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Center Newsby Joan DeClaire
People and ProgramsDavid Grossman, MD, MPH, named director of preventive care David Grossman, MD, MPH, has been named director of preventive care for Group Health and a senior investigator at Group Health Center for Health Studies. Recognized for his work in injury prevention, gun safety, and research regarding health services for Native Americans, Grossman has served as director of the Harborview Injury Prevention and Research Center (HIPRC) in Seattle since 2000 and its co-director since 1994. Grossman is a professor of pediatrics at the University of Washington (UW) Medical School and co-director of UW’s Robert Wood Johnson Clinical Scholars Program, which trains physicians for leadership in health care. Grossman’s job at Group Health will be to develop and ensure the continued delivery of preventive care services to Group Health members. As a CHS senior investigator he will also lead a group of physician/scientists conducting research into the design, promotion, delivery, and evaluation of preventive care services. Grossman will fill a position vacated by the retirement of Robert S. "Tom" Thompson, MD, who founded the Department of Preventive Care at Group Health in 1975. Grossman, arriving August 1, will also have a clinical practice within Group Health. "We’re delighted that David has decided to join us," said Stephen Tarnoff, MD, director of the integrated group practice at Group Health. "His experience developing and implementing solid, population-based prevention programs makes him a perfect fit." Eric B. Larson, MD, MPH, director of CHS, added, "David’s track record at research and research leadership will be put to good use as we develop innovations that benefit not only Group Health members, but the larger community as well." Grossman said he’s looking forward to broadening the scope of his work in his new position at Group Health, while applying his ideas within an integrated, group practice model. "As I’ve become convinced that the nation’s health care system is broken, I can see that solutions lay in the hands of large, not-for-profit health plans like Group Health," said Grossman. "Also, I’m intensely interested in finding the best ways to prioritize preventive services for a population. With Group Health’s long-standing commitment to prevention, I feel it’s an ideal setting to examine such questions." Grossman is known for his creative and practical approaches to prevention programs and research. For example, his evaluation of a program used in the Seattle Public Schools in the early 1990s was the first of its kind to show that social skills training can be highly effective in reducing physical and verbal aggression among children. A current study, funded by the Centers for Disease Control and Prevention, is testing the effectiveness of locking and unloading guns as a way to reduce suicide and unintentional gun injuries among youth. Grossman’s other research interests have included studies of motor vehicle safety, prevention of dental problems, and improving preventive care services for rural populations. A 1982 graduate of the UCLA School of Medicine, Grossman completed his internship and residency in pediatrics at the University of North Carolina at Chapel Hill. He spent three years as a pediatrician for the U.S. Public Health Service’s Indian Hospital in Fort Defiance, Arizona. He then accepted a fellowship at the University of Washington’s Robert Wood Johnson Clinical Scholars Program, where he earned a master’s degree in public health and community medicine in 1990. A member of the UW pediatrics faculty since 1990, he has been a mentor to dozens of new physicians training for careers as clinicians and researchers. He currently serves as chairman of the American Academy of Pediatrics’ Committee on Native American Child Health. Grants to HIPRC grew from about $3 million to more than $5 million annually during Grossman’s tenure as director. He also oversaw many successful collaborations between CHS and Harborview—a relationship he envisions will grow even stronger. He also hopes to foster the continued success of such collaborations between CHS and the UW Schools of Medicine and Public Health. A native of San Francisco, Grossman describes himself as an avid reader of political science and history. He enjoys kayaking, hiking, and traveling with two teen daughters and wife, Cezanne Garcia, manager of patient and family education services at UW Medical Center. His community service activities have included teaching an injury prevention class for a public health network in Vietnam. Larson leads internal medicine task force calling for health system change A task force of leading internal medicine doctors led by Center for Health Studies Director Eric B. Larson, MD, MPH, is recommending significant changes to their profession and the health care industry. Calling for innovations to quell the "chaos" and "dysfunction" in the current health care system, a summary of the group’s report appears in the April 