[show abstract][hide abstract] ABSTRACT: While previous studies focused on the effectiveness of individual complementary and alternative medical (CAM) therapies, the value of providing patients access to an integrated program involving multiple CAM and conventional therapies remains unknown. The objective of this study is to explore the feasibility and effects of a model of multidisciplinary integrative care for subacute low-back pain (LBP) in an academic teaching hospital.
This was a pilot randomized trial comparing an individualized program of integrative care (IC) plus usual care to usual care (UC) alone for adults with LBP.
Twenty (20) individuals with LPB of 3-12 weeks' duration were recruited from an occupational health clinic and community health center.
Participants were randomized to 12 weeks of individualized IC plus usual care versus UC alone. IC was provided by a trained multidisciplinary team offering CAM therapies and conventional medical care.
The outcome measures were symptoms (pain, bothersomeness), functional status (Roland-Morris score), SF-12, worry, and difficulty performing three self-selected activities.
Over 12 weeks, participants in the IC group had a median of 12.0 visits (range 5-25). IC participants experienced significantly greater improvements at 12 weeks than those receiving UC alone in symptom bothersomeness (p=0.02) and pain (p=0.005), and showed greater improvement in functional status (p=0.08). Rates of improvement were greater for patients in IC than UC in functional status (p=0.02), bothersomeness (p=0.002), and pain scores (p=0.001). Secondary outcomes of self-selected most challenging activity, worry, and the SF-12 also showed improvement in the IC group at 12 weeks. These differences persisted at 26 weeks, but were no longer statistically significant.
It was feasible for a multidisciplinary, outpatient IC team to deliver coordinated, individualized intervention to patients with subacute LBP. Results showed a promising trend for benefit of treating patients with persistent LBP with this IC model, and warrant evaluation in a full-scale study.
Journal of alternative and complementary medicine (New York, N.Y.) 03/2012; 18(4):354-62. · 1.69 Impact Factor
[show abstract][hide abstract] ABSTRACT: Few studies have evaluated the association between patient expectations for recovery and clinical outcomes, and no study has evaluated whether asking patients to choose their therapy modifies such an association.
To evaluate the association between patients' expectations and functional recovery in patients with acute low back pain (LBP), and to determine whether that association is affected by giving patients choice of therapy.
A secondary analysis of a randomized controlled trial comparing usual care alone to usual care plus choice of chiropractic, acupuncture, or massage in 444 adults with acute LBP, lasting less than 21 days.
Primary outcome was functional disability (Roland score) at 5 and 12 weeks. Patients' general expectations for improvement were associated with improvement in functional status (beta = 0.96, 95% CI = 0.56, 1.36). A 1-point increase in general expectations was associated with a 0.96-point improvement in Roland score. The association of expectation with outcome was 2-3 times greater in the usual care group than the choice group. However, these differences did not reach statistical significance.
In patients with acute LBP, higher expectations for recovery are associated with greater functional improvement. Eliciting patient expectations for improvement may be a simple way to identify patients with the highest (or lowest) likelihood of experiencing functional improvement. Incorporating questions about patient expectations in future trials may clarify the role of this important correlate of clinical outcomes.
Journal of General Internal Medicine 03/2008; 23(2):148-53. · 3.28 Impact Factor
[show abstract][hide abstract] ABSTRACT: To describe hormone therapy (HT) initiation after the 2002 publication of the Women's Health Initiative.
Observational cohort (1999-2003) of women ages 40 to 79 years, five health plans, used HT in July 2002 and subsequently discontinued or never used before August 2002.
Of discontinuers, 15.8% (3,203 of 20,205) reinitiated HT. Reinitiation was higher among estrogen users (23.8%) versus estrogen with progestin users (11.3%), and lower among those with diabetes (relative risk [RR]=0.68, 95% CI: 0.61-0.76), cardiovascular disease (RR=0.87, 95% CI: 0.83-0.92), and hyperlipidemia (RR=0.83, 95% CI: 0.79-0.88). Only 2.3% (2,072 of 90,261) of never users initiated (August 2002 to December 2003). First-time initiation was associated with cardiovascular disease (RR=1.17, 95% CI: 1.10-1.25) and hyperlipidemia (RR=1.24, 95% CI: 1.17-1.33) and was less common among those with diabetes (RR=0.70, 95% CI: 0.63-0.79).
After the Women's Health Initiative, a minority of women reinitiated or became first-time initiators of HT. Women with cardiovascular disease, diabetes, and hyperlipidemia were less likely to reinitiate; women with cardiovascular disease and hyperlipidemia were more likely to be first-time initiators.
