1998

Children
Anesthesia for Newborn Circumcision
Measles Vaccination for Infants and Toddlers
Of Bilis and Babies: Newborn Jaundice Research
Working Together to Improve Sevices: Project ACCORD
Children with Chronic Illness and Disability

Chronic Disease
Diabetic Peripheral Neuropathy
Improving Diabetic Care: Ready to Change
Physical Fitness and Chronic Disease
The War on Cardiovascular Disease

Medications
Are Adverse Drug Reactions Common?
A New Approach to Treat Alzheimer's Disease
Pharmacists on the Medical Team

Prevention
TEAMing Up Against Smoking
Teens and Tobacco
Being Systematic About Prevention

Research Update
Adapting to Jet Lag and Shift Work
Burn Follow-Up Through Telemedicine
Deaths Caused by Hospital Bedrails
HIV/AIDS Research

1994 / 1995 / 1996 / 1998 / 1999 / 2000 / 2001 / 2002 / 2003 / 2004

Despite the debate that continues over the benefits and risks of newborn circumcision, it remains the most commonly performed surgical procedure with over 1.2 million operations per year. There is ample evidence that newborns are capable of experiencing pain and several studies document the benefits and safety of local anesthesia.

To determine which primary care physicians perform circumcisions and the pattern of anesthetic use, a representative sample of obstetricians (OB), family practitioners (FP), and pediatricians (PED) in the U.S. was surveyed by mail. Of the 3,066 deliverable questionnaires, 58 percent (1768) were returned and analyzed.

Of all the respondents, 956 (54%) perform at least one circumcision per month (35% of PED, 60% of FP, 70% of OB). Of the physicians performing circumcisions, 45% utilize some form of anesthesia (71% of PED, 56% of FP, 25% of OB).

A significantly higher percentage of male physicians (57%) are performing circumcisions than females (45%), but there was no difference in the percentage utilizing anesthesia. Recently trained PED and FP were more likely to use anesthetics than their older colleagues, but OB use of pain relief was independent of their practice longevity. Physicians in the western states were significantly more likely to utilize anesthesia than physicians in the rest of the U.S.

Respondents who did not utilize anesthesia cited "concern over adverse drug effects" (54%), followed by "procedure does not warrant anesthesia" (44%) as the most common explanations.

With recent recognition of the importance of pain reduction in neonatal procedures and the lack of substantiated contraindications, data from this study should stimulate further research and education of current practitioners, residents, and parents to increase the utilization of anesthesia for newborn circumcisions.

Research Team
HealthPartners Medical Group: Howard J. Stang, M, Leonard W. Snellman, MD
HealthPartners Research Foundation: Cheri Rolnick, PhD, MPH, Mary Kelley

Funding
Group Health Foundation and the American Academy of Pediatrics: Research in Pediatrics Practice Fund.

Related Publications
Stang HJ, Snellman LW. Circumcision practice patterns in the United States. Pediatrics 1998;101(6):e5.

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Studies done in the 1960s and 1970s found that most infants acquired an immunity to measles from their mothers before birth and retained their immunity through at least 15 months of age. Based on these studies, the measles-mumps-rubella (MMR) vaccine was routinely given to children at 15 months. In 1990 and 1991, a major measles epidemic occurred in the United States. More than 40 percent of the children who had measles in that epidemic were less than 15 months of age. This was different from previous measles epidemics in which primarily older children were affected. What had changed?

HealthPartners Research Foundation, funded and aided by the Centers for Disease Control and Prevention, began a study in 1992 to assess the immunity of infants. Are children immune to measles at ages 9, 12, and 15 months? How do children respond to the MMR vaccine at those ages?

Approximately 1,200 children were enrolled and randomized to receive the vaccine at 9, 12, or 15 months of age. The children now have been followed at age three and five to assess the persistence of antibody.

Because mothers pass on antibodies to their unborn babies, infants have some measure of protection for the first few months of their lives. Once these antibodies leave the system, the baby can be immunized.

The study found that when the mother was born makes a big difference in how infants respond to immunization. Most children whose mothers were born after 1962 had no remaining immunity by age 9 months. They responded well to immunization at all three ages. Children with older mothers responded poorly to immunization at age 9 months, but responded well at ages 12 and 15 months.

Here's the explanation: mothers born before 1962 got their immunity to measles from the disease, while younger mothers got their immunity from a vaccine instead of the disease. As a result, younger mothers pass less antibody to their children who lose their immunity sooner.

This research helped to create a new national guideline that children receive their MMR immunization at age 12 months. This should lessen the national risk of a measles epidemic in the future. As a follow-up, researchers at HealthPartners Research Foundation are working with the CDC to design an active measles surveillance system.

