Kate Johnson

A 6-month genetics educational initiative significantly improved the confidence and competence of family physicians, according to the findings of a small study.

“Primary care providers are going to be increasingly involved in the delivery [of genetics services]. There's a huge literature out there that we're deficient in. We have to be able to assess risk. We have to know when to refer. We have to provide counseling and follow-up after test results. And we are probably increasingly going to be asked to tailor our preventive care, medication choice, and treatments to people's individual genetic profiles,” said Dr. June Carroll, the Sydney G. Frankfort Chair in Family Medicine at Mount Sinai Hospital and the University of Toronto.

The study randomized 125 primary care physicians to an educational intervention (61 physicians) aimed at improving primary care genetics skills, or to a control arm (64 physicians), that received the educational material at the end of the study.

Participating physicians came from both rural and urban practices in the province of Ontario.

The intervention involved a 1-hour workshop conducted by a genetics counselor and a family physician, and a portfolio of primary care–appropriate genetics “tools,” such as genetics pearls, red flags, risk-triage cards, and tables outlining possible consequences of genetic test results.

The most exciting aspect was access to an information service called “Gene Messenger,” according to Dr. Carroll. “Our team scanned the newspapers every day during the time of the trial, and we looked for any big headlines or articles about a new genetic test or a genetic disorder. We then very rapidly developed a critical review of that disorder or test, and came up with bottom-line recommendations for primary care,” she explained.

The one- to two-page reports were written by a genetics counselor, with input from geneticists and family physicians, and were e-mailed or faxed to study participants every 2 weeks during the 6 months of the study.

“We produced 16 of these reviews over the course of the project. They were as evidence based as possible, although sometimes we did have to use expert opinion. And they were fully referenced,” she said.

Study participants were assessed 1 month before and 6 months after the intervention for the primary outcome of the study, which was the appropriate intention to refer a patient for genetic counseling. Secondary outcomes looked at the participants' perception of the difficulty in making a decision and their self-rated confidence in a set of 11 core genetics competencies, as defined by the National Coalition for Health Professional Education in Genetics.

All participating physicians also answered the following three questions about hereditary breast and colorectal cancer:

▸ Is there paternal inheritance of the BRCA mutations? (Answer: yes)

▸ What percentage of breast cancer patients have a BRCA mutation? (Answer: fewer than 10%)

▸ What percentage of people with the HNPCC (hereditary nonpolyposis colo-rectal cancer) gene will get colorectal cancer? (Answer: more than 50%)

These are the “big ticket items” in genetics that family physicians need to know in order to advise their patients, she said.

Compared with physicians in the control arm, those in the intervention arm showed a statistically significant improvement from baseline in their appropriate intention to refer patients, based on a set of 10 clinical vignettes (7.8 of 10 vs. 6.4 of 10 for controls).

In addition, self-reported confidence was significantly higher among physicians in the intervention group (43 of 55, compared with 34 in the control group).

“We saw an increase across all 11 items of family physician core competencies in genetics,” said Dr. Carroll. For example, physicians were more confident eliciting genetic information from a family history; doing risk assessment and deciding who should be offered referral; discussing risks, benefits, and limitations of genetic testing; knowing where to refer; providing psychosocial support for those who have had genetic test results; providing management and following people who have had genetic test results; and reassuring patients who are at low risk. Handling all of these areas is “going to be a big job for us in the future,” she said.

Yet despite their increased confidence, physicians in the intervention group scored no better than controls on the first two knowledge questions. The percentage of correct answers “was low for two of the questions, and a large percentage said they weren't sure,” said Dr. Carroll.

The group hopes to expand the intervention to include a wider range of conditions, and to distribute the material to more physicians. “It would be ideal to have one center that was developing these reviews and recommendations in response to the media and new discoveries, and having them disseminated widely so that family physicians could get timely information to share with their patients about new genetic information,” she said.

The Gene Messengers are being published by Canadian Family Physician and can be seen at www.cfp.ca/misc/collections.dtlwww.mtsinai.on.ca/FamMedGen

The study was funded by the Canadian Institutes of Health Research, and Dr. Carroll reported having no conflicts of interest.

A 6-month genetics educational initiative significantly improved the confidence and competence of family physicians, according to the findings of a small study.

“Primary care providers are going to be increasingly involved in the delivery [of genetics services]. There's a huge literature out there that we're deficient in. We have to be able to assess risk. We have to know when to refer. We have to provide counseling and follow-up after test results. And we are probably increasingly going to be asked to tailor our preventive care, medication choice, and treatments to people's individual genetic profiles,” said Dr. June Carroll, the Sydney G. Frankfort Chair in Family Medicine at Mount Sinai Hospital and the University of Toronto.

The study randomized 125 primary care physicians to an educational intervention (61 physicians) aimed at improving primary care genetics skills, or to a control arm (64 physicians), that received the educational material at the end of the study.

Participating physicians came from both rural and urban practices in the province of Ontario.

The intervention involved a 1-hour workshop conducted by a genetics counselor and a family physician, and a portfolio of primary care–appropriate genetics “tools,” such as genetics pearls, red flags, risk-triage cards, and tables outlining possible consequences of genetic test results.

The most exciting aspect was access to an information service called “Gene Messenger,” according to Dr. Carroll. “Our team scanned the newspapers every day during the time of the trial, and we looked for any big headlines or articles about a new genetic test or a genetic disorder. We then very rapidly developed a critical review of that disorder or test, and came up with bottom-line recommendations for primary care,” she explained.

The one- to two-page reports were written by a genetics counselor, with input from geneticists and family physicians, and were e-mailed or faxed to study participants every 2 weeks during the 6 months of the study.

“We produced 16 of these reviews over the course of the project. They were as evidence based as possible, although sometimes we did have to use expert opinion. And they were fully referenced,” she said.

Study participants were assessed 1 month before and 6 months after the intervention for the primary outcome of the study, which was the appropriate intention to refer a patient for genetic counseling. Secondary outcomes looked at the participants' perception of the difficulty in making a decision and their self-rated confidence in a set of 11 core genetics competencies, as defined by the National Coalition for Health Professional Education in Genetics.

All participating physicians also answered the following three questions about hereditary breast and colorectal cancer:

▸ Is there paternal inheritance of the BRCA mutations? (Answer: yes)

▸ What percentage of breast cancer patients have a BRCA mutation? (Answer: fewer than 10%)

▸ What percentage of people with the HNPCC (hereditary nonpolyposis colo-rectal cancer) gene will get colorectal cancer? (Answer: more than 50%)

These are the “big ticket items” in genetics that family physicians need to know in order to advise their patients, she said.

Compared with physicians in the control arm, those in the intervention arm showed a statistically significant improvement from baseline in their appropriate intention to refer patients, based on a set of 10 clinical vignettes (7.8 of 10 vs. 6.4 of 10 for controls).

In addition, self-reported confidence was significantly higher among physicians in the intervention group (43 of 55, compared with 34 in the control group).

“We saw an increase across all 11 items of family physician core competencies in genetics,” said Dr. Carroll. For example, physicians were more confident eliciting genetic information from a family history; doing risk assessment and deciding who should be offered referral; discussing risks, benefits, and limitations of genetic testing; knowing where to refer; providing psychosocial support for those who have had genetic test results; providing management and following people who have had genetic test results; and reassuring patients who are at low risk. Handling all of these areas is “going to be a big job for us in the future,” she said.

Yet despite their increased confidence, physicians in the intervention group scored no better than controls on the first two knowledge questions. The percentage of correct answers “was low for two of the questions, and a large percentage said they weren't sure,” said Dr. Carroll.

The group hopes to expand the intervention to include a wider range of conditions, and to distribute the material to more physicians. “It would be ideal to have one center that was developing these reviews and recommendations in response to the media and new discoveries, and having them disseminated widely so that family physicians could get timely information to share with their patients about new genetic information,” she said.

The Gene Messengers are being published by Canadian Family Physician and can be seen at www.cfp.ca/misc/collections.dtlwww.mtsinai.on.ca/FamMedGen

The study was funded by the Canadian Institutes of Health Research, and Dr. Carroll reported having no conflicts of interest.

A 6-month genetics educational initiative significantly improved the confidence and competence of family physicians, according to the findings of a small study.

“Primary care providers are going to be increasingly involved in the delivery [of genetics services]. There's a huge literature out there that we're deficient in. We have to be able to assess risk. We have to know when to refer. We have to provide counseling and follow-up after test results. And we are probably increasingly going to be asked to tailor our preventive care, medication choice, and treatments to people's individual genetic profiles,” said Dr. June Carroll, the Sydney G. Frankfort Chair in Family Medicine at Mount Sinai Hospital and the University of Toronto.

The study randomized 125 primary care physicians to an educational intervention (61 physicians) aimed at improving primary care genetics skills, or to a control arm (64 physicians), that received the educational material at the end of the study.

Participating physicians came from both rural and urban practices in the province of Ontario.

The intervention involved a 1-hour workshop conducted by a genetics counselor and a family physician, and a portfolio of primary care–appropriate genetics “tools,” such as genetics pearls, red flags, risk-triage cards, and tables outlining possible consequences of genetic test results.

The most exciting aspect was access to an information service called “Gene Messenger,” according to Dr. Carroll. “Our team scanned the newspapers every day during the time of the trial, and we looked for any big headlines or articles about a new genetic test or a genetic disorder. We then very rapidly developed a critical review of that disorder or test, and came up with bottom-line recommendations for primary care,” she explained.

The one- to two-page reports were written by a genetics counselor, with input from geneticists and family physicians, and were e-mailed or faxed to study participants every 2 weeks during the 6 months of the study.

“We produced 16 of these reviews over the course of the project. They were as evidence based as possible, although sometimes we did have to use expert opinion. And they were fully referenced,” she said.

