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Biomedical subjects

T Bush

Publications and source records attributed to T Bush.

At least 37 records · Page 2Linked to original sources
PubMed1998

Randomized trial of estrogen plus progestin for secondary prevention of coronary heart disease in postmenopausal women. Heart and Estrogen/progestin Replacement Study (HERS) Research Group.

CONTEXT: Observational studies have found lower rates of coronary heart disease (CHD) in postmenopausal women who take estrogen than in women who do not, but this potential benefit has not been confirmed in clinical trials. OBJECTIVE: To determine if estrogen plus progestin therapy alters the risk for CHD events in postmenopausal women with established coronary disease. DESIGN: Randomized, blinded, placebo-controlled secondary prevention trial. SETTING: Outpatient and community settings at 20 US clinical centers. PARTICIPANTS: A total of 2763 women with coronary disease, younger than 80 years, and postmenopausal with an intact uterus. Mean age was 66.7 years. INTERVENTION: Either 0.625 mg of conjugated equine estrogens plus 2.5 mg of medroxyprogesterone acetate in 1 tablet daily (n = 1380) or a placebo of identical appearance (n = 1383). Follow-up averaged 4.1 years; 82% of those assigned to hormone treatment were taking it at the end of 1 year, and 75% at the end of 3 years. MAIN OUTCOME MEASURES: The primary outcome was the occurrence of nonfatal myocardial infarction (MI) or CHD death. Secondary cardiovascular outcomes included coronary revascularization, unstable angina, congestive heart failure, resuscitated cardiac arrest, stroke or transient ischemic attack, and peripheral arterial disease. All-cause mortality was also considered. RESULTS: Overall, there were no significant differences between groups in the primary outcome or in any of the secondary cardiovascular outcomes: 172 women in the hormone group and 176 women in the placebo group had MI or CHD death (relative hazard [RH], 0.99; 95% confidence interval [CI], 0.80-1.22). The lack of an overall effect occurred despite a net 11% lower low-density lipoprotein cholesterol level and 10% higher high-density lipoprotein cholesterol level in the hormone group compared with the placebo group (each P<.001). Within the overall null effect, there was a statistically significant time trend, with more CHD events in the hormone group than in the placebo group in year 1 and fewer in years 4 and 5. More women in the hormone group than in the placebo group experienced venous thromboembolic events (34 vs 12; RH, 2.89; 95% CI, 1.50-5.58) and gallbladder disease (84 vs 62; RH, 1.38; 95% CI, 1.00-1.92). There were no significant differences in several other end points for which power was limited, including fracture, cancer, and total mortality (131 vs 123 deaths; RH, 1.08; 95% CI, 0.84-1.38). CONCLUSIONS: During an average follow-up of 4.1 years, treatment with oral conjugated equine estrogen plus medroxyprogesterone acetate did not reduce the overall rate of CHD events in postmenopausal women with established coronary disease. The treatment did increase the rate of thromboembolic events and gallbladder disease. Based on the finding of no overall cardiovascular benefit and a pattern of early increase in risk of CHD events, we do not recommend starting this treatment for the purpose of secondary prevention of CHD. However, given the favorable pattern of CHD events after several years of therapy, it could be appropriate for women already receiving this treatment to continue.

Aged↗
PubMed1998

Heart and Estrogen/progestin Replacement Study (HERS): design, methods, and baseline characteristics.

