Physician Communication Training and Parental Vaccine Hesitancy: A Randomized Trial.

BACKGROUND AND OBJECTIVES: Physicians have a major influence on parental vaccine decisions. We tested a physician-targeted communication intervention designed to (1) reduce vaccine hesitancy in mothers of infants seen by trained physicians and (2) increase physician confidence in communicating about vaccines. METHODS: We conducted a community-based, clinic-level, 2-arm cluster randomized trial in Washington State. Intervention clinics received physician-targeted communications training. We enrolled mothers of healthy newborns from these clinics at the hospital of birth. Mothers and physicians were surveyed at baseline and 6 months. The primary outcome was maternal vaccine hesitancy measured by Parental Attitudes on Childhood Vaccines score; secondary outcome was physician self-efficacy in communicating with parents by using 3 vaccine communication domains. RESULTS: We enrolled 56 clinics and 347 mothers. We conducted intervention trainings at 30 clinics, reaching 67% of eligible physicians; 26 clinics were randomized to the control group. Maternal vaccine hesitancy at baseline and follow-up changed from 9.8% to 7.5% in the intervention group and 12.6% to 8.0% in the control group. At baseline, groups were similar on all variables except maternal race and ethnicity. The intervention had no detectable effect on maternal vaccine hesitancy (adjusted odds ratio 1.22, 95% confidence interval 0.47-2.68). At follow-up, physician self-efficacy in communicating with parents was not significantly different between intervention and control groups. CONCLUSIONS: This physician-targeted communication intervention did not reduce maternal vaccine hesitancy or improve physician self-efficacy. Research is needed to identify physician communication strategies effective at reducing parental vaccine hesitancy in the primary care setting.

Relationships between sitting time and health indicators, costs, and utilization in older adults.

OBJECTIVE: To examine whether self-reported sitting time is related to various health indicators, health costs, and utilization in adults over age 65. METHODS: A retrospective cross-sectional cohort study was conducted using the electronic health record (EHR) from an integrated health system in Washington State. Members who completed an online health risk assessment (HRA) between 2009 and 2011 (N = 3538) were eligible. The HRA assessed sitting time, physical activity, and health status. Diagnosis codes for diabetes and cardiovascular disease (CVD), height and weight for body mass index (BMI) calculations, health care utilization and health costs were extracted from the EHR. Linear regression models with robust standard errors tested differences in sitting time by health status, BMI category, diabetes and CVD, health costs, and utilization adjusting for demographic variables, BMI, physical activity, and health conditions. RESULTS: People classified as overweight and obese, that had diabetes or CVD, and with poorer self-rated health had significantly higher sitting time (p < .05). Total annual adjusted health care costs were $126 higher for each additional hour of sitting (p < .05; not significant in final models including health conditions). CONCLUSION: Sitting time may be an important independent health indicator among older adults.

Characteristics of older adult physical activity program users.

OBJECTIVES: Physical activity levels are low among older adults. Many Medicare members have access to low-cost programs including Silver Sneakers (SS) and EnhanceFitness (EF) at no additional cost, however, utilization of these programs is low. We aimed to compare characteristics of people using SS and EF to nonusers of these programs to better understand the characteristics of these 2 populations and to guide future physical activity promotion program design. STUDY DESIGN: Cross-sectional. METHODS: We used 2010 and 2011 electronic health records including demographic, health condition, Charlson comorbidity score, healthcare cost and utilization, and SS and EF program utilization data from 37,492 Medicare members from a large integrated health care system. Models were fit using logistic and negative binomial regression adjusting for age, gender, race, ethnicity, BMI category, and primary care clinic location. RESULTS: Compared with nonusers (N = 30,733; 82%), SS users (N = 6200; 16.5%) were younger and less likely to be male, obese, or have diabetes or cardiovascular disease; they also had lower Charlson scores and fewer hospital admissions than nonusers. EF users (N = 721; 2%) were older, were less likely to be male, had lower Charlson scores, and had fewer hospital admissions compared to nonusers. CONCLUSIONS: Low-cost, evidence-based physical activity programs are vastly underused by Medicare members. Our data suggest that targeting more chronically ill and obese older adults for physical activity programs might help improve the reach of existing evidence-based programs.

