Linda M. Robison

Adult dietary intake and prostate cancer risk in Utah: a case-control study with special emphasis on aggressive tumors

A population-based case-control study in Utah of 358 cases diagnosed with prostate cancer between 1984 and 1985, and 679 controls categorically matched by age and county of residence, were interviewed to investigate the association between dietary intake of energy (kcal), fat, protein, vitamin A, β-carotene, vitamin C, zinc, cadmium, selenium, and prostate cancer. Dietary data were ascertained using a quantitative food-frequency questionnaire. Data were analyzed separately by age (45–67, 68–74) and by tumor aggressiveness. The most significant associations were seen for older males and aggressive tumors. Dietary fat was the strongest risk factor for these males, with an odds ratio (OR) of 2.9 (95 percent confidence interval [CI] 1.0–8.4) for total fat; OR=2.2 (CI=0.7–6.6) for saturated fat; OR=3.6 (CI=1.3−9.7) for monounsaturated fat; and OR=2.7 (CI=1.1−6.8) for polyunsaturated fat. Protein and carbohydrates had positive but nonsignificant associations. Energy intake had an OR of 2.5 (CI=1.0−6.5). In these older men, no effects were seen for dietary cholesterol, body mass, or physical activity. There was little association between prostate cancer and dietary intake of zinc, cadmium, selenium, vitamin C, and β-carotene. Total vitamin A had a slight positive association with all prostate cancer (OR=1.6, CI=0.9−2.4), but not with aggressive tumors. No associations were found in younger males, with the exception of physical activity which showed active males to be at an increased but nonsignificant risk for aggressive tumors (OR=2.0, CI=0.8−5.2) and β-carotene which showed a nonsignificant protective effect (OR=0.6, CI=0.3−1.6). The findings suggest that dietary intake, especially fats, may increase risk of aggressive prostate tumors in older males.

National Trends in the Prevalence of Attention-Deficit/Hyperactivity Disorder and the Prescribing of Methylphenidate among School-Age Children: 1990-1995

It has been reported that during the past decade the prevalence of attention-deficit/ hyperactivity disorder (ADHD) (ICD-9-CM code 314.00 or 314.01) and its pharmacologic treatment have increased dramatically in the United States. Herein, a single national data source is used to discern trends in the prevalence of U.S. office-based visits resulting in a diagnosis of ADHD, and trends in the prescribing of stimulant pharmacotherapy (including methylphenidate) for its treatment. Data from the National Ambulatory Medical Care Survey (NAMCS) for the years 1990 through 1995, for children aged 5 through 18 years, were utilized for this analysis. Results indicate that the number of office-based visits documenting a diagnosis of ADHD increased from 947,208 in 1990, to 2,357,833 in 1995. Between 1990 and 1995, the number of visits by girls diagnosed with ADHD rose 3.9-fold (p<0.05), and the mean patient age increased by more than 1 year, from 9.7 in 1990, to 10.8 in 1995 (p<0.05). The percentage of office-based visits resulting in a diagnosis of ADHD increased from 1.1% of all visits in this age group in 1990, to 2.8% by 1995. We discerned a 2.3-fold increase (p<0.05) in the population-adjusted rate of office-based visits documenting a diagnosis of ADHD; a 2.9-fold increase (p<0.05) in the population-adjusted rate of ADHD patients prescribed stimulant pharmacotherapy; and a 2.6-fold increase (p<0.05) in the population-adjusted rate of ADHD patients prescribed methylphenidate.

Is attention deficit hyperactivity disorder increasing among girls in the US? Trends in diagnosis and the prescribing of stimulants.