Research Team
HealthPartners Research Foundation: James Nordin, MD, MPH, Mary Kelley, Marie Buttrey.
Centers for Disease Control and Prevention: Gayle King, MD, MPH, Steve Redd, MD, MPH, William Bellini, PhD

Funding
Centers for Disease Control and Prevention

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About sixty percent of newborns become jaundiced. Although jaundice is a minor problem for most babies, there is a very small risk that it can lead to severe brain injury. Because most newborns go home from the hospital before jaundice typically peaks, recognizing and managing jaundice has become a challenging problem in health care.

The traditional method of measuring the severity of jaundice is through blood bilirubin levels. But it is inconvenient to obtain blood samples after discharge. A series of studies are in progress that could improve the assessment of newborn jaundice without blood bilirubin tests.

A completed study performed at Regions Hospital examined how well parents, nurses, and physicians could detect the presence and severity of newborn jaundice while babies were in the nursery, with the aid of a simple, inexpensive jaundice meter. The study found that parents can be taught to accurately assess jaundice in their newborns, and that the jaundice meter was a helpful tool.

Two additional ongoing studies are examining the problem of assessing newborn jaundice after babies are discharged from the hospital. In one study, home health nurses are examining infants in the homes, using jaundice meters, and comparing their findings to blood bilirubin levels. The purpose of this study is to determine whether the home health nurses can accurately assess jaundice severity without having to obtain a blood bilirubin test. A third study will examine how accurately mothers can assess jaundice in their infants when they are home. Mothers will be taught how to examine their infants for jaundice and how to use a jaundice meter. The mothers will examine their babies for jaundice daily for one week after discharge from the hospital. A home health nurse will also examine the babies once during that week and obtain blood for a bilirubin test.

If successful, these methods of assessment can be widely used by mothers and home health nurses to identify infants who are significantly jaundiced before brain damage can occur. In addition, many infants may safely be spared unnecessary bilirubin blood testing.

Research Team
Family Medicine Residency Program: Diane J. Madlon-Kay, MD, Pamela Ristau, Laura Lantz, Annette Swain. Integrated Home Care: Mary Jo Feely

Funding
Ramsey Foundation

Related Publications
Madlon-Kay DJ. Recognition of the presence and severity of newborn jaundice by parents, nurses, physicians and icterometer. Pediatrics 1997'100(3):e3.

Madlon-Kay DJ. The clinical significance of ABO incompatibility. Arch Fam Med 1993;2:285-7.

Madlon-Kay DJ. Identifying ABO incompatibility in newborns: selective vs. automatic testing. J Fam Pract 1992;35:278-80.

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Children with chronic health problems and disabilities have special needs for health and social services and require help from many organizations. Project ACCORD (Advancing Child Centered Outcomes through Relationship Development) is a community-wide collaboration between HealthPartners and the Minnesota Department of Health. The goal of this collaborative effort is to improve care in the community for children with chronic conditions or disabilities.

Now in its fourth year, the project has established a multi-disciplinary pediatric asthma task force to design a set of services that complement and "wrap-around" medical care. To better serve children with special needs, the ACCORD team has developed materials to share with educators and health care providers including:
· a teaching unit based on peak flow meter use, to be incorporated into existing elementary school curricula
a manual for parents of children with special health care needs

In addition, the project held a statewide workshop in September, 1998.

Research Team
HealthPartners Research Foundation: Cheri J. Rolnick, PhD, MPH, Sharon Kaufer Flores, MS;
Minnesota Department of Health: Ann M. O'Fallon, MA; Jan Jernell; Nancy Vanderburg, PHN

Funding
Minnesota Department of Health through Federal Title V funds for Maternal and Child Health Improvement Projects

Related Publication
Rolnick, SJ, O'Connor, PJ. Assessing the impact of clinical guidelines: research lessons learned. J Ambulatory Care Manag 1997;20:47-55.

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How can manage care organizations provide the best care for children with chronic illness and disability? A recently completed planning grant, funded by The Robert Wood Johnson Foundation, examined the needs of these children and their families. The purpose of the planning grant, which involved a collaboration among HealthPartners, the Center for Children with Chronic Illness and Disability at the University of Minnesota, and PACER Center, was to create a model of integrated care.

