Integrated Health Plan Research Articles

Preference for Colonoscopy in a Program of Annual Fecal Occult Blood Testing

Purpose: American College of Gastroenterology guidelines suggest that colonoscopy is the preferred screening strategy with fecal immunochemical test as the first alternative to colonoscopy. We assessed the cross-over rate to colonoscopy among study participants randomized to annual fecal occult blood test (FOBT) in a randomized controlled trial (RCT) comparing colonoscopy and annual (sensitive) FOBT. High cross-over rates would indicate that additional colonoscopy capacity will be required in a screening program of FOBT beyond that required for evaluating positive FOBTs if annual FOBT is not readily accepted as the screening modality. Methods: The National Colonoscopy Study is a feasibility study comparing screening colonoscopy to a program of annual FOBT conducted at 3 clinical centers: University of Minnesota (predominantly private insurance setting dominated by managed care organizations), Group Health Cooperative (integrated health plan setting), and Louisiana State University at Shreveport (minority-serving institution). Use of colonoscopy in the study period among those assigned to FOBT who had only negative or uncompleted FOBTs during the study period was the endpoint of this analysis. Subjects submitting a positive FOBT were censored at the time of their test. The cumulative percent crossing over to colonoscopy up to 4 years after randomization, overall and by center, was estimated using Kaplan-Meier curves. Results: Of 1765 randomized to a program of annual FOBT, the cross-over rate varied by clinical site with the highest cross-over rate in the private-insurance site (29% over 4 years) and with lower rates for the managed care plan (16%) and the minority serving institution (5%) (Figure). Conclusion: Colonoscopy use was observed for a substantial subset of subjects assigned to annual FOBT screening. This happened more frequently in patient populations with some fee-for-service insurance compared to the settings of an integrated health plan or a minority-serving institution. This phenomenon should be recognized in planning for a screening FOBT program and in clinical practice using FOBT.Figure

Synergistic Effect of Statins and Postmenopausal Hormone Therapy in the Prevention of Skeletal Fractures in Elderly Women

To examine the role of concurrent 3-hydroxy-3-methylglutaryl coenzyme A reductase inhibitor (statin) use and postmenopausal hormone therapy on osteoporosis-related fractures. Case-control study. Data Source. Large integrated health plan in New Mexico. Patients. Case patients were 1001 women with incident fractures of the hip, wrist, forearm, or spine that occurred between January 1, 2000, and December 31, 2005, and controls were 2607 women without fractures during the same time frame; both groups were selected from the same population of women aged 50 years or older who utilized health plan services during the study time frame. Postmenopausal hormone therapy use was classified as "current" (12 mo before index date) or "never or past." The risk of fractures was ascertained among continuous (> or = 80% medication possession ratio during 12 mo before the index date) and current (3 mo before index date) statin users relative to patients without hyperlipidemia who did not use lipid-lowering drugs. The interaction between statins and hormone therapy was examined in multivariable logistic regression. The association between statin use and fractures was examined separately among current and never or past hormone therapy users after controlling for other risk factors. Nineteen percent of the study participants were current hormone therapy users; 9.5% were current and 4.8% were continuous statin users. No association between continuous statin use and fractures was observed among never or past hormone therapy users (odds ratio [OR] 0.80, 95% confidence interval [CI] 0.53-1.22). In contrast, a strong protective effect (OR 0.19, 95% CI 0.04-0.87) was observed among women who concurrently used statins and hormone therapy for 1 year, independent of age; corticosteroid, bisphosphonate, thiazide diuretic, calcitonin, methotrexate, or antiepileptic drug use; chronic kidney disease; and Charlson comorbidity index. Concurrent statin use and hormone therapy may have a synergistic protective effect on skeletal fractures beyond the additive effect of each individual therapy.