Alcohol and associated characteristics among older persons living with human immunodeficiency virus on antiretroviral therapy.

BACKGROUND: Alcohol use, and particularly unhealthy alcohol use, is associated with poor human immunodeficiency virus (HIV)-related outcomes among persons living with HIV (PLWH). Despite a rapidly growing proportion of PLWH ≥50 years, alcohol use and its associated characteristics are underdescribed in this population. The authors describe alcohol use, severity, and associated characteristics using data from a sample of PLWH ≥50 years who participated in a trial of a telephone-based intervention to improve adherence to antiretroviral therapy (ART). METHODS: Participants were recruited from acquired immunodeficiency syndrome (AIDS) service organizations in 9 states and included PLWH ≥50 years who were prescribed ART, reported suboptimal adherence at screening (missing >1.5 days of medication or taking medications 2 hours early or late on >3 days in the 30 days prior to screening), and consented to participate. The AUDIT-C (Alcohol Use Disorders Identification Test-Consumption) alcohol screen, sociodemographic characteristics, substance use, and mental health comorbidity were assessed at baseline. AUDIT-C scores were categorized into nondrinking, low-level drinking, and mild-moderate unhealthy, and severe unhealthy drinking (0, 1-3, 4-6, and 7-12, respectively). Analyses described and compared characteristics across drinking status (any/none) and across AUDIT-C categories among drinkers. RESULTS: Among 447 participants, 57% reported drinking in the past year (35%, 15%, and 7% reported low-level drinking, mild-moderate unhealthy drinking, and severe unhealthy drinking, respectively). Any drinking was most common among men and those who were lesbian, gay, bisexual, or transgender (LGBT), married/partnered, had received past-year alcohol treatment, and never used injection drugs (P values all <.05). Differences in race, employment status, past-year alcohol treatment, and positive depression screening (P values all <.05) were observed across AUDIT-C categories, with African American race, less than full-time employment, past-year alcohol treatment, and positive depression screening being most common among those with the most severe unhealthy drinking. CONCLUSIONS: In this sample of older PLWH with suboptimal ART adherence, a majority reported past-year alcohol use and 22% screened positive for unhealthy alcohol use. Any and unhealthy alcohol use were associated with demographics, depression, and substance use history. Further research is needed regarding alcohol use among older PLWH.

Chronic illness burden and quality of life in an aging HIV population.

The population of persons living with HIV (PLWH) is growing older and more prone to developing other chronic health conditions. Disease progression has been shown to be related to quality of life (QoL). However, descriptions of chronic comorbid illnesses and the unique QoL challenges of older adults living with HIV are not well understood and have not been examined in multiple geographic locations. About 452 PLWH aged 50 years or older were recruited from AIDS Service Organizations in nine states. Participants completed a telephone survey that included measures of other chronic health conditions, perceived stress, depression, and health-related quality of life. As much as 94% of the sample reported a chronic health condition in addition to HIV (mode = 2). The highest reported conditions were hypertension, chronic pain, hepatitis, and arthritis. Despite relatively high rates of depression, overall QoL was moderately high for the sample. Physical functioning was most impacted by the addition of other chronic health problems. Social functioning, mental health functioning, stress, and depression were also strongly associated with chronic disease burden. Additional chronic health problems are the norm for PLWH aged 50 years and older. QoL is significantly related to the addition of chronic health problems. As increasing numbers of PLWH reach older age, this raises challenges for providing comprehensive healthcare to older PLWH with multiple chronic conditions.

Adjunctive naturopathic care for type 2 diabetes: patient-reported and clinical outcomes after one year.