The project convened two community working groups-a Parent Advisory Council and a Community Advisory Council. Key finds from the planning grant include the following:

· There is a need for care coordination across service sites.
· Most families are satisfied with their child's pediatrician and the health care, overall.
· The school system is the primary provider of occupational therapy, physical therapy, and speech and language services.
· There is a need for mental health support services-88% of families say they could use help with stress management.
· Although median out-of-pocket expenditures for families enrolled in HealthPartners are currently low, they rely on a hodgepodge of financing sources that are at risk of being substantially reduced in the near future.

Research Team
HealthPartners: Barbara Staub, MD, W. Brooks Donald, MD, MPH, Andrew Nelson, MPH, Kirsten Hase, Brita Hedblom. PACER Center: Ceci Shapland, RN. Center for Children with Chronic Illness and Disability, University of Minnesota: Robert W. Blum, MD, PhD, Anne Kelly, MD, MPH, Peggy Mann Rinehart.

Funding
Robert Wood Johnson Foundation

Related Publication
Brave new partnerships: Children with disabilities, families and managed care. Center for Children with Chronic Illness and Disability, University of Minnesota, 1996.

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Peripheral neuropathy, a group of disorders that may cause damage to the nerves in the head, trunk, and arms, is a frequent problem for diabetic patients. As many as 40% to 60% of diabetic patients have peripheral neuropathy. The patient may complain of pain, numbness and/or weakness. The most important treatment for the diabetic patient is good control of blood sugar. However, in the severely affected patient, good blood sugar control alone may not be sufficient.

The HealthPartners Department of Neurology is currently involved in clinical trials aimed at finding effective treatments for the symptoms and signs of peripheral neuropathy.

One project will determine if recombinant human nerve growth factor (rhNGF) can alter the progression of symptoms and signs of peripheral nerve disease. Initial animal and preliminary human studies have demonstrated the potential benefits of rhNGF. Patients selected for the study inject the rhNGF subcutaneously three times each week. The results of this study will be available in 1999. The Department of Neurology is the Quality Control Center for this project, which involves 90 study sites around the country.

A second clinical trial for diabetic patients involves thioctic acid, an antioxidant that has been shown in animals and humans to affect the course of peripheral neuropathy by minimizing free radical-mediated oxidative stress. Patients recruited for this study will be asked to take the drug for four years and will be evaluated regularly to determine if the drug is beneficial. The Department of Neurology is also the Quality Control Center for this study, which involves study sites throughout the U.S. and Europe.

Clinical trials often represent the culmination of years of investigation of the epidemiology, physiology, and pathophysiology of a disease. These clinical trials provide critical data on the effectiveness and safety of pharmaceutical agents for the treatment diseases in humans.

Research Team
William J. Litchy, MD, Winfried Raabe, MD, Ansar Ahmed, MD, Victoria Crofton, EMG/EEG Tech II, Nancy Danforth, EMG/EEG Tech II, Jenni Hegseth, EMG/EEG Tech, Judy Jasmer, EMG/EEG Tech II, Kay Kane-Oltmann, EMG/EEG Tech II, Joyce Riedel, EMG/EEG Tech II, Clarke Stone, Research Technician.

Funding
Genentech, Inc. and ASTA Medica, Inc.

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For adults with diabetes, controlling blood glucose levels and reducing risk factors for heart disease can make a huge difference in their health and well-being. HealthPartners is collaborating with the Centers for Disease Control and Prevention, the Minnesota Department of Health, and the Institute for Clinical Systems Integration to improve health outcomes for patients with diabetes.

Pilot studies, conducted between 1994 and 1996, found dramatic improvements in glucose control based on "readiness-of-change" approach. Health care professionals, including physicians, nurses, and health educators, assess each patient's readiness to take actions to improve their own health-for example, by changing diet or increasing exercise. Then, a program is individually tailored for patients to help them move in the right direction.

Results to date have been impressive. Since 1994, about 5,000 adults with diabetes treated at HealthPartners Medical Group clinics have shown sustained improvement in their glucose control. It is estimated that their level of improvement in glucose control will mean a 30 percent reduction in diabete-related complications from eye, foot, and kidney problems.

The basic readiness-to-change approach used to imp9orve glucose control is now being extended to address cardiovascular risk factors, with a special focus on patients with diabetes. There is evidence that diabetes patients can substantially reduce their risk of heart disease and stroke if they control their cholesterol and blood pressure, stop smoking and take low-dose aspirin.

Research Team
HealthPartners: Patrick J. O'Connor, MD, MPH, Cynthia Fay, MD, Susan Freeman, MD, Richard Gray, MD, Nicolaas Pronk, PhD, Leif I. Solberg, MD

Funding
Centers for Disease Control and Prevention with the Minnesota Department of Health

Related Publications
Gilmer, TP, O'Connor PJ, Manning WG, Rush WA. The cost to health plans of poor glycemic control. Diabetes Care 1997;20:1847-1853.

