (58 persons with major stroke, 36 persons with minor stroke, and 63 persons without stroke) as to NH case mix at first assessment, number of NH days, and per diem Medicaid reimbursement. Results Characteristics at first NH assessment after baseline revealed that NH residents with major stroke were younger and more disabled and required more services than residents without stroke. Over the full period of follow-up, the mean number of NH days was similar for NH residents with major stroke and those without stroke, yet per diem Medicaid reimbursement was 11% higher for residents with major stroke compared with residents without stroke. Nursing home residents with minor stroke appeared similar to those without stroke with respect to time to admission, characteristics at first assessment, number of NH days, and per diem Medicaid reimbursement. Conclusion Lower incidence and severity of stroke may contribute to lower care needs and per diem cost, but no fewer NH days. To estimate the impact of incident stroke on nursing home (NH) costs and level of care. This retrospective population-based cohort study is part of a larger study that identified all Rochester, Minn, residents with a confirmed first stroke occurring between January 1, 1988, and December 31, 1989. One Rochester resident who had not had a stroke was matched to each person with stroke. Persons with and without stroke were followed up in provider-linked medical records and NH files from baseline (ie, date of stroke) through December 31, 1994, for evidence of NH use. This study characterized the NH activity of those individuals with any NH activity after baseline (58 persons with major stroke, 36 persons with minor stroke, and 63 persons without stroke) as to NH case mix at first assessment, number of NH days, and per diem Medicaid reimbursement. Characteristics at first NH assessment after baseline revealed that NH residents with major stroke were younger and more disabled and required more services than residents without stroke. Over the full period of follow-up, the mean number of NH days was similar for NH residents with major stroke and those without stroke, yet per diem Medicaid reimbursement was 11% higher for residents with major stroke compared with residents without stroke. Nursing home residents with minor stroke appeared similar to those without stroke with respect to time to admission, characteristics at first assessment, number of NH days, and per diem Medicaid reimbursement. Lower incidence and severity of stroke may contribute to lower care needs and per diem cost, but no fewer NH days.