Scott E. Sherman

The Safety of Transdermal Nicotine as an Aid to Smoking Cessation in Patients with Cardiac Disease

BACKGROUND Transdermal nicotine therapy is widely used to aid smoking cessation, but there is uncertainty about its safety in patients with cardiac disease. METHODS In a randomized, double-blind, placebo-controlled trial at 10 Veterans Affairs medical centers, we randomly assigned 584 outpatients (of whom 576 were men) with at least one diagnosis of cardiovascular disease to a 10-week course of transdermal nicotine or placebo as an aid to smoking cessation. The subjects were monitored for a total of 14 weeks for the primary end points of the study (death, myocardial infarction, cardiac arrest, and admission to the hospital due to increased severity of angina, arrhythmia, or congestive heart failure); the secondary end points (admission to the hospital for other reasons and outpatient visits necessitated by increased severity of heart disease); any side effects of therapy; and abstinence from smoking. RESULTS There were 48 primary and 78 secondary end points noted in a total of 95 subjects. At least one of the primary end points was reached by 5.4 percent of the subjects in the nicotine group and 7.9 percent of the subjects in the placebo group (difference, 2.5 percent; 95 percent confidence interval, -1.6 to 6.5 percent; P=0.23). In the nicotine group, 11.9 percent of the subjects had at least one of the secondary end points, as compared with 9.7 percent in the placebo group (difference, 2.2 percent; 95 percent confidence interval, -2.2 to 7.4 percent; P= 0.37). After 14 weeks the rate of abstinence from smoking was 21 percent in the nicotine group, as compared with 9 percent in the placebo group (P=0.001), but after 24 weeks the abstinence rates were not significantly different (14 percent vs. 11 percent, P= 0.67). CONCLUSIONS Transdermal nicotine does not cause a significant increase in cardiovascular events in high-risk outpatients with cardiac disease. However, the efficacy of transdermal nicotine as an aid to smoking cessation in such patients is limited and may not be sustained over time.

Physical activity and mortality in women in the Framingham Heart Study.

Men who are more active live longer, but it is not clear if the same is true for women. We monitored 1404 women aged 50 to 74 who were free of cardiovascular disease. We assessed physical activity levels and ranked subjects into quartiles. After 16 years, 319 (23%) women had died. The relative risk of mortality, compared to the least active quartile, was as follows: second quartile, 0.95 (95% confidence interval [CI] 0.72 to 1.26); third quartile, 0.63 (95% CI 0.46 to 0.86); most active quartile, 0.67 (95% CI 0.48 to 0.92). The relative risks were not changed by adjustment for cardiac risk factors, chronic obstructive pulmonary disease, or cancer or by excluding all subjects who died in the first 6 years (to eliminate occult disease at baseline). There was no association between activity levels and cardiovascular morbidity or mortality. We conclude that women who were more active lived longer; this effect was not the result of decreased cardiovascular disease.

Physicians' attitudes about obesity and their associations with competency and specialty: A cross-sectional study

BackgroundPhysicians frequently report negative attitudes about obesity which is thought to affect patient care. However, little is known about how attitudes toward treating obese patients are formed. We conducted a cross-sectional survey of physicians in order to better characterize their attitudes and explore the relationships among attitudes, perceived competency in obesity care, including report of weight loss in patients, and other key physician, training, and practice characteristics.MethodsWe surveyed all 399 physicians from internal medicine, pediatrics, and psychiatry specialties at one institution regarding obesity care attitudes, competency, including physician report of percent of their patients who lose weight. We performed a factor analysis on the attitude items and used hierarchical regression analysis to explore the degree to which competency, reported weight loss, physician, training and practice characteristics explained the variance in each attitude factor.ResultsThe overall response rate was 63%. More than 40% of physicians had a negative reaction towards obese patients, 56% felt qualified to treat obesity, and 46% felt successful in this realm. The factor analysis revealed 4 factors–Physician Discomfort/Bias, Physician Success/Self Efficacy, Positive Outcome Expectancy, and Negative Outcome Expectancy. Competency and reported percent of patients who lose weight were most strongly associated with the Physician Success/Self Efficacy attitude factor. Greater skill in patient assessment was associated with less Physician Discomfort/Bias. Training characteristics were associated with outcome expectancies with newer physicians reporting more positive treatment expectancies. Pediatric faculty was more positive and psychiatry faculty less negative in their treatment expectancies than internal medicine faculty.ConclusionPhysician attitudes towards obesity are associated with competency, specialty, and years since postgraduate training. Further study is necessary to determine the direction of influence and to explore the impact of these attitudes on patient care.