The Heart and Estrogen/progestin Replacement Study (HERS) is a randomized, double-blind, placebo-controlled trial designed to test the efficacy and safety of estrogen plus progestin therapy for prevention of recurrent coronary heart disease (CHD) events in women. The participants are postmenopausal women with a uterus and with CHD as evidenced by prior myocardial infarction, coronary artery bypass graft surgery, percutaneous transluminal coronary angioplasty, or other mechanical revascularization or at least 50% occlusion of a major coronary artery. Between February 1993 and September 1994, 20 HERS centers recruited and randomized 2763 women. Participants ranged in age from 44 to 79 years, with a mean age of 66.7 (SD 6.7) years. Most participants were white (89%), married (57%), and had completed high school or some college (80%). As expected, the prevalence of coronary risk factors was high: 62% were past or current smokers, 59% had hypertension, 90% had serum LDL-cholesterol of 100 mg/dL or higher, and 23% had diabetes. Each woman was randomly assigned to receive one tablet containing 0.625 mg conjugated estrogens plus 2.5 mg medroxyprogesterone acetate daily or an identical placebo. Participants will be evaluated every 4 months for an average of 4.2 years for the occurrence of CHD events (CHD death and nonfatal myocardial infarction). We will also assess other major CHD endpoints, including revascularization and hospitalization for unstable angina. The primary analysis will compare the rate of CHD events in women assigned to active treatment with the rate in those assigned to placebo. The trial was designed to have power greater than 90% to detect a 35% reduction in the incidence of CHD events, assuming a 50% lag in effect for 2 years and a 5% annual event rate in the placebo group. The design, analysis, and conduct of the study are controlled by the Steering Committee of Principal Investigators and coordinated at the University of California, San Francisco. HERS is the largest trial of any intervention to reduce the risk of recurrent CHD events in women with heart disease and is the first controlled trial to seek evidence of the efficacy and safety of postmenopausal hormone therapy to prevent recurrent CHD events.

Aged↗
PubMed1998

Assessing the feasibility of using computerized pharmacy refill data to monitor antidepressant treatment on a population basis: a comparison of automated and self-report data.

This article compares self-report and automated data as measures of dose and duration of antidepressant use in order to assess the feasibility of using automated pharmacy data in a disease management context. We used self-report and computerized refill data to identify two treatment failures-premature discontinuation of the medication and sub-optimal dosages-at time points 1 and 4 months after initiation of antidepressant therapy. The sources showed modest agreement regarding identification of current users at 1 month (kappa = .33); agreement was high at 4 months (kappa = .72). Agreement regarding dosage adequacy was also higher later in treatment, with kappas of .52 and .65 at 1 and 4 months, respectively. The two sources showed high agreement on an overall measure of acute phase treatment adequacy (kappa = .80). Data completeness was another outcome, with data on current users and overall treatment adequacy generally available from computerized files, data on dose less so. Automated pharmacy data appear to be a feasible means of monitoring treatment adequacy and quality of care as part of a disease management approach to improving care for populations of patients.

Antidepressive Agents↗
PubMed1998

Impact of improved depression treatment in primary care on daily functioning and disability.

BACKGROUND: Few data are available regarding the impact of improved depression treatment on daily functioning and disability. METHODS: In two studies of more intensive depression treatment in primary care, patients initiating antidepressant treatment were randomly assigned to either usual care or to a collaborative management programme including patient education, on-site mental health treatment, adjustment of antidepressant medication, behavioural activation and monitoring of medication adherence. Assessments at baseline as well as 4 and 7 months included several measures of impairment, daily functioning and disability: self-rated overall health, number of bodily pains, number of somatization symptoms, changes in work due to health, reduction in leisure activities due to health, number of disability days and number of restricted activity days. RESULTS: Average data from the 4- and 7-month assessments in both studies, intervention patients reported fewer somatic symptoms (OR 0.68, 95% CI 0.46, 0.99) and more favourable overall health (OR 0.50, 95% CI 0.28, 0.91). While intervention patients fared better on other measures of functional impairment and disability, none of these differences reached statistical significance. CONCLUSIONS: More effective acute-phase depression treatment reduced somatic distress and improved self-rated overall health. The absence of a significant intervention effect on other disability measures may reflect the brief treatment and follow-up period and the influence of other individual and environmental factors on disability.

Absenteeism↗
PubMed1997

Population-based care of depression: effective disease management strategies to decrease prevalence.

