From Colorado:
Treatment
decisions about lumbar herniated disk in a shared decision-making program
Barrett PH, Beck A, Schmid K, Fireman B, Brown JB. Jt
Comm J Qual Improv 2002 May;28(5):211-9
background:
An explicit process of collaborative (shared) decision making involving
the patient and physician has been recommended for discretionary surgical
procedures in which small-area analysis demonstrates high variation
not attributable to differences in the patient population in the area.
One such example is laminectomy for lumbar herniated disk (HD). An observational
study was undertaken to evaluate the impact of an HD videodisk program
on patient satisfaction, decision making, and treatment preferences.
methods: Enrollment occurred in the outpatient offices of surgeons
treating Kaiser Permanente (Colorado Region) patients with HD who had
indications for surgery. Enrollment took place from May 1993 to December
1995, and follow-up surveys of patients were completed by January 1997.
results: A 6.0% decrease in the undecided group and a 1.3% decrease
in the group preferring nonsurgical treatment drove a shift of patients
toward laminectomy, from 26.7% to 35.8% (Wilcoxon signed rank test =
349.5, p = .017). Postviewing preference (74.0%) was a better aggregate
predictor of the ultimate treatment than previewing preference (70.0%)
for laminectomy.
discussion: Viewing the videodisk increased the preference for laminectomy.
However, limitations in the data prevented us from determining whether
this change in preference was actually reflected in patients' ultimate
decisions. The fact that the strongest predictor of choosing surgery
was the patient's valuation of his or her condition supports shared
decision making, with its emphasis on patient's values. Participation
in other videodisk programs has been low; perhaps physicians should
ask patients to view these videodisks before their visits.
Reprinted with permission.
From Northern
California:
Quality assurance
and risk management in online medical discussion groups
Eshleman
AM. Am J Med Qual 2002 May-Jun;17(3):89-93
There
are thousands of sites on the Internet and World Wide Web where health
care professionals and lay people interact to share medical information
and health concerns. The majority of these sites do not have procedures
in place to assess the quality of the information supplied by the providers
or lay people, nor do they have any formal risk management policies
to respond to posted material that may reveal a potential risk situation.
This paper describes the quality assurance and risk management procedures
that have been developed for KP Online--the Web site for members of
the Kaiser Foundation Health Plan, Inc--and shares some preliminary
findings based on these procedures.
| clinical
implication: It's inevitable that, in time, most physicians
will engage in some form of electronic communication with their
patients. This powerful medium presents some unique possibilities
for miscommunication. Fortunately, Frankel and Stein's "Four
Habits" model for in-person clinician-patient communication
maps well to online communication. By following a few simple guidelines,
clinicians can increase the value of online communication, prevent
misunderstandings, and increase their and their patients' satisfaction.
Data in the article was obtained through a three-year experience
moderating members' message boards on the KP Online Web site. --
AE |
From Southern
California:
A preliminary
psychometric analysis of a computer-assisted administration of the Telephone
Interview of Cognitive Status-modified
Buckwalter JG, Crooks VC, Petitti DB. J Clin Exp Neuropsychol 2002 Apr;24(2):168-75
Most screening
tests of cognitive functioning require face-to-face administration by
trained examiners. This limits their utility in epidemiology and in
primary care settings. Further, existing screening tests have not been
developed using established psychometric principles. We adapted the
Telephone Interview of Cognitive Status-modified (TICSm) for administration
as a computer-assisted telephone interview (CATI). We screened 3681
elderly women with the CATI version of the TICSm, using lay staff as
part of a longitudinal study. A preliminary analysis of the psychometric
properties of the TICSm indicated good internal consistency. Test-retest
reliability is needed to confirm reliability. Further work remains to
adequately judge the validity of the TICSm including comparisons with
well-standardized tests and assessment of its predictive properties
in identifying dementia. However, the CATI version of the TICSm appears
to have potential as a cost-effective means of testing cognitive performance.
© Swets Zeitlinger 2002.
| clinical
implications:
The evaluation of cognitive performance is increasingly recognized
as a crucial part of effective diagnosis and treatment planning.
