JAMA news releases are made available to the public after 3 pm US Central time on the first 4 Tuesdays of each month. The Archives of Journals news releases are made available to the public after 3 pm Central time on Mondays. We also provide a list of previous news releases.
THIS WEEK'S CONTENTS
ARCHIVES OF INTERNAL MEDICINE NEWS RELEASES
(Embargoed Until: 3 P.M. (CT), Monday, September 22, 2008)
PHYSICIANS MAY MISS OPPORTUNITIES TO RESPOND WITH EMPATHY TOWARD PATIENTS WITH LUNG CANCER
LOW NEIGHBORHOOD INCOME, MEDICAID INSURANCE ASSOCIATED WITH LONGER DELAYS IN REACHING HOSPITAL FOR HEART ATTACK TREATMENT
CALORIE RESTRICTION DOES NOT APPEAR TO INDUCE BONE LOSS IN OVERWEIGHT ADULTS
MODEL HIGHLIGHTS BENEFITS AND RISKS OF CERVICAL CANCER SCREENING METHODS
STUDY EXAMINES COST-EFFECTIVENESS OF HIV MONITORING STRATEGY IN COUNTRIES WITH LIMITED RESOURCES
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EMBARGOED FOR RELEASE UNTIL 3 P.M. (CT), MONDAY, September 22, 2008
Media Advisory: To contact Diane S. Morse, M.D., call Michael Wentzel at 585-275-1309.
PHYSICIANS MAY MISS OPPORTUNITIES TO RESPOND WITH EMPATHY TOWARD PATIENTS WITH LUNG CANCER
CHICAGO—In a small study of 20 audiorecorded interactions, physicians seldom responded empathetically to concerns raised by patients with lung cancer, according to a report in the September 22 issue of Archives of Internal Medicine, one of the JAMA/Archives journals.
“Empathy is an important element of effective communication between patients and physicians and is associated with improved patient satisfaction and compliance with recommended treatment,” the authors write as background information in the article. “Patients who are more satisfied with the communication in their medical encounters have improved understanding of their condition, with less anxiety and improved mental functioning.” However, responding to patients’ emotional needs can be challenging for physicians; they may begin medical school with empathy for their patients but gradually learn detachment, perhaps in order to cope with time constraints or sadness.
Diane S. Morse, M.D., of the University of Rochester Medical Center, Rochester, N.Y, and colleagues conducted an analysis of 20 recorded and transcribed consultations between lung cancer patients (average age 65, all male) and nine physicians (three oncologists and six thoracic surgeons). Each visit contained an average of 326 statements, and those made by patients were coded into three themes: statements about the impact of lung cancer, statements about diagnosis or treatment and statements about health system issues affecting care.
Throughout the 20 visits, the researchers identified 384 statements by patients that provided opportunities for physicians to offer empathy. These included statements such as “This is kind of overwhelming” and “I’m fighting it.” Most often—in 61 percent of the cases—opportunities for empathy were classified as relating to the impact of lung cancer. “Patients’ morbidity [illness] and mortality [death] expectations and concerns were the most commonly coded empathic opportunity, which hinted at fears, worries and existential concerns and comprised 32 percent of overall empathic opportunities,” the authors write.
Physicians responded with empathy to 39 (10 percent) of all 384 opportunities. “Otherwise, physicians provided little emotional support, often shifting to biomedical questions and statements,” the authors write. “With a mean [average] of less than two empathic physician responses per encounter, empathy was an infrequent occurrence.” Half of the empathic responses that physicians offered occurred in the last one-third of the encounter, although patients’ concerns were raised throughout the visit.
There are several reasons that physicians may not display empathy, the authors note. They may believe there is no time for empathic responses, they may be too busy with other tasks to recognize opportunities for empathy or they may consciously avoid responding empathetically, perhaps believing that biomedical information is reassuring.
“We suggest the use of interval empathy to respond to empathic opportunities offered by patients periodically throughout the encounter, particularly in encounters with patients with life-threatening conditions who may be most likely to raise multiple empathic opportunities,” the authors write. “Use of this communication skill may allow increased understanding and progressive rapport and trust with patients. Fortunately, studies indicate that expressing empathy can be taught and that these statements can be brief and powerful, not prolonging the encounter or necessarily changing a physician’s style.”
(Arch Intern Med. 2008;168[17]:1853-1858. Available to the media pre-embargo at www.jamamedia.org)
Editor's Note: This research was supported in part by a Career Development Award to co-author Dr. Gordon from the Office of Research and Development, Health Services Research and Development Service, Department of Veterans Affairs, and by a grant from the Agency for Healthcare Research and Quality. Please see the article for additional information, including other authors, author contributions and affiliations, financial disclosures, funding and support, etc.
For more information, contact JAMA/Archives media relations at 312/464-JAMA (5262) or e-mail mediarelations{at}jama-archives.org.