[show abstract][hide abstract] ABSTRACT: The landmark Women's Health Initiative (WHI) Postmenopausal Hormone Therapy Trial published in 2002 showed that the health risks of combination hormone therapy (HT) with estrogen and progestin outweighed the benefits in healthy postmenopausal women. Dissemination of results had a major impact on prescriptions for, and physician beliefs about HT. No study has fully examined the influence of the widely publicized WHI on physicians' practice and attitudes or their opinions of the scientific evidence regarding HT; in addition, little is known about how physicians assist women in their decisions regarding HT.
We conducted in-depth telephone interviews with family practitioners, internists, and gynecologists from integrated health care delivery systems in Washington State (n = 10 physicians) and Massachusetts (n = 12 physicians). Our objectives were to obtain qualitative information from these physicians to understand their perspectives on use of HT, the scientific evidence regarding its risks and benefits, and counseling strategies around HT use and discontinuation.
We used Template Analysis to code transcribed telephone interviews and identify themes.
Physicians were conflicted about the WHI results and its implications. Seven themes identified from in-depth interviews suggested that the WHI (1) was a ground-breaking study that changed clinical practice, including counseling; (2) was not applicable to the full range of patients seen in clinical practice; (3) raised concerns over the impact of publicized health information on women; (4) created uncertainty about the risks and benefits of HT; (5) called for the use of decision aids; (6) influenced discontinuation strategies; and (7) provided an opportunity to discuss healthy lifestyle options with patients. As a result of the WHI, physicians reported they no longer prescribe HT for prevention and were more likely to suggest discontinuation, although many felt women should be in charge of the HT decision.
Physicians varied in their opinions of HT and the scientific evidence (positive and negative). Whereas the WHI delineated the risks and benefits of HT, physicians reported that decision aids are needed to guide discussions with women about menopause and HT. Better guidance at the time of WHI study publication might have been valuable to ensure best practices.
Journal of General Internal Medicine 10/2007; 22(9):1311-6. · 3.28 Impact Factor
[show abstract][hide abstract] ABSTRACT: A randomized controlled trial.
To investigate the effectiveness and cost of usual care plus patient choice of acupuncture, chiropractic, or massage therapy (choice) compared with usual care alone in patients with acute low back pain (LBP).
Few studies have evaluated care models with facilitated access to and financial coverage for adjunctive complementary and alternative medicine therapies.
A total of 444 patients with acute LBP (<21 days) were recruited from 4 clinical sites and randomized into 2 groups: usual care or choice. Outcomes included symptoms (bothersomeness), functional status (Roland), and satisfaction between baseline and 5 weeks, and cost of medical care in the 12 weeks after randomization.
After 5 weeks, providing patients with a choice did not yield clinically important reductions in symptoms (median -4, [interquartile range -7, -2] for usual care, and -5 [-7, -3] for choice; P = 0.002) or improvements in functional status (-8 [-13, -2] for usual care, and -9 [-15, -4] for choice; P = 0.15). Although there was a significantly greater satisfaction with care in the choice group, this came at a net increase in costs of 244 dollars per patient. This consisted of a 99 dollars reduction in the average cost to the insurer for medical care but an additional cost of 343 dollars, for an average of 6.0 complementary and alternative medicine treatments per patient.
A model of care that offered access to a choice of complementary and alternative medicine therapies for acute LBP did not result in clinically significant improvements in symptom relief or functional restoration. This model was associated with greater patient satisfaction but increased total costs. Future evaluations of this choice model should focus on patients with chronic conditions (including chronic back pain) for which conventional medical care is often costly and of limited benefit.
[show abstract][hide abstract] ABSTRACT: Determine the impact of fracture, coronary disease, and diabetes on changes in rates of discontinuation and initiation of estrogen therapy with (EPT) and without (ET) progestin, before (September 1, 1999 to June 30, 2002, baseline) versus 5 months after (follow-up) release of the Women's Health Initiative EPT trial results (WHI).
Observational cohort; 169,586 women 40 to 80 years old from 5 U.S. HMOs.
We used pharmacy data to identify ET and EPT users. A woman was a user any month she filled > or =1 estrogen prescription and in subsequent months based upon the number of pills/patches dispensed. We used inpatient and outpatient claims to identify fracture January 1, 1999 to June 30, 2002 and pharmacy data to identify disease-based groups of medications for diabetes and cardiovascular disease.
EPT/ET prevalence, initiation, and discontinuation rates.