Study participants were assessed 1 month before and 6 months after the intervention for the primary outcome of the study, which was the appropriate intention to refer a patient for genetic counseling. Secondary outcomes looked at the participants' perception of the difficulty in making a decision and their self-rated confidence in a set of 11 core genetics competencies, as defined by the National Coalition for Health Professional Education in Genetics.

All participating physicians also answered the following three questions about hereditary breast and colorectal cancer:

▸ Is there paternal inheritance of the BRCA mutations? (Answer: yes)

▸ What percentage of breast cancer patients have a BRCA mutation? (Answer: fewer than 10%)

▸ What percentage of people with the HNPCC (hereditary nonpolyposis colo-rectal cancer) gene will get colorectal cancer? (Answer: more than 50%)

These are the “big ticket items” in genetics that family physicians need to know in order to advise their patients, she said.

Compared with physicians in the control arm, those in the intervention arm showed a statistically significant improvement from baseline in their appropriate intention to refer patients, based on a set of 10 clinical vignettes (7.8 of 10 vs. 6.4 of 10 for controls).

In addition, self-reported confidence was significantly higher among physicians in the intervention group (43 of 55, compared with 34 in the control group).

“We saw an increase across all 11 items of family physician core competencies in genetics,” said Dr. Carroll. For example, physicians were more confident eliciting genetic information from a family history; doing risk assessment and deciding who should be offered referral; discussing risks, benefits, and limitations of genetic testing; knowing where to refer; providing psychosocial support for those who have had genetic test results; providing management and following people who have had genetic test results; and reassuring patients who are at low risk. Handling all of these areas is “going to be a big job for us in the future,” she said.

Yet despite their increased confidence, physicians in the intervention group scored no better than controls on the first two knowledge questions. The percentage of correct answers “was low for two of the questions, and a large percentage said they weren't sure,” said Dr. Carroll.

The group hopes to expand the intervention to include a wider range of conditions, and to distribute the material to more physicians. “It would be ideal to have one center that was developing these reviews and recommendations in response to the media and new discoveries, and having them disseminated widely so that family physicians could get timely information to share with their patients about new genetic information,” she said.

The Gene Messengers are being published by Canadian Family Physician and can be seen at www.cfp.ca/misc/collections.dtlwww.mtsinai.on.ca/FamMedGen

The study was funded by the Canadian Institutes of Health Research, and Dr. Carroll reported having no conflicts of interest.

MONTREAL — Locally designed and delivered lifestyle interventions can result in clinically meaningful improvements in patient health, according to preliminary findings from a statewide initiative aimed at decreasing health disparities.

“The idea behind it is to locally define the interventions, because the people who live and work in those communities know the most about what might work best,” said Lauren Whetstone, Ph.D., who presented the findings in a poster at the annual meeting of the North American Primary Care Research Group.

Using a $9.2 million grant from the North Carolina Health and Wellness Trust Fund, 18 local governments and nonprofit organizations developed local interventions targeting obesity, cardiovascular disease, diabetes, and lifestyle issues in the specific communities.

Most of the communities had large African American or Native American populations that were underserved and had poor access to health care, explained Dr. Whetstone of East Carolina University, Greenville, N.C.

Some of the interventions involved health systems implementing home medical visits for diabetic patients. Other interventions involved churches establishing physical exercise and nutrition classes before Bible study, Dr. Whetstone explained in an interview.

In each community, a cohort of participants were followed longitudinally for an average of 19.5 months. Data were collected on biologic and behavioral outcomes such as blood pressure, blood glucose and cholesterol levels, dietary habits, physical activity, and smoking.

Each community had different needs, so the interventions were different and the specific measures for determining outcomes varied. However, a collective analysis of the combined data for 2,504 participants (average age, 53 years) showed a positive impact in several areas.

Among 67 diabetic patients, mean hemoglobin A_1c levels dropped from a baseline level of 8.9% to 8.0% by the end of the study period.

Among 203 hypertensive patients, mean systolic blood pressure dropped from a baseline of 141.62 mm Hg to 137.24 mm Hg.

Mean body mass index did not change, but data from the first half of the study period showed significant increases in self-reported daily fruit and vegetable intake (2.34 to 2.88 servings), mean days of physical activity per week (3.22 to 3.56), and mean self-rated health. There was a slight decrease in the number of current smokers (13.9% to 13.2%).

Although the study had significant limitations, including possible selection bias and lack of controls, improvements of this magnitude, if sustained, have been associated with reductions in diabetes and cardiovascular morbidity and mortality, Dr. Whetstone said.

She attributed the success to the fact that the interventions were locally defined and administered. “We've learned a lot about the differences in how organizers work within one population compared to another,” she said. For example, within the Native American population, communication and the development of trust were rooted in the tribal circle, where all community organization and business is centered.

“I think going directly to communities is going to be the way we can make the most change,” said Dr. Sally P. Weaver, a meeting delegate who commented on the study.

Dr. Weaver, of the McLennan County Medical Education and Research Foundation in Waco, Tex., added that the study's blood pressure results were not clinically significant. However, she said she was particularly impressed by the reported drop in blood glucose levels.

“I was surprised to see that much of a change. It was clinically significant. So whatever they're doing is working,” she said.

MONTREAL — Locally designed and delivered lifestyle interventions can result in clinically meaningful improvements in patient health, according to preliminary findings from a statewide initiative aimed at decreasing health disparities.

“The idea behind it is to locally define the interventions, because the people who live and work in those communities know the most about what might work best,” said Lauren Whetstone, Ph.D., who presented the findings in a poster at the annual meeting of the North American Primary Care Research Group.

Using a $9.2 million grant from the North Carolina Health and Wellness Trust Fund, 18 local governments and nonprofit organizations developed local interventions targeting obesity, cardiovascular disease, diabetes, and lifestyle issues in the specific communities.

Most of the communities had large African American or Native American populations that were underserved and had poor access to health care, explained Dr. Whetstone of East Carolina University, Greenville, N.C.

Some of the interventions involved health systems implementing home medical visits for diabetic patients. Other interventions involved churches establishing physical exercise and nutrition classes before Bible study, Dr. Whetstone explained in an interview.

In each community, a cohort of participants were followed longitudinally for an average of 19.5 months. Data were collected on biologic and behavioral outcomes such as blood pressure, blood glucose and cholesterol levels, dietary habits, physical activity, and smoking.

Each community had different needs, so the interventions were different and the specific measures for determining outcomes varied. However, a collective analysis of the combined data for 2,504 participants (average age, 53 years) showed a positive impact in several areas.

Among 67 diabetic patients, mean hemoglobin A_1c levels dropped from a baseline level of 8.9% to 8.0% by the end of the study period.

Among 203 hypertensive patients, mean systolic blood pressure dropped from a baseline of 141.62 mm Hg to 137.24 mm Hg.

Mean body mass index did not change, but data from the first half of the study period showed significant increases in self-reported daily fruit and vegetable intake (2.34 to 2.88 servings), mean days of physical activity per week (3.22 to 3.56), and mean self-rated health. There was a slight decrease in the number of current smokers (13.9% to 13.2%).

Although the study had significant limitations, including possible selection bias and lack of controls, improvements of this magnitude, if sustained, have been associated with reductions in diabetes and cardiovascular morbidity and mortality, Dr. Whetstone said.

She attributed the success to the fact that the interventions were locally defined and administered. “We've learned a lot about the differences in how organizers work within one population compared to another,” she said. For example, within the Native American population, communication and the development of trust were rooted in the tribal circle, where all community organization and business is centered.

“I think going directly to communities is going to be the way we can make the most change,” said Dr. Sally P. Weaver, a meeting delegate who commented on the study.

Dr. Weaver, of the McLennan County Medical Education and Research Foundation in Waco, Tex., added that the study's blood pressure results were not clinically significant. However, she said she was particularly impressed by the reported drop in blood glucose levels.

“I was surprised to see that much of a change. It was clinically significant. So whatever they're doing is working,” she said.

MONTREAL — Locally designed and delivered lifestyle interventions can result in clinically meaningful improvements in patient health, according to preliminary findings from a statewide initiative aimed at decreasing health disparities.

“The idea behind it is to locally define the interventions, because the people who live and work in those communities know the most about what might work best,” said Lauren Whetstone, Ph.D., who presented the findings in a poster at the annual meeting of the North American Primary Care Research Group.

Using a $9.2 million grant from the North Carolina Health and Wellness Trust Fund, 18 local governments and nonprofit organizations developed local interventions targeting obesity, cardiovascular disease, diabetes, and lifestyle issues in the specific communities.

Most of the communities had large African American or Native American populations that were underserved and had poor access to health care, explained Dr. Whetstone of East Carolina University, Greenville, N.C.

Some of the interventions involved health systems implementing home medical visits for diabetic patients. Other interventions involved churches establishing physical exercise and nutrition classes before Bible study, Dr. Whetstone explained in an interview.

In each community, a cohort of participants were followed longitudinally for an average of 19.5 months. Data were collected on biologic and behavioral outcomes such as blood pressure, blood glucose and cholesterol levels, dietary habits, physical activity, and smoking.

Each community had different needs, so the interventions were different and the specific measures for determining outcomes varied. However, a collective analysis of the combined data for 2,504 participants (average age, 53 years) showed a positive impact in several areas.

Among 67 diabetic patients, mean hemoglobin A_1c levels dropped from a baseline level of 8.9% to 8.0% by the end of the study period.

Among 203 hypertensive patients, mean systolic blood pressure dropped from a baseline of 141.62 mm Hg to 137.24 mm Hg.

Mean body mass index did not change, but data from the first half of the study period showed significant increases in self-reported daily fruit and vegetable intake (2.34 to 2.88 servings), mean days of physical activity per week (3.22 to 3.56), and mean self-rated health. There was a slight decrease in the number of current smokers (13.9% to 13.2%).

Although the study had significant limitations, including possible selection bias and lack of controls, improvements of this magnitude, if sustained, have been associated with reductions in diabetes and cardiovascular morbidity and mortality, Dr. Whetstone said.

