Estrogen replacement therapy in breast cancer survivors. A time for change. Breast Cancer Committees of the Eastern Cooperative Oncology Group.
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Breast Neoplasms↗
Biomedical subjects
T Bush
Publications and source records attributed to T Bush.
An international comparison of back surgery rates.
SUMMARY OF BACKGROUND DATA: Although high geographic variation in back surgery rates within the United States have been documented, international comparisons have not been published. METHODS: The authors compared rates of back surgery in eleven developed countries to determine if back surgery rates are higher: 1) in the United States than in other developed countries, 2) in countries with more neurologic and orthopaedic surgeons per capita, and 3) in countries with higher rates of other surgical procedures. Data on back surgery rates and physician supply were obtained from health agencies within these eleven countries. Country-specific rates of other surgical procedures were available from published sources. RESULTS: The rate of back surgery in the United States was at least 40% higher than in any other country and was more than five times those in England and Scotland. Back surgery rates increased almost linearly with the per capita supply of orthopaedic and neurosurgeons in the country. Countries with high back surgery rates also had high rates of other discretionary procedures such as tonsillectomy and hysterectomy. CONCLUSIONS: These findings illustrate the potentially large impact of health system differences on rates of back surgery. Better outcome studies, however, are needed to determine whether Americans are being subjected to excessive surgery or if those in other developed countries are suffering because back surgery is underutilized.
Australia↗
The predictors of persistence of depression in primary care.
164 patients in primary care who were recognized as depressed by their physicians and started on antidepressants were interviewed at 1 and 4 months after initiation of treatment. Ten factors hypothesized to be related to persistence of depressive symptoms were entered into a multivariate analysis to determine predictors of persistence of affective symptoms. Patients with minor depression were significantly older, more likely to be married or cohabitating, more likely to have serious medical illness, and had significantly less comorbid panic disorder, recurrent depression and lower neuroticism scores compared to patients with major depression. Approximately half of the patients in this primary care sample with major depression and one-third of those with minor depression were still distressed at 4 months, although few met criteria for major depression. Severity of depression and high neuroticism scores were the best predictors of persistent depressive symptoms.
Adolescent↗
The utility of the rheumatoid factor.
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Arthritis, Rheumatoid↗
The impact of physician attitudes on patient satisfaction with care for low back pain.
We wished to determine whether patient satisfaction was related to physicians' confidence in their abilities to effectively manage low back pain, and to examine their attitudes about patients with back pain. The confidence and attitudes of primary care providers were determined using self-administered questionnaires. Patient satisfaction with care was assessed during telephone interviews conducted 3 weeks after a clinic visit for low back pain. The study was conducted in a primary care clinic of a large health maintenance organization. Completed surveys were obtained from 21 primary care providers (18 physicians and three physician assistants) and 270 of their patients with low back pain. Three satisfaction scales specific to low back pain were used to measure patient satisfaction with regard to information received from provider, caring, and effectiveness of treatment. The results showed that the providers' attitudes about patients with low back pain were not associated with any of the patient satisfaction measures. However, patients of more confident providers were significantly more satisfied with the information they received than were patients of less confident providers. These differences could not be explained by years in practice, length of visit, patient demographics, or the severity and duration of low back pain. These findings suggest that providers who have more confidence in their abilities to effectively manage low back pain may in fact be more effective patient educators.
Adolescent↗
A randomized trial of psychiatric consultation with distressed high utilizers.
This study reports the results of a randomized trial of a psychiatric consultation intervention with distressed, high utilizing patients of 18 physicians in two primary care clinics. Psychiatric consultation was associated with a significant increase in the use of antidepressants in intervention patients compared with controls in the first 6 months after intervention. Intervention patients were also significantly more likely to continue antidepressant treatment than control patients. The primary care physicians receiving psychiatric consultations increased the rate of prescribing antidepressant medications in their practice from 32 prescriptions filled per 1,000 visits before their participation in four consultations to 44 new prescriptions per 1,000 visits in the 12-month period after. There were no significant differences between intervention patients and controls at 6 and 12 months after randomization in psychiatric distress, functional disability, or utilization of health care (ambulatory visits, radiographic and laboratory testing services, admissions to inpatient medical care).