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EMBARGOED FOR RELEASE UNTIL 3 P.M. (CT), MONDAY, September 22, 2008
Media Advisory: To contact Randi E. Foraker, M.A., call Ramona DuBose at 919-966-7467.
LOW NEIGHBORHOOD INCOME, MEDICAID INSURANCE ASSOCIATED WITH LONGER DELAYS IN REACHING HOSPITAL FOR HEART ATTACK TREATMENT
CHICAGO—Individuals with Medicaid insurance and those who live in neighborhoods with lower household incomes appear less likely than others to reach the hospital within two hours of having a heart attack, according to a report in the September 22 issue of Archives of Internal Medicine, one of the JAMA/Archives journals.
Patients tend to have better outcomes after an acute myocardial infarction (heart attack) if they receive medical treatment in a timely manner, according to background information in the article. Time-dependent treatments, such as clot-dissolving therapy or heart catheterization to reopen blocked arteries, are more likely to be given to patients who arrive at the hospital quickly. “Despite efforts to reduce time elapsed between the onset of acute myocardial infarction symptoms and hospital arrival, prehospital delay times have not improved over the years,” the authors write.
Randi E. Foraker, M.A., of the University of North Carolina, Chapel Hill, and colleagues examined the medical records of 6,746 men and women hospitalized with heart attack between 1993 and 2002. From the records, the researchers determined the prehospital delay time, or the time elapsed between the onset of symptoms and arrival at the hospital. Participants’ addresses were geocoded and linked with 2000 U.S. census socioeconomic data. Median (midpoint) household income for each participant’s area was classified as low (less than $33,533), medium ($33,533 to $50,031) or high ($50,032 or more). Health insurance status was noted and the distance from the residence to the hospital was calculated.
A total of 36 percent of the patients arrived at the hospital within two hours of developing symptoms (short delay), 42 percent between two hours and 12 hours (medium delay) and 22 percent between 12 and 72 hours (long delay). “Low neighborhood household income was associated with a higher odds of long vs. short delay and medium vs. short delay compared with high neighborhood household income in a model including age, sex, race and study community,” the authors write. “These associations persisted after additionally controlling for health insurance status, diabetes, hypertension, emergency medical services (EMS) use, chest pain, year of acute myocardial infarction event and distance from residence to hospital.”
In addition, patients with Medicaid were more likely to have a long or medium vs. a short delay than were patients with prepaid insurance or with prepaid insurance plus Medicare.
“Reducing socioeconomic and insurance disparities in prehospital delay is critical because excess delay time may hinder effective care for acute myocardial infarction,” the authors note. “Prolonged prehospital delay among patients from low neighborhood income areas and among Medicaid recipients suggests a need for increased recognition of and rapid response to acute myocardial infarction symptoms within these populations. Interventions that have been considered include the following: community education and awareness campaigns, targeted interventions by health care professionals aimed at reducing prehospital delay among patients with known coronary heart disease and promoting EMS use throughout the community.”
(Arch Intern Med. 2008;168[17]:1874-1879. Available to the media pre-embargo at www.jamamedia.org)
Editor's Note: This research was supported by a contract from the National Heart, Lung, and Blood Institute and was also funded in part by a National Institutes of Health, NHLBI and National Research Service Award training grant. The Atherosclerosis Risk in Communities (ARIC) study is carried out as a collaborative study supported by NHBLI contracts. Please see the article for additional information, including other authors, author contributions and affiliations, financial disclosures, funding and support, etc.
For more information, contact JAMA/Archives media relations at 312/464-JAMA (5262) or e-mail mediarelations{at}jama-archives.org.
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EMBARGOED FOR RELEASE UNTIL 3 P.M. (CT), MONDAY, September 22, 2008
Media Advisory: To contact corresponding author Eric Ravussin, Ph.D., call Glen Duncan at 225-763-2599.
CALORIE RESTRICTION DOES NOT APPEAR TO INDUCE BONE LOSS IN OVERWEIGHT ADULTS
CHICAGO—Young adults who follow a diet that is low in calories but nutritionally sound for six months appear to lose weight and fat without significant bone loss, according to a report in the September 22 issue of Archives of Internal Medicine, one of the JAMA/Archives journals.
Calorie restriction is the only intervention known to decrease the rate of biological aging and increase longevity, according to background information in the article. However, it is well known that chronic energy deficiency impairs bone mineral uptake and that weight loss is associated with bone loss in obese individuals. Calorie restriction, therefore, could also lead to bone loss and fracture.
Leanne M. Redman, Ph.D., and colleagues at Pennington Biomedical Research Center, Baton Rouge, La., studied 46 healthy, overweight men and women (average age 37) who were randomly assigned to one of four groups for six months. Eleven formed the control group, assigned to eat a healthy diet; 12 were assigned to consume 25 percent fewer calories than they expended per day; 12 were assigned to create a 25 percent energy deficit through eating fewer calories and exercising five days per week; and 11 ate a low-calorie diet (890 calories per day) until they achieved 15 percent weight loss, at which time they switched to a weight maintenance plan. All diets included recommended levels of vitamins and minerals, including calcium, and contained 30 percent fat, 15 percent protein and 55 percent carbohydrates, based on American Heart Association guidelines.
After six months, average body weight was reduced by 1 percent in the control group, 10.4 percent in the calorie restriction group, 10 percent in the calorie restriction plus exercise group and 13.9 percent in the low-calorie diet group.
Bone mineral density and blood markers of bone resorption and formation (processes by which bone is broken down and regenerated on a regular basis) were measured at the beginning of the study and again after six months. “Compared with the control group, none of the groups showed any change in bone mineral density for total body or hip,” the authors write. Markers of bone resorption were increased in all three intervention groups, while markers of bone formation were decreased in the calorie restriction group but were unchanged in the low-calorie diet or calorie restriction plus exercise group.
“Our data do not support the notion that extreme weight loss (more than 10 percent) over short periods (three months) has a worse prognosis on bone health than gradual weight loss achieved over six months by moderate calorie restriction with or without aerobic exercise,” the authors write. “We speculate that in young individuals undergoing calorie restriction, minor adjustments in bone occur as a normal physiological adaptation to the reduced body mass. Further studies of longer duration are warranted and should include an assessment of bone architecture to ensure that bone quality is preserved with weight loss.”
(Arch Intern Med. 2008;168[17]:1859-1866. Available to the media pre-embargo at www.jamamedia.org).
Editor's Note: This work was supported by a grant and the Neil Hamilton-Fairley Training Fellowship from the National Health and Medical Research Council of Australia and by funds from the HaPE Division, Pennington Biomedical Research Center. Please see the article for additional information, including other authors, author contributions and affiliations, financial disclosures, funding and support, etc.
For more information, contact JAMA/Archives media relations at 312/464-JAMA (5262) or e-mail mediarelations{at}jama-archives.org.
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EMBARGOED FOR RELEASE UNTIL 3 P.M. (CT), MONDAY, September 22, 2008
Media Advisory: To contact Natasha K. Stout, Ph.D., call Todd Datz at 617-432-3952.
MODEL HIGHLIGHTS BENEFITS AND RISKS OF CERVICAL CANCER SCREENING METHODS
CHICAGO—In an analysis based on a computer model, it appears that comparing the benefits and risks of different cervical cancer prevention approaches may help women and their physicians choose appropriate screening strategies, according to a report in the September 22 issue of Archives of Internal Medicine, one of the JAMA/Archives journals.
Routine screening with cervical cytologic testing, commonly known as Pap smears, is credited with reducing the incidence of cervical cancer through the early detection of abnormal cells, according to background information in the article. Today, U.S. women have an average lifetime cervical cancer risk of 0.7 percent. Recently, even more sensitive DNA testing for the human papillomavirus (HPV), which contributes to cervical cancer, has become available, along with vaccines against HPV. This leaves women and their physicians with several prevention options and considerations.
Natasha K. Stout, Ph.D., and colleagues at the Harvard School of Public Health, Boston, used a computerized simulation model of cervical cancer in the United States to assess the benefits and risks associated with various screening strategies. The strategies differed by type of primary screening test, process for handling abnormal results and screening frequency. “These strategies pose trade-offs between minimizing cancer risk (already small with regular screening) and minimizing the risk of false-positive test results and excessive diagnostic procedures,” the authors write.
Differences in women’s lifetime cancer risk varied little between screening strategies; however, the difference between the strategy offering the least and most frequent referrals for colposcopy (a procedure in which physicians look directly at the cervix through a microscope) was three-fold. For a representative group of 1,000 20-year-old women undergoing annual screening for 10 years, combined cytologic and HPV testing would lead to an estimated 1,795 referrals for colposcopy and other follow-up procedures (1,788 of them excessive, or not associated with cancer). The same women would receive 403 referrals (396 excessive) from cytologic testing following by triage HPV testing for those with abnormalities; 333 referrals (326 excessive) from conventional cytologic testing; and 223 referrals (216 excessive) from HPV testing followed by cytologic triage testing.
“For women who experience short-term anxiety around screening and diagnostic workup, quality of life could be an important criterion for decision making if several screening options associated with similar cancer risk reduction are available,” the authors write. “Using cytologic testing followed by triage testing in younger women minimizes both diagnostic workups and positive HPV test results, whereas in older women diagnostic workups are minimized with HPV DNA testing followed by cytologic triage testing.”
“There is great promise in the availability of accurate HPV diagnostics, new screening technology and HPV vaccination for successful cervical cancer prevention in the United States. From both an individual and population perspective, the range of new options for prevention will ideally be assembled in such a way as to improve cancer outcomes, reduce disparities and minimize the risk of overdetection of abnormalities likely to resolve on their own,” they conclude.
“These results provide an initial step toward a comprehensive set of clinically relevant information highlighting trade-offs among screening policies to ultimately better inform women’s decisions and provide additional dimensions for the construction of clinical guidelines.”
(Arch Intern Med. 2008;168[17]:1881-1889. Available to the media pre-embargo at www.jamamedia.org).
Editor's Note: This work was supported in part by the Harvard Center for Risk Analysis, the National Science Foundation’s Graduate Research Fellowship, a National Cancer Institute grant and the American Cancer Society. Please see the article for additional information, including other authors, author contributions and affiliations, financial disclosures, funding and support, etc.
For more information, contact JAMA/Archives media relations at 312/464-JAMA (5262) or e-mail mediarelations{at}jama-archives.org.
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EMBARGOED FOR RELEASE UNTIL 3 P.M. (CT), MONDAY, September 22, 2008
Media Advisory: To contact Eran Bendavid, M.D., call Ruthann Richter at 650-725-8047.
STUDY EXAMINES COST-EFFECTIVENESS OF HIV MONITORING STRATEGY IN COUNTRIES WITH LIMITED RESOURCES
CHICAGO—In a computer-based model evaluating the benefits and costs of three types of HIV disease monitoring strategies, early initiation of antiretroviral therapy and monitoring using the CD4 count, a measure of immune system function, instead of based on symptoms appear to provide health benefits in low- and middle-income countries, according to a report in the September 22 issue of Archives of Internal Medicine, one of the JAMA/Archives journals.
“Two-thirds of the world’s HIV-infected population resides in Africa, and most of the world’s new infections occur in low- and middle-income countries,” the authors write as background information in the article. Although progress has been made in increasing access to treatment, only 20 percent of adults who need highly active antiretroviral therapy (HAART) receive it. Among those who do, treatment is often managed without regular checks of CD4 counts (lower counts indicate less immune system function) or viral loads; this lack of monitoring may decrease HAART’s effectiveness. “Therefore, key questions in the management of HIV infection in resource-constrained settings are whether and how to monitor persons infected with HIV and when to initiate HAART.”
Eran Bendavid, M.D., of Stanford University, Calif., and colleagues developed a computer model to compare three types of HIV monitoring strategies for starting, switching and stopping HAART: those based on symptoms, those based on CD4 counts and those that combine CD4 counts with viral load. “We used clinical and cost data from southern Africa and performed a cost-effectiveness analysis,” the authors write. “All assumptions were tested in sensitivity analyses.”
Compared with approaches based on symptoms, monitoring CD4 counts every six months and beginning treatment when CD4 counts reached 200 cells per microliter was associated with an additional 6.5 months of life expectancy and a reduction in lifetime medical costs of $464 per person. CD4-based strategies in which treatment was initiated at the higher threshold of 350 cells per microliter provided an additional 5.3 months of life expectancy at a cost-effectiveness of $107 per year gained compared with the 200-per-microliter threshold. The increased life expectancy with CD4 count monitoring was associated with a large decrease in opportunistic infections—314 fewer during the course of 1,000 patients’ lifetimes.
“Monitoring viral load with CD4 was more expensive than monitoring CD4 counts alone, added two months of life and had an incremental cost-effectiveness ratio of $5,414 per life-year gained relative to monitoring of CD4 counts,” the authors write. In sensitivity analyses, monitoring by CD4 count became more cost-effective as the average costs of inpatient care in a given country increased, because the monitoring was associated with fewer hospitalizations for opportunistic infections. The cost-effectiveness of monitoring viral load depended on the cost of the test in that area as well as the rates of virologic failure, which occurs when treatment fails to reduce the levels of virus in a patient’s blood.
“Our analysis shows that, where HAART is available, CD4 count monitoring with earlier treatment initiation provides a substantial increase in life expectancy, which in some settings may be achievable while reducing total expenditures for HIV infection,” the authors write. “As the number of persons receiving HAART increases, the potential health benefit and cost savings from use of CD4 monitoring will also increase.”
(Arch Intern Med. 2008;168[17]:1910-1918. Available to the media pre-embargo at www.jamamedia.org).
Editor's Note: This study was supported in part by grants from the Agency for Healthcare Research and Quality and from the National Institute on Drug Abuse, and the Department of Veterans Affairs. Please see the article for additional information, including other authors, author contributions and affiliations, financial disclosures, funding and support, etc.
For more information, contact JAMA/Archives media relations at 312/464-JAMA (5262) or e-mail mediarelations{at}jama-archives.org.
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