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Letters
to the Editor
From
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The Permanente
Journal,
I'm disappointed
that an officially sponsored case vignette is so at odds with the values
of Permanente medicine (Blue Sky Care Delivery 2015, Part 1. The Permanente
Journal 2003 Fall; 7(4):47-50). First of all, the medical care is
questionable. The computer recommends a home strep test and, when it's
positive, offers antibiotics vs a watch-and-wait option. The most important
consequence of strep throat, rheumatic fever, isn't mentioned. Second,
the care isn't cost-effective. Why do a test, unless the result will influence
treatment? Incidentally, I hope having to buy a computer doesn't become
a financial barrier to care.
Finally,
Dad is presented as a whining oaf. If Mom were presented as a "typical
woman driver," you'd get letters about sexism. Well, this is sexist
too, and cultural sensitivity shouldn't exclude men. I know this wasn't
meant to be taken too seriously, and I'll try to keep an open mind about
the Blue Sky--but not so open my brain falls out!
Scott McKenzie,
MD
Internal Medicine
Panorama
City
--Reply
The
focus for our clinicians and other visionaries at the Phase 1 meeting
was the manner and the modality of the care provided to Tommy and his
parents and not the actual "clinical guideline" per se. That
being said, if you read on to the second bullet on the same page, you
will see that Tommy's "pediatrician's 'Web site' and the Pediatric
Department's protocols guided the care provided to Tommy." We would
all assume that KP protocols in 2015 will be guided by the same care,
cost-effectiveness principles and attention that our KP clinicians provide
today with the added dimension of providing as much information to patients
to assure their engagement in the decision-making process. In the interest
of time and message brevity, our visionaries only included elements
relevant to the broader Care Delivery Vision, with the assumption that
the reader/audience would understand its illustrative nature. Thanks
for your interest in the Blue Sky Vision.
Terhilda
Garrido, Senior Director
Clinical Systems Planning and Consulting
terhilda.garrido@kp.org
The Permanente
Journal,
I recently
came across an article by Eric Blau, MD (In
the Shadow of Obesity. The Permanente Journal 2000 Summer;
4(3):47-55) while doing a Google search on Pararescue. The note by JP
(400 lbs) broke my heart, especially as I am completing training in the
VA as a psychiatrist and understand the heart and soul of JPs, having
been blessed with their friendship. Please express to him that his brothers
are available to support him through www.pjassn.org. Also, I understand
that there might be some consideration of divided loyalties, but many
VAs have a particular interest in traumatized soldiers--I know my VA would
take him in with open arms. If you can find JP, you can give him my e-mail
if it would be any help. He's already earned any services we can provide
for him.
Regina Bahten,
DO
University of Nevada, Reno
VA Sierra Nevada Health Care System
--Reply
We
are pleased that you enjoyed reading this article and appreciate the
correction.
Greetings,
I enjoyed
reading about the National Weight Control
Registry, (The Permanente Journal 2003 Summer; 7(3):34-7) but
I noticed an error. When you spoke of keeping off 30 pounds for one year,
it was referred to as 6.6 kg. Thirty pounds equates to 13.6 kg, not 6.6
kg.
Regards,
Gale Carey, PhD
University of New Hampshire, Durham, NH
Dr Jacobson,
I appreciated
your attempt to interpret the Women's Helath Initiative (WHI) for some
of the non-gynecologists who don't have time to keep up on all the current
bantering about the WHI results (A Perspective
on the Women's Health Initiative Findings. The Permanente Journal
2003 Fall;7(4):62-4). However, unfortunately, I think you fell into the
trap that so many have--including the WHI investigators. And that is extrapolation.
Your comment of "Asymptomatic perimenopausal women balancing the
potential benefit and risk of hormone therapy (HT) might weigh "a
41% increased risk of stroke after one year of using E+P" or "1.29
times more likely to have a stroke" differently than "a 97.1%
chance (risk) of not having a stroke after ten years of using E+P,"
etc. Please be reminded that the WHI specifically excluded peri- and symptomatic
menopausal women from their study. I'm not sure you can confidently extrapolate
the data from elderly 60+-year-old women on a 0.625 mg dose of CEE to
a 50-year-old woman. The Nurses' Study1 showed that
stroke risk is dose-dependent: 1.3 RR with the 0.625 mg dose and 0.7 RR
with the 0.3 mg dose. So for the WHI to only give the 0.625 mg dose and
to get the same RR as the Nurses' Study RR confirms at least that part
of the study in older women. But most of my patients who wish to stay
on HT have decreased their dose by the time they're 55, specifically to
decrease the risk of stroke.