AbstractObjective: To use a single national data source to discern trends in the prevalence of office-based visits resulting in a diagnosis of attention deficit hyperactivity disorder (ADHD) among girls, and trends in the prescribing of stimulant pharmacotherapy (including methylphenidate) for its treatment in the US. Methods: Data from the US National Ambulatory Medical Care Survey were utilised for this analysis. The number and rate of office-based physician visits resulting in a diagnosis of ADHD (International Classification of Diseases, 9th Revision, Clinical Modification code 314.00 or 314.01) were discerned from the beginning of 1990 to the end of 1998, for children aged 5 to 18 years. Gender-specific trend analyses were conducted using four time intervals: 1991 to 1992, 1993 to 1994, 1995 to 1996, and 1997 to 1998. Results: The estimated number of office-based visits documenting a diagnosis of ADHD among children increased from 947 208 in 1990 to 3 234 180 in 1998. The rate of office-based visits documenting a diagnosis of ADHD among children increased from 19.4 per 1000 of the US population aged 5 to 18 years in 1990 to 59.0 per 1000 in 1998, a 3-fold increase (p < 0.05). The annualised mean number of office-based visits documenting a diagnosis of ADHD among girls tripled between 1991 to 1992 and 1997 to 1998 (from 296 389 to 886 798), whereas the number for boys increased 2.2-fold (from 1 006 243 to 2 200 021). The US population-adjusted rate of office-based visits documenting a diagnosis of ADHD among girls increased 2.7-fold between 1991 to 1992 and 1997 to 1998 (from 12.3 per 1000 girls to 33.4 per 1000; p < 0.05), whereas the rate among boys doubled (from 39.5 per 1000 boys to 78.7 per 1000; p < 0.05). Documentation of a diagnosis of ADHD and the prescribing of stimulant pharmacotherapy increased 2.8-fold for girls, from 7.5 per 1000 girls in 1991 to 1992 to 21.1 per 1000 in 1997 to 1998 (p < 0.05), as compared with a 2.2-fold increase among boys (from 25.5 per 1000 boys to 57.0 per 1000; p < 0.05). Conclusion: Over the time frame 1990 to 1998, the rate of ADHD as well as the prescribing of stimulant medications for its treatment increased significantly among children aged 5 to 18 years. Between 1991 to 1992 and 1997 to 1998, the increased rate of diagnosis of ADHD among girls contributed to the overall upward trend. The rapidly increasing rate of ADHD among girls, and the prolonged nature of the disorder, represent significant public health problems. There exists a need for additional research examining both the aetiology and treatment of ADHD by gender.

Tobacco, alcohol, coffee, and caffeine as risk factors for colon cancer in a low-risk population.

We used data from a population-based case-control study to examine how use of tobacco products and consumption of alcohol, coffee, and caffeine relate to colon cancer in Utah. We hypothesized that low use of these substances is one factor contributing to the low colon cancer incidence in Utah and could help explain the low risk associated for colon cancer with being a member of the Church of Jesus Christ of Latter-day Saints. In females, we observed little or no increase in risk of colon cancer from smokingcigarettes or from consumption of alcohol, caffeine, or coffee. Males who used pipes, however, experienced an increased risk for colon cancer (OR = 4.1, 95% CI = 1.3–12.3). Risk for colon cancer associated with alcohol use was greatly attenuated after adjusting for caffeine and pipe use in males; males who consumed-higher levels of caffeine during the two to three years prior to the interview were at higher risk than males who consumed low levels of caffeine (OR = 2.0, 95% CI = 1.0–4.2); similar associations were observed for coffee consumption. Nonuse of these substances could explain the low colon cancer incidence rates observed in members of the Church of Jesus Christ of Latter-day Saints and Utah males.

Trends in the rate of depressive illness and use of antidepressant pharmacotherapy by ethnicity/race: an assessment of office-based visits in the United States, 1992–1997

OBJECTIVE This study was undertaken to determine ethnicity/race-specific (white, black, and Hispanic) population-adjusted rates of US office-based physician visits in which a diagnosis of a depressive disorder was recorded or in which a diagnosis of a depressive disorder was recorded and antidepressant pharmacotherapy was prescribed. METHODS Data from the National Ambulatory Medical Care Survey for 1992 through 1997 were partitioned into three 2-year periods: 1992-1993, 1994-1995, and 1996-1997. For each 2-year period, data from office-based physician visits for patients aged 20 to 79 years were extracted to assess, by ethnicity/race, (1) the number of visits in which a diagnosis of a depressive illness was recorded (International Classification of Diseases, Ninth Revision, Clinical Modification codes 296.2-296.36, 300.4, or 311) and (2) the number of visits in which a diagnosis of a depressive illness was recorded and antidepressant pharmacotherapy was prescribed. We calculated ethnicity/race-specific rates (per 100 US population aged 20 to 79 years) of office-based visits in which a diagnosis of a depressive disorder was recorded and in which a diagnosis of a depressive disorder was recorded and antidepressant pharmacotherapy was prescribed. The specialty of the reporting physician and the proportion of patients receiving a selective serotonin reuptake inhibitor (SSRI) were also discerned. RESULTS From 1992-1993 to 1996-1997, the rate of office-based visits (per 100 US population aged 20 to 79 years) in which a diagnosis of a depressive disorder was recorded increased 3.7% for whites (from 10.9 to 11.3; P = 0.001), 31.0% for blacks (from 4.2 to 5.5; P = 0.001), and 72.9% for Hispanics (from 4.8 to 8.3; P = 0.001). The rate of office-based visits in which a diagnosis of a depressive disorder was recorded and antidepressant pharmacotherapy was prescribed increased 18.5% for whites (from 6.5 to 7.7 per 100; P = 0.001), 38.5% for blacks (from 2.6 to 3.6 per 100; P = 0.001). and 106.7% for Hispanics (from 3.0 to 6.2 per 100; P = 0.001). Between 1992-1993 and 1996-1997, use of an SSRI increased among whites and blacks (from 50.0% to 65.8% and from 40.5% to 58.2%, respectively), but declined among Hispanics (from 51.4% to 48.6%; all comparisons P = 0.001). CONCLUSION By 1996-1997, the population-adjusted rates for Hispanics were within a quartile of those observed for whites, whereas the rates for blacks remained at less than half those observed in whites. The observed divergence in population-adjusted rates by ethnicity/race may reflect the nature of the patient-physician relationship, sensitivity and specificity of diagnostic techniques and instruments, and the wider social context in which an office-based visit occurs, including access to and type of health insurance and coverage for mental health services.

