CHS Research News
Volume 14, Issue 2, Spring/Summer 2002

by Joan DeClaire

 

Report from MacColl Institute features chronic-care successes

A report on better management of chronic disease—developed and edited by staff from the MacColl Institute for Healthcare Innovation at Group Health Center for Health Studies—was released May 16 at a meeting hosted by the Institute of Medicine at the National Academy of Sciences in Washington, D.C.

"Curing the System: Stories of Change in Chronic Illness Care" chronicles the experiences of 12 very different organizations that have redesigned systems to provide better care to patients with diabetes, asthma, heart failure, depression, and other chronic illnesses. Included in the report are two Seattle organizations—Seattle's Polyclinic and the Senior Wellness Project, part of Senior Services of Seattle/King County, Washington.

The changes these institutions made were based on the "Chronic Care Model"—a model of care that was developed and tested at Group Health by the MacColl Institute. The Institute staff members are now disseminating this work as part of Improving Chronic Illness Care (ICIC), a $25 million Robert Wood Johnson Foundation project housed at Group Health. Experts believe that if these changes are adopted widely, they could dramatically improve quality of care and control costs of chronic disease care nationwide.

The work of ICIC is being disseminated nationally through initiatives sponsored by the National Coalition on Health Care (NCHC), the nation's largest alliance to improve the health care system, and the Institute for Healthcare Improvement, an independent non-profit education and research organization fostering quality improvement.

The colorful 40-page report released in May uses a magazine-style format to profile organizations using the Chronic Care Model and its six components: 1) a supportive health care organization; 2) delivery system design; 3) decision support; 4) clinical information systems; 5) patient self-management; and 6) community resources.

Printed copies can be obtained by calling the MacColl Institute at 206-287-2704 or sending an e-mail to actinfo@improvingchroniccare.org.

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Greg Simon wins national mental-health research awards

Greg Simon, MD, a Group Health Cooperative psychiatrist and Center for Health Studies investigator, received two prestigious awards at the American Psychiatric Association's (APA) Annual Meeting in Philadelphia on May 18.

Simon received the 2002 American Psychiatric Institute for Research and Education/GlaxoSmithKline Senior Scholar Award, which is given in recognition of outstanding contributions to the field of mental health services research. He was also granted the "2002 Welcome Back Award" sponsored by Eli Lilly and Company for his exceptional achievements in improving the treatment of depression.

Much of Simon's research has centered on identifying problems in administering depression treatment and then implementing targeted solutions to improve results. For example, his research has revealed that in many clinical settings, patients are prescribed inappropriate doses of medication, stop medication too soon, or don't receive adequate follow-up.

To solve these problems, Simon has developed systematic programs to provide ongoing patient care after an initial diagnosis of depression. Currently, he is researching the benefits of providing medication monitoring, support, and counseling over the telephone as a way to make talk therapy more accessible.

Simon's research has been published in major medical journals, influencing depression care worldwide. Within Group Health, he is recognized for helping to design improved processes for depression care at the primary care level.

"Greg is the sort of physician/scientist hybrid who comes along once in a lifetime," says Michael Quirk, PhD, director of Group Health's Behavioral Health Services. "He develops powerful new ideas, translates them into research proposals that are funded and that are eventually translated into improved care here at Group Health."

Simon's work was recognized in a resolution passed by the Washington State Senate on March 12. Senator Pat Thibaudeau, Chair of the Senate Health & Long Term Care Committee, introduced the resolution to congratulate Simon for receiving the Welcome Back Award and to thank him for "his advocacy and compassion" in addressing mental health issues.

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Study links gene to success of a hypertension treatment

University of Washington researchers affiliated with Group Health Center for Health Studies (CHS) recently found that people with hypertension who have a particular genetic variant were twice as likely to avoid heart attacks and strokes if they took a diuretic medication.

The case-control study, conducted at Group Health, was published in the April 3 edition of the Journal of the American Medical Association. About 50 million Americans have high blood pressure; about 25 million take medication for it.

"If these findings are confirmed in other studies, screening for the adducin variant could identify hypertensive patients especially likely to benefit from low-dose diuretic therapy," says Dr. Bruce M. Psaty, a professor of medicine, epidemiology, and health services and co-director of the UW's Cardiovascular Health Research Unit, and an affiliate investigator at CHS.

The test for the adducin variant is now a research tool, and Psaty says it's not appropriate for clinical testing. Additional studies need to define the risks and benefits of genetic testing.

Psaty and co-authors studied the alpha-adducin (pronounced A-dew-sin) gene in the case-control study. Adducin is a protein linked to the inner surface of cell membranes, and one adducin genetic variant (Gly460Trp) is known to increase sodium retention by the kidney. High-salt diets, as well as sodium retention, are one cause of high blood pressure.