She attributed the success to the fact that the interventions were locally defined and administered. “We've learned a lot about the differences in how organizers work within one population compared to another,” she said. For example, within the Native American population, communication and the development of trust were rooted in the tribal circle, where all community organization and business is centered.

“I think going directly to communities is going to be the way we can make the most change,” said Dr. Sally P. Weaver, a meeting delegate who commented on the study.

Dr. Weaver, of the McLennan County Medical Education and Research Foundation in Waco, Tex., added that the study's blood pressure results were not clinically significant. However, she said she was particularly impressed by the reported drop in blood glucose levels.

“I was surprised to see that much of a change. It was clinically significant. So whatever they're doing is working,” she said.

MONTREAL — Primary care physicians are not confident when it comes to diagnosing and managing patients with bipolar depression, according to a cross-sectional survey of providers participating in a national electronic health record database.

Among 85 primary care providers in GE Healthcare's Medical Quality Improvement Consortium, self-rated confidence in managing bipolar disorder averaged 1.7 on a scale of 1 to 5, with 5 being “very confident,” said Dr. Dana King, who presented the findings as a poster at the annual meeting of the North American Primary Care Research Group.

“For other more common disorders such as reflux disease, heart disease, or diabetes, these physicians have more confidence in their ability to sort out complex problems and deal with them. But bipolar disorder is less common and people have less exposure to it during their training,” explained Dr. King, a professor at the Medical University of South Carolina, Charleston.

Of the respondents, 86% had been using electronic health records for 3 or more years, and 94% had access to the Internet from their clinical workstations. At the same time, only 8% had recommended Web site information on bipolar disorder to their patients in the last 3 months.

Although 72% of the respondents said they screened depressed patients for bipolar disorder, 38% reported frequently using a standard screening tool, the most common being the Mood Disorder Questionnaire.

Informal screening was more common than was the use of standardized tools and consisted of “a few questions about manic activity in patients with depression,” Dr. King said. Such information screening may involve questions such as, “Do you go on spending sprees? Do you stay up all night? Do you find yourself having ups and downs, including periods of high irritability, anger, or stress?”

As the use of electronic medical records becomes more widespread, they may help prompt physicians to screen patients for bipolar disorder by offering pop-up information, he said. This represents an opportunity for quality improvement.

“Physicians seem to like the idea that we could offer them quick medical information via the electronic medical record that will give them some quick answers,” he said.

The survey did not include formal interviews, but discussions with the participants have revealed that they prefer referring patients with suspected bipolar disorder to mental health specialists if screening comes up positive, Dr. King said. “Many are willing to comanage the patient, but they first want the diagnosis to be confirmed, typed according to bipolar I or II, with an identification of the phase and recommended medications.”

The study was funded by Delaware Valley Outcomes Research and GE Healthcare as part of a quality improvement project dealing with several medical disorders.

MONTREAL — Primary care physicians are not confident when it comes to diagnosing and managing patients with bipolar depression, according to a cross-sectional survey of providers participating in a national electronic health record database.

Among 85 primary care providers in GE Healthcare's Medical Quality Improvement Consortium, self-rated confidence in managing bipolar disorder averaged 1.7 on a scale of 1 to 5, with 5 being “very confident,” said Dr. Dana King, who presented the findings as a poster at the annual meeting of the North American Primary Care Research Group.

“For other more common disorders such as reflux disease, heart disease, or diabetes, these physicians have more confidence in their ability to sort out complex problems and deal with them. But bipolar disorder is less common and people have less exposure to it during their training,” explained Dr. King, a professor at the Medical University of South Carolina, Charleston.

Of the respondents, 86% had been using electronic health records for 3 or more years, and 94% had access to the Internet from their clinical workstations. At the same time, only 8% had recommended Web site information on bipolar disorder to their patients in the last 3 months.

Although 72% of the respondents said they screened depressed patients for bipolar disorder, 38% reported frequently using a standard screening tool, the most common being the Mood Disorder Questionnaire.

Informal screening was more common than was the use of standardized tools and consisted of “a few questions about manic activity in patients with depression,” Dr. King said. Such information screening may involve questions such as, “Do you go on spending sprees? Do you stay up all night? Do you find yourself having ups and downs, including periods of high irritability, anger, or stress?”

As the use of electronic medical records becomes more widespread, they may help prompt physicians to screen patients for bipolar disorder by offering pop-up information, he said. This represents an opportunity for quality improvement.

“Physicians seem to like the idea that we could offer them quick medical information via the electronic medical record that will give them some quick answers,” he said.

The survey did not include formal interviews, but discussions with the participants have revealed that they prefer referring patients with suspected bipolar disorder to mental health specialists if screening comes up positive, Dr. King said. “Many are willing to comanage the patient, but they first want the diagnosis to be confirmed, typed according to bipolar I or II, with an identification of the phase and recommended medications.”

The study was funded by Delaware Valley Outcomes Research and GE Healthcare as part of a quality improvement project dealing with several medical disorders.

MONTREAL — Primary care physicians are not confident when it comes to diagnosing and managing patients with bipolar depression, according to a cross-sectional survey of providers participating in a national electronic health record database.

Among 85 primary care providers in GE Healthcare's Medical Quality Improvement Consortium, self-rated confidence in managing bipolar disorder averaged 1.7 on a scale of 1 to 5, with 5 being “very confident,” said Dr. Dana King, who presented the findings as a poster at the annual meeting of the North American Primary Care Research Group.

“For other more common disorders such as reflux disease, heart disease, or diabetes, these physicians have more confidence in their ability to sort out complex problems and deal with them. But bipolar disorder is less common and people have less exposure to it during their training,” explained Dr. King, a professor at the Medical University of South Carolina, Charleston.

Of the respondents, 86% had been using electronic health records for 3 or more years, and 94% had access to the Internet from their clinical workstations. At the same time, only 8% had recommended Web site information on bipolar disorder to their patients in the last 3 months.

Although 72% of the respondents said they screened depressed patients for bipolar disorder, 38% reported frequently using a standard screening tool, the most common being the Mood Disorder Questionnaire.

Informal screening was more common than was the use of standardized tools and consisted of “a few questions about manic activity in patients with depression,” Dr. King said. Such information screening may involve questions such as, “Do you go on spending sprees? Do you stay up all night? Do you find yourself having ups and downs, including periods of high irritability, anger, or stress?”

As the use of electronic medical records becomes more widespread, they may help prompt physicians to screen patients for bipolar disorder by offering pop-up information, he said. This represents an opportunity for quality improvement.

“Physicians seem to like the idea that we could offer them quick medical information via the electronic medical record that will give them some quick answers,” he said.

The survey did not include formal interviews, but discussions with the participants have revealed that they prefer referring patients with suspected bipolar disorder to mental health specialists if screening comes up positive, Dr. King said. “Many are willing to comanage the patient, but they first want the diagnosis to be confirmed, typed according to bipolar I or II, with an identification of the phase and recommended medications.”

The study was funded by Delaware Valley Outcomes Research and GE Healthcare as part of a quality improvement project dealing with several medical disorders.

MONTREAL — Locally designed and delivered lifestyle interventions can result in clinically meaningful improvements in patient health, according to preliminary findings from a statewide initiative aimed at decreasing health disparities.

People who live and work in a community “know the most about what might work best,” said Lauren Whetstone, Ph.D., who presented the findings in a poster at the annual meeting of the North American Primary Care Research Group.

Using a $9.2 million grant from the North Carolina Health and Wellness Trust Fund, 18 local governments and nonprofit organizations developed local interventions targeting obesity, cardiovascular disease, diabetes, and lifestyle issues in the specific communities.

Most of the communities had large African American or Native American populations that were underserved and had poor access to health care, explained Dr. Whetstone of East Carolina University, Greenville, N.C.

Some of the interventions involved health systems implementing home medical visits for diabetic patients. Other interventions involved churches establishing physical exercise and nutrition classes before Bible study.

In each community, a cohort of participants were followed longitudinally for an average of 19.5 months. Data were collected on biologic and behavioral outcomes such as blood pressure, blood glucose and cholesterol levels, dietary habits, physical activity, and smoking. Several of the communities had lay health advisers who were trained to collect some of the clinical information, or who arranged for the data to be collected by a health professional.

Each individual community had different needs, so the interventions were different and the specific measures for determining outcomes varied. However, a collective analysis of the combined data for 2,504 participants (average age 53 years) showed a positive impact.

Among 67 diabetic patients, mean hemoglobin A_1c levels dropped from a baseline level of 8.9% to 8.0% by the end of the study period.

Among 203 hypertensive patients, mean systolic blood pressure dropped from a baseline of 141.62 mm Hg to 137.24 mm Hg.

Mean body mass index did not change, but data from the first half of the study period showed significant increases in self-reported daily fruit and vegetable intake (2.34 to 2.88 servings), mean days of physical activity per week (3.22 to 3.56), and mean self-rated health. There was a slight decrease in the number of current smokers (13.9% to 13.2%).

Although the study had significant limitations, including possible selection bias and lack of controls, improvements of this magnitude, if sustained, have been associated with reductions in diabetes and cardiovascular morbidity and mortality, Dr. Whetstone said.

“We've learned a lot about the differences in how organizers work within one population compared to another,” she said. For example, within the Native American population, communication and the development of trust were rooted in the tribal circle, where all community organization and business is centered.

“I think going directly to communities is going to be the way we can make the most change,” said Dr. Sally P. Weaver, director of research for the Family Health Center at the McLennan County Medical Education and Research Foundation in Waco, Tex. “Interventions need to somehow get into the broader community for people who are not seeing physicians, because I think so much of our health problems are community based with the availability of fast foods and lack of safe places to exercise.”

'I think going directly to communities is going to be the way we can make the most change.'