This paper reviews the concepts of population-based care and disease management of major depression. Population-based care and disease management strategies motivated by health care reform provide approaches for organizing health services to lower the prevalence of common medical and psychiatric illnesses in primary care populations. We apply these concepts to the organization of services for patients with major depression.

Cross-Sectional Studies↗
PubMed1997

Collaborative management to achieve depression treatment guidelines.

Two models that integrate the psychiatrist into treatment of depression in primary care have been evaluated in randomized controlled trials. In the psychiatrist/primary care model, a psychiatrist alternated visits with a primary care physician to assist in the education and pharmacologic treatment of the patient. In the psychiatrist/psychologist team model, the psychiatrist worked with a team of psychologists to improve adherence to and effectiveness of antidepressant treatment, with psychologists also providing brief behavioral treatment in the primary care clinic. Findings with the psychiatry/primary care model are reported. It was found that the collaborative model was associated with improved adherence to treatment, increased patient satisfaction with depression care, and improved depression outcome compared with usual care by primary care physicians alone. Similar results were found in the study of the psychiatrist/psychologist collaborative care model. The success of these models indicates the appropriateness of a novel role for the psychiatrist and psychologist, i.e., that of collaboration with primary care physicians in care of the depressed patient in the primary care setting.

Antidepressive Agents↗
PubMed1997

The education of depressed primary care patients: what do patients think of interactive booklets and a video?

BACKGROUND: Clinicians, policy makers, and health care administrators are attempting to improve depression outcomes in the primary care setting. Despite positive evidence about the efficacy of self-help materials and psychoeducational interventions, use of educational materials designed for the primary care patient are receiving little attention in present depression initiatives. The present study describes the use and evaluation of three educational materials by depressed primary care patients. METHODS: As a part of a randomized control trial, depressed primary care patients were identified by primary care physicians and randomized to a clinical trial exploring a new method of treating depression. Patients assigned to the new method of treatment received a package of educational materials at the time of the baseline interview. These materials included two brief interactive booklets (medication booklet, behavioral health booklet) and a short video. The present analysis concerns data obtained from 108 intervention patients in a telephone survey conducted 1 week after they received the package of educational materials. RESULTS: Approximately three quarters of the subjects reported that they read or viewed all of the educational products. The majority rated the products as somewhat to significantly helpful: medication booklet 81%; behavioral health booklet 82%; and video 69%. Previously reported results include findings of significantly better medication adherence and improved clinical outcomes by patients with major depression who received a primary care intervention that included the educational products discussed in this paper. CONCLUSIONS: Educational materials may play a significant role in improving depression treatment outcomes in the primary care setting.

Adaptation, Psychological↗
PubMed1996

A multifaceted intervention to improve treatment of depression in primary care.

BACKGROUND: This research study evaluates the effectiveness of a multifaceted intervention program to improve the management of depression in primary care. METHODS: One hundred fifty-three primary care patients with current depression were entered into a randomized controlled trial. Intervention patients received a structured depression treatment program in the primary care setting that included both behavioral treatment to increase use of adaptive coping strategies and counseling to improve medication adherence. Control patients received "usual" care by their primary care physicians. Outcome measures included adherence to antidepressant medication, satisfaction with care of depression and with antidepressant treatment, and reduction of depressive symptoms over time. RESULTS: At 4-month follow-up, significantly more intervention patients with major and minor depression than usual care patients adhered to antidepressant medication and rated the quality of care they received for depression as good to excellent. Intervention patients with major depression demonstrated a significantly greater decrease in depression severity over time compared with usual care patients on all 4 outcome analyses. Intervention patients with minor depression were found to have a significant decrease over time in depression severity on only 1 of 4 study outcome analyses compared with usual care patients. CONCLUSION: A multifaceted primary care intervention improved adherence to antidepressant regimens and satisfaction with care in patients with major and minor depression. The intervention consistently resulted in more favorable depression outcomes among patients with major depression, while outcome effects were ambiguous among patients with minor depression.