BACKGROUND: Several small, uncontrolled studies have found improvements in self-care behaviors and reductions in clinical risk in persons with type 2 diabetes who received care from licensed naturopathic physicians. To extend these findings and determine the feasibility and promise of a randomized clinical trial, we conducted a prospective study to measure the effects of adjunctive naturopathic care (ANC) in primary care patients with inadequately controlled type 2 diabetes. METHODS: Forty patients with type 2 diabetes were invited from a large integrated health care system to receive up to eight ANC visits for up to one year. Participants were required to have hemoglobin A1c (HbA1c) values between 7.5-9.5 % and at least one additional cardiovascular risk factor (i.e., hypertension, hyperlipidemia or overweight). Standardized instruments were administered by telephone to collect outcome data on self-care, self-efficacy, diabetes problem areas, perceived stress, motivation, and mood. Changes from baseline scores were calculated at 6- and 12-months after entry into the study. Six and 12-month changes in clinical risk factors (i.e., HbA1c, lipid and blood pressure) were calculated for the ANC cohort, and compared to changes in a cohort of 329 eligible, non-participating patients constructed using electronic medical records data. Between-cohort comparisons were adjusted for age, gender, baseline HbA1c, and diabetes medications. Six months was pre-specified as the primary endpoint for outcome assessment. RESULTS: Participants made 3.9 ANC visits on average during the year, 78 % of which occurred within six months of entry into the study. At 6-months, significant improvements were found in most patient-reported measures, including glucose testing (P = 0.001), diet (P = 0.001), physical activity (P = 0.02), mood (P = 0.001), self-efficacy (P = 0.0001) and motivation to change lifestyle (P = 0.003). Improvements in glucose testing, mood, self-efficacy and motivation to change lifestyle persisted at 12-months (all P < 0.005). For clinical outcomes, mean HbA1c decreased by -0.90 % (P = 0.02) in the ANC cohort at 6-months, a -0.51 % mean difference compared to usual care (P = 0.07). Reductions at 12-months were not statistically significant (-0.34 % in the ANC cohort, P = 0.14; -0.37 % difference compared to the usual care cohort, P = 0.12). CONCLUSIONS: Improvements were noted in self-monitoring of glucose, diet, self-efficacy, motivation and mood following initiation of ANC for patients with inadequately controlled type 2 diabetes. Study participants also experienced reductions in blood glucose that exceeded those for similar patients who did not receive ANC. Randomized clinical trials will be necessary to determine if ANC was responsible for these benefits.

Patient race/ethnicity and shared medical record use among diabetes patients.

BACKGROUND: Previous studies have documented racial/ethnic differences in patients' use of websites providing shared electronic medical records between patients and health care professionals. Less is known about whether these are driven by patient-level preferences and/or barriers versus broader provider or system factors. METHODS: Cross-sectional study of diabetes patients in an integrated delivery system in 2008-2009. Primary measures were race/ethnicity and shared medical record (SMR) use. Covariates included sociodemographics (age, sex, income, education), health status (comorbidity, diabetes severity), and provider characteristics (encouragement of SMR, secure messaging use, clinic). RESULTS: The majority (62%) of Whites used the SMR, compared with 34% of Blacks, 37% of Asians, and 55% of other race/ethnicity (P<0.001). Most respondents (76%) stated that their provider had encouraged them to use the SMR, with no differences by race/ethnicity. Patients saw primary care providers who used a similar amount of secure messaging in their practices-except Asians, who were less likely to see high-messaging providers. In fully adjusted models, Blacks [odds ratio (OR), 0.18; 95% confidence interval (CI), 0.11-0.30] and Asians (OR, 0.40; 95% CI, 0.20-0.77) were significantly less likely than Whites to use the SMR. When restricted to individuals reporting at least occasional Internet use, this finding remained for Black respondents (OR, 0.25; 95% CI, 0.10-0.63). CONCLUSIONS: Among diabetes patients, differences in SMR use by race/ethnicity were not fully explained by differences in age, sex, sociodemographics, health status, or provider factors-particularly for Black patients. There were few racial/ethnic differences in provider encouragement or provider secure messaging use that would have suggested disparities at the provider level.

Communication about diabetes risk factors during between-visit encounters.

