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Center Newsby Joan DeClaire
MacColl Institute hosts Congress on Improving Chronic Care More than 300 health-services researchers and innovators in chronic illness care attended the first Congress on Improving Chronic Care: Innovations in Research and Practice at The Westin Seattle, September 8–10. The Congress was hosted by the MacColl Institute at Group Health Center for Health Studies, which serves as the national office for the Robert Wood Johnson Foundation's (RWJF) Improving Chronic Illness Care (ICIC) program. RWJF and the U.S. Agency for Healthcare Research and Quality (AHRQ) co-sponsored the event. The conference gave participants an opportunity to exchange experience and knowledge on a wide range of research topics and quality-improvement issues affecting the nearly 100 million people who suffer from chronic illnesses in the U.S. As described in the March 2001 Institute of Medicine (IOM) report, Crossing the Quality Chasm, the American health care system is badly in need of reforms to address the growing chronic-care needs of its aging population. This meeting was one of the first opportunities since the publication of that report for leading researchers and clinicians to gather and discuss recent progress toward the IOM's recommendations. In addition to investigators from Group Health's MacColl Institute and Group Health Center for Health Studies, presenters included officials from the World Health Organization, RAND, the Robert Wood Johnson Foundation, the Joint Commission on Accreditation of Healthcare Organizations, AHRQ, and several prominent universities. Topics included the current state of practice, cultural competence in chronic care, integration of self-management and practice, performance measures and accreditation, and innovations happening in developing countries. Anthology gives voice to chronically ill patients Health care is an industry, an art, and a science. But mostly, it’s the experience of individual patients interacting with their health care providers. Keeping the patient’s voice prominent was one goal of the MacColl Institute staff as they planned the first Congress on Improving Chronic Care, held at The Westin Seattle, September 8–10. To this end, the Institute has published a literary anthology, entitled To Come to Light: Perspectives on Chronic Illness in Modern Literature (Whit Press 2002). The anthology is edited by Amy Bonomi, a research associate at the MacColl Institute, a PhD candidate in health services at the University of Washington, and a published poet. Sherry Lauf, MacColl Institute business manager, assisted with design, editing, and production of the publication. The book comprises 37 poems and prose excerpts, including work from authors such as Margaret Atwood, Raymond Carver, Jane Kenyon, Vincent van Gogh, and Leo Tolstoy. Group Health neurosurgeon and author Richard Rapport, MD, contributed to the collection with an excerpt from his essay, "Surgeon’s Knots," which was originally published in Open Spaces Quarterly in 1998. The work in the anthology "confirms that quality in health care begins and ends with understanding people with illness, and designing systems of care that meet their needs without sapping their strengths or robbing them of their personhood," writes Ed Wagner, MD, director of the MacColl Institute. Selected readings from the limited-edition anthology were performed at the opening reception for the Congress. A second printing of the book is being planned. For information about ordering a copy, contact Bonomi at bonomi.a@ghc.org. Lisa Jackson named an associate director for Department of Preventive Care Lisa Jackson, MD, MPH, has been named an associate director in Group Health Permanente’s (GHP) Department of Preventive Care (DPC), a subspecialty group within GHP that works with Group Health Center for Health Studies on prevention-services research. An internist, Jackson has been a scientific investigator with the Center while serving as faculty in the University of Washington Department of Epidemiology since 1996. In her new job, she will continue to provide scientific leadership to Group Health in the areas of immunizations and infectious disease prevention, helping the organization in its ongoing efforts to develop and evaluate population-based service-improvement strategies in this area. In addition, Jackson will continue her research in vaccine safety and efficacy, the epidemiology of vaccine-preventable diseases, and infectious causes of chronic diseases. She is the principal investigator of several federally funded research projects, including Group Health’s involvement in the Vaccine Safety Datalink (VSD) project. This collaboration—begun in 1991 with the Centers for Disease Control and Prevention and seven HMOs—is the cornerstone of national efforts to evaluate the safety of immunizations given to children and adults. The results of Jackson’s VSD work have been widely disseminated through several