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Patient Care/Clinical Decisionmaking

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Lifestyle changes no more effective than placebo in reducing mild hypertension

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 treatment decisions

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 alternative treatments.

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 healthier.

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. 152-162.

ER physicians' attitudes toward risk affect triage decisions

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 orders

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 resuscitation.

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 rural hospitals.

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 2063-2068.

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