Ambulatory Care↗
Adequacy and duration of antidepressant treatment in primary care.
Among a sample of 119 distressed high-utilizers of primary care, 45% of patients evaluated by a psychiatrist as needing antidepressant treatment had been treated in the year before the examination. However, only 11% of the patients needing antidepressants had received adequate dosage and duration of pharmacotherapy. In the year following the intervention, study patients whose physicians were advised regarding treatment during a psychiatric consultation were more likely to receive antidepressant medications (52.7%) relative to a randomized control group (36.1%). However, the intervention did not significantly increase the provision of adequate antidepressant therapy (37.1% vs 27.9%). Among study patients using antidepressants, patient characteristics did not differentiate patients who received adequate dosage and duration of antidepressant medications from those who did not. Analysis of data on the duration of antidepressant therapy for all health maintenance organization enrollees initiating use of antidepressants showed that only 20% of patients who had been given prescriptions for first-generation antidepressants (amitriptyline, imipramine, or doxepin) filled four or more prescriptions in the following six months, compared to 34% of patients who had prescriptions for newer antidepressants (nortriptyline, desipramine, trazodone and fluoxetine). Experimental research evaluating whether these newer medications (with more favorable side effect profiles) improve adherence, and thereby patient outcome, is needed.
Adult↗
Somatization: a spectrum of severity.
OBJECTIVE: The DSM-III-R diagnosis of somatization disorder requires that a patient have a specific number of medically unexplained somatic symptoms. This number of symptoms was developed by committee consensus, and it is not clear whether patients with this specific number of symptoms can be differentiated from patients with lower but still substantial numbers of somatic symptoms. METHOD: Fifty-one percent of 767 high utilizers of two primary care clinics were identified as distressed by an elevated SCL anxiety, depression, or somatization scale score or by their primary care physician. The Diagnostic Interview Schedule (DIS) was completed on 119 distressed high utilizers who were randomly assigned to an intervention group in a controlled trial of psychiatric consultation. The 119 distressed high utilizers were separated into four categories according to the number of unexplained somatic symptoms found on the DIS and were compared on demographic, psychiatric distress, disability, medical, and health utilization variables. RESULTS: The data suggest that many clinical and behavioral features of somatization are significantly more common in patients with four to 12 medically unexplained somatic symptoms rather than changing dramatically at the diagnostic threshold for somatization disorder. The data also showed that patients who meet the DSM-III-R criteria for somatization disorder are severely ill and have a high burden of psychiatric illness and disability. CONCLUSIONS: The results suggest that the DSM-IV somatoform disorders section should include somatization disorder, an abridged definition of somatization disorder often associated with anxiety and depression, as well as a type of somatization associated with an adjustment disorder.
Activities of Daily Living↗
The impact of estrogen on cardiovascular disease. The Lipid Research Clinics Program.
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Adult↗
Predictors of disease course in patients with probable Alzheimer's disease.
The presence of extrapyramidal signs or psychosis may indicate greater disability in patients with probable Alzheimer's disease. We evaluated the ability of these signs, noted at a patient's first visit, to predict one of two specific clinical endpoints: (1) a preselected score on the modified Mini-Mental State examination (cognitive endpoint), and (2) a preselected score on the Blessed Dementia Rating Scale (functional endpoint). Sixty-five patients were followed either until they reached the endpoints or to the end of the study period. Survivorship curves were drawn to predict the distribution of time to onset of an endpoint in patients with and without the clinical signs. Time to reach the cognitive endpoint was shorter for patients with extrapyramidal signs or psychosis compared with those without these signs and symptoms. These clinical signs did not predict the functional endpoint. We conclude that extrapyramidal signs and psychosis may be useful predictors of intellectual decline in Alzheimer's disease.
Activities of Daily Living↗
Can depression treatment in primary care reduce disability? A stepped care approach.