Does exercise reduce mortality rates in the elderly? experience from the Framingham Heart Study☆

Regular physical activity decreases the mortality rate in middle-aged men and probably in middle-aged women. It is unknown whether this is also true in the elderly. We studied 285 men and women aged 75 years or older who were free of cardiovascular disease. Subjects were ranked by baseline physical activity levels and grouped into quartiles. After adjustments were made for cardiac risk factors, chronic obstructive pulmonary disease, and cancer, women in the second most active quartile had a much lower risk of mortality at 10 years (relative risk 0.24, 95% confidence interval 0.12 to 0.51). There was no statistically significant difference in men. There appeared to be an excess of sudden cardiac deaths in the most active women, although this group still lived longer than the least active women. We conclude that women aged 75 years or older who are more active live longer. This benefit may be attenuated in those who are extremely active.

Ethnic Disparities in the Use of Nicotine Replacement Therapy for Smoking Cessation in an Equal Access Health Care System

Purpose. To examine ethnic variations in the use of nicotine replacement therapy (NRT) in an equal access health care system. Design. Cross-sectional survey. Setting. Eighteen Veterans Affairs medical and ambulatory care centers. Subjects. A cohort of male current smokers (n = 1606). Measures. Use of NRT (nicotine patch or nicotine gum), ethnicity, sociodemographics, health status, smoking-related history, and facility prescribing policy. Results. Overall, only 34% of African-American and 26% of Hispanic smokers have ever used NRT as a cessation aid compared with 50% of white smokers. In the past year, African-American smokers were most likely to have attempted quitting. During a serious past-year quit attempt, however, African-American and Hispanic smokers reported lower rates of NRT use than white smokers (20% vs. 22% vs. 34%, respectively, p = .001). In multivariate analyses, ethnicity was independently associated with NRT use during a past-year quit attempt. Compared with white smokers, African-American (adjusted odds ratio, .53; 95% confidence interval, .34–.83) and Hispanic (adjusted odds ratio, .55; 95% confidence interval, .28–1.08) smokers were less likely to use NRT. Conclusions. Assessment of variations in use of NRT demonstrates that African-American and Hispanic smokers are less likely to use NRT during quit attempts. Future research is needed on the relative contributions of patient, physician, and system features to gaps in guideline implementation to provide treatment for ethnic minority smokers.

Using evidence-based quality improvement methods for translating depression collaborative care research into practice.

OBJECTIVE Translating Initiatives in Depression into Effective Solution (TIDES) aimed to translate research-based collaborative care for depression into an approach for the Veterans Health Administration (VA). SITES: Three multistate administrative regions and seven of their medium-sized primary care practices. INTERVENTION Researchers assisted regional leaders in adapting research-based depression care models using evidence-based quality improvement (EBQI) methods. EVALUATION We evaluated model fidelity and impacts on patients. Trained nurse depression care managers collected data on patient adherence and outcomes. RESULTS Among 72% (128) of the 178 patients followed in primary care with depression care manager assistance during the 3-year study period, mean PHQ-9 scores dropped from 15.1 to 4.7 (p < .001). A total of 87% of patients achieved a PHQ-9 score lower than 10 (no major depression). 62% achieved a score lower than six (symptom resolution). Care managers referred 28% (50) TIDES patients to mental health specialty (MHS). In the MHS-referred group, mean PHQ-9 scores dropped from 16.4 to 9.0 (p < .001). A total of 58% of MHS-referred patients achieved a PHQ-9 score lower than 10, and 40%, a score less than 6. Over the 2 years following the initial development phase reported here, national policymakers endorsed TIDES through national directives and financial support. CONCLUSIONS TIDES developed an evidence-based depression collaborative care prototype for a large health care organization (VA) using EBQI methods. As expected, care managers referred sicker patients to mental health specialists; these patients also improved. Overall, TIDES achieved excellent overall patient outcomes, and the program is undergoing national spread.