OBJECTIVES: Secure messaging and phone encounters are becoming widespread to increase patient access to providers between ambulatory care visits. Although these encounters have the potential to improve the control of diabetes risk factors,we know little about their content in relation to traditional in-person visits. STUDY DESIGN: Cross-sectional analysis of survey and electronic health record data of patients with diabetes receiving care at Group Health Cooperative in 2008 to 2009. METHODS: The primary outcome was patient-reported communication with their providers about risk factors for diabetes complications (glucose, blood pressure [BP], and cholesterol) during in-person, phone, and secure messaging encounters. Additional variables included patient demographic, health, and utilization characteristics. We examined unadjusted associations with reported communication by risk factor, encounter type, and demographic/health characteristics. RESULTS: Among 569 patients, 50% were aged ≥ 65 years, 50% were male, 35% had ≥ college education, and 64% were white; 77% had ≥ 1 between-visit encounter (63% phone, 41% secure messaging). Discussions about glucose were reported by 89% during in-person visits and 42% during between-visit encounters compared with 81% and 17% for BP and 76% and 20% for cholesterol (all P < .001). Those who were younger, more educated, of black or other race/ethnicity, on insulin, or in poor control of glycated hemoglobin were more likely to report risk factor discussions during between-visit encounters. CONCLUSIONS: In this system, patients with diabetes reported significantly fewer risk factor discussions during between-visit encounters compared with in-person visits. These results suggest potential missed opportunities for proactive support of risk factor management.

Survey of CAM interest, self-care, and satisfaction with health care for type 2 diabetes at group health cooperative.

BACKGROUND: Very little research has explored the factors that influence interest in complementary and alternative medicine (CAM) treatments. We surveyed persons with sub-optimally controlled type 2 diabetes to evaluate potential relationships between interest in complementary and alternative medicine (CAM) treatments, current self-care practices, motivation to improve self-care practices and satisfaction with current health care for diabetes. METHODS: 321 patients from a large integrated healthcare system with type 2 diabetes, who were not using insulin and had hemoglobin A1c values between 7.5-9.5%, were telephoned between 2009-2010 and asked about their self-care behaviors, motivation to change, satisfaction with current health care and interest in trying naturopathic (ND) care for their diabetes. Responses from patients most interested in trying ND care were compared with those from patients with less interest. RESULTS: 219 (68.5%) patients completed the survey. Nearly half (48%) stated they would be very likely to try ND care for their diabetes if covered by their insurance. Interest in trying ND care was not related to patient demographics, health history, clinical status, or self-care behaviors. Patients with greater interest in trying ND care rated their current healthcare as less effective for controlling their blood sugar (mean response 5.9 +/- 1.9 vs. 6.6 +/- 1.5, p = 0.003), and were more determined to succeed in self-care (p = 0.007). Current CAM use for diabetes was also greater in ND interested patients. CONCLUSIONS: Patients with sub-optimally controlled type 2 diabetes expressed a high level of interest in trying ND care. Those patients with the greatest interest were less satisfied with their diabetes care, more motivated to engage in self-care, and more likely to use other CAM therapies for their diabetes.

Feasibility and acceptability of a multiple risk factor intervention: the Step Up randomized pilot trial.

BACKGROUND: Interventions are needed which can successfully modify more than one disease risk factor at a time, but much remains to be learned about the acceptability, feasibility, and effectiveness of multiple risk factor (MRF) interventions. To address these issues and inform future intervention development, we conducted a randomized pilot trial (n = 52). This study was designed to assess the feasibility and acceptability of the Step Up program, a MRF cognitive-behavioral program designed to improve participants' mental and physical well-being by reducing depressive symptoms, promoting smoking cessation, and increasing physical activity. METHODS: Participants were recruited from a large health care organization and randomized to receive usual care treatment for depression, smoking, and physical activity promotion or the phone-based Step Up counseling program plus usual care. Participants were assessed at baseline, three and six months. RESULTS: The intervention was acceptable to participants and feasible to offer within a healthcare system. The pilot also offered important insights into the optimal design of a MRF program. While not powered to detect clinically significant outcomes, changes in target behaviors indicated positive trends at six month follow-up and statistically significant improvement was also observed for depression. Significantly more experimental participants reported a clinically significant improvement (50% reduction) in their baseline depression score at four months (54% vs. 26%, OR = 3.35, 95% CI [1.01-12.10], p = 0.05) and 6 months (52% vs. 13%, OR = 7.27, 95% CI [1.85-37.30], p = 0.004) CONCLUSIONS: Overall, results suggest the Step Up program warrants additional research, although some program enhancements may be beneficial. Key lessons learned from this research are shared to promote the understanding of others working in this field. TRIAL REGISTRATION: The trial is registered with ClinicalTrials.gov (NCT00644995).