20 issue of the Annals of Internal Medicine. The task force was charged by the Society of General Internal Medicine—a group of physician researchers in the field—to redefine their profession in light of its "uncertain future." The report points to serious problems in the American health care system—including declining access to primary care, high levels of uninsurance, inefficiency, medical errors, and inconsistent quality control. The group’s recommendations include changes in the ways doctors are paid, general internists are trained, and many internal medicine practices are organized. "Examining the crisis in our nation’s current non-system, we became convinced that the time is ripe for innovation," said Larson. "As general internists, we are guided by what’s best for patients and the public at large, and we’re making these recommendations based on those interests." The recommendations include steps to:
The report has been presented at national meetings of the major internal medicine organizations and other professional groups, including the American Academy of Family Practice. The summary of the report is available on the Annals of Internal Medicine Web site. The full report is available on the Web site for the Society of General Internal Medicine. CHS and UW School of Public Health and Community Medicine sign affiliation agreement A long-standing bond between Group Health Center for Health Studies and the University of Washington (UW) School of Public Health and Community Medicine recently became official with the signing of an affiliation agreement. The two organizations have been working together for many years to conduct research and provide graduate-student training. "This agreement formalizes the arrangements for this long-term, successful relationship and provides a context for strengthening our shared efforts," says CHS Associate Director Michael Von Korff, ScD. "For example, CHS is a performance site for a new pre- and post-doctoral training grant in the school’s Department of Health Services. There are also important opportunities to evaluate innovations in care in the Group Health system that are of interest to both UW and CHS faculty. This agreement will help both sides to develop these kinds of opportunities in the future." CHS Director Eric B. Larson, MD, MPH, joined Patricia Wahl, PhD, dean of the UW School of Public Health and Community Medicine, in a special signing ceremony at UW on January 15. Larson becomes chair of nation’s second largest physician group On April 22, Group Health Center for Health Studies Director Eric B. Larson, MD, MPH, will become chair of the Board of Regents of the American College of Physicians, the national organization of doctors of internal medicine. With 115,000 members, ACP is the second largest physician group in the U.S. Larson also will be honored on May 15 by the Society of General Internal Medicine (SGIM), an international organization of physicians and others who combine caring for patients with educating and doing research. SGIM will present Larson with its highest honor, the Robert J. Glaser Award, which recognizes outstanding contributions to research and education in generalism in medicine. Research HighlightsCommon cholesterol drugs may decrease breast cancer risk Use of a popular class of cholesterol-lowering drugs called "statins" does not increase the risk of breast cancer in women between ages 65 and 79, according to a study led by Denise M. Boudreau, PhD, research associate at Group Health Center for Health Studies. The study, which was conducted at Fred Hutchinson Cancer Research Center, also found that long-term use of statins may actually reduce breast cancer risk in older women by as much as 30 percent. The findings appear in the April 26, 2004 online edition of Cancer, a peer-reviewed journal of the American Cancer Society. This study is the first large, population-based, case-control study to find this reduced risk. It was funded by the National Cancer Institute. The study team analyzed health information from 975 women between the ages of 65 and 79 with breast cancer and 1,007 women the same age without breast cancer. The researchers then compared statin use in the two groups to see if there was an association between the drug and breast cancer. Cases were identified through the Cancer Surveillance System, a population-based tumor registry that serves 13 western Washington counties and participates in the Surveillance, Epidemiology, and End Results (SEER) program of the National Cancer Institute (NCI). First approved by the FDA in 1987, statin use has increased dramatically because of its effectiveness in lowering cholesterol and reducing heart disease. Concerns about a possible link between cancer and statins were raised following two early studies. One of these papers was a review of statin studies in mice and the other was a clinical trial with a limited number of women. However, more recent studies showed that statins may actually reduce the risk of breast cancer. Also, laboratory studies and a population-based study