Measures of Functional Status in Community‐Dwelling Elders

OBJECTIVE: To evaluate two performance-based measures of functional status and assess their correlation with self-report measures.DESIGN: Cross-sectional study.PARTICIPANTS: Of the 363 community-dwelling elders enrolled in a trial of comprehensive geriatric assessment who participated, all had at least one of four target conditions (urinary incontinence, depression, impaired functional status, or history of falling).MEASUREMENTS: Two performance-based measures, National Institute on Aging (NIA) Battery, and Physical Performance Test (PPT), and three self-report functional status measures, basic and intermediate activities of daily living and the Short-Form-36 (SF-36) physical functioning subscale, were used. Measures of restricted activity days, patient satisfaction and perceived efficacy were also used.MAIN RESULTS: All measures were internally consistent. There was a high correlation between the NIA and PPT (κ=0.71), while correlations between the performance-based and self-report measures ranged from 0.37 to 0.50. When patients with values above the median on the two performance-based measures were compared with those below, there were significant differences (p ≤ .0001) for age, number of medications, and the physical function, pain, general health, and physical role function SF-36 subscales.CONCLUSIONS: Performance-based measures correlated highly with each other and moderately with questionnaire-based measures. Performance-based measures also had construct validity and did not suffer from floor or ceiling effects.

Comparison of past versus recent physical activity in the prevention of premature death and coronary artery disease

BACKGROUND People who are physically active live longer, but it is unclear whether this is because of physical activity in the distant or more recent past. METHODS We assessed activity levels in 5209 men and women in the Framingham Heart Study from 1956 to 1958 and again from 1969 to 1973. We included individuals who were alive and without cardiovascular disease in the period 1969 to 1973. The primary outcome was death from all causes during the 16 years after the 1969 to 1973 assessment. Secondary outcomes were incidence and mortality rate of cardiovascular disease. We used Cox proportional hazards regression to calculate the relative risk of being sedentary, both unadjusted and controlling for smoking, weight, systolic blood pressure, cholesterol, glucose intolerance, left ventricular hypertrophy, chronic obstructive pulmonary disease, and cancer. RESULTS The overall 16-year mortality rate was 37% for men and 27% for women. When both distant and recent activity levels were included along with major cardiovascular disease risk factors, for recent activity the most active tertile had lower overall mortality rate than the least active tertile for men (risk ratio 0.58, 95% confidence interval, 0.43-0.79) and women (risk ratio 0.61, 95% confidence interval, 0.45-0.82). For distant activity there was no difference in overall mortality rate between the most and least active tertiles either for men or for women. Adjusting for major cardiovascular disease risk factors had little effect on the results. CONCLUSIONS The reduction in overall mortality rates is more associated with recent activity than distant activity. These results suggest that for sedentary patients, it may never be too late to begin exercising.

Exercise counseling: how do general internists do?