Self-reported changes in providers' hormone therapy prescribing and counseling practices after the Women's Health Initiative.

BACKGROUND: Prescribing and counseling practices in hormone therapy (HT) since publication of the Women's Health Initiative (WHI) trials have changed. Our objective was to compare changes by practice field and region. METHODS: Between December 2005 and May 2006, we mailed surveys to 938 practitioners from two large integrated health systems in the Northeastern and Northwestern United States. We received 736 responses and excluded 144 who do not prescribe/counsel about HT, leaving 592. Data included prescriber characteristics, knowledge about HT trials, and self-reported HT counseling and prescribing changes. We compared provider characteristics and HT counseling and prescribing by region and practice field (obstetrician/gynecology [OB/GYN] or primary care). RESULTS: Respondents included 79 OB/GYNs and 513 primary care providers. OB/GYNs were more likely, than primary care providers to consider themselves experts regarding the Heart and Estrogen/progestin Replacement Study (HERS) and WHI trials (30.4% vs. 8.2%, p < 0.001). The majority (87%) were cautious about HT use, especially primary care providers (p < 0.01 compared to OB/GYNs). Respondents reported prescribing less oral unopposed estrogen (64%) and combination estrogen/progestin (81%) post-WHI. OB/GYNs were less likely to report decreases in oral unopposed estrogen use (p = 0.006). Use of lower-dose and transdermal products (low-dose estrogen, vaginal estrogen, estradiol vaginal ring) increased, especially by OB/GYNs. CONCLUSIONS: Our study highlights numerous HT prescribing and counseling differences between primary care and OB/GYN providers. Reasons for these differences are unknown but may be related to self-reported WHI/HERS knowledge. HT formulations used in the WHI trials are being replaced by low-dose and alternate formulations. Studies to support this practice are needed.

Use of a shared medical record with secure messaging by older patients with diabetes.

OBJECTIVE: Evaluate use of a web-based shared medical record (SMR) between older patients with diabetes and providers. RESEARCH DESIGN AND METHODS: This was a retrospective cohort study. Health records and SMR use patterns of 6,185 enrollees aged ≥65 years with diabetes were analyzed from implementation of a SMR in August 2003 through December 2007. We analyzed baseline predictors of age, sex, distance from clinic, socioeconomic status, insulin use, morbidity, and associated primary care provider's (PCP) secure messaging use on patients' initial and subsequent use of the SMR. Changes in morbidity, PCP, or diabetes treatment were evaluated for impact on outcomes. RESULTS: A total of 32.2% of enrollees used the SMR; median rate was 1.02 user-days/month. Numbers of users and rate of use continued to increase. In adjusted analyses, likelihood of SMR use was associated with younger age, male sex, and higher socioeconomic status neighborhood, as well as clinical characteristics of overall morbidity and assigned PCP's use of secure messaging. Initial SMR use was more likely within 3 months of an increase in morbidity (hazard ratio 1.61, 95% CI 1.28-2.01) and within 1 month of changing to a PCP with higher use (3.02, 1.66-5.51). CONCLUSIONS: Four years after implementation, one-third of older individuals with diabetes had used the web-based SMR. Higher morbidity predicted initial and continued use of SMR services. Providers' use of the communication feature was associated with higher likelihood of SMR engagement by their patients. Web-based SMRs may be an effective form of non-visit-based health care for older individuals with diabetes.

Brief telephone intervention increases soy intake in peri- and postmenopausal US women: the Herbal Alternatives Trial (HALT).