medical journals including The Journal of the American Medical Association, which published her study of revaccination with pneumococcal polysaccharide vaccine in 1999. She is also a co-investigator in an NIH-sponsored, multi-center, randomized placebo-controlled trial of the common antibiotic azithromycin for prevention of heart attacks. After her move to Group Health, Jackson will maintain an academic appointment with the University of Washington. A 1988 graduate of the University of Virginia School of Medicine, Jackson earned her master’s degree in epidemiology from the University of Washington’s School of Public Health and Community Medicine in 1996. She served in the CDC’s Epidemic Intelligence Service program from 1991 to 1994. She works with Group Health’s Immunization Road Map Team and the Pharmacy and Therapeutics Committee. She also represents Group Health on the Washington State Department of Health’s Vaccine Advisory Committee. "Lisa is a first-rate scientist and a leader," said Robert S. Thompson, MD, director of DPC. "We feel very fortunate to have her join us. I am certain that her commitment to her work will continue to be of great benefit to Group Health and its members, as well as to the national research agenda for immunizations and vaccine-preventable diseases." CHS takes part in international effort to define depression Social scientists have long noted huge differences in prevalence of depression across cultures, with the highest incidence in South American counties and the lowest incidence in Asia. Some have suggested that these differences prove that the condition called depression by Americans and Western Europeans doesn’t really exist. But others have proposed that differences in prevalence might be linked to the way scientists typically describe and measure the disease; maybe their diagnostic tools—which are highly dependent on language and culture—simply don’t correlate well across cultures. The only way to find out would be to use a new tool to measure depression and see if the same differences in prevalence across cultures are revealed. Mental health researchers from Group Health Center for Health Studies recently participated in a World Health Organization (WHO) research project to do just that. Along with scientists from 15 countries, CHS senior investigators Greg Simon, MD, MPH, and Michael Von Korff, ScD, came up with a tool that measures people’s actual disability. They found that differences in prevalence, as measured by disability, correlate with differences in prevalence as reported in patient interviews. In fact, their study showed that depressive disorder showed up 15 times more often in South America than in Asia, with Americans and Western Europeans measuring in the middle. "The study proves that cross-cultural differences in prevalence of depression cannot be attributed to the idea that the disorder doesn’t really exist," says Simon, the lead author of an article about the study that was published in the May 2002 issue of Psychological Medicine. It also suggests that the differences in reported prevalence may be due to: 1) true cross-cultural differences in how many people have depression, or 2) that there are differences in the thresholds at which people are diagnosed. This research helps to lay the foundation for scientists studying the treatment of mental health problems in cultures other than the United States and Western Europe, says Simon. The research was funded by grants from the World Health Organization, the U.S. National Institute of Mental Health, Delagrange Laboratories, and Synthelabo Pharamacie. MacColl Institute contributes to WHO initiative on chronic care Staff from the MacColl Institute have been consulting with researchers from the World Health Organization to develop an initiative to improve chronic care worldwide. The first major product of this partnership is a recently published WHO Global Report, entitled "Innovative Care for Chronic Conditions: Building Blocks for Action." The report proposes the development or restructuring of primary care systems to provide high-quality chronic illness care. A model of chronic care pioneered at Group Health Cooperative by the MacColl Institute plays a central role in the report. Working with advisors from developing countries, authors of the report expanded on the model to address community and regulatory factors in other regions of the world. Plans are underway at the MacColl Institute for further dissemination of ICIC’s work in several Latin American, Middle Eastern, and North African countries. Group Health physicians honor Greg Simon with Beekman Award Greg Simon, MD, MHP, recently received the Jerome F. Beekman Award for Outstanding Physician Leadership from the Group Health Permanente (GHP) Medical Group. The GHP Board of Directors gives the award each year to a physician who "consistently demonstrates an exceptional level of leadership competency" and "is deeply knowledgeable of the principles of medical practice