suggest that statins may have protective effects. Still, these study populations were not large enough to provide a definitive answer. So Boudreau and her colleagues analyzed data from a population that included far more women with breast cancer, providing a more accurate picture. "Older women who take statins can be reassured that the drugs do not appear to increase their risk of breast cancer," said Boudreau. "Statins may even protect against breast cancer, but more research needs to be done before we can know for sure." She further explained that there are several theories that might explain how statins could have a protective effect. One important theory points to a process called apoptosis, where certain cells are activated to remove potentially cancerous cells from their midst. Laboratory scientists have shown that statins may encourage this process. But more experiments need to be done to find out. Boudreau recently received funding from NCI to continue population-based research into the association between statins and cancer. This work will include a larger, more detailed study of statins and their link to breast cancer, and studies of the association between these drugs and the risk of other forms of cancer—specifically, cancer of the prostate and cancer of women’s reproductive organs. In addition to Boudreau, researchers on the study published in Cancer are: Jacqueline S. Gardner, PhD, University of Washington School of Pharmacy; Kathleen E. Malone, PhD, Fred Hutchinson Cancer Research Center; Susan R. Heckbert, MD, PhD, University of Washington Department of Epidemiology; David K. Blough, PhD, University of Washington School of Pharmacy; and Janet R. Daling, PhD, Fred Hutchinson Cancer Research Center. Study identifies predictors of longevity in Alzheimer’s disease How long can a patient newly diagnosed with Alzheimer’s disease (AD) expect to live? This important question has been difficult to answer for patients, families, and health professionals planning care of this irreversible brain disorder. But a new study from Group Health Center for Health Studies and the University of Washington suggests that assessing several key clinical aspects of the disease soon after diagnosis can help. The study, published in the April 6 issue of the journal Annals of Internal Medicine, included these key findings:
"We’ve always known that Alzheimer’s disease shortens patients’ lives, but there have been few long-term studies that relate patient age and symptoms to length of survival," said Eric B. Larson, MD, MPH, director of CHS and principal investigator of the study, which was supported by National Institute on Aging (NIA). To conduct the study, Larson’s team recruited 521 study participants from a population base of 23,000 people living in the Seattle area, who were then added to an Alzheimer’s disease patient registry. All 521 were Group Health members aged 60 and older who had been recently diagnosed with Alzheimer’s disease. "One strength of the study is that it examined the experience of newly diagnosed patients just as they are typically found in everyday outpatient settings," said Larson. "Previous studies have relied on populations of more severe cases, such as those in nursing homes." As patients entered the study, each person was evaluated for cognitive and memory problems and examined for other conditions including heart disease, heart failure, diabetes, stroke, depression, and urinary incontinence. They were also assessed for a history of agitation, wandering, paranoia, falls, and walking difficulties. Survival was measured from the time of initial diagnosis until death or when the study ended in 2001. The average follow-up period was about five years, with an approximate range from two-and-a-half months to 14 years. The researchers found that:
The findings may help public health officials refine cost projections and plan services for the growing number of older Americans at risk for AD, Larson said. Other researchers who contributed to the study were the University of Washington’s Marie-Florence Shadlen, MD; Li Wang, MS; Wayne C. McCormick, MD, MPH; James D. Bowen, MD; Linda Teri, PhD; and Walter A. Kukull, PhD. Antibiotics linked to increased risk of breast cancer Antibiotic use is associated with an increased risk of breast cancer, according to a new study conducted by researchers from Group Health Center for Health Studies, the University of Washington, Fred Hutchinson Cancer Research Center, and the National Cancer Institute. The study appears in the February 18 issue of the Journal of the American Medical Association (JAMA). "In our study of more than 10,000 women enrolled in Group Health Cooperative over an average of 17 years, we found that the more antibiotics the women took, the more likely they were to develop breast cancer," said Christine Velicer, PhD, a CHS research associate and the lead author of the study. The researchers discovered that women who took antibiotics for more than 500 days (or more than 25 individual prescriptions) during their enrollment at Group Health had