Dietary vitamins A, C, and E and selenium as risk factors for cervical cancer.

The relation between cervical cancer and dietary intake of vitamins A, C, and E, beta-carotene, and selenium was examined in a population-based case-control study in Utah. Cervical cancer cases (n = 266) and population-based controls (n = 408) were interviewed between 1984 and 1987. Protective effects were observed for vitamins A, C, and E and beta-carotene but were attenuated by age, level of education, and lifetime cigarette use. Associated risk (comparing highest with lowest quartiles of intake) went from 0.53 (crude) to 0.71 (adjusted) for vitamin A; from 0.55 (crude) to 0.82 (adjusted) for beta-carotene; from 0.45 (crude) to 0.55 (adjusted) for vitamin C; from 0.58 (crude) to 0.60 (adjusted) for vitamin E; and from 0.95 (crude) to 0.70 (adjusted) for selenium. Adjustment for number of sex partners and church attendance, factors significantly related to cervical cancer risk, only slightly attenuated these adjusted risk estimates.

Cancer-Screening Determinants Among Hispanic Women Using Migrant Health Clinics

This study was designed to identify determinants of breast and cervical cancer screening among rural, low-income Hispanic women using migrant health clinics in eastern Washington state. Five hundred and twelve foreign-born Hispanic women were interviewed. Odds ratios and 95 percent confidence intervals generated via logistic regression analysis were used to discern the influence of independent factors on use or nonuse of Papanicolaou (Pap) smear, breast self-examination (BSE), and mammography. Being married, having a higher income, more years of education, and longer U.S. residency predicted receipt of Pap smear. Women who performed BSE had higher incomes and were more likely to have been taught how to perform the procedure. Low concern for direct expenditure and increasing years of U.S. residency predicted receipt of mammogram. On the basis of these findings, implications for developing cancer-screening interventions using inreach and outreach strategies to target this high-risk subgroup are discussed.

Trends in the prescribing of antidepressant pharmacotherapy : Office-based visits, 1990-1995

Data from the National Ambulatory Medical Care Survey for the period 1990 through 1995 were used to discern the population-adjusted rate of office-based physician-patient encounters at which the prescribing or continuation of antidepressant pharmacotherapy (tricyclic antidepressants [TCAs], selective serotonin reuptake inhibitors [SSRIs], or others), a diagnosis of depression (International Classification of Diseases, 9th Revision, Clinical Modification codes 296.2 through 296.36, 300.4, or 311), or both were documented. National estimates of the number of office-based visits resulting in a prescription for or continuation of antidepressant pharmacotherapy for any purpose escalated from 16,534,268 in 1990 to 28,664,796 in 1995, a 73.4% increase. Although the number of office-based visits at which a diagnosis of depression was documented increased 23.2% during this period, the proportion of patients with a diagnosis of depression who were prescribed or continued antidepressant pharmacotherapy increased only 14.9%, from 52.1% in 1990 to 67.0% in 1995. Among patients with a diagnosis of depression, use of a TCA declined from 42.1% in 1990 to 24.9% in 1995. In contrast, use of an SSRI for the treatment of depression increased from 37.1% in 1990 to 64.6% in 1995. The rate of office-based visits at which the use of antidepressant pharmacotherapy for any purpose was documented increased from 6.7 per 100 US population in 1990 to 10.9 in 1995, a 62.7% increase; documentation of a diagnosis of depression increased from 6.1 per 100 US population in 1990 to 7.1 in 1995, a 16.4% increase; and the recording of a diagnosis of depression in concert with the prescribing or continuation of antidepressant pharmacotherapy increased from 3.2 per 100 US population in 1990 to 4.8 in 1995, a 50.0% increase. Further research is required to elucidate the effect of observed trends on clinical and financial outcomes.