Complex Hyperplasia With and Without Atypia

Limited data exist to inform clinicians and patients as to the likelihood of long-term endometrial hyperplasia response to progestin therapy, especially for atypical hyperplasia. We evaluated women with complex and atypical endometrial hyperplasia, comparing those prescribed progestin with those not prescribed progestin. This retrospective cohort study was conducted in 1985-2005 among women aged 18-88 years at an integrated health plan in Washington State. Women were ineligible if they achieved an outcome (endometrial carcinoma, hysterectomy, or both) within 8 weeks of hyperplasia diagnosis. Exposure was progestin use for at least 14 days by duration and recency. Outcomes included rate of 1) endometrial carcinoma, 2) hysterectomy, or 3) both. Analyses performed included Kaplan-Meier, incident rate ratios, and Cox proportional hazard ratios. One thousand four hundred forty-three eligible women were identified. One thousand two hundred one had complex (n=164 no progestin) and 242 had atypical (n=62 no progestin) hyperplasia. During follow-up, a median of 5.3 years (range 8 weeks to 20.8 years), 71 women were diagnosed with endometrial carcinoma (35 complex, 36 atypia) and 323 underwent hysterectomy (216 complex, 107 atypia). Among women with complex and atypical hyperplasia, rates of endometrial carcinoma among progestin users were 3.6 and 20.5 per 1,000 woman-years, respectively (compared with women who did not use progestin, 10.8 and 101.4). Among women with complex and atypical hyperplasia, rates of hysterectomy among progestin users were 23.3 and 61.4 per 1,000 woman-years, respectively (compared with women who did not use progestin, 55.1 and 297.3). Endometrial carcinoma risk is diminished approximately threefold to fivefold in women diagnosed with complex or atypical endometrial hyperplasia and dispensed progestin; hysterectomy risk is also decreased. II.

Individuals receiving addiction treatment: are medical costs of their family members reduced?

To examine whether alcohol and other drug (AOD) treatment is related to reduced medical costs of family members. Using the administrative databases of a private, integrated health plan, we matched AOD treatment patients with health plan members without AOD disorders on age, gender and utilization, identifying family members of each group. Kaiser Permanente Northern California. Family members of abstinent and non-abstinent AOD treatment patients and control family members. We measured abstinence at 1 year post-intake and examined health care costs per member-month of family members of AOD patients and of controls through 5 years. We used generalized estimating equation methods to examine differences in average medical cost per member-month for each year, between family members of abstinent and non-abstinent AOD patients and controls. We used multilevel models to examine 4-year cost trajectories, controlling for pre-intake cost, age, gender and family size. AOD patients' family members had significantly higher costs and more psychiatric and medical conditions than controls in the pre-treatment year. At 2-5 years, each year family members of AOD patients abstinent at 1 year had similar average per member-month medical costs to controls (e.g. difference at year 5 = $2.63; P > 0.82), whereas costs for family members of non-abstinent patients were higher (e.g. difference at year 5 = $35.59; P = 0.06). Family members of AOD patients not abstinent at 1 year, had a trajectory of increasing medical cost (slope = $10.32; P = 0.03) relative to controls. Successful AOD treatment is related to medical cost reductions for family members, which may be considered a proxy for their improved health.

Integrating depression and chronic disease care among patients with diabetes and/or coronary heart disease: The design of the TEAMcare study

Diabetes and coronary heart disease (CHD) are two of the most prevalent medical illnesses in the US population and comorbid depression occurs in up to 20% of these patients. Guidelines for management of diabetes and CHD overlap for healthy lifestyle and disease-control recommendations. However, the majority of patients with these medical illnesses have been shown to have inadequate control of key risk factors such as blood pressure, LDL cholesterol, or blood sugar. Comorbid depression has been shown to adversely affect self-care of diabetes and CHD, and is associated with an increased risk of complications and mortality. Interventions that have improved quality and outcomes of depression care alone in patients with diabetes and CHD have not demonstrated benefits in self-care, improved disease control or morbidity and mortality. This paper describes the design and development of a new biopsychosocial intervention (TEAMcare) aimed at improving both medical disease control and depression in patients with poor control of diabetes and/or CHD who met the criteria for comorbid depression. A team approach is used with a nurse interventionist who receives weekly psychiatric and primary care physician caseload supervision in order to enhance treatment by the primary care physician. This intervention is being tested in an NIMH-funded randomized controlled trial in a large integrated health plan.

