Mary E. Murphy

Bio: Mary E. Murphy is an academic researcher from Mayo Clinic. The author has contributed to research in topics: Kidney transplantation & Guideline. The author has an hindex of 8, co-authored 10 publications receiving 507 citations.

Urolithiasis in pediatric patients.

Abstract: Urolithiasis in pediatric patients has been perceived as uncommon, and the appropriate evaluation and management have been controversial. To determine the clinical characteristics, types of stone problems, and outcomes of pediatric patients with urolithiasis encountered in a referral center, we retrospectively assessed 221 patients (113 girls and 108 boys) with urolithiasis examined at the Mayo Clinic between 1965 and 1987. The median age at onset of symptoms was 11 6 / 12 years among the female patients and 10 6 / 12 years among the male patients. Analysis of stone constituents in 122 patients showed the proportion of calcium oxalate (44.7%), calcium phosphate (23.6%), and cystine (8.1%) stones to be similar in all age-groups. Overall, struvite stones were found in 17.1% and uric acid stones in 1.6% of patients. Conditions that predisposed to metabolic urolithiasis were identified in 115 patients (52%). Hypercalciuria was confirmed in 49 of 145 patients (33.8%) and hyperoxaluria in 25 of 124 (20.2%). Eight of 96 patients had hyperuricosuria, and 5 of 54 had hypocitraturia. Forty-one patients (18.6%) had infection-related stones. Of 66 patients with structural anomalies of the genitourinary tract, 24 (36%) had metabolic abnormalities and 26 (39%) had chronic infection. Among patients with chronic infection, 29% had metabolic abnormalities. Of the 221 patients, 148 (67%) had two or more stones during a mean follow-up of 59 months. Among 140 patients with 12 months or more of follow-up, metabolic activity was present in 31 (22.1%) at the time of most recent examination. Overall, 166 of 221 children (75.1%) were found to have factors that predisposed to urolithiasis. Infected, obstructed, or structurally anomalous urinary tracts seem to be factors permissive for formation of stones and do not obviate the need for careful metabolic assessment in all young patients who form renal stones.

Impact of a Diabetes Electronic Management System on the Care of Patients Seen in a Subspecialty Diabetes Clinic

Abstract: OBJECTIVE To compare the compliance with diabetes care performance indicators by diabetes specialists using a diabetes electronic management system (DEMS) and by those using the traditional paper medical record. RESEARCH DESIGN AND METHODS A DEMS has been gradually introduced into our subspecialty practice for diabetes care. To assess the value of this DEMS as a disease management tool, we completed a retrospective review of the medical records of 82 randomly selected patients attending a subspecialty diabetes clinic (DC) during the first quarter of 1996. Eligible patients were defined by the suggested criteria from the American Diabetes Association Provider Recognition Program. During the first quarter of 1996, ∼ one half of the providers began using the DEMS for some but not all of their patient encounters. Neither abstractors nor providers were aware of the intent to examine performance in relationship to use of the DEMS. RESULTS Several measures were positively influenced when providers used the DEMS. The number of foot examinations, the number of blood pressure readings, and a weighted criterion score were greater ( P P = 0.043) in patients and for number of glycated hemoglobins documented ( P = 0.018) by users of the DEMS. CONCLUSIONS Performance and documentation of the process of care for patients with diabetes in a subspecialty clinic are greater with the use of a DEMS than with the traditional paper record.

Improving performance in diabetes care: a multicomponent intervention.

Abstract: CONTEXT: Compliance with recommendations from the American Diabetes Association for management of patients with diabetes is not optimal. Changing physician practice patterns with provider-focused interventions can be difficult. We report results after implementation of a type 2 diabetes mellitus guideline. OBJECTIVE: To increase the annual rate of microalbumin/urine protein testing, dilated eye examinations, and foot examinations for patients with diabetes and to reduce overall levels of hemoglobin A1c (Hb A1c). DESIGN: Before-after study. INTERVENTION: From April 1996 to June 1998, a guideline on type 2 diabetes mellitus was implemented with multicomponent interventions. These included small group educational sessions led by opinion leaders, an electronic version of the guideline, audit with feedback, and enhanced clinical orders support. Medical records of random samples of patients with diabetes were audited for specific diabetes performance measures on a monthly basis. Baseline data were compared with results at the end of the implementation effort. SETTING: Southeastern Minnesota, excluding Olmsted County. PARTICIPANTS: Adult patients seen at one practice of 18 general internists. OUTCOME MEASURES: Outcome measures included Hb A1c values and annual performance of a urine protein test, foot examination, and dilated eye examination. RESULTS: Gradual, sustained; and statistically significant improvements in the three annual performance measures were observed. Urine protein testing increased from 24% to 66% (P = 0.001), dilated eye examinations increased from 63% to 84% (P = 0.001), and foot examinations increased from 86% to 97% (P = 0.001). Mean Hb A1c values +/- SD also improved from 7.8% +/- 1.0% to 7.1% +/- 0.7% (P < 0.001) in patients who received continuing care for diabetes. CONCLUSIONS: Statistically significant improvements were observed after continuous improvement efforts were focused on providers in an individual group practice. When used to implement a diabetes guideline, such interventions may improve delivery of services and reduce Hb A1c levels in patients with diabetes.

