Treatment for older men with fractures.

UNLABELLED: Less than 10% of men receive osteoporosis treatment, even after a fracture. A study of 17,683 men revealed that older men, those with spinal fractures, and those taking steroids or antidepressants are more likely to receive treatment after a fracture. Seeing a primary care physician also increases osteoporosis treatment rates. INTRODUCTION: In 2000, the FDA approved bisphosphonates for the treatment of osteoporosis in men. The purpose of this study is to estimate the frequency of bisphosphonate therapy within 12 months following a fracture and describe patient/physician factors associated with treatment. METHODS: Health insurance claims for 17,683 men ≥ 65 years of age, who had a claim for an incident fracture from 2000 to 2005, were followed for at least 6 months post-fracture for the initiation of treatment with a bisphosphonate. Patient characteristics, diagnostic procedures, therapies, co-morbidities, and provider characteristics were compared for men who received treatment with those who did not. RESULTS: Eight percent of men (n = 1,434) received bisphosphonate therapy. Overall treatment increased from 7% in 2001 to 9% in 2005 (p < 0.001). Treatment for hip fractures remained at 7% (p = 0.747). Treatment increased with age: 6% in men aged 65-69 compared to 11.6% in men aged 85-89 (p < 0.001). Factors associated with treatment included: diagnosis of osteoporosis (OR = 8.8; 95% CI, 7.7, 10.4), glucocorticoid therapy (OR = 3.2; 95% CI, 2.4, 4.3), bone mineral density measurement (OR = 3.4; 95% CI, 2.9, 4.0), and antidepressant therapy with tricyclics (OR = 2.0; 95% CI, 1.2, 3.5) or selective serotonin reuptake inhibitors (OR = 1.7; 95% CI, 1.3, 2.4). Men with vertebral fractures (OR = 2.2; 95% CI, 1.8, 2.6) and men seen by primary physicians (OR = 2.6; 95% CI, 2.3, 3.1) were more likely to receive treatment. CONCLUSIONS: Less than 10% of men received bisphosphonate therapy following a low-impact fracture. Men with a primary physician were more likely to receive bisphosphonate therapy; however, <25% of men were seen by a primary physician.

Screening for prostate cancer with the prostate-specific antigen test: are patients making informed decisions?

BACKGROUND: The benefits of early detection of prostate cancer are uncertain, and the American College of Physicians and the American Academy of Family Physicians recommend individual decision making in prostate cancer screening. This study reports the knowledge of male primary care patients about prostate cancer and prostate-specific antigen (PSA) testing and examines how that knowledge is related to PSA testing, preferences for testing in the future, and desire for involvement in physician-patient decision making. METHODS: The sample included 160 men aged 45 to 70 years with no history of prostate cancer who presented for care at a university-based family medicine clinic. Before scheduled office visits, patients completed a questionnaire developed for this study that included a 10-question measure of prostate cancer knowledge, the Deber-Kraestchmer Problem-Solving Decision-Making Scale, sociodemographic indicators, and questions on PSA testing. RESULTS: In general, patients who were college graduates were more knowledgeable about prostate cancer and early detection than those with a high school education or less. Aside from college graduates, most patients could not identify the principle advantages and disadvantages of PSA testing. Patients indicating previous or future plans for PSA testing demonstrated greater knowledge than other patients. Desire for involvement in decision making varied by patient education but was not related to past PSA testing. CONCLUSIONS: Patients lack knowledge about prostate cancer and early detection. This knowledge deficit may impede the early detection of prostate cancer and is a barrier to making an informed decision about undergoing PSA testing.

A randomized controlled trial of shared decision making for prostate cancer screening.

OBJECTIVE: To evaluate a patient-educational approach to shared decision making for prostate cancer screening. DESIGN: Randomized controlled trial with preoffice visit assessment and 2-week follow-up. SETTING: University-based family practice center. PATIENTS: Men aged 45 through 70 years with no history of prostate cancer or treatment for prostate disease (N = 160). Two patients were unavailable for follow-up. INTERVENTION: Twenty-minute educational videotape on advantages and disadvantages of prostate-specific antigen (PSA) screening for prostate cancer. MAIN OUTCOME MEASURES: A measure of patients' core knowledge of prostate cancer developed for this study, reported preferences for PSA testing, and ratings of the videotape. RESULTS: Patients' core knowledge at baseline was poor. At 2-week follow-up, subjects undergoing videotape intervention showed a 78% improvement in the number of knowledge questions answered correctly (P = .001), and knowledge increased about mortality due to early-stage prostate cancer, PSA screening performance, treatment-related complications, and disadvantages of screening. No overall change was observed for control subjects. At follow-up, 48 (62%) of 78 intervention patients planned to have the PSA test compared with 64 (80%) of 80 control patients (18.5% absolute reduction; 95% confidence interval, 4.6%-32.4%; P = .009). Intervention subjects rated favorably the amount of information provided and the clarity, balance, and length of the videotape and would recommend the videotape to others. CONCLUSIONS: Patient education regarding the potential benefits and harms of early detection of prostate cancer can lead to more informed decision making. Incorporating the PSA videotape into the periodic health examination for asymptomatic men aged 50 years and older is recommended.