Adult↗
PubMed1996

Reduced mortality associated with long-term postmenopausal estrogen therapy.

OBJECTIVE: To compare all-cause and specific-cause mortality rates in women who had or had not used long-term postmenopausal estrogen replacement therapy (ERT). METHODS: We identified women who used long-term postmenopausal ERT and compared them with a sample of age-matched postmenopausal nonusers. Through linking of these subjects' medical record numbers to various data bases, we examined survivorship and cause of death among estrogen users and nonusers. The risk of death in 232 postmenopausal women who began ERT within 3 years of menopause and used it for at least 5 years was compared with that of 222 age-matched postmenopausal nonusers. In the users, the mean length of estrogen use was 17.1 years. RESULTS: Statistically significant reductions in all-cause mortality were found in users compared with nonusers. For death from any cause, the age-adjusted relative risk (RR) and associated 95% confidence interval (CI) in estrogen users was 0.54 (0.38-0.76). The reduction in all-cause mortality was largely due to reductions in coronary heart disease (RR 0.40, CI 0.16-1.02) and other cardiovascular disease (RR 0.27, CI 0.10-0.71). Overall cancer mortality was similar in the two groups (RR 0.85, CI 0.46-1.58), although estrogen users had a higher risk of death from breast cancer (RR 1.89, CI 0.43-8.36) and lower risk of death from lung cancer (RR 0.22, CI 0.04-1.15). CONCLUSION: Long-term ERT use is associated with lower all-cause mortality and confers this apparent protection primarily through reduction in cardiovascular disease.

Cause of Death↗
PubMed1996

Factors associated with glucose and insulin levels in healthy postmenopausal women.

OBJECTIVE: Little is known about the covariates of hyperglycemia and hyperinsulinemia. We examined candidate factors in postmenopausal women. RESEARCH DESIGN AND METHODS: We determined the cross-sectional associations of sociodemographic, body-size, lifestyle, reproductive, and menopausal factors with pretrial fasting and postchallenge glucose and insulin levels in 869 postmenopausal women aged 45-65 years. Women were participants in the Postmenopausal Estrogen/Progestin Interventions study who were not taking estrogen or insulin. RESULTS: Plasma glucose levels increased significantly with age; serum insulin levels did not. BMI and waist-to-hip ratio (WHR) each showed graded positive and independent associations with glucose and insulin levels. Alcohol intake, cigarette smoking, physical activity, parity, education, and income were also associated with insulin or glucose in age-adjusted models. In multivariable models, BMI and WHR explained 18% of the variability in fasting glucose, 16% in postchallenge glucose, 28% in fasting insulin, and 17% in postchallenge insulin. Age and all other factors combined accounted for < 6% of the variance in glucose or insulin. In multiply adjusted models, African-American and Hispanic women had higher fasting and 2-h insulin levels than non-Hispanic white women. CONCLUSIONS: Most of the variance in glycemia and insulin is unexplained. Measures of obesity and fat distribution account for nearly all the explained variance.

Aged↗
PubMed1995

Collaborative management to achieve treatment guidelines. Impact on depression in primary care.