Resistance to Insulin Therapy Among Patients and Providers Results of the cross-national Diabetes Attitudes, Wishes, and Needs (DAWN) study

Abstract: OBJECTIVE - To examine the correlates of patient and provider attitudes toward insulin therapy. RESEARCH DESIGN AND METHODS - Data are from surveys of patients with type 2 diabetes not taking insulin (n = 2,061) and diabetes care providers (nurses = 1,109; physicians = 2,681) in 13 countries in Asia, Australia, Europe, and North America. Multiple regression analysis is used to identify correlates of attitudes toward insulin therapy among patients, physicians, and nurses. RESULTS - Patient and provider attitudes differ significantly across countries, controlling for individual characteristics. Patients rate the clinical efficacy of insulin as low and would blame themselves if they had to start insulin therapy. Self-blame is significantly lower among those who have better diet and exercise adherence and less diabetes-related distress. Patients who are not managing their diabetes well (poor perceived control, more complications, and diabetes-related distress) are significantly more likely to see insulin therapy as potentially beneficial. Most nurses and general practitioners (50-55%) delay insulin therapy until absolutely necessary, but specialists and opinion leaders are less likely to do so. Delay of insulin therapy is significantly less likely when physicians and nurses see their patients as more adherent to medication or appointment regimens, view insulin as more efficacious, and when they are less likely to delay oral diabetes medications. CONCLUSIONS - Patient and provider resistance to insulin therapy is substantial, and for providers it is part of a larger pattern of reluctance to prescribe blood glucose-lowering medication. Interventions to facilitate timely initiation of insulin therapy will need to address factors associated with this resistance.

Effects of quality improvement strategies for type 2 diabetes on glycemic control: a meta-regression analysis.

Abstract: ContextThere have been numerous reports of interventions designed to improve the care of patients with diabetes, but the effectiveness of such interventions is unclearObjectiveTo assess the impact on glycemic control of 11 distinct strategies for quality improvement (QI) in adults with type 2 diabetesData Sources and Study SelectionMEDLINE (1966-April 2006) and the Cochrane Collaboration's Effective Practice and Organisation of Care Group database, which covers multiple bibliographic databases Eligible studies included randomized or quasi-randomized controlled trials and controlled before-after studies that evaluated a QI intervention targeting some aspect of clinician behavior or organizational change and reported changes in glycosylated hemoglobin (HbA1c) valuesData ExtractionPostintervention difference in HbA1c values were estimated using a meta-regression model that included baseline glycemic control and other key intervention and study features as predictorsData SynthesisFifty randomized controlled trials, 3 quasi-randomized trials, and 13 controlled before-after trials met all inclusion criteria Across these 66 trials, interventions reduced HbA1c values by a mean of 042% (95% confidence interval [CI], 029%-054%) over a median of 13 months of follow-up Trials with fewer patients than the median for all included trials reported significantly greater effects than did larger trials (061% vs 027%, P = 004), strongly suggesting publication bias Trials with mean baseline HbA1c values of 80% or greater also reported significantly larger effects (054% vs 020%, P = 005) Adjusting for these effects, 2 of the 11 categories of QI strategies were associated with reductions in HbA1c values of at least 050%: team changes (067%; 95% CI, 043%-091%; n = 26 trials) and case management (052%; 95% CI, 031%-073%; n = 26 trials); these also represented the only 2 strategies conferring significant incremental reductions in HbA1c values Interventions involving team changes reduced values by 033% more (95% CI, 012%-054%; P = 004) than those without this strategy, and those involving case management reduced values by 022% more (95% CI, 000%-044%; P = 04) than those without case management Interventions in which nurse or pharmacist case managers could make medication adjustments without awaiting physician authorization reduced values by 080% (95% CI, 051%-110%), vs only 032% (95% CI, 014%-049%) for all other interventions (P = 002)ConclusionsMost QI strategies produced small to modest improvements in glycemic control Team changes and case management showed more robust improvements, especially for interventions in which case managers could adjust medications without awaiting physician approval Estimates of the effectiveness of other specific QI strategies may have been limited by difficulty in classifying complex interventions, insufficient numbers of studies, and publication bias

Cardiovascular risk reduction in high-risk pediatric patients: a scientific statement from the American Heart Association Expert Panel on Population and Prevention Science; the Councils on Cardiovascular Disease in the Young, Epidemiology and Prevention, Nutrition, Physical Activity and Metabolism, High Blood Pressure Research, Cardiovascular Nursing, and the Kidney in Heart Disease; and the Interdisciplinary Working Group on Quality of Care and Outcomes Research: endorsed by the American Academy of Pediatrics.

Abstract: Although for most children the process of atherosclerosis is subclinical, dramatically accelerated atherosclerosis occurs in some pediatric disease states, with clinical coronary events occurring in childhood and very early adult life. As with most scientific statements about children and the future risk for cardiovascular disease, there are no randomized trials documenting the effects of risk reduction on hard clinical outcomes. A growing body of literature, however, identifies the importance of premature cardiovascular disease in the course of certain pediatric diagnoses and addresses the response to risk factor reduction. For this scientific statement, a panel of experts reviewed what is known about very premature cardiovascular disease in 8 high-risk pediatric diagnoses and, from the science base, developed practical recommendations for management of cardiovascular risk.