Volume 17, Issue 2
Spring 2005
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CHS Research News
Vol 17, Issue 2, Spring 2005
Center News
by Joan DeClaire
New Findings
"e-BP" explores Web-based help for
patients with hypertension
Can Web-based information and communication technology enhance care for
people with hypertension? Scientists from Group Health’s Center for
Health Studies (CHS) are exploring this question in a four-year, $2.8
million study called "e-BP." The NIH-funded project is slated to
start enrolling Group Health members with high blood pressure into the
study this summer.
Group Health provides a prime environment for this kind of study, says
Beverly Green, MD, MPH, a CHS affiliate investigator co-leading the study.
"One, Group Health is a leader in improving the care of patients with
chronic health conditions. And two, Group Health has built an electronic
medical record and patient Web portal that is centered on our patients’
needs first." Group Health’s Web portal, MyGroupHealth, is one of
the largest of its kind—with more than 85,000 registered users to date—and
is internationally recognized as a leading-edge example of
patient-centered information technology.
A total of 780 study participants with uncomplicated hypertension will
be randomly assigned to one of three groups. One group will receive usual
care. The second will get home blood-pressure monitors and instructions
for using MyGroupHealth (www.ghc.org). The third will get all of the
above, plus support from a Group Health pharmacist via the secure e-mail
feature on MyGroupHealth. Patients in this third group will e-mail their
blood pressure readings to a study pharmacist, who, if necessary, will
provide support for better medication use and lifestyle goals. The study
team will then compare how the various interventions affect outcomes such
as blood pressure control, change in diastolic and systolic blood
pressure, cost of care, patient satisfaction, and patient health status.
"Early research indicates that electronic communications and
access to online records may be especially valuable in caring for people
who live with ongoing health conditions," explains James Ralston, MD,
MPH, a CHS investigator who is also working on the project. "People
with conditions like high blood pressure make decisions everyday that
affect their health, and our system gives patients and their providers
joint access to medical records and secure e-mail around the clock."
Adds Green, "With this study, we’ll find out what happens when
we leverage that technology in a way that can support the use of
self-monitoring and pharmacist assistance to improve blood pressure
control and decrease the risk of heart disease and strokes."
Group Health Center for Health Studies will send letters to about 4,000 Group
Health patients who potentially qualify for the study. Participants must
be 25 to 75 years old, have high blood pressure, take medication for their
condition, and have regular access to the Internet and an e-mail address.
The e-BP study is funded by the National Heart, Lung, and Blood
Institute, which is part of the National Institutes of Health. Robert S.
"Tom" Thompson, MD, and Beverly Green, MD—two physicians with
Group Health’s Department of Preventive Care who also do research
through CHS—are the co-principal investigators for the research team.
Other team members are Assistant Director of Pharmacy Administration James
Carlson, and Harold Goldberg, MD, from the University of Washington
Department of Medicine, and CHS scientists James Ralston, MD, MPH, Sheryl
Catz, PhD, Paul Fishman, PhD, and Carolyn Rutter, PhD. Lynda Tyll is the
CHS manager coordinating the project.
The Group Health pharmacists who will be working with patients in the
intervention arm of the study are Jilene Winther, Shannon Lavy, and
Danette Feuling. Pharmacists Mary Fors and Lindsay Jahng assisted with the
pilot phase of the study.
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Katherine Newton named associate director-external research
Katherine Newton, PhD, has been appointed to the position of associate
director—external research at Group Health Center for Health Studies. A
nationally respected researcher in the areas of women’s health and
chronic illness, Newton first joined the Center as a postdoctoral fellow
in 1995, and became an investigator in 1997. She held the post of acting
associate director—internal research from 2000 to 2002, and has served
as chair of the Center’s Scientific Policy Committee since 2002.
As associate director, Newton will help develop and guide a variety of
external research projects. She will also be responsible for enhancing the
Center’s alignment with Group Health, increasing integration of
affiliate investigators, strengthening partnerships with other
institutions, and managing clinician involvement in the Center’s
research.
Newton holds a doctorate degree in epidemiology and a master’s degree
in nursing from the University of Washington, and a bachelor’s degree in
nursing from the University of California, San Francisco.
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A common bacterium leads to serious blood infections in many
seniors, new Group Health study finds
A new study finds that E. coli bacteremia—a potentially
life-threatening bloodstream infection caused by a common bacterium also
associated with less dangerous urinary tract infections—poses a
significant public health threat in the United States, especially among
seniors.
The study, published by Group Health researchers in the May 2005 issue
of the Journal of Infectious Diseases, finds that E.coli
bacteremia may affect as many as 53,000 non-institutionalized people, aged
65 and older, each year. It also suggests that a vaccine or other
preventive intervention, targeted at high-risk groups, could have an
important, positive impact on public health.