Investigation of a severity-based classification of mood and anxiety symptoms in primary care patients.

BACKGROUND: Current Diagnostic and Statistical Manual of Mental Disorders (DSM) classifications describe spectrums of symptoms that define mood and anxiety disorders. These DSM classifications have been applied to primary care populations to establish the frequency of these disorders in primary care. DSM classifications, however, might not adequately describe the underlying or natural groupings of mood and anxiety symptoms in primary care. This study explores common clusters of mood and anxiety symptoms and their severity while exploring the degree of cluster congruency with current DSM classification schemes. We also evaluate how well the groupings derived from these different classifying methods explain differences in patients' health-related quality of life. METHODS: Study design was cross-sectional, using a sample of 1333 adult primary care patients attending a university-based family medicine clinic. We applied cluster analysis to responses on a 15-item instrument measuring symptoms of mood and anxiety and their severity. We used the PRIME-MD to determine the presence of DSM-III-R disorders. The SF-36 Health Survey was used to assess health-related quality of life. RESULTS: Cluster analysis produced four groups of patients different from groupings based on the DSM. These four groups differed from each other on sociodemographic indicators, health-related quality of life, and frequency of DSM disorders. Cluster membership was associated in three of four clusters with a clinically significant and progressive decrease in mental and physical health functioning as measured by the SF-36 Health Survey. This decline was independent of the presence of a DSM diagnosis. CONCLUSIONS: A primary care classification scheme for mood and anxiety symptoms that includes severity appears to provide more useful information than traditional DSM classifications of disorders.

Health-related quality of life in primary care patients with recognized and unrecognized mood and anxiety disorders.

OBJECTIVE: Primary care providers have been criticized for underrecognizing and undertreating mental health disorders. This criticism assumes patients with recognized disorders and those with unrecognized disorders suffer the same burden of illness. This study describes differences in health-related quality of life (HRQOL) in patients with recognized and unrecognized mood and anxiety disorders in a primary care setting. METHODS: A probability sample of 500 adult ambulatory patients from a university-based, family practice clinic, completed the PRIME-MD mood and anxiety disorder modules and the SF-36 Health Survey. Computerized patient records were reviewed retrospectively to determine recognition of mood and anxiety disorders. The Mental Health (MCS) and Physical Health (PCS) Component Summary scales of the SF-36 served as the primary outcome measures. RESULTS: Sub-threshold mood and anxiety disorders were less likely to be recognized by physicians than disorders meeting DSM-III-R criteria. Recognized mood disorders were associated with a significant decrement in MCS scores (poorer HRQOL) compared with unrecognized disorders. In contrast, recognized mood disorders demonstrated slightly higher PCS scores. Recognized and unrecognized mood disorders differed significant ly in physical functioning, vitality, social functioning, role functioning related to emotional state, and mental health. Recognition of anxiety disorders was not related to HRQOL. CONCLUSIONS: Patients with mental health disorders that have been recognized by their health providers appear to suffer from poorer HRQOL than patients whose disorders have not been recognized. This relationship, though, is only apparent for mood disorders. Poorer physical functioning may mask less severe emotional symptoms in mood disorders; profound emotional symptoms make recognition easier.

Does the severity of mood and anxiety symptoms predict health care utilization?

BACKGROUND: Traditional diagnostic criteria for depression and anxiety fail to account for symptom severity. We previously evaluated a severity-based classification system of mood and anxiety symptoms. This study examines whether those severity groups are predictive of differences in health care utilization. METHODS: We used a cohort design to compare the health care utilization of 1232 subjects classified into 4 groups according to symptom severity. Health care billing data were evaluated for each subject for a 15-month period around the index visit. Multiple linear regression models were used to examine relative contributions of individual variables to differences in health care utilization. Analysis of variance procedures were used to compare charges among the severity groups after adjusting for demographic and medical comorbidity variables. RESULTS: After adjustment, significant differences in health care utilization between groups were seen in all but 3 of the 15 months studied. Also, after adjustment, the presence of a mood or anxiety disorder influenced utilization for only a 6-month period. At 9 to 12 months, subjects in the high-severity group showed a more than twofold difference in adjusted charges compared with the low-severity group ($225.36 vs $94.37). CONCLUSIONS: Our severity-based classification predicts statistically and clinically significant differences in health care utilization over most of a 15-month period. Differences in utilization persist even after adjustment for medical comorbidity and significant demographic covariates. Our work lends additional evidence that beyond screening for the presence of mood and anxiety disorders, it is important to assess symptom severity in primary care patients. Further study directed toward developing effective methods of identifying patients with high levels of mood and anxiety symptom severity could result in significant cost savings.