Source DR. WEAVER

MONTREAL — Locally designed and delivered lifestyle interventions can result in clinically meaningful improvements in patient health, according to preliminary findings from a statewide initiative aimed at decreasing health disparities.

People who live and work in a community “know the most about what might work best,” said Lauren Whetstone, Ph.D., who presented the findings in a poster at the annual meeting of the North American Primary Care Research Group.

Using a $9.2 million grant from the North Carolina Health and Wellness Trust Fund, 18 local governments and nonprofit organizations developed local interventions targeting obesity, cardiovascular disease, diabetes, and lifestyle issues in the specific communities.

Most of the communities had large African American or Native American populations that were underserved and had poor access to health care, explained Dr. Whetstone of East Carolina University, Greenville, N.C.

Some of the interventions involved health systems implementing home medical visits for diabetic patients. Other interventions involved churches establishing physical exercise and nutrition classes before Bible study.

In each community, a cohort of participants were followed longitudinally for an average of 19.5 months. Data were collected on biologic and behavioral outcomes such as blood pressure, blood glucose and cholesterol levels, dietary habits, physical activity, and smoking. Several of the communities had lay health advisers who were trained to collect some of the clinical information, or who arranged for the data to be collected by a health professional.

Each individual community had different needs, so the interventions were different and the specific measures for determining outcomes varied. However, a collective analysis of the combined data for 2,504 participants (average age 53 years) showed a positive impact.

Among 67 diabetic patients, mean hemoglobin A_1c levels dropped from a baseline level of 8.9% to 8.0% by the end of the study period.

Among 203 hypertensive patients, mean systolic blood pressure dropped from a baseline of 141.62 mm Hg to 137.24 mm Hg.

Mean body mass index did not change, but data from the first half of the study period showed significant increases in self-reported daily fruit and vegetable intake (2.34 to 2.88 servings), mean days of physical activity per week (3.22 to 3.56), and mean self-rated health. There was a slight decrease in the number of current smokers (13.9% to 13.2%).

Although the study had significant limitations, including possible selection bias and lack of controls, improvements of this magnitude, if sustained, have been associated with reductions in diabetes and cardiovascular morbidity and mortality, Dr. Whetstone said.

“We've learned a lot about the differences in how organizers work within one population compared to another,” she said. For example, within the Native American population, communication and the development of trust were rooted in the tribal circle, where all community organization and business is centered.

“I think going directly to communities is going to be the way we can make the most change,” said Dr. Sally P. Weaver, director of research for the Family Health Center at the McLennan County Medical Education and Research Foundation in Waco, Tex. “Interventions need to somehow get into the broader community for people who are not seeing physicians, because I think so much of our health problems are community based with the availability of fast foods and lack of safe places to exercise.”

'I think going directly to communities is going to be the way we can make the most change.'

Source DR. WEAVER

MONTREAL — Locally designed and delivered lifestyle interventions can result in clinically meaningful improvements in patient health, according to preliminary findings from a statewide initiative aimed at decreasing health disparities.

People who live and work in a community “know the most about what might work best,” said Lauren Whetstone, Ph.D., who presented the findings in a poster at the annual meeting of the North American Primary Care Research Group.

Using a $9.2 million grant from the North Carolina Health and Wellness Trust Fund, 18 local governments and nonprofit organizations developed local interventions targeting obesity, cardiovascular disease, diabetes, and lifestyle issues in the specific communities.

Most of the communities had large African American or Native American populations that were underserved and had poor access to health care, explained Dr. Whetstone of East Carolina University, Greenville, N.C.

Some of the interventions involved health systems implementing home medical visits for diabetic patients. Other interventions involved churches establishing physical exercise and nutrition classes before Bible study.

In each community, a cohort of participants were followed longitudinally for an average of 19.5 months. Data were collected on biologic and behavioral outcomes such as blood pressure, blood glucose and cholesterol levels, dietary habits, physical activity, and smoking. Several of the communities had lay health advisers who were trained to collect some of the clinical information, or who arranged for the data to be collected by a health professional.

Each individual community had different needs, so the interventions were different and the specific measures for determining outcomes varied. However, a collective analysis of the combined data for 2,504 participants (average age 53 years) showed a positive impact.

Among 67 diabetic patients, mean hemoglobin A_1c levels dropped from a baseline level of 8.9% to 8.0% by the end of the study period.

Among 203 hypertensive patients, mean systolic blood pressure dropped from a baseline of 141.62 mm Hg to 137.24 mm Hg.

Mean body mass index did not change, but data from the first half of the study period showed significant increases in self-reported daily fruit and vegetable intake (2.34 to 2.88 servings), mean days of physical activity per week (3.22 to 3.56), and mean self-rated health. There was a slight decrease in the number of current smokers (13.9% to 13.2%).

Although the study had significant limitations, including possible selection bias and lack of controls, improvements of this magnitude, if sustained, have been associated with reductions in diabetes and cardiovascular morbidity and mortality, Dr. Whetstone said.

“We've learned a lot about the differences in how organizers work within one population compared to another,” she said. For example, within the Native American population, communication and the development of trust were rooted in the tribal circle, where all community organization and business is centered.

“I think going directly to communities is going to be the way we can make the most change,” said Dr. Sally P. Weaver, director of research for the Family Health Center at the McLennan County Medical Education and Research Foundation in Waco, Tex. “Interventions need to somehow get into the broader community for people who are not seeing physicians, because I think so much of our health problems are community based with the availability of fast foods and lack of safe places to exercise.”

'I think going directly to communities is going to be the way we can make the most change.'

Source DR. WEAVER

MONTREAL — Four different injection therapies appear to be effective for refractory lateral epicondylosis (tennis elbow) and offer additional treatment options for patients who have failed conservative care, suggest results of a systematic review.

“We know that 80% of these injuries get better on their own, but for the ones that don't, these injection therapies make sense,” Dr. David Rabago said at the annual meeting of the North American Primary Care Research Group.

Dr. Rabago of the University of Wisconsin, Madison, reviewed the evidence for prolotherapy, polidocanol injection, autologous whole-blood injection, and platelet-rich plasma injection therapies (Br. J. Sports Med. 2009;43:471–81).

Out of 21 possible studies, 9 studies met inclusion criteria: 5 prospective case series and 4 controlled trials. Three studies focused on prolotherapy, two on polidocanol injection, three on autologous whole-blood injection, and one on platelet-rich plasma injection.

The total number of patients in all studies combined was 201, and they ranged in age from 19 to 66 years old. Refractory elbow pain ranged anywhere from 3 to 25 months, and the follow-up periods ranged from 9 to 108 weeks.

Reduced pain was the primary outcome of each study, rated according to a visual analog scale or pain questionnaire. Improvement from baseline or compared with controls ranged from 51% to 94%, said Dr. Rabago. Secondary outcomes, which included elbow function and a decrease in abnormalities or vascularity on ultrasound, also showed improvement in all studies.

These moderate to large effect sizes were sustained over 12–25 months, and “far exceed minimal clinically relevant effect sizes for chronic pain,” said Dr. Rabago.

There were no adverse events reported.

Polidocanol is a vascular sclerosant that is injected into areas of high intratendinous blood flow in the elbow, using high-resolution ultrasound and color Doppler visualization. Its mechanism of action is believed to be the interruption of neovascular pathology, which is associated with pain and degeneration. Polidocanol is the most commonly used therapy worldwide, but is not available in the United States.

Prolotherapy also involves the injection of vascular sclerosants (most often hyperosmolar dextrose or morrhuate sodium), but does not require ultrasound guidance.

Autologous whole blood involves drawing blood from the patient and injecting it into the painful area to trigger a healing response.

Platelet-rich plasma is centrifuged from autologous whole blood and injected into the painful area to trigger healing with platelet-derived growth factors.

While prolotherapy is the easiest of the four therapies to implement, the reviewed studies showed that it required three treatment sessions, compared with the one or two sessions needed for the other therapies, Dr. Rabago noted.

With some basic training and equipment, all four therapies can be performed in a family medicine office on an outpatient basis, Dr. Rabago said in an interview.

“Each of the studies reviewed is small, and their methodological limitations prevent a consensus recommendation on the use of any of the three therapies, compared with another, at this time. However, the large effect sizes reported by all studies are compelling and suggest several areas of clinical, theoretical, and research interest,” wrote Dr. Rabago and his coauthors in their paper.

One of Dr. Rabago's coauthors is a consultant and lecturer for Harvest Technologies, a manufacturer of centrifuge and ancillary equipment for platelet-rich plasma injection therapy. Harvest had no direct or indirect role in the study. No other coauthor reported any conflict of interest.

MONTREAL — Four different injection therapies appear to be effective for refractory lateral epicondylosis (tennis elbow) and offer additional treatment options for patients who have failed conservative care, suggest results of a systematic review.

“We know that 80% of these injuries get better on their own, but for the ones that don't, these injection therapies make sense,” Dr. David Rabago said at the annual meeting of the North American Primary Care Research Group.

Dr. Rabago of the University of Wisconsin, Madison, reviewed the evidence for prolotherapy, polidocanol injection, autologous whole-blood injection, and platelet-rich plasma injection therapies (Br. J. Sports Med. 2009;43:471–81).

Out of 21 possible studies, 9 studies met inclusion criteria: 5 prospective case series and 4 controlled trials. Three studies focused on prolotherapy, two on polidocanol injection, three on autologous whole-blood injection, and one on platelet-rich plasma injection.

The total number of patients in all studies combined was 201, and they ranged in age from 19 to 66 years old. Refractory elbow pain ranged anywhere from 3 to 25 months, and the follow-up periods ranged from 9 to 108 weeks.

Reduced pain was the primary outcome of each study, rated according to a visual analog scale or pain questionnaire. Improvement from baseline or compared with controls ranged from 51% to 94%, said Dr. Rabago. Secondary outcomes, which included elbow function and a decrease in abnormalities or vascularity on ultrasound, also showed improvement in all studies.