Ethnic Disparities in Accessing Treatment for Depression and Substance Use Disorders in an Integrated Health Plan

This study examined ethnic differences in accessing treatment for depression and substance use disorders (SUDs) among men and women in a large integrated health plan, and explored factors potentially contributing to health care disparities. Participants were 22,543 members ages 20 to 65 who responded to health surveys in 2002 and 2005. Survey questions were linked to provider-assigned diagnoses, electronic medication, psychiatry, and chemical dependency program records. Among women diagnosed with depression, Latinas (p < .01) and Asian-Americans (p < .001) were less likely than Whites to fill an antidepressant prescription. Among men diagnosed with depression, African Americans (p < .01) were less likely than Whites to do so. Among women diagnosed with an SUD, African Americans (p < .05) were less likely than Whites to have one or more chemical dependency program visits. Results demonstrated ethnic differences in accessing depression and SUD treatment among patients diagnosed with these disorders, which persisted after controlling for education, income, having a regular health care provider and length of health plan enrollment. Findings highlight potential gender differences in ethnic disparities, lower antidepressant utilization among Asian Americans, and the effects of co-occurring disorders in accessing behavioral health care.

Circulating 25-Hydroxyvitamin-D and Risk of Colorectal Adenomas and Hyperplastic Polyps

Abstract Background: Colorectal adenomas are clear precursors of cancer; hyperplastic polyps have recently been hypothesized to also have malignant potential. However, these two distinct colorectal lesions are probably on different molecular pathways to neoplasia. An inverse association between vitamin D and adenoma risk has been reported, but this is the first study, to our knowledge, that examines circulating 25(OH)D in relation to risk of hyperplastic polyps. Methods: We conducted a colonoscopy-based case-control study of adenomas and hyperplastic polyps among 474 members of a large integrated health plan. Self-administered questionnaires provided data on demographics and colorectal polyp risk factors, and we assayed plasma samples donated by participants at the time of the colonoscopy for total 25-hydroxyvitamin-D (25(OH)D) concentration. Polytomous regression was used to estimate separate odds ratios for adenomas (n = 153) and hyperplastic polyps (n = 91) by tertile of 25(OH)D. Results: An inverse association between 25(OH)D and adenomas was observed (comparing upper to lower tertiles: adjusted OR [95%CI]: 0.60 [0.34-1.08]). After restriction of the analyses to study participants with no history of polyps, this OR estimate moved further from the null and became statistically significant (adjusted OR [95%CI]: 0.43 [0.20-0.96]). In comparison, no statistically significant association between hyperplastic polyps and 25(OH)D was observed among the full study participants (adjusted OR [95%CI]: 1.12 [0.59-2.13]) nor among those without prior polyps (adjusted OR [95%CI]: 1.27 [0.57-2.35]). Conclusions: There is no evidence in our study that the established inverse association between circulating 25(OH)D and colorectal adenoma applies to hyperplastic polyps.

PS2-11: Characteristics of Medicare Part D Beneficiaries Who Obtain Prescriptions at Pharmacies External to Their Health Plan

Background: For Medicare Part D beneficiaries, drug costs after reaching the drug benefit threshold (DBT) could contribute to non-adherence and adverse outcomes. Because beneficiaries who reach the DBT might take prescriptions (Rx) to pharmacies that offer low-priced generic drugs, there is potential for loss of integrated care, as those pharmacies may not be affiliated with beneficiaries’ health plans. Potential implications of Rx dispensing external to members’ health plans include drug interactions, adverse events, lack of monitoring, and inaccurate adherence data. We sought to examine the extent to which Medicare beneficiaries take Rx outside a health plan and to describe those patients. We hypothesized that beneficiaries who reach the DBT are more likely than those who do not reach the DBT to have Rx dispensed at external pharmacies. Methods: This retrospective study included all Kaiser Permanente Colorado (KPCO) Medicare beneficiaries with membership in 2006 and 2007 (n=37,092). Data collected from electronic databases included demographics, membership, benefit structure, and comorbidities (Quan comorbidity index, QCI). A random sample of electronic medical records (n=100) was abstracted for information not available from administrative data. Chi-square and Wilcoxon Rank Sum tests were used to compare beneficiaries. Results: Among 27,354 beneficiaries who had a DBT, 1,655 (6%) took Rx to external pharmacies in 2007. Of 1,785 beneficiaries who reached the DBT, 12.4% (n=222) had external Rx compared to 5.6% (n=1433) of 25,569 who did not reach the DBT (P<0.001). Of those who reached the DBT, beneficiaries with external Rx had more comorbidity (external Rx mean QCI 4.2 [±2.8]; no external Rx mean QCI 2.4 [±2.1]; P<0.001). Chart review determined that not all Rx written externally were filled at pharmacies offering low price Rx: only 14% were documented taken to pharmacies advertising low price Rx, while 16%, 21%, and 43% were documented taken to military pharmacies, hospice/ nursing homes, or no dispensing location, respectively. Additionally, 11% of external Rx were nonformulary drugs. Subsequent prescriptions for 20% of all external Rx were dispensed at KPCO pharmacies. Conclusions: KPCO Medicare beneficiaries who reached the DBT more often had Rx dispensed externally. Of those who reached the DBT, beneficiaries with external Rx had more chronic illnesses. Clinical consequences of Rx dispensed outside integrated health plans require further study.

