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Lifestyle changes no more effective than placebo in reducing
Concern about the effects of beta blockers like propran-olol on
lipid levels, glucose tolerance, and electrolyte levels have led
physicians to question their use in the initial treatment of mild
or moderate high blood pressure and to recommend lifestyle
modification instead. But a recent study shows that modifying
several behaviors such as diet and exercise is no more effective
than placebo in reducing mild diastolic hypertension (90 to 104
mmHg). Normal diastolic blood pressure is below 90 mmHg.
Researchers, supported in part by the Agency for Health Care
Policy and Research (HS07373), studied 312 men and women, 22 to
59 years of age, with mild diastolic hypertension. They measured
diastolic blood pressure levels in patients randomly assigned to
four treatment groups: (1) lifestyle modification designed to
alter dietary habits, increase physical activity, and teach
relaxation techniques, plus a placebo drug; (2) life-style
modification and propranolol; (3) propranolol alone; and (4)
placebo alone. The subjects were followed for 1 year with
periodic measurement of blood pressure.
The mean decrease in diastolic blood pressure (DBP) at 12 months
was 8.5 mmHg for the lifestyle plus propranolol group, 7.7 mgHg
for the propranolol group, 5.9 mmHg for the placebo group, and
5.4 mmHg for the lifestyle plus placebo group. Although the
lifestyle modification program did result in reductions in
urinary sodium, dietary sodium, total calories ingested, and
weight, and significant increases in dietary phosphorus and
minutes of exercise at 3 months, lifestyle changes had no effect
on DBP at 3 or 12 months. Lifestyle modification failed to show
any effect on DBP when compared with placebo-only treatment.
Moreover, among subjects receiving placebo, 48 percent had normal
DBP after 12 months compared with 60 percent of the
propranolol-treated patients. This finding supports a DBP control
strategy of cautious clinical followup without treatment for many
patients who have mild hypertension but no other cardiovascular
risk factors. Finally, the adverse effects from propranolol were
not substantially different from those of placebo and may have
been overestimated in the past, according to the researchers.
Details are in "Comparison of a lifestyle modification program
with propranolol use in the management of diastolic
hypertension," by Eliseo J. Perez-Stable, M.D., Thomas J. Coates,
Ph.D., Robert B. Baron, M.D., and others, in the Journal of
General Internal Medicine 10, pp. 419-428, 1995.
Changes in lifestyle had no effect on diastolic blood pressure
compared with placebo-only treatment.
Age and other nonclinical factors affect prostate cancer
For men with local or regional prostate cancer, the optimal
approach to treatment remains controversial. Variations in
practice, which are substantial, are due to many factors. A study
supported by the Agency for Health Care Policy and Research
(HS06714) describes the utilization of various approaches for
managing prostate cancer for men treated between 1985 and 1989
and identifies key nonclinical variables associated with
In this study, patient age was the overriding variable in type of
treatment for prostate cancer, even after controlling for other
factors such as a patient's other medical problems. The
proportion of patients receiving surgery, radiation, or both
decreased with increasing age. More than half of the men 65 to 69
years of age received radiation or surgery, compared with less
than 17 percent of men over 80 years of age. On the other hand, a
higher proportion of very elderly men (more than 85 years of age)
received no treatment or hormonal manipulation alone.
Race also had an effect on therapy: black men were less likely
than white men to receive surgery (10 percent vs. 17 percent) and
radiotherapy (21 percent vs. 29 percent). White men with prostate
cancer underwent radical prostatectomy nearly three times as
often as their black counterparts. Also, men living outside a
metropolitan area had more hormonal therapy and surgery and less
radiation therapy than those living in metropolitan areas.
Finally, fewer than 30 percent of men with a significant number
of coexisting medical problems had surgery, radiation, or
combinations of aggressive therapy compared with men who were
These are the findings of Christopher E. Desch, M.D., of Virginia
Commonwealth University. Dr. Desch and his colleagues used tumor
registry data linked to Medicare data to examine the patterns of
prostate cancer treatment throughout Virginia.