OBJECTIVE: To assess effects of stepped collaborative care depression intervention on disability. DESIGN: Randomized controlled trial. SETTING: Four primary care clinics of a large health maintenance organization. PATIENTS: Two hundred twenty-eight patients with either 4 or more persistent major depressive symptoms or a score of 1.5 or greater on the Hopkins Symptom Checklist. Depression items were randomized to stepped care intervention or usual care 6 to 8 weeks after initiating antidepressant medication. INTERVENTION: Augmented treatment of persistently depressed patients by an on-site psychiatrist collaborating with primary care physicians. Treatment included patient education, adjustment of pharmacotherapy, and proactive monitoring of outcomes. MAIN OUTCOME MEASURES: Baseline, 1-, 3-, and 6-month assessments of the Sheehan Disability Scale and the social function and role limitation subscales of the Medical Outcomes Study 36-Item Short-Form Health Survey (SF-36). RESULTS: Patients who received the depression intervention experienced less interference in their family, work, and social activities than patients receiving usual primary care (Sheehan Disability Scale, z = 2.23; P =.025). Patients receiving intervention also reported a trend toward more improvement in SF-36-defined social functioning than patients receiving usual care (z = 1.63, P =.10), but there was no significant difference in role performance (z = 0.07, P =.94). CONCLUSIONS: Significant disability accompanied depression in this persistently depressed group. The stepped care intervention resulted in small to moderate functional improvements for these primary care patients. Arch Fam Med. 2000;9:1052-1058
Data Collection↗
Frustrating patients: physician and patient perspectives among distressed high users of medical services.
OBJECTIVE: To identify differences between patients viewed as frustrating by their physicians and those considered typical and satisfying. DESIGN: This cross-sectional observational study focused on psychologically distressed high users of medical services. Frustrating patients were compared with typical and satisfying patients, using data from patient questionnaires, physician assessments, structured psychiatric interviews, and computerized utilization records. SETTING: Group Health Cooperative of Puget Sound, a large health maintenance organization. PATIENTS/PARTICIPANTS: Study patients were in the top decile for ambulatory visits, and bad elevated scores for anxiety, depression, and somatization. Among the 339 patients invited to participate in the study, 251 agreed, and 228 were rated by their physicians. MAIN RESULTS: A substantial proportion (37%) of the high users were viewed as frustrating by their physicians. Physicians' ratings of physical disease severity did not differ among the groups, but frustrating patients rated their own health status less favorably and reported more somatic symptoms and disabilities. The frustrating group utilized more medical services than did other distressed high utilizers. All three groups had a high prevalence of mental disorders. However, frustrating patients had higher rates of somatization and generalized anxiety disorder. CONCLUSIONS: Physicians and their frustrating patients had contrasting views of the patients' illnesses. The best predictors of physician frustration were somatization and increased medical service utilization. There is need for further research and clinical attention concerning optimal clinical management for patients with somatization.
Adult↗
Neuroticism and extraversion as predictors of health outcomes in depressed primary care patients.
Depressed primary care patients (N = 217) were assessed to determine if certain personality characteristics predict health domains independent of chronic disease, demographics, depression, and psychiatric diagnoses. Eleven health variables were used to create three outcome factor scores: disability (e.g., days missed work); somatization (e.g., medically unexplained symptoms); and subjective pain (severity, interference). Neuroticism explained significant variance in all health outcomes independent of the other predictors. Depression and neuroticism interacted in the disability and pain models. Depression was related to health in neurotic patients, while in the absence of neuroticism, little relation between depression and health was observed. Neuroticism may explain why persons with similar health problems have differing levels of disability, pain, and somatization.
Depressive Disorder↗
Methodologic issues in randomized trials of liaison psychiatry in primary care.
Most anxiety, depressive, and substance abuse disorders are treated exclusively in the primary care health system. However, recognition and treatment of these disorders in primary care is deficient. Psychopharmacologic and psychotherapeutic interventions have been developed and proven effective in randomized trials in specialty care. However, the results of successful trials of mental health interventions in specialty settings may not generalize to primary care settings because of epidemiologic differences in patients, differences in skills of providers, as well as differences in the very structure of care. The importance of the development of innovative randomized trials to improve recognition and treatment of mental illness in primary care is emphasized, as well as the methodologic problems inherent in carrying out these trials.