OBJECTIVE: To compare the effectiveness of a multifaceted intervention in patients with depression in primary care with the effectiveness of "usual care" by the primary care physician. DESIGN: A randomized controlled trial among primary care patients with major depression or minor depression. PATIENTS: Over a 12-month period a total of 217 primary care patients who were recognized as depressed by their primary care physicians and were willing to take antidepressant medication were randomized, with 91 patients meeting criteria for major depression and 126 for minor depression. INTERVENTIONS: Intervention patients received increased intensity and frequency of visits over the first 4 to 6 weeks of treatment (visits 1 and 3 with a primary care physician, visits 2 and 4 with a psychiatrist) and continued surveillance of adherence to medication regimens during the continuation and maintenance phases of treatment. Patient education in these visits was supplemented by videotaped and written materials. MAIN OUTCOME MEASURES: Primary outcome measures included short-term (30-day) and long-term (90-day) use of antidepressant medication at guideline dosage levels, satisfaction with overall care for depression and antidepressant medication, and reduction in depressive symptoms. RESULTS: In patients with major depression, the intervention group had greater adherence than the usual care controls to adequate dosage of antidepressant medication for 90 days or more (75.5% vs 50.0%; P < .01), were more likely to rate the quality of the care they received for depression as good to excellent (93.0% vs 75.0%; P < .03), and were more likely to rate antidepressant medications as helping somewhat to helping a great deal (88.1% vs 63.3%; P < .01). Seventy-four percent of intervention patients with major depression showed 50% or more improvement on the Symptom Checklist-90 Depressive Symptom Scale compared with 43.8% of controls (P < .01), and the intervention patients also demonstrated a significantly greater decrease in depression severity over time compared with controls (P < .004). In patients with minor depression, the intervention group had significantly greater adherence than controls to adequate dosage of antidepressant medication for 90 days or more (79.7% vs 40.3%; P < .001) and more often rated antidepressant medication as helping somewhat to helping a great deal (81.8% vs 61.4%; P < .02). However, no significant differences were found between the intervention and control groups in the percentage of patients who were satisfied with the care they received for depression (94.4% vs 89.3%), in the percentage who experienced a 50% or more decrease in depressive symptoms, or in the decrease of depressive symptoms over time. CONCLUSION: A multifaceted intervention consisting of collaborative management by the primary care physician and a consulting psychiatrist, intensive patient education, and surveillance of continued refills of antidepressant medication improved adherence to antidepressant regimens in patients with major and with minor depression. It improved satisfaction with care and resulted in more favorable depressive outcomes in patients with major, but not minor, depression.

Adult↗
PubMed1995

Application of multivariable optimal discriminant analysis in general internal medicine.

OBJECTIVE: To illustrate the use of multivariable optimal discriminant analysis (MultiODA). DESIGN: Data from four previously published studies were reanalyzed using MultiODA. The original analysis was Fisher's linear discriminant analysis (FLDA) for two studies and logistic regression analysis (LRA) for two studies. MEASUREMENTS AND MAIN RESULTS: In Study 1, FLDA achieved an overall percentage accuracy in classification (PAC) for the training sample of 69.9%, compared with 73.5% for MultiODA. In Study 2, the LRA model required three attributes to achieve a 76.1% overall PAC for the training sample and a 79.4% overall PAC for the hold-out sample. Using only two attributes, the MultiODA model achieved similar values. In Study 3, the FLDA model achieved an overall PAC of 82.5%, compared with 87.5% for the MultiODA model. In Study 4, MultiODA identified a two-attribute model that achieved a 93.3% overall training PAC, when an LRA model could not be developed. CONCLUSIONS: MultiODA identified: a superior training model (Study 1); a more parsimonious model that achieved superior overall training and identical hold-out PAC (Study 2); a model that achieved a higher hold-out PAC (Study 3); and a two-attribute model that achieved a relatively high PAC when a multivariable LRA model could not be obtained (Study 4). These findings suggest that MultiODA has the potential to improve the accuracy of predictions made in general internal medicine research.

Acquired Immunodeficiency Syndrome↗
PubMed1995

Outcomes of "inadequate" antidepressant treatment.

