CHS Research News
Volume 16, Issue 1, Winter 2004

by Joan DeClaire

 

Larson describes CHS' role in health care transformation at Birnbaum Lecture

With Group Health Center for Health Studies' (CHS) 20th Anniversary as a backdrop, members of the local health sciences and health care community gathered November 13 for the Fourth Annual Hilde and Bill Birnbaum Endowed Lecture on Benefiting Patients Through Health Care Research.

CHS Director Eric B. Larson provided the keynote address for an audience of 217 at the Seattle Sheraton luncheon event, which was co-sponsored by the Group Health Community Foundation.

In his lecture, Larson related how the Institute of Medicine's report, Crossing the Quality Chasm: A New Health System for the 21st Century inspired him to accept his job at CHS a year ago. "The report eloquently described a quality chasm—not a gap or a valley, but a real chasm—between what we know to be possible in patient care and the actual care received by patients in the United States," said Larson. "It also stated, ‘the changes needed to realize a substantial improvement in health care involve the health care system as a whole.'…I began to ask myself: Where would such fundamental change occur? …How could I make a difference and help make that change?"

Larson's answers came as he turned his attention to Group Health, with its integration of health coverage and health care delivery. Not only does the structure create incentives to improve health care outcomes, it also provides a favorable environment for research into quality improvement, he discovered. "I decided to come to Group Health because it is well situated to cross the quality chasm," he explained. "In fact, the CHS team has distinguished itself throughout its 20 years by pointing the way."

Larson's lecture included a brief review of 20 years of significant discoveries by CHS researchers over the past two decades. He also provided an overview of new directions in research for the Center, including investigations into genomics, proteomics, medical informatics, prevention and treatment of obesity, and delivery system design.

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Identifying colorectal cancer via screening benefits patients and lowers costs

Colorectal cancer patients whose cancer is caught by routine screening have an earlier stage of the disease and significantly lower health care costs than those who are diagnosed because of symptoms, according to a study by researchers from Fred Hutchison Cancer Research Center (FHCRC) and Group Health Center for Health Studies.

The study, published in the December issue of Gastroenterology, is the first evaluation of cancer-attributable costs of diagnosis and care for screening-detected versus symptom-detected colorectal cancer. Conducted among Group Health patients, the study found that Group Health saved approximately $200,000 per year in diagnosis and treatment costs over what would have been spent in the absence of screening. FHCRC's Scott D. Ramsey, MD, PhD, is the lead author of the study. CHS associate investigator Meg Mandelson, PhD, and CHS analyst/programmer Robert Harrison are co-authors.

"By shifting diagnosis to earlier, asymptomatic stages, screening programs catch cancer at an earlier, more curable stage and significantly reduce the costs of both diagnosis and treatment among people with cancer," says Ramsey. "Besides the obvious benefit to patients, the savings from earlier detection represent a substantial offset to the costs of screening at Group Health Cooperative."

Colorectal cancer is one of the most treatable cancers if it is detected in its early stages. More than 90 percent of patients diagnosed with early-stage colorectal cancer survive beyond five years; only eight percent of patients with late-stage colorectal cancer survive beyond five years.

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National evaluation of Healthy Steps Program shows positive results

The nation's first, large clinical trial designed to improve delivery of developmental and behavioral services to young children—which is the basis of the Healthy Steps study nearing completion at Group Health Cooperative—has shown impressive results, according to a national evaluation of the program in the December 16 issue of the Journal of the American Medical Association.

The evaluation of "Healthy Steps for Young Children" by researchers at the Johns Hopkins Bloomberg School of Public Health showed that the program improved quality of care, enhanced communication between pediatricians and parents, and helped children receive appropriate preventive services.

Primary care practices at Group Health's Northgate Medical Center and Capitol Hill Family Health Center were among the initial 24 sites nationwide that participated in the project, which integrated childhood development specialists (such as a nurse, a nurse practitioner, social worker, or early childhood educator) into pediatric and family medicine health care teams. These specialists monitored children's behavioral development, promoted good health practices, made home visits, and responded to parental concerns about infant and toddler development.

The national evaluation of the program found that practices with childhood developmental specialists on staff showed "significant improvements" in effectiveness, patient-centeredness, timeliness, and efficiency of care. These improvements included marked parental satisfaction with the services they received; timelier preventive care such as immunizations; and receipt of more developmental services.

Following 5,565 children enrolled in Healthy Steps from birth to age 3, the Hopkins evaluators found that families participating in the program were more likely to:

In addition, evaluators found that parents who participated in the intervention were less likely to use severe discipline on their child, such as spanking with an object, yelling, or slapping in the face; and, mothers considered at high-risk for depression who participated in the Healthy Steps program were more likely to discuss their feelings of sadness with someone in the practice.

The national evaluation does not include data from Group Health's experience in the program, because the Group Health study included a prenatal component that other sites in the national program did not have. However, an evaluation that focuses specifically on Group Health Cooperative's experience in the Healthy Steps Program will be published in 2004, according to Dr. Robert S. Thompson, the principal investigator of the study at Group Health.