Baseline to follow-up EPT and ET prevalence declined 45% and 22%, respectively, with no difference by comorbidity. Follow-up EPT initiation was half the baseline rate irrespective of comorbidity. Compared to baseline, follow-up EPT discontinuation rates increased among women with diabetes (relative risk [RR], 6.9; 95% confidence interval [CI], 5.6 to 8.4), cardiovascular disease (RR, 5.5; 95% CI, 4.9 to 6.2), fracture (RR, 3.8; 95% CI, 2.4 to 5.7), and no comorbidity (RR, 4.4; 95% CI, 3.9 to 4.9). The RRs for follow-up versus baseline EPT discontinuation were higher among women with diabetes (P<.01) and cardiovascular disease (P<.01) versus women without these comorbidities. ET discontinuation rates among these same groups were elevated 2- to 2.8-fold.
Diabetes and cardiovascular disease were associated with higher EPT discontinuation rates post-WHI compared to women without comorbidity; comorbidity had little impact on changes in prevalence or initiation of ET/EPT after release of the WHI.
Journal of General Internal Medicine 05/2005; 20(4):350-6. · 3.28 Impact Factor
[show abstract][hide abstract] ABSTRACT: Recent randomized trials have indicated that the risks of hormone therapy for menopausal women may outweigh the benefits. The purpose of this study was to describe how health plans responded to the findings of the Women's Health Initiative (WHI) estrogen plus progestin trial. We surveyed five health plans affiliated with the HMO Research Network and the Cancer Research Network to document the response of each plan to the WHI in terms of patient and provider education and guidelines. Every health plan issued responses within 3 months of WHI's termination in a variety of formats. Recommendations were relatively consistent across the organizations. Given the documented changes in hormone therapy use in these five health plans in the post-WHI era, we conclude that attempts on the part of each organization to educate patients and providers about the implications of the WHI may have contributed to the observed changes in hormone therapy use.
[show abstract][hide abstract] ABSTRACT: We examined the impact of race, education, and household income on changes in rates of discontinuation and initiation of hormone therapy before and after release of the Women's Health Initiative estrogen plus progestin trial results.
We conducted an observational cohort study of 221 378 women aged 40-80 years enrolled in five health maintenance organizations to estimate the prevalence and rates of discontinuation and initiation of estrogen plus progestin and estrogen only between September 1, 1999, to June 31, 2002 (baseline), and December 31, 2002 (follow-up). We identified the census block group for each participant by geocoding her 2003 residential address. We categorized women into racial, education, and income groups based on the distribution of these characteristics in her community from year 2000 census data and the distributions of these characteristics within her HMO.
There were significant differences in estrogen plus progestin and estrogen only prevalence by race, education level, and household income, and in estrogen plus progestin initiation by race and education level, but not by household income at follow-up. However, there were no differences by community race, education, or household income in change in the prevalence of either hormone therapy use at follow-up or in the rates of hormone therapy discontinuation or initiation from baseline to follow-up.
Given the wide spread media attention to the Women's Health Initiative estrogen plus progestin trial results, our findings suggest comparable dissemination of this information across diverse socioeconomic groups.
[show abstract][hide abstract] ABSTRACT: We sought to examine prescribing patterns (prevalence and rates of initiation and discontinuation) for estrogen plus progestin (hormone therapy [HT] and estrogen alone [ET]) in the United States in the 2 years before the published results of Women's Health Initiative's (WHI) HT trial's early termination and for 5 months after their release.
We conducted an observational cohort study of 169,586 women aged 40-80 years who were enrolled in 5 health maintenance organizations in the United States to estimate the prevalence of HT and ET and discontinuation and initiation rates between September 1, 1999, to June 31, 2002 (baseline), and December 31, 2002 (follow-up). We used automated pharmacy data to identify all oral and transdermal estrogen and progestin dispensed during the study period.
The prevalence of HT declined 46% from baseline to follow-up (14.6% to 7.9%); ET use declined 28% during the same period (12.6% to 9.1%). The discontinuation of HT increased almost immediately, from 2.5% at baseline to 13.8% in October 2002. We saw an immediate decrease in HT and ET initiation rates, from 0.4% and 0.3% at baseline, respectively, to 0.2% for HT and ET at follow-up.
The diffusion of the WHI HT trial results had an immediate impact on the discontinuation of HT and ET and is likely responsible for the 46% and 28% decline in the initiation of these respective therapies. Further exploration of why women continue to use HT and identification of methods for addressing reasons for continued use are indicated.
[show abstract][hide abstract] ABSTRACT: Although back pain is the most common reason patients use complementary and alternative medical (CAM) therapies, little is known about the willingness of primary care back pain patients to try these therapies. As part of an effort to refine recruitment strategies for clinical trials, we sought to determine if back pain patients are willing to try acupuncture, chiropractic, massage, meditation, and t'ai chi and to learn about their knowledge of, experience with, and perceptions about each of these therapies.