Given the likelihood that cognitive testing will expand in medical
practice, cost effective, yet psychometrically sound, means of assessing
cognitive performance are needed. We suggest computer-assisted telephone
interviews warrant further development for this purpose. -- JB |
From the Northwest:
Group cognitive-behavioral
treatment for depressed
adolescent offspring of depressed parents in a health maintenance organization
Clarke
GN, Hornbrook M, Lynch F, et al. J Am Acad Child Adolesc Psychiatry
2002 Mar;41(3):305-13
objective:
A randomized, controlled effectiveness trial of group cognitive-behavioral
therapy (CBT) for depressed adolescent offspring of depressed parents
in a health maintenance organization (HMO) was conducted.
method:
Potential adult cases were found by reviewing antidepressant medication
prescriptions, mental health appointments, and medical charts. Introductory
study letters signed by each parent's treating physician were mailed
to the appropriate adults. Eligible offspring aged 13 to 18 who met
current DSM-III-R criteria for major depression and/or dysthymia were
randomly assigned to either usual HMO care (n = 47) or usual care plus
a 16-session group CBT program (n = 41). Assessments were conducted
at baseline, after treatment, and at 12- and 24-month follow-up.
results:
Using intent-to-treat analyses, the authors were unable to detect any
significant advantage of the CBT program over usual care, either for
depression diagnoses, continuous depression measures, nonaffective measures,
or functioning outcomes.
conclusions:
Group CBT does not appear to be incrementally beneficial for depressed
offspring of depressed parents who are receiving other mental health
care. However, given that many other studies have found positive effects
of CBT for youth depression, this single study should not be viewed
as evidence that CBT is ineffective overall.
|
clinical
implications:
The similar outcomes observed in the usual care and CBT group
conditions indicate that usual care was as effective as state
of the art, research-tested programs. However, both conditions
resulted in unsatisfactorily low recovery rates. Clearly new and
more intensive approaches are needed for this very at-risk segment
of the depressed adolescent population. Candidates for more intensive
treatment include a greater focus on successful treatment for
the depressed parent(s), more joint parent-child therapy, and
possibly pharmacological treatments for the adolescents. However,
the usefulness of any of these approaches is not yet known. --
GC
|
From Northern
California:
Race, epithelial
ovarian cancer survival, and membership in a large health maintenance
organization
McGuire
V, Herrinton L, Whittemore AS. Epidemiology 2002 Mar;13(2):231-4
background:
African-American ovarian cancer patients present with more advanced
disease and have poorer survival than do white patients.
methods:
To determine whether these differences occur among African-American
and white patients who have equal access to medical care, we analyzed
ovarian cancer patient characteristics separately for 1587 members of
the Kaiser Permanente Medical Plan of Northern California and 5757 non-members.
results:
The distributions of disease stage at diagnosis were similar among African-American
and white patients, both in the Kaiser plan and elsewhere. However,
ovarian cancer death rates, adjusted for disease stage and age at diagnosis
and for histology, were higher for African-American patients compared
with white patients, regardless of Kaiser membership status. The death
rate ratios for African-Americans compared with whites were 1.32 (95%
CI = 1.02-1.70) for Kaiser members and 1.20 (95% CI = 1.04-1.40) for
Kaiser non-members.
conclusion:
Further research within an equal-access care system is needed to evaluate
other important factors such as specialty of surgeon, extent of residual
tumor after surgery, chemotherapy treatment, and postoperative management
to determine whether these factors are contributing to the differences
in survival between African-American and white ovarian cancer patients.
From the
Northwest:
Efficacy
and tolerability of venlafaxine compared with selective serotonin reuptake
inhibitors and other antidepressants: a meta-analysis
Smith D, Dempster C, Glanville J, Freemantle N, Anderson I. Br J Psychiatry
2002 May;180:396-404
background:
In individual studies and limited meta-analyses venlafaxine has been
reported to be more effective than comparator antidepressants, particularly
selective serotonin reuptake inhibitors (SSRIs).
aims: To perform a systematic review of all such studies.
method: We conducted a systematic review of double-blind, randomised
trials comparing venlafaxine with alternative antidepressants in the
treatment of depression. The primary outcome was the difference in final
depression rating scale value, expressed as a standardised effect size.