O'Connor PJ, Crabtree BF, Abourizk NN. Longitudinal study of a diabetes education and care intervention: predictors of imporved glycemic control. JABFP 1992;5:381-387.

Solberg LI, Reger LA, Perason, TL, Cherney LM, O'Connor PJ, Freeman SL, Lasch SL, Bishop DB. Using continuous quality improvement to improve diabetes care in populations: the IDEAL Model. Jt Comm J Qual Improv 1997;23:581-592.

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Regular physical activity reduces the risk for development of heart disease, diabetes, hypertension and other chronic conditions. Does this mean that persons with chronic conditions tend to be less physically fit than other people in general?

A better understanding of the relationship between physical fitness and chronic disease may help clinicians provide advice and support for the adoption and maintenance of physical activity for their patients

As part of an ongoing, longitudinal study on health improvement, a survey was conducted of 8,000 enrollees in HealthPartners. The sample was randomly selected from members age 40+ either diagnosed with a chronic condition-hypertension, diabetes, dyslipidemia, or heart disease-or with none of these conditions.

Members with diabetes, hypertension and heart disease reported significantly lower physical fitness levels than those without chronic conditions. People without chronic conditions were much more likely to be in average, good and excellent fitness categories.

Lack of physical activity and low levels of physical fitness have been shown to be causal factors in the development of chronic conditions. The findings from this study suggest that attention needs to be paid to the physical activity of patients who already have chronic conditions. Physical fitness should be part of the doctor's prescription for health.

Research Team
HealthPartners Center for Health Promotion: Nicolaas P. Pronk, PhD, HealthPartners Research Foundation: Raymond B. Boyle, PhD, Patrick J. O'Connor, MD, MPH

Funding
HealthPartners Center for Health Promotion

Related Publications
Boyle RG, O'Connor PJ, Pronk NP, Tan A. Stages of change for physical activity, diet, and smoking among HMO members with chronic conditions. Am J Health Promot 1998;12(1):170-6.

O'Connor PJ, Rush WA, Pronk NP. Identifying health maintenance organization members with diabetes mellitus or heart disease; sensitivity, specificity, predictive value and cost of survey and database methods. Am J Managed Care 1998;4(3):335-42.

Pronk NP, Boyle RG, O'Connor PJ. The association between physical fitness and diagnosed chronic disease in health maintenance organization members. Am J Health Promot 1998;12(5):300-6.

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In the past 30 years, death rates from cardiovascular disease have declined nearly 50 percent. Even so, the war against our number one killer is far from over. Cardiovascular disease remains the leading cause of death in this country, outstripping cancer deaths by about two to one.

The main focus of cardiovascular research at Regions Hospital is to prevent and treat heart disease. Research at Regions has enabled patients to benefit from cutting edge treatments.

One project -SADHART- investigates the safety and effectiveness of a newer type of anti-depression medication for heart attack and angina (chest pain) patients who are depressed. Depression is a significant risk factor for heart disease and a strong predictor of further cardiovascular events.

Project PEACE, sponsored by the National Institutes of Health (NIH), is one of several large, placebo-controlled prevention trials at Regions. These trials are attempting to show that, for patients with known heart disease, cardiovascular events can be forestalled or prevented by the use of various cardiac medications.

Several trials are focused on acute management of high risk hospitalized patients, including an improved "clot busting" drug for heart attacks and a more effective blood thinning strategy in these clot-prone patients. Several surgical studies are also planned or underway, including the use of an experimental heart valve (limited to only a small number of implanting centers in the U.S.), and a procedure known as "transmyocardial revascularization" (TMR). Used in conjunction with coronary bypass surgery, this procedure may provide relief to patients with persistent angina unresponsive to other treatments. A laser is used to produce small channels in areas of the heart muscle that have poor blood flow and are unreachable through bypass surgery.

Research Team
Regions Hospital: Zeyhani Bankwala, MD; Richard Gray, MD; Jackie Huebsch, PhD, RNCS; Robert Straka, PharmD; J. Thomas Suh, MD, (Director of Cardiovascular Research), Lyle Swenson, MD. Study Coordinators: Bonnie Foster, RN; Kathy Vittum, RN; Marilyn Wiest, RN
Research Assistant: Michelle Gallus

Funding
National Institutes of Health, Veteran's Administration, various study consortiums and pharmaceutical companies

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Adverse drug reactions can cause serious illness and even death. Both new drugs and combinations of existing drugs can be hazardous to certain patients. Although testing is required before drugs are approved for marketing, drug trials often do not include large enough populations of specific sub-populations-such as children or pregnant women-to detect relatively rare adverse events.