We identified English-speaking patients with diagnoses consistent with chronic low back pain using automated visit data from one health care organization in Boston and another in Seattle. We were able to confirm the eligibility status (i.e., current low back pain that had lasted at least 3 months) of 70% of the patients with such diagnoses and all eligible respondents were interviewed.
Except for chiropractic, knowledge about these therapies was low. Chiropractic and massage had been used by the largest fractions of respondents (54% and 38%, respectively), mostly for back pain (45% and 24%, respectively). Among prior users of specific CAM therapies for back pain, massage was rated most helpful. Users of chiropractic reported treatment-related "significant discomfort, pain or harm" more often (23%) than users of other therapies (5-16%). Respondents expected massage would be most helpful (median of 7 on a 0 to 10 scale) and meditation least helpful (median of 3) in relieving their current pain. Most respondents indicated they would be "very likely" to try acupuncture, massage, or chiropractic for their back pain if they did not have to pay out of pocket and their physician thought it was a reasonable treatment option.
Most patients with chronic back pain in our sample were interested in trying therapeutic options that lie outside the conventional medical spectrum. This highlights the need for additional studies evaluating their effectiveness and suggests that researchers conducting clinical trials of these therapies may not have difficulties recruiting patients.
BMC Complementary and Alternative Medicine 08/2004; 4:9. · 2.08 Impact Factor
[show abstract][hide abstract] ABSTRACT: To determine the association of modifiable factors, such as smoking, body mass index, and alcohol use, with hot flashes, and to ascertain whether the association with hot flashes varies by menopausal stage.
A written survey completed by perimenopausal and postmenopausal women enrolling in a randomized, controlled trial of a menopause risk management program in 1999. Survey items included questions on demographics, health status, and health behaviors.
A Massachusetts-based health maintenance organization.
Female members, age 40 to 65, excluding women with chronic conditions precluding study participation, were randomly selected from an automated medical record system.
The majority of the 287 postmenopausal and 468 perimenopausal women participating in the study were white, college educated, and nonsmoking. Approximately 30% of both groups reported experiencing hot flashes. Separate multivariable logistic regression models were developed for perimenopausal and postmenopausal women to identify correlates of reporting any versus no hot flashes. After controlling for age, race, oral contraceptive use, hormone replacement therapy use, and depression, correlates of hot flashes in perimenopausal women were body mass index >/=25 kg/m(2) (odds ration [OR], 2.00; 95% confidence interval [CI], 1.28 to 3.12) and alcohol use of 1 to 5 drinks per week (OR, 0.52; 95% CI, 0.31 to 0.86). The only significant correlate of hot flashes in the postmenopausal population was high dietary fat intake (OR, 0.35; 95% CI, 0.15 to 0.81).
Although study respondents were from similiar sociodemographic groups and received their health care in the same health maintenance organization, modifiable factors associated with hot flashes were different for perimenopausal and postmenopausal women.
Journal of General Internal Medicine 07/2004; 19(7):740-6. · 3.28 Impact Factor
[show abstract][hide abstract] ABSTRACT: It is not known whether factors associated with primary care career choice affect trainees differently at different times or stages of medical education.
To examine how role models, encouragement, and personal characteristics affect career choice at different stages (medical school vs residency) and periods (1994 vs 1997) of training.
A split-panel design with 2 cross-sectional telephone surveys and a panel survey in 1994 and 1997.
A national probability sample of fourth-year students (307 in 1994, 219 in 1997), 645 second-year residents in 1994, and 494 third-year residents in 1997. Of the fourth-year students interviewed in 1994, 241 (78.5%) were re-interviewed as third-year residents in 1997.
Primary care (general internal medicine, general pediatrics, or family medicine) career choice.
Having a primary care role model was a stronger predictor of primary care career choice for residents (odds ratio [OR], 18.0; 95% confidence interval [95% CI], 11.2 to 28.8 in 1994; OR, 43.7; 95% CI, 24.4 to 78.3 in 1997) than for students (OR, 6.5; 95% CI, 4.3 to 10.2; no variation by year). Likewise, peer encouragement was more predictive for residents (OR, 5.4; 95% CI, 3.3 to 8.9 in 1994; OR, 16.6; 95% CI; 9.7 to 28.4 in 1997) than for students (OR, 2.1; 95% CI, 1.3 to 3.2; no variation by year). Orientation to the emotional aspects of care was consistently associated with primary care career choice across stages and years of training.
The effect of peer encouragement and role models on career choice differed for students and residents and, in the case of residents, by year of training, suggesting that interventions to increase the primary care workforce should be tailored to stage of training.
Journal of General Internal Medicine 04/2003; 18(3):159-69. · 3.28 Impact Factor