PS2-21: The Return on Investment of a Laboratory Program to Decrease Adverse Events of ACE Inhibitors and ARBs

Introduction: The efficiency of patient safety interventions is not well studied, including laboratory monitoring for drug therapy. Although 30% of patients receiving inhibitors of rennin-angiotensin system (RAS i.e. ACEI and ARB medications) are not monitored according to guidelines, knowledge of the efficiency of decreasing adverse drug events through monitoring programs above usual care is lacking. Methods: We focused on laboratory monitoring of new users of RAS inhibitors to help prevent adverse events of hyperkalemia and acute renal failure. We used a probabilistic decision model to synthesize multiple data sources to inform how increasing monitoring above usual practice changes cost and outcomes from the payer perspective. We accounted for differential timing of costs and benefits and discounted at a 5% rate. Costs included the monitoring program, offsets from reduced care (e.g., hospitalization) and litigation costs. Data from a large integrated health plan were used to estimate the community-based probability of adverse events. The potential to reduce adverse events was estimated from chart review. We examined cost-effectiveness at $30K and $100K per QALY in the overall population, patients with diabetes, and patients with chronic kidney disease (CKD). Results: Adverse events were most common in those with CKD; their cumulative incidence rate was 0.041 (95% CI, 0.047 to 0.037) compared to 0.016 (0.017 to 0.014) and 0.010 (0.011 to 0.010) in the diabetes and overall populations, respectively. Intervening on all new users or the subset with diabetes was cost saving <1% of the time. A monitoring program restricted to patients with CKD was cost saving with a probability of 95% in the base case. In CKD patients, if the program was only half as effective, the probability of cost savings was 65%; if the program had a lower uptake rate (49% instead of 82%) the probability of cost-savings was 30%. Intervening on all patients, or the subset with diabetes, was never cost-effective with a probability exceeding 5%. Intervening on patients with CKD was cost-effective at least 65% of the time even under the most pessimistic scenario. Discussion: Our findings illustrate that, for laboratory monitoring to be cost-effective using commonly accepted definitions, the patient population must be at high enough baseline risk of adverse events. Further inquiry into the willingness to pay for patient safety interventions is needed.

Breast and Cervical Cancer Screening: Specific Effects of Depression and Obesity

Obesity and depression may each be associated with lower rates of cervical and breast cancer screening. Studies have examined obesity or depression alone, but not together, despite the established link between them. This article aims to disentangle the effects of depression and obesity on receipt of breast and cervical cancer screening. A stratified sampling design was used to recruit women aged 40-65 years with information on BMI from an integrated health plan in Washington State in 2003-2005. A telephone survey included the Patient Health Questionnaire-9 for depression, weight, and height. Automated data assessed Paps for 3097 women over a 3-year period and screening mammograms over a 2-year period for 2163 women aged > or =51 years. Logistic regression models (conducted in 2008) examined the association between obesity and depression and receipt of screening tests. In univariate logistic regression models, women were less likely to receive a Pap if they were obese (OR=0.53, 95% CI=0.41, 0.69) or depressed (OR=0.60, 95% CI=0.42, 0.87). Further, women were less likely to receive a screening mammogram if they were depressed (OR=0.45, 95% CI=0.30, 0.67). In multivariable models, only obesity remained significantly associated with a lower likelihood of Pap screening (OR=0.67, 95% CI=0.0.49, 0.93), and only depression remained significantly associated with lower rates of screening mammography (OR=0.49, 95% CI=0.31, 0.76). Obesity and depression did not interact significantly in either model. Obesity and depression appear to have specific effects on receipt of different cancer-screening tests.