Objective: To assess how often physicians counsel patients about exercise and to identify which primary care internists infrequently counsel about it.Design: Cross-sectional survey of a random sample of primary care internists in Massachusetts. Questions covered physicians’ attitudes, beliefs, and practices with respect to counseling about exercise; physicians’ perceived barriers to counseling about exercise; physicians’ personal exercise frequency; and physician demographics.Participants: Of 1,000 physicians, 687 were eligible and 422 returned usable questionnaires (response rate 61%).Results: Data describing physician demographics, practice setting, measures of personal fitness, and beliefs regarding exercise were entered into a logistic regression model. The characteristic that best identified physicians who infrequently counsel about exercise was their perceived lack of success at counseling (OR 22.83, 95% CI 8.36–62.31). Other independent predictors of infrequent counseling were physicians’ lack of conviction that exercise is very important (OR4.86,95% CI 1.70–13.91), physician ages 40years (OR 308, 95% CI 1.33–7.15), and higher physician resting heart rate (OR 345, 95% CI 1.46–8.18).Conclusions: Several factors were found to be independently associated with the likelihood of a physician’ counseling about exercise. These included physician perceived success at counseling, physician belief that exercise is important, physician age, and physician resting heart rate. These results suggest possible strategies to improve physicians’ counseling efforts.Objective: To assess how often physicians counsel patients about exercise and to identify which primary care internists infrequently counsel about it. Design: Cross-sectional survey of a random sample of primary care internists in Massachusetts. Questions covered physicians’ attitudes, beliefs, and practices with respect to counseling about exercise; physicians’ perceived barriers to counseling about exercise; physicians’ personal exercise frequency; and physician demographics.Participants: Of 1,000 physicians, 687 were eligible and 422 returned usable questionnaires (response rate 61%). Results: Data describing physician demographics, practice setting, measures of personal fitness, and beliefs regarding exercise were entered into a logistic regression model. The characteristic that best identified physicians who infrequently counsel about exercise was their perceived lack of success at counseling (OR 22.83, 95% CI 8.36–62.31). Other independent predictors of infrequent counseling were physicians’ lack of conviction that exercise is very important (OR4.86,95% CI 1.70–13.91), physician ages 40years (OR 308, 95% CI 1.33–7.15), and higher physician resting heart rate (OR 345, 95% CI 1.46–8.18). Conclusions: Several factors were found to be independently associated with the likelihood of a physician’ counseling about exercise. These included physician perceived success at counseling, physician belief that exercise is important, physician age, and physician resting heart rate. These results suggest possible strategies to improve physicians’ counseling efforts.

Primary care provider attitudes are associated with smoking cessation counseling and referral.

Objective:Most primary care providers (PCPs) endorse the importance of smoking cessation, but counseling rates are low. We evaluated the consistency of PCPs attitudes toward smoking cessation counseling and corresponding smoking-cessation behaviors. Design:This was a postintervention analysis of a population-based sample from a group randomized controlled trial to improve adherence to smoking cessation guidelines. Setting:A total of 18 VA sites in Southwestern and Western United States participated. Participants:A total of 280 PCPs completed a survey at 12 months after the implementation of a smoking-cessation quality improvement (QI) program. Their patients also completed 12- (n = 1080) and 18-month (n = 924) follow-up surveys. Intervention:The quality improvement intervention included local priority setting, quality improvement plan development, implementation, and monitoring. Measurements and Main Results:PCPs at intervention sites were more likely to report counseling patients about smoking cessation (P = 0.04) but not referral. PCP attitude toward smoking-cessation counseling was strongly associated with reported counseling (P < 0.001) and with referral (P = 0.01). Other associations with counseling were the perceived barrier “patients are not interested in quitting” (P = 0.01) and fewer years in practice (P = 0.03); other associations with referral were specialty consultation (P < 0.0001) and the perceived barrier “referral not convenient” (P = 0.001) (negative association). PCP attitudes were associated with higher rates of counseling, referral, and program attendance. Conclusions:PCPs, regardless of intervention participation, had attitudes consistent with their reported smoking-cessation behaviors and more favorable attitudes were associated with higher rates of patient-reported smoking cessation behavior. Findings suggest that PCPs who endorse smoking-cessation counseling and referral may provide more treatment recommendations and have higher patient quit rates.