I think
we have to be very careful how much we extrapolate from the WHI. As Marcia
Stephanic said at our regional teleconference: "This was not a menopause
study, but a study of prevention in the elderly." So let's not apply
it to the example you gave.
Katherine
Brubaker, MD, Gynecolody
Milpitas Medical Offices, TPMG
Reference
- Lokkegaard
E, Jovanovic Z, Heitmann Bl, et al. Increased risk of stroke in hypertensive
women using hormone therapy: analysis based on the Danish Nurse Study.
Arch Neurol 2003 Oct;60(10):1379-84.
--Reply
Dr
Brubaker,
The
trap of extrapolation is what prompted the commentary, and the tools
provided are intended as a springboard to facilitate careful discussion
of the WHI findings with our patients in order to individualize their
care.
The
WHI, as I noted, was "designed to study major causes of death,
disability, and frailty in postmenopausal women." Its goal was
to use "prevention and intervention strategies and risk factor
identification to reduce incidence of CHD, breast and colorectal cancer,
and osteoporotic fracture in women." It is not a study of menopause
or the elderly. I did not suggest that its design or intention was to
study symptomatic perimenopausal women. Most practitioners are quite
comfortable counseling their asymptomatic 63-year-old postmenopausal
patients about WHI and HT. However, the reality is that it is the symptomatic
perimenopausal woman that practitioners will have the most difficult
discussions with regarding HT and WHI--and the situation described perfectly
exemplifies the dilemma posed by the typical patient encounter that
health care practitioners are facing on a daily basis.
Health
care providers caring for these symptomatic perimenopausal women must
decide how they are going to address the risks and benefits of HT with
them in light of WHI. Even if a provider chooses to dismiss the findings
as not applicable, patient awareness of WHI will often dictate that
their questions and concerns be acknowledged and addressed. As I noted,
individual "practitioners must clearly understand this WHI study
in detail if they are to apply its results to individual perimenopausal
patients."
There
have been many powerful critical reviews of WHI. Creasman, Hoel, and
DiSaia's recent commentary in the American Journal of Obstetrics and
Gynecology (2003 Sep;189(3):621-6) is particularly scathing. They suggest
that data of this type be "disregarded in managing patients,"
and conclude that "this, as well as other like publications, should
be taken with a grain of salt."
However,
despite such criticisms, virtually every major medical organization
that is strongly associated with women's health care has essentially
extrapolated the WHI findings and adopted positions similar to that
stated in KP's Clinical Guidelines, namely that "the sole indication
for HT is for the treatment of menopausal symptoms. When HT is elected
for symptom relief, prescribe the lowest effective dose for the shortest
possible time." These guidelines do not specify that this is only
applicable to asymptomatic postmenopausal women with a mean age of 63,
mean BP 128/76, mean BMI 28.5, etc. Our patients are keenly aware of
positions taken by respected health care organizations, whether it's
our own organization or the American College of Obstetrics and Gynecology
or the FDA. As individual practitioners our practice is not dictated
by any of these guidelines, but we should be cognizant of them and have
an understanding of their foundation, even if one believes they were
all trapped into their positions.
The
quality of studies and data I would like to help me counsel my symptomatic
perimenopausal patients just does not exist. While flawed, I still find
WHI the best quality data available to extrapolate from. We have to
start from somewhere, and for me its Table 1 summarizing WHI--from there
it is easy for me to individualize.
Your
attempts to compare WHI and the Nurse's study to better understand and
explain WHI findings exemplify the unique approaches practitioners take
to educate their patients, though I find the comparison akin to comparing
apples and oranges because of the fundamentally different goals, study
designs, and methodology of the two studies. And while personally I
am unlikely to have a lengthy discussion with a 55 year old focusing
on decreasing her dose of premarin from 0.625 mg to 0.3 mg so that she
can reduce her risk of stoke--if that works for you and your patient
population, that is great. Regardless of our different approaches, it
is encouraging to see that your practice clearly reflects my concluding
advice that "health care practitioners will need not only to critically
assess the clinical significance, scope, and magnitude of study findings,
but also develop tools that will enable our patients to do the same."
Thank
you for your interest and comments.
Gavin
Jacobson, MD
South
San Francisco, CA
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