Depression in primary care: linking clinical and systems strategies.

Depression is a serious, often chronic disease that can be managed effectively with a chronic care model in primary care settings. Depressed persons are likely to be seen by a primary care physician, but their condition often goes unrecognized and untreated. There are effective treatment models that consist of efficacious psychotherapeutic and pharmacological interventions, use of evidence-based guidelines for primary care treatment of depression, development of explicit plans and protocols, reorganization of practice, longitudinal follow-up, patient self-management, decision-making support, access to community resources and leadership commitment. Moving these models into everyday practice requires overcoming both clinical and system barriers. Barriers consist of issues surrounding patients, providers, practices, plans, and purchasers. An understanding of these barriers at each level helps to provide a framework for the changes required to overcome them. The Robert Wood Johnson Foundation National Program on Depression in Primary Care will seek to apply simultaneously both clinical and system strategies in a new five-year initiative to overcome these barriers.

Comparing the national economic burden of five chronic conditions.

Using a nationally representative sample of 23,230 U.S. residents, we examine patterns of economic burden across five chronic conditions: mood disorders, diabetes, heart disease, asthma, and hypertension. Almost half of U.S. health care costs in 1996 were borne by persons with one or more of these five conditions; of that spending amount, only about one-quarter was spent on treating the conditions themselves and the remainder on coexistent illnesses. Each condition demonstrated substantial economic burden but also unique characteristics and patterns of service use driving those costs. The findings highlight the differing challenges involved in understanding needs and improving care across particular chronic conditions.

Hormone replacement therapy: a survey of Ontario physicians' prescribing practices.

BACKGROUND: Although much has been written about hormone replacement therapy (HRT), there are few clearcut recommendations on its use. The purpose of this study was to determine Ontario physicians' patterns of and reasons for prescribing HRT, their use of pretreatment investigations and their surveillance of HRT users, and to determine whether physicians' reported practice is consistent with existing recommendations. METHODS: A self-administered questionnaire was mailed to a nonproportional stratified sample of 327 Ontario physicians (23.9% gynecologists, 76.1% general practitioners/family physicians [GP/FPs]). Outcome measures were ranking of reasons for prescribing HRT, nature of preliminary testing, regimens prescribed, duration of HRT and frequency of follow-up. RESULTS: The response rate was 60.9% overall (70.9% of the gynecologists, 58.3% of the GP/FPs). Prevention of osteoporosis was reported by 97.4% as an important or very important reason for prescribing HRT; prevention of coronary artery disease was important or very important for 89.3%. When considering whether or not to prescribe HRT, 97.3% stated that breast cancer was an important or very important factor. When presented with hypothetical cases, 97.0% stated that they would prescribe combined estrogen-progestin for a symptomatic woman with an intact uterus; 13.6% stated that they would do so for a woman with no uterus. Most reported that they would prescribe HRT for 12 or more years (73.3%) and would follow up patients every 1 to 2 years (70.6%). INTERPRETATION: Despite controversy about HRT in the published literature, the Ontario physicians surveyed reported similar reasons and patterns of prescribing, pretreatment investigations, and surveillance of postmenopausal women using HRT. These results suggest that Ontario physicians' knowledge about HRT is consistent with recommendations in the published literature.

Policy development for compensating workers exposed to crystalline silica in Ontario, Canada.

The Ontario Workers' Compensation Board develops policy for diseases by considering scientific information within legal, political, and social contexts. The purpose of this paper is to describe the process used to develop a policy for lung cancer among gold miners and to examine the extent to which this process assists the development of similar guidelines for workers with silica dust exposure. The scientific and policy questions are similar, both requiring consultation with stakeholders. To improve the development process for the gold miner policy, consultation for silica and lung cancer needs to be more inclusive. The resulting procedures would also need to be precise enough to assist adjudicators to make decisions without limiting their ability to decide each claim on the merits of the case. The major challenge is to ensure that the final policy is scientifically and legally supportable and acceptable to both workers and employers.