Early and Late Complications Among Long-Term Colorectal Cancer Survivors With Ostomy or Anastomosis

Among long-term (>or=5 y) colorectal cancer survivors with permanent ostomy or anastomosis, we compared the incidence of medical and surgical complications and examined the relationship of complications with health-related quality of life. The incidence and effects of complications on long-term health-related quality of life among colorectal cancer survivors are not adequately understood. Participants (284 survivors with ostomies and 395 survivors with anastomoses) were long-term colorectal cancer survivors enrolled in an integrated health plan. Health-related quality of life was assessed via mailed survey questionnaires from 2002 to 2005. Information on colorectal cancer, surgery, comorbidities, and complications was obtained from computerized data and analyzed by use of survival analysis and logistic regression. Ostomy and anastomosis survivors were followed up for an average of 12.1 and 11.2 years, respectively. Within 30 days of surgery, 19% of ostomy survivors and 10% of anastomosis survivors experienced complications (P < .01). From 31 days on, the percentages were 69% and 67% (after adjustment, P < .001). Bleeding and postoperative infection were common early complications. Common long-term complications included hernia, urinary retention, hemorrhage, skin conditions, and intestinal obstruction. Ostomy was associated with long-term fistula (odds ratio, 5.4; 95% CI 1.4-21.2), and among ostomy survivors, fistula was associated with reduced health-related quality of life (P < .05). Complication rates remain high despite recent advances in methods of surgical treatment. Survivors with ostomy have more complications early in their survivorship period, but complications among anastomosis survivors catch up after 20 years, when the 2 groups have convergent complication rates. Among colorectal cancer survivors with ostomy, fistula has especially important implications for health-related quality of life.

Factors Associated with Aromatase Inhibitor Use in a Large Cohort of Women Cared for in an Integrated Health Plan.

Abstract Background: Third generation aromatase inhibitors (AI) have been well tolerated in clinical trials and may have fewer side effects than tamoxifen. While national treatment guidelines recommend AI for postmenopausal women with ER+ tumors, the extent to which women are prescribed AIs in community settings in the U.S., and as front-line or extended therapy, remains unknown. Using data from a large non-profit health plan that serves over 3 million residents in Southern California, we report results examining the characteristics of breast cancer (BCa) survivors who were ever prescribed AIs.Methods: This cross-sectional analysis examined a cohort of 25,577 BCa (in situ and invasive cases) diagnosed from 1996-2006. We collected demographic, tumor, and cancer treatment information from automated health plan databases and SEER-affiliated cancer registry files. We identified patient and clinical factors associated with AI use. P-values (2-sided) were based on the chi-square distribution. Adjusted odds ratios (for age and year at diagnosis) and 95% confidence intervals were estimated using logistic regression.Results: In this cohort, nearly 37% ever used AIs (P&amp;lt;0.0001). Use of AIs increased by year (P&amp;lt;0.0001). Compared to non-Hispanic whites, minority women were less likely prescribed AIs (AOR=0.75 for blacks, 95% CI: 0.69-0.81). Although most women who used AI were first diagnosed with early stage disease (2 cm vs. &amp;lt;1cm). Women with positive lymph nodes had twice the odds of AI use (OR=2.27, 95% CI: 2.13-2.42) than those with negative nodes. Women with ER+ or PR+ lesions were more likely to have ever used AI (P&amp;lt;0.0001) as were those with HER- tumors (AOR=1.67, 95% CI: 1.48-1.89). Women who underwent breast conserving surgery without radiation were 36% less likely to use AI (AOR=0.64 95% CI: 0.59-0.69) than those with radiation. Of the total cohort, nearly 64% received adjuvant treatment. Among the 6716 women who received tamoxifen, about 43% (2918/6716) also used AI. Of note, during the 2005-2006 diagnosis years, the percentage treated with tamoxifen dropped among women ever prescribed AI. Of the 6627 women treated with chemotherapy only, 36% also received AI (2354/6627).Conclusions: Odds of AI use were greater among older women (age 60+), white race, higher stage at diagnosis, worse histology, positive lymph nodes, and those with ER+, PR+, or HER- tumors. However, grade and tumor size did not influence AI use. More work is needed to determine how patterns of AI use alone or following tamoxifen, medication changes, and tumor characteristics at initial diagnosis impact long-term breast cancer recurrence in this diverse group of patients in southern California. Citation Information: Cancer Res 2009;69(24 Suppl):Abstract nr 2079.

