Patterns of use, expenditures, and perceived efficacy of complementary and alternative therapies in HIV-infected patients.

BACKGROUND: Complementary and alternative medicine (CAM) use is common in the general population, accounting for substantial expenditures. Among patients with human immunodeficiency virus (HIV) infection, few data are available on the prevalence, costs, and patterns of alternative therapy use. METHODS: We carried out detailed telephone surveys and medical chart reviews for 289 active patients with HIV in a general medicine practice at a university-based teaching hospital in Boston, Mass. Data were collected on prevalence and patterns of CAM use, out-of-pocket expenditures, associated outcomes, and correlates of CAM use. RESULTS: Of 180 patients who agreed to be interviewed, 122 (67.8%) used herbs, vitamins, or dietary supplements, 81 (45.0%) visited a CAM provider, and 43 (23.9%) reported using marijuana for medicinal purposes in the previous year. Patients who saw CAM providers made a median of 12 visits per year to these providers compared with 7 visits per year to their primary care physician and nurse practitioner. Mean yearly out-of-pocket expenditures for CAM users totaled $938 for all therapies. For the main reason CAM was used, respondents found therapies "extremely" or "quite a bit" helpful in 81 (81.0%) of 100 reports of supplement use, in 76 (65.5%) of 116 reports of CAM provider use, and in 27 (87%) of 31 reports of marijuana use. In multivariable models, college education (odds ratio [OR]=3.7, 95% confidence interval [CI]=1.9-7.1) and fatigue (OR=2.7, 95% CI=1.4-5.2) were associated with CAM provider use; memory loss (OR=2.3, 95% CI=1.1-4.8) and fatigue (OR=0.4, 95% CI=0.2-0.9) were associated with supplement use; and weight loss (OR=2.6, 95% CI=1.2-5.6) was associated with marijuana use. CONCLUSIONS: Patients with HIV infection use CAM, including marijuana, at a high rate; make frequent visits to CAM providers; incur substantial expenditures; and report considerable improvement with these treatments. Clinical trials of frequently used CAMs are needed to inform physicians and patients about therapies that may have measurable benefit or measurable risk.

Brief communication: detecting depression: providing high quality primary care for HIV-infected patients.

Depression is common among HIV-infected patients, but little is known about risk factors for depression in this population. Several studies before protease inhibitors became available have reported inconsistent associations between depression and disease severity. Delivering high quality HIV care includes adequate detection and treatment of depression. The objective of this study was to describe the prevalence and correlates of depression among a contemporary group of HIV-infected patients. The setting and design for the study was a chart abstraction for HIV-infected patients in a primary care practice in Boston, Mass, in June 1997. Among 275 HIV-infected patients, depression was documented in 147 patient charts (53%), half of whom (n = 73, 27%) also received antidepressant medications. We used multivariable logistic regression to identify risk factors for depression among patients with both a chart diagnosis of depression and current antidepressant medication use. We observed increased risk of depression among patients with a history of substance use (odds ratio 2.7, 95% confidence interval 1.5-4.7), recent medical hospitalization (2.6, 1.4-5.0), and homosexual risk behavior (2.1, 1.1-4.2). Depression remains a common problem for HIV-infected patients, particularly among those with history of substance abuse, medical hospitalization, or homosexual risk behavior. Routine screening for depression in this population with special attention to those at higher risk may offer opportunities for earlier diagnosis and treatment.

Delays in protease inhibitor use in clinical practice.

OBJECTIVE: To determine the clinical factors associated with delayed protease inhibitor initiation. DESIGN: Chart review and telephone survey. SETTING: General medicine practice at an academic medical center in Boston, Mass. PATIENTS: One hundred ninety patients living with HIV and a viral load of more than 10,000 copies/ml. MEASUREMENTS AND MAIN RESULTS: The main outcome measurement was time to first protease inhibitor prescription after first elevated HIV viral load (>10,000 copies/ml). In this cohort, 190 patients had an elevated viral load (median age 39; 87% male; 12% history of injection drug use; 63% AIDS; 53% with depression; 17% history of pneumocystis pneumonia; 54% CD4 <200). In Cox proportional hazards modeling, significant univariate correlates for delayed protease inhibitor initiation were higher CD4 cell count (hazard ratio [HR] 2. 38 for CD4 200-500 compared with <200, 95% confidence interval [CI] 1.59, 3.57; and HR 8.33 for CD4> 500; 95% CI 2.63, 25.0), higher viral load (HR 0.43 for each 10-fold increase; 95% CI 0.31, 0.59), injection drug use (HR 2.08; 95% CI 1.05, 4.17), AIDS (HR 0.24; 95% CI 0.15, 0.36), and history of pneumocystis pneumonia (HR 0.32; 95% CI 0.21, 0.49). In multivariate models adjusted for secular trends in protease inhibitor use, factors significantly associated with delay of protease inhibitor initiation (p <.05) were higher CD4 cell count (for CD4 200-500, HR 2.63; 95% CI 1.61, 4.17; for CD4> 500, HR 11.11; 95% CI 3.57, 33.33), higher viral load (HR 0.66 for each 10-fold increase; 95% CI 0.45, 0.98), history of pneumocystis pneumonia (HR 0.57; 95% CI 0.37, 0.90), history of depression (HR 1. 49; 95% CI 1.03, 2.13), and history of injection drug use (HR 2.70; 95% CI 1.35, 5.56). CONCLUSIONS: HIV-infected patients with higher CD4 cell counts or a history of depression or history of injection drug use have significant and lengthy delays of protease inhibitor therapy. Although some delays may be clinically appropriate, enhancement of provider and patient education might prove beneficial. Further research should examine reasons for delays in protease inhibitor initiation and their appropriateness.