Researchers at HealthPartners Research Foundation, along with collaborators at Harvard Pilgrim Health Plan, and Fallon Community Health Plan, are investigating potential adverse effects in prescription drugs. The Food and Drug Administration will use results from this study to identify the prevalence of adverse drug reactions.

The same research team is also participating in an eight-site study of alendronate (also called Fosamax), a drug used for osteoporosis. That study will use medical records on enrollees in eight HMOs to determine if alendronate increases the risk of bleeding in the stomach and esophagus.

Research Team
Michael J. Goodman, PhD, Teri A. DeFor, MS, and Susan X. Cooper, MS

Funding
Food and Drug Administration

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Researchers at HealthPartners' Alzheimer's Research Center and the University of Minnesota are testing a novel, noninvasive method of delivering medications to the brain-through the nose. This research involves using the olfactory nerve pathway to administer nerve growth factors, natural proteins that protect nerve cells from damage. The blood-brain barrier makes it difficult to administer these drugs that have the potential to improve memory and other cognitive functions in Alzheimer's patients. The intranasal method of delivery bypasses the blood-brain barrier and shows promise in the treatment and prevention of Alzheimer's disease, stroke, and other central nervous system disorders.

Studies conducted in rats have shown that therapeutic agents, which cannot reach the brain when given as a pill or shot, do reach the brain when given by this new intranasal method. The Alzheimer's Research Center of the HealthPartners Research Foundation is working closely with Chiron Corporation in California to further perfect this method for use in humans. A U.S. patent has been granted on this new method of delivering therapeutic agents to the brain.

Research Team
Alzheimer's Research Center of the HealthPartners Research Foundation: William H. Frey II, PhD, Thomas A. Ala, MD

Funding
HealthPartners Research Foundation, Chiron Corporation

Related Publications
Frey II WH, Liu J, Chen X, Thorne RG, Fawcett Jr, Ala TA, Rahman YE. Delivery of 125I-NGF to the brain via the olfactory route. Drug Delivery 1997;4:87-92.

Chen X, Fawcett JR, Rahman YE, Ala TA, Frey II WH. Delivery of nerve growth factor to the brain via the olfactory pathway. J Alzheimer Dis 1998;1:35-44.

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Pharmaceutical care offers an expanded role for pharmacists - not just dispensing pills, but also reviewing patients' current medications, advising them how to properly administer both prescribed and over-the-counter medications, checking for potential problems (such as inappropriate use or adverse reactions), and helping physicians monitor their patients' use of medications.

The Pharmaceutical Care Project at HealthPartners was designed to evaluate the effectiveness of pharmaceutical care. Six pharmacies, owned or affiliated with HealthPartners clinics, served as study sites. Approximately 260 patients with chronic conditions (asthma or other lung or breathing problems, heart disease, and hypertension), received the pharmaceutical care intervention. A group of patients with the same chronic conditions but from other clinics constituted a control sample.

Preliminary findings from this project indicate that pharmaceutical care is a potentially useful tool for identifying drug-related problems. The pharmacists identified drug therapy problems for more than two-thirds of patients receiving pharmaceutical care. The most common problems included: undesirable side effects, untreated conditions, and incorrect use of medications. The pharmacists contacted physicians concerning medication changes for more than three-fifths of the patients.

According to a recent article in the Journal of the American Medical Association, over 2,000,000 patients are hospitalized each year with adverse drug reactions (ADRs) and there are an estimated 100,000 fatalities associated with ADRs. Pharmaceutical care has the potential to reduce drug-related problems by monitoring medication use, helping patients take the right medications, and providing guidance so that both prescribed and over-the-counter medications are taken appropriately and consistently.

Research Team
HealthPartners: Lucy Rose Fischer, PhD, Lynn Scott, RPH, Kirsten Hase, Diann Boonstra, RPH, Marilyn Eelkema, RPH, Susan Cooper, RPH, Gerald Amundson, Theresa DeFor, MS.

Funding
Pharmaceutical Care Consortium-HealthPartners, Astra Merck, Bristol-Myers Squibb, Dupont, Forest Pharmaceuticals, Hoechst Marion Roussell, Novartis Pharmaceuticals Corporation, Novo Nordisk, Pfizer Pharmaceuticals, Rhone-Polenc Rorer, Schering-Plough, Searle, Wyeth-Ayerst, Encara

Related Publications
Fischer LR, Young K, von Sternberg TL, Boonstra D. The geriatric pharmacy counseling project. Group Health Institute Proc 1994:21-38.