Humans↗
Treatment costs, cost offset, and cost-effectiveness of collaborative management of depression.
OBJECTIVE: The report estimates the treatment costs, cost-offset effects, and cost-effectiveness of Collaborative Care of depressive illness in primary care. STUDY DESIGN: Treatment costs, cost-offset effects, and cost-effectiveness were assessed in two randomized, controlled trials. In the first randomized trail (N = 217), consulting psychiatrists provide enhanced management of pharmacotherapy and brief psychoeducational interventions to enhance adherence. In the second randomized trial (N = 153). Collaborative Care was implemented through brief cognitive-behavioral therapy and enhanced patient education. Consulting psychologist provided brief psychotherapy supplemented by educational materials and enhanced pharmacotherapy management. RESULTS: Collaborative Care increased the costs of treating depression largely because of the extra visits required to provide the interventions. There was a modest cost offset due to reduced use of specialty mental health services among Collaborative Care patients, but costs of ambulatory medical care services did not differ significantly between the intervention and control groups. Among patients with major depression there was a modest increase in cost-effectiveness. The cost per patient successfully treated was lower for Collaborative Care than for Usual Care patients. For patients with minor depression. Collaborative Care was more costly and not more cost-effective than Usual Care. CONCLUSIONS: Collaborative Care increased depression treatment costs and improved the cost-effectiveness of treatment for patients with major depression. A cost offset in specialty mental health costs, but not medical care costs, was observed. Collaborative Care may provide a means of increasing the value of treatment services for major depression.
Adult↗
Beyond HERS: some (not so) random thoughts on randomized clinical trials.
Science is the process of discovering truth, and "truth" is sampled each time we do a study. The results from all of our studies will be distributed around the truth, and different study designs give different amounts and different qualities of sampled material. Truth is ascertained only when sufficient numbers of appropriate studies are conducted, and no one study or one study design has a monopoly on truth. Currently, the randomized clinical trial is considered the penultimate study design and the ultimate test of the hypothesis, but only if it is double-blinded, placebo-controlled, and analyzed by an intention-to-treat protocol. The study design most similar to the randomized controlled trial is the prospective cohort study. In this observational approach, a cohort (group of individuals) is assembled and followed in real time while end points (e.g. breast cancers, heart attacks, fractures) accrue. This is contrasted to the randomized controlled trial, where a group of individuals is assembled, intervened upon, and followed in real time while end points accrue. The major advantage of the randomized controlled trial over an observational study is that the randomization process should eliminate any "bias" in the exposure of interest. However, the randomized controlled trial, like all study designs, has other limitations. Major limitations of the randomized controlled trial include significant financial and other costs, problems with external generalizability, the placebo effect, external monitoring, multi-center differences, and the (frequently problematic) intention-to-treat analysis rule. Many of these limitations do not occur in prospective cohort studies. For example, since a placebo is not administered in an observational study, there is no placebo effect, and since the study is not monitored by a data and safety monitoring board, abrupt truncation of the study duration is not usually seen in observational cohort studies. These limitations of randomized controlled trials are discussed, with specific references to several recently published randomized controlled trials in women (HERS, NSABP P-1, and the Royal Marsden Hospital trials). The HERS trial is significant because despite overwhelming observational evidence that menopausal estrogen therapy prevents heart disease, HERS found no overall difference in heart disease events in women assigned to an estrogen-plus-progestin intervention. The NSABP P-1 and the Royal Marsden Hospital trials are significant in that they were testing the same hypothesis (whether tamoxifen can prevent breast cancer), but came to entirely different conclusions. Two major questions will be posed from this specific review: One: Given conflicting evidence by study design (observational vs. randomized clinical trial), does menopausal estrogen therapy protect against heart disease? Two: Given conflicting evidence within study design (conflicting randomized clinical trials), does tamoxifen prevent breast cancer?
Breast Neoplasms↗