Risk of ovarian carcinoma and consumption of vitamins A, C, and E and specific carotenoids: a prospective analysis.

BACKGROUND: Antioxidant vitamins may decrease risk of cancer by limiting oxidative DNA damage leading to cancer initiation. Few prospective studies have assessed relations between antioxidant vitamins and ovarian carcinoma. METHODS: The authors prospectively assessed consumption of vitamins A, C, and E and specific carotenoids, as well as fruit and vegetable intake, in relation to ovarian carcinoma risk among 80,326 participants in the Nurses' Health Study who had no history of cancer other than nonmelanoma skin carcinoma. Women reported on known and suspected ovarian carcinoma risk factors including reproductive factors, smoking, and use of vitamin supplements on biennial mailed questionnaires from 1976 to 1996. Food frequency questionnaires were included in 1980, 1984, 1986, and 1990. The authors confirmed 301 incident cases of invasive epithelial ovarian carcinoma during 16 years of dietary follow-up (1980-1996). Pooled logistic regression was used to control for age, oral contraceptive use, body mass index, smoking history, parity, and tubal ligation. RESULTS: The authors observed no association between ovarian carcinoma risk and antioxidant vitamin consumption from foods, or foods and supplements together. The multivariate relative risks (95% confidence intervals [CIs]) for ovarian carcinoma among women in the highest versus lowest quintile of intake were 1.04 (95% CI, 0.72-1.51) for vitamin A from foods and supplements; 1.01 (95% CI, 0.69-1.47) for vitamin C; 0.88 (95% CI, 0.61-1.27) for vitamin E; and 1.10 (95% CI, 0.76-1.59) for beta-carotene. Among users of vitamin supplements, the authors found no evidence of an association between dose or duration of any specific vitamin and ovarian carcinoma risk, although the authors had limited power to assess these relations. No specific fruits or vegetables were associated significantly with ovarian carcinoma risk. The authors found no association between ovarian carcinoma and consumption of total fruits or vegetables, or specific subgroups including cruciferous vegetables, green leafy vegetables, legumes, or citrus fruits. Women who consumed at least 2.5 total servings of fruits and vegetables as adolescents had a 46% reduction in ovarian carcinoma risk (relative risk, 0.54, 95% CI, 0.29-1.03; P value for trend 0.04). CONCLUSIONS: These data do not support an important relation between consumption of antioxidant vitamins from foods or supplements, or intake of fruits and vegetables, and incidence of ovarian carcinoma in this cohort. However, modest associations cannot be excluded, and the authors' finding of an inverse association for total fruit and vegetable intake during adolescence raises the possibility that the pertinent exposure period may be much earlier than formerly anticipated.

Impact of relational coordination on quality of care, postoperative pain and functioning, and length of stay: a nine-hospital study of surgical patients.

BACKGROUND: Health care organizations face pressures from patients to improve the quality of care and clinical outcomes, as well as pressures from managed care to do so more efficiently. Coordination, the management of task interdependencies, is one way that health care organizations have attempted to meet these conflicting demands. OBJECTIVES: The objectives of this study were to introduce the concept of relational coordination and to determine its impact on the quality of care, postoperative pain and functioning, and the length of stay for patients undergoing an elective surgical procedure. Relational coordination comprises frequent, timely, accurate communication, as well as problem-solving, shared goals, shared knowledge, and mutual respect among health care providers. RESEARCH DESIGN: Relational coordination was measured by a cross-sectional questionnaire of health care providers. Quality of care was measured by a cross-sectional postoperative questionnaire of total hip and knee arthroplasty patients. On the same questionnaire, postoperative pain and functioning were measured by the WOMAC osteoarthritis instrument. Length of stay was measured from individual patient hospital records. SUBJECTS: The subjects for this study were 338 care providers and 878 patients who completed questionnaires from 9 hospitals in Boston, MA, New York, NY, and Dallas, TX, between July and December 1997. MEASURES: Quality of care, postoperative pain and functioning, and length of acute hospital stay. RESULTS: Relational coordination varied significantly between sites, ranging from 3.86 to 4.22 (P <0.001). Quality of care was significantly improved by relational coordination (P <0.001) and each of its dimensions. Postoperative pain was significantly reduced by relational coordination (P = 0.041), whereas postoperative functioning was significantly improved by several dimensions of relational coordination, including the frequency of communication (P = 0.044), the strength of shared goals (P = 0.035), and the degree of mutual respect (P = 0.030) among care providers. Length of stay was significantly shortened (53.77%, P <0.001) by relational coordination and each of its dimensions. CONCLUSIONS: Relational coordination across health care providers is associated with improved quality of care, reduced postoperative pain, and decreased lengths of hospital stay for patients undergoing total joint arthroplasty. These findings support the design of formal practices to strengthen communication and relationships among key caregivers on surgical units.