twice the risk of breast cancer as those who had taken no antibiotics. Women who had between one and 25 prescriptions were about one and a half times more likely to get breast cancer than those who took no antibiotics. Velicer emphasized that this is the first study of this association in the United States, and more research is needed to evaluate whether it’s actually the antibiotics that lead to an increased risk of breast cancer. "It may be that women who take a lot of antibiotics have some other processes happening in their bodies—such as a weak immune response or a hormonal imbalance—which may be an underlying cause of breast cancer," said Velicer. She reiterated that the comparison group consisted of women who had never taken antibiotics during their enrollment at Group Health. "Women who have had no antibiotic use may be a uniquely healthy group in terms of general well-being or lifestyle characteristics, and this possibly could account for some—but probably not all—of the increased breast cancer risk we saw among antibiotic users," Velicer said. The researchers also said it’s too early to draw conclusions about the medical and public health implications of the study. "This is not the time to say all antibiotics are bad," said John D. Potter, MD, PhD, director of the Public Health Sciences Division at Fred Hutchinson Cancer Research Center and co-author of the study. "Antibiotics are an extremely useful tool for the treatment of infection, but they must be used appropriately." At the same time, the study’s findings are remarkable in their strength and consistency, said Potter. "We found that the association between breast cancer risk and antibiotic use is similar over the broad range of antibiotics studied," he said. "Also, there’s a clear dose response; the women who consumed the greatest amount of antibiotics had the highest risk." The researchers point to various theories that suggest antibiotics could indeed lead to breast cancer. One theory is that antibiotics affect the bacteria in the intestine, interfering with the metabolism of certain foods that are known to protect the body against cancer. Other theories involve antibiotics’ impact on the body’s immune and inflammatory responses, both of which could be related to the development of cancer. "Much more research is needed in these areas," said Velicer. The study was conducted using Group Health’s computerized pharmacy and breast cancer screening databases. The researchers compared differences in antibiotic use among 2,266 women prior to their diagnosis of primary, invasive breast cancer and 7,953 similar women who did not get breast cancer. The study included a wide variety of the most frequently prescribed antibiotic medications. Topical medications and mouth rinses were not included in the study. All the women in the study were age 20 or older. Until additional research clarifies the association between antibiotic use and breast cancer risk, the researchers offer the following recommendations for women who take antibiotics or who may need them in the future:
The study was funded by grants from the National Cancer Institute and the Gustavus and Louise Pfeiffer Research Foundation. In addition to Velicer and Potter, the study’s authors are Susan R. Heckbert, MD, PhD, of the University of Washington Department of Epidemiology; Johanna W. Lampe, PhD, RD, of Fred Hutchinson Cancer Research Center’s Public Health Sciences Division; Carol A. Robertson, RPh, of Group Health Cooperative’s Northgate Medical Center; and Stephen H. Taplin, MD, MPH, of the National Cancer Institute and formerly a senior investigator at Group Health Center for Health Studies. Breast implants interfere with mammograms Breast implants decrease the ability of mammography to detect breast cancer, according to a large national study led by researchers at Group Health Center for Health Studies (CHS) and six other institutions that participate in the NIH-funded Breast Cancer Surveillance Consortium. This study is published in the January 28 issue of the Journal of the American Medical Association. The study found that screening mammography missed 55 percent of breast cancers in women with implants, compared to only 33 percent among women without implants. "With breast implants on the rise, it’s important to know whether implants interfere with the detection of breast cancer," said Diana L. Miglioretti, PhD, an investigator at CHS and the lead author of the article. More than 260,000 women in the United States received breast implants for cosmetic reasons in 2002, an increase of 11 percent since 2000. Breast implants make mammograms more difficult to read because the implants show up as a solid white mass on the mammography film, blocking the view of breast tissue, Miglioretti explained. The researchers also found that although mammography does not find cancer as well in women with implants, this problem does not result in more advanced cancers at diagnosis. Women with implants were diagnosed with cancers of similar stage and size as women without implants. Even among women