Short-term (1-2 mo) hormone therapy cessation before mammography

Some healthcare providers recommend hormone therapy (HT) cessation before mammography to improve performance. Our objective was to evaluate characteristics of women willing to consider HT cessation before screening mammography. We performed a randomized clinical trial, the Radiological Evaluation and Breast Density study, within an integrated health plan (2004-2007). Women aged 45 to 80 years who used HT at their most recent screening (index) mammogram, who were due for a screening (study) mammogram, and who were still using HT were invited to participate. Randomization groups were: (1) no, (2) 1-month, or (3) 2-month cessation. Women's willingness to participate was evaluated by age, race, ethnicity, education, hysterectomy, type of HT (unopposed estrogen and estrogen plus progestin), duration of HT use, body mass index, breast cancer risk, and breast density. A total of 5,861 women were invited to participate; 2,999 refused. An additional 169 women agreed to participate but withdrew before data collection. Compared with women who participated (n = 1,535), nonparticipants (n = 3,168; 2,999 + 169; 54%) were older, were less educated, and had lower body mass index (all P < 0.05). Among nonparticipants, 1,876 (59.2%) were unwilling to stop HT. Among estrogen-plus-progestin users, women with a first-degree relative with a history of breast cancer had lower odds of refusal than women without a family history of breast cancer (adjusted odds ratio, 0.71; 95% CI, 0.54-0.93). Most women were unwilling to stop HT, even for a short period, when the intent was to improve mammographic accuracy, and even when informed that they could restart HT at any time during the 2-month study. Some factors predicted willingness to stop HT; the magnitude of the differences may not be clinically meaningful.

Physician support for diabetes patients and clinical outcomes

BackgroundPhysician practical support (e.g. setting goals, pro-active follow-up) and communicative support (e.g., empathic listening, eliciting preferences) have been hypothesized to influence diabetes outcomes.MethodsIn a prospective observational study, patients rated physician communicative and practical support using a modified Health Care Climate Questionnaire. We assessed whether physicians' characteristic level of practical and communicative support (mean across patients) and each patients' deviation from their physician's mean level of support was associated with glycemic control outcomes. Glycosylated haemoglobin (HbA1c) levels were measured at baseline and at follow-up, about 2 years after baseline.ResultsWe analysed 3897 patients with diabetes treated in nine primary care clinics by 106 physicians in an integrated health plan in Western Washington, USA. Physicians' average level of practical support (based on patient ratings of their provider) was associated with significantly lower HbA1c at follow-up, controlling for baseline HbA1c (p = .0401). The percentage of patients with "optimal" and "poor" glycemic control differed significantly across different levels of practical support at follow (p = .022 and p = .028). Communicative support was not associated with differences in HbA1c at follow-up.ConclusionThis observational study suggests that, in community practice settings, physician differences in practical support may influence glycemic control outcomes among patients with diabetes.

Preferred modes of travel among older adults: What factors affect the choice to walk instead of drive?

There are many factors that influence older adults' travel choices. This paper explores the associations between mode of travel choice for a short trip and older adults' personal characteristics. This study included 406 drivers over the age of 64 who were enrolled in a large integrated health plan in the United States between 1991 and 2001. Bivariate analyses and generalized linear modeling were used to examine associations between choosing to walk or drive and respondents' self-reported general health, physical and functional abilities, and confidence in walking and driving. Having more confidence in their ability to walk versus drive increased an older adult's likelihood of walking to make a short trip by about 20% (PR=1.22; 95% CI: 1.06-1.40), and walking for exercise increased the likelihood by about 50% (PR=1.53; 95% CI=1.22-1.91). Reporting fair or poor health decreased the likelihood of walking, as did cutting down on the amount of driving due to a physical problem. Factors affecting a person's decision to walk for exercise may not be the same as those that influence their decision to walk as a mode of travel. It is important to understand the barriers to walking for exercise and walking for travel to develop strategies to help older adults meet both their exercise and mobility needs. Increasing walking over driving among older adults may require programs that increase confidence in walking and encourage walking for exercise.

