Kathleen K. Brody

Maternal smoking cessation and relapse prevention during health care visits.

BACKGROUND Although effects of maternal smoking during pregnancy could be alleviated if women quit early in pregnancy, most do not. Relapse rates among quitters are high. OBJECTIVE To test the effects of a low-intensity, smoking-cessation/relapse-prevention intervention delivered by clinic staff and providers and based on stages-of-change constructs of the transtheoretical model and brief motivational interviewing techniques. METHODS A quasi-experimental prospective cohort design employed in obstetric, in-patient, and pediatric care delivery settings of a large health maintenance organization in Portland, Oregon. Subjects were pregnant smokers registered for their first prenatal visit. Primary outcome measures were sustained (self-reported) quit rates during pregnancy and smoking abstinence between 6 and 12 months after delivery. RESULTS Regression analyses found statistically significant improvement for intervention women in sustained pregnancy quit rates (OR=2.7, CI=1. 2-5.7) and on smoking abstinence between 6 and 12 months after delivery (OR=2.4, CI=1.1-5.3). CONCLUSIONS While these outcomes are based on self-report only, they emerged despite variable delivery of the intervention across clinics and represent clinically meaningful improvements in rates of nonsmoking. The intervention supports women who want to quit smoking during pregnancy and improves the likelihood of their remaining nonsmokers for the long term.

β-Blockers and Depression: The More the Murkier?

OBJECTIVE: To review the literature regarding the purported association between oral ingestion of β-blocker drugs and depressed mood. DATA SOURCE: MEDLINE was searched for published articles using the key words propranolol, atenolol, metoprolol, nadolol, timolol, β-blocker, β-adrenergic antagonist, or β-adrenergic blocker in combination with the key words depression, depressive symptomatology, major depressive disorder, or depressed mood from January 1966 through December 1996. DATA SYNTHESIS: Findings regarding the association are equivocal. Plausible explanations include study design, case definition, and confounding disease states. Most of the evidence supporting an association has used case series and case reports. Findings from cross-sectional observational studies and case–control studies are equivocal. Case definition and measurement instruments may partially explain these inconsistencies. Studies using a diagnosis of depression generally do not support the relationship. Trials using depressive symptoms are about evenly split, but they have generally enrolled a small number of patients and have questionable statistical power. Studies defining antidepressant prescriptions dispensed as a marker for depression generally support the association. Evidence exists both for and against the hypothesis that lipophilic β-blockers cause more depression than do hydrophilic β-blockers. CONCLUSIONS: β-Blockers may have been unjustly associated with depression and their use avoided for that reason. Future studies into the association between depression and β-blocker use should evaluate whether the association is affected by case definition and study design characteristics, including disease, dose–response, bias, measurement error, or ability to precisely measure the length of the exposure.

Community-based care and risk of nursing home placement

Objective. To test the substitution hypothesis, that community-based care reduces the probability of institutional placement for at-risk elderly. Research Design. The closure of the Social Health Maintenance Organization (Social HMO) at HealthPartners (HP) in Minnesota in 1994 and the continuation of the Social HMO at Kaiser Permanente Northwest (KPNW) in Oregon/Washington comprised a “natural experiment.” Using multinomial logistic regression analyses, we followed cohorts of Social HMO enrollees for up to 5 years, 1995 to 1999. To adjust for site effects and secular trends, we also followed age- and gender-matched Medicare-Tax Equity and Fiscal Responsibility Act (TEFRA) cohorts, enrolled in the same HMOs but not in the Social HMOs. Subjects. All enrollees in the Social HMO for at least 4 months in 1993 and an age-gender matched sample of Medicare–TEFRA enrollees. To be included, individuals had to be alive and have a period out of an institution after January 1, 1995 (total n = 18,143). Measures. The primary data sources were the electronic databases at HP and KPNW. The main outcomes were long-term nursing home placement (90+ days) or mortality. Covariates were age, gender, a comorbidity index, and geographic site effect. Results. Adjusting for variations in the 2 sites, we found no difference in probability of mortality between the 2 cohorts, but approximately a 40% increase in long-term institutional placement associated with the termination of the Social HMO at HealthPartners (odds ratio, 1.43; 95% confidence interval, 1.15–1.79). Conclusions. The Social HMO appears to help at-risk elderly postpone long-term nursing home placement.