What factors influence the prescribing of antidepressant pharmacotherapy ? An assessment of national office-based encounters

Objective: This study was designed to identify: 1) predictors of antidepressant pharmacotherapy among patients diagnosed with depression; and 2) predictors of prescription for either a selective-serotonin reuptake inhibitor (SSRI), or a serotonin-norepinephrine reuptake inhibitor (SNRI). Method: Data from the 1995 National Ambulatory Medical Care Survey (NAMCS) were used to discern the number of office-based encounters documenting a diagnosis of depression (ICD-9-CM codes 296.2–296.36; 300.4; or 311) among patients eighteen years of age or older. Logistic regression-derived odds ratios (OR) and 95 percent confidence intervals (CI) were used to elucidate factors predictive of receipt of antidepressant pharmacotherapy, and, more specifically, factors predictive of receipt of an SSRI or an SNRI. Model variables included age (18–49 years as compared to ⩾ 50 years); race (white as compared to nonwhite, inclusive of Hispanics); gender; self-report of depression as a reason for the office-based encounter; and payer type (private insurance program as compared to public). Results: Among the estimated 18,046,293 office-based visits resulting in a diagnosis of depression, 56.2 percent of patients self-reported depression as a reason for the office-based encounter; 67.5 percent were prescribed or continued a regimen of antidepressant pharmacotherapy; and 48.3 percent were prescribed an SSRI or an SNRI. Factors predictive of receipt of antidepressant pharmacotherapy included age less than fifty years (OR = 1.30, CI = 1.01–1.67); female gender (OR = 1.45, CI = 1.13–1.85); and self-report of depression as a reason for the office-based encounter (OR = 1.98, CI = 1.57–2.51). Factors predictive of receipt of an SSRI or an SNRI included age less than fifty years (OR = 1.31, CI = 1.03–1.65); female gender (OR = 1.55, CI = 1.23–1.95); and self-report of depression as a reason for the office-based encounter (OR = 1.56, CI = 1.25–1.95). In addition, having private insurance increased the likelihood of having been prescribed an SSRI or SNRI by 46 percent (OR = 1.46, CI = 1.13–1.89). Conclusions: Among patients with a diagnosis of depression, the pattern of prescribing antidepressant pharmacotherapy is influenced by a patients age, gender, self-report of depression, and type of insurance coverage. Further research is required to discern the reasons for these observed effects and to advance clinically rational and equitable access to pharmacotherapeutic innovation.

Economic valuation of amitriptyline, desipramine, nortriptyline, and sertraline in the management of patients with depression

Abstract The high prevalence of depression and its associated morbidity, mortality, and economic consequence to the health care delivery system and society mandate the selection of both efficacious and effective treatment. Recent pharmacotherapeutic advances in the treatment of patients with depression have included the development of selective serotonin re-uptake inhibitors (SSRIs). The present study was designed to contrast direct health service expenditures for the treatment of depression among pateins enrolled in a health maintenance organization (HMO) and prescribed either the SSRI sertraline or one of three tricyclic antidepressants (TCAs) (amitriptyline, desipramine, or nortriptyline). Information regarding health service utilization was derived from the computer archive of a network-model MHO system serving 500,000 beneficiaries. A total of 823 HMO beneficiaries were found to satisfy the study selection criteria. Multivariate regression analysis was used to discern the incremental influence of selected demographic, clinical, financial, and provider characteristics on 1-year post-period expenditures (PPE) for health care. Analysis-of-variance procedures with Duncans multiple-range test or chi-square analyses revealed no significant baseline difference across antidepressant pharmacotherapy for age, 6-month prior-period expenditures for physician visits, psychiatric visits, laboratory tests, or psychiatric hospital services related to the treatment of depression (as defined via International Classification of Diseases, 9th revision, Clinical Modification or Diagnostic and Statistical Manual of Mental Disorders, 4th edition code 296.2), or number of medications for concomitant disease state processes other than depression. Receipt of sertraline was associated with a significantly ( P ≤ 0.05) higher rate of initial prescribing by psychiatrists and an increase in the number of prescriptions for antidepressant pharmacotherapy obtained (30-day supplies). Multivariate findings indicate that receipt of a TCA resulted in an increase in the use of physician visits (