These moderate to large effect sizes were sustained over 12–25 months, and “far exceed minimal clinically relevant effect sizes for chronic pain,” said Dr. Rabago.

There were no adverse events reported.

Polidocanol is a vascular sclerosant that is injected into areas of high intratendinous blood flow in the elbow, using high-resolution ultrasound and color Doppler visualization. Its mechanism of action is believed to be the interruption of neovascular pathology, which is associated with pain and degeneration. Polidocanol is the most commonly used therapy worldwide, but is not available in the United States.

Prolotherapy also involves the injection of vascular sclerosants (most often hyperosmolar dextrose or morrhuate sodium), but does not require ultrasound guidance.

Autologous whole blood involves drawing blood from the patient and injecting it into the painful area to trigger a healing response.

Platelet-rich plasma is centrifuged from autologous whole blood and injected into the painful area to trigger healing with platelet-derived growth factors.

While prolotherapy is the easiest of the four therapies to implement, the reviewed studies showed that it required three treatment sessions, compared with the one or two sessions needed for the other therapies, Dr. Rabago noted.

With some basic training and equipment, all four therapies can be performed in a family medicine office on an outpatient basis, Dr. Rabago said in an interview.

“Each of the studies reviewed is small, and their methodological limitations prevent a consensus recommendation on the use of any of the three therapies, compared with another, at this time. However, the large effect sizes reported by all studies are compelling and suggest several areas of clinical, theoretical, and research interest,” wrote Dr. Rabago and his coauthors in their paper.

One of Dr. Rabago's coauthors is a consultant and lecturer for Harvest Technologies, a manufacturer of centrifuge and ancillary equipment for platelet-rich plasma injection therapy. Harvest had no direct or indirect role in the study. No other coauthor reported any conflict of interest.

MONTREAL — Four different injection therapies appear to be effective for refractory lateral epicondylosis (tennis elbow) and offer additional treatment options for patients who have failed conservative care, suggest results of a systematic review.

“We know that 80% of these injuries get better on their own, but for the ones that don't, these injection therapies make sense,” Dr. David Rabago said at the annual meeting of the North American Primary Care Research Group.

Dr. Rabago of the University of Wisconsin, Madison, reviewed the evidence for prolotherapy, polidocanol injection, autologous whole-blood injection, and platelet-rich plasma injection therapies (Br. J. Sports Med. 2009;43:471–81).

Out of 21 possible studies, 9 studies met inclusion criteria: 5 prospective case series and 4 controlled trials. Three studies focused on prolotherapy, two on polidocanol injection, three on autologous whole-blood injection, and one on platelet-rich plasma injection.

The total number of patients in all studies combined was 201, and they ranged in age from 19 to 66 years old. Refractory elbow pain ranged anywhere from 3 to 25 months, and the follow-up periods ranged from 9 to 108 weeks.

Reduced pain was the primary outcome of each study, rated according to a visual analog scale or pain questionnaire. Improvement from baseline or compared with controls ranged from 51% to 94%, said Dr. Rabago. Secondary outcomes, which included elbow function and a decrease in abnormalities or vascularity on ultrasound, also showed improvement in all studies.

These moderate to large effect sizes were sustained over 12–25 months, and “far exceed minimal clinically relevant effect sizes for chronic pain,” said Dr. Rabago.

There were no adverse events reported.

Polidocanol is a vascular sclerosant that is injected into areas of high intratendinous blood flow in the elbow, using high-resolution ultrasound and color Doppler visualization. Its mechanism of action is believed to be the interruption of neovascular pathology, which is associated with pain and degeneration. Polidocanol is the most commonly used therapy worldwide, but is not available in the United States.

Prolotherapy also involves the injection of vascular sclerosants (most often hyperosmolar dextrose or morrhuate sodium), but does not require ultrasound guidance.

Autologous whole blood involves drawing blood from the patient and injecting it into the painful area to trigger a healing response.

Platelet-rich plasma is centrifuged from autologous whole blood and injected into the painful area to trigger healing with platelet-derived growth factors.

While prolotherapy is the easiest of the four therapies to implement, the reviewed studies showed that it required three treatment sessions, compared with the one or two sessions needed for the other therapies, Dr. Rabago noted.

With some basic training and equipment, all four therapies can be performed in a family medicine office on an outpatient basis, Dr. Rabago said in an interview.

“Each of the studies reviewed is small, and their methodological limitations prevent a consensus recommendation on the use of any of the three therapies, compared with another, at this time. However, the large effect sizes reported by all studies are compelling and suggest several areas of clinical, theoretical, and research interest,” wrote Dr. Rabago and his coauthors in their paper.

One of Dr. Rabago's coauthors is a consultant and lecturer for Harvest Technologies, a manufacturer of centrifuge and ancillary equipment for platelet-rich plasma injection therapy. Harvest had no direct or indirect role in the study. No other coauthor reported any conflict of interest.

MONTREAL – In women with documented cardiovascular risk factors, those with comorbid depression have a greater risk of clinical events, compared with their nondepressed counterparts, according to findings from the Women's Ischemic Syndrome Evaluation (WISE), trial sponsored by the National Heart, Lung, and Blood Institute.

“Many studies have associated depression with an increased risk of cardiovascular disease incidence,” reported Thomas Rutledge, Ph.D., of the department of psychiatry at the University of California, San Diego. “We wanted to know whether the added presence of depression would statistically worsen the relationship between cardiac risk factors and outcome,” he said at the annual meeting of the Society of Behavioral Medicine.

Dr. Rutledge examined the association of cardiovascular disease (CVD) risk factors with actual CVD events in 153 depressed and 718 nondepressed women who were enrolled in the WISE trial. The women were a mean age of 60 years and all of them had been referred for coronary angiography.

CVD risk factors were assessed, including smoking, dyslipidemia, hypertension, obesity, diabetes, and level of physical activity. Depression was defined as self-reported current use of antidepressants to treat depression.

Over a mean follow-up period of 5.9 years, the CVD mortality rate was higher in depressed women with CVD risk factors than it was in nondepressed women with the same risk factors (11.5% vs. 9.2%, respectively). Similarly, depressed women experienced more cardiovascular events such as stroke, myocardial infarction, and heart failure (23.9% vs. 13.3%).

MONTREAL – In women with documented cardiovascular risk factors, those with comorbid depression have a greater risk of clinical events, compared with their nondepressed counterparts, according to findings from the Women's Ischemic Syndrome Evaluation (WISE), trial sponsored by the National Heart, Lung, and Blood Institute.

“Many studies have associated depression with an increased risk of cardiovascular disease incidence,” reported Thomas Rutledge, Ph.D., of the department of psychiatry at the University of California, San Diego. “We wanted to know whether the added presence of depression would statistically worsen the relationship between cardiac risk factors and outcome,” he said at the annual meeting of the Society of Behavioral Medicine.

Dr. Rutledge examined the association of cardiovascular disease (CVD) risk factors with actual CVD events in 153 depressed and 718 nondepressed women who were enrolled in the WISE trial. The women were a mean age of 60 years and all of them had been referred for coronary angiography.

CVD risk factors were assessed, including smoking, dyslipidemia, hypertension, obesity, diabetes, and level of physical activity. Depression was defined as self-reported current use of antidepressants to treat depression.

Over a mean follow-up period of 5.9 years, the CVD mortality rate was higher in depressed women with CVD risk factors than it was in nondepressed women with the same risk factors (11.5% vs. 9.2%, respectively). Similarly, depressed women experienced more cardiovascular events such as stroke, myocardial infarction, and heart failure (23.9% vs. 13.3%).

MONTREAL – In women with documented cardiovascular risk factors, those with comorbid depression have a greater risk of clinical events, compared with their nondepressed counterparts, according to findings from the Women's Ischemic Syndrome Evaluation (WISE), trial sponsored by the National Heart, Lung, and Blood Institute.

“Many studies have associated depression with an increased risk of cardiovascular disease incidence,” reported Thomas Rutledge, Ph.D., of the department of psychiatry at the University of California, San Diego. “We wanted to know whether the added presence of depression would statistically worsen the relationship between cardiac risk factors and outcome,” he said at the annual meeting of the Society of Behavioral Medicine.

Dr. Rutledge examined the association of cardiovascular disease (CVD) risk factors with actual CVD events in 153 depressed and 718 nondepressed women who were enrolled in the WISE trial. The women were a mean age of 60 years and all of them had been referred for coronary angiography.

CVD risk factors were assessed, including smoking, dyslipidemia, hypertension, obesity, diabetes, and level of physical activity. Depression was defined as self-reported current use of antidepressants to treat depression.

Over a mean follow-up period of 5.9 years, the CVD mortality rate was higher in depressed women with CVD risk factors than it was in nondepressed women with the same risk factors (11.5% vs. 9.2%, respectively). Similarly, depressed women experienced more cardiovascular events such as stroke, myocardial infarction, and heart failure (23.9% vs. 13.3%).

MONTREAL — Primary care patients with asthma face a significantly increased risk of developing depression, compared with the nonasthmatic population, according to a longitudinal study.

Furthermore, the combination of asthma and depression carries significantly increased mortality, reported Dr. Paul Walters of the Institute of Psychiatry, King's College, London.

Taken together, the findings suggest that it may be useful for family physicians to consider screening their asthmatic patients for depression, he said at the annual meeting of the North American Primary Care Research Group.

In a previous study, Dr. Walters and his colleagues found that asthma was the third-largest predictor of antidepressant prescriptions in the United Kingdom (Br. J. Psychiatry 2008;193:235–9).

The current longitudinal cohort study, designed to explore the association between asthma and depression, identified 11,275 asthmatic patients with no history of depression and an equal number of control subjects, matched for age and sex from the United Kingdom's General Practice Research Database.