Cancer incidence in an urban community: an historical cohort study.

This historical cohort study tested the hypothesis that residents of an industrialized urban community were at higher risk of cancer than residents of a comparable, but non-industrialized, community. The exposed (C1) and the unexposed (C2) cohorts resided in their respective neighbourhoods between 1952 and 1956. All incident cancers were identified through linkage with the Ontario Cancer Registry for 1964-1982. Cancer incidence rates in the two cohorts were 7.0 and 7.3 per 1,000 person-years, respectively. Relative risk estimates for all cancers, lung cancer and cancers associated with environmental exposure, were not significantly different from 1.0. Only colorectal cancers were significantly more frequent in the C1 than the C2 cohort, and these only in one sub-analysis. Overall, we conclude that if there was increased risk of cancer related to environmental pollution in the industrially exposed community, it was less than a two-fold increase.

Cystic disease, family history of breast cancer, and use of oral contraceptives.

Epidemiologic studies show a lower frequency of fibrocystic breast disease among users of oral contraceptives than among women who have never used them. Family history of breast cancer appears to be more common among benign breast disease patients than among their controls. To determine the use of oral contraceptives and the presence of family history of breast cancer, information was obtained from 211 cystic cases and their matched controls from the metropolitan Toronto area. Cystic cases compared to controls had a higher proportion of women with a family history of breast cancer (21% vs 15%). For both a positive and negative family history of breast cancer, as well as for all women combined, the mean duration of oral contraceptive use was lower for cystic cases than for controls. The odds ratio for oral contraceptive use according to family history of breast cancer for cystic cases and controls was 0.42 and 0.81 respectively. The possibility that a woman is more protected against benign breast disease by using oral contraceptives if she has a family history of breast cancer deserves more attention in future investigations on the long-term effects of birth control pills.

Benign breast disease: estriol proportions and family history of breast cancer.

Urine samples were analyzed for estrone (E1), estradiol (E2), and Estriol (E3) to test the hypothesis that women diagnosed with benign breast disease (high risk for breast cancer?) will have lower estriol proportions (E3/E1 + E2 + E3) than a comparison control group. Luteal urine samples were collected from 64 women recently diagnosed with benign breast disease (cases) and from 64 controls matched for age and education. Compared to their controls, benign breast disease patients had a lower mean weight (P less than 0.05), lower Quetelet's index (P less than 0.02), and higher frequency of family history of breast cancer (P less than 0.01) and of family history of any breast disease (P less than 0.01). The mean estriol proportions were similar for cases and controls before and after stratification by family history and Quetelet's index. Results of this study indicate that if women with benign breast disease are at high risk of breast cancer, that risk is not transmitted by the estriol proportion.

Estrogen profiles in young women: effect of maternal history of breast cancer.

To examine the hypothesis that familial breast cancer risk is related to estrogen metabolism, we analyzed urines of daughters of breast cancer patients and their matched controls for estrone (E1), estradiol (E2), and estriol (E3). From this, we computed estriol proportions (E3/E1 + E2 + E3). "Patient-daughters" and the matched controls showed no differences in estriol proportions. Our results failed to support the hypothesis that high-risk women (those with a family history of breast cancer) have relatively lower estriol proportions, and we concluded that whatever family history contributes to breast cancer risk, that risk is not likely to be transmitted by the estrogen profile.

PIP: A study designed to test the hypothesis that daughters of breast cancer patients would have "less favorable" estriol proportions than would a group of otherwise similar controls is reported. Urinary estrogen profiles of 46 daughters born to 45 women who later developed breast cancer and of 46 controls were examined. Computed estriol proportions (estriol/estrone plus estradiol plus estriol) revealed no differences in "patient-daughters" and the matched controls. It is concluded that whatever family history contributes to breast cancer risk, that risk is not likely transmitted by the estrogen profile.