OBJECTIVE: To examine outcomes of primary care patients receiving low levels of antidepressant treatment. DESIGN: Cohort study comparing patients receiving anti-depressant treatment within and below the recommended dosing range. SETTING: Primary care clinics of a staff-model health maintenance organization. PATIENTS: Primary care patients initiating antidepressant treatment for depression. MEASUREMENTS AND MAIN RESULTS: Of 88 patients beginning antidepressant treatment, 49 (56%) used "adequate" doses for 30 days or more. Likelihood of "adequate" pharmacotherapy was not related to patient age, gender, medical comorbidity, or baseline depression severity. All the patients showed substantial clinical improvement after four months. Compared with those using "adequate" pharmacotherapy, the patients receiving low-intensity treatment had lower likelihood of clinical response (64% vs 84%; chi-square = 4.44; df = 1; p = 0.035). At four months, however, those receiving low-intensity and those receiving higher-intensity treatment did not differ significantly in either the score on the 20-item Symptom Checklist depression scale (18.91 and 15.72, respectively; F = 1.45; df = 1.86; p = 0.23) or the proportion with persistence of major depression (10% and 4%, respectively; chi-square = 1.30; df = 1; p = 0.25). A replication sample of 157 patients (assessed only at baseline and four months) yielded similar results. CONCLUSIONS: While the patients receiving recommended levels of pharmacotherapy showed somewhat higher improvement rates, many of the patients receiving "inadequate" treatment experienced good short-term outcomes. Efforts to increase the intensity of depression treatment in primary care should focus on the subgroup of patients who fail to respond to initial treatment.

Adult↗
PubMed1995

The role of the primary care physician in patients' adherence to antidepressant therapy.

In this study, the authors attempted to determine predictors of adherence to antidepressant therapy and to identify specific educational messages, side effects, and features of doctor-patient collaboration that influence adherence. Patients newly prescribed antidepressants for depression at a health maintenance organization were identified by using automated pharmacy data and medical records review. Patients (n = 155) were interviewed 1 and 4 months after starting antidepressant medication. Approximately 28% of patients stopped taking antidepressants during the first month of therapy, and 44% had stopped taking them by the third month of therapy. Patients who received the following five specific educational messages--1) take the medication daily; 2) antidepressants must be taken for 2 to 4 weeks for a noticeable effect; 3) continue to take medicine even if feeling better; 4) do not stop taking antidepressant without checking with the physician; and 5) specific instructions regarding what to do to resolve questions regarding antidepressants--were more likely to comply during the first month of antidepressant therapy. Asking about prior experience with antidepressants and discussions about scheduling pleasant activities also were related to early adherence. Side effects, only at severe levels, were associated with early noncompliance. Neuroticism, depression severity, and other patient characteristics did not predict adherence. Primary care physicians may be able to enhance adherence to antidepressant therapy by simple and specific educational messages easily integrated into primary care visits.

Adult↗
PubMed1995

Primary care physician use of cognitive behavioral techniques with depressed patients.

BACKGROUND: Although researchers are paying more attention to the treatment of depression in the primary care setting, little is known about the nature of psychotherapeutic interactions that occur between primary care physicians and their patients in the context of a visit for depression. In recent years, brief cognitive behavioral therapy has been demonstrated to be efficacious, and the public has become more familiar with these techniques through media exposure and self-help books. METHODS: Depressed primary care patients were surveyed regarding the extent to which cognitive behavioral (CB) techniques were suggested during the primary care visit in which antidepressant medication was initially prescribed. One hundred fifty-five patients completed responses to phone surveys 1 month and 4 months after the visit. Patients were also surveyed regarding the recommendation of counseling by the primary care physician. RESULTS: The majority of patients (61%) reported that their physician advised them to identify activities they were already doing that helped them feel better. Physician recommendations regarding planning pleasurable activities, problem solving, challenging depressive thoughts, and planning activities that boost confidence were reported by 22% to 40% of study patients. Older patients reported fewer interactions about CB strategies. Primary care physicians' suggestion of CB strategies was associated with both patient use of CB strategies in the months following the visit and better adherence to recommended medication therapy during the first month of treatment. CONCLUSIONS: Many patients seem to recognize the occurrence of psychotherapeutic interactions during visits to their primary care physician in which an antidepressant medication was prescribed, and patients' recognition of these interactions is associated with increased adherence to the recommended course of antidepressant prescriptions.

Adaptation, Psychological↗