During a 10-year follow-up period, the incidence of depression was significantly higher in the group with asthma, compared with controls (22.4 versus 13.8 per 1,000 person-years); after adjustment for age, sex, chronic illness, and smoking, the odds ratio for depression among asthmatic patients remained elevated (1.5).

Looking next at the asthmatic patients only, the researchers noted those with comorbid depression had an elevated mortality ratio (1.87), compared with those with asthma alone.

“We don't have any information on cause of death, so we're not able to say if it was due to asthma-related reasons or depression-related reasons or a combination of both,” he said.

The biggest difference between the groups was in their frequency of primary care visits (8.3 visits a year for depressed patients versus 5.3 for nondepressed patients).

Dr. Walters had no conflicts of interest to report.

MONTREAL — Primary care patients with asthma face a significantly increased risk of developing depression, compared with the nonasthmatic population, according to a longitudinal study.

Furthermore, the combination of asthma and depression carries significantly increased mortality, reported Dr. Paul Walters of the Institute of Psychiatry, King's College, London.

Taken together, the findings suggest that it may be useful for family physicians to consider screening their asthmatic patients for depression, he said at the annual meeting of the North American Primary Care Research Group.

In a previous study, Dr. Walters and his colleagues found that asthma was the third-largest predictor of antidepressant prescriptions in the United Kingdom (Br. J. Psychiatry 2008;193:235–9).

The current longitudinal cohort study, designed to explore the association between asthma and depression, identified 11,275 asthmatic patients with no history of depression and an equal number of control subjects, matched for age and sex from the United Kingdom's General Practice Research Database.

During a 10-year follow-up period, the incidence of depression was significantly higher in the group with asthma, compared with controls (22.4 versus 13.8 per 1,000 person-years); after adjustment for age, sex, chronic illness, and smoking, the odds ratio for depression among asthmatic patients remained elevated (1.5).

Looking next at the asthmatic patients only, the researchers noted those with comorbid depression had an elevated mortality ratio (1.87), compared with those with asthma alone.

“We don't have any information on cause of death, so we're not able to say if it was due to asthma-related reasons or depression-related reasons or a combination of both,” he said.

The biggest difference between the groups was in their frequency of primary care visits (8.3 visits a year for depressed patients versus 5.3 for nondepressed patients).

Dr. Walters had no conflicts of interest to report.

MONTREAL — Primary care patients with asthma face a significantly increased risk of developing depression, compared with the nonasthmatic population, according to a longitudinal study.

Furthermore, the combination of asthma and depression carries significantly increased mortality, reported Dr. Paul Walters of the Institute of Psychiatry, King's College, London.

Taken together, the findings suggest that it may be useful for family physicians to consider screening their asthmatic patients for depression, he said at the annual meeting of the North American Primary Care Research Group.

In a previous study, Dr. Walters and his colleagues found that asthma was the third-largest predictor of antidepressant prescriptions in the United Kingdom (Br. J. Psychiatry 2008;193:235–9).

The current longitudinal cohort study, designed to explore the association between asthma and depression, identified 11,275 asthmatic patients with no history of depression and an equal number of control subjects, matched for age and sex from the United Kingdom's General Practice Research Database.

During a 10-year follow-up period, the incidence of depression was significantly higher in the group with asthma, compared with controls (22.4 versus 13.8 per 1,000 person-years); after adjustment for age, sex, chronic illness, and smoking, the odds ratio for depression among asthmatic patients remained elevated (1.5).

Looking next at the asthmatic patients only, the researchers noted those with comorbid depression had an elevated mortality ratio (1.87), compared with those with asthma alone.

“We don't have any information on cause of death, so we're not able to say if it was due to asthma-related reasons or depression-related reasons or a combination of both,” he said.

The biggest difference between the groups was in their frequency of primary care visits (8.3 visits a year for depressed patients versus 5.3 for nondepressed patients).

Dr. Walters had no conflicts of interest to report.

MONTREAL – The first real-world effectiveness trial of varenicline for smoking cessation showed that combining the medication with behavioral counseling results in fairly substantial quit rates at 6 months.

Gary Swan, Ph.D., of SRI International, an independent, nonprofit, research and development organization in Menlo Park, Calif., reported on the findings of a trial in which 1,202 smokers, all taking varenicline 2 mg/day, were randomized to one of three behavioral counseling arms: phone only, Internet only, or a combination of both. The counseling programs were available for up to 12 months. The medication was provided by Pfizer Inc., which manufactures varenicline, and the study was funded by the National Cancer Institute. The trial also included researchers from Group Health Center for Health Studies and Free & Clear Inc., both of Seattle.

All of the subjects received a 5–10 minute orientation phone call at the start of the study and were given access to a toll-free phone line. Behavioral counseling based on Free & Clear's Quit for Life Program was then provided via interactive Web tools or through one-on-one phone counseling, or both, Dr. Swan reported at the annual meeting of the Society of Behavioral Medicine.

The average age of the subjects was 47.3 years; two-thirds were female; and they smoked an average of about 20 cigarettes a day.

At the end of the 12-week treatment period, the subjects in the phone counseling group had the highest abstinence rate (48.5%), followed by the phone/Web group (43%), and then the Web-only group (39%). At the 6-month mark, abstinence rates had fallen overall, and there was no longer any statistical difference between groups (34%, 34%, and 31% respectively).

“For those of us who have been working in the field for many years, these are really quite exciting results when compared with other medications, and our results are consistent with those seen in the pre-approval efficacy trials of varenicline,” said Dr. Swan, noting that moderate to severe side effects, including flatulence, altered dreams, altered taste perception, sleep difficulties and changes in appetite, were reported.

He suggested the drop in abstinence after treatment cessation might indicate the need to extend the duration of medication or increase the intensity (frequency of calls) of the behavioral counseling. Phone counseling might improve tolerance to the medication and thus reduce discontinuation because of side effects, he said.

In fact, after 21 days of treatment, a significantly higher percentage of patients in the phone counseling group (87.5%) reported that they were still taking their medication, compared with those in the Web-only group (79%), but not the phone/Web group (83%).

Roughly half of the subjects (48%) reported having made a quit attempt within the preceding year, and the duration of this attempt was a predictor of subsequent success, Dr. Swan noted.

Dr. Swan disclosed that he served as a consultant to Pfizer's National Advisory Board in 2008.

MONTREAL – The first real-world effectiveness trial of varenicline for smoking cessation showed that combining the medication with behavioral counseling results in fairly substantial quit rates at 6 months.

Gary Swan, Ph.D., of SRI International, an independent, nonprofit, research and development organization in Menlo Park, Calif., reported on the findings of a trial in which 1,202 smokers, all taking varenicline 2 mg/day, were randomized to one of three behavioral counseling arms: phone only, Internet only, or a combination of both. The counseling programs were available for up to 12 months. The medication was provided by Pfizer Inc., which manufactures varenicline, and the study was funded by the National Cancer Institute. The trial also included researchers from Group Health Center for Health Studies and Free & Clear Inc., both of Seattle.

All of the subjects received a 5–10 minute orientation phone call at the start of the study and were given access to a toll-free phone line. Behavioral counseling based on Free & Clear's Quit for Life Program was then provided via interactive Web tools or through one-on-one phone counseling, or both, Dr. Swan reported at the annual meeting of the Society of Behavioral Medicine.

The average age of the subjects was 47.3 years; two-thirds were female; and they smoked an average of about 20 cigarettes a day.

At the end of the 12-week treatment period, the subjects in the phone counseling group had the highest abstinence rate (48.5%), followed by the phone/Web group (43%), and then the Web-only group (39%). At the 6-month mark, abstinence rates had fallen overall, and there was no longer any statistical difference between groups (34%, 34%, and 31% respectively).

“For those of us who have been working in the field for many years, these are really quite exciting results when compared with other medications, and our results are consistent with those seen in the pre-approval efficacy trials of varenicline,” said Dr. Swan, noting that moderate to severe side effects, including flatulence, altered dreams, altered taste perception, sleep difficulties and changes in appetite, were reported.

He suggested the drop in abstinence after treatment cessation might indicate the need to extend the duration of medication or increase the intensity (frequency of calls) of the behavioral counseling. Phone counseling might improve tolerance to the medication and thus reduce discontinuation because of side effects, he said.

In fact, after 21 days of treatment, a significantly higher percentage of patients in the phone counseling group (87.5%) reported that they were still taking their medication, compared with those in the Web-only group (79%), but not the phone/Web group (83%).

Roughly half of the subjects (48%) reported having made a quit attempt within the preceding year, and the duration of this attempt was a predictor of subsequent success, Dr. Swan noted.

Dr. Swan disclosed that he served as a consultant to Pfizer's National Advisory Board in 2008.

MONTREAL – The first real-world effectiveness trial of varenicline for smoking cessation showed that combining the medication with behavioral counseling results in fairly substantial quit rates at 6 months.

Gary Swan, Ph.D., of SRI International, an independent, nonprofit, research and development organization in Menlo Park, Calif., reported on the findings of a trial in which 1,202 smokers, all taking varenicline 2 mg/day, were randomized to one of three behavioral counseling arms: phone only, Internet only, or a combination of both. The counseling programs were available for up to 12 months. The medication was provided by Pfizer Inc., which manufactures varenicline, and the study was funded by the National Cancer Institute. The trial also included researchers from Group Health Center for Health Studies and Free & Clear Inc., both of Seattle.

All of the subjects received a 5–10 minute orientation phone call at the start of the study and were given access to a toll-free phone line. Behavioral counseling based on Free & Clear's Quit for Life Program was then provided via interactive Web tools or through one-on-one phone counseling, or both, Dr. Swan reported at the annual meeting of the Society of Behavioral Medicine.

The average age of the subjects was 47.3 years; two-thirds were female; and they smoked an average of about 20 cigarettes a day.

At the end of the 12-week treatment period, the subjects in the phone counseling group had the highest abstinence rate (48.5%), followed by the phone/Web group (43%), and then the Web-only group (39%). At the 6-month mark, abstinence rates had fallen overall, and there was no longer any statistical difference between groups (34%, 34%, and 31% respectively).