with implants who had breast symptoms such as a breast lump, the tumors were not more advanced. In fact, among the subset of women with symptoms, women with implants had smaller tumors than women without implants. In addition, the study showed that breast implants do not cause more false-positive mammography results compared to women without implants. The researchers suggested several possible reasons for finding little difference in tumor characteristics among women with implants and women without implants, despite the way implants interfere with mammography. It may be that women with implants detect cancer more easily than other women because they have less of their own breast tissue or because the implant provides a firm platform to press against, which may make the tumors more noticeable. Also, women with breast implants are told to check their breasts often for any problems, so they may be more likely to find lumps on their own. In addition, women with implants may be more body conscious and seek medical advice more quickly if they have a symptom. "We really don’t know for certain," said Miglioretti. The researchers advise women with breast implants, as well as all women, to continue getting their mammograms at recommended intervals. "While mammography is less sensitive for women with implants, it did catch 45 percent of their cancers and it’s still the best method for early detection of breast cancer," Miglioretti said. The researchers further advise women with implants to:
How the study was conducted Data on more than 1.7 million women who had mammograms was collected from seven mammography registries in Colorado, New Hampshire, New Mexico, North Carolina, San Francisco, Seattle, and Vermont. From these, they found 137 women with implants who had breast cancer, and they matched them with 685 women without implants who had breast cancer. After determining which women had had a screening mammogram within a year of breast cancer diagnosis, they calculated the proportion of these women whose breast cancer was detected by mammography. This allowed the researchers to determine that mammography was more likely to miss cancers in women with implants. When they looked at cancer characteristics, such as tumor stage and size, they found no difference between the cancers in women with implants and women without implants. Funded by the National Cancer Institute, the study was conducted by the Breast Cancer Surveillance Consortium, a group of seven mammography registries nationwide that combines their data and links mammogram interpretations with cancer outcomes. Group Health’s Center for Health Studies serves as the Statistical Coordinating Center for the Consortium. In addition to Miglioretti, the study’s authors include Carolyn M. Rutter, PhD, and William E. Barlow, PhD, of Group Health’s Center for Health Studies; Berta M. Geller, EdD, and Donald L. Weaver, MD, of the University of Vermont; Gary Cutter, PhD, of the University of Nevada; Robert Rosenberg, MD, of the University of New Mexico; Stephen H. Taplin, MD, and Rachel Ballard-Barbash, MD, MPH, of the National Cancer Institute; Patricia A. Carney, PhD, of Dartmouth Medical School; Bonnie C. Yankaskas, PhD, of the University of North Carolina; and Karla Kerlikowske, MD, of University of California, San Franscisco. More research highlights:The frequency of anaphylaxis did not increase among children and teens enrolled at Group Health between 1991 and 1997, according to a study by CHS Research Associate Kari Bohlke, ScD. Published in the March issue of the Journal of Allergy and Clinical Immunology, the study is one of the first to provide a population-based estimate of the frequency of this severe allergic reaction. Bohlke’s team identified 85 episodes of anaphylaxis during the study period, describing symptoms, causes, and treatment. The most common causes were food, bee stings, and medications. Peanuts and tree nuts were the most common food-related causes. A home-based program of detecting and managing minor depression in older adults was shown to be effective in a University of Washington/Group Health study published in the April 6 issue of the Journal of the American Medical Association. The researchers, led by UW Assistant Professor of Psychiatry Paul Ciechanowski, MD, MPH, conducted the randomized controlled trial, among 138 people age 60 and older who were clients of senior service agencies or living in senior public housing. The study intervention consisted of problem-solving therapy, social and physical activation, and potential recommendations to patients’ providers regarding antidepressant medications. CHS Senior Investigator Ed Wagner, MD, MPH, is a co-author of the study Teen use of the injectable contraceptive Depo-Provera did not result in statistically significant bone loss, according to a CHS study published in the February issue of the journal Contraception. The study, which involved 174 women ages 14–17, was led by CHS Associate Investigator Delia Scholes, PhD. In a previous study led by Scholes, women ages 18–39 did show