and managed care." Simon serves Group Health both as a psychiatrist in the Central Behavioral Health Clinic and as a senior investigator for Group Health Center for Health Studies. His research on depression care and other mental health issues has been published in many prestigious medical journals. According to nominating documents, Simon was cited for the award because he "contributes powerful new ideas, and translates them into research proposals that are funded, which translates into improved care at Group Health." The award is named in memory of Jerome Beekman, MD, a Group Health pulmonologist who served as the Cooperative’s medical director for specialty services before he died in 1997. Study shows strong link between Depo-Provera and bone loss; but the loss is largely reversible Depo-Provera, an injectable form of birth control particularly popular among young and low-income American women, is strongly associated with bone loss, according to a recent study conducted at Group Health Center for Health Studies. The research, published in the September 2002 issue of Epidemiology, also found that the bone loss appears to be largely reversible once the injections are discontinued. Loss of bone density increases the risk for osteoporosis, a disease in which bones become fragile and are more likely to break. Group Health scientists, in one of the most thorough studies of the issue to date, found that women who used Depo-Provera continuously for three years experienced about the same amount of bone loss as women who are breast-feeding or going through menopause. "Bone loss is certainly a concern, but the study is also reassuring since it showed that women steadily regained bone density once they stopped using the contraceptive," said Delia Scholes, PhD, associate investigator at the Center and the principal investigator for this study. Some earlier studies have found an association between Depo-Provera use and decreased bone density, while others have not. However, many of the previous studies only measured subjects’ bone density and their exposure to Depo-Provera at a single point in time, rather than following women forward over time. Because both new and long-term users were enrolled in the study, researchers could assess both short-term and long-term changes. Furthermore, only one previous study looked at the effects on bone density of stopping Depo-Provera use. About 2 percent of American women who use contraceptives use Depo-Provera. However, rates are higher for younger women. Among women 15–19 years of age, 8 percent of non-Hispanic white women and 19 percent of non-Hispanic black women who use birth control use Depo-Provera. Depo-Provera, which is given once every three months via injection, is relatively low-cost, private, and easy-to-use, said Scholes. It is a popular choice among women for whom other types of contraception have not worked well, she added. "Choosing a contraceptive involves a highly individualized set of decisions," Scholes said, adding that she hopes the findings will alert women and their providers to consider bone density when comparing the plusses and minuses of Depo-Provera. "Although bone loss is one consideration, an unintended pregnancy has huge consequences in a woman’s life as well," she added. Scholes advised that the following steps may help women improve or maintain bone health, whether they are using Depo-Provera or not:
How the study was conducted Scholes and her colleagues compared hip and spine bone density measurements from 440 women, ages 18 to 39, who were enrolled in Group Health Cooperative, a Seattle-based health plan. A total of 182 participants were receiving Depo-Provera injections and 258 comparable women were not. Bone density measurements were taken at the start of the study, and at six-month intervals over the next three years. Compared to non-users, Depo-Provera users had greater decreases in average bone density throughout the follow-up period. Women who used Depo-Provera continuously experienced a loss of bone density at the hip of 1.12 percent per year compared with 0.05 percent per year among non-users. Women who discontinued the use of Depo-Provera during the course of the study showed marked increases in bone density after discontinuation, although they recovered bone density at the hip more slowly than at the spine. By approximately 30 months after stopping Depo-Provera, bone density values for most Depo-Provera users were similar to those of non-users. Funded by an $870,000 grant from the National Institute of Child Health and Human Development, the study was conducted by scientists from Group Health Center for Health Studies, the University of Washington’s Departments of Epidemiology and Biostatistics, and UW’s School of Medicine. Although this project is complete, the researchers are continuing to study the effects of Depo-Provera injections and other risk factors on bone density in adolescent women. |
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