“For those of us who have been working in the field for many years, these are really quite exciting results when compared with other medications, and our results are consistent with those seen in the pre-approval efficacy trials of varenicline,” said Dr. Swan, noting that moderate to severe side effects, including flatulence, altered dreams, altered taste perception, sleep difficulties and changes in appetite, were reported.

He suggested the drop in abstinence after treatment cessation might indicate the need to extend the duration of medication or increase the intensity (frequency of calls) of the behavioral counseling. Phone counseling might improve tolerance to the medication and thus reduce discontinuation because of side effects, he said.

In fact, after 21 days of treatment, a significantly higher percentage of patients in the phone counseling group (87.5%) reported that they were still taking their medication, compared with those in the Web-only group (79%), but not the phone/Web group (83%).

Roughly half of the subjects (48%) reported having made a quit attempt within the preceding year, and the duration of this attempt was a predictor of subsequent success, Dr. Swan noted.

Dr. Swan disclosed that he served as a consultant to Pfizer's National Advisory Board in 2008.

MONTREAL — Pregnant women with group B streptococcal infection and allergy to penicillin frequently receive inappropriate antibiotic therapy despite established guidelines, said Dr. Jennifer Verani, a medical epidemiologist at the Centers for Disease Control and Prevention.

New guidelines will clarify the wording in current CDC guidelines on group B streptococci (GBS) prevention, she said.

Most penicillin-allergic mothers are receiving clindamycin for the treatment of GBS, and very few are getting susceptibility testing done. “However, we and others have found increasing levels of resistance to clindamycin and macrolides in general among GBS isolates,” she said at the annual meeting of the Infectious Diseases Society for Obstetrics and Gynecology.

In a separate study presented at the meeting, one hospital significantly improved appropriate antibiotic therapy for penicillin-allergic GBS-positive pregnant women through the implementation of several hospital-based interventions.

Before the interventions, the hospital's 2004–2006 data showed that although 95% of GBS-positive penicillin-allergic mothers received antibiotics, only 16% received the appropriate antibiotic, and only 11% had sensitivity tests performed.

The situation was “clearly far from ideal,” said Dr. Agatha Critchfield of the Women and Infants Hospital and Brown University, both in Providence, R.I.

The hospital interventions aimed at improving adherence to the guidelines included provider education through a resident research day, staff meetings, and grand rounds, as well as a change in lab requisition forms that required providers to mark a patient as penicillin allergic, thus prompting the lab to perform sensitivity testing.

A retrospective cohort study following the intervention revealed that the level of appropriate antibiotic therapy increased from 16% to 76%, and sensitivity testing increased from 11% to 79%, Dr. Critchfield reported.

Among the 24% of women who did not receive appropriate antibiotic therapy, 80% received clindamycin and 10% received erythromycin, even though antimicrobial resistance has been increasing in the United States, with up to 15% of GBS isolates being resistant to clindamycin and 25% being resistant to erythromycin, she said.

Overall, however, there was a significant decrease in the use of clindamycin, from 83% before the intervention to 49% after, and an increase in the use of vancomycin, from 6.6% to 29%.

In the upcoming CDC guideline revision, some consideration was given to dropping clindamycin altogether as a recommended antibiotic, Dr. Verani commented. “But people ended up arguing against that because places that do susceptibility testing shouldn't have to lose this as an option,” she said. “So we have decided to stick with clindamycin but to have really explicit language with regard to who should get cefazolin, clindamycin, or vancomycin.”

The new guidelines are expected to recommend that patients with a high risk or a history of penicillin anaphylaxis, including angioedema, respiratory distress, or urticaria, receive clindamycin if susceptibility tests are available and are positive. If the tests are not performed or results are not yet available, patients should receive vancomycin. Patients at low risk for anaphylaxis, meaning “any other reaction including rashes or simply reporting a history of penicillin allergy,” should be getting cefazolin, she said.

“This has been in the guidelines all along, but clearly this is not what people have been doing, so the hope is that by more explicitly putting this wording into the guidelines, we can improve the implementation for [penicillin]-allergic women.”

MONTREAL — Pregnant women with group B streptococcal infection and allergy to penicillin frequently receive inappropriate antibiotic therapy despite established guidelines, said Dr. Jennifer Verani, a medical epidemiologist at the Centers for Disease Control and Prevention.

New guidelines will clarify the wording in current CDC guidelines on group B streptococci (GBS) prevention, she said.

Most penicillin-allergic mothers are receiving clindamycin for the treatment of GBS, and very few are getting susceptibility testing done. “However, we and others have found increasing levels of resistance to clindamycin and macrolides in general among GBS isolates,” she said at the annual meeting of the Infectious Diseases Society for Obstetrics and Gynecology.

In a separate study presented at the meeting, one hospital significantly improved appropriate antibiotic therapy for penicillin-allergic GBS-positive pregnant women through the implementation of several hospital-based interventions.

Before the interventions, the hospital's 2004–2006 data showed that although 95% of GBS-positive penicillin-allergic mothers received antibiotics, only 16% received the appropriate antibiotic, and only 11% had sensitivity tests performed.

The situation was “clearly far from ideal,” said Dr. Agatha Critchfield of the Women and Infants Hospital and Brown University, both in Providence, R.I.

The hospital interventions aimed at improving adherence to the guidelines included provider education through a resident research day, staff meetings, and grand rounds, as well as a change in lab requisition forms that required providers to mark a patient as penicillin allergic, thus prompting the lab to perform sensitivity testing.

A retrospective cohort study following the intervention revealed that the level of appropriate antibiotic therapy increased from 16% to 76%, and sensitivity testing increased from 11% to 79%, Dr. Critchfield reported.

Among the 24% of women who did not receive appropriate antibiotic therapy, 80% received clindamycin and 10% received erythromycin, even though antimicrobial resistance has been increasing in the United States, with up to 15% of GBS isolates being resistant to clindamycin and 25% being resistant to erythromycin, she said.

Overall, however, there was a significant decrease in the use of clindamycin, from 83% before the intervention to 49% after, and an increase in the use of vancomycin, from 6.6% to 29%.

In the upcoming CDC guideline revision, some consideration was given to dropping clindamycin altogether as a recommended antibiotic, Dr. Verani commented. “But people ended up arguing against that because places that do susceptibility testing shouldn't have to lose this as an option,” she said. “So we have decided to stick with clindamycin but to have really explicit language with regard to who should get cefazolin, clindamycin, or vancomycin.”

The new guidelines are expected to recommend that patients with a high risk or a history of penicillin anaphylaxis, including angioedema, respiratory distress, or urticaria, receive clindamycin if susceptibility tests are available and are positive. If the tests are not performed or results are not yet available, patients should receive vancomycin. Patients at low risk for anaphylaxis, meaning “any other reaction including rashes or simply reporting a history of penicillin allergy,” should be getting cefazolin, she said.

“This has been in the guidelines all along, but clearly this is not what people have been doing, so the hope is that by more explicitly putting this wording into the guidelines, we can improve the implementation for [penicillin]-allergic women.”

MONTREAL — Pregnant women with group B streptococcal infection and allergy to penicillin frequently receive inappropriate antibiotic therapy despite established guidelines, said Dr. Jennifer Verani, a medical epidemiologist at the Centers for Disease Control and Prevention.

New guidelines will clarify the wording in current CDC guidelines on group B streptococci (GBS) prevention, she said.

Most penicillin-allergic mothers are receiving clindamycin for the treatment of GBS, and very few are getting susceptibility testing done. “However, we and others have found increasing levels of resistance to clindamycin and macrolides in general among GBS isolates,” she said at the annual meeting of the Infectious Diseases Society for Obstetrics and Gynecology.

In a separate study presented at the meeting, one hospital significantly improved appropriate antibiotic therapy for penicillin-allergic GBS-positive pregnant women through the implementation of several hospital-based interventions.

Before the interventions, the hospital's 2004–2006 data showed that although 95% of GBS-positive penicillin-allergic mothers received antibiotics, only 16% received the appropriate antibiotic, and only 11% had sensitivity tests performed.

The situation was “clearly far from ideal,” said Dr. Agatha Critchfield of the Women and Infants Hospital and Brown University, both in Providence, R.I.

The hospital interventions aimed at improving adherence to the guidelines included provider education through a resident research day, staff meetings, and grand rounds, as well as a change in lab requisition forms that required providers to mark a patient as penicillin allergic, thus prompting the lab to perform sensitivity testing.

A retrospective cohort study following the intervention revealed that the level of appropriate antibiotic therapy increased from 16% to 76%, and sensitivity testing increased from 11% to 79%, Dr. Critchfield reported.

Among the 24% of women who did not receive appropriate antibiotic therapy, 80% received clindamycin and 10% received erythromycin, even though antimicrobial resistance has been increasing in the United States, with up to 15% of GBS isolates being resistant to clindamycin and 25% being resistant to erythromycin, she said.

Overall, however, there was a significant decrease in the use of clindamycin, from 83% before the intervention to 49% after, and an increase in the use of vancomycin, from 6.6% to 29%.

In the upcoming CDC guideline revision, some consideration was given to dropping clindamycin altogether as a recommended antibiotic, Dr. Verani commented. “But people ended up arguing against that because places that do susceptibility testing shouldn't have to lose this as an option,” she said. “So we have decided to stick with clindamycin but to have really explicit language with regard to who should get cefazolin, clindamycin, or vancomycin.”

The new guidelines are expected to recommend that patients with a high risk or a history of penicillin anaphylaxis, including angioedema, respiratory distress, or urticaria, receive clindamycin if susceptibility tests are available and are positive. If the tests are not performed or results are not yet available, patients should receive vancomycin. Patients at low risk for anaphylaxis, meaning “any other reaction including rashes or simply reporting a history of penicillin allergy,” should be getting cefazolin, she said.

