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Research Highlights
Investigators from Group Health Center for Health Studies continue to publish findings in epidemiology, health services, behavioral health, and clinical research, addressing a wide and evolving range of clinical and public health issues. Abstracts of several recent studies are excerpted below. Hormone Replacement Therapy in Relation to Breast Cancer. Studies of long-term hormone replacement therapy (HRT) suggest an associated increased risk of breast cancer, but whether this association differs according to histologic type of cancer has not been extensively studied. The objective of this study was to determine whether the association between HRT and risk of breast cancer varies by HRT formulation and differs across histologic cancer types. The investigation was a case-control study among 705 postmenopausal women enrolled in the Group Health Cooperative who were aged 50 to 74 years and had primary invasive breast cancer (cases), and 692 randomly selected aged-matched female members of GHC (controls)…. Results showed the incidence of breast cancer, all histologic types combined, was increased by 60 percent to 85 percent in recent long-term users of HRT, whether estrogen alone or estrogen plus progestin. Longer use of HRT and current use of combination therapy were associated with increased risk of lobular breast cancer. Long-term HRT use was associated with a 50 percent increase in nonlobular cancer. Conclusion: Our data add to the growing body of evidence that recent long-term use of HRT is associated with an increased risk of breast cancer and that such use may be related particularly to lobular tumors. Chen C-L, Weiss N, Newcomb P, and Barlow W, White E. Journal of the American Medical Association 2002; 287: 734–741. Enhancing primary care HIV prevention: a
comprehensive clinical intervention. The diagnosis and treatment of patients with chronic low-back pain by traditional Chinese medical acupuncturists. The selection of appropriate treatments in clinical trials of acupuncture requires understanding how acupuncturists diagnose and treat specific conditions. The authors examined the Traditional Chinese Medical (TCM) diagnoses and treatments for patients with chronic low-back pain using two separate sets of treatment records. Information from more than 150 initial visits was available for analysis. A diagnosis of Qi and Blood Stagnation or Qi Stagnation was made for 85 percent of patients. A diagnosis of kidney deficiency (or one of its three subtypes) was made for 33 percent–51 percent of patients. Other specific diagnoses were made for less than 20 percent of the patients. An average of 12–13 needles was used in each treatment. Although more than 85 different acupoints were used in each data set, only 5 or 6 acupoints were used in more than 20 of the treatments in each data set. Only two of those acupoints (UB23, UB40) were the same for both sources of data. More than half of the patients received adjunctive treatments, including heat (36 percent–67 percent), and cupping (16 percent–21 percent). There was substantial variability in treatments among providers. Such diversity will make it challenging to select a single treatment that has wide applicability. Conclusion: The authors recommend that researchers attempt to develop a treatment that is considered credible by expert acupuncturists and has broad features characteristic of patterns of common clinical practice. Sherman KJ, Cherkin DC, Hogeboom CJ. Journal of Alternative and Complementary Medicine 2001;7:641–50. Cost-effectiveness of a collaborative care program for primary care patients with persistent depression. The authors evaluated the incremental cost-effectiveness of stepped collaborative care for patients with persistent depressive symptoms after usual primary care management. Primary care patients initiating antidepressant treatment completed a standardized telephone assessment 6–8 weeks after the initial prescription. Those with persistent major depression or significant subthreshold depressive symptoms were randomly assigned to continued usual care or collaborative care. The collaborative care included systematic patient education, an initial visit with a consulting psychiatrist, 2–4 months of shared care by the psychiatrist and primary care physician, and monitoring of follow-up visits and adherence to medication regimen.… Results showed that patients receiving collaborative care experienced a mean of 16.7 additional depression-free days over 6 months. The mean incremental cost of depression treatment in this program was $357. The additional cost was attributable to greater expenditures for antidepressant prescriptions and outpatient visits. No offsetting decrease in use of other health services was observed.