A comparison of two methods for identifying frail medicare-aged persons

This article compares the efficacy of two screening methods to identify frail Medicare‐aged persons using self‐report questionnaire data: a clinical judgment method developed by nurse and social worker professionals in a community‐based long‐term care department and an empirical research method previously developed by the Center for Health Research using computer formulas and stepwise logistic regression coefficients. A sub‐aim was to see whether the empirical method proved robust over time by measuring aggregate utilization and mortality in frail and nonfrail cohorts, which would increase the interest of physicians, managed care organizations, and other agencies providing service to Medicare beneficiaries.

Depression, Functional Status, Treatment for Psychiatric Problems, and the Health-Related Practices of Elderly HMO Members:

Purpose. To study relationships between depression, functional limitations, psychiatric treatment, and the health-related practices of elderly individuals. Design. Cross-sectional, observational study based on survey data (response rate = 90%) analyzed using multiple linear and logistic regression models. Setting. Kaiser Permanente Northwest, a large nonprofit HMO. Subjects. Medicare members (4615) aged 65–103 years who responded to a health status survey. Measures. Depression, health and functional status, frequency of alcohol consumption, smoking status, advance medical directive completion, influenza or pneumonia vaccinations, mammograms, recent psychiatric treatment, and attempts to lose weight or increase exercise. Results. Self-reported depression was related to a greater risk of smoking (odds ratio [OR] = 1.54). Health-related functional limitations were related to fewer attempts to change health behaviors and less preventive service use (significant ORs ranged from 0.84 to 0.94). Minority group membership and Supplemental Security Income were negatively associated with better health practices and with completing advance medical directives (ORs 0.41 and 0.79, respectively). Falls in the prior year, more prescription medications, and psychiatric treatment were positively associated with better health practices (significant ORs ranged from 1.12 to 1.88). Conclusions. Depression and smoking are associated among elderly individuals, as are psychiatric treatment and attempts to lose weight. Those with functional limitations, minority status, or Supplemental Security Income use fewer preventive services; the latter two groups are less likely to complete advance medical directives. Older adults with these characteristics might need assistance in improving health-related practices.

Self-reported severe memory problems as a screen for cognitive impairment and dementia

Undetected cognitive impairment (CI) and dementia are important clinical and epidemiological problems. This study addresses the effectiveness of using a single self-reported measure of severe memory problems (SMP) as a screen for CI and dementia. For the purposes of the study, 3220 elderly women participated in a mailed Health Survey Questionnaire and telephone interviews. Cognitive scores derived from the Telephone Interview for Cognitive Status–modified (TICSm) were calculated. Based on a multi-stage assessment strategy, all subjects were classified in one of three status categories: dementia, CI, or unimpaired. The SMP question was suggestive of cognitive problems in the majority of responders. t-tests found affirmative responders scored much lower on the cognitive test than negative responders. The SMP question had a sensitivity of .24 and a specificity of .99 for screening CI and dementia. While other assessment measures are needed, the SMP question is highly suggestive of CI and may serve as a first-stage screen in clinical and research settings.

Integrating Prenatal-Postnatal Smoking Interventions into Usual Care in a Health Maintenance Organization:

Consistent with the increasing national emphasis on providing health promotion in clinical care settings, Stop Smoking for OuR Kids (STORK), a research-derived, prenatal-postnatal smoking cessation intervention, was implemented throughout prenatal clinics, inpatient postpartum services, and pediatric clinics of Kaiser Permanente Northwest. Process data collected during the project rollout and maintenance to monitor the clinical practices of clinicians and staff members, patient responses to the intervention, and penetration of the intervention into the health maintenance organization priority population of prenatal smokers highlighted barriers to intervention delivery. These barriers fell into three categories related to the smoking intervention design, clinicians and staff members, and the organization. By monitoring the intervention implementation process, such problems were identified early. This allowed for implementing strategies to overcome many of these barriers and to assess their effectiveness. Keys to implementation success included simplifying the intervention activities, considering stakeholder needs, and providing tangible organizational resources and goals.