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Six and a half million adults are hospitalized each year. For smokers, being hospitalized may become a special opportunity. Away from their usual environment, they are removed from their accustomed cues to smoke, they have access to health care providers, and they have reason to be concerned about their health. For these reasons, a hospital stay may be a TEAchable Moment for smoking cessation.

Three interventions are being evaluated by the TEAM Project. Minimal intervention consists of usual care, an informed consent interview, and a smoking cessation manual. The physician advice condition consists of advice from nurses and attending physicians. The physician advice plus nurse clinician condition includes the above plus a 25 minute bedside counseling session and three to six follow-up phone calls after discharge.

Three hospitals (Regions, Methodist, and Hennepin) are recruiting 2,910 patients. Patient are eligible if they are smokers, age 18-75, have a hospital stay of at least 24 hours, and are admitted for medical or surgical care. As of January 1998, 1,126 patients have been recruited.

Enrollment will be completed in 1999; study results will be available in 2000. The ultimate goal of TEAM is to establish a nationally mandated hospital standard of care for smoking cessation services.

Research Team
University of Minnesota: Harry Lando, PhD (PI), Willard Manning, PhD, David Murray, PhD.
HealthSystem Minnesota: Susan Sullivan, PhD, Donald Peine, MD.
HealthPartners Como Medical Center: David Klevan, MD.
Regions Hospital: Jackie Hubsch, PhD, Neal Holtan, MD.
Hennepin County General Hospital: Paul Pentel, MD.

Funding
National Institutes of Health

Related Publications
Lando HA, Rolnick SJ, Klevan DH, Roski J, Cherney LM, Lauger G. Telephone support as an adjunct to transdermal nicotine. Am J Pub Health 1997;87:1670-74.

Klevan DH, Talarico BJ, Lange J, Rolnick SJ, Beck M. HealthPartners nicotine dependence class: results since January 1994 (abstract). J Addict Dis 1997;16:130.

Klevan DH, Rolnick SJ. Interventions to accomplish a clinic based smoking cessation guideline in a staff model HMO. J Addiction Med 1998 (In press)

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Despite efforts to combat smoking among youths in the U.S., the number of young smokers has been rising. From 1991 to 1995, smoking among high school students rose from 27.5 to 34.5 percent, a shocking gain of more than 25 percent.

Three studies, beginning in 1998, will examine strategies to reduce the use of tobacco products. Two of these studies, both involving partnerships with the University of Minnesota School of Public Health, focus on adolescent smoking. Although extensive research has been conducted on changing youth smoking, previous studies have focused largely on prevention is school settings.

The first study is a demonstration project intended to reduce the number of older adolescents who start smoking and to encourage teens who are already smoking to try quitting. Over a two-year period, large numbers of adolescents (ages 14-17) will be sent information about tobacco. They also will be encouraged to get involved with others in a campaign against tobacco through youth action teams charged with examining smoking and youth.

The second study also focuses on prevention and cessation, delivering the anti-smoking message at the time of a preventive dental visit at HealthPartners' dental clinics. Adolescents who are using tobacco or who are at risk for tobacco use will be invited to join the study and to receive specific tailored counseling about tobacco. Follow-up telephone calls will encourage young smokers to think about quitting.

The third study is about smokeless tobacco-snuff or chew. Smokeless tobacco is associated with high blood pressure, nicotine dependence, and oral cancer. Smokeless tobacco users will receive either a packet of educational materials and/or follow-up telephone calls from the Center for Health Promotion at HealthPartners.

Together, these studies will provide valuable information about adolescent tobacco use, adult smokeless tobacco use, and the relative effectiveness of strategies for reducing the use of tobacco products. In addition, the studies will educate teens about the dangers of tobacco, hopefully getting them involved in the fight to save themselves.

Research Team
HealthPartners: Raymond Boyle, PhD; Kirsten Hase, Brad Rindal, DDS; Craig Amunson, DDS; Brian Martinson, PhD; Nico Pronk, PhD; Jackie Labat, RD, MS. University of Minnesota: Harry Lando, PhD, DeAnn Lazovich, PhD; Deborah Hennrikus, PhD

Funding
National Cancer Institute, National Institute of Dental Research

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Project IMPROVE (IMproving PRevention through Organization, Vision & Empowerment) was designed to test a method for systemizing preventive services in primary care clinics. This four year scientific trial applied quality improvement concepts to improve prevention services. Forty-four primary care clinics that volunteered to participate in the project were randomly assigned to intervention and control groups.

