EMBARGOED FOR RELEASE UNTIL 3 P.M. (CT), MONDAY, July 26, 2004
To contact Steven B. Hardin, M.D., call Annie Tuttle at 909/583-6193.

END-OF-LIFE TREATMENT DECISIONS MIGHT NOT BE CONSISTENT WITH PATIENTS' ADVANCE DIRECTIVES

CHICAGO—In a study using hypothetical cases, physicians commonly made end-of-life treatment decisions that were not consistent with patient preferences stated in explicit advance directives, according to an article in the July 26 issue of the Archives of Internal Medicine, one of the JAMA/Archives journals.

According to background information in the article, significant concern remains about how well physicians know and follow the treatment preferences of their patients. Decisions are particularly problematic for critically ill and dying patients who lose their capacity to make medical decisions. A variety of factors may influence treatment decisions - including the probability of survival or recovery, and perceived quality of life. While advance directives have been widely promoted as a means to ensure that patients' treatment preferences are followed, there is limited evidence that they actually accomplish this purpose.

Steven B. Hardin, M.D., and colleagues with the Jerry L. Pettis Memorial Veterans Affairs Medical Center and Loma Linda University School of Medicine, Loma Linda, Calif., devised a survey of six hypothetical cases describing patients with serious or life-threatening illnesses who had lost their decision-making capacity. Each case contained an explicit advance directive with potential conflict between the directive and (1) prognosis, (2) wishes of family or friends, or (3) quality of life. The study participants were all internal medicine faculty and resident physicians from Loma Linda University Medical Center and affiliated hospitals.

Data were collected on the clinical treatment decisions made by physicians and the reasons for those decisions. Of the 250 surveys mailed, 117 analyzable surveys were returned from 77 faculty and 40 resident physicians.

"Despite the presence of an explicit advance directive, physicians frequently made treatment decisions contrary to documented patient preferences," the authors report.

In 65 percent of cases, decisions by faculty and residents were not consistent with the advance directive. This inconsistency was similar for faculty (68 percent of cases) and residents (61 percent of cases). When physicians made decisions inconsistent with the advance directive, they were more likely to list reasons other than the directive for their decisions.

"In difficult clinical situations, internists appear to consider other factors such as prognosis, perceived quality of life, and the wishes of family or friends as more determinative than the directive," the authors write.

The authors point out that advance directives have helped to encourage physicians and patients to start conversing about treatment decisions. But they assert that the limitation of advance directives illustrates the need for more effective conflict resolution when patients, family, and staff disagree about treatment choices.

EMBARGOED FOR RELEASE UNTIL 3 P.M. (CT), MONDAY, July 26, 2004
To contact Randall S. Stafford, M.D., Ph.D., call Susan Ipaktchian at 650/725-5375.

NEWER OSTEOPOROSIS DRUGS ASSOCIATED WITH INCREASED PATIENT VISITS AND TREATMENT

CHICAGO—New medications for osteoporosis, offering improved efficacy and convenient dosing, are associated with increased frequency of patient visits and treatment. The finding suggests new drug therapy contributes to increased disease recognition and treatment, according to an article in the July 26 issue of the Archives of Internal Medicine, one of the JAMA/Archives journals.

According to background information in the article, osteoporosis is a condition of low bone mass and deterioration of bone microarchitecture, leading to increased susceptibility to fracture and painful disease. Osteoporosis is determined clinically by bone mineral density (BMD) testing; its prevalence in the United States was approximately ten percent in 2000, using the World Health Organization definition of low BMD. Research on physicians' prescribing practices for osteoporosis treatment is limited.

Randall S. Stafford, M.D., Ph.D., and colleagues from the Stanford Prevention Research Center, Stanford University, Palo Alto, Calif., tracked trends from 1988 to 2003 in the frequency of osteoporosis visits and patterns of pharmacotherapy associated with these visits. The authors used nationally representative data on prescribing patterns of office-based U.S. physicians from the IMS HEALTH National Disease and Therapeutic Index.

"The number of physician visits for osteoporosis increased four-fold between 1994 (1.3 million visits) and 2003 (6.3 million visits), whereas it had remained stable in prior years," the authors report. "This increase coincided with the availability of oral daily bisphosphonates and the selective estrogen receptor modulator raloxifene." Bisphosphonates and the selective estrogen receptor modulator raloxifene are drugs used to both prevent and treat osteoporosis.

"The annualized percentage of osteoporosis visits where medications were prescribed increased from 82 percent in 1988 to 97 percent by 2003," the authors write.

Prior to 1994, the leading choices for osteoporosis therapy were calcium and estrogens, with lesser roles played by bisphosphonates and calcitonins (drugs made up of a naturally occurring hormone involved in calcium regulation and bone metabolism). "Between 1994 and 2003, the percentage of visits where bisphosphonates and raloxifene were prescribed increased from 14 percent to 73 percent and from 0 percent to 12 percent, respectively, while prescriptions for other medications declined," the authors report.

"Treatment of osteoporosis has improved in recent years in association with the availability of new medications. Physicians are prescribing drugs with greater effectiveness and convenience, and recognition of osteoporosis is increasing," they write.