OBJECTIVE: Effective dietary intervention strategies that can be widely disseminated and have the potential for sustainable dietary modifications are needed. The purpose of this study was to describe and evaluate the effectiveness of a telephone-based soy intervention. DESIGN: A randomized controlled trial comparing self-reported intake and serum measures of soy during a 1-year dietary soy (Soy) to fruit and vegetable (Placebo) intervention conducted in two of five arms from the Herbal Alternatives Trial between May 2001 and September 2004. SUBJECTS/SETTING: One hundred sixty-three peri- and postmenopausal women (mean age=52 years) consuming self-selected diets in the Pacific Northwest, United States. INTERVENTION: Five telephone contacts with a registered dietitian during a 12-month intervention with the goal to increase soy food consumption to two servings daily. MAIN OUTCOME MEASURES: Change from baseline in self-reported soy servings and serum isoflavone (daidzein and genistein) concentrations were estimated using analysis of variance and generalized estimating equations. Proportions of participants achieving the intervention goal were compared using chi(2) tests. RESULTS: Ninety-four percent (n=74) of participants in the Soy arm and 89% (n=75) in the Placebo arm completed the trial, and slightly more than one third (n=27) received five phone contacts. Mean (+/-standard deviation) intakes of soy were similar for the Soy and Placebo arms at baseline (0.6+/-1.0 vs 0.4+/-0.8 servings/day; P>0.05). At 12-month follow-up visit, mean+/-standard deviation servings of soy per day were 1.6+/-1.4 for the Soy intervention compared to 0.5+/-0.9 within the Placebo arm (P<0.001). There were concomitant increases in serum isoflavones at 3 and 6 months from baseline in the Soy arm only, with approximately twofold increases in both daidzein (mean=66.4 nmol/L, 95% confidence interval [CI]: 39.0 to 93.9 [mean 16.9 ng/mL, 95% CI: 9.9 to 23.8]) and genistein (mean=100.4 nmol/L, 95% CI: 60.9 to 139.9 [mean 27.1 ng/mL, 95% CI: 16.5 to 37.8]) concentrations. Mean weight changed by <1 kg during the 12-month period in each group and physical activity remained stable, suggesting that participants incorporated soy foods into their diet by substituting for non soy foods rather than adding them to their diet. CONCLUSIONS: A brief telephone-based intervention with a focused message delivered by a registered dietitian is a feasible approach for encouraging targeted dietary changes, such as an increase in soy intake among peri- and postmenopausal women.

Impact of spirometry feedback and brief motivational counseling on long-term smoking outcomes: a comparison of smokers with and without lung impairment.

OBJECTIVE: We compared long-term outcomes among smokers with and without impaired lung functioning who received brief counseling highlighting their spirometric test results. METHODS: Participants in this analysis all received a brief motivational intervention for smoking cessation including spirometric testing and feedback ( approximately 20 min), were advised to quit smoking, offered free access to a phone-based smoking cessation program, and followed for one year. Outcomes were analyzed for smokers with (n=99) and without (n=168) impaired lung function. RESULTS: Participants with lung impairment reported greater use of self-help cessation materials at 6 months, greater use of non-study-provided counseling services at 6 and 12 months, higher 7-day PPA rates at 6 months, and were more likely to talk with their doctor about their spirometry results. CONCLUSION: Further research is warranted to determine if spirometry feedback has a differential treatment effect among smokers with and without lung impairment. PRACTICE IMPLICATIONS: It is premature to make practice recommendations based on these data.

Immediate and short-term impact of a brief motivational smoking intervention using a biomedical risk assessment: the Get PHIT trial.

INTRODUCTION: Providing smokers with biologically based evidence of smoking-related disease risk or physical impairment may be an effective way to motivate cessation. METHODS: Smokers were recruited for a free health risk assessment and randomized to receive personally tailored feedback based on their lung functioning, carbon monoxide (CO) exposure, and smoking-related health conditions or generic information about the risks of smoking and personalized counseling based on their diet, body mass index, and physical activity. All (n = 536) were advised to quit smoking and offered access to a free telephone cessation program. Participants were surveyed immediately after intervention and 1 month later to assess the impact on various indices of motivation to quit. RESULTS: Immediately posttreatment, experimental participants rated themselves as more likely to try to quit (p = .02) and reported a greater mean increase in their motivation to quit than controls (p = .04). At 1-month follow-up, however, we found no significant group differences on any motivational indices. In post-hoc analyses comparing smokers in the experimental group with and without lung impairment, persons with impaired lung functioning had a greater change from baseline in posttreatment motivation to quit (adjusted p = .05) and perceived risk of developing a smoking-related disease (p = .03) compared with persons with no lung impairment, but we found no significant treatment effect on any motivational indices at 1 month. DISCUSSION: The results suggest that the intervention had a small, temporary effect, but we found no clear evidence that the intervention increased motivation to quit smoking during the first month postintervention.