Baseline findings from Project IMPROVE documented that primary care clinics lack organized systems to provide preventive services in any consistent way. For example, almost no clinics had clear methods for documenting the preventive services needs of each patient, reminders to act, or ways to help patients change unhealthy behaviors.

Despite the lack of such systematic help, the patients in these clinics were receiving preventive services at rates generally above the national average. Even so, there was still substantial room for improvement. For example, at most office visits, fewer than one-third of patients needing additional preventive services received recommendations for them.

For participating clinics, involvement in Project IMPROVE increased the focus on preventive services, created multi-disciplinary teams to address a variety of organizational problems and tasks, and promoted the concept that clinics can and should improve their systems of care.

Research Team
Investigators: PI-Leif I. Solberg, MD; Co-PI-Tom Kottke, MD, MPH, Gail Amundson, MD. Milo L. Brekke, PhD, Sanne Magnan, MD, MPH, Andrew Nelson, MPH, Greg Angstman, MD, Gestur Davidson, PhD, John Wheeler, MD. Project Coordinator: Katherine Giles, BSN, MBA. Interventions Consultants: Carolyn Calomeni, MPA, Shirley Conn, RN, MSN, Kathleen Conboy, BSN. Evaluation Staff: Carol Westrum, MA, Gerald Amundson, BS, Lynne Dancha, BS, FLMI, Brian Harmon, BA. Support Staff: Ann Sisel, BA

Funding
Agency for Health Care Policy and Research (AHCPR), Grant R01 HS08091

Related Publications
Solberg LI, Kottke TE, Brekke ML, Conn SA, Magnan S, Amundson GM. The case of the missing clinical preventive services delivery systems. Effective Clin Pract 1998 (In press)

Solberg LI, Kottke TE, Conn SA, Brekke ML, Calomeni CA, Conboy KS. Delivering clinical preventive services is a systems problem. Ann Behv Med 1997;19(3):271-83.

Kottke TE, Solberg LI, Brekke ML, Cabrera A, Marquez M. Delivery rates for preventive services in 44 Midwestern clinics. Mayo Clinic Proc 1997;72:515-23.

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The human body has built-in daily rhythms that regulate most body functions in an approximate 24-hour cycle. The timing of these innate circadian rhythms is affected by environmental influences, such as the light-dark cycle, social routine, etc. When there are changes in the timing of environmental factors, the body's rhythm adapts slowly, with different physiologic variables adapting at different speeds. For example, blood pressure and heart rate tend to adapt quickly; the cell-division process adapts slowly; and body temperature and physical performance are intermediate. Long-distance travelers who experience jet lag and shift workers have similar problems adapting to time disruptions. Their normally synchronized body-rhythms become temporarily out of synchrony.

Researchers at Regions Hospital monitored body temperature, blood pressure and heart rate in a sample of adult men and women during and after more than 60 transmeridian flights over six to eight time zones. Blood pressure and heart rate tended to adapt to time change within one to three days. In contrast, the adaptation of the rhythm in body temperature took about eleven days after west-to-east flights and about six to eight days after east-to-west flights. It took longer for bodies to adapt to west-to-east travel, irrespective of whether the flight was to or from home.

The research also found that the degree of adaptation to prolonged night shifts varied widely from individual to individual-from full adaptation to none. In some subjects and for some variables (e.g., circulating lymphocytes, plasma cortisol), the time required for full adaptation to a twelve hour shift in schedule was three to six weeks.

This research demonstrates the importance of internal desynchronization and the potential impact on health, well being, and ability to perform work and other daily activities.

Research Team
Regions Hospital: Erhard Haus, MD, PhD, Linda Sackett-Lundeen MT (ASCP)

Funding
Ramsey Foundation, Regions Hospital Department of Pathology

Related Publications
Haus E, Touitou Y. Principles in clinical chronobiology. In: Touitou Y, Haus E, editors. Biologic rhythms in clinical and laboratory medicine. Heidelberg: Springer-Verlag, 1992:6-34.

Haus E. Chronobiology of circulation blood cells and platelets. In: Touitou Y, Haus E, editors. Biologic rhythms in clinical and laboratory medicine. Heidelberg: Springer-Verlag, 1992:504-26.

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Funding
Department of Surgery, Regions Hospital, HealthPartners Information Services, Regions Hospital

Related Publications
Solem LD, Massman NJ, Dodge JD. Burn follow-up : An innovative application of telemedicine. Scientific paper presented at the American Telemedicine Association Annual Meeting, Orlando Florida, April 5-8,1998.

Solem LD, Massman NJ, Dodge JD. Correction consultations: An economically successful application of technology. Scientific paper presented at the American Telemedicine Association Annual Meeting, Orlando Florida, April 5-8,1998.