Secondary outcomes were response rate, remission rate and tolerability.
results: A total of 32 randomised trials were included. Venlafaxine
was more effective than other antidepressants (standardised effect size
was -0.14, 95% Cl -0.07 to -0.22). A similar significant advantage was
found against SSRIs (20 studies) but not tricyclic antidepressants (7
studies).
conclusions: Venlafaxine has greater efficacy than SSRIs although
there is uncertainty in comparison with other antidepressants. Further
studies are required to determine the clinical importance of this finding.
www.rcpsych.ac.uk
| clinical
implications: This research, which combined data on depression
outcomes from 32 randomized trials comparing venlafaxine to other
antidepressants, suggests that venlafaxine offers clinically important
benefit over other antidepressants, particularly SSRIs. Overall,
patients on venlafaxine had a final Hamilton Depression Rating Scale
score 1.2 points lower than patients on other antidepressants. While
further investigation of these findings in diverse populations is
warranted, venlafaxine could be considered in patients failing therapy
with other antidepressants. -- DS |
From the Northwest:
Evaluating
primary care behavioral counseling interventions: an evidence-based
approach
Whitlock
EP, Orleans CT, Pender N, Allan J. Am J Prev Med 2002 May;22(4):267-84
Risky
behaviors are a leading cause of preventable morbidity and mortality,
yet behavioral counseling interventions to address them are underutilized
in health care settings. Research on such interventions has grown steadily,
but the systematic review of this research is complicated by wide variations
in the organization, content, and delivery of behavioral interventions
and the lack of a consistent language and framework to describe these
differences. The Counseling and Behavioral Interventions Work Group
of the United States Preventive Services Task Force (USPSTF) was convened
to address adapting existing USPSTF methods to issues and challenges
raised by behavioral counseling intervention topical reviews.The systematic
review of behavioral counseling interventions seeks to establish whether
such interventions addressing individual behaviors improve health outcomes.
Few studies directly address this question, so evidence addressing whether
changing individual behavior improves health outcomes and whether behavioral
counseling interventions in clinical settings help people change those
behaviors must be linked. To illustrate this process, we present two
separate analytic frameworks derived from screening topic tools that
we developed to guide USPSTF behavioral topic reviews. No simple empirically
validated model captures the broad range of intervention components
across risk behaviors, but the Five As construct--assess, advise, agree,
assist, and arrange--adapted from tobacco cessation interventions in
clinical care provides a workable framework to report behavioral counseling
intervention review findings. We illustrate the use of this framework
with general findings from recent behavioral counseling intervention
studies. Readers are referred to the USPSTF (www.ahrq.gov/clinic/prevenix.htm
or 1-800-358-9295) for systematic evidence reviews and USPSTF recommendations
based on these reviews for specific behaviors.
Reprinted
by permission of Elsevier Science from Evaluating primary care behavioral
counseling interventions: an evidence-based approach. American Journal
of Preventive Medicine, Vol 22 No 4, 267-84. Copyright 2002 by American
Journal of Preventive Medicine.
From Southern
California:
Relationship
of body iron stores to levels of serum ferritin, serum iron, unsaturated
iron binding capacity and transferrin saturation in patients with iron
storage disease
Beutler
E, Felitti V, Ho NJ, Gelbart T. Acta Haematol 2002;107(3):145-9
None of
the methods for assessing total body iron burden in patients with hemochromatosis
is satisfactory. Although it is commonly believed that a relationship
exists between serum ferritin levels and total iron burden, the extent
of this relationship has not previously been documented. In the present
investigation we measured the total body iron burden of 88 patients
with putative hemochromatosis, 54 of whom were homozygotes for the 845G-->A
(C282Y) mutation. The total body iron stores were estimated from the
volume of red cells removed during therapeutic phlebotomy corrected
for an estimated 2 mg/day dietary iron absorbed during the phlebotomy
period; the amount of storage iron was compared to the serum ferritin,
serum iron, unsaturated iron binding capacity, and transferrin saturation
before the beginning of phlebotomy. The serum ferritin proved to be
the best predictor of body iron stores. The correlation between all
of the analytes and the body iron burden was greater in patients homozygous
for the C282Y mutation than in those who were not, including the compound
heterozygotes for C282Y and H63D. The body iron burden tended to be
greater in patients homozygous for the C282Y mutation than the other
patients at any other given ferritin level. We conclude that the serum
ferritin level does provide some information regarding total iron burden
but even in the case of C282Y homozygotes, the correlation is not very
strong.
Copyright 2002 S Karger AG, Basel.
| clinical
implications: Many clinicians believe that there is a close
relationship between serum ferritin levels and body iron stores.