… Conclusions: A stepped collaborative care program for depressed primary care patients led to substantial increases in treatment effectiveness and moderate increases in costs. These findings are consistent with those of other randomized trials. Improving outcomes of depression treatment in primary care requires investment of additional resources, but the return on this investment is comparable to that of many other widely accepted medical interventions. Simon GE, Katon WJ, VonKorff M, Unützer J, Lin EHB, Walker EA, Bush, T, Rutter C, Ludman E. American Journal of Psychiatry 2001; 158:1638–1644. Improving chronic illness care: translating evidence into action. The growing number of persons suffering from major chronic illnesses face many obstacles in coping with their condition, not least of which is medical care that often does not meet their needs for effective clinical management, psychological support, and information. The primary reason for this may be the mismatch between their needs and care delivery systems largely designed for acute illness. Evidence of effective system changes that improve chronic care is mounting. The authors have summarized this evidence in the Chronic Care Model (CCM) to guide quality improvement. In this paper they describe the CCM, its use in intensive quality improvement activities with more than 100 health care organizations, and insights gained in the process. Wagner EH, Austin B, Davis C, Hindmarsh M, Schaefer J, Bonomi A. Health Affairs 2001;20(6):64–78. The risk of seizures after receipt of whole-cell pertussis or measles, mumps, and rubella vaccine. The administration of the diphtheria and tetanus toxoids and whole-cell pertussis (DTP) vaccine and measles, mumps, and rubella (MMR) vaccine has been associated with adverse neurologic events, including seizures. The authors studied the relation between these vaccinations and the risk of a first seizure, subsequent seizures, and neurodevelopmental disability in children. This cohort study was conducted at four large health maintenance organizations and included reviews of the medical records of children with seizures. The authors calculated the relative risks of febrile and nonfebrile seizures among 679,942 children after 340,386 vaccinations with DTP vaccine, 137,457 vaccinations with MMR vaccine, or no recent vaccination. Children who had febrile seizures after vaccination were followed to identify the risk of subsequent seizures and other neurologic disabilities.…Conclusions: There are significantly elevated risks of febrile seizures on the day of receipt of DTP vaccine and 8 to 14 days after the receipt of MMR vaccine, but these risks do not appear to be associated with any long-term, adverse consequences. Barlow WE, Davis RL, Glasser JW, Rhodes PH, Thompson RS, Mullooly JP, Black SB, Shinefield HR, Ward JI, Marcy SM, DeStefano F, Chen RT, Immanuel V, Pearson JA, Vadheim CM, Rebolledo V, Christakis D, Benson PJ, Lewis N; Centers for Disease Control and Prevention Vaccine Safety Datalink Working Group. New England Journal of Medicine 2001;345:656–661. Risk of recurrent coronary events in relation to use and recent initiation of postmenopausal hormone therapy. The finding from the Heart and Estrogen/Progestin Replacement Study (HERS) of increased coronary risk restricted to the first year after starting postmenopausal hormone therapy raises new questions about the role of hormone therapy in women with coronary heart disease. The authors assessed the risk of recurrent myocardial infarction or coronary heart disease death associated with the use and recent initiation of hormone therapy in women who survived a first myocardial infarction. The authors studied 981 postmenopausal women enrolled in Group Health who survived to hospital discharge after their first myocardial infarction. Results showed that during median follow-up of 3.5 years, there were 186 recurrent coronary events. There was no difference in the risk of recurrent coronary events between current users of hormone therapy and other women…. Relative to the risk in women not currently using hormones, there was a suggestion of increased risk during the first 60 days after starting hormone therapy and reduced risk with current hormone use for longer than 1 year. Conclusion: These results are consistent with the findings from the HERS, suggesting a transitory increase in coronary risk after starting hormone therapy in women with established coronary heart disease and a decreased risk thereafter. Heckbert SR, Kaplan RC, Weiss NS, Psaty BM, Lin DY, Starr JR, Furberg CD, Anderson GD, LaCroix AZ. Archives of Internal Medicine 2001;161:1709–1713. Concordance of breast imaging reporting and data system assessments and management recommendations in screening mammography. The purpose of this study was to examine how frequently Breast Imaging Reporting and Data System (BI-RADS) mammographic screening assessments were associated with expected clinical management recommendations. Seven Breast Cancer Surveillance Consortium mammography registries recorded screening assessments and recommendations in 1997 to identify the proportion of women in each BI-RADS category. The first screening assessment for a woman without cancer or a prior mammogram within 9 months was associated with its independently recorded recommendation…. Conclusion: BI-RADS assessments and management recommendations are consistent for negative and benign assessments, but inconsistencies were found in assessments and recommendations for mammographic abnormalities. Taplin S, Ichikawa L, Kerlikowske K, Ernster V, Rosenberg R, Yankaskas B, Carney P, Geller B, Urban N, Dignan M, Barlow WE, Ballard-Barbash R. Radiology 2002; 222:529–35. Rethinking practitioner roles in chronic illness: the specialist, primary care physician, and the practice nurse. In this article, the authors describe an evidence-based stepped care approach to improving the care of chronic illness in organized health care systems. They review the common principles that have been found to improve the management and outcomes of patients with major depression, asthma, diabetes, and congestive heart failure. These population-based methods to improve care of chronic illness require reorganizing the roles of specialists, primary care physicians, and nurses. Katon W, Von Korff M, Lin E, Simon G. General Hospital Psychiatry 2001;23:138–144. |
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