Reprint of The Herbal Alternatives for Menopause (HALT) Study: background and study design.

We designed a randomized double-blind randomized trial to examine the short and long-term effects of alternative approaches commonly used to manage menopause symptoms. Women were randomly assigned to: (1) black cohosh 160 mg daily; (2) multibotanical (50 mg black cohosh, alfalfa, chaste tree, dong quai, false unicorn, licorice, oats, pomegranate, Siberian ginseng, boron) four capsules daily; (3) multibotanical plus telephone counseling to increase dietary soy; (4) conjugated equine estrogen 0.625 mg +/- 2.5 mg medroxyprogesterone acetate; or (5) placebo. Working with a skilled CAM provider helped us choose interventions that reflected naturopathic practices worthy of study. Mass mailing, with careful tracking and rapid responses to recruitment rates, was an effective and cost-effective recruitment strategy. Creativity was necessary to construct methods for blinding capsules and the dietary soy intervention. Independent testing of herbal products was vital to confirming their constituents. The Data and Safety and Monitoring Committee, and project officers at the funding agency, were critical partners in designing responses to unanticipated Women's Health Initiative findings published during the HALT trial. Careful monitoring of adverse events may provide much needed information about side effects of herbal products and supplements. Despite inherent challenges, the study of alternative therapies for menopause symptoms is a rewarding and important area deserving of further inquiry.

Delivering effective primary care to older adults: a randomized, controlled trial of the senior resource team at group health cooperative.

OBJECTIVES: To assess the effect of a team of geriatrics specialists on the practice style of primary care providers (PCPs) and the functioning of their patients aged 75 and older. DESIGN: Randomized, controlled trial. SETTING: Two primary care clinics in the Seattle, Washington, area. PARTICIPANTS: Thirty-one PCPs and 874 patients aged 75 and older. INTERVENTION: An interdisciplinary team of geriatrics specialists worked with patients and providers to enhance the geriatric focus of care. MEASUREMENTS: Main outcomes were a practice style reflecting a geriatric orientation and patient scores on the physical and affect subscales of the Arthritis Impact Measurement Scale 2-Short Form. Secondary outcomes were hospitalizations, incident disability in activities of daily living (ADLs), and PCP perceptions of the intervention. Death rates were also assessed. RESULTS: Intervention providers screened significantly more for geriatric syndromes at 12 months, but this finding did not persist at 24 months. There were no significant differences in adequate hypertension control or high-risk prescribing at 12 or 24 months of follow-up. There were no significant differences in patient functioning or significant differences in hospitalization rates at either time point. Meaningful differences were observed in ADL disability at 12 but not 24 months. PCPs viewed the intervention favorably. Seventy-eight participants died over the 24 months of follow-up; the proportion dying was higher in the intervention group (11.4% in intervention group vs 7.1% of controls, P=.03). CONCLUSION: The addition of an interdisciplinary geriatric team was acceptable to PCPs and had some effect on care of geriatric conditions but little effect on patient function or the use of inpatient care and was associated with greater mortality.

How the Women's Health Initiative (WHI) influenced physicians' practice and attitudes.