“This has been in the guidelines all along, but clearly this is not what people have been doing, so the hope is that by more explicitly putting this wording into the guidelines, we can improve the implementation for [penicillin]-allergic women.”

MONTREAL — Uncomplicated urinary tract infections can be diagnosed and treated by a medical assistant over the telephone with no increased risk to the patient and at a substantial cost savings, according to the findings of a randomized, controlled trial.

Patients had similar outcomes and levels of satisfaction regardless of whether they were randomly assigned to be treated in house or over the telephone, according to the findings that were presented as a poster at the annual meeting of the North American Primary Care Research Group.

“There was no statistically significant difference between the groups,” said co-investigator Dr. Chandrika Iyer from St. John Hospital and Medical Center in Detroit.

The literature shows that women have a 50% likelihood of having a urinary tract infection (UTI) if they present with at least one of the following symptoms: dysuria, urgency, frequency, or abdominal pain, Dr. Iyer said in an interview.

With the specific combination of dysuria and frequency, and in the absence of vaginal discharge or itching, there is a 90% likelihood of UTI (JAMA 2002; 287:2701–10). “Physical examination and lab testing don't add much more,” she continued.

To test this observation, the study was conducted at two primary care centers: the Masonic Medical Center, in St. Clair Shores, Mich., a private practice; and the Family Medical Center in Detroit, a family medicine residency clinic.

A total of 122 women, aged 18–65 years, who called the clinic with symptoms of uncomplicated UTI, were invited to participate and screened for inclusion. Exclusion criteria were pregnancy, diabetes, kidney disease, UTI in the past month, bladder catheterization in the past 6 months, chemotherapy, vaginal discharge, flank pain, fever, chills, vomiting, or nausea. A total of 36 patients were excluded and 5 declined to participate, leaving 81 patients (mean age 39 years) to be randomized to either office or telephone treatment.

Participants in the telephone treatment arm were managed by a medical assistant who called or faxed a prescription to the patients' pharmacy. Treatment included 3 days of trimethoprim and sulfamethoxazole (Bactrim DS), one tablet twice daily, or, in the case of sulfa allergy, ciprofloxacin 500 mg twice daily. Questionable cases were reviewed with the patient's assigned physician or the principal investigator.

Patients randomized to office treatment had a regular visit with a primary care physician, where urine analyses and cultures were performed and treatment was prescribed.

In the case of persistent symptoms, women in both groups were instructed to call the clinic and be seen by their physician.

All women were called 1 week after treatment for a survey about their symptoms and satisfaction with treatment.

Ten patients did not follow up after treatment, and one patient was later diagnosed with vaginitis. Of the remaining participants, there were no statistically significant differences between groups in the rate of symptom resolution (80% with the telephone treatment versus 70% with office treatment), or complete satisfaction (86% with telephone treatment versus 79% with office treatment). Eighty percent of the telephone treatment group and 85% of the office treatment group said they would like the same treatment next time.

A cost comparison of both strategies revealed a saving of between $49 and $133 per patient in the telephone treatment group, Dr. Iyer said. This was calculated based on an office visit code of 99212 or 99213, at a cost of $34 or $68, respectively (excluding patient copayment). The average patient copayment ranges from $10 to $20. In addition, urine analysis costs up to $5 and urine cultures cost up to $40.

With an estimated 8.5 million women seeking care for bladder infections each year, at a cost of about $2.5 million, telephone treatment is an appealing alternative to office-based management, Dr. Iyer said.

MONTREAL — Uncomplicated urinary tract infections can be diagnosed and treated by a medical assistant over the telephone with no increased risk to the patient and at a substantial cost savings, according to the findings of a randomized, controlled trial.

Patients had similar outcomes and levels of satisfaction regardless of whether they were randomly assigned to be treated in house or over the telephone, according to the findings that were presented as a poster at the annual meeting of the North American Primary Care Research Group.

“There was no statistically significant difference between the groups,” said co-investigator Dr. Chandrika Iyer from St. John Hospital and Medical Center in Detroit.

The literature shows that women have a 50% likelihood of having a urinary tract infection (UTI) if they present with at least one of the following symptoms: dysuria, urgency, frequency, or abdominal pain, Dr. Iyer said in an interview.

With the specific combination of dysuria and frequency, and in the absence of vaginal discharge or itching, there is a 90% likelihood of UTI (JAMA 2002; 287:2701–10). “Physical examination and lab testing don't add much more,” she continued.

To test this observation, the study was conducted at two primary care centers: the Masonic Medical Center, in St. Clair Shores, Mich., a private practice; and the Family Medical Center in Detroit, a family medicine residency clinic.

A total of 122 women, aged 18–65 years, who called the clinic with symptoms of uncomplicated UTI, were invited to participate and screened for inclusion. Exclusion criteria were pregnancy, diabetes, kidney disease, UTI in the past month, bladder catheterization in the past 6 months, chemotherapy, vaginal discharge, flank pain, fever, chills, vomiting, or nausea. A total of 36 patients were excluded and 5 declined to participate, leaving 81 patients (mean age 39 years) to be randomized to either office or telephone treatment.

Participants in the telephone treatment arm were managed by a medical assistant who called or faxed a prescription to the patients' pharmacy. Treatment included 3 days of trimethoprim and sulfamethoxazole (Bactrim DS), one tablet twice daily, or, in the case of sulfa allergy, ciprofloxacin 500 mg twice daily. Questionable cases were reviewed with the patient's assigned physician or the principal investigator.

Patients randomized to office treatment had a regular visit with a primary care physician, where urine analyses and cultures were performed and treatment was prescribed.

In the case of persistent symptoms, women in both groups were instructed to call the clinic and be seen by their physician.

All women were called 1 week after treatment for a survey about their symptoms and satisfaction with treatment.

Ten patients did not follow up after treatment, and one patient was later diagnosed with vaginitis. Of the remaining participants, there were no statistically significant differences between groups in the rate of symptom resolution (80% with the telephone treatment versus 70% with office treatment), or complete satisfaction (86% with telephone treatment versus 79% with office treatment). Eighty percent of the telephone treatment group and 85% of the office treatment group said they would like the same treatment next time.

A cost comparison of both strategies revealed a saving of between $49 and $133 per patient in the telephone treatment group, Dr. Iyer said. This was calculated based on an office visit code of 99212 or 99213, at a cost of $34 or $68, respectively (excluding patient copayment). The average patient copayment ranges from $10 to $20. In addition, urine analysis costs up to $5 and urine cultures cost up to $40.

With an estimated 8.5 million women seeking care for bladder infections each year, at a cost of about $2.5 million, telephone treatment is an appealing alternative to office-based management, Dr. Iyer said.

MONTREAL — Uncomplicated urinary tract infections can be diagnosed and treated by a medical assistant over the telephone with no increased risk to the patient and at a substantial cost savings, according to the findings of a randomized, controlled trial.

Patients had similar outcomes and levels of satisfaction regardless of whether they were randomly assigned to be treated in house or over the telephone, according to the findings that were presented as a poster at the annual meeting of the North American Primary Care Research Group.

“There was no statistically significant difference between the groups,” said co-investigator Dr. Chandrika Iyer from St. John Hospital and Medical Center in Detroit.

The literature shows that women have a 50% likelihood of having a urinary tract infection (UTI) if they present with at least one of the following symptoms: dysuria, urgency, frequency, or abdominal pain, Dr. Iyer said in an interview.

With the specific combination of dysuria and frequency, and in the absence of vaginal discharge or itching, there is a 90% likelihood of UTI (JAMA 2002; 287:2701–10). “Physical examination and lab testing don't add much more,” she continued.

To test this observation, the study was conducted at two primary care centers: the Masonic Medical Center, in St. Clair Shores, Mich., a private practice; and the Family Medical Center in Detroit, a family medicine residency clinic.

A total of 122 women, aged 18–65 years, who called the clinic with symptoms of uncomplicated UTI, were invited to participate and screened for inclusion. Exclusion criteria were pregnancy, diabetes, kidney disease, UTI in the past month, bladder catheterization in the past 6 months, chemotherapy, vaginal discharge, flank pain, fever, chills, vomiting, or nausea. A total of 36 patients were excluded and 5 declined to participate, leaving 81 patients (mean age 39 years) to be randomized to either office or telephone treatment.

Participants in the telephone treatment arm were managed by a medical assistant who called or faxed a prescription to the patients' pharmacy. Treatment included 3 days of trimethoprim and sulfamethoxazole (Bactrim DS), one tablet twice daily, or, in the case of sulfa allergy, ciprofloxacin 500 mg twice daily. Questionable cases were reviewed with the patient's assigned physician or the principal investigator.

Patients randomized to office treatment had a regular visit with a primary care physician, where urine analyses and cultures were performed and treatment was prescribed.

In the case of persistent symptoms, women in both groups were instructed to call the clinic and be seen by their physician.

All women were called 1 week after treatment for a survey about their symptoms and satisfaction with treatment.

Ten patients did not follow up after treatment, and one patient was later diagnosed with vaginitis. Of the remaining participants, there were no statistically significant differences between groups in the rate of symptom resolution (80% with the telephone treatment versus 70% with office treatment), or complete satisfaction (86% with telephone treatment versus 79% with office treatment). Eighty percent of the telephone treatment group and 85% of the office treatment group said they would like the same treatment next time.

A cost comparison of both strategies revealed a saving of between $49 and $133 per patient in the telephone treatment group, Dr. Iyer said. This was calculated based on an office visit code of 99212 or 99213, at a cost of $34 or $68, respectively (excluding patient copayment). The average patient copayment ranges from $10 to $20. In addition, urine analysis costs up to $5 and urine cultures cost up to $40.

With an estimated 8.5 million women seeking care for bladder infections each year, at a cost of about $2.5 million, telephone treatment is an appealing alternative to office-based management, Dr. Iyer said.