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A series of studies, conducted over the last six years, have examined lethal accidents in hospital and nursing home beds associated with bedrails and vests. Data for these studies come from federal and state records and from coroners and attorneys. One project identified 122 deaths caused by asphyxiation in various vests and restraining belts. Another project described 70 deaths caused by bedrails.

These studies show that impulsive, confused, and agitated people are at high risk of entrapment. The combination of restraints and rails appears to have about the same potential for lethal harm as rails or vests alone. Many patients "rehearsed their deaths;" that is, shortly before their deaths, they were found suspended or entrapped in a vest or rail in a manner similar to the way they subsequently died. Such events should prompt a swift, fundamental modification of the bed environment for the patient's safety.

It will be difficult to prevent these deaths. Rail entrapment can occur with a single half-bedrail, split bedrails, or full length rails. Patients can become entrapped in spaces as small as four inches-such gaps are found in nearly all hospital and nursing home beds that were sold prior to 1995. Because these events can occur in a matter of minutes, alarms and surveillance are simply not adequate to prevent them. Preventing these deaths requires more restricted use of rails and vests. Fundamental changes in the design of the bed environment are needed.

This research has changed federal and state policy on the use of restraints and rails.

Research Team
Regions Hospital: Steven Miles, MD. University of Minnesota: Kara L. Parker

Funding
Open Society Institute

Related Publications
Miles SH, Parker KL. Deaths from bedrails: lessons from a videotape and photograph. Am Fam Physician 1998. (In press)

Parker KL, Miles, SH. Deaths caused by bedrails. J Am Geriatr Soc 1997;45:797-802.

Miles SH. A case of death by physical restraint: new lessons from a photograph. J Am Geriatr Soc 1996;44:291-2.

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HIV infection arrived suddenly on the medical scene in the early 1980's, bringing tragic morbidity and mortality to many young people. A decade later, significant research efforts have helped to bring about a dramatic improvement in prognosis for HIV infected persons in the U.S.

The HIV program at Regions has been on the forefront of research with a number of important projects over the years. Dr. Keith Henry started the first HIV clinic in Minnesota in 1985. In 1994, he formed a community research consortium called AIDS Research Consortium in the Twin Cities, ARCTiC. Several new protocols are starting this summer.

ARCTiC was chosen to be one of seven sites nationally to participate in a national research program to test protocols for HIV infected individuals who are failing the presently available HIV drugs. Despite improved prognosis, many HIV-infected people continue to fail present treatment recommendations.

A vaccine study began in late summer 1998. Up to 100 persons who are HIV negative but at high risk for acquiring the virus will be vaccinated at the Regions affiliated sites.

In another new project, HIV patients with chronic diarrhea are being assessed for tolerance of a new anti-diarrheal agent. A significant proportion of HIV infected individuals have had chronic diarrhea associated with HIV and/or their HIV treatment regimens (a likely cause is protease inhibitors).

A new study is investigating cholesterol levels in HIV patients. Many HIV patients have elevated cholesterol levels-hyperlipidemia, which has been associated with protease inhibitors. Preliminary data suggest that about 70% of patients on inhibitors, develop hyperlipidemia within a very short period of time.

Research Team
Regions Hospital: Keith Henry, PhD, Holly Melroe, RN, NP, Ray Nelson, RN, Ellen Kane, RN, Jessica Hermundson, Jane Simpson, Craig Vine, MD, Chris Sullivan, MD, Kathy McCabe, RN, Adrienne Block, MSW, Scott Cruse, MSW, Betty Jarosch, Helen Olson, RN

Funding
Agauron Pharmaceuticals, Bristol Myers Squibb, Pharmacia Upjohn, Shaman, Anderson Windows, Minnesota Mutual, Roxanne, Roche Laboratories, Abott Pharmaceuticals, Merck, Glaxo-Welcome, AT&T, National Institutes of Health

Related Publications
Henry K, Melroe H, Huebsch J, Hermundson J, Levine C, Swensen L, Daley J. Severe premature coronary artery disease with protease inhibitors. Lancet 1998 May;351:1328.

Zhang Z, Henry K, Haase A, et al. Kinetics of CD4 Tcell repopulation of lymphoid tissue after treatment of HIV infection. Proceedings of National Academy of Science 1988:85:1554-1159.

Henry K, Melroe H, Huebsch J, Hermundson J, Levine C, Swensen L, Daley J. Severe premature coronary artery disease with protease inhibitors. Presented at the 12th World AIDS Conference, Geneva, Switzerland, June, 1998.

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