Impacts on clinical decision making - changing hormone therapy management after the WHI.

BACKGROUND: Medical news often receives intense, but distorted, media coverage, which can lead to high levels of insecurity in both patients and doctors. OBJECTIVE: To elicit general practitioners' self reported behaviour regarding hormone therapy (HT) advice and prescribing, before, immediately after, and 2 years following the release of the first results of the combined oestrogen and progesterone arm of the Women's Health Initiative (WHI) study; to elicit GPs' understanding of statistical risk terminology; and to explore their personal preferences relative to the trade offs between quality and length of life in medical treatment. METHOD: In October 2004, a questionnaire was sent to all 169 GPs working on the central coast of New South Wales. RESULTS: The response rate was 67.5%. Before the release of the WHI study, 43.8% of GPs recommended HT; 5.9% did so immediately after, and 1.8% 2 years later. When expressed as number needed to treat (NNT), 20.8% of GPs stated that they were unable to interpret the absolute risk of HT use. Half of the 84 GPs who stated that they understood the concept of NNT were not going to reconsider the advice to give HT. General practitioners with a personal preference toward length of life over quality of life proved to be significantly more likely to advise against HT use (p=0.008 in a group comparison). CONCLUSION: The sensationalising of the disease specific mortality differences in HT users had a dramatic and lasting effect on GPs' attitudes to, and prescribing of, HT. General practitioners acknowledged their poor understanding of basic statistical risk terminology. Providing absolute risk terms did not alter clinical decision making in 50% of GPs, clinical decision making may well be more powerfully influenced by a doctor's personal preferences relative to the trade off between quality and quantity of life.

Who is identified when screening for depression is undertaken in general practice? Baseline findings from the Diagnosis, Management and Outcomes of Depression in Primary Care (diamond) longitudinal study.

OBJECTIVES: To report the baseline characteristics of the Diagnosis, Management and Outcomes of Depression in Primary Care (diamond) study cohort and discuss the implications for depression care in general practice. DESIGN: A prospective longitudinal study beginning in January 2005. PARTICIPANTS AND SETTING: Adult patients with depressive symptoms identified via screening with the Center for Epidemiologic Studies Depression Scale (CES-D > or = 16) in 30 randomly selected Victorian general practices. MAIN OUTCOME MEASURE: Depression status on the Patient Health Questionnaire (PHQ). RESULTS: 789 patients form the cohort (71% women). At baseline, 47% were married, 21% lived alone, 36% received a pension or benefit, 15% were unable to work, 23% reported hazardous drinking, 32% were smokers, 39% used antidepressants and 19% used sedatives. 27% satisfied criteria for current major depressive syndrome (MDS) on the PHQ, while 52% had "persistent" depressive symptoms, and 22% had "transient" depressive symptoms, lasting at most a few weeks. Of those satisfying criteria for MDS, 49% were also classified with an anxiety syndrome, 40% reported childhood sexual abuse, 57% reported childhood physical abuse, 42% had at some time been afraid of their partner, and 72% reported a chronic physical condition; 84% were receiving mental health care (either taking antidepressants or seeing a health practitioner specifically for mental health care) compared with 66% of those with persistent depressive symptoms and 57% with transient depressive symptoms. CONCLUSION: This method of screening for depressive symptoms in general practice identifies a group of patients with substantial multiple comorbidities -- psychiatric, physical and social problems coexist with depressive symptoms, raising challenges for the management of depression in general practice.

Complementary and alternative medicine therapies in acne, psoriasis, and atopic eczema: results of a qualitative study of patients' experiences and perceptions.

OBJECTIVES: The aim of this study was to explore the use of complementary and alternative medicine (CAM) therapies in patients with acne, psoriasis, or atopic eczema and the attitudes about CAM of these patients. DESIGN: This was a qualitative study, utilizing semistructured interviews and thematic analysis. SETTING: Patients were recruited from the practices of dermatologists and general practitioners in a noncapital Australian city. RESULTS: Twenty-six (26) interviews were conducted with patients with acne, 29 with psoriasis, and 7 with atopic eczema. Use of CAM therapies was common. Participants tended to value CAM over orthodox therapies because of their preference for natural approaches to their skin diseases and the perceived lesser potential for adverse effects of CAM therapies. Respondents with acne were more confident about the efficacy of CAM than were those with psoriasis or eczema. The resulting sense of control attenuated psychologic sequelae of acne. This was not apparent in psoriasis or eczema. CONCLUSIONS: Practitioners should be cognizant of the likely use of CAM and its implications (including the potential for attenuation of psychologic morbidity) in their patients who have skin diseases.