Progestin Therapy of Complex Endometrial Hyperplasia With and Without Atypia

Women with complex or atypical endometrial hyperplasia have an increased risk of endometrial carcinoma. Generally, complex hyperplasia is treated with progestins, and women with atypical hyperplasia undergo hysterectomy despite the lack of clear evidence for the efficacy of hormonal therapy, and a continuing debate on the merits of progestins compared with hysterectomy in complex and atypical hyperplasia. The risk for persistence/progression of endometrial hyperplasia among women treated with progestin has varied widely in previous studies, but appears to be greater for atypical hyperplasia than complex hyperplasia. This observational cohort study compared the likelihood of histologic persistence/progression of complex or atypical hyperplasia among women treated over 2 to 6 months with progestin and those not treated with progestin. The study was conducted in 185 women, average age 55.9 years, with complex (n = 115) or atypical (n = 70) hyperplasia at an integrated health plan in Washington State between 1985 and 2005. Independent pathology review of endometrial specimens was performed at the time of index diagnosis and at a follow-up of 2 to 6 months (mean: 16.1weeks). Automated databases were examined linking medical and pharmacy information. Mantel-Haenszel analysis was used to estimate relative risks (RRs) adjusted for age, body mass, and other potential confounding factors. The control group was comprised of 38 (20.5%) women who received no progestin therapy. The likelihood of persistence/progression of complex hyperplasia among women who received progestin treatment in comparison to controls who did not, was similar and relatively low (30.0% vs. 28.4%, respectively); the adjusted RR was 1.20, with a 95% confidence interval (CI) of 0.53 to 2.72. In contrast, the risk of persistence/progression among women with atypical hyperplasia treated with progestin was substantially reduced compared to the controls (26.9% vs. 66.7%); the adjusted RR was 0.39, with a 95% CI of 0.21 to 0.70. Among women with atypia, treatment with progestin for a duration of at least 3 months had less than a 15% probability of persistence/progression. These data show a high frequency of spontaneous regression of complex hyperplasia. Progestin therapy for 2 to 6 months does not improve the rate of regression for complex hyperplasia in this study population, but is associated with more than a 2-fold increase in the likelihood of regression of atypical hyperplasia. The relatively small number of women in the study is problematic.

Incidence of endometrial hyperplasia

The objective of the study was to estimate the age-specific incidence of endometrial hyperplasia: simple, complex, and atypical, in order of increasing likelihood of progression to carcinoma. Women aged 18-90 years with endometrial pathology specimens (1985-2003) at a large integrated health plan were identified using automated data. Incidence rates were obtained by dividing the number of cases by the estimated number of female health plan enrollees who retained a uterus. Endometrial hyperplasia peak incidence was: simple, 142 per 100,000 woman-years, complex, 213 per 100,000 woman-years, both in the early 50s; and atypical, 56 per 100,000 woman-years in the early 60s. Age-adjusted incidence decreased over the study period, especially for atypical hyperplasia. Endometrial hyperplasia incidence without and with atypia peaks in the early postmenopausal years and in the early 60s, respectively. Given that some cases of endometrial hyperplasia likely go undiagnosed, the figures provided should be viewed as minimum estimates of the true incidence.