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Better depression care for older adults also eases arthritis problems

A large randomized trial of an innovative model for depression care in the elderly shows an added benefit: Effective depression treatment can improve problems related to arthritis—a condition that affects about half of people over age 65.

The study, published in the Nov. 12 issue of the Journal of the American Medical Association, focuses on enhancing the primary care team to provide systematic depression care for older adults. Those who had both arthritis and depression not only experienced improved mood; they also had less arthritis pain, enhanced functioning, and better quality of life.

"Older adults with depression commonly cope with several chronic illnesses on a daily basis," says principal investigator Elizabeth H. B. Lin, MD, MPH, a Group Health Cooperative family-medicine physician and affiliate scientific investigator at Group Health's Center for Health Studies. "This research suggests that we can lessen their pain, improve their outcomes, and enhance their quality of life by re-organizing primary care practices to better treat their depression. We did not use any "magic bullet"—no new medication or technology. We simply used existing treatments more effectively."

Lin's research was part of a large, multi-site study of depression care called the IMPACT study, led by Jürgen Unützer, MD, MPH, professor and vice chair of the Department of Psychiatry at the University of Washington. A total of 1,801 patients over age 60 were randomly assigned to two groups. One group received usual depression care—typically treatment with antidepressants and referral to psychiatric care as needed. The other group received care using the IMPACT model, where patients had access to a depression-care manager in their primary care physician's office. This specialized member of the primary-care team worked with each patient's primary-care doctor to provide education and follow-up of depression treatment and possible side-effects. Care managers also offered a brief course of psychotherapy focusing on solving day-to-day problems.

When Lin and her colleagues examined the subset of 1,001 patients who had both depression and arthritis, they found that IMPACT depression care not only improved symptoms of depression, it also lessened the patients' pain and impairment due to arthritis. These improvements continued for an entire year and were seen in a wide range of primary care settings.

"The good news is that more effective treatment for depression not only helped patients with arthritis to feel less depressed, but also to cope better with their arthritis pain, to be more active, and to have a higher quality of life," says Lin.

Lin's research and the IMPACT study are supported by grants from the John A. Hartford Foundation, the California HealthCare Foundation, the Hogg Foundation, and the Robert Wood Johnson Foundation.

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More research highlights:

Although the rates of breast cancer detection are similar in the two countries, U.S. doctors perform two to three times more open surgical biopsies than British doctors, according to a study co-authored by CHS assistant investigator Diana Miglioretti, PhD. In addition, American women are recalled, or referred for further testing, twice as often as British women are, the authors wrote in the October 22 issue of the Journal of the American Medical Association. Led by Rebecca Smith-Bindman, MD, from the University of California–San Francisco, the researchers examined data from 5.5 million mammograms conducted in the U.S. and U.K. over a four-year period. This data includes nearly 1 million mammograms from the Breast Cancer Surveillance Consortium—a group of eight institutions that combine their data for research to improve breast cancer screening. CHS is part of the Consortium and serves as its Statistical Coordinating Center. The authors credited the U.K.'s "centralized program of continuous quality improvement" for the nation's success at reducing recall rates. "Screening women aged 50 to 69 years biennially and reducing recall rates could substantially decrease the cost of mammography, as well as associated anxiety caused by false-positive diagnosis. Efforts to improve U.S. mammographic screening should be targeted to lowering the recall rate without substantially lowering the cancer detection rate," the authors concluded.

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Use of estrogen and progestin postmenopausal hormone therapy for five years or more increases the likelihood of developing breast cancer, including both tumors with favorable and unfavorable characteristics. This is according to a large study co-authored by CHS assistant investigator Diana Miglioretti, PhD, that appeared in the December issue of the Journal of Clinical Oncology. The researchers also found that women who used only estrogen were at slightly increased risk for estrogen receptor-positive tumors, but not other kinds of breast cancer. Karla Kerlikowske, MD, of the University of California–San Francisco, led the study, which included data from nearly 375,000 women aged 50 to 79 who had undergone mammography screening from 1996 to 2000. The researchers calculated the relative risk of breast cancer and type of breast cancer among hormone users and compared those with nonusers. This study's findings regarding estrogen and progestin HRT were in line with those of the Women's Health Initiative (WHI), a randomized controlled trial of HRT published last year. The current study also reported results regarding estrogen-only use and tumor characteristics (breast cancers of certain types) in addition to overall cancer risk—issues not addressed in the 2002 article from the WHI study. The data from this study came from six mammography registries, including Group Health, that participate in the Breast Cancer Surveillance Consortium.

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Researchers found no significant links between the mercury-containing vaccine preservative thimerosal and increased risk for developmental or neurological problems in a study that involved more than 140,000 children from three health plans. The study—part of the Center for Disease Control and Prevention's Vaccine Safety Datalink—appeared in the November 2003 issue of Pediatrics. CHS Senior Investigator Robert L. Davis, MD, MPH, was a co-author.