BACKGROUND: The landmark Women's Health Initiative (WHI) Postmenopausal Hormone Therapy Trial published in 2002 showed that the health risks of combination hormone therapy (HT) with estrogen and progestin outweighed the benefits in healthy postmenopausal women. Dissemination of results had a major impact on prescriptions for, and physician beliefs about HT. No study has fully examined the influence of the widely publicized WHI on physicians' practice and attitudes or their opinions of the scientific evidence regarding HT; in addition, little is known about how physicians assist women in their decisions regarding HT. DESIGN AND PARTICIPANTS: We conducted in-depth telephone interviews with family practitioners, internists, and gynecologists from integrated health care delivery systems in Washington State (n = 10 physicians) and Massachusetts (n = 12 physicians). Our objectives were to obtain qualitative information from these physicians to understand their perspectives on use of HT, the scientific evidence regarding its risks and benefits, and counseling strategies around HT use and discontinuation. APPROACH: We used Template Analysis to code transcribed telephone interviews and identify themes. RESULTS: Physicians were conflicted about the WHI results and its implications. Seven themes identified from in-depth interviews suggested that the WHI (1) was a ground-breaking study that changed clinical practice, including counseling; (2) was not applicable to the full range of patients seen in clinical practice; (3) raised concerns over the impact of publicized health information on women; (4) created uncertainty about the risks and benefits of HT; (5) called for the use of decision aids; (6) influenced discontinuation strategies; and (7) provided an opportunity to discuss healthy lifestyle options with patients. As a result of the WHI, physicians reported they no longer prescribe HT for prevention and were more likely to suggest discontinuation, although many felt women should be in charge of the HT decision. CONCLUSIONS: Physicians varied in their opinions of HT and the scientific evidence (positive and negative). Whereas the WHI delineated the risks and benefits of HT, physicians reported that decision aids are needed to guide discussions with women about menopause and HT. Better guidance at the time of WHI study publication might have been valuable to ensure best practices.

Night sweats, sleep disturbance, and depression associated with diminished libido in late menopausal transition and early postmenopause: baseline data from the Herbal Alternatives for Menopause Trial (HALT).

OBJECTIVE: The objective of the study was to evaluate the association of depression, sleep disturbance, and menopausal symptoms with diminished libido. STUDY DESIGN: Data from a 2001-2002 baseline survey of 341 peri- and postmenopausal women, aged 45-55 years, participating in a randomized trial, was analyzed. Eligibility included at least 2 hot flashes and/or night sweats per day and no hormone therapy for at least the prior 3 months. The survey evaluated sexual function, depression, sleep, and vasomotor symptoms. We examined the association between these factors, using multivariate regression models. RESULTS: Of 341 women, 64% had diminished libido, 18% had moderate to severe depression, and 43% had poor sleep quality. Women averaged 4.6 hot flashes and 1.9 night sweats per day. Depressive symptoms (P = .003), poor sleep (P = .02), and night sweats (P = .04) were significantly associated with diminished libido. CONCLUSION: Factors associated with diminished libido in midlife are complex but include depression, disturbed sleep, and night sweats, all common symptoms of the menopausal transition and early menopause.

Chlamydia screening in at-risk adolescent females: an evaluation of screening practices and modifiable screening correlates.

PURPOSE: To identify modifiable correlates of chlamydia screening that could offer intervention targets to enhance screening. METHODS: We surveyed a representative sample of primary care providers (n = 186) at an integrated healthcare delivery system to document their self-reported adherence to annual screening of sexually-active adolescents and to identify specific, modifiable constructs that were correlated with annual chlamydia screening. To cross-validate providers' self-report, we also used automated data to examine adolescent screening in an anonymous sample of primary care providers (n = 143). RESULTS: Forty-two percent of providers reported annual chlamydia screening of sexually-active adolescents. Univariate correlates of annual screening were: provider type (non-physician) (p = .01), female gender (p = .001), fewer years of clinical experience (p = .001), greater perceived knowledge about chlamydia (p = .001), greater confidence across a range of screening-related activities (p < or = .01), greater comfort recommending screening for sexually transmitted diseases (p = .001), and greater perceived patient comfort discussing sexual issues (p < .01). In multivariate analyses, providers' perceived knowledge, confidence, comfort, and perceived patient comfort continued to be significantly associated with annual chlamydia screening after controlling for other relevant provider characteristics. Self-reported screening practices were consistent with observed screening rates in the anonymous provider sample. CONCLUSIONS: Routine chlamydia screening among asymptomatic, at-risk adolescent females could be enhanced through additional intervention targeting specific provider attitudes and beliefs about chlamydia screening.