significant loss of bone density with use of Depo-Provera. However, results also suggested that the effects were largely reversed when women stopped using the drug. Older adults’ views of "successful aging" is the subject of a study by researchers from CHS and UW that appears in the February issue of the Journal of the American Geriatrics Society. The investigators found that older adults’ definition of successful aging is multidimensional, encompassing physical, functional, psychological, and social well being. Most previous research in this area has focused only on psychological or mental health. The study of more than 4,500 people over age 65 was led by Elizabeth Phelan, MD, MS, of UW’s Division of Gerontology and Geriatric Medicine. CHS authors on the study were Eric B. Larson, MD, MPH, and Andrea LaCroix, PhD. Enrollment in an organized breast-cancer screening program is associated with increased likelihood of mammography and reduced odds of late-stage breast cancer, according to a new study conducted among Group Health women and published in the February issue of Cancer Epidemiology, Biomarkers & Prevention. The study was led by former CHS Senior Investigator Stephen Taplin, MD, MPH, who is now at the National Cancer Institute. Other CHS staff on the study were Biostatistician Laura Ichikawa, MS, Assistant Investigator Diana Buist, PhD, and Analyst/Programmer Deborah Seger. COMVAX—a combination Hepatitis B-Haemophilus b vaccine for children—appears to be safe according to a study led by CHS Senior Investigator Robert L. Davis, MD, MPH, and published in the January 2004 issue of the journal Vaccine. The study examined the outcome of more than 27,000 doses of the vaccine via computerized clinical databases. Looking for adverse events such as deaths, hospitalizations, emergency room visits, and certain diagnoses in outpatient visits, researchers found that seven children who had recently received the vaccine were hospitalized for fever. All recovered fully. New Funding: Group Health Center for Health Studies has received word of several large grants in recent months, including awards to study: Alzheimer’s disease—A five-year, $5.7 million grant from the National Institute on Aging to continue a broad-range research project on Alzheimer’s disease (AD) and cognitive changes that occur with aging. Major goals of the project include analysis of the link between many common drugs and dementia and AD; the evaluation of other potential risk factors for AD, such as blood pressure, high cholesterol, exercise history, obesity, diabetes, and tobacco use; and to continue to maintain the Group Health/UW AD Patient Registry, which serves as a source of long-term, comprehensive data and research subjects for other investigators. The principal investigator is CHS’ Eric B. Larson, MD, MPH. Oral contraceptive use and bone mineral density in young women—A five-year, $3.1 million grant from the National Institute for Child Health and Human Development to continue research into the impact of oral contraceptive use and discontinuation on bone density and bone biomarkers in young women. The study is following a group of adolescent and young-adult women for up to three years, using periodic laboratory tests and bone-mineral density scans. The principal investigator is CHS’ Delia Scholes, PhD. Social role disability and mental physical co-morbidity—A four-year, $2.2 million grant from the National Institute of Mental Health to determine the extent and nature of disability among people with mental disorders who also have major chronic physical conditions. The study will use data from 28 coordinated national population survey projects participating in the World Health Organization’s World Mental Health initiative. The principal investigator is CHS’ Michael Von Korff, ScD. Endometrial hyperplasia—A four-year, $1.8 million grant from the National Institute of Child Health and Human Development to establish the rates and progression or persistence of the most severe forms of endometrial hyperplasia in response to progestin therapy or expectant management. The principal investigator is Susan Reed, MD, MPH, of the University of Washington’s Department of Obstetrics and Gynecology. The lead CHS investigator is Katherine Newton, PhD. Long-term cost and outcomes of breast cancer screening—A three-year, $787,000 grant from the National Cancer Institute to evaluate the long-term costs and effectiveness of various efforts to promote participation in breast cancer screening programs. The principal investigator is CHS’ Paul Fishman, PhD. Integrated care for depression and back pain—A three-year, $711,000 grant from the National Institute of Mental Health to improve functional, symptom, and cost-of-care outcomes for chronic back pain patients who also have major depression. The project will include developing and disseminating an intervention suitable for implementation by health professionals in general health care settings. The principal investigator is CHS’ Michael Von Korff, ScD. |
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