Sleep Apnea in Early and Advanced Chronic Kidney Disease

Sleep apnea (SA) has been reported to be highly prevalent in the dialysis population. The reported rates of SA in dialysis are severalfold greater than the 2 to 4% estimated in the general population. This study sought to determine whether an association exists between SA and early stages of chronic kidney disease (CKD) where SA may represent an important comorbidity and potential risk factor in kidney disease.Cross-sectional study of adults from an integrated health plan with documented serum creatinine levels in the period January 1, 2002, through December 31, 2004. SA diagnosis determined by International Classification of Diseases, ninth revision, coding for SA and Current Procedural Terminology coding for positive airway pressure devices. Kidney function was determined by the estimated glomerular filtration rate (eGFR). Logistic was regression used to estimate the relative risk for SA.The overall prevalence of SA was 2.5% in the study population that included subjects with normal renal function and those with CKD. The odds ratios (ORs) for SA by eGFRs of 75 to 89, 60 to 74, 45 to 59, 30 to 44, and 15 to 29 mL/min per 1.73 m(2), respectively, compared to normal kidney function, after adjustment for age, sex, and number of visits, were as follows: 1.22 (95% confidence interval [CI], 1.18 to 1.25); 1.32 (95% CI, 1.27 to 1.37); 1.42 (95% CI, 1.35 to 1.50); 1.37 (95% CI, 1.25 to 1.50); and 1.32 (95% CI, 1.13 to 1.55). The increased ORs for eGFRs > 45 mL/min per 1.73 m(2) were sustained even after controlling for diabetes, heart failure, and hypertension.This study demonstrated an increased risk of SA in patients with early CKD. Further evidence of a causal relationship should be sought in the hope that the detection and management of SA may improve the course of CKD.

Progestin Therapy of Complex Endometrial Hyperplasia With and Without Atypia

To assess the likelihood of histologic persistence/progression of complex hyperplasia and atypical hyperplasia among women treated with progestin compared with those not treated, with attention to type, dose, and duration. This was a cohort study at an integrated health plan of women, ages 18-85 years, with complex or atypical hyperplasia on independent pathology review with a second endometrial specimen in the 2-6 months after the index diagnosis. Progestin therapy between index diagnosis and follow-up biopsy was determined from the pharmacy database. Medical record abstraction was performed. Relative risks (RRs), adjusted for age and body mass index, were calculated. Among 185 women, average age 55.9 years, follow-up 16.1 weeks, 115 had complex and 70 had atypical hyperplasia. Among women with complex hyperplasia, 28.4% of those treated with progestin and 30.0% of those not treated had persistence/progression (RR 1.20, 95% confidence interval [CI] 0.53-2.72). Among women with atypical hyperplasia, 26.9% of those treated with progestin and 66.7% of those not treated had persistence/progression (RR 0.39, 95% CI 0.21-0.70); there was a suggestion that use of at least a medium dose, or a duration of at least 3 months, was associated with a particularly low probability of persistence/progression. Although progestin treatment of women with atypical hyperplasia was associated with a substantial increase in the likelihood of regression of the lesion during the ensuing 2-6 months, persistence/progression was nonetheless present in more than one quarter of treated women. Regression of complex hyperplasia without atypia was common whether progestin had or had not been used.

Depressive symptoms and menopausal burden in the midlife

The goal of this study was to assess whether menopausal symptoms were more common and/or more severe among women with depressive symptoms. A cross-sectional survey of 1358 women, ages 45-70, at two large integrated health plans (Seattle; Boston) was performed. Information on demographics, medical and reproductive history, medication use, menopausal experience and depressive symptoms (PHQ-8) were collected. Women taking HT were excluded. Logistic regression models adjusted for age and body mass index tested the associations between menopausal symptoms (hot flushes, night sweats, vaginal dryness and dyspareunia) and presence of moderate/severe depressive symptoms. 770 women were included; 98 (12.7%) had moderate/severe depressive symptoms and 672 (87.3%) had no/mild depressive symptoms. Women with moderate/severe depressive symptoms were almost twice as likely to report recent vasomotor symptoms (hot flashes and or night sweats) vs. women with no/mild depressive symptoms (adjusted odds ratio (aOR) 1.67, 95%CI 1.04-2.68), and to report them as severe (aOR 1.63, 95%CI 0.95-2.83). A higher symptom burden was observed despite the fact that 20% of women with moderate/severe depressive symptoms (vs. 4.6% no/mild depressive symptoms) were using an SSRI or SNRI, medications known to improve vasomotor symptoms. The percentage of women with menopausal symptoms, and the percentage with severe vasomotor symptoms were linearly associated with the depressive symptom score. Depressive symptoms "amplified" the menopausal experience, or alternatively, severe vasomotor symptoms worsened depressive symptoms.