Yellow fever 17D vaccine virus isolated from healthy vaccinees accumulates very few mutations.

The live attenuated yellow fever (YF) vaccine strain 17D is one of the safest vaccines in use today with only 22 cases of reversion to virulence documented from over 300 million doses administered. We have isolated virus in cell culture from sera of six volunteers who received 17D vaccine and found that very few nucleotide mutations were detected in the consensus sequence of the entire genome of each of the serum viruses. Moreover, most of these mutations accumulated in the non-structural protein genes, especially the NS5 protein gene. Although no nucleotide change was identified in the structural protein genes of any of these six serum viruses, minor sequence heterogeneity existed in the serum virus population. Our results indicate that 17D vaccine virus accumulates mutations at a very low frequency and may explain in part the excellent safety record of 17D vaccine.

Alcohol use disorders, consumption patterns, and health-related quality of life of primary care patients.

This study examined the association of alcohol use disorders and consumption patterns with various dimensions of Health-Related Quality of Life (HRQOL) in primary care patients, as measured by the SF-36 Health Survey. A probability sample of 1333 primary care patients completed the Alcohol Use Disorder and Associated Disabilities Interview Schedule to determine the presence of alcohol abuse or dependence disorders, and answered questions about patterns of alcohol consumption. Physical and Mental Health Component Summaries and primary scales of the SF-36 were used as measures of HRQOL. Patients meeting criteria for alcohol dependence scored lower (poorer HRQOL) on the Mental Health Component Summary and each primary scale of the SF-36, whereas no differences were observed for alcohol abusers compared with patients not meeting criteria for a disorder. The association of alcohol dependence with diminished mental health functioning was mediated by its co-occurrence with mood and anxiety disorders. Patients who drank in a Frequent, Low-Quantity pattern generally had better overall HRQOL than patients from other consumption groups. Binge drinkers and Frequent, High-Quantity Drinkers showed markedly lower scores in the areas of Role Functioning and Mental Health. In contrast to recent studies of mental health problems in primary care, alcohol use disorders and consumption patterns seem to have a modest impact on patients' HRQOL. These effects, though, vary by dimension of functioning, the presence of alcohol dependence rather than abuse, and pattern of alcohol consumption. Global measures of HRQOL such as the SF-36 Health Survey may provide important indicators of treatment effectiveness in primary care intervention studies for patients with drinking problems.

Preferences of husbands and wives for prostate cancer screening.

The benefits of screening for prostate cancer are uncertain. Outcomes of treatment are particularly important to couples because they challenge the most intimate aspects of a couple's relationship. This study used clinical decision analysis to explore the preferences of 10 couples for prostate cancer screening. The decision-analytic model found that 7 of 10 husbands preferred the no screening strategy, while 9 of 10 wives preferred screening for their husbands. Wives associated little burden with complications of treatment, preferring to maximize their husbands' quantity of life regardless of complications. The issue of who is the decision maker is paramount in the case of prostate cancer screening. Optimal screening strategies may differ for husbands and wives. Guidelines for prostate cancer screening and management should consider assessing preferences on an individual couple basis.

Item bias in the CAGE screening test for alcohol use disorders.

OBJECTIVE: To explore potential item bias in the CAGE questions (mnemonic for cut-down, annoyed, guilty, and eye-opener) when used to screen for alcohol use disorders in primary care patients. DESIGN AND SETTING: Cross-sectional study, conducted in a university-based, family practice clinic, with the presence of an alcohol use disorder determined by structured diagnostic interview using the Alcohol Use Disorder and Associated Disabilities Interview Schedule. PATIENTS: A probability sample of 1,333 adult primary care patients, with oversampling of female and minority (African-American and Mexican-American) patients. MAIN RESULTS: Unadjusted analyses showed marked differences in the sensitivity and specificity of each CAGE question against a lifetime alcohol use disorder, across patient subgroups. Women, Mexican-American patients, and patients with annual incomes above $40,000 were consistently less likely to endorse each CAGE question "yes," after adjusting for the presence of an alcohol use disorder and pattern of alcohol consumption. In results from logistic regression analyses predicting an alcohol use disorder, cut-down was the only question retained in models for each of the subgroups. The guilty question did not contribute to the prediction of an alcohol use disorder; annoyed and eye-opener were inconsistent predictors. CONCLUSIONS: Despite its many advantages, the CAGE questionnaire is an inconsistent indicator of alcohol use disorders when used with male and female primary care patients of varying racial and ethnic backgrounds. Gender and cultural differences in the consequences of drinking and perceptions of problem alcohol use may explain these effects. These biases suggest the CAGE is a poor "rule-out" screening test. Brief and unbiased screens for alcohol use disorders in primary care patients are needed.