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Varicella virus (chickenpox) does not appear to be excreted in breast milk, and postpartum vaccination of susceptible women need not be delayed due to breastfeeding, according to a study by CHS Research Associate Kari Bohlke, ScD, in the November issue of Obstetrics & Gynecology. CHS Associate Investigator Lisa A. Jackson, MD, MPH, and research interventionist Pat Starkovich, RN, were among the co-authors of this study.

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The combination of sustained-release bupropion (brand name ZYBAN) and minimal or moderate counseling for smoking cessation was associated with one-year quit rates of 24 to 33 percent in a study conducted by Group Health investigators and colleagues at SRI International, an independent non-profit research organization. The study was published in the October 27 issue of the Archives of Internal Medicine. Tim McAfee, MD, MPH, of the Center for Health Promotion, Inc., which provided the moderate counseling intervention through its Free & Clear Program, was a co-author of the study. Group Health authors included Sarah Dacey, MD, of Group Health Permanente; and Katherine Bergman, RPh, of Pharmacy Administration. Susan Curry, PhD, a former CHS investigator now with the University of Illinois at Chicago, was also a co-author. At one year, the quit rates were highest for those who received proactive phone counseling (e.g., moderate vs. minimal counseling).

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Seven researchers named CHS affiliates

CHS recently added seven new researchers to its roster of affiliate investigators. These are scientists from other organizations who contribute significantly to the CHS mission through their collaborations with Center investigators. They are:

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Group Health's Information Systems Division wins Birnbaum Award

Group Health's Cooperative's Information Systems Division (ISD) was named winner of the Second Annual Birnbaum Award for Supporting Research that Benefits Group Health Members.

CHS Associate Director Dan Cherkin presented the award to Janice Newell, Group Health vice president and chief information officer, and Steve Horsley, director of Planning, Data Resources, and Business Systems for ISD, at the Birnbaum Lecture at the Seattle Sheraton on November 13. CHS gives the award each year to a Group Health work team that has made extraordinary contributions to successful research at the Cooperative.

In presenting this year's award, Cherkin expressed appreciation for the support the Center has received from the Planning, Data Resources, and Business Systems section of ISD in particular, noting that "this group's attention to data quality and data access have made Group Health a national leader in the use of automated health care data for research and quality improvement."

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New Funding:

Group Health Center for Health Studies has received word of several large grants in recent months, including:

Health Communications Research—Previous research has shown that tailoring health information to an individual's circumstances (for example, motivation style, home environment, and gender) is more effective than providing generic health information at modifying risky behaviors. Yet why tailoring works is not fully understood. Group Health will receive $2.6 million over five years from the National Cancer Institute for its participation in a study of tailored health information. The study is designed to determine which components of tailoring most influence health behavior change and cancer prevention. The study includes three research projects, each addressing a different aspect of cancer prevention: quitting smoking, eating fruits and vegetables, and deciding whether to use tamoxifen to try to prevent breast cancer. The principal investigator of the study is Victor J. Strecher, PhD, of the University of Michigan Department of Health Behavior and Health Education. The Group Health site principal investigator is CHS' Jennifer B. McClure, PhD.

Pathogenic Mechanisms in UTI—This is a five-year, $889,000 grant from the National Institute of Diabetes & Digestive & Kidney Diseases to determine the prevalence of selected genetic variations (certain single nucleotide polymorphisms and haplotypes) among women with varying histories of urinary tract infection and their potential role in increased susceptibility to recurrent UTI and kidney infections. The principal investigator on this study is Walter E. Stamm, MD, head of the Department of Allergy and Infectious Diseases at the University of Washington. CHS' Delia Scholes, PhD, is the lead Group Health investigator.

Evaluating Therapeutic Massage for Chronic Neck Pain—This two year, $395,000 grant from the National Center for Complementary and Alternative Medicine will be used to develop key components for a study of massage for chronic neck pain and to conduct a small pilot study. The principal investigator is CHS' Karen Sherman, PhD.

Breast and Bone Density: Impact of Colonic Environment—This project, funded by a four-year grant from the National Cancer Institute to CHS of about $800,000, is designed to test the hypothesis that differences between individual women's intestinal bacteria may change the amounts and/or forms of circulating estrogens, thus influencing the risk of breast cancer. The principal investigator is Johanna W. Lampe of the Fred Hutchison Cancer Research Center. The lead Group Health investigator is CHS' Katherine M. Newton.

Organized Self-Management Support for Chronic Depression—This three-year, $472,000 grant from the National Institute of Mental Health will be used to test two core elements of an organized care program for patients with chronic or recurrent depression. These elements are systematic telephone outreach and monitoring to improve drug therapy; and structured psycho-educational group programs focused on patient activation and self-management. The principal investigator is CHS' Evette Ludman, PhD.

The Effects of Hormone Replacement Therapy (HRT) Cessation on the Recall Rates for Screening Mammography—Previous studies have shown that HRT tends to make women's breasts more dense, which may decrease the accuracy of their mammograms. This $900,000 grant from the U.S. Department of Defense will fund a randomized controlled trial to test how cessation of HRT for one or two months prior to screening mammography affects the mammogram's accuracy. The principal investigator is CHS' Diana Buist, PhD.

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