Diuretics are currently recommended as first-line drug therapy for hypertension by the U.S. Joint National Committee on the Prevention, Detection, Evaluation and Treatment of High Blood Pressure. Diuretics lower blood pressure by making the kidney excrete sodium. The idea for the study arose from the observation that diuretics and the adducin variant have opposing effects on sodium handling by the kidney.

This study was funded by grants from the National Heart, Lung and Blood Institute and the American Heart Association.

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Ed Wagner leads draft of IOM report on health consequences for the uninsured

Americans without health insurance are more likely to have poorer health and die prematurely than those with insurance, according to a report released May 21 from the National Academies' Institute of Medicine.

The report's authors—led by Ed Wagner, MD, director of the MacColl Institute for Healthcare Innovation at Group Health Center for Health Studies—concluded that uninsured patients with colon or breast cancer face up to a 50 percent greater chance of dying from these conditions than patients with private coverage. Uninsured victims of trauma also are more likely to die from their injuries. Being uninsured for even a year appears to lower a person's general health.

"Too often uninsured Americans don't gain access to care until their medical problems are severe," says Wagner, "When uninsured adults do get care, they're frequently unable to afford ongoing treatment of their chronic health problems, including needed specialty care or effective medications."

Differences in access to effective care are most striking for people with chronic illnesses, including cancer, heart disease, diabetes, and HIV infection—conditions for which early diagnosis and effective treatment can profoundly improve quality of life and survival, Wagner adds.

The report focused on the roughly 30 million—one in seven—working-age Americans without health insurance.

The full report, entitled Care Without Coverage: Too Little, Too Late, is available at www.national-academies.org. It is the second of six that will constitute an extensive review of research into who lacks health insurance and why. The series will also examine the personal, social, and economic consequences of having no insurance. The committee's final report will identify strategies for addressing the problems of the uninsured in the United States. The ongoing study is sponsored by the Robert Wood Johnson Foundation.

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Proper patient positioning may improve breast cancer detection, study finds

Proper positioning during mammograms makes a significant difference in doctors' ability to find breast cancer, according to a recent study led by Stephen Taplin, MD, senior investigator at Group Health Center for Health Studies (CHS).

The study—the first of its kind—was published in the April 2002 issue of the American Journal of Roentgenology, a major medical journal for radiologists. Researchers found that the chances of missing a cancer during mammography are more than twice as high when poor positioning occurs. Proper positioning allows visualization of the muscle behind the breast, the entire breast, and the nipple.

Moreover, Taplin and colleagues found that a woman's position during the screening may have more impact in detecting breast cancer than other measures of image quality, such as breast compression, radiation exposure, and even the sharpness and contrast of the mammography film.

"Proper positioning depends on cooperation between the technologist and the patient during the screening," explains Taplin. "When the technologist asks a woman to lean in so more of her breast can be seen on the film, it really does make a difference."

Breast positioning has improved since the study data was collected (1988–1993), according to Edward Sickles, MD, professor of radiology at the University of California San Francisco School of Medicine. "We have learned more effective positioning maneuvers, and these have been widely taught over the past several years," Sickles says. In fact, federal guidelines passed in the mid-1990s now call for more education about breast positioning.

"Still, the field has never developed specific criteria that measure whether positioning is being done correctly," says Taplin. "This study came up with such criteria and then determined how many missed cancers were associated with mammograms where the criteria were not met. This had not been done before."

Taplin emphasizes that the study shows only a correlation between positioning and cancers missed. There's no evidence of a direct cause and effect. Still, he believes that more training for technologists may improve outcomes.

"One implication of this study is that people in health care need to consider how well they are using the technology and what they can do to improve it," he added. "We won't get the outcomes we want unless we optimize the technology."

The CHS study should encourage further research into the link between breast positioning and clinical outcomes, according to Stephen A. Feig, MD, of Mount Sinai School of Medicine's Department of Radiology. In a commentary that accompanies the article, Feig wrote that the study should also "encourage efforts to further ensure proper image quality in (radiology) practices and around our nation."

The study included 152 women who were diagnosed with breast cancer within two years after a negative mammogram. When the women's mammogram films were reviewed and scored according to a measurement tool developed for the study, the researchers found that women with missed cancers were more than twice as likely to have mammograms that did not meet the new positioning criteria. Problems with other quality measures—such as breast compression, radiation exposure, and image contrast—were rare.

The study is part of a large breast-cancer screening research program at Group Health, which is funded by a five-year, $4.3 million grant from the National Cancer Institute. The study was conducted by scientists from CHS, the FDA, the University of Washington's Department of Family Medicine, and the Fred Hutchinson Cancer Research Center.

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