The bacterium Escherichia coli (E. coli), which grows
naturally in the human digestive tract, is a leading cause of urinary
tract infections. Medical researchers have long known that E. coli
is also a cause of bloodstream infection. But until this study, the number
of non-institutionalized seniors affected by E. coli bacteremia
has not been clear.
"E. coli is a less serious problem in the urinary tract, but
if it spreads to the bloodstream it causes bacteremia, which can lead to a
dangerous drop in blood pressure called septic shock," explained Lisa
Jackson, MD, MPH, a senior investigator at Group Health’s Center for
Health Studies and the lead author of the study. "Bacteremia is
associated with a death rate of about 10 percent," Jackson added.
While there is a vaccine to protect seniors from pneumococcal
bacteremia, which starts in the lungs, there is no similar vaccine to
protect against E. coli bacteremia. "Our study finds E.
coli bacteremia three times more common than the pneumococcal
infection," said Jackson. "That suggests that development of a
vaccine could save many lives."
While studies are underway at other institutions on a vaccine that
would prevent bacteria from taking hold in the urinary tract, Jackson said
she is not aware of any work currently underway to develop a vaccine
specifically to prevent E. coli bacteremia.
Jackson’s study, conducted among 46,000 Group Health members, also
identified risk factors for E. Coli bacteremia. In men, they
include urinary catheterization and incontinence. In women, risk factors
are linked to incontinence, congestive heart failure, and coronary artery
disease.
Certain health behaviors can help prevent urinary tract infections,
and, by association, may also help reduce the risk of bacteremia.
Information on these preventive measures is available online at: http://kidney.niddk.nih.gov/kudiseases/pubs/uti_ez/index.htm#7.
Other study authors include Patti Benson of Group Health’s Center for
Health Studies and Kathleen Neuzil, MD, Marcus Grandjean, and Jennifer L.
Marino of the University of Washington.
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Study shows bone density testing is linked to fewer fractures
Offering bone density testing to women aged 60 and older as part of a
comprehensive fracture prevention program can significantly reduce the
total number of fractures in that population, according to a Group Health
Cooperative study published in the March 2005 issue of the journal Medical
Care.
Led by researchers from Group Health Center for Health Studies
(CHS), the study evaluated the impact of three different fracture
prevention strategies involving various levels of screening and education
among more than 9,000 women, aged 60 to 80. The researchers found that
offering bone density testing to all women in a program, regardless of
their risk, resulted in a fracture rate that was 19 percent lower than
offering testing only to high-risk women. The study also found that bone
density testing was linked to a reduction in some fracture risk factors
and a better understanding of osteoporosis.
"It's not the bone density test itself that makes the
difference," said Andrea Z. LaCroix, PhD, senior investigator at CHS
and the principal investigator on the study. "But the test appears to
heighten women's awareness of bone health." It provides "a
teachable moment for women" to get personalized feedback about their
risk factors, education about osteoporosis, and consultation with their
doctors, she added. "These are all important components of an
effective fracture prevention program."
While past studies have shown a positive link between bone density
testing and higher rates of drug therapy for osteoporosis treatment and
prevention, this is the first large-scale study to show that bone density
testing is linked to a reduction in fractures.
Finding effective strategies for reducing fractures is an important
public health issue, the authors note. They point to an October 2004
report from the U.S. Surgeon General that set specific goals for Americans
to improve bone health, in order to reduce fracture rates in the U.S.
population by 2010. The authors noted that in 1999, nearly 300,000 hip
fractures occurred among Americans aged 65 and older. Hip fractures are a
significant cause of death and disability, and cost an estimated $8.7
million in health care annually in the United States.
"These findings will hopefully promote the implementation of
effective fracture prevention programs in health care organizations that
serve millions of older women in our country who are at risk of
fracture," said LaCroix. The study results also support the recent
U.S. Preventive Services Task Force recommendations that all women aged 65
and older be screened routinely for osteoporosis, the authors note.
To reduce fracture risk, women in the program were encouraged to:
- Exercise regularly
- Eat foods rich in calcium and Vitamin D
- Avoid smoking
- Maintain a healthy body weight
- Consult with a doctor if in a high-risk group
More information about bone health is available at the Surgeon
General's Web site.
The study was funded by a grant from Merck & Co., Inc. Other
investigators on the study were Diana S.M. Buist, PhD, of CHS; and Susan
K. Brenneman, PT, PhD, and Thomas A. Abbott III, PhD, of the Outcomes
Research & Management Division at Merck & Co., Inc.
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JAMA commentary explores physician empathy as part of the
healing process
Business scholars for more than 20 years have explored the concept of
"emotional labor"—i.e., the management of emotions to present
a certain image in service workers. Now, researchers from Group Health
Cooperative and the University of Washington Business School have teamed up
to explore how the concept can be applied to the medical profession.
"We propose that the emotional labor of physicians is characterized
by the display of empathy," said Eric B. Larson, MD, MPH, director of
Group Health Center for Health Studies and co-author of a commentary in
the March 2, 2005 issue of the Journal of the American Medical
Association.
"Empathy is essential to healing relationships, so it's something
all health professionals should be expected to show—even when it's hard
to do so."
Drawing from previous research that equates service workers' labor to the
work of stage actors, Larson and his co-author, Xin Yao, a doctoral student
in the UW Business School, describe a model for applying acting techniques
to the delivery of empathy in doctor-patient interactions. They suggest that
doctors can use two techniques separately or in combination—"deep
acting," which uses imagination and emotional memories to generate
genuine feelings of empathy for the patient, and "surface acting,"
in which the doctor forges emotional expressions inconsistent with internal
feelings. This would allow the doctor to display behaviors the patient can
interpret as empathic.
The authors contend that deep acting is preferred because it makes
doctors more effective as healers. They also believe doctors have greater
professional satisfaction and less professional burnout when they practice
deep acting, but doctors may have to rely on surface acting when genuine
empathy seems impossible. Surface acting may be needed, for example, in
situations in which the doctor's values or beliefs are entirely different
from the patient's.
The authors urge doctors to recognize that their work has an element of
emotional labor and to consciously practice deep and surface acting to
empathize with their patients. They also recommend long-term, regular
training to help doctors develop empathy.
"This will be valuable for both physicians and patients facing the
increasingly fragmented and technological world of modern medicine,"
the authors write.
"For patients, our message is that it's reasonable to expect
physicians to show empathy," said Larson. "It's part of the
physician's job."
Larson also urged health care consumers to seek long-term, continuous
relationships with physicians they like. "The better the physician
knows you, the easier it is to develop an empathic, healing
relationship."
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Research Highlights
Increasing Pap screening adherence and improving the accuracy of Pap
screening could reduce the incidence of invasive cervical cancer among women
with access to screening, according to a new study by researchers from
seven large health plans, including Group Health Cooperative. To reveal
factors associated with screening failure, Wendy A. Leyden, MPH, of Kaiser
Permanente Northern California, and colleagues examined the medical records
of 833 women enrolled in the comprehensive health care plans who were
diagnosed with cervical cancer despite having access to cancer screening and
treatment services. They found that 56 percent of cases were in women who
had not had a Pap test during the period 4–36 months prior to diagnosis,
whereas 32 percent of cases were attributed to Pap test detection failure
and 13 percent of cases to failure to follow up an abnormal test result.
Most (81 percent) of the women with no Pap screening had had at least one
unrelated outpatient visit 4–36 months prior to their cancer diagnosis.
"Despite the many exciting new technologies that may improve our
ability to predict or detect cervical neoplasia, we must not lose sight of
the need to increase screening adherence," the authors wrote in the May
4, 2005 issue of the Journal of the National Cancer Institute.
"Even the most perfect screening method will not detect disease in a
woman who has not participated in the prevention process." Former CHS
investigator Stephen Taplin, MD, MPH, (now with the National Cancer
Institute) was the Group Health investigator on the study.
Breast density is related to tumor size, lymph node status, and lymphatic
or vascular invasion in screen-detected cancers, according to a Group
Health study published in the March 2005 issue of the journal Cancer
Epidemiology Biomarkers & Prevention. CHS Research Associate Erin
Aiello, PhD, is the lead author of the work, which was based on data from
more than 500 Group Health enrollees. "Additional studies are needed to
address whether these associations are due to density masking the detection
of some tumors, a biological relationship, or both," concluded Aiello
and her co-authors—CHS Assistant Investigator Diana Buist, PhD, and CHS
affiliate investigators Emily White, PhD, of the UW Department of
Epidemiology, and Peggy L. Porter, MD, of the Fred Hutchinson Cancer
Research Center.
A one-year course of the antibiotic azithromycin taken weekly did not
alter the risk of cardiac events among patients with stable coronary
artery disease, according to a study in the April 21, 2005 issue of The
New England Journal of Medicine. Co-authored by CHS Associate
Investigator Lisa Jackson, MD, MPH, the study reported the results of a
randomized, double-blind, placebo-controlled trial conducted at 28 centers
in the United States. The lead author of the study was J. Thomas Grayston,
MD, professor of epidemiology at the University of Washington. Many previous
studies have found the bacteria Chlamydia pneumoniae in the arterial plaque
of patients with coronary artery disease. This led to the investigation of
whether antibiotics could be used to treat the bacteria and therefore reduce
the risk of cardiac events.
Urinary incontinence is highly prevalent in women across their adult life
span, and its severity increases linearly with age, according to a Group
Health study published in the March 14, 2005 issue of the Archives of
Internal Medicine. The lead author of the article is Jennifer Melville,
MD, MPH, of the UW Department of Obstetrics and Gynecology and CHS affiliate
investigator. Other authors include UW psychiatry professor Wayne Katon, MD,
CHS Analyst/Programmer Kristin Delaney, MPH, and CHS Associate Investigator
Katherine Newton, PhD. The study of 6,000 women found that older age, higher
body mass index, greater medical co-morbidity, current major depression,
history of hysterectomy, and having given birth increased the odds of
urinary incontinence.
Current market forces discourage the development of a primary care-based
health care system in the United States, according to an editorial by
CHS Director Eric Larson, MD, MPH, in the April 19, 2005 Annals of
Internal Medicine. Along with co-authors Kenneth B. Roberts, MD, of the
University of North Carolina School of Medicine and Kevin Grumbach, MD, of
the University of California, San Francisco, Larson suggests that solutions
might be found by examining how society has tackled other tough public
health problems—issues like reducing smoking rates and increasing
automobile safety. In addition, they call for combining research with
advocacy, public discussion, and policy to create successful campaigns for
change.
Community-based mammography facilities do not have enough radiologists
and certified technologists to adequately deliver screening and diagnostic
services to the public, and the situation may get worse, according to a
study published in the May 2005 issue of the journal Radiology. Led
by Carl D’Orsi, MD, professor of radiology at Emory University, the study
is based on a 2001–2002 survey of 45 mammography facilities (including six
from Group Health) in Washington, New Hampshire, and Colorado. The article
explores the clinical implications of the shortage and suggests ways to
attract radiologists and technologists to the field of mammography.
Co-authors of the study include CHS researchers Linn Abraham, MS, and Bill
Barlow, PhD, Stephen Taplin, MD, MPH (now with the National Cancer
Institute), and CHS Affiliate Investigator Joann G. Elmore, MD, MPH, of
Harborview Medical Center.
Racial inequities exist in breast cancer detection, diagnosis, and
initiation of treatment, according to a study published in the February
2005 issue of the journal Medical Care. Conducted in Connecticut by
researchers from UW, Harvard Medical School, and CHS, the study found racial
disparities "at each step in the evaluation and treatment clinical
pathway, including method of detection, timing from first symptoms of cancer
to pathologic diagnosis, and timing from diagnosis to initiation of
treatment." The study was led by UW’s Joanne Elmore, MD, MPH, of
Harborview Medical Center, who serves as an affiliate investigator at CHS.
CHS Director Eric Larson, MD, MPH, was a co-author. "The findings
highlight the need to provide equal opportunity for timing medical care and
treatment," the authors wrote.
Implementation of the Chronic Care Model (developed by the MacColl
Institute at CHS) has resulted in a 49.6 percent decrease in infant
mortality among the three million people living in the resource-poor
Russian state of Tver Oblast. This is according to a lecture published in
the April 2005 issue of Health Services Research. Author Don Berwick,
MD, MPP, president and CEO of the Institute for Healthcare Improvement,
points to this result as an example of the power of well-conducted health
services research. The Chronic Care Model "offers an evidence-based,
disciplined, practical understanding of what care should look like,"
Berwick writes. "In action, it is brilliantly successful. Dozens of
organizations are now using this model to make profound changes in the
well-being, function, risk level and cost of care for thousands of
patients."
Integrating depression care into primary medicine can improve the mental
health of African American and Latino seniors, according to a study
conducted at 18 sites across the United States, including Group Health. The
study, which appears in the April 2005 issue of Medical Care, is part
of Project IMPACT, a randomized clinical trial that compares usual care to
having a depression-care manager work with primary-care providers to treat
seniors with depression. When barriers to specialized treatment are reduced,
older Latinos and African Americans are more likely to make use of mental
health services—an innovation that addresses an historical disparity in
their care, the researchers concluded. CHS Affiliate Investigator Elizabeth
Lin, MD, MPH, led the Group Health arm of the study.
A three-day regimen of the antibiotic amoxicillin-clavulanate is not as
effective as ciprofloxacin at treating an uncomplicated bladder infection in
women, according to a study conducted at Group Health and the UW.
Published in the February 23, 2005 issue of the Journal of the American
Medical Association, the study is important because management of these
infections has been made more complicated in recent years by increasing
antimicrobial resistances. CHS Associate Investigator Delia Scholes, PhD, is
a co-author of the study, which was led by Thomas M.Hooton, MD, of the UW
Department of Medicine.
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