While this relationship exists, and serum ferritin is the best predictor
of total body iron burden, the correlation is weak, especially in
patients with iron overload who have no HFE mutations (the gene
implicated in hereditary hemochromatosis). Other clinical measurements
such as serum iron or transferrin saturation have even less predictive
value. There are no robust measurements that accurately predict
the size of increased body iron stores. Nonetheless, serum ferritin
levels continue to be very useful in the diagnosis of iron deficiency.
-- EB |
From the Southeast
and Southern California:
Exposure
to abuse, neglect, and household dysfunction among adults who witnessed
intimate partner violence as children: implications for health and social
services
Dube
SR, Anda RF, Felitti VJ, Edwards VJ, Williamson DF. Violence Vict 2002
Feb;17(1):3-17
Intimate
partner violence (IPV) damages a woman's physical and mental well-being,
and indicates that her children are likely to experience abuse, neglect
and other traumatic experiences. Adult HMO members completed a questionnaire
about adverse childhood experiences (ACEs) including childhood abuse,
neglect, and household dysfunction. We used their responses to retrospectively
assess the relationship between witnessing intimate partner violence
and experiencing any of the nine ACEs and multiple ACEs (ACE score).
Compared to persons who grew up with no domestic violence, the adjusted
odds ratio for any individual ACE was approximately two to six times
higher if IPV occurred (p < 0.05). There was a powerful graded increase
in the prevalence of every category of ACE as the frequency of witnessing
IPV increased. In addition, the total number of ACEs was increased dramatically
for persons who had witnessed IPV during childhood. There was a positive
graded risk for self-reported alcoholism, illicit drug use, iv drug
use and depressed affect as the frequency of witnessing IPV increased.
Identification of victims of IPV must include screening of their children
for abuse, neglect and other types of adverse exposures, as well as
recognition that substance abuse and depressed affect are likely consequences
of witnessing IPV. Finally, this data strongly suggest that future studies,
which focus on the effect of witnessing IPV on long-term health outcomes,
may need to take into consideration the co-occurrence of multiple ACEs,
which can also affect these outcomes.
From Northern
California:
Severity
of premenstrual symptoms in a health maintenance organization population
Sternfeld
B, Swindle R, Chawla A, Long S, Kennedy S. Obstet Gynecol 2002 Jun;99(6):1014-24
objective:
To describe severity of emotional and physical symptoms in a large diverse
sample; to examine demographic, health status, and behavioral correlates
of symptom severity; and to describe use of medications and alternative
remedies for premenstrual symptoms.
methods:
A total of 1194 women, ages 21-45, selected from members of a large
northern California health maintenance organization, completed daily
ratings of symptom severity for two menstrual cycles. An empirically
derived algorithm defined symptom severity groups as minimal (n = 186),
moderate (n = 801), severe (n = 151), or premenstrual dysphoric disorder
(n = 56). Symptom severity as a continuous variable was defined by the
two-cycle mean symptom ratings in the luteal phase. Demographic, health
status, and behavioral factors and use of treatments for premenstrual
symptoms were assessed by self-report.
results: Luteal phase symptom-specific ratings were generally significantly
greater in the premenstrual dysphoric disorder group than in the other
groups (p < .001). Symptom severity score increased with each comorbidity
and decreased with each year of age. Symptom severity was also inversely
associated with oral contraceptive use (emotional symptoms) and better
perceived health (physical symptoms). Hispanics reported greater severity
of symptoms, and Asians less, relative to whites. Use of herbal and
nutritional supplements for premenstrual symptoms steadily increased
from 10.8% in the minimal group to 30.4% in the premenstrual dysphoric
disorder group (p < .01).
conclusion: The degree of premenstrual symptom severity varies in
the population, is relatively constant within each woman over two consecutive
cycles, particularly for emotional symptoms, and is influenced by age,
race/ethnicity, and health status.
Reprinted with permission from the American College of Obstetricians
and Gynecologists (Obstetrics and Gynecology 2002 Jun;99(6):1014-24).
|
clinical
implications: This study suggests that gynecologists should
assess the degree of premenstrual symptom severity in their patients
since a sizeable proportion of women suffer from moderate to severe
symptoms and are at risk for overall poorer health and more co-morbidity.
Because symptom severity is relatively consistent from one cycle
to the next, providers may not need to use prospective symptom
reporting over two menstrual cycles for accurate diagnosis. --
BS
|