For more information, see "Factors that determine the treatment
for local and regional prostate cancer," by Dr. Desch, Lynne
Penberthy, M.D., M.P.H., Craig J. Newschaffer, M.S., and others,
in the February 1996 issue of Medical Care 34(2), pp.
ER physicians' attitudes toward risk affect triage
Physicians who tend to be risk takers are less likely than more
risk-averse physicians to admit into the hospital patients they
evaluate in the emergency department (ED), according to a study
supported in part by the Agency for Health Care Policy and
Research (HS06452). It shows that physicians who are "risk
seekers" admitted only about one-third (31 percent) of ED
patients with acute chest pain whom they evaluated, compared with
half (53 percent) of similar ED patients admitted to the hospital
by risk-averse physicians.
This finding does not necessarily mean that risk-seeking
physicians release patients who need to be in the hospital.
However, it does suggest that the impact of physicians'
risk-seeking and risk-avoiding attitudes on the appropriateness
of triage decisions merits further study, explain the
researchers, who are from Harvard Medical School, the Harvard
Community Health Plan, and Brigham and Women's Hospital. They
used a risk-taking scale and a stress and uncertainty scale to
assess the risk attitudes of physicians who were primarily
responsible for ED triage of at least one patient with acute
chest pain from July 1990 to July 1991.
Physicians' scores on the risk-taking subscale correlated
significantly with hospital admission rates. The risk avoiders
admitted 53 percent of all the patients they saw; the
middle-scoring physicians, 44 percent; and the risk seekers, only
31 percent. Risk-seeking physicians admitted significantly fewer
patients at low and medium risk of heart attack. They also
admitted fewer patients at higher risk of heart attack, although
the difference was not statistically significant.
For more information, see "Triage decisions for emergency
department patients with chest pain: Do physicians' risk
attitudes make the difference?" by Steven D. Pearson, M.D.,
M.Sc., Lee Goldman, M.D., M.P.H., E. John Orav, Ph.D., and
others, in the October 1995 Journal of General Internal
Medicine 10, pp. 557-564.
Disparities found among patient groups in use of
Do-not-resuscitate (DNR) orders may be under used even among the
sickest patients, and their impact on patient outcomes is not
well understood, according to two studies supported by the Agency
for Health Care Policy and Research (HS06546). In the first
study, only about one-third (31 percent) of elderly patients with
a 65 percent chance of death within 6 months received DNR orders
during hospital admission, even though few of these patients had
a good chance of meaningful survival following cardiopulmonary
It is not understood why DNR orders are written for certain
patients and not for others in similar health states, puzzles
Katherine L. Kahn, M.D., of the University of California, Los
Angeles, principal investigator of the studies. Dr. Kahn and her
colleagues analyzed a nationally representative sample of 14,008
Medicare patients hospitalized with congestive heart failure,
acute myocardial infarction, pneumonia, cerebrovascular accident,
or hip fracture. They evaluated the rates of DNR orders,
characteristics of patients with these orders, and the impact of
DNR orders on patient outcomes.
After adjusting for hospital characteristics and patients' health
status and functional impairment upon admission, the researchers
found that DNR orders were written more often for older patients,
women, and patients with dementia or incontinence and less often
for patients who were black, had Medicaid insurance, or were in
In-hospital death for patients with DNR orders was four times
that of patients without DNR orders after accounting for burden
of illness, functional status, and demographics (40 percent vs. 9
percent) and the risk of death within 6 months of hospital
admission was 2.3 times greater. Neil S. Wenger, M.D., M.P.H.,
lead author of this study, suggests that DNR orders may be a
marker of unmeasured sickness, or patients with DNR orders may
simply receive different care than patients without them, for
example, "comfort care" rather than life-prolonging treatment.
For more information, see "Epidemiology of do-not-resuscitate
orders" and "Outcomes of patients with do-not-resuscitate
orders," by Dr. Wenger, Marjorie L. Pearson, Ph.D., M.S.H.S.,
Katherine A. Desmond, M.S., and others, in the October 23, 1995
